;., '.rv^Jse-.- pi^Ximy^l 1 JO UVIIM IVNOUVN 1NOIQ3W JO AaViail IVNOUVN INI9I01W JO »l»llll IVNOUVN ini: k\m>\ 1 \Xi U LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NA I /VlV\ - 2 4T\S) ' v^±Qs. w jo Aavaau ivnouvn inoioiw jo A*vaaii ivnouvn iNisiaiw jo A»vaan ivnouvn jn > 5 I ^/ 1 U LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NA O i w jo Aivaaii ivnouvn iniskiiw jo Aivaan ivnouvn jnoiojw jo Anvaaii ivnouvn jn U LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NA 0 \ 0£\ tw jo Aavaan ivnouvn in i a i a j*v jo Aavaa n l vnou vn in i d io a w jo A»v»a n ivnou vn in ,1 LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF M I 0 I C I noioiw jo Aavaau ivnouvn inidioiw jo Aavaau tvnouvn jnoioiw jo a.v.an ivnou iNoiaiw jo A.vian ivnouvn iNUiaiw jo Aavaau ivnouvn iNDiaiw jo Aavaan ivnou NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDIC Nijiaaw jo Aavaan ivnouvn inidkhw jo Aavaau ivnouvn jnokiiw jo Aavaan ivnou NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDIC * / > i X THE CYCLOPEDIA OF PEACTICAL MEDICINE. VOL. IV. THE CYCLOPEDIA > <« OF PEACTICAL MEDICINE: COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC., ETC. • EDITED BY JOHN FORBES, M.D. F.R.S. PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. ALEXANDER TWEEDIE, M.D. F.R.S. PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. JOHN CONOLLY, M.D. LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO THE HOPEWELL LUNATIC ASYLUM, ETC. THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY ROBLEY DUNGLISON, M.D. PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. " Hec demum sunt qua; non subgessit phantasiae iniaginatricia temeritas sed phenomena practica edocuere."—Sydenham. IN FOUR VOLUMES. VOL. IV. REFRIGERANTS—YAWS. PHILADELPHIA: LEA AND BLANCHARD. 1845. Entered, according to Act of Congress, in the year 1845, by LEA AND BLANCHARD, ■in the clerk's office of the District Court of the United States for the Eastern District of Pennsylvania. J. FAGAN, STEREOTYPER. T. K. AND P. G. COLLINS, PRINTERS. W CONTENTS OF THE FOURTH VOLUME. Refrigerants. Rheumatism Rickets............ Roseola........... Rubeola........... Rupia............... Corrigan Scabies.............. Houghton 23 Contributors. Page Dr.A. T. Thomson. 17 Barlow... Dunglison Cumin....... 43 Tweedie...... 50 Montgomery .. 51 58 59 .. Scarlatina............ Tweedie...... 67 Scirrhus............. Carswell...... 82 ., Scorbutus............ Kerr.........104 • Scrofula ............ Cumin.......125 . Sedatives..........S j-T.mnuon ? 14fi £ Dunglison .. $ , Sex, Doubtful........ Beatty.......153 ,, Small-Pox........... Gregory......159 s Softening of Organs... Carswell......175 r Somnambulism and Ani- mal Magnetism..... Prichard.....194 * Spermatorrhoea....... Dunglison___211 — Spinal Marrow, Diseases of the............ - Spleen, Diseases of the " Dislocation of the - Statistics, Medical. I R.B. Todd ...213 Bigsby.......223 Dunglison___229 Hawkins ... ~i „„„ Dunglison .. 5 Stethoscope.......... Williams.....237 Stimulants........... A. T. Thomson. 239 Stomach, Organic Dis- eases of the........ Houghton.....253 Stomatitis............ Dunglison___275 Strophulus........... Dunglison___276 Succession of Inheritance —Legitimacy....... Montgomery . .276 Suppuration.......... R. B. Todd .. .284 Contributors. Page U Survivorship.........Dr. Beatty.......290 j-Sycosis.............. Cumin.......296 ^-Symptomatology...... M. Hall.......298 -Syncope............. Ash..........329 j* Tabes Mesenterica___ Joy..........333 j- ■ Temperament........ Prichard.....349 Tetanios............ Dunglison___363 Tetanus ............ Symonds.....364 -Throat, Diseases of the i ^edie • • • • ? 376 £ Dunglison .. $ Tissue, Adventitious... 390 Tonics.............. Tweedie......391 Toothache........... Dunglison___404 «•»"*"........f fifc::}*" ►Transformations...... Duesbury.....464 •Transfusion.......... Kay.........468 ►Tubercle............. Carswell......474 'Tubercular Phthisis ... Clark,(Sir Jas.)489 •Tympanites.......... Kerr.........570 •Urine, Incontinence of . Cumin.......575 Suppression of... Carter.......578 Morbid states of the Bostock......581 Bloody......... Goldie........588 •Urticaria............ Houghton.....590 "Jterus, Pathology of the Lee..........596 •■Vaccination.......... Gregory......620 ^■Varicella............ Gregory......636 •-Veins, Diseases of the.. Lee..........639 • Ventilation.......... Brown.......650 [^Wakefulness......... Cheyne......653 •Waters, Mineral...... T. Thomson... 658 •Worms............. Joy..........704 •Yaws............... Kerr.........750 (5) 3 t3 CYCLOPAEDIA OF PRACTICAL MEDICINE. REFRIGERANTS (from refrigere, to grow cold), may be defined, medicines which diminish the morbid heat of the body. Their influence is generally admitted, but the theory of their opera- tion is not well understood ; and, consequently, many and very opposite hypotheses have been ad- vanced upon the subject. The first of these which deserve notice is that of Cullen, based upon a doctrine of Needham; it forms a remarkable in- stance of the obscurity into which hypothesis leads men otherwise distinguished for the perspicuity and soundness of their reasoning. This hypothe- sis supposes " that there is every where, in nature, an expansive and a resisting power; and that, particularly under a certain degree of heat, the expansive power appears in all the parts of organ- ized bodies, in consequence of which they show a singular vegetating power; while, at the same time, there is, in other bodies, a power resisting and preventing the action of this vegetating power, and, at least, of diminishing its force." And it is assumed that this power is found in those sub- stances which are usually employed as refrigerants. (Mat. Med. ii. 121.) It is unnecessary to com- ment upon these opinions ; indeed, their obscurity is such as to render them scarcely intelligible. A later theory is that of Dr. John Murray, whose habit of reasoning upon chemical princi- ples led him to call in the aid of these to explain the operation of refrigerants. He founds his opi- nion on the presumption of the truth of the theory of Dr. Crawford, that, in the process of respira- tion, the arteries in the lungs absorb the caloric liberated there; and, owing to the great capacity of arterial blood for caloric, they instantly render it latent, in which state it remains until the subse- quent conversion of the arterial into venous blood, when it is liberated equally through the system. Now, Dr. Murray considers that the consumption of oxygen in the lungs, supplying the caloric to the arterial blood, is greatly influenced by the na- ture of the food and other ingesta received into the stomach. He supposes that when these substances contain a small proportion of oxygen, the demand for that component of the air, and its consumption by the lungs, are augmented ; and, consequently, the animal temperature is elevated; whereas an opposite effect takes place when the ingesta con- tain much oxygen, more especially if it exist in a loose state of combination. According to this theory, therefore, all substances containing much oxygen capable of being extricated by the powers Vol. IV. — 3 b * of the stomach, should possess a refrigerant influ- ence. Plausible as this theory appears to be, its accuracy is very questionable; but, in order to reason correctly upon its merit, it is necessary to take a cursory view of the theory of animal heat upon which it is founded ; for if the difference of capacity of arterial and venous blood for caloric be insufficient to account for the temperature of the living body, Dr. Murray's theory of the changes produced by refrigerants must necessarily fall to the ground. Dr. Crawford's object was to prove, as already stated, that arterial blood has a greater capacity for caloric than venous blood; and this is also the case in reference to common or atmospherical air and carbonic acid gas. The latter fact explains the augmentation of temperature arising from the change which the air undergoes in the lungs when carbonic acid is present in them; but as the caloric thus evolved is absorbed by the arterial blood, and rendered latent, the sensible temperature of the blood is not augmented ; and it only becomes so as the arterial blood changes to venous in the course of its circulation. By this evolution of caloric the loss of temperature which the body sustains is compensated. Respiration, therefore, and the greater capacity of the arterial than the venous blood, are, according to this theory, the true sources of the peculiar temperature of the living body. Many facts might be mentioned as favouring the truth of Dr. Crawford's hypothesis ; for example, the greater the comparative size of the lungs, and the greater the quantity of blood which passes through them, the higher is the temperature of the animal. Thus, the capacity of the lungs is greatest in birds, which have the highest temperature among animals ; and it is a well-known fact, that what- ever lessens the free action of the lungs and dimi- nishes the consumption of oxygen, reduces the temperature of the animal. Individuals who la- bour under a malformation of the heart sufficient to prevent the arterialization of the blood, are always of a temperature below the natural stand- ard. In hybernating animals, also, the tempera- ture falls as the respiration is suspended; and it rises with the return and the progress of respira- tion : and, farther, M. Gallois ascertained, by ex- periment, that the temperature of the body falls exactly in the ratio of any diminished quantityof oxygen consumed in respiration. These opinions are strengthened by some experiments of Dr. Wil- 18 REFRIGERANTS. son Philip; and>, upon the whole, it is tolerably well ascertained that the temperature of the body sinks, if it be not maintained by the chemical changes which occur in respiration. But, notwithstanding the support thus given to Dr. Crawford's opinion, many and as strong facts have been advanced in support of that view of the subject which regards nervous energy as the source of animal heat. The most important ex- periments on this side of the question are those of Mr. [Sir B.] Brodie. He found that, by maintain- ing the action of the heart by artificial respiration after the brain is removed, although the blood undergoes its ordinary changes, yet that the tem- perature of the animal thus treated is rapidly lowered. Sir B. Brodie's experiments were made on rabbits, in which the functions of the brain were suspended by dividing the spinal marrow: the blood, in both systems, underwent no change different from that which occurs in natural res- piration. " It may perhaps be urged," says Sir B. Brodie, "that, in these experiments, the secre- tions had nearly, if not entirely, ceased: it is probable that the other changes which take place in the capillary vessels had ceased also, and that, although the action of the air on the blood might have been the same as under ordinary circum- stances, yet there might not have been the same alteration in the specific heat of the fluid as it flowed from the arteries into the veins. But, on this supposition, if the theory of Dr. Crawford be admitted as correct, there must have been a gradual but enormous accumulation of latent heat in the blood, which we cannot suppose to have taken place without its nature having been en- tirely altered. If the blood undergo the usual change in the capillary system of the lungs, it is probable that it must undergo the usual change in the capillary system of the greater circulation also, since these changes are obviously dependent on and connected with each other." From the "experiments of Sir B. Brodie it appears that, when the functions of the brain are suspended, the power of generating animal heat is also sus- pended ; although the same quantity of oxygen be consumed as in natural respiration under ordi- nary circumstances. It is, nevertheless, proper to mention here the opinion of M. Le Gallois, that, owing to the nature of artificial respiration, upon -which Sir B. Brodie's conclusions are founded, the temperature may fall, and the animal be killed by cold, although every, part remain uninjured. The air in artificial respiration does not enter the pulmonary cells in the same manner as in natural respiration, but is forcibly propelled into them; a large formation of frothy mucus occurs, which both prevents the air coming in contact with the lining membrane of the air-cells, and by its eva- poration tends to cool the body. Many other facts concur, also, to prove that the temperature of the body is regulated by the nervous energy. It is true that these demonstrate its effect chiefly in maintaining the heat of parts; but if its influence on parts be admitted, it is not easy to conceive on what grounds its power over the entire system can be denied. Sir Everard Home divided the nerves going to the growing antler of a "stag, and found that the temperature almost immediately fell; and although, after a few days, it rose again higher than before, yet this may have originated from the reunion of the divided nerves : at all events it does not invalidate the fact that the temperature fell on the division of the nerves, and, consequently, was regulated by their condition. In paralyzed limbs the tem- perature sinks, although in many cases the circu- lation in the limb is unaffected, and the paralysis is confined to the sensibility of the member. In a case recorded by Mr. Earle, in which the axil- lary plexus of nerves on one side was crushed, the paralyzed limb of that side was of a lower temperature than the opposite limb: indeed, in general we find that increased nervous action, whether depending on affections of the mind or on other causes, augments the heat of the body ; whilst the effect of depressing passions, which diminish nervous energy, is followed by either general chilliness, or coldness of the extremities. These facts undoubtedly go far to prove that animal heat is a vital principle closely connected with the integrity of the nervous system ; but at the same time, as the stimulus of arterial blood is requisite for the excitement of the brain and nerves, and arterialization is the result of respira- tion, the influence of respiration in the production of animal heat must be so far admitted; for with- out the function of the lungs the brain would lose its energy, and the temperature of the system be necessarily greatly lowered. This opinion re- ceives also considerable support from some ex- periments of Dulong to ascertain whether the quantity of caloric, developed by the consumption of oxygen in respiration, be equivalent to the quantity given out by the body. He found that in carnivorous animals the proportion is equal to forty-nine and fifty-five parts in one hundred of the heat generated by the whole body during the same interval of time; and, in phytivorous ani- mals, to betwixt sixty-five and seventy-five parts; and that the whole quantity of caloric and water together is equivalent to sixty and eighty parts only ; so that the animal heat is greater than can be accounted for by the fixation of oxygen during respiration. Upon the whole, the examination of both sides of the question leads us to conclude that both opinions are to a certain extent true; that animal heat is influenced chiefly by the state of the nervous system, but partly, a-lso, by the chemical changes which take place in the lungs during respiration. [See, on all this subject, the physiological works of Miiller, Carpenter or Dun- glison.] If this view of the sources of animal heat be correct, it presents a considerable obstacle to the admission of Dr. Murray's explanation of refrige- rants, which can only be regarded in the light of an ingenious hypothesis. The subject, therefore, remains as he found it; and the question presents itself—can no rational explanation of the opera- tion of refrigerants be suggested 1 The writer of this article, although he does not venture to offer a theory likely to be generally adopted, yet con- ceives that some approach to a rational explana- tion may be attained by ascertaining how far the action of refrigerants taken into the stomach re- sembles that produced on the skin by similar substances. In abstracting caloric from the surface of the REFRIGERANTS. 19 body, or, in other words, cooling the skin, what- ever agent be employed, whether diluted acids, salts in a state of solution, cold air, or cold water or ice, the activity of the capillaries of the part is immediately diminished ; and as their action can- not be materially lessened without the whole vas- cular system being more or less influenced, the vigour of the heart and arteries is also materially depressed. The consequence of this diminished vascular action is immediately felt on the respira- tion ; the blood does not undergo its necessary change ; venous blood is conveyed to the brain, the function of which being impeded from defect of stimulus, a state somewhat resembling para- lysis of the nervous system ensues, so that torpor of every organ, the function of which depends on the energy of the brain and nerves, must neces- sarily follow. The effect of the abstraction of caloric on the nerves is strikingly illustrated by the numbness and insensibility which follow the exposure of the hands, in many individuals, in cold weather; a result which is more likely to arise from the direct influence of cold on the nerves themselves, than from the diminished supply of blood to the parts. Indeed, as in this case the effect on the nerves is partial, we can scarcely imagine any other cause of the diminished action of the capillaries than the depression of the nervous energy. Now if we suppose,—and the supposi- tion is far from being unreasonable,—that an effect resembling that produced on the surface takes place in the stomach when refrigerant agents are introduced into it, we may readily admit that the effect on the capillaries of that organ is extended by sympathy over the system. The possibility of such a result is equally probable in the one case as in the other. This opinion receives some support from the fact that nitrate of potassa operates as a powerful general refrigerant when it is swallowed at the instant of its solution ; but it acts as an excitant when it is not taken into the stomach until after it have been some time dis- solved. The sensation of cold which the nitre, during solution, causes in the stomach, is evi- dently owing ,to a partial abstraction of stimulus, and the effect of this being extended through the nerves to the heart and larger branches of the arterial system, a general reduction of action is produced, and this is followed by a sensation of cold over the whole body. Let us now inquire how far this theory is borne out by the known effects of refrigerants upon the functions of the stomach, the lungs, and other organs. 1. In the healthy condition of the stomach, re- frigerants exert little perceptible influence upon it; but when it is either in an irritable state, or affected with inflammation, the continued use of refrigerants, particularly cold and iced water and lemonades, allays the sensation of heat, nausea, and general uneasiness. Even when no local in- flammation exists, cold water and other cold, bland fluids, received into the stomach, moderate general excitement and control febrile action; an effect which can only be explained by the influence of the refrigerants on the nervous energy. The same results follow the administration of refri- gerants in enteritis. 2. Refrigerants exert no evident influence on the circulating and respiratory^ organs, in the state of health; although in some individuals, owing to idiosyncrasy, acidulated fluids cannot be taken without so powerfully affecting the larynx as to cause a temporary loss of voice; but in a diseased state of these organs the influence of refrigerants is well marked. In an excited state of the vascular system, when the pulse is both quicker and stronger than natural, acidulated drinks reduce both states, both moderating the action, and relaxing the tension of the pulse; nor is their effect on the capillaries less manifest; and it is to their influence on these that we must attribute the diminished tempera- ture which follows their administration. It is surely unnecessary to say how intimately this is connected with their impression on the nerves of the stomach. In the febrile state, the effects of refrigerants on the circulation are necessarily com- municated to the lungs; but besides this sympa- thetic influence, some of this class of medicines, in particular, acids, seem to operate directly on the pulmonary tissue. In acute inflammation of the air-tubes, or even of the pleura, acid fluids greatly augment the cough and oppress the breath- ing, when administered before the excitement be subdued; and after this is effected, we still per- ceive the evidence of their action on the mucous membrane by the aid which they afford to ex- pectoration. 3. But the most decisive illustration of the extent to which the nervous system is influenced by refrigerants, is observed in the effects which acidulated fluids produce on those who are la- bouring under diseased conditions of the spinal cord. The author had an opportunity of wit- nessing this in a gentleman who was labouring under subacute inflammation of the spinal theca. Whenever he swallowed a spoonful of lemonade, or even an ordinary effervescing draught, a sensa- tion of pricking was felt over the surface, the skin became so sensitive as scarcely to admit of being touched, and the whole system restless and un- easy. Hypochondriacal and hysterical persons, not unfrequently, suffer in a similar manner from the internal use of acids ; and, as this effect is not confined to particular individuals, it cannot be ascribed to idiosyncrasy. Upon the whole, it is evident that refrigerants operate to a certain extent as sedatives ; diminish- ing the force and rapidity of the pulse, depressing morbid temperature, and calming, generally, the disturbance which always attends acute diseases. The substances employed as refrigerants operate either on the organic functions or on the sensi- bility of the body in a state of disease. 1. The refrigerants operating on the organic functions are chiefly vegetable acids. The in- fluence of acetic acid, in its diluted impure state or as vinegar, in cooling the body labouring under disease, was very early known. In its undiluted state it is a powerful stimulant; and when daily taken in large doses into the stomach in its diluted form, it produces great uneasiness, cramps, and colic, and gradually destroys so effectually the texture of the organ and its digestive function, as to cause emaciation of the body. When it is only occasionally taken, largely diluted with water and moderately sweetened, it displays decided soothing and refrigerant properties, and is em- 20 REFRIGERANTS. ployed with advantage in inflammatory and bilious fevers, for quenching thirst, calming the vascular excitement, re-establishing the perspiratory func- tion of the skin, and restoring the action of the kidneys. In inflammatory affections of the lungs, however, it increases the cough, and augments the morbid sensibility of the mucous membrane in the same manner as all other acids; and, therefore, it is contra-indicated in such diseases, even as an expectorant, until the excitement be subdued. The refrigerant influence of diluted vinegar on the surface is undoubted ; it not only diminishes heat but allays pain. In hemorrhagic affections, the cold feeling which it produces on the skin is extended to the whole system; hence the benefit derived from it in internal hemorrhages, and in the inflammation of cavities; as, for instance, in uterine hemorrhages applied to the thighs and ab- domen ; and in acute meningitis applied as a lotion to the shaved scalp. In general fever, sponging the body with vinegar and water is ap- plicable to every case in which the skin is preter- naturally hot, when no idiosyncrasy stands in the way. When diluted acetic acid is internally admi- nistered, if opium be prescribed at the same time, it should be recollected that it decomposes the meconate of morphia of the opium and forms an acetate, which is a more powerful narcotic than the meconate. The combination of this acid with ammonia, in the preparation known by the namf liquor ammonix acetatis, possesses refrigerant powers nearly equal to those of the diluted acid, acting at the same time as a diaphoretic ; and it is more generally employed than the acid in mo- dern practice. The salts procured by the com- bination of acetic acid with the other alkalies operate chiefly on the kidneys. The citric acid is more frequently employed than the acetic as a refrigerant; but chiefly in its combined state as prepared by the hand of nature, in the juice of the lemon, the orange, and other fruits. It is more grateful in its combined than in its uncombined state ; a fact which is quickly perceived by patients in fever, when it is ordered to form the common effervescing draught for checking nausea and vomiting. When simply diluted with water, in the proportion of the juice of two moderately-sized lemons to a pint of water, and slightly sweetened, forming lemonade, citric acid constitutes a most serviceable and agreeable beverage in fevers; and in those of a typhoid character this is rendered more grateful and bene- ficial by using water impregnated with carbonic acid gas instead of common water. In the ordi- nary condition of the stomach, citric acid, either pure or combined, does not weaken the stomach; and in some irritable states of that organ, charac- terized by a sensation of heat, painful digestion, an unpleasant taste in the mouth, and a disgust of food, it removes these symptoms and proves decidedly beneficial: but on the other hand, when the stomach is highly irritable, and its nervous susceptibility great, lemon-juice, or the citric acid, even when largely diluted, causes heat, uneasi- ness, and pain, and not unfrequently obstinate vomiting. Nevertheless, as M. Broussais has remarked, (Phlegmas. Chron. t. iii. p. 254,) the citric acid is that which the stomach supports best when suffering under inflammation. The citrates of potassa and of ammonia are also refrigerant: the citrate of soda, which is not an officinal preparation, operates as a purgative. The above remarks are applicable to the juice of the orange, the apple, the currant, and the gooseberry, all of which owe much of their acidity to the citric acid. The tartaric acid, except as it is contained in the tamarind, is much less frequently prescribed than the citric as a refrigerant, being more apt to disorder the digestive organs, to produce colic and to purge; and its morbid influence on those labouring under affections of the spine is more constant and evident than that occasionally re- sulting from the employment of citric acid: indeed, so obvious is this, that patients sometimes refuse to continue taking it on account of the nervous agitation which it causes. Its combination in the form of the bitartrale is more frequently em- ployed ; and in small doses at moderate intervals, it does not operate as a purgative, but as a simple acidulous refrigerant. It is best administered in the form of whey, or of cream-of-tartar beverage ; it moderates febrile heat and softens the skin; but when its employment is followed by a red and dry tongue, it ought to be discontinued. Both the acid and the bitartrate are incompatible in mix- tures with the nitrate of potassa, which it decom- poses, and, uniting with its alkaline base, forms either a bitartrate or a tartrate. The oxalic acid in the form of the binoxalate, as found in the oxalis acetosella and rumex ace- tosa, was formerly much prescribed as a refrige- rant ; but these plants, and, indeed, the oxalic acid in any form, are now rarely employed. Nitrate of potassa, in small doses, is a well- known refrigerant: it produces a powerful sym- pathetic effect on the nervous system, depressing the strength and diminishing the frequency of the pulse, and lowering the animal heat: the skin becomes pale, and a sensation of languor is felt. To obtain the full refrigerant effect of nitre, the salt must not only be administered in small doses at short intervals, but it should not be dissolved until the instant in which it is to be administered. As a refrigerant, the dose should not exceed a scruple, or, at the utmost, half a drachm. The bicarbonate of soda, although seldom pre- scribed as a general refrigerant in this country, yet is frequently administered in inflammatory febrile affections on the continent. It is, however, better calculated for operating as a local than as a gene- ral refrigerant, 2. The refrigerants operating on the sensibility of the body are few ; but they are more directly refrigerant than those which have been already noticed. Cool air, the first of these, is so agree- able to the feelings in a heated state of the body, that observation alone might have led to its early employment as a remedial agent; and nothing marks more strikingly the perversity of mankind than the opposition of physicians, at one period to the indulgence of the instinctive desire for this remedy in fever patients. Its utility in moderating high vascular action and operating as a sedative refrigerant is now generally acknowledged • and REFRIGERANTS. 21 consequently its admission to the apartments of the sick, in febrile diseases, is almost universal. If cool air be beneficial in the above-mentioned conditions of the body, cold water and ice are still more so; and their application is extensive. For an account of the effects of cold water and ice in reducing the temperature of the body in its healthy condition, we must refer our readers to the articles Bathing and Cold. When cold water and ice are employed as curative agents, their influence may be obtained either by their internal adminis- tration or by their application to the surface; in both cases their effects are extended by sympathy over the system; but they are modified by the manner in which these agents are used. If the body be immersed in the cold bath, the most striking effect is the shock or nervous impression which produces the vascular reaction so beneficial when cold bathing is used as a tonic; an effect, however, which must be avoided as much as pos- sible when the refrigerant influence only of the bath is required. To insure simple refrigeration, the water should be of a temperature not much below that of the skin; but as, even at such a de- gree of heat, the sudden immersion of the body is likely to cause more reaction than would be safe in cases requiring mere refrigeration, the cold bath is rarely or never employed in this country for producing that effect The shock and reaction caused by dashing cold water over the body, con- stituting the cold affusion as it is termed, is as considerable as when the cold bath is used, but it is more transitory, and therefore it is a more use- ful refrigerant. Sponging the body with cold water, as far as a simple refrigerant effect is de- sired, is preferable to either the cold bath or the cold affusion : there is no shock ; the fluid, being left to evaporate, merely cools the surface; and by persevering in the process, the cooling effect is fully obtained, and rendered permanent. One great advantage of sponging the surface with cold water is the facility of limiting the extent of the effect according to the feelings of the patient: in general it may be continued until the sensation of chilliness comes over the body, when the patient should be dried and placed in bed. The more simultaneously the influence of cold water is ex- tended over the surface, the better; the process of sponging should, therefore, be performed by several attendants with large sponges on the dif- ferent parts of the body at the same time. In ordinary cases the temperature of the water may be regulated by the feelings of the patient, as the beneficial effect depends on the evaporation, which may be aided by the addition of vinegar or alcohol. Evaporating lotions applied to a part, operate locally in the same manner as general sponging; the sedative and refrigerant influence is not con- fined to the part, but extends to other parts of the body, even to the interior, as, for instance, to the brain, the contents of the abdomen, and to joints. The sedative effect is still more powerful when a small stream of cold water is directed upon the part: the author of this article has seen this most strikingly exemplified in burns; the mere immer- sion of the part in cold water, or the application of cloths dipped in cold or even iced water, is much inferior in its effect to this method of em- ploying cold water. It is scarcely necessary to comment on the influence of the local application of ice, which operates exactly in the same manner as evaporating lotions, but more effectively, owing to the steady continuation of the same low tempe- rature to the parts. The foregoing remarks lead to this conclusion— the utility of refrigerants as curative agents is more limited than that of most other classes of remedies. They are chiefly employed to depress inordinate vascular action, and thereby to lower temperature ; consequently, it is in inflammation, active hemor- rhages, and febrile affections that they are found beneficial; and in such cases they are, undoubt- edly, most valuable remedies. In local inflammations on the surface of the body, cold water and evaporating lotions prove highly serviceable; whilst in those more deeply seated, as, for instance, inflammation of the brain and its membranes, ice applied to the scalp is to be preferred : the steady abstraction of caloric which it effects, operates not only upon the vessels and nerves of the integuments, but, by diminish- ing action in the carotids and large vessels, it pro- duces the most decisive benefit in reducing the vascular action within the cranium. These ap- plications have been lately recommended in other internal inflammations, even those of the thorax and abdomen, and under proper circumstances have been found highly beneficial. Hemorrhage arising from increased action, or accompanied by it, is frequently checked by the sedative influence of refrigerants. When the bleeding is internal, the degree of cold should be such as to operate sympathetically on the whole system; and to lessen not only the action of the vessels of the part, but to restrain, to a certain de- gree, that of the heart. Thus in haemoptysis, not only should the patient be freely exposed to cold air, but ice and cold acidulous fluids should be freely administered ; indeed, the temperature may be with safety, and even with advantage, dimi- nished so much as to be uncomfortable to the feelings of the patient. In such a case, the low degree of temperature is accompanied with an evi- dent diminution of the irritability of the contrac- tile fibres of the whole vascular system, and, con- sequently, aids greatly in checking the flow of blood. The liquids administered as drink should be cooled down to 32°, either by ice or by a freezing mixture, and slowly swallowed. The in- fluence of nitre has long been regarded as con- siderable in such cases ; and much of the benefit received has been attributed to a chemical change effected on the blood ; but if the opinions advanced in this article be correct, it is unnecessary to assert that this explanation of the operation of nitre must fall to the ground. [The notion of nitrate of potassa being refrige- rant has probably arisen from the coldness which it occasions whilst undergoing solution in water. Indeed, as elsewhere stated, (General Therapeutics, Philad. 1836, and General Therapeutics and Ma- teria Medica, ii. 206, Philad. 1843,) all internal refrigerants probably act wholly by their being comparatively of low temperature, and thus re- ducing the heat of the stomach. A recent writer, Dr. Spillan, (Manual of General Therapeutics, p. 185, London, 1841,) after citing the published opinion of writers on this subject, states that 22 REFRIGERANTS. " the refrigerant effects of nitrate of potassa as a sedative, when given dissolved in even tepid drinks, such as whey, are known to every one." They certainly are not known to the writer ; yet he has watched most carefully for them; nor have others been more fortunate. Dr. A. T. Thomson says, that " the dose of the salt should not be dis- solved until the instant in which it is to be swal- lowed," (Elements of Mat. Med. and Therap., 2d edit. Lond. 1835) ; and Dr. Pereira (Elements of Mat. Med. and Therap., Amer. edit. i. 438,) ac- cords with him; whilst Dr. Christison (Dispen- satory, p. 741, Edinb. 1842,) expresses himself in a manner that still more strongly corroborates the views of the writer:—" Its refrigerant action, gene- rally admitted by systematic writers on materia medica and by many practitioners, is of doubtful existence, having probably been inferred rather from the coldness it occasions while dissolving in water, than from actual evidence of its effects in disease. The sedative action ascribed by some to it has been probably inferred from its supposed re- frigerant property, and not from observation."] In haematemesis occurring in young and vigo- rous perons, the same assiduous employment of refrigerants is requisite as in hemoptysis; and when the bleeding is so violent as to threaten quickly serious consequences, the other refrigerant plans may be aided by injecting iced water into the rectum, and by the local application of cold to the epigastrium. In no species of hemorrhage is the sympathetic influence of refrigerants more strikingly obvious than in epistaxis. Thus dash- ing cold water on the genitals has sometimes in- stantaneously suppressed bleeding at the nose ; and on the same principle is explained, what it is scarcely necessary to notice, the popular remedy of applying a large cold key or a piece of metal between the shoulders under the clothes. It is superfluous to say that, however useful refrigerants may prove in all cases of active he- morrhages, their employment in the passive is to be most carefully avoided. But it is in fevers that refrigerants under every form are to be regarded as the most valuable set of therapeutical agents. In continued fever, the vegetable acids largely diluted are internally administered, especially those found in fruits; and not unfrequently nothing is more grateful to fever patients than cold water slightly acidulated with either the sulphuric or the nitric acid. It is, how- ever, the general application of cold to the surface which proves the most useful refrigerant in con- tinued fever. In those forms of the disease which assume a typhoid type, ventilation and the free admission of cool air into the apartments of the sick are absolutely necessary: irritation is allayed, debility obviated, and the whole complexion of the disease often changed in a few hours, by the removal of the patient into a cool and well-venti- lated, from a close and filthy apartment. The most direct and effective refrigerant, however, in continued fevers is the cold affusion; but its employment requires certain cautions, without at- tention to which much mischief may be incurred. In the first place, the exact temperature of the body must be carefully ascertained. In this country, in the severest attacks of fever, it has rarely exceeded 108° Fah.; but in tropical climates it rises sometimes to 112°; the higher the temperature of the patient, the more benefit may be anticipated from the cold affusion. The temperature of the water should vary according to the season of the year and the feelings of the patient, the average range being from 40° to 70° Fah. The effect is to diminish the morbid heat of skin, to lower the force and retard the rapidity of the pulse, and to induce perspiration and sleep; and when such results follow, the cold affusion proves beneficial in any form of fever. The thermometer is employed to determine the temperature of the patient; but if he feel cold when that instrument indicates an augmented morbid temperature; or if he feel hot when the thermometer demonstrates that the heat of the body is below that of the natural standard ; then in neither case should this form of refrigerant be resorted to. It is also improper when the skin is bedewed with perspiration; or if the patient dread greatly its use; nor is it less so during menstrua- tion, and in the latter months of pregnancy. In the advanced stages of fever, refrigerants of any kind are injurious. With respect to the kinds of continued fever in which refrigerants are indicated, we may enumerate six. 1. In inflammatory fever, (synocha,) a rare dis- ease when unaccompanied with topical inflamma- tion, the advantages to be derived from refriger- ants are well understood. The cold affusion is admirably adapted for rapidly abstracting the stimulus of heat, diminishing general excitement, and operating as a powerful sedative. In the more advanced stages of the disease, cool spong- ing is often substituted for the affusion ; but when the patient can bear the fatigue of the affusion, it is always to be preferred. The greater frequency of this form of fever among the ancients than the moderns explains their constant employment of cold drinks and cold bathing in continued fever. 2. In fevers of a typhoid type, the disease has been cut short by the cold affusion; but in this case more perhaps is to be attributed to the shock and the reaction which follows, than to the refri- gerant influence of the affusion. 3. In synochus or inflammatory fever, gradually assuming the typhoid character, refrigerants in general, but more especially the cold affusion, are chiefly applicable to the early stages of the disease; and, indeed, no form of remedy is more advanta- geous when there are no local determinations; but when these exist, particularly if the lungs be affected, much caution is required. 4. In remittent fevers, especially those of warm climates, and in their more intense and excited variety, the cold affusion may be employed with great benefit. In severe attacks, also, much advantage is derived from the application of ice or cold water to the scalp ; in the remissions, how- ever, the application of cold in any form must be suspended. In yellow fever, the safety of the patient frequently depends solely on the early ap- plication of the cold affusion. 5. If hectic be symptomatic of pulmonary af- fections, or determination to internal organs, the cold affusion is decidedly contra-indicated; but even in such cases much benefit is often obtained by sponging the trunk of the body with cold REFRIGERANTS —RHEUMATISM. 23 water mixed with vinegar, whilst the lower ex- tremities are kept warm in bed. We must, never- theless, bear in mind that, under any form of hectic, although general refrigerants are useful auxiliaries, yet the cold affusion can scarcely be regarded as admissible. 6. In most eruptive fevers, except measles, the body should be freely exposed to cool air; and even the cold affusion may be safely and advan- tageously prescribed, should the state of the sur- face require it, nor should the presence of the eruption operate as a reason against its employ- ment. The Hindoo physicians plunge their patients, during the eruption of small-pox, into cold water, and with the best results. It dimin- ishes the fever, lessens the number of the pus- tules, and is said to prevent pitting. The writer of this article has long been in the habit of em- ploying the cold affusion in scarlatina during the height of the eruption, and has seen the severity of the disease instantly checked by it. In intermittent fevers, when the skin is dry and parched, and the general heat greatly augmented, cold in every form applied to the surface, and cold acidulated fluids taken into the stomach, are of the same value as in continued fever, and greatly favour the accession of the sweating stage. The affusion should be used in the hot stage of the paroxysm, and continued until the temperature of the body of the patient be reduced to the natural standard. It is unnecessary to discuss the nature of the various diseases, besides idiopathic fevers, in which refrigerants are indicated : in all, much depends on the degree of the attendant fever, and the ex- istence of local affections. In one local disease, phrenitis, however, their advantageous effects are very conspicuous: the most furious delirium is quickly subdued by allowing cold water to drop on the vertex, whilst the rest of the scalp is cov- ered with cloths moistened with vinegar and water. The degree of collapse, indeed, which is thus produced, is often so great as to require most active measures to counteract it; when such occurs, the state of sinking is to be treated exactly in the same manner as when extreme debility suddenly appears from other causes: external warmth, particularly the application of bladders of hot water to the scrobiculus cordis, friction, electricity, and sometimes artificial respiration, are the means to be employed to restore animation; and when the power of deglutition returns, the administration of excitants, especially aromatics and ammonia, is to be resorted to. From the foregoing remarks, it is evident that, although, as we have already said, refrigerants constitute a class of medicines of limited applica- tion, yet they are of much value in a few impor- tant diseases. Like every other class of thera- peutical agents, their utility will be more or less obvious as the discrimination, the judgment, and the observation of the practitioner are properly exercised, in determining the exact condition of the body which demands their employment. A. T. Thomson. RHEUMATISM, from (icv/ia, a dejluxion. This term, originally adopted when diseases ac- companied with swelling were usually attributed to the flow of some special humour to the part affected, has been used for ages to designate an affection which has so much of distinct character as to justify its being considered a special dis- ease. So loosely, however, has the term been applied, that a host of ailments, with no character in common save that of pain, have been classed under it, and much both of false experience and of bad practice has thence resulted. Diseases called rheumatic have been relieved by stimulant remedies, which from the character thus acquired have been empirically resorted to in states of con- stitution for which they were utterly unsuited. In acute rheumatism, a disease intensely inflam- matory, we have known the use of the most pow- erful stimulants confidently urged by well-meaning but misguided friends, who in support of their prescription have pleaded the wonderful cures which they had seen their favourite specific per- form in what they assumed to have been rheuma- tism ; thus misled by a name to recommend in active inflammation what could have benefited only in a totally opposite state of the system. As many affections really rheumatic present an equi- vocal character which to superficial observation too often appears to justify the use of stimulants, it is very necessary to discriminate the real dis- ease, so as to distinguish it from those diseases with which it is liable to be confounded; and however difficult it may be to class the latter, it is better to leave their place in nosology unassigned, than, by ranging them under the head of rheuma- tism, to beget confusion where clearness and pre- cision are of the first importance. In the investigation of rheumatism, the best mode, similar to what was followed in treating of gout, is to consider, first, the simple disease in its most perfect form ; and then, with the lights thus supplied, to elucidate the more complex conditions which the larger portion of rheumatic affections present. So contradictory, and, we may add, so ineffectual are the means ordinarily used in treat- ing the latter, that no greater benefit could be con- ferred both on patients and practitioners, than to divest the treatment of perplexing confusion and inconsistency by reducing it to fixed principles, and bringing it wilhin the pale of rational and scientific practice. In determining the diseased condition to which the name of rheumatism should be specially as- signed, it is expedient to examine the representa- tions given of it by the systematic nosologists. Sauvages describes rheumatism as «< dolor diutur- nus in parte carnosa artuum," and places it in the class Dolores, order Vagi, of his nosology. Ac- cording to Linnaeus, it is " musculorum dolor ad motum, a tunica cellulosa injecta;" class Dolores, order Extrinseci." Vogel places it in class Dolores, as merely « cutis et musculorum dolor." It would be difficult to recognise in these brief and meagre specifications the ordinary disease of rheumatism, such as we daily witness it. Sagar is both more copious and more precise. He describes two diseases, a chronic one ranged in the class Dolores, order Vagi,- and an acute under the specific name of myositis, in the class Phlegmasise, order Phlegmasia: musculosae, giv- ing respectively the following definitions. « Rheu- matismus. Dolor Diuturnus in parte carnosa 24 RHEUMATISM, tendinosa artuum, vagabundus, saepius sine coryza, rheumate, catarrho, erysipelete, et sine febre nota- bili; (acutus rheumatismus facit genus inter Phleg- masias, myositin a me dictum;) sanguis missus rheumatismo laborantium, est gelatinosa crusta tectus, et urina ssepe ad sulphureum colorem ten- dit." " Myositis. Febris acuta inflammatoria, dolores in diversis musculis artuum, eorundemque involucris, diu noctuque discruciantes, motum ve- tantes fere omnem, ad noctem exacerbantes ; san- guis missus est tectus crusta inflammatoria subge- latinosa, vel pelli tenui tenaci: hie morbus vulgo audit rheumatismus acutus." It is worthy of re- mark that Sagar notices the blood drawn in chro- nic rheumatism as exhibiting a buffy crust. Cullen considers acute rheumatism alone as a special dis- ease, regarding the chronic form as only a sequel of it. He places it in the class Pyrexia;, order Phlegmasia:, and gives the following definitions. " Rheumatismus. Morbus ab externa et plerum- que et evidente causa ; pyrexia ; dolor circa arti- culos musculorum tractum sequens, genua et reli- quos majores, potius quam pedum vel manuum articulos infestans, calore externo euctus." " Rheu- matismi sequela est, Arthrodynia. Post rheuma- tismum, nisum violentem vel subluxationem, do- lores artuum vel musculorum, sub motu praesertim aucti, plus minusve fugaces, calore lecti vel alio externo levati; artus debiles rigidi, facile et sa?pe sponte frigescentes; pyrexia nulla; tumor ple- rumque nullus. Rheumatismus chronicus aucto- rum." I.— Acute Rheumatism. This disease is often designated by the trivial name of rheumatic fever, a term which implies a constitutional disturbance as well as a local. The ordinary phenomena which characterize it are so familiarly known, that a very brief account of its accession and progress will here suffice. That given by Sydenham, derived as it was from actual observation, and marked by his wonted truth and accuracy, presents in few words as clear a descrip- tion of the early seizure as can well be rendered. " This disease happens at any time, but espe- cially in autumn, and chiefly affects such as are in the prime of life. It is generally occasioned by exposing the body to the cold air immediately after having heated it by violent exercise, or some other way. It begins with chilliness and shiver- ing, which, are soon succeeded by heat, restless- ness, thirst, and the other concomitants of fever. In a day or two, and sometimes sooner, there arises an acute pain in some one or other of the limbs, especially in the wrists, shoulders, knees ; which shifting between whiles, affects these parts alternately, leaving a redness and swelling in the part last affected. In the beginning of the illness the fever and the above-mentioned symptoms do sometimes come together, but the fever goes off gradually, while the pain continues, and some- times increases." The latter circumstance Sydenham, in con- formity with the pathology then prevalent, attri- butes to the " derivation of the febrile matter to the limbs," which he conceives to be sufficiently shown "by the frequent return of fever from the repulsion of morbific matter by external remedies." The thenrv here propounded may be questionable as resting on hypothesis, but the facts with which it is connected are not the less valuable. It appears, then, that acute rheumatism pre- sents a state of active fever accompanied with local inflammation of one or more joints. And here one of the most important questions respecting rheumatism arises—whether the local inflamma- tion be the cause of the fever, or only its attend- ant ? On the solution of this, much both of the pathology and treatment of rheumatism must de- pend, and accordingly its elucidation will form a prominent part of the present article. In the foregoing description of Sydenham, it appears that the state of febrile excitement pre- cedes the local inflammation. In theoretic specu- lations this fact seems generally recognised, yet it does not appear to have been kept steadily in view either by speculative or practical writers. The term symptomatic fever, so often applied to the constitutional disturbance, implies that this was regarded rather as a contingent result of the local inflammation, than as a precursor or cause of it. To determine this point is of much importance, for by the decision must the whole course of treat- ment be influenced. If the local inflammation, whether seated in the muscular, though more fre- quently in the fibrous tissue of the affected parts, be the cause of fever, as implied by the term symptomatic, the reduction of local inflammation by the most direct means would be the best and most effectual relief; and this being duly attended to, the contingent fever might, according to the familiar axiom, sublata causa tolliiur effectus, be little regarded. On the contrary, if the state of fever, or rather that condition of the habit which gives rise to fever, be the real source of rheumatic seizure, then should the constitutional state be chiefly attended to, and local treatment be only subsidiary to that by which the derangements of the constitution are rectified. Wc hope clearly to show that the constitutional state is that which chiefly claims our regard in the treatment of rheu- matism. When acute rheumatism occurs in its most active state, so intense is the inflammatory fever attendant, that whatever theory of the disease be entertained, the fever claims its full portion of at- tention, and is met by adequate activity of treat- ment. Bleeding, purging, and other means of reducing fever are promptly and freely employed, the more so as experience has shown this treat- ment to be indispensable for abating the local in- flammation. This being the case, then, it may be asked, of what importance is it to decide whether the local or constitutional affection is to be re- garded as the primary disturbance, inasmuch as the same treatment relieves both ? It would be sufficient to answer that truth ought always to be ascertained, for it can never be unimportant. Were acute rheumatism in its more active state to be alone considered, the importance of the decision might be less, both the local and constitutional disturbance demanding the vigorous employment of corresponding means. But when the minor degrees of the same disease, constituting what is | termed chronic rheumatism, come to be investi- I gated, it will be seen that their essential character involves the point at issue; and that unless this , be determined as truth and reason dictate the RHEUMATISM. 25 practice in a malady which is more prevalent, causes more suffering, and leads to more decrepi- tude than almost any other; must be vacillating, imperfect, and unsuccessful. It will materially abridge the present article to refer to certain general principles of pathology al- ready detailed in the articles Gout and Pletho- ra. These principles apply directly to rheuma- tism, and through them alone can its pathology be adequately unfolded, or its treatment rationally explained. Acute rheumatism principally attacks the young and vigorous. The period of life most subject is said to be from puberty to thirty-five years. Though no age is exempt, it yet more rarely oc- curs in the very young, or in advanced life. This circumstance alone would seem to indicate some connection between rheumatism and fulness of habit, or that approximation to plethora which was formerly noticed as exuberance of health; and if rheumatic seizures be duly scrutinized, they will be found to take place in those who from plethora, whether absolute or relative, are prone to fever or inflammation on any exciting cause being applied. The extraordinary health so often remarked by patients as having immediately preceded the rheu- matic attack is sufficiently intelligible. But direct evidence of the state of constitution in which at- tacks of rheumatism occur is amply shown in those who, having had the disease, are liable to its recurrence, and on this account compelled to watch the premonitory indications of an attack. In these, constitutional disturbance of a febrile kind, marked by all the phenomena formerly de- tailed as denoting the transition of plethora into febrile excitement, will be invariably found to exist for a sensible time before the disease presents its full character by the establishment of a local inflammation. And to these premonitory indica- tions should the earliest attention be given, for it is in this stage that relief can be most speedily and effectually afforded. By reducing plethora and subduing febrile action in this stage, the local inflammation may be wholly averted, and thus may be prevented not only the injury which the joints, when affected, are liable to sustain, but also the susceptibility to impression from slight causes which reiterated attacks of rheumatic in- flammation never fail to leave. The local inflammation of acute rheumatism undergoes a change during its progress which seems to have escaped observation. It exhibits at different stages two conditions, which may be conveniently distinguished as primary and second- ary. The former is the immediate result of the rheumatic seizure, and must be attributed to the specific cause, whatever it may be, from which the disease derives its distinctive character. It differs from common inflammation in being more tran- sient, for it is capable of rapid subsidence without any trace of its attack remaining. When this inflammation migrates from joint to joint, the oc- currence of a fresh inflammation is oftentimes followed by a quick subsidence of that which im- mediately preceded. Still more signally does this rapid subsidence take place if active treatment for the relief of the constitutional inflammation be resorted to immediately on the attack occurring, Vol. IV. —4 c and before the secondary inflammation has had time to supervene. In this respect the primary or specific inflammation of rheumatism has a close analogy with that of gout, from which it differs, however, in having a stronger tendency to pass into inflammation of a more ordinary and perma- nent kind. This specific inflammation is promptly relievable by constitutional treatment, no local ap- plications being at all needed. When from the severity of the attacks, or from neglect or delay in having recourse to suitable discipline, the specific inflammation lingers in a joint, a secondary inflammation results, more per- manent in its nature, which does not immediately subside on the constitutional inflammation being subdued, and which generally leaves some traces of its existence, in effusion into the cellular mem- brane or bursa? mucosae, or in more or less thick- ening and rigidity of the ligaments and other membranes surrounding the joints. The distinc- tion here noticed is important, because it has a sensible influence on the local treatment of rheu- matism, both acute and chronic. Causes of acute Rheumatism.—The chief, if not the only exciting cause, is the application of cold to the body when unusually heated. Cold is more liable to produce this effect when com- bined with moisture, whence a cold and humid atmosphere, and wet or damp clothes, are the most frequent sources to which rheumatism can be traced. Partial cold, as when parts of the body are subjected to currents of cold air, is very apt to give rise to rheumatism. When the body is pre- disposed, a very transitory exposure of this kind will suffice to bring on an attack ; if the current be sustained for any time, few will wholly escape some contingent suffering. Of the fact that rheu- matism is so excited there can be no doubt. When it is reflected, however, that for every instance of rheumatism so induced, numbers continually en- dure a much or greater exposure to the alleged cause without any disease ensuing, too much im- portance should not be attached to it. [Other causes have been enumerated, 6uch as the repercussion of eruptions, the stoppage of an accustomed flux, &c. These may exert an influ- ence, if a predisposition exist; but such influence is not easily appreciable. Recently, it has been affirmed by Messrs. Maddock and Sigmond, that where there is a disposition to acute rheumatism, the use of copaiba may develop it.] Of far greater moment is it to regard the predis- position, without the concurrence of which either no rheumatism will take place, or it will be slight and partial, exhibiting none of the constitutional disturbance and febrile excitement which charac- terize acute rheumatism. A predisposition is said to be given by many circumstances, as age, tem- perament, climate, season of the year. Even he- reditary liability has been classed among the pre- disposing causes, and possibly with reason, [and it is affirmed by Dr. R. B. Todd, (Practical Remarks on Gout, Rheumatic Fever, &c. Lond. 1843,) that the children of gouty parents are more liable to the disease than those who have not laboured under the gouty diathesis.] Each of these merits attention, but the circumstance common to all of them, and that which has most influence in pro- 2G RHEUMATISM. ducing the disease, is a state of general constitu- tion, which from the prevalence of plethora, either absolute or relative, is prone to be aroused by any excitement into febrile or inflammatory action. This subject having been fully discussed in its proper place, (sec Plethora,) it will suffice on the present occasion to apply to the consideration of rheumatism the doctrines already explained. It furnishes a presumption, at least, of these doc- trines having some foundation in truth, that cor- responding principles have been advocated by one of the most enlightened pathologists of the present day. M. Andral, in various parts of his luminous Treatise on Pathological Anatomy, traces a variety of structural lesions, as well as the inflammatory actions which induce them, to a redundancy of nutritive matter in the blood, supporting his views with a copiousness of illustration, matured expe- rience, clear discernment, and sound judgment, which claim the respect and confidence of every intelligent mind. These views, too, are so reiter- ated throughout the work as to show that they were not a mere transient conception, but a deli- berate conviction deeply impressed. A few extracts will evince that in these asser- tions we do not misrepresent this acute and philo- sophic writer. In disoussing the effects of hyper- aemia, or excess of blood, on particular tissues, he says: — "The hyperaemia, instead of being con- fined to a simple organ, may exist at the same time in every organ of the body. The general capillary system is thus overloaded with blood, and the whole system is said to be in a state of plethora or polysemia. I shall not enter into a de- tail of the circumstances which characterize this state, the essential character of which seems to consist in the formation of a greater quantity of blood than is necessary for the purposes of nutri- tion and secretion. There are some individuals who, according to common observation, naturally make a greater quantity of blood than others. In general, those persons who live high, and make but little exertion, mental or corporeal, are most liable to this affection. It has been said, but with- out the slightest proof being adduced in support of the assertion, that an appearance of plethora has been produced in some individuals by an in- ordinate expansibility of the blood. When the blood-vessels contain a greater proportion of the nutritive fluid than is necessary to supply the de- mands of the different organs, the superabundant quantity becomes a permanent source of excitation to the solids, and at the same time the blood has a remarkable tendency to accumulate in different organs; so that, in such case, the whole system is in a general state of excitation, and some of the organs may become the seats of local congestions of various degrees of duration and intensity. In- deed, the phenomena which result from the ple- thoric diathesis, cannot properly be termed morbid unless when some local congestion is formed. Sometimes the brain is the seat of the congestion, and then follow the various symptoms of the cere- bral disease, giddiness, headach, drowsiness, alter- ation of the sensorial and intellectual faculties, &c. which may be so violent as to induce death, and yet leave no trace of disease except a little more blood than usual in the cerebral vessels. Sometimes the congestion more particularly affects the pulmonary organs. The dyspnoea which ac- companies this form of the disease arises from an unusual quantity of blood transmitted through the lungs, which necessarily requires a corresponding quantity of air to fit it for the purposes of the general circulation. It is this want of proportion between the blood which requires to be aerated, and the quantity of air inspired for that purpose, which produces the dyspnoea. In other cases the complication of palpitation with various degrees of dyspnoea proves that the heart has become the seat of congestion." Corresponding effects are traced through other organs and tissues, and due notice is taken of the constitutional derangements resulting from polys- mia when no organ more especially suffers, as well as of the prostration of strength or false ady- namia, as it is expressively called, which so gene- rally attends this state. The section closes with remarks which are too apposite to our present purpose to be omitted, however reluctant we may be to indulge in lengthened quotations:—" The morbid state which I have now described, and to which may be referred some of the species of con- tinued fever described by the older nosologists, may terminate in recovery or death. When the termina- tion is favourable, the symptoms gradually improve as the superabundant quantity of blood, the original source of all the accidents, is diminished by absti- nence and bloodletting. When death ensues^ the post-mortem examination generally exhibits traces of well-marked inflammation of one or more organs. This inflammation seems to have taken place subsequently to the commencement of the febrile paroxysm; at least the symptoms would lead us to this conclusion. But on other occasions no trace of inflammation can be discovered, and the only morbid appearance consists in a simple accumulation of blood in the capillaries of the dif- ferent organs, their textures remaining perfectly unaltered. These slight congestions affecting si- multaneously several organs, may, by the various morbid sympathies which they excite, produce as violent and formidable symptoms as the most seri- ous organic lesion of any individual organ. In such case, where are we to assign the origin of the disease ?—Wherever the blood is distributed, there derangement of function is found. In the blood, then, indisputably resides the first cause of the disease; the lesion of the solids is only a se- condary affection, but may, notwithstanding, be- come, during the progress of the disease, the pro- minent affection, and give rise to many and for- midable accidents. In noticing fevers, he particularises one class which he refers specially to excess of fibrine in the blood. " Lastly, the third class of fevers appears to be more particularly connected with alterations of the blood. On this head I can but refer to what I have already said, when treating of the diseases that may arise from that source. I shall content myself at present with repeating that the fever termed inflammatory seems to me often to arise from no other source than the blood being too rich in fibrine." Again, in considering the lesions of the blood, he refers the occurrence of inflammatory fever, not only to a general hyperemia or excess in quantity of the circulating fluid, but more particularly to an altered condition RHEUMATISM. 27 of its quality arising from redundancy of fibrine. "I haw already established the fact that, under the influence of a state of general hypereemia, every organ becomes excited ; that death may result from such excitation; and that a super- abundance of blood is found all over the body, but in no part is there any serious lesion, any alteration of texture. In such cases there exists that state of pyrexia, termed by nosologists in- flammatory fever. But if, instead of being simply in excess, the blood contains more fibrine than ordinary, its exciting power will be still greater, and what it did in the former case merely by its increased quantity, it will now do by its alteration of quality." In fine, he applies the doctrines thus propounded to the particular disease which is the subject of the present essay. " Now if we mark the symptoms and progress of acute rheumatism, we find that very often a well-marked febrile action with a strong reaction, but without any symptom whatever of local affection, precedes the pain. In a word, there is first an inflammatory fever, and then rheumatism. Next observe the extreme mobility of the rheumatic pains. They run along in a manner wherever the blood is dis- tributed ; the application of leeches often removes the pain from one part, but it soon shifts to an- other, and not unfrequently it quits the articu- lating tissues and fixes on different internal organs, producing, by the derangement of their functions, symptoms more or less severe. It often happens that bleeding from a large orifice puts an end to the disease, as if by diminishing the mass of blood it proportionally diminished the stimulus that promoted all these shifting irritations." The doctrines here advanced we believe to be founded in truth, and capable of furnishing much valuable guidance in the investigation and treat- ment of disease. In such copious extracts we may appear to have made too free with the pages of an author whose works are so generally known, but we could not resist the temptation of fortify- ing, by the authority of so distinguished a patho- logist, principles which we have long maintained, and which we have endeavoured already to illus- trate in the articles Gout and Plethora. They will suffice, we trust, to justify the assertion lately made, that whatever importance may attach to the exciting cause of acute rheumatism, the pre- disposition induced by a plethoric state of consti- tution is far more entitled to the practitioner's attention. [As stated, however, in the article Plethora, M. Andral has pointed out the marked difference between the condition of the blood in it and in in- flammation, and has shown that the increase of fibrin in it obeys the same laws as in the ordinary phlegmasia?. He analyzed the blood of forty-three bleedings: in one of which the fibrin marked four, —the healthy proportion being three in 1000 ; in six, it marked five; in fifteen, six; in thirteen, seven ; in three, eight; in three, nine; and in two, ten. When, however, the rheumatism was sub-acute, it oscillated between four and five; and when decidedly chronic, it did not exceed the healthy proportion. A recent writer, Dr. R. B. Todd, (op. cit.) regards both acute rheumatism and gout to be diseases of the blood, the pheno- mena of which are due to the presence of a mor- bid element in it, generated under the influence of particular causes, " by an abnormal chemical action of the blood itself." It does not often happen that opportunities oc- cur for examining the textures around the joints, whilst the rheumatic affection is active in them. As the disease rarely proves fatal, except by the supervention of inflammation in some of the fibrous or muscular tissues, seated internally, the mischief there is generally so predominant, that, for some time before death, the joints cease to be the source of suffering. Under these circum- stances, it is not surprising that pathologists should differ as to the precise seat of acute rheu- matism of the joints. It has been already re- marked, that it invades every muscular and fibrous tissue, and that alternately the serous membranes may be implicated. Such may be the case in the articulations,—the synovial, which is a serous mem- brane, becoming affected last. On dissection, no decisive appearances may be met with. At times, the veins around the joints have been found gorged with blood; the ligaments, periosteum, and syno- vial membrane being injected, and thickened, with small collections of matter in the surrounding cel- lular tissue, and accumulations of pus or serum in the cavity of the synovial membrane. (Ferrus, art. Rhumatisme, in Diet, de Med. 2de. edit, xxvii. 567, Paris, 1843.) It is clear, that the hyperaemia of acute rheuma- tism—active as it is—can scarcely occasion any great organic changes, inasmuch as, in the course of a few hours, it shifts its seat, and leaves behind no evidences of its previous existence. This mobility has, indeed, given rise to the opinion, amongst many, that the disease is essentially seated in the nervous system; that the sanguiferous system is affected secondarily, and that it is very probable the nervous filaments of the diseased parts are more considerably involved than any other tissue. Dr. Mackintosh, (Principles of Pathology, &c. 2d Amer. edit. ii. 461, Philad. 1837,) who sup- ports this view, remarks, however, that he has seen cases, which presented symptoms similar to those of rheumatism, in which, after death, the lymphatics of the limb were found inflamed, and filled with a puriform fluid. Some, again, have considered acute rheumatism to be nothing more than acute inflammation of the lining membrane of the arteries. The whole disease is certainly peculiar, and appears to be more neuropathic than ordinary inflammation. Its extremely changeable character sanctions this idea, and the remedies are not always those which we should think of pre- scribing in ordinary active phlegmasia.] Diagnosis of acute Rheumatism.—This may be briefly disposed of. The only disease with which it is liable to be confounded is gout, in treating of which the distinctive character of each malady has been sufficiently noticed. For- merly discrimination in this respect was deemed of high importance, the prevailing theories of gout demanding a course of treatment very dif- ferent from that to which rheumatism was sub- jected. In the present day a juster pathology of gout assimilates the treatment of both diseases sufficiently to render extreme accuracy of dis- crimination of very slight moment. Prognosis of acute Rheumatism. — The 28 RHEUMATISM. prognosis is so dependent on the promptitude with which suitable treatment is resorted to, that any remarks on the natural course or duration of the disease are of little worth. Generally speak- ing, there is little immediate danger to life, there being no inflammatory disease of equal intensity which so little deranges the vital functions. This, most probably, is owing to the disease expending its violence on the joints and other external parts, and being little prone to attack the viscera. The peculiar character of the inflammatory action too, and the little liability which it has to pass into suppuration, or undergo the other changes conse- quent to phlegmonous inflammation, may account for the safety with which even the metastasis of rheumatism to internal parts is borne. It is cer- tain that such metastasis is not attended with so much danger as the severity of the symptoms would seem to denote. In early life we were often appalled by the metastasis of rheumatism from the joints to the heart, an organ more pecu- liarly liable to this transition than any other. More extended experience abated such fears, by showing that the immediate danger was by no means commensurate with the suffering expe- rienced. [Still, the pericarditis and endocarditis of acute rheumatism must be regarded as most dan- gerous complications—if they may be so termed —of the disease ; for even if the patient recovers, which is often the case, from the immediate attack, cardiac lesions are apt to remain, which may lay the foundation for disease afterwards. M. Bouillaud (Traite Clinique du Rhumatisme articulaire, Paris, 1840,) has affirmed, that about one half of those who suffer under acute articu- lar rheumatism are affected with pericarditis; and we know that endocarditis is a common accom- paniment. One of the most important points, therefore, in the management of acute rheuma- tism is to watch the supervention of the morbid action in the fibro-serous tissues of the heart. It is not necessary to repeat here the symptoms of pericarditis and endocarditis (See Pericardi- tis) ; but the occurrence of dyspnoea, witfi more or less anxiety, jerking, or feeble and rapid pulse, and tumultuous action of the heart, ought to direct the attention of the practitioner to that viscus, and if he discover, by the physical signs and functional phenomena, the existence of in- flammatory action there, it must be treated as if the disease were unconnected with rheumatism; for nothing is better established, according to M. Andral, (Cours de Pathologic Interne,) than that, although primary rheumatism, seated in the fibrous and muscular tissues around the joints, is remarkable for its great and rapid change of seat; secondary rheumatism—if it may be so termed— loses this mobility when it fixes upon a serous membrane. Dr. Graves (Clinical Lectures, Amer. edit. Philad. 1842,) states, that rheumatic fever may exist without the affection of the joints; and that pericarditis may occur as a primary symptom before the appearance of the articular swelling. This is probable. The writer has certainly seen many cases in which the signs of pericarditis were amongst the earliest phenomena.] If an attack of rheumatism be treated at the onset with due activity and discrimination, it may be relieved in a very few days without the affected joints sustaining any injury. But both with respect to time and local ravages, much will depend on suitable discipline being resorted to and adequately pursued, ere the specific inflam- mation of the joints becomes complicated with that which we have termed secondary. The specific inflammation we have repeatedly seen subside in twenty-four hours, leaving behind but little trace of its accession. When secondary inflammation, however, has been suffered to su- pervene, the case is materially altered, and greater obstinacy of local affection may 6e expected. It might be laid down almost as an axiom, that tho severity and duration of the disease are propor- tionate to the degree of plethora present, the ac- tivity of inflammation, and the length of time during which the morbid actions are suffered to prevail unrestrained. If the plethora be great, inflammation high, and much delay take place in resorting to efficient means for correcting the con- stitutional derangements, then would it be diffi- cult to assign limits either to the constitutional disturbance or local ravages, both of which may continue, though with abated force, for months or years, to undermine health and cripple the limbs; in other words, acute rheumatism may then pass into chronic of the most inveterate and intractable kind. Thus, though acute rheuma- tism rarely destroys life by its immediate seizure, however violent, this furnishes no excuse for su- pineness or inactivity in the treatment; for if not radically relieved in its early stage, the disease, even when of no extraordinary violence, may be- come so confirmed as to yield afterwards with difficulty to the most active and judicious use of remedies, while progressive disorganization of joints may entail protracted suffering and lasting decrepitude. It is true that a slight rheumatic seizure may, like a gouty paroxysm, pass away without medical interference, the efforts of the constitution sufficing for relief. But this is not its general character; and to rely on such a contingency would be in the highest degree rash and inexcusable. When- ever an attack of acute rhematism occurs, the constitution must need some relief, which enlight- ened practice will never withhold. To neglect of this principle may be ascribed a very large pro- portion of the decrepitude which the victims of rheumatism so continually present. There is no truth of which we are more thoroughly persuaded, than that if rheumatism were at its onset treated as its real nature demands, and if due care were afterwards taken to guard against its recurrence by prophylactic measures judiciously directed and adequately pursued, there need not from this malady be one case of disorganized and crippled joints for every hundred that are so afflicted. The effects of the earlier treatment will, therefore, in general, decide the prognosis. There is inflamma- tory fever to subdue, local inflammation to remove. If early bloodletting in subduing the fever make prompt impression on the local affection, so that both pain and swelling quickly subside, thus marking the local inflammation as still retaining its specific character unmixed with secondary effects, speed" and effectual relief may be coil- RHEUMATISM. 29 fidently predicted, medical treatment judiciously conducted being fully capable of ensuring it. When febrile action is inveterate, and it is often- times very obstinate, though chiefly so when the earlier periods of disease have been neglected or inadequately treated, a tedious progress may be expected, for so long as fever remains unsubdued are the local inflammations incapable of removal, either keeping their ground unmitigated, or if abated by topical remedies, continually recurring. Again, when abatement of fever is not followed by quick subsidence of local swellings, in conse- quence of the latter having passed into the secon- dary stage, and especially when effusion and organic changes have already taken place in the affected joints, then is the restoration of the joints much more tedious, though great local derange- ments will admit both of speedy and decisive relief, provided the local mischief be not rendered inveterate, or continually renewed by unsubdued fever. Much, too, depends on the state of constitution in which acute rheumatism occurs. In a healthy subject, capable of bearing the depletory and other treatment required for relief, great reliance may be placed on the efficacy and certainty of the curative process. When the constitution is depraved by long-continued relative plethora, with its attendant febrile excitement, and especially if the feebleness, natural or acquired, be such as to render caution necessary in carrying bloodletting and other reme- dial processes to the requisite extent, more pro- tracted disease and more tedious recovery must be the natural and inevitable consequence. It is said that rheumatic inflammation does not tend to suppuration or gangrene, and the remark is generally true. Yet we have seen abscess of the cellular membrane supervene on rheumatic inflammation, and we have also witnessed slough- ing ensue when leeches have been applied to a highly inflamed joint without adequate constitu- tional treatment being conjoined. The most frequent consequences are, gelatinous effusion into the burs®, thickening and rigidity of the liga- ments and other membranes surrounding the joints, contractions of the limbs, and wasting of the muscles, all of which will come under considera- tion in the latter part of this essay, where it treats of chronic rheumatism. Treatment of acute Rheumatism.—The indications are here to subdue fever and remove inflammation. It has been already shown that the former claims the first consideration. The promptitude with which the local inflammation in its earliest stage yields to the treatment by which a plethoric state of constitution is corrected, and febrile action allayed,—and the obstinacy of the local ailments, whenever the constitutional state is overlooked or inadequately treated, furnish the best proofs of the correctness of this pathology. In its simplest form and early stage, acute rheuma- tism is speedily and effectually relieved by anti- phlogistic treatment, properly directed and ade- quately pursued. Bleeding, purging, salines with antimony, diluents, and abstinence, suffice both for subduing the general fever and removing the local inflammation. It continually happens, however, that these means, however actively or perseveringly employed, will not succeed in re- establishing health ; a lurking fever remaining unsubdued, the blood retaining its buffy crust even when the crassamentum is reduced far below its natural and healthful proportions, and the local inflammation maintaining its hold of the affected joints. Further means are then required, which will be noticed in their proper place. The treatment of the simple and more manageable form must be first discussed. One of the earliest practical writers on this complaint was Sydenham ; and so direct and ju- dicious was his practice, that we cannot do better than to make it the text on which to comment in treating this part of the subject. Sydenham's theories of disease often involved the pathological fantasies prevalent in his day ; but it is his signal merit that he never suffered them to mislead him from the path which his clear discernment and practical experience enjoined him to follow. He attributed the local affection to "the derivation of the febrile matter to the limbs," which, as he observes, «the frequent return of the fever from the repulsion of the morbific matter by external remedies sufficiently shows." But we cannot perceive that he was influenced by this hypotheti- cal principle, further than to adduce it in explana- tion of facts which his experience had taught him. He had witnessed the inefficacy of local treat- ment, and also the increase of constitutional dis- turbance which resulted when this alone was trusted to, and he wisely abstained from repellent applications. Having described the disease with some of its modifications, he gives the following concise instructions for its cure. " Since both kinds of this disease seem to arise from inflamma- tion, as appears from the concomitants just men- tioned, and especially by the colour of the blood taken away, which exactly resembles that of per- sons in pleurisy, which is universally allowed to be an inflammatory disease, so I judge that the cure ought to be attempted only by bleeding, the heat of the blood being in the mean time abated by cooling and thickening remedies along with a proper regimen. Accordingly, as soon as I am called I order ten ounces of blood to be immedi- ately taken away from the arm of the side affected, and prescribe a cooling and incrassating julep. To ease the pain I order a cataplasm prepared of the crumb of white bread and milk tinged with saffron, or a cabbage-leaf to be applied to the part affected, and frequently renewed. With respect to diet I enjoin a total abstinence from flesh, and even from the thinnest flesh broths, substituting in the place barley-broth, water-gruel, panada, and the like. I allow only small-beer for drink, or, what is more proper, a ptisan prepared of pearl- barley, liquorice, sorrel-roots, &c. boiled in a suf- ficient quantity of water, and I allow the patient to sit up some hours every day, because the heat which arises from lying always in bed promotes and increases the disease. The next day I repeat the bleeding to the same quantity, and in a day or two after, as the strength will allow, I bleed again. Then interposing three or four days, as the strength, age, constitution of the patient, and other circumstances indicate, I bleed a fourth time, which is generally the last, unless too hot a regimen has preceded, or heating remedies have been exhibited without necessity. But the use 30 RHEUMATISM. of opiates requires more copious bleeding; and, therefore, though the pain be ever so violent during the whole course of the disease, yet when I intend to effect the cure solely by bleeding, I judge it highly necessary to refrain from opiates, because the disease is fixed thereby, and does not yield so readily to bleeding; so when such medi- cines are given too frequently, bleeding must in consequence be- oftener repeated than is otherwise necessary. Besides, in the height of the disease, they do not answer the expectations we have con- ceived of them. Whilst the above-mentioned remedies and regimen are carefully continued, I inject glysters made of milk and sugar, between times on the intermediate days of bleeding, earnestly recommending the exact observance of these directions for at least eight days after the last bleeding; and then I prescribe a gentle purging potion to be taken in the morning, and in the evening a large dose of the syrup of white poppies in cowslip flower-water, whereby a check is put to the tumultuary motion of the blood which might otherwise occasion a relapse. This being done, I allow the patient to return by de- grees to his customary way of living in relation to diet, exercise, and air; but, at the same time, caution him to refrain for a considerable time from wine and all spirituous liquors, salt or high- seasoned flesh, and, in general, from all food of difficult digestion. After having repeated bleed- ing as above specified, the pain greatly abates, though it does not go quite off; but as soon as the strength returns, which bleeding had greatly impaired, the symptoms will vanish, and the patient perfectly recover." In the simplicity, fitness, and activity of the foregoing course of treatment, there is much to admire. It comprises the more essential articles of antiphlogistic discipline, bleeding and absti- nence; it discourages the premature use of nar- cotics, which, when employed too early, or in substitution of depletory measures, only mask the symptoms even when they allay pain, while they too often exasperate the disease, rendering it both more violent and more obstinate. It also incul- cates a salutary reserve in the return to animal food and fermented liquors. That under this simple treatment many would pass safely through the disease, there can be no doubt, although re- covery would certainly be slower than it might be rendered. But cases continually occur in which this treatment would be utterly inadequate, the febrile action maintaining its ground, and the local inflammation migrating from joint to joint, notwithstanding the diligent employment of all the means which Sydenham's practice in the dis- ease comprises. In this practice one great defi- ciency is observable, the use of purgatives in aid of bloodletting not being at all enjoined. For regulation of the bowels, clysters of milk and sngar are trusted to, and not until eight days after the last bleeding is a gentle purging potion pre- scribed. In this and other respects, later expe- rience has added much to our means of combating acute rheumatism. When this disease occurs in its most active state, the means suited for reducing plethora, abating fever, and checking the progress of in- flammation, must be promptly and adequately employed; full bloodletting and active purging, with the united powers of colchicum and antimo- ny, being required to lower the circulation and arrest the evils which inflammatory action when unrestrained is sure to occasion. The first pro- cedure in respect both of time and importance is bloodletting. In many instances the use of this directed by Sydenham would suffice, but in many it would fail. As a rule of practice, therefore, Sydenham's directions in this respect are defective, as not embracing conditions of disease which are of frequent occurrence, and for which the deple- tion directed by him would prove utterly inade- quate. Indeed, no express rule in this respect could be laid down, boih the amount and fre- quency of venesection being in every instance dependent on the degree of plethora existing, the activity of fever and inflammation present, and the natural powers of the constitution to be acted on. The pathology of inflammation, and the use of bloodletting most effectual for subduing it, have been so amply discussed in the articles Gout and Plethora, that to recapitulate what has been already advanced on these points must be need- less. We shall proceed, therefore, on the pre- sumption of the principles inculcated in those articles being clearly comprehended, and in con- formity with these principles state practically how the lancet can be most successfully used. In or- dinary cases the loss of twelve, sixteen, or twenty ounces of blood may suffice to check disease and prepare the way for the subsidiary treatment. But if absolute plethora be considerable, inflam- matory action high, and the constitution robust, blood must be drawn to much greater extent if adequate impression is to be made on disease. In such case the rule should be not to abstract any assigned quantity, but to carry the bloodletting to the extent of making a sensible impression on the force of circulation. Thirty or forty ounces of blood may require to flow ere this is effected, and so essential is the impression alluded to, that even large bleedings, if not carried to this extent, will fail to produce their full effect in restraining in- flammatory action. It continually happens in cases of active inflammation, that notwithstanding the loss of thirty or forty ounces of blood, the pulse does not yield, but maintains its hardness, while the abstraction of a few ounces more, by inducing a disposition to syncope, completely checks the inflammatory action and abates the violence of the disease. By making the consti- tutional powers the measure of the depletion, less bleeding on the whole is needed; thus by this mode blood is virtually saved and unnecessary exhaustion prevented, a single venesection carried to the necessary extent being far more effectual than reiterated bleedings to a far greater aggregate amount, if these be respectively of insufficient extent. Bleeding to actual syncope is not desira- ble, but if inflammation be high, some impression on the pulse should be manifested. If this begin to falter, while nausea is felt, the lips grow pale, and perspiration begin to bedew the forehead, such bloodletting may be relied on for accomplishing all that this remedy is capable of effecting. This use of the lancet, however, can only be required where severity of symptoms with vigorous habit demands such active treatment. In a lar«»e pro- RHEUMATISM. 31 portion of cases much more moderate depletion will suffice. From twelve to twenty-four ounces of blood may be regarded as the ordinary limits, and many repetitions are never advisable; for when bloodletting to such extent, assisted by purging and other febrifuge treatment, does not make sensible impression on disease, other more adequate means of arresting its progress must be resorted to. Blood may be drained away until the body is blanched and the crassamentum reduced to a tithe of its just proportions, yet febrile action will continue, inflammation be unsubdued, and the blood drawn be still buffed and cupped. It is right to mention here, that although a full and hard pulse is generally attendant on acute rheumatism, yet the absence of hardness is no evidence of active inflammation not being present, or of bloodletting not being needed. If the gene- ral symptoms concur to indicate inflammatory action, then, though the pulse be soft and com- pressible, bloodletting is nevertheless essential, the blood drawn in such case being almost uniformly buffed and cupped, the pulse rising after venesec- tions, and disease more rapidly subsiding. [Of late years, the profession have been startled^ by the extent to which bloodletting has been re- commended by M. Bouillaud (Op. cit.) -, bleeding coup sur coup, with the view of " strangling" the disease, to use his own expression. The writer has had recourse to it in what appeared favourable cases; but the results have not been equally happy ; and it has seemed to him, that the too vigorous use of the lancet has occasionally rather favoured the shifting of seat, which has been so much dreaded. It can, of course, only be admis- sible in vigorous individuals, and even in them, a more sparing use of the lancet, with the agents to be mentioned presently, appears to be less liable to objection. There are cases in private practice, and most of those that are seen in our eleemosy- nary institutions, in which any abstraction of blood from the general system could not fail to prove injurious. As an adjunct to general bloodletting, the tar- trate of antimony and potassa has been highly extolled of late years, and there are cases in which its sedative influence has been highly advantageous. The writer has frequently prescribed it under the restrictions and inculcations mentioned under another head (See Pneumonia), and occasion- ally with the best effects. It has seemed to him, however, that the antimony has acted most bene- ficially when it produced nausea, and the nausea was kept up two or three days in succession.] The next measure is to purge freely the stomach and bowels; and here again we must refer to what was formerly advanced on this subject in illustration of the necessity of suitable and ade- quate purging being employed in aid of blood- letting. As soon as may be after bloodletting, a full dose of calomel combined with antimony (either James's powder or tartarized antimony) should be given, and in a few hours after a cathartic draught. The bowels being well evacu- ated, diaphoretic salines with antimony and col- chicum contribute much to allay fever, quieting the pulse, and promoting the several excretions. One of the best forms of saline for this purpose is a combination of acetate of ammonia, camphor mixture, antimonial wine, and wine of the col- chicum seeds, as in the following formula: R. Liquor, ammon. acet. Mist, camphorse, aa f.gss. Vin. sem. colch. Vin. ant. tart, aa. m. xx. Syrup, aurant. f.£i. m. fiat haustus quartis vel sextis horis sumendus. The properties of colchicum and the best modes of administering it have already been so fully dis- cussed in the article Gout, that to avoid needless repetition, we shall refer to what is there stated. It is only necessary to remark that the effect of colchicum on the bowels requires to be watched, for when it irritates them so as to excite active purging, its use must be discontinued. In our early trials of colchicum in gout and rheumatism, we were accustomed to give it in full doses, but, for reasons already explained, we have for many years discontinued them, the salutary effect of the remedy being fully attainable from the more moderate exhibition of it which has just been prescribed. When the use of it irritates the bowels, producing frequent watery stools, discon- tinuing the colchicum suffices in general for the relief of this disturbance ; but should it continue troublesome, moderate doses of Dover's powder are sure to allay it. It has been surmised that the use of colchicum has through irritation of bowels led to ulceration of their mucous membrane, but ' this effect we altogether distrust. It must be a very rash use of the remedy which could produce any such effect, and where it has appeared to re- sult, our persuasion is, that the membrane was in an advanced stage of subacute inflammation ere the colchicum was exhibited. We have given colchicum freely and extensively for many years, with caution certainly, though not greater than is required in the administration of every active drug, yet a single instance has never occurred to us in which we could trace any injury to its use, while its medicinal properties have rendered val- uable aid, not only in gout and rheumatism, but in many other inflammatory diseases. [Aconitia, delphinia, and veratria, have been used both internally and externally ; and cimici- fuga carried to the extent of producing catharsis, and even slight narcosis, has likewise been of service. Of the different revellents, cupping on the back, strongly recommended by Dr. J. K. Mitchell, has appeared to be most frequently attended with happy results. An idea has been entertained that this has been owing to the depletion and revulsion effected near the origin of the nerves that are con- cerned in the articular inflammation. Whatsoever view may be entertained as to this matter, it is unquestionable that the highly sensitive integu- ment of the back is an excellent locality for revul- sion in many diseases; and it is not necessary that the mischief should be directly or indirectly connected with the spinal marrow, or its sheath, to explain this. The writer has seen the intense suffering in the joints as effectively relieved by cupping over the loins as by any other agency.] As the extent and repetition of bloodletting must depend on the activity of disease and vigoui of constitution, so must the use of purgatives ba regulated by the condition of the bowels, and the necessity for purging which the stools may evince. 32 RHEUMATISM. So long as these are dark, slimy, fetid, and other- wise unhealthy, must purgatives be used; and the most effectual are those by which the morbid se- cretions of the alimentary canal are evacuated. Pills of colocynth, calomel, and tartarized antimony should be given at intervals, and, if necessary, cathartic draughts should be interposed. When fever declines, and the stools present a more healthy appearance, milder aperients will suffice. Under such treatment low diet and a cooling regimen are indispensable. Barley-water or toast-water is quite sufficient during the inflammatory stage. Animal food and fermented liquors of every kind are prejudicial, and should be carefully withheld. The several means now pointed out will in many instances suffice to allay fevers, remove in- flammation, and restore health. But cases occur in which neither fever nor inflammation can be thus subdued. If active treatment be not resorted to on the first accession of disease, or if it be not urged to the requisite extent, inflammatory action acquires an inveteracy which simple antiphlogistic treatment is quite unable to correct. In such cir- cumstances bloodletting may be pursued until the patient become nearly exanguious, yet the blood, will still be buffed and cupped, febrile action will remain unsubdued, and local inflammation con- tinue to disorganize and cripple the joints. Even in milder cases of this kind, although per- manent injury may be averted, and perfect reco- very ultimately ensue, yet the successive migra-. tions of local inflammations prove harassing to both patient and practitioner. We have seen such inflammation traverse almost every joint of the body, attacking several a second and a third time before the disease yielded. When the pro- gress is favourable, each successive inflammation becomes slighter, until towards the close a mere blush of redness marks the morbid effort. But this course of proceeding is at best tedious and unsatisfactory, even where an issue so favour- able as has just been mentioned is attained. Such result, however, is not to be relied on ; for in the form of disease now considered, it will more fre- quently happen that unsubdued fever will exhaust the general powers, and inflammation inflict its ravages on the joints, producing effusion, thicken- ing of ligaments, with enlargement, rigidity, or contraction. When, therefore, one or two full bloodlettings, assisted by purging, abstinence, and other means, fail to make adequate impression on the disease, it becomes necessary to call in other aids in order to prevent the exhaustion and other ills which repeated bloodletting would occasion. And fortunately one exists which is worthy of our fullest confidence. This is mercury, which, when judiciously administered and made subsidiary to bleeding and purging, is capable of subduing rheumatic inflammation with as much certainty as attaches to the operation of any remedy in any disease. The practice of arresting the progress of rheumatism by mercury has been before the public sufficiently to have made it more generally known and more justly appreciated than it appears to have been. It originated with Dr. Robert Ha- milton of Lynn Regis, who published, in the Me- dical Commentaries of the year 1783, an interest- ing account of the success with which he had administered calomel and opium in the treatment of several inflammatory diseases. So far back as the year 1764 he had been induced to employ calomel for the cure of hepatitis. Its efficacy in the disease and in several other inflammatory affec- tions led him to extend his views of its applica- bility, and to conceive that it was a suitable remedy for inflammation in whatever viscus or tis- sue this might be situated. He accordingly em- ployed its aid with the best effects in inflamma- tions of every part, and particularly in acute rheu- matism. His practice in the latter was to take blood in proportion to the violence of the inflam- matory symptoms and to the age and constitution of the patient; after which he exhibited calomel and opium at suitable intervals until the disease yielded, or until the influence of the remedy on the constitution was evinced by increased secre- tions from the salivary glands, bowels, or skin. If in twenty-four hours after the use of mercury was commenced, relief did not ensue, or if inflamma- tory symptoms continued unabated, he bled again, and gave the calomel more frequently. Salines, antimony, camphor, and other auxiliaries were combined with bleeding and mercury, and through their united agency he found disease subside with a promptitude which no other mode of treatment could command. When this treatment was em- ployed early in the disease, recovery was soon ac- complished ; if postponed to a later period, its effects were more tedious and uncertain. His ex- perience also taught him that the curative process was most favourable when the salivary glands be- came affected by the medicine. This brief account of Dr. Hamilton's rational and effective practice in rheumatism embraces so many essential points of the treatment of this disease, that we shall have little to add save the detailed instructions which the young practitioner may need for conducting that treatment with discrimination and effect. In confirmation of the truth and accuracy of Dr. Hamilton's views, we may here remark, that hav- ing for five-and-twenty years pursued the practice and applied the principles which he inculcates, our faith in them has never wavered, and that with ample opportunities for subjecting them to the test of experience, we can truly say that we know of no fact in medicine better established than the power which mercury possesses of subduing inflammations, when used as subsidiary to bleeding and purging. Every case of acute rheumatism does not re- quire mercury for its cure. Bleeding, purging, abstinence, and salines, with antimony and colchi- cum, will frequently suffice. But if, after twenty- four hours, the early discipline has not produced sensible effect on the disease ; if after this period fever continues unabated, inflammation unallayed, and further bloodletting be required ; as obstinacy of disease is here sufficiently announced, it is ex- pedient to lose no more time, but to resort to the only means by which an adequate check can be given to the malady. Profuse use of mercury is not needed; both the amount of dose and frequency of exhibition must be determined by the circumstances of the particu- lar case. Although it is desirable to obtain evi- dence of the constitution being affected by the remedy, bo fer as tenderness of gums indicates, it is not expedient to produce this effect very speedily, RHEUMATISM. 33 and there are many reasons for enjoining caution in the administration of this medicine. It is not necessary to urge on its full operation, for the curative effect commences ere the specific action on the salivary glands appears. Unless the ple- thoric state of constitution, too, be adequately re- lieved by depletion, there is considerable risk of pressing the use of mercury. On this subject we must once more refer to what has been already advanced respecting it in the article Plethora. The susceptibility of impression from mercury, too, varies greatly in different persons, so much so, that while some cannot be salivated by any quantity, a few grains of calomel will in others induce severe ptyalism, with inordinate swelling of the jaws and extensive sloughing. On every account, then, it is advisable to incline to the mi- nimum quantity capable of acting on the disease. The expediency of combining opium with calo- mel, when exhibited for this purpose, admits not of question. When thus conjoined, it allays pain, abates irritability, prevents the calomel passing off too quickly by the bowels, and promotes its more certain absorption. In general, two grains of calo- mel and a quarter of a grain of opium is a suffi- cient dose, and the frequency of its exhibition will be best guided by the severity and threatened ob- stinacy of the attack to be combated. In severe cases it is beneficial to commence with five grains of calomel, one of opium, and one of tartarised antimony at bedtime, and to pursue the course the next day with the smaller dose. In mild cases it may suffice to give this night and morning; to administer it thrice a day is no inactive practice, and by this use the gums will in general soon become affected. Given every six hours, so ihat, in the four-and-twenty, four doses are taken, is perhaps the frequency that will most commonly be needed. We have never had occasion to en- large the dose, nor to exhibit it oftener than every four hours; but to this extent we have been occa- sionally compelled to employ it. The cases, how- ever, requiring the active use of it are rare. The circumstances to guide its use are the curative effects on the constitutional and local symptoms, and its specific effects on the salivary glands, bowels, and skin : if any of these be signally in- duced, the use of it should abate, and the intervals of its exhibition be lengthened. Unless active salivation take place suddenly, and unexpect- edly, it is never expedient to withdraw it wholly so long as fever lurks or inflammation keeps its ground. The best practice is to lengthen the in- terval, and to do this progressively by reducing the employment from four times a day to three, then to twice, and finally to continue a single dose daily for a short time. By this cautious proceeding, if bloodletting be adequately practised, the bowels freely purged, and no error in diet committed, the beneficial effects of mercury may be ensured with- out any risk of injury and scarcely of inconve- nience. Should salivation chance to advance beyond what would be wished, the evil is but a slight counterbalance to the benefit which mercury confers in the case of this most painful and disor- ganizing malady. When the mouth becomes pain- fully affected, we may here remark that saline purges abate the distress, and that gargles of chlo- ride of soda or of nitrate of silver have considera- Voi. IV. — 5 ble power in allaying the morbid sensibility of the gums and tongue which is sometimes experienced. There are constitutions on which mercury acts so unfavourably, producing great derangement of the nervous system, that its use cannot be borne. When such sinister effects occur, its use must of course be abandoned ; but such instances are not common, and when they do occur, we strongly suspect that neglect of early depletion is more in fault than any idiosyncrasy inimical to the remedy. While mercury is exhibited in the way directed, the salines formerly prescribed should be continued, and occasional purges should be interposed. The use of the latter should be regulated by the degree of fever and the state of the stools. If fever con- tinues high, with a dry tongue and costive bowels, or if the stools be very dark and slimy, purgatives must be the more freely used. When the bowels are unusually torpid, it is often expedient to sub- stitute for the diaphoretic saline a solution of sul- phate of magnesia in rose infusion, giving this at such intervals as shall keep the bowels free. It is generally conceived that purgatives impede the constitutional operation of mercury, and in conse- quence, when this operation is the object in view, purgatives are usually withheld. Without dis- cussing this point, we shall merely observe that if the degree of fever or the foulness of bowels de- mands purging.it should be carried to the full ex- tent required, without regard to its supposed inter- ference with the effects of mercury. Under such circumstances greater injury would result from the neglect of purging, than even the unimpeded action of mercury would compensate. There are cases in which it is not expedient to combine opium with the calomel, but they are rare. If headach prevail,—if the tongue, instead?! of becoming moist and clean, grow parched and dark, and the skin be hot and dry,—opium should be withheld, and the calomel given either alone or conjoined with James's powder. [Opium has not unfrequently been given in acute rheumatism, with the view of inducing nar- cosis, and of establishing a new impression and action on the nervous system. Care must, of course, be taken not to push the remedy too far, and yet to keep the patient clearly under its influ- ence. With this view, any of the preparations of opium may be prescribed ; but the soft pill is as efficacious as any other; or the acetate or the sul- phate of morphia or the pulvis ipecacuanhae com- positus ; but the last can be seldom given in quan- tity sufficient for the opium to produce its narco- tic action, without the ipecacuanha disordering the stomach.] The progress of recovery and the experience of a few cases thus treated will readily guide the practitioner in that adaptation of remedies to the exigencies of each case which no specific rules could prescribe. He who possesses himself of the principles on which the treatment here directed is founded, will commit no error in the extent or duration to which he may carry it. There is a period, however, in the progress of rheumatism, even when actively and judiciously treated, which calls for something more than has yet been enjoined. In a large proportion of cases, the treatment now prescribed will fully suffice. It will subdue fever, remove local inflammation, pre- 34 RHEUMATISM. vent disorganization of joints, and restore the pa- case has always yielded to the remedy ; and I have tient in moderate time to health and the free ex-; also recommended it in violent pains o ercise of limbs. But it occasionally happens that joints, accompanied by alarming complicai , notwithstanding the full employment of all the : but never in any one case injuriously to the nut means directed, a certain degree of fever lingers, ' of my patient. I have, therefore, no, dilluult>in Sllll It'll 111 Uie joints. »v ucu una o»'^ "'-"• •"*■- ~— ....•- — -......— -ri ,, . _._,,__r:l,-a view, so completely did the assemblage of symp- , matism in its earlier stages. Dr. Dav.s prescOes toms simulate active inflammation, that we hesi- the cinchona in the dose of from a scruple to half tated whether there was not an actual relapse of a drachm, repeated three or four times daily. He disease, and a necessity for reverting to active re- always, however, premises the free abstraction of medies. But the indecision was of short duration ; j blood. (See, also, Popham, Dublin J°u™al °J for assured by the treatment already pursued, and I Medical Science, Sept. 1844, p. 50.) M. Briquet, the effects produced by it, that inflammation had and others, have advised large doses of the sul- been successfully combated, we could not regard , phate of quinia—from £i to ^iss in the course the supervening state as corresponding in its na- of the 24 hours; and, they affirm, with unusual ture to that which we had already corrected, and j success. M. Briquet considers, from his obscrva- instead of recurring to bleeding and mercury, we , tion, that the sulphate is a powerful sedative, made trial of bark as a preferable agent, and with j diminishing nervous excitability, retarding the such benefit, that we have seen it remove, in ■ pulse, and lowering the temperature. It has been twenty-four hours, the whole train of symptoms objected by M. Devergie to this plan, that it is apt which we have just mentioned. Half a drachm [ to cause serious disturbance in the functions of of bark with ten grains of nitre is the combination j the brain and organs of sense ; but care in regu- on which we most rely, giving this twice or thrice I Iating the dose may prevent this.] a day; and so effectually does it answer the pur- | The cure of rheumatism by profuse perspira- pose that we are slow to change it. What we : tion has fallen so much into disuse that it can have now 6tated may serve to explain the confi- hardly be necessary to notice it. Yet it was held dence with which some writers have advocated the in high estimation not many years back, and very use of bark as almost a specific in rheumatism, generally deemed the most effectual mode of treat- There is undoubtedly a stage of the disease in ment. The late Dr. Gregory, in his lectures, used which it may be beneficially given, but in the to represent sweating as the evacuation most to acute stage, to which we have hitherto chiefly re- . be relied on for the cure of rheumatism, and to ferred, we at least would not compromise the bear his testimony to its efficacy. He gave a patient's safety by trusting to bark, while bleed- J caution, however, against resorting to it until the ing, purging, and mercury were applicable; and pyrexia had been abated by bloodletting, and even in what is called chronic rheumatism we stated that his test was, never to employ it until would as little rely on it so long as plethora was the pulse was reduced to 100. The chief agent unrelieved, the pulse high, the bowels loaded, and '■ was Dover's powder, given in doses of ten grains active fever predominant. When the general every two or three hours, assisted by warm cover- state of constitution is restored to the proper ba- ing and copious diluents, the latter to be used lance of its several functions, should some febrile > only when the perspiration commenced. To be indications linger, and pains continue to infest the effectual, this required to be kept up for forty-eight joints or muscles, bark furnishes then a valuable ; hours. This practice has, we believe, been very and unexceptionable means of correcting the slight ! generally, and, as we think, judiciously, laid aside, remnant of disease, but not before. j the treatment recommended in the foregoing pages [The writer has had frequent opportunities for j being far more certain and effectual, producing witnessing the exclusive use of both modes of j less exhaustion, and leaving less susceptibility to treatment, antiphlogistic and tonic, and it is but recurrence of disease. proper to say, that he does not recollect to have [Recently, iodide of potassium has been recom- seen the symptoms in any case aggravated, under ! mended both internally and externally, and the the prudent employment of either. In the mass ! treatment by large doses of nitrate of" potassa, so of cases that occur, except in very active, vigor- highly advised in the last century by Dr. Broc kles- ous habits,—and it is generally applicable even to by, has been revived, and, it is said with much them,—a combination of the two modes of treat- t success,—from a quarter of an ounce to an ounce inent has appeared as advantageous as any other, being given dissolved in a large quantity of gruel —treating the disease during the early period, by in the twenty-four hours.] the ordinary antiphlogistics, and afterwards en deavouring to remedy the neuropathic condition by the cautious employment of tonics, as the sul We have hitherto treated chiefly of constitu- tional disorder, and have considered the local in- flammation only so far as it was connected with phate of quinia. Dr. D. Davis, late Profes- j or dependent on the constitutional state. It is sor in the London University, has expressed a . necessary, however, to scrutinize the local afl'ec- confident belief, that cinchona " is the most pow- , tions still further. So directly is the local dis- erful remedy that can be employed even in an in- , turbance dependent on the constitutional in the cipient case of acute rheumatism, and affirms, that (incipient stage, that if the latter be rheumatism during its acutest stage, and the dis- jside in rheumatism equally as in a first attack of RHEUMATISM. 35 mild gout, leaving as little trace of its visitation. ft must be admitted, however, that such speedy decline is not the general character of this local affection. Notwithstanding the abatement of fever, a position and attitude should be given to the limb that would be most favourable to resolution. An elevated position would certainly tend to prevent the engorgement of the parts. The writer has seen some pain, heat, and swelling will continue to good effects from compression where it could be affect the joint for a longer or shorter time; and in borne, and a simple flannel bandage is all-sufficient.] order to understand the treatment which this | We would here impress, as we formerly did requires, it is necessary to bear in mind what was '■ when treating of gout, the importance of an early formerly stated respecting the change of character in the local inflammation. If on fever becoming subdued by the means directed, the local inflam- mation declines, no topical treatment whatever is needed, nor is it expedient that any should be resorted to. Decline of inflammation thus ob- tained affords conclusive evidence of disease being arrested at its source, and relapse need not here be apprehended; while, if the local inflammation be checked by topical remedies, its abatement af- fords no such assurance, and if the constitutional derangement be not thoroughly rectified, repeated renewal of motion in the affected joints, as indis- pensable for re-establishing their health and pre- serving their flexibility and power. From neglect of this, much protracted confinement and ultimate decrepitude continually result. On the subsidence of inflammation, the parts so lately disturbed are indisposed to motion, and some pain attends the early attempts at its removal. Yet leaving them at rest is not the means by which the power of motion is best restored. Exercise of the parts is necessary not only to restore those which have been morbidly affected to their healthy functions, renewal of the local inflammation with successive i but to preserve in due energy and activity the migrations from joint to joint will most probably muscular apparatus by which they are moved. ensue. But independently of this consideration By exercise healthy circulation is maintained, there are other objections to the early use of topi- ! effusion prevented, absorption promoted and flexi- cal remedies which ought not to be overlooked, j bility preserved. By it, too, the muscles sub- Repellent applications may remove inflammation j servient to the motions of the joint are kept in a from any particular part; but only to transfer it healthy and efficient condition. When, from too to some other, if not to the heart, stomach, or great apprehension of exciting pain or renewing other internal organ. Local bloodletting would inflammation, quiescence is too long continued, beget less danger of this kind, but neither is it the ligaments and other parts surrounding the free from objection. The inflamed part is ill joints become rigid; if these be kept bent, con- suited to sustain the operations by which blood tractions take place, and the mobility of the pait can be abstracted. We have seen leeches when applied to a rheumatic joint prematurely and without sufficient regard to the constitutional becomes permanently impaired; while the several muscles, from want of exercise essential to the maintenance of their nutritive and healthy actions, state, exasperate every symptom, and cause in- progressively waste and lose power. This lattrr crease of inflammation both in the skin and cellu- j contingency is, we are persuaded, much more fie- lar membrane, ending in extensive sloughing, quently owing to the continued inactivity to with troublesome ulceration, and followed by which the muscles are consigned than to any thickening of the ligaments with rigidity and con- ! morbid action induced in them by the disease; tractions of unusually obstinate kind. So long as and as we before observed, so satisfied are we of it is possible, therefore, to procure decline of local ! the mischiefs resulting from long-continued rest inflammation by the constitutional treatment, we after rheumatic inflammation, that we would jn consider it the better practice to abstain from to- ' our own person much rather hazard any renewal pical remedies. of inflammatory attack, than suffer those derange- When inflammation continues in the joint, ' ments to proceed which spring from a 6tate of however, after fever has been sufficiently subdued, inaction too long continued. thus manifesting its having passed into what we I [Capsular Rheumatism. — When rheuma- have distinguished as the secondary state, it then I tism is seated in the lining membrane of the becomes necessary to regard it as a local disease, J joints, and bursse of the tendons, it is termed cap- and by appropriate topical treatment to avert those '' sular. The parts most liable to its attacks are ravages which its continuance would occasion. ! the feet and hands. It is recognised by the en- The means are cupping, leeches, warm fomenta- j largement of the joints, which is circumscribed, tions, poultices, cold lotions, modified according ' owing to the distension of the synovial capsule to the degree of inflammation, the sensations of '< with fluid ; and is thus distinguishable from the the patient, and the effects produced. By such smaller and more diffused swelling of ordinary means, the local inflammation in this its secondary J rheumatic fever. In its history, too, it differs state may be so corrected as to prevent organic generally, as Dr. Macleod (On Rheumatism, &c, lesion, and preserve unimpaired the mobility of I London, 1842) has observed—affecting seve- the joint. | ral joints, but commonly becoming more especially [The application of methodical compression fixed in a limited number, and ultimately local- around the affected joints by means of a flannel ized, and, in some cases, inducing permanent bandage is often productive of great relief. It was changes of structure, or disorganization. When advised many years ago, and has been revived, death occurs in the acute stage, the joints are (Sec the writer's New Remedies, 4th edit. p. 183, found to contain an increased quantity of syno- Philad. 1843.) It is especially serviceable where via: when the disease has been more prolonged, there is great effusion. It has been recommended, ' distensions and nodosities are seen, similar to that the compression should be made by means of ! what occur in gout. Deposits are often formed in compresses covered with mercurial cerate ; and that such cases on the cartilages of the joint,—which 36 RHEUMATISM. Dr. Macleod found to be of urate of soda, as in gout. In casts of old synovial rheumatism, how- ever, Dr. Chambers found them to consist of car- bonate of lime. At times, suppuration has been observed in the joint; but these cases are rare. Partial rheumatism of the joints, when of great intensity, is almost always of the capsular kind. This form of rheumatism is said to occur gene- rally in persons of feeble or debilitated constitution; or in the robust, after great and protracted men- tal or corporeal exertion. It is said, also, to super- vene on gonorrhoea and other venereal affections, but in the latter case almost exclusively, accord- ing to Dr. Macleod," where long-continued courses of mercury have been adopted." It is very rare for metastasis to take place to internal organs, and when it does, it usually passes to the pleura or membranes of the brain, and proves fatal in a very high ratio. Of 81 cases of capsular rheumatism, recorded by Dr. Macleod, 47 occurred in men, and 34 in women. These were much more equally diffused over the different periods of adult age than acute rheumatism, and much more prone to affect persons under forty than genuine gout; at the same time, it appeared to be more the dis- ease of middle life than either rheumatic fever or muscular rheumatism; — from forty to forty-five years of age giving twenty-two out of eighty-one cases, or rather more than one-fourth, which is a much larger proportion than holds good with re- spect to either of the two others." The average duration of capsular rheumatism was found to be more than twice that of acute rheumatism. The general treatment, both internal and ex- ternal, is that recommended under Rheumatism and Goct.] What remains to be said respecting acute rheu- matism, and the sequelae occasionally left by it, will be more properly noticed in the division of the sub- ject which treats of the chronic form of the disease, to the consideration of which we shall now proceed. II. Chronic Rheumatism. It would simplify the consideration of this form of the disease, if it were limited to that morbid condition to which analogy with the acute affec- tion discussed in the foregoing pages would jus- tify the name of rheumatism being applied. So many and various, however, are the derange- ments loosely classed under this generic term, that to give any history of the disease which should comprise the whole, would present a mass of con- fusion, if indeed it were not utterly impracticable. It has been too much the practice to pronounce as rheumatic every chronic pain of which the nature is obscure, or to which no other specific character is assigned. Practical writers have not overlooked this tendency; it is noticed by Heberden in the following very expressive passage : « Multi dolo- res quibus nomina nondum propria imposita sunt, quanquam inter se distent, ex causis longe diversis orti, tamen ad rheumatismum pariter referuntur." In order to ensure as much clearness as possible in the following observation, it will be expedient to commence with that modification of disease which, presenting all the essential characters of rheumatism, differs from the acute affection already treated of only in being less violent in its symp- toms, and of longer duration. The distinctive characters of this malady are a febrile state of the general system, with more or less of pain and swelling in certain tissues and joints. And in this, precisely as in acute rheuma- tism, the continuance of febrile action undermines the general health, while the local inflammation, however indolent, disorganizes the joints, occasion- ing eventual decrepitude. The pain and swelling of joints with progressive thickening of the liga- ments, and effusion in the several bursae, sufficient- ly evince the morbid actions from which such effects result. But, coincident with these will generally be found in the instances now referred to, evidences of constitutional derangement suffi- ciently marked to denote that a plethoric and febrile state of the circulation is also present. A quickened pulse, some increased heat of skin, and a furred tongue, are in greater or less degree the invariable attendants of chronic rheumatism of the joints so long as the disease in them continues to advance. It, no doubt, occasionally happens that in the course of time all febrile symptoms disap- pear, and the morbid action in the joints ceases to make further ravage. In such cases there is no longer rheumatism, but only the disorganization produced by it; and the distinction is important, for where such ravages alone remain, so far as they are concerned, constitutional remedies can be of no avail, and any treatment, to be effectual, must have special reference to the local lesions by which the free motion of the limbs is impeded. In the larger proportion of cases, however, the disease is strictly rheumatic, that is, it consists of a constitutional derangement having a febrile character, and of a local inflammation seated in the joints. This condition may be, and frequently is, the sequela of acute rheumatism ; but it may be fully formed without any particular acute attack having preceded. Cullen regarded it in the former light, as appears from his definition of arthrodynia being introduced as "rheumatismi sequela." In the definition itself he somewhat incongruously represents this as ensuing to violent sprains and luxations, though why the pains re- sulting from such accidents should be deemed rheumatic it is difficult to imagine. In this defi- nition, too, which ought to embrace every form in which chronic rheumatism presents itself, he states somewhat too positively the absence of fever and of swelling, — "pyrexia nulla, tumor plerumque nullus;" characters which do not apply generally to the disease, and which seem to have been introduced as an antithesis to the definition of acute rheumatism. This imperfec- tion obliged him, when treating of chronic rheu- matism, to enter into explanations rather at vari- ance with his own definition, and in the follow- ing passage he describes more correctly and intelli- gibly the transition of the acute into the chronic stage. « The limits between the acute and chronic , rheumatism are not always exactly marked. When | the pains are still ready to shift their place,— when they are especially severe in the night time, -when at the same time they are attended with some degree of pyrexia, and with some swelling, and especially with some red ness of the joints, he disease is to be considered as still partaking , the nature of acute rheumatism. But when there I is no degree of pyrexia remaining, _ when the RHEUMATISM. 37 pained joints are without redness, when they are cold and stiff,—when they cannot easily be made to sweat, or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the joints,—and when especi- ally the pains of these joints are increased by cold and relieved by heat applied to them, the case is to be considered as that of purely chronic rheuma- tism." If the character of chronic rheumatism is to be derived from the most numerous and pre- dominant instances, then we would say that the former of these descriptions is far more applicable to the disease, as generally met with, than the latter; for though all the phenomena recited as indicating the continuance of febrile and inflamma- tory action may not attend, it rarely happens that some or other of them are not present. As the former condition is capable of indefinite duration, for it may endure for years, and is hence strictly entitled to be called chronic,—it could not, where any distinction were made, be classed with the acute disease lately treated of; while, if it consti- tute any part of the chronic malady, a definition professing to characterize this ought assuredly to embrace it. Perhaps the more perfect representa- tion of the disease, if it be necessary or beneficial to make any such distinction, would be to include both descriptions under arthrodynia, subdividing this into sthenic and asthenic. In this view the sthenic arthrodynia is by far the most frequent form in which the disease presents itself; and, what is no less important, it is that which, if un- relieved or improperly treated, is productive of the greatest mischief and of most distressing results; for under it the disease both local and constitution- al, however indolent it may appear, is yet suffi- ciently active to continue and extend its peculiar ravages, deranging the general health, enfeebling and crippling the body through progressive disor- ganization of joints, and consequent wasting of muscles. In the asthenic form, the mischief is already done, and, however the body may suffer under the ravages sustained, there is no longer the active constitutional derangement inflicting further injury, which forms so essential a part of rheumatism. In the latter form there is little to do but support the general health, and remedy, as far as may be, the local lesions. But sthenic arthrodynia both admits of and demands more corrective treatment, the judicious, discriminating, and persevering use of suitable remedies being capable of accomplishing much, both in renovating health, and restoring power of motion to the still inflamed though rigid and contracted joints. With the consideration of this form we shall now pro- ceed. [The chronic form of rheumatism is often de- scribed as being frequently the sequel to the acute. This does not accord, however, with the experience of the writer. So far as his observa- tion has gone, the subjects of acute rheumatism j rarely suffer from the chronic form ; and, on the other hand, persons who are constantly more or i less crippled by chronic rheumatism may pass through life without suffering from the acute.] It is a prevailing impression that a chronic I disease cannot be inflammatory. How this origi- nated it is needless to conjecture; but, however I the misconception arose, it is a familiar truth that j D the term chronic conveys to most minds not the simple idea of duration, which alone it expresses, but something the opposite of inflammatory; some state to which the treatment proper for in- flammation cannot be applicable. The pure chronic rheumatism of Cullen as described in the foregoing extract, is unquestionably of this latter character; but as the disease comprises, in addition to this, the subacute or sthenic condition also noticed by him, it is necessary to understand the term chronic, when its application is thus extend- ed, in that restricted sense alone which rightly belongs to it. Practitioners who are accustomed to regard chronic rheumatism as asthenic, and to treat it accordingly, are little aware of how long a deci- dedly inflammatory character may attach to it. Years may elapse, yet a distinctly febrile 6tate, indicated by its appropriate phenomena, prevail, accompanied with evidences of disorganizing in- flammatory action on the joints. And so long as this state endures, is there progressive deteriora- tion of general health, and increasing structural derangement of joints. It gratifies the writer of this article to see this fact unequivocally stated by Dr. Elliotson, in his excellent clinical lectures de- livered at St. Thomas's Hospital. He acknow- ledges the inflammatory character, and also the great length of time for which this may be retained, specifying this form of rheumatism as active in contradistinction to the term acute, which in its strict sense could not apply to it. The same cha- racter was long ago indirectly recognised by Sagar, when, in his definition of chronic rheumatism, he stated the blood drawn to exhibit a buffy crust. In this form, however subdued the symptoms may be, the characteristics of rheumatism, as they have been exhibited in the acute disease, are distinctly traceable. There is a febrile state of the general constitution, and more or less of inflammatory action in the joints; and the principles of treat- ment are precisely similar, though they require to be modified in their application so as to adapt this to the derangements, both constitutional and local, which need relief. It will assist in comprehend- ing the real nature of this form of the disease to bear in mind what was formerly stated in treating of relative plethora. Certain delusive appearances were then noticed, as misleading practitioners from a right conception of the state of circulation or condition of health existing ; and to similar delu- sions has it been owing that the febrile character of active or sthenic arthrodynia has been so fre- quently overlooked. An apparently feeble and compressible pulse induces the persuasion of de- bility ; the enfeebled powers of the body sanction the conclusion ; and relief is sought from a class of remedies which, in such case, cannot give other than transient relief, if, indeed, they do not aggra- vate every symptom. Were we sure that the doctrines of plethora formerly illustrated were rightly understood, we could at once close the discussion of the constitutional state prevailing in sthenic arthrodynia, by representing it briefly as that of relative plethora. It differs from the con- dition formerly described as relative plethora, only in having the local inflammations with their con- sequences superadded. In order to determine ac- curately this state of constitution, it is necessary 38 RHEUMATISM. to judge, not from any one indication, but from accustomed to institute an artificial fever «h™uSh that assemblage of evidences which, when collec- the operation of mercury to effect the purpwi . tively present, cannot mislead. The pulse, if This, however, is not to be forced ; i» ™£"™ alone trusted to, may deceive, at least where the time for safe and salutary progress : runute vee- practitioner is not on his guard against the delu- sels long obstructed cannot be a 1 at once rendered sive lowness of pulse which belongs to incipient pervious and efficient for the discharge■?* «™°; tions long disused; and hence, in treatm* the plethora, or is unacquainted with the peculiar changes which the pulse undergoes when the con- gestive state is passing into that of febrile action. Though apparently low in force, it yet evinces some resistance to pressure, and is more or less quickened; the skin, too, is hotter than natural, and the tongue is white and furred. The gastro- intestinal membrane will also be found charged with redundant mucus, such as it generally se- cretes under febrile action. When all these phe- nomena are present, and especially when they are accompanied by evidences of local inflammation in the joints, no doubt need be entertained either of the nature of the disease, or of the principles of treatment. In this form of disease, then, it is obvious that the indications of cure are in no respect different from those which have been already shown as applying to acute rheumatism, namely, to subdue fever, and remove local inflam- mation. And the rationale of the practice suited for fulfilling these indications will be clearly per- ceived by those who have taken the trouble to comprehend the doctrines respecting the patho- logy of the circulation advanced in the article Plethora. The constitutional state of sthenic arthrodynia bears the same relation to relative plethora that the acute form does to absolute; and in the prin- ciples of treatment laid down for the correction of relative plethora, with its concomitant disturbances, will be found the best guidance for conducting febrile state of chronic rheumatism, the practice, though corresponding in principle with that of acute, must be much less energetic. Bleedings must be of smaller amount and at longer inter- vals ; a free state of excretion must be moderately but steadily maintained; and mercury must be employed for that renewal of function in the ca- pillary vessels and their secerning extremities, which the powers of the constitution, unaided by mercury, are inadequate to accomplish. It will be recollected that in relative plethora the redundancy of blood results more from its im- perfect appropriation than from absolute excess; and that correction of this state requires, not only that the larger vessels be relieved from the load which oppresses them, but that the aggregate capa- city of vessels be enlarged by renewal of the sus- pended activity of the capillaries, and also by pro- moting the natural expenditure of blood through the several secretions and excretions. These are the curative effects of febrile action; they consti- tute also the beneficial operation of mercury on the system, and on regulating them conformably with the views here displayed will the success of medical practice in a great measure depend, not only in this but in many other diseases. In the diseased state now under consideration, the first object should be to relieve the oppressed circula- tion, and thus arouse the energies of the system by taking away some blood; and in conducting with precision and effect that of active chronic i this part of the treatment, judgment and discrimi- rheumatism. On the same principle as in acute rheumatism, it is the constitutional state which demands the first attention; for, unless this be radically corrected, all efforts to cure permanently the local ailments must fail, or be only of tran- sient effect. In treating the constitutional dis- turbance, it is necessary to bear in mind that it is connected with relative rather than absolute ple- thora; that, consequently, the derangements exist- ing are more complex, and that the practice must hence embrace considerations which it was not necessary to insist on particularly in discussing the acute disease. In acute rheumatism, active bloodletting was directed ; the object being not only to reduce plethora, but to make speedy im- pression on febrile action, in order to arrest prompt- ly the injuries which unrestrained continuance of this would occasion. In the more chronic form it is necessary to diminish plethora, but not equally so to make so speedy impression on febrile action. This latter requires to be regulated, but not ex- tinguished ; for some increased energies of circu- lation are absolutely necessary for correcting the concomitant derangements of function produced by defective capillary circulation. To restore the impeded circulation of the capillaries, and renew the secretory and excretory processes of which they are the agents, seems to be the final cause for which febrile action is instituted; it is assur- edly the end which it often attains, and hence, nation are so requisite, that, even at the hazard of being deemed unnecessarily minute, we must dwell on the several circumstances from which any guidance can be derived. If, with the general evidences of plethoric op- pression and febrile action, the powers of the con- stitution be very low, and the pulse very feeble, it may be advisable to suspend for a while direct depletion, and to trust to purgatives. It may, in such case, be even expedient to employ gentle stimulants in order to arouse the dormant energies, and enable them to bear direct bloodletting ; this being the end to which the use of stimulants should in this stage be directed. The necessity for this degree of caution, however, is not of most frequent occurrence. Much more generally may the curative treatment commence with small bleed- ings ; and in these it should never be forgotten that the object is not to make impression on the moving powers, but to withdraw a portion of the circula- ting mass, and this with a view of arousing the natural powers to the discharge of functions re- quired for the re-establishment of health. Small bleedings here suffice; and the extent of six or eight ounces will best answer the end designed. According as power increases, larger bleedings will be borne; but beyond twelve ounces it is rarely necessary to carry them. In general, even the farst portions of blood drawn will be buffed if not cupped; and under such circumstances the when natural fever fails to accomplish it, we are pulse, if previously low, will be found t RHEUMATISM. 39 under bleeding. As was before remarked, a soft ] pulse is no contra-indication of bloodletting; for we continually find buffy blood and increase of power after venesection, where the previous soft- ness and feebleness of pulse would, to unreflecting observers, appear to prohibit all direct depletion. This deceptive character of pulse is too often allowed to influence the practice even in acute rheumatism; yet it has been so often the subject of remark, that practitioners ought to be fully aware of it. Dr. Gregory, who in the treatment of acute rheumatism did not employ bloodletting indiscriminately, nor deem it essentially necessary, but who trusted rather to sweating as the prefer- able evacuation, used to acknowledge that he had been obliged to have recourse to bleeding after several weeks' duration of disease, where he had at first been apprehensive of employing it from the smallness and apparent debility of the pulse; and that after bleeding, the pulse rose and disease sub- sided. This is not peculiar to rheumatism, but a general fact connected with derangement of circu- lation, and worthy of attention in many diseases. The explanation of it has been fully and clearly given in the article Plethora ; and if the prin- ciples there inculcated be duly regarded and dis- criminately applied, there will be little hazard either of bloodletting being withheld where it is needed, or of its being carried to any injurious extent. Next to bloodletting, the most important evacua- tion is purging, which requires to be regulated both according to the degree of febrile action present, and to the state of the bowels as manifested by the stools. In proportion as fever is active will the free use of purgatives be required, and saline ca- thartics be needed in aid of those which more pe- culiarly deterge the mucous membrane of its mor- bid secretions; but so long as these continue dark, slimy, and unnatural, must suitable purgatives be assiduously employed. Pills of calomel, colocynth, and antimony, with occasional doses of sulphate of magnesia and senna, are the most effectual means of adequate purgation. According as ac- tive fever prevails, as evinced by a quick pulse, hot skin, and white or furred tongue, salines with antimony and colchicum, assisted by antiphlogistic regimen, should also be conjoined. If under this treatment febrile action does not speedily abate, and local inflammation subside, mercury will be required, and for purposes similar to those for which its use was directed in acute rheumatism. According as fever is active will calomel and opium be necessary, for the proper administration of which no further instruction can be here needed, it being only necessary to observe, that as the morbid actions requiring correction yield more slowly than in acute rheumatism, a more slow and cautious administration of the remedy is here expedient. The direct agency of the medicine is to excite freer circulation in the capillary vessels, by which the larger vessels be- come relieved, both through the increased capacity thus given to the vessels through which the mass of blood circulates, and the increased expenditure of blood in the several secretions and excretions thus promoted. Whoever bears these facts and principles in mind, will experience no difficulty in regulating the administration of mercury in this or any other disease. In many cases, however, febrile action, though sufficiently manifested by its appropriate pheno- mena, is less developed than in those just referred to. The pulse is feeble and irregular, the several secretory and excretory functions are inactive, and the whole frame displays a deficiency of power. Here stimulants are needed, and the most effectual for arousing the dormant energies is mercury. The milder preparations in small doses, repeated at intervals, are what should here be employed. The compound calomel pill, blue pill, hydrargy- rum cum creta, are the remedies chiefly in use where a slowly alterative effect is desired. In old and obstinate cases minute doses of the oxymu- riate have effect when other preparations fail. When the latter is resorted to, decoction of sar- saparilla is beneficially combined. Whenever mercury is employed for such purposes, it is highly necessary to watch closely the state both of the circulation and of the bowels. If under its use the arterial system becomes excited, and the pulse rises, becoming full, hard, or resisting, blood should he taken; and as mercury, when so administered, promotes the intestinal excre- tions, these should be assiduously evacuated by suitable purges, which in such case serve the double purposes of removing from the intestines a source of irritation, and of maintaining the excretories in an active exercise of those functions which so materially assist the curative process. Under the foregoing treatment part of the local inflammation will subside without any topical remedies being applied. But as these inflamma- tions have long reached the secondary stage, and as local derangements, such as were formerly no- ticed, have become more or less established, the local treatment suited to the special circumstances of each case is here indispensable. According as the local inflammation presents an active charac- ter, cupping or leeches will be required ; and by these, with fomentations, or with cooling and sedative lotions, much impression may bo made. Blisters, too, in time, are of much effect, especially where the bursa? are loaded with glairy effusion, the ligaments thickened and rigid, and the whole joint enlarged. To these changes all the joints are liable; they peculiarly occur in the wrists, where they materially impede the motions of the hands, rendering the patients very helpless. These swellings, when accompanied with heat and red- ness, require leeching and cold lotions ; other- wise, repeated blisters are the means by which the enlargement can be best reduced, the effusions absorbed, the ligaments attenuated, and the flexi- bility of the articulations restored. In the inter- vals of blistering, stimulant embrocations are very serviceable; and frictions, especially the kind of manipulation termed shampooing, are of much avail. In the inveterate cases which continually occur in practice, it is not any one remedy that can be relied on. The combined agency of all is re- quired, and they should be assiduously employed in such succession and alternation as enlightened judgment may direct. By a judicious and steady use of them many a case, apparently hopeless, 40 RHEUMATISM. may be restored to the enjoyment of good general health, and to considerable freedom of the affected limbs. Throughout the whole course of treat- ment warm bathing is signally beneficial, as is largely attested by the records and daily expe- rience of the noble institution to which the writer of this essay is indebted for much practical know- ledge—the Bath Hospital. It cooperates with the constitutional treatment to improve general health, promoting a free circulation in all the capillary vessels, and calling into renewed activity the highly important excretory functions of the skin, while its special effect on the pained and crippled joints is eminently salutary. For the latter pur- pose, pumping on the limbs, as it is termed, that is, directing against those affected a stream of tepid water, impelled with such force as to exert a mechanical influence on the part, is oftentimes a very powerful auxiliary. Even when general warm bathing is not admissible, this partial appli- cation of warm water may be used with much advantage for the relief of local ailments. Subsidiary to these several means, one of the most effectual aids for restoring motion to rigid or contracted joints is the persevering endeavour to render them flexible by assiduous exercise ; and the more this can be promoted through the appro- priate muscles of the affected joints, the greater will be the benefit resulting; for the muscles pre- viously wasted will thus recover bulk and strength, and through renewal of exertion will prove a most valuable instrument both in preserving and ex- tending any power of motion that may be gained. Frictions and shampooing are a sort of passive exercise, and through this, as well as by pro- moting absorption and inducing a freer circula- tion in the extreme vessels, their effect on en- larged or rigid joints is considerable. But even where, from great rigidity and extreme muscular feebleness, the joints are incapable of being exercised by their own proper muscles, the advantage derivable from passive exercise is not to be despised. Frictions and shampooing may lessen rigidity, so as to give more effect to the feeble muscles in their languid efforts. When the wrist and finger joints are affected, the parlies may materially benefit themselves by moderate but continually renewed attempts to move the joints of each hand by means of the other. The joints may resist for a long time, but this should not discourage, and the slightest renewal of mo- bility should be hailed as the sure harbinger of further improvement. It is needless to urge this further. The principles are obvious, the effects proved by ample experience; and at all events perseverance in such endeavours, however little it may in extreme cases accomplish, holds out to the rheumatic cripple the only hope of recovering mobility in joints rendered inflexible by the effects of rheumatic inflammation. Attempts to restore mobility in such cases by internal medicines alone, is worse than fruitless. They may correct constitutional derangements where these coexist, and, by restoring general health, prevent further mischief; but they can have no effect in renew- ing either mobility or power to limbs so affected. It has been shown that the secondary inflam- mation of acute rheumatism may survive the cause in which it originated. In like manner the local inflammation of chronic rheumatism may continue, although the febrile state which nurtured and aggravated it may have wholly subsided ; and, further, the ravages of rheumatism in the joints may remain when all fever, as well as local in- flammation, whether primary or secondary, has ceased to exist. Chronic rheumatism, therefore, may be said to present three conditions which de- serve to be practically distinguished ; — active fever with local inflammation;—inflammation un- accompanied with fever ;—and structural derange- ments of joints unattended by either fever or local inflammation. Each of these conditions requires to be treated on principles applicable to its pecu- liar state; and any treatment adopted merely on account of its being specifically suited for rheu- matism, must, if indiscriminately applied, be pro- ductive of much mischief. There is another diseased condition often con- sequent to rheumatism, namely, a loss of nervous energy, which constitutes a modification of par- alysis ; but this demands a separate consideration, which belongs rather to paralysis than to the pre- sent subject. The first condition of chronic rheumatism, or that which comprises both active fever and local inflammation, has been sufficiently discussed. The next in order is where the local inflammation, with the attendant pains and other derangements, endures after fever has subsided. This form also is of frequent occurrence, and it differs from the former in not requiring general bloodletting for its cure. Local depletion and occasional blisters constitute the principal topical treatment; and mercury with sarsaparilla and other such auxili- aries, is the chief agent for inciting the constitu- tional energies to cooperate in the cure. It is this form of the disease that has misled even intelli- gent practitioners into pronouncing that general bloodletting is not necessary in chronic rheuma- tism. Dr. Elliotson in his admirable clinical lec- tures has expressed himself of this opinion, and declared that he has relinquished general bleeding in active rheumatism, unless when some internal inflammation coexists. That in many such cases the treatment recommended by him, namely, local bleeding, colchicum, and mercury, will succeed without general bleeding, we were well aware; but we are no less assured that in very many it would prove very tedious, if not wholly fail. We consider, therefore, that Dr. Elliotson has stated this opinion somewhat too broadly ; and that on reconsideration he will himself admit that the criterion for employing the lancet should be, not the presence of an internal inflammation, but such degree of plethora and febrile excitement as in itself demands direct depletion, independently of all coexisting local derangements. Topical bleed- ing, low diet, colchicum, and mercury, form a combination of influences which has great power in subduing febrile and inflammatory action ; but if plethora exist to a certain extent, even their united agency will be insufficient, unless direct depletion be conjoined. And in such case it re- quires to be borne in mind, that, as has been already explained, the operation of mercury is not devoid of danger. When there is local inflam- mat.on without plethora or fever, the treatment recommended by Dr. Elliotson cannot be improved RHEUMATISM. 41 When there is only the local affection to treat, repeated cupping or leeching, and blistering, with the warm bath, and a cautious return to exercise, But when plethora and fever exist to any extent, I will do much to effect restoration. Stimulant and sedative embrocations too, are occasionally of ser- Evcn where plethora and fever exist only in slight degree, it may also succeed, although the progress will be slower than when venesection is conjoined. then, even though there be no internal inflamma tion, general bleeding ought unquestionably to ! form part of the treatment. Chronic rheumatism has been sometimes dis- tinguished into hot and cold,—the hot being the active rheumatism of Elliotson, the cold the arthrodynia of Cullen. In the last, various stim- ulants are of much avail, and for the relief of I such disease they should undoubtedly be resorted to. It is to be hoped, however, that their misap- plication to acute or to any active rheumatism as the appropriate remedies, has passed away, or is confined only to ignorant empirics. It illustrates the difficulty of adapting treatment explicitly to the name of a disease, or even to special degrees of it, that there are modifications of active rheu- matism in which even stimulants, cautiously ad- ministered, are not only safe but beneficial; and this circumstance confirms the necessity of all medical treatment being regulated, not by express j rules, but by those principles from which all rules ought to emanate, and to which they ought to be subservient. It would be vain to enumerate the various stimulants which have obtained character for the cure of cold rheumatism. The principal are essential oils drawn from resinous substances, such . as turpentine ; various balsams and gum-resins ; the latter either in substance or in simple or am- moniated tinctures ; sudorific decoctions ; electri- city. Any of these may benefit according as the ! general constitution is prepared for their operation, or as the special ailments may require. If there be no plethoric or febrile state present, their use ! will at least be harmless, if not beneficial ; but should the case be such as to need depletory treat- ment and the operation of mercury, then must the use of such stimulants as are now named be watched with great caution. Warm bathing and active exercise are among the unexceptionable and most powerful means of relieving chronic rheumatism. The local treat- ment formerly directed for the sequelae of acute rheumatism also requires to be assiduously em- ployed. There are some affections generally regarded as rheumatic, which, however connected with rheu- matism, seem to depend chiefly on a morbid condi- tion of particular nerves. Of this kind are scia- tica and lumbago, both of which differ so much in their symptoms from acute rheumatism, as scarcely to admit of their being classed under it. A mere error of arrangement, however, is of little consequence, as the same principles of treatment apply to all. If the state of constitution be such as to require for its correction bleeding, purging, colchicum, and mercury, these remedies must be employed, else the local affection will not readily yield. That sciatica arises from some lesion of the sciatic nerve or its investments, most practi- tioners are agreed. That this lesion results from a primary congestion or inflammatory action, seems evidenced both by the whole train of symptoms, and by the treatment most successful in giving relief. Vol. IV. —6 d* In lumbago, though the spinal nerves affected are less distinctly indicated, yet the character of the pain marks it as more neuralgic than rheuma- tic. Free cupping and the general treatment of acute rheumatism will best succeed in relieving this disease. But there is a form of neuralgia occasionally attendant on rheumatism which causes much suf- fering, and which does not seem to be generally understood. It occurs in paroxysms of great in- tensity, attended with a severity of pain which few can patiently endure. This may arise ere the febrile state has thoroughly subsided; and this circumstance is apt to mislead, for a continuance or removal of inflammation is thus apprehended, and depletory treatment is pursued, under which the disease is aggravated instead of relieved. The character of this affection is best denoted by the suddenness of the painful accessions. The nature of the pain, too, so different from that which at- tends inflammation, seems to distinguish it. For this affection the most certain and effectual reme- dy is iron ; but it must be largely used, and as- sisted, if necessary, by full doses of opium. The carbonate is the best preparation, and this should be given in doses of two drachms three or four times a day. By administering it with equal parts of treacle, as directed by Dr. Elliotson, its consti- pating effects are obviated. Should opium be re- quired, it should be given in full doses, and the best preparation for the purpose is Battley's seda- tive solution, of which from thirty to ninety min- ims may be given at bed-time without any sinister effect resulting. Under this treatment it may be necessary to purge occasionally with the common senna draught, which is sensibly improved by the addition of half a drachm of spirit of ammonia. In the progress of rheumatism the chest is apt to become affected with pain and great dyspnoea, the distress being referred to the lower part of the chest, and described as if the point of the sternum were drawn back to the spine. This arises from the extension or translation of rheumatism to the diaphragm. The means of relief are bleeding, purging, and colchicum, with calomel and opium. So soon as the gums are touched, the distress finally ceases. One of the most important affections connected with rheumatism is that in which the heart or its investments becomes the seat of rheumatic inflam- mation. This inflammation may be of the most acute kind, constituting complete carditis or peri- carditis ; or it may be only such increased action of blood-vessels as ultimately leads to hypertrophy. For the acute attack the most active treatment is required ; full bloodletting, purging, antimony and colchicum, but above all the early and decisive operation of calomel and opium. If the latter be not speedily and effectually obtained in subservi- ency to bloodletting, this will be required to such extent as to render recovery extremely doubtful, sink greatly the powers of life, and occasion a very tedious convalescence. Some interesting cases of 42 RHEUMATISM. rheumatic pericarditis have been recently pub- lished by Dr. Davis, the senior physician of the Bath hospital. He seems, however, to have trusted to general antiphlogistic regimen, without calling in the aid of mercury. The principles advocated in this article display the merits of mer- cury as an adjuvant; and the experience of the writer fully confirms their truth and practical uti- lity. But independently of this acute seizure there is continually found in connection with rheumatism inordinate action of the heart, with evidences of actual enlargement or hypertrophy of that organ. The treatment of this affection, we can from much experience say, is best con- ducted on the principles inculcated in this article. Moderate bleedings are indispensable, the blood being almost invariably buffed and cupped. In judging of the state of circulation, the pulse at the wrist would mislead, for it may be soft and compressible even when the action of the heart is tumultuous. The carotid should here be exa- mined as furnishing a more certain criterion. Free bowels and antiphlogistic discipline are indi- cated by the same necessity which calls for ab- straction of blood. Mercury with opium is also required to produce its specific effects, by which alone the morbid action can be effectually or per- manently subdued. The use of this requires to be cautiously conducted, for its slowest operation is that which is here most beneficial. The morbid condition is generally of slow formation ; the changes wrought are not of a nature to be sud- denly rectified; and attempts to accelerate the case beyond what nature permits, would beget mischief and lead only to disappointment. Cup- ping and leeching over the heart are valuable aux- iliaries, and blisters are occasionally needed. In fine, when inflammation both general and local is allayed, and the action of the heart still continues inordinate, or is too easily excited, the application of belladonna to the side, in the form of plaster, affords a valuable means of quieting the heart's motions, and of procuring rest from a disturbance which is always distressing. Tin this as well as in every form of rheumatism, the iodide of potassium, given in large doses, has been greatly extolled. (New Remedies, 4th edit. p. 396, Philad. 1843.)] By the cautious adaptation of such means, and steady perseverance in their use, the disturbance of heart here treated of may in time be effectually relieved. Time, however, is required, for the dis- ease yields slowly; and though impression be made on it by the early procedures, months may elapse ere perfect tranquillity of circulation can be restored. The patience, however, which can await this result, and pursue steadily the means of accomplishing it, will be amply rewarded. There is one more form of rheumatism which requires to be noticed, namely, that which is called rheumatic gout; and so far as a name is con- cerned, this appellation, though only a popular term, is not misapplied. So much has this disease in common both with gout and with rheumatism, that it is scarcely possible to regard it otherwise than as a hybrid malady, in which the elements of both these diseases coexist, Its accession cor- responds most with rheumatism; its ravages have a greater resemblance to those of gout. The en- largement of joints to which it is so prone presents much more of the character of gout than of rheu- matism. Dr. Haygarth has described this disease, and proposed to denominate it nodosity of the joints. Of its history and treatment there is lit- tle to be said beyond what has been already ad- vanced under the heads of gout and of rheumatism. It is more frequent in women than in men. Its commencement is often marked by active fever, and in proportion as this is disregarded or inade- quately treated, are its ravages more severe and inveterate. But in many it advances by a slow and insidious progress, disorganizing the joints without materially deranging the general health. The local swellings long retain the character of active inflammation, being hot, red, and painful. They in general surround the whole joint, and, so far as mere touch can determine, they seem to arise from a general enlargement of all the struc- tures constituting the joint. It seems strange that the structures actually enlarged have not been long since ascertained by actual dissection ; yet we are not aware of any account of them, founded on anatomical examination, having been published. In 1805 Dr. Haygarth had not met with any such account, as appears from the following paragraph of his treatise: " In this disease the ends of the bones, the periosteum, capsules, or ligaments which form the joint, gradually increase. These nodes are not separate tumours, but feel as if they were an enlargement of the bones themselves. This point might be anatomically ascertained without any difficulty or doubt." The disease, according to Dr. Haygarth, does not appear to shorten life; the first patient whom he saw so affected reached the age of ninety-three. As to treatment, this must be regulated accord- ing to the state of constitution and local symp- toms, and on the principles inculcated in this arti- cle. By local treatment much relief may be ren- dered. Frequent leeching has much effect in abating heat, swelling, and pain. In the purely chronic stage, successive blisters contribute much to reduce swelling and restore flexibility. As the hands particularly suffer from this malady, it be- comes necessary to blister each finger separately, and even each joint; a process, which, however irksome, is yet ultimately recompensed by the in- creased power of using the hands which may be thus obtained. [Under the name Rheumatic Dermalgia, Mr. Beau (Note sur la Dermalgie, in Archiv. general de Med. x. ii. 120, Paris, 1840) has described an affection characterized by the following symptoms. The head and lower extremities are the parts most usually attacked, but the pain does not remain in one place, often changing its seat gradually, and wandering from place to place. Two kinds of pain are experienced, the one enduring, the other intermittent and severe, resembling the prick of a pin or an electric shock, and recurring about every half minute. The enduring pain is often little more than an exaltation of the natural sensibility of the skin. Friction of the part with the finger, or with the patient's dress, always augments the pain; and if there be hair on the affected part, very severe suffering may be produced by passing the hand over the hair. Rheumatism of the skin commonly alternates RICKETS. 43 with that form of the disease, which affects the muscular and fibrous tissues. Its usual duration is a day or two, after which it gradually subsides. It is said to be a more frequent occurrence among men than women, to be induced by damp, cold, and the ordinary causes of rheumatism, and, in general, not to require much treatment.] E. Barlow. [Robley Dunglison.] RICKETS.—Rhachitis, Rachitis. The term rhachitis was derived by Glisson from the Greek Hx** (sl'me)> because this disease affects, in an especial manner, the spinal column ; but he ac- knowledges that he was induced to adopt this term from its near resemblance to rickets, a word by which the malady was commonly known in England even before his time.* The work of Whistler, and the remarkably clear and full ac- count of rickets afterwards given by Glisson and his associates Bate and Regemorter, have procured a currency for their opinion that the disease made its first appearance in the western parts of England towards the middle of the seventeenth century, and have obtained for rickets among continental writers the designation of the English malady, (Morbus Anglicus, Maladie Anglaise, Englische Krankheit.) That rickets was never distinctly described by any medical author before the times of Whistler and Glisson, we readily admit; but that it was of such recent origin as the period stated above, we conceive to be quite inconsistent with the several terms in the Greek and Latin languages denoting deformity and decrepitude of the human body, and with the instances recorded in ancient history of persons so afflicted who were distinguished in various departments of letters and even in arms. The essential characteristic of rickets is a soft- ening of the bones ; but the exact change which takes place in their structure, and the general symptoms by which this alteration is attended, are considerably different at different periods of life. Taking the term rhachitis in this extended sense, to which perhaps osteomalakia would be more properly applied, the disease may be divided into two species;—1st, softening of the bones of chil- dren, or common rickets ; 2d, that of adults, mol- lifies ossiutn, or osteo-sarcosis. Softening of the bones, like scrofula, is not unfrequently met with among the inferior animals. Thus Lordat dis- sected a rickety monkey; Bicherod found soften- ing of the ribs of an ox (Act. Maris Balthici, 1707); Dupuy describes the skeleton of a rickety horse (Dupuy, De l'Affection Tuberculeuse); Mason Good (Study of Medicine, vol. v. p. 327) asserts that rickets occurs in the lion ; and Comber has written a dissertation on the disease as it ap- pears in sheep. (Letter on the Rickets in Sheep. Lond. 1772.) But to descend from the researches of the learned to the information of those who are observant of the manners and diseases of our domestic animals, curvature of the bones and swelling at the joints are not unfrequently seen in whole broods of young geese and ducks, when * David Whistler, Dissprtat. Inaugur. de Morbo Puerili Anglor. dicto •' The Rickets." Lugdun. Batavor. 1G45. This work, which preceded that of Glisson, is now ex- ceedingly rare: a copy still exists in the Bodleian Li- brary. they have been continually exposed to cold and wet. The same affection is met with in young pointers, and more frequently in greyhound pup- pies, when kept in confined and cold damp ken- nels. In pigs, the same disease is in some places named krinckets; its causes arc cold and moisture, and bad nourishment; and for its cure baths of hot grains are used, oily frictions, nutritious food, and removal to a warm and dry place. I. Rickets or Children. 1. History.—This disease rarely appears before the seventh month, and most commonly does not declare itself until the child first begins his attempts to walk, or until he suffers from the severity of the first dentition. Rickets has also been observed at birth, and in the foetus : of the former Glisson (De Rachitide, p. 178), Henckel (Abhandl. CJii- rurg. Oper. Th. ii. p. 14), Klein, and Lepelletier (Maladie Scrofuleuse, Paris, 1830), have given examples; and of the latter Bordenave (Mem. de Mathemat. et Physique, torn. iv. p. 545), and Pinel.f [Of 346 rickety children observed by M. Guerin, (Gazette Medicate de Paris, pp. 433, 449, 481, Paris, 1839,) 209 had been attacked with the dis- ease at from one to three years old; three cases only had occurred before birth ; and 34 at from four to twelve years of age. Girls appeared to be more liable to it than boys. Of the 346 indivi- duals referred to above, 198 were females, and 148 males. (Guersant, art. Rachitisme, in Diet, de Med., 2de edit, xxxii. 155, Paris, 1843.)] When a child is about to be affected with rickets, he becomes dull and languid, the appetite is varia- ble and capricious, the bowels are irregular, the stools unhealthy and usually pale. Constitutional disturbance now arises, and a febrile state is soon established : the limbs become emaciated, the belly tumid, the face full, and the head disproportionately large, the forehead projecting, and the sutures of the cranium remaining open or perhaps expanding slightly. The extremities of the long bones which are least concealed by muscle, as those of the | wrists and ankles, and the sternal ends of the ribs, particularly these last, are swelled out into knobs. Some have doubted the tumefaction of the extremi- ties of the bones in rickets, ascribing the appear- ance of swelling to the emaciation of the limbs; but an attentive examination of rickety cases has convinced us of the correctness of the former opi- nion. The firm texture of the bony framework of the body now begins to yield, and its increasing softness becomes apparent by the change of form which takes place. The sides of the chest are approximated by the combined operation or the pressure of the child's arms, the weight of the j f In Fourcroy'g Journal, La Medecine eclairGe par les Sciences Phys. torn. i. p. 111. This was the case of a rick- ' ety foetus of eight months, in which the distortion was | chiefly confined to the lower extremities. Farther illus- i trations of foetal and congenital rickets will be found by ! referring to the following authorities. I Soemmering Abbildung, et Bcschreib. Einiger Missge- burten, p. 30, pi. 11. I Otto. Seltene Beobachtung. I. Sam. tab. i. fig. 1. Romberg. De Rhachit. Congenit. Berol. 1817, cum ta- bulis. | Sartorius. Rhachit. Congenit. Observ. 4to. Lips. 182C, cum tabulis. Loder. Index Praparator. &c. Mosqus, 1823. Sect. 11. D. 44 RICKETS, body when laid on its side,and the mode in which j children are usually carried ; and thus the sternum is made to project like that of a bird, or like the keel of a boat. The lower extremities bend under j the weight of the body, while they yield at the same time to the action of the most powerful mus- cles : the knees are usually bent inwards and the feet thrown out, so that the patient when he walks rests on the inside rather than on the sole of the foot. At other times the whole of each lower ex- , tremity forms an irregular curve with its convexity looking outwards, and thus the knees, instead of | knocking against each other, stand far apart. Among some of the native tribes of North Ame- rica, this particular form of the limbs is esteemed handsome: and the utmost care is taken in early infancy to mould them by continued pressure into the admired shape, which, therefore, must not be regarded as any proof of the previous existence of rickets. In this disease the natural convexity of the thigh-bone is often so much increased as to form an elbow ; and the angle between the neck and the shaft is converted from an obtuse to a right angle, or even to an acute one. The pelvis is usually deformed in the reverse direction of the chest, the pubes approaching to the sacrum; but in all cases where the pelvis suffers, its cavity is diminished, which to the female in after-life is ne- cessarily attended with more or less dangerous consequences in the event of pregnancy. The vertebral column exhibits in a remarkable manner the effects of rickets in retarding the completion of the bones, and softening their texture : the spi- nous processes of the last dorsal and of the lum- bar vertebrae are sometimes deficient, and the na- tural form of the spine is variously changed; its uppermost portion is often bent backwards, while the dorsal part projects into a hump, the loins fall in, and the extremity of the sacrum is unnaturally protruded : thus the gait of the hunchback, who has survived the severity of the disease, is stiff and formal, and the face directed upwards. The distortion of the arms of rickety children is usu- ally outwards at the upper part of the humerus from the action of the deltoid, and in other parts also it is chiefly determined by the operation of the most powerful muscles ; but much will depend on the positions in which the limbs may chance to be placed at the time when the bones are recover- ing their strength and firmness. Rickets is con- sidered by some to produce little or no change on the bones of the cranium, face, hands, and feet. Those of the two last, we believe, are little affected; but the vertex in rickety children is, with few ex- ceptions, unnaturally flattened, the centres of the parietals are expanded, and the forehead is promi- nent from an enlargement of the frontal sinuses : the bones of the face also appear in most cases to undergo some change of form, indicated by the shortness of visage and elongated under-jaw usu- ally observed in those who have suffered from general rickets. In such children the process of dentition is protracted, and the teeth soon decay : the enamel of the permanent teeth is often craggy and worm-eaten, showing its imperfect formation, though sufficiently hard ; but the fang during the progress of the disease has been found somewhat softer than natural. (Wilson, Lectures on the Human Skeleton.) The rapidity with which the bones are softened by rickets is sometimes altogether extraordinary. Brunninghaiisen observed the whole of the bones in one instance become soft in the short space of six weeks, and the case proving fatal, he preserved the skeleton. As the disease proceeds, the bones are readily fractured when even a slight force is applied, and it is remarkable that, softened as they are, they usually reunite: at length they become completely pliant. We have seen those of the fore-arm of a child of four years as flexible as a piece of soft gristle, bending with the weight of the hand whichever way it was turned. The muscles grow more and more flabby, the abdomen more tumid, the appetite becomes keen, and the bowels slug- gish. The urine in rickets is rarely healthy, sometimes clear, but more frequently turbid, de- positing a copious whitish or light brown sedi- ment, indicating the very disordered condition of the digestive organs, and consisting in all proba- bility of lithate of ammonia, with a large admix- ture of the phosphates. During the continued progress of rickets, the febrile excitement abates until its latter stages, when at length a regular hectic is established, and contributes by its perspi- rations and diarrhoea to exhaust and destroy the patient. The intellect of the subjects of rickets generally possesses a degree of development far beyond what is usual in healthy children of the same age ; the children exhibiting a quickness of perception and a fluency of language sometimes astonishing. In other instances, though much more rarely, they are taciturn and stupid, or even verge to a state of idiotcy. The frequent precocity of understand. ing has been ascribed to the expansion of the skull, and the earlier development of the brain con- sequent on that determination of blood to the head which appears always to exist at least in the first stages of rickets ; but when this disease does not occur until the sutures of the cranium have closed, the same circumstance of an increased flow of blood acting on a part no longer capable of yield- ing has been assigned as the cause of the mental torpor or fatuity occasionally met with. Almost all those who become rickety soon after birth perish, but many in whom the disease has appeared later recover before their fifth or sixth year; the general health gradually improving, the tumefaction of the abdomen subsiding, and the bones acquiring firmness, though retaining, with scarcely an exception, a certain degree of defor- mity. The head remains disproportionately large, the child preserving its acuteness and vivacity. At other times recovery takes place after smart febrile reaction, which is occasionally accompanied by the appearance of a cutaneous eruption. Some- times the child at the approach of convalescence exhibits an extraordinary liking to particular arti- cles of food. We have known the desire for com- mon salt so strong that the little patient would de- vour it as others do sweetmeats. The quantity taken in one instance was very great, and to the parents it seemed as if the salt had proved the means of cure. After the cessation of the disease, the bones ac- quire a degree of solidity and strength even greater than natural, and many persons whose form proves RICKETS. 43 that they were rickety in early years, are in after-1 the attempt is often productive of the fracture of life distinguished for robustness and activity. The I some bone : hectic fever is now established, with deficiency of earthy salts in the bones, which ex- its attendant colliquative perspirations and diar- isted during rickets, is succeeded by their exces- rhcea. At this period also, a variety of nervous sive deposition ; and that state is induced which symptoms sometimes present themselves ; such has been named hyperostosis: the long bones be- as temporary deafness, or blindness, irritation of come more rounded and massy ; and the sutures the bladder or inability to expel the urine, or of the cranium are often obliterated, and the lines paroxysms of epilepsy, or convulsions. Should of junction raised into flattened ridges. In some these last not prove the cause of death, the patient instances rickets has been followed after some in- at length sinks under debility, and dies exhausted. terval by a remarkable tendency to the production On examining the bodies of those who have of bony growths. There is related by the Bishop died while still labouring under rickets, the brain of Cork, in the Philosophical Transactions for is found disproportionately large, but often in other 1740, 1741, the case of a man who had been so , respects quite natural; in some instances the rickety in his youth that almost every bone in his ventricles are filled, or perhaps considerably di- body was distorted. At the age of eighteen he ' lated with a liquid fluid; and a similar fluid is began to grow stiff, and at length, having lost all also found in the basis of the skull and within the use of his limbs, he became like a statue : he sur- canal of the vertebrae. The cavities of the thorax vived till his sixty-first year, and at his death his and abdomen likewise sometimes contain serous skeleton was found to be one continuous bone or bloody liquid; the lungs are compressed and from the top of his head to his knees. Many , occasionally displaced by the alteration in the osseous growths, some of them of the most gro- ■ form of the thorax; marks of inflammation are tesque forms, branched from his head, back, and often apparent in the pleura and pulmonary sub- haunches; and a portion of fully-formed bone was stance, which last is sometimes hepatized, and at also found imbedded within one of the large other times contains numerous tubercles in various muscles. ! stages of advancement. It is remarkable that in Should the disease not yield before the seventh some cases of rickety children from one to ten or eighth year, the individuals, if they survive, are years old, the thymus gland has been found much condemned to a life of infirmity, which is seldom enlarged, and the upper part of the sternum bulg- prolonged beyond middle age. Such persons suffer '■ ing out, so as to form a concavity, within which exceedingly from the unnatural pressure and dis- : the overgrown organ was lodged. (Lobstein, placement to which the organs of the chest, and | Anatomie Patholog. t. i. p. 54.) The heart is not even the most important of those of the abdomen, found diseased where death occurs during the are more or less subjected. The stomach in these ! active progress of rickets; but in those who have cases is frequently pushed as low as the umbilicus, survived with deformity of the chest, the obstacle and even the urinary functions have been disor- | thus occasioned to the circulation, especially dered by a projecting vertebra pressing upon the j through the lungs, rarely fails to produce in the kidney. These unfortunate individuals are re- ' end hypertrophy of that organ. (Hope, on Dis- markable for their shrill voice, dilated nostrils, and j eases of the Heart, p. 194.) The liver and spleen panting respiration; and life is generally cut short I of rickety subjects are almost in every case en- by one of those attacks of pulmonary inflammation larged, the former in particular. The mesenteric to which they are peculiarly prone ; at other glands are usually enlarged, and often filled with times they are destroyed by the development of j tuberculous matter; and the other absorbent tubercular disease, and occasionally by dropsy. ' glands, both within the abdomen and externally, In rickets, as in most chronic disorders, the present similar alterations. change which takes place at puberty is productive < In the soft parts little or no adipose substance of amendment, or of an increase of the disease, is found ; the muscles are pale, flabby, and wasted; Ravaton has detailed a remarkable case, which i and the rigidity of death is rarely met with in serves well to illustrate this influence. A girl, i such subjects. The bones, during the active whose legs were so deformed that at thirteen years stage of rickets, are found to resemble very vas- she was only three feet high, was seized with con- cular cartilage; the medullary cavities are filled tinued fever ; the catamenia appeared, the limbs with a bloody gelatinous-like substance in place then gradually straightened, and in less than of marrow; and the osseous texture presents three months her height was five feet one inch. every where, even in the cortex, numerous minute The progress of rickets is accelerated by con- cells, from which a thin bloody fluid can be finement and exposure to cold and damp, by bad pressed. The appearance of rickety bones has clothing, imperfect nourishment, and careless been well compared to that of a healthy bone nursing; and retarded by circumstances the re- deprived of its earthy materials by immersion in verse of these : hence it may be that the disease a weak acid ; but there is this difference, that is now of less frequent occurrence than in former the rickety bone is much more vascular, and that times, and that it has been observed to make less the cartilage of which it consists is of so loose a progress in spring and summer, and to advance texture, that it is soluble in the same acid which most quickly in winter and autumn. But the will deprive common bone of its earthy consti- progress of rickets often varies without any ob- j tuents. We are not acquainted with any analysis vious cause ; it sometimes appears to be arrested j of recent bone affected with infantile rickets ; and as if recovery were at hand, then revive, and pro- the examination of those which have been dried ceed with more rapidity than before. As the dis- cannot afford much accurate information respect- ease advances to a fatal termination, the little suf- ing the constituents of parts which obviously con- ferer cannot bear even to be moved in bed, and I tain so unnaturally large a proportion of fluid and 46 RICKETS. easily destructible ingredients. Nothing, indeed, has tended so much to obscure the pathology of the bones as the almost exclusive practice of ma- cerating and preserving them in a dry state. When the bones of those who have recovered from rickets are examined, their texture is found to be more dense, in consequence of a morbidly increased deposition of the earthy salts; even small exostoses and bony spiculae are sometimes observed; and in cases where the spine is de- formed, the bodies of many of the vertebrae are found united by new osseous substance. The bones of the cranium are observed to be much heavier and thicker than natural, the sutures often obliterated, and the grooves formed by the me- ningeal arteries greatly deeper than common. Wherever the bones have been bent during their yielding state, a larger deposition of earthy salts is observed in the interior of the curve where its weakness had been the greatest; and to such an extent does the deposit of osseous matter some- times take place, that the bone at the point of curvatiye has been converted into a solid sub- stance, the medullary cavity being wholly ob- literated. (Stanley, Lond. Medico-Chir. Trans. vol. vii. See also Wilson's Lectures on the Hu- man Skeleton.) Perhaps to some it may appear sufficient to say that the earthy salts are thus deposited, because they are most wanted at the weakest point of the bony shaft; but the real cause of this arrangement seems to be that the bending of the bone has compressed into the in- terior of the curve a larger quantity of cartilaginous substance, which is afterwards filled with an earthy deposit; while it stretches and attenuates that on the exterior of the arch, and so diminishes there the matrix for the reception of earthy ma- terials. It may be observed also, that the effect of bending the pliant bone is to bring its opposite sides into closer approximation, and thus to pre- pare the way for that ossification throughout its whole diameter to which allusion has already been made. Bones which are distorted are commonly named rickety, whether in the active stage of that disease or after its cure, when they have ac- quired an unnatural density from hyperostosis : hence some confusion has arisen in stating the composition of rickety bones ; and the assertion has been hazarded that a deficiency of phosphate of lime is not an essential, but merely an adven- titious circumstance in rickets. Dr. John Davy found 100 parts of the dry tibia of a healthy sub- ject of fifteen to yield 46.4 of animal matter, and 53.6 of earthy; while the same quantity of the dry tibia of a rickety child contained 74 parts of animal and 26 of earthy substance. (Monro, Elements of Anatomy, vol. i. p. 27.) 2. Causes. — Rickets appears under very dif- ferent circumstances, and therefore may be sup- posed to derive its origin from a diversity of causes. It is met with among the children of the affluent, enjoying every advantage of careful nurs- ing, warm clothing, nutritious food, and airy apartments; and it is found likewise in the damp unwholesome dwellings of the artisan and la- bourer, where the child is neglected, scantily clothed, and poorly fed. In the former of these classes it is almost always a hereditary disease, or if not, it exists in connection with a scrofulous I habit transmitted from the parent: in the latter it | may also arise from hereditary influence ; but it seems more generally to originate from those un- favourable circumstances in the rearing of the child which have just been enumerated. Some writers have endeavoured to trace a connection between rickets and gout, syphilis, and scurvy; but it has not been satisfactorily shown that any of these diseases, either in parent or child, can operate as causes of rickets excepting by the de- bility which they may induce, and the predisposi- tion to the malady which may thus be occasioned. Of scrofula, on the other hand, we would speak in very different terms; for the connection of this disease with rickets appears to be very intimate; although we are far from agreeing with Dr. Tho- mas Young in the propriety of classing rickets as 1 a mere species of scrofula, scrofula rhachitis. (Introduction to Medical Literature.) Rickets rarely occurs excepting in delicate and sickly children: instances are occasionally met with where robust children, born of healthy parents, have been attacked with the disease; but it may be questioned whether such cases were truly rickety, or if the yielding of the bones had not rather arisen from the great weight of the infant's body, and from too early endeavours to make him walk. Many cases have occurred which prove the close connection which exists between rhachitic disease and affections of the encephalon, such as hydrocephalus and convulsions. Biichner (De Rhachitide in Haller. Disput. Medic®, torn, vi.) relates that he saw almost the whole of a family of eleven brothers affected with rickets. Most of them died of the disease in an advanced stage, while the rest were carried off by convulsions. Rickets has been observed to prevail in particu- lar localities, probably from their unhealthiness, | and the indigence and misery of their inhabitants. | Hence it may be regarded as occasionally an en- ■ demic disease; it is so described by Glisson in reference to England, (De Rachitide, p. 3. Lugd. Batav. 12mo. 1761,) and instances are recorded : where it assumed the same character in different parts of Germany. (Acta Nat. Curios, vol. ii. obs. 153. Ephemerid. Nat. Curios, cent. i. et ii. append. p. 23.) 3. Treatment.—During the existence of the acute febrile symptoms of rickets, it will be pro- per to administer moderate doses of antimonials, i to employ the tepid bath, and in some instances even to apply leeches to the forehead or nape of the neck, according to the urgency of the case and the strength of the little patient. The im- paired appetite, morbid stools, and disordered j urine require the use of small doses of calomel or | hydrargyrum cum creta; followed by magnesia and rhubarb, or rhubarb and soda, with an occa- j sional dose of a more active aperient, such as castor oil or senna. If the disease have occurred i at a very early age, it may be advisable to try the effect of changing the wet-nurse; and in general it will be proper to wean the child about the end of the ninth month, for protracted suckling is cer- tainly one of the debilitating causes which dispose to rickets. While the child continues at the breast, the diet of the nurse ought to be carefully attended to, in order that her milk may prove RICKETS. 47 nutritious and easy of digestion : or its powers may be assisted by allowing the infant, in addi- tion, small quantities of isinglass-jelly, beef-tea, or yolk of egg, provided the absence of febrile excitement will permit. After the child has been weaned, the diet must be suited to the degree of constitutional irritation which exists; but one leading principle should be to support the strength as much as possible without quickening the circu- lation or oppressing the stomach. Farinaceous food has been condemned by many writers as in- jurious to rickety patients, from its inferior nutrient properties; yet it will not be denied that, during the existence of febrile symptoms, the various pre- parations of starch will be found to yield a mild and appropriate nourishment. Whenever the state of irritation has so far subsided that a more substantial diet can be borne, it ought to be given freely, and even a little wine or sound ale may be allowed as long as it causes no morbid excite- ment. In the second stage of the disease our principal objects in selecting the means of cure are, to give tone to the system, and improve its nutrient and reparative powers; and for these purposes the cold plunge-bath, the affusion of cold water with salt, careful friction of the whole body, and the employment of tonic medicines, will be found very useful. Among the tonics best adapted for cases of rickets may be enumerated sulphate of quinia, gentian, calumba, oxide of zinc, and va- rious preparations of iron, of which, perhaps, the wine and carbonate are to be preferred. With many of these it will be found highly advantage- ous to combine the alkalies and alkaline earths, the choice of some of them being determined by the state of the bowels and the rapidity or languor of the circulation; carbonate of soda being pre- ferable when the bowels are relaxed, and carbonate of ammonia when the action of the heart is lan- guid. In rickety cases, where the nervous energy appears defective, it may be proper, in addition to the means of invigorating the frame already enu- merated, to employ electricity or galvanism, but in a very cautious manner. The clothing of the child ought to be warm, and great care should be taken to preserve it free from damp. The apartment in which he sleeps should be dry and well ventilated, and his resi- dence should be in a pure temperate atmosphere, either in the country or on the sea-coast; and when the weather permits, he should be carried ubout in the open air as much as possible. When the rickety child is carried, it should be alternately in either arm ; and when placed in a chair or laid in bed, his position should be such in regard to the various objects of attraction around him, that he shall not incline continually to one side only ; or so varied from day to day, that the formation of any fixed deformity may if possible be prevented. His bed should be smooth and comfortably firm, and the head but little elevated ; the bed-clothes light, yet sufficiently warm. As soon as the con- stitution appears to be rallying, and the bones acquiring renewed strength and firmness, attempts should be made to restore them to their natural shape by well-directed manipulations, and the employment of such mechanical contrivances as will give support without injurious confinement. Considerable success is known to have attended the treatment practised by the Baron Dupuytren (Repertoire generate d'Anat. et de Phys. Patholog. torn. v. p. 198,) in deformity of the chest. His plan is to place the child with his back against the knee or a wall, and make moderate and gradually increasing pressure with the palm of the hand on the sternum, so as to diminish the antero-posterior diameter of the chest, and force out the ribs to- wards their natural convexity. This practice is repeated day after day very frequently, and at suitable intervals, with increasing force and for a longer time, augmenting and relaxing the pressure so as to suit the movements of respiration ; until at length, after long and careful perseverance, the natural shape of the thorax is to a certain extent restored. II. Rickets of Adults.—Mollifies ossium. 1. History. — The softening of the bones which is met with in persons of adult or advanced age, presents itself in various degrees of severity. Sometimes it is merely a protracted form of in- fantile rickets, which has continued with numerous checks and interruptions, and successive revivals and increase of symptoms, even to advanced life. On other occasions, and these are not rare, soften- ing of the bones occurs during pregnancy or fol- lows parturition, and increases in severity during each successive gestation. The parts of the osseous system chiefly affected in these cases are the spine and the pelvis ; hence the difficulties of childbirth are usually augmented at every suc- ceeding confinement. But the disease has been observed in its most aggravated form among males as well as females, although certainly more often among the latter. Several notices of this intense form of mollifies ossium are to be met with among the early historians and biographers of modern times: thus Abbon, the monk, who lived in the ninth century, relates an extraordinary instance where a very large man was reduced by it to the diminutive size of a child. (Guerres de Paris.) And Abulfedda asserts that the body of the prophet Gatleb was without bones, so that his limbs could be folded up like a garment. (Vita Mohammed.) Perhaps the first medical writer who has made mention of mollities ossium is Hollerius (De Morbis Internis. Rara Quaedam, No. 7. 4to. Paris 1609) : he states briefly that there was a woman in Paris whose whole body was soft and flexible, and without solid bones. The next case on record, and it is a well-marked and interesting one, is that detailed by Abraham Bauda, which occurred at Sedan in 1650. (Mi- crocosmus Mirabilis. Sedan, 1665.) Since that period many instances of mollities ossium have been published in different countries, references to the most important of which will be found in the present article. The softening of the bones in this disease is preceded by severe and long-continued pains, which are usually confounded with rheumatism, and have sometimes been supposed to arise from syphilis: a gradually increasing debility seizes the limbs, the nervous system acquires an excessive morbid irritability, the patient walks with the utmost fearfulness, and the slightest jar or con- 48 RICKETS. cussion of the body causes agony.* Some bone now suffers fracture, which all the efforts of the surgeon are perhaps unable to unite; the patient being constantly confined to bed, the bones soften more and more, assume the most strangely dis- torted forms, and before death have in some cases been so completely disorganized that the extremi- ties were as limber as a rag. (Bevan, in Philos. Trans, v. 42.) The patient lies coiled up in bed, sometimes scarcely preserving, except in counte- nance, the semblance of a human being; the limbs appearing more deformed, and the stature much more shortened than they are actually found to be after death. Every attempt to alter the po- sition of the patient produces agonizing pain, and perhaps new fractures, if the bones be not already too much softened to snap asunder. In such cir- cumstances it is truly astonishing to observe how little the general health suffers, the appetite, di- gestion, and excretions remaining unimpaired till within a few weeks of death, and the mind con- tinuing calm and intelligent, almost to the last. The urine in such cases is frequently turbid, de- positing a copious white sediment; and in some instances small urinary calculi have been voided. But this morbid state of the urine is not constant, for it becomes clear and then again turbid, and occasionally clear for weeks before death. At length hectic fever comes on, sometimes with a feeling of intense burning heat, such that the pa- tient can bear with difficulty the thinnest covering, and requires the windows to be kept open even in the middle of winter.-j- Diarrhoea and perspira- tions now exhaust the patient, and death at length, after years of protracted suffering, comes to his relief. The appearances on inspection after death from mollities ossium differ considerably from those which are observed in the bodies of rickety children. The bones, instead of presenting the appearance of cartilage, as in rickets, are reduced to a mere shell resembling the rind of cheese, and are sometimes described as soft and membranous, and of the thickness of the peritoneum; in one instance the form of some of the bones seems to have been preserved merely by the periosteum ;$ and in the case related by Saviard, (Saviard, Nouv. Recueil d'Observat. Chirurg. p. 276,) the remnants of the bones are described as crumbling between the fingers like the rotten bark of a tree. The cavity within the changed and wasted bone has been found filled with a soft red or liver-colour- ed substance, which in the living body has been ascertained to be devoid of sensibility, (Thomson, Med. Observ. and Inquiries, vol. v. p. 259); at other times the contents have been a reddish fluid of the consistence of thick honey, and free from any disagreeable odour. (Bevan, Phil. Trans, vol. *See a very interesting case by Mr. Howship. Ed. Med. Chir. Trans, v. ii. t Planck, de Osteosarcosi Commentatio, 4to. Tubing. 1782. This writer has been quoted as an authority ori osteosarcoma, but his essay refers wholly to mollities ossium, of which it contains a very interesting case with an able and learned commentary. I Case of Madame Supiol, Moraud, in Mem. de I'Acad. R. des Sciences, i:55.—Hosty, in Phil. Trans. 1753, 54. — Bromfield, Surgical Cases, vol. ii. p. 35. Here she is called Queriot, her maiden name. The skeleton of Madame Supiol is still preserved iu the Museum at the Jardin des Plantes in Paris. xlii. p. 488.) In Mr. Howship's case (Edin. Med. Chir. Trans, vol. ii.) the contents of the wasted bony shell were various in their appearance : one mass resembled coagulated blood, another gorged liver, a third light fibrinous matter, and a fourth was like compact fleshy substance. The last portions of the long bones which undergo these remarkable transformations are the extremities; and the remnants of osseous substance which they present are found softened and honey-combed with numerous irregular apertures, appearing, when macerated, like a thin piece of ice when partly melted ; thus affording unequivocal evidence of the powerful action of the absorbent vessels' to which the osseous tissue had been subjected. The cartilaginous coverings of the articular extremities of the bones have sometimes been found entire, at other times attenuated, but the surface polished and raised into eminences ; the cavities of the joints sound ; and even when unused for six years, filled with healthy synovia. (Case by Thomson, Med. Obs. and Inquiries, vol. v.) Although fractures of the bones have not appear- ed during the life of the patient to have united, yet after death a callus has occasionally been found to have formed, sometimes only within the cavity of the disorganized bone, occupying it com- pletely at the point of fracture ; at others it has ap- peared externally as a prominent ring, and formed within a solid osseous partition, (Planck, de Osteo- sarcosi Comment); thus proving that the solution of continuity had served to restore to the part its ossific powers while they were everywhere else deficient. The muscles, in cases of mollities ossium, are found pale, and in general totally altered in their appearance, so that it would be quite impossible from their adhesions and displacement to unfold them by dissection. The viscera of those who have died of this disease have sometimes been found quite healthy, (Saviard, Rec. des Observ. p. 276. — Howship, Ed. Medico-Chir. Trans, v. ii.); and in most of the cases they are not stated to have suffered much serious alteration; in one instance indeed the liver was enlarged, (Bevan, Phil. Trans.); in another the gall-bladder was contracted, and contained no bile, but many minute black calculi. (Thomson, Med. Ob. and Inq.) It is obvious, however, from the histories of other cases, that the lungs and mucous membrane of the bowels must in these instances, if carefully examined, have presented abundant traces of active disease. 2. The Causes of mollities ossium are exceed- ingly obscure : syphilis, gout, rheumatism, and scurvy, have all been accused as the sources of this singular disorganization of the solid frame- work of the body. The sagacious Saviard ob- serves that syphilis produces caries; but this is a softening and melting down of a totally different nature: as to the other diseases named above, they possess nothing in common with that now under consideration, excepting pain, languor, and debility. In well-marked and extreme cases of syphilis, gout, rheumatism, and scurvy, where death has been the result, we do not meet with mollities ossium as a concomitant, yet authors gravely tell us that softening of the bones arises from the diseases now enumerated lyin the eruption is prominent, the face swells greatly, and many pustules actually suppurate like those in the small-pox ;" and he adds, « the cough and other catarrhal symptoms are the things which distinguish this from the small-pox." Such a disease as that here described RUBEOLA. 57 we have never seen, except it should be merely what we have already alluded to,—measles ac- companied by a great number of miliary vesicles, some of which occasionally suppurate, but bear no resemblance whatever to small-pox : the occa- sional conjunction of the two diseases has been already spoken of. Inoculation.—Some time about the middle of the last century it was proposed to adopt inoc- ulation of measles for the purpose of rendering the disease milder ; and Dr. Home (Clinical Facts and Experiments, 1758,) of Edinburgh performed several experiments on the subject, inoculating with a little blood drawn from one of the exan- thematous patches. The result does not appear to have been either very decisive or satisfactory ; nor has the eligibility of the practice been at all proved by subsequent trials, many of which failed altogether; and even where they succeeded in producing the disease, the operation did not always ensure a mild form of the complaint; on the con- trary, many of the cases so produced were as severe as those arising naturally. On this point we have no evidence to offer from our own expe- rience, never having seen the practice put to the test; and we can only find that authorities of equal weight are completely at variance on the subject. Theurmen and Tellegen, as we learn from Rayer, inoculated five infants without any other result than the production of slightly in- flamed spots where the punctures were made. The same want of success attended the trials made by Dewees and Chapman at the Philadelphia Dispensary in 1801. The most recent trials of which we are aware are those made by Professor Speranza of Mantua: he inoculated in the first instance six individuals, and afterwards himself, with blood taken from a vivid patch of the erup- tion : in a few days the measles appeared, and proceeded mildly and regularly; in consequence of this he made further experiments, and he says they were all successful. Dr. Elliotson thinks it "likely that the vesicles which occasionally ac- company the eruption may contain the contagion itself in a concentrated form." Prognosis.—The prognosis in simple measles is almost always favourable ; but nothing is more certain than that the mildest form may be speedily converted into the most dangerous; a sudden change taking place in the symptoms which could not have been foreseen, or produced by improper treatment, such as the administration of stimulants, by too much heat, or by exposure to cold. It is to be recollected that it is not the eruption or the mere disease which endangers the safety of the patient, but the internal inflammation which may accompany or follow it; and hence the great ne- cessity for ascertaining exactly the degree of their development by a most careful examination of the organs of respiration and digestion, to enable us to form a correct opinion as to the probable result. There is a very general impression that adults are in greater danger from measles than younger sub- jects ; but as far as our experience enables us to judge, we should pronounce exactly a contrary opinion, supposing each to be in an equally good state of health at the time of being attacked. Of course, if an adult encounters the disease with a constitution naturally delicate or previously broken Vol. IV. —8 up by intemperate habits, or with some old pul- monary complaint, such a patient would be in great danger ; but as a general rule, young chil- dren are most likely to suffer severely, because they are most disposed to severe attacks of pul- monary inflammation; so that, in our opinion, the younger the subject the greater the danger. Pregnant women are known to bear all the exanthematous diseases badly, and especially small- pox ; this might, a, priori, be expected, because their system is already in a state very unfavoura- ble for the reception of an inflammatory disease. Rayer considers measles under such circumstances peculiarly dangerous. The cases which the writer has seen have done well; and Heberden (Com- mentaries, p. 322,) expressly mentions that he " attended several who were greatly harassed by the violence of all the usual symptoms in this ill- ness, but never knew it make one woman mis- carry, or be in more danger on account of the pregnancy." The character of a prevailing epidemic should always be taken into account: thus that of 1670, described by Sydenham, was particularly mild, while that of 1674 was remarkable for the frequen- cy of pneumonia.* The season of the year also has no inconsiderable influence on the progress and issue of the complaint, which is likely to pro- ceed more favourably and safely in mildly warm and temperate weather than when there prevails either extreme of heat or cold. When measles and some other disease are conjoined, as for instance variola or pertussis, or when measles follow close upon the subsidence of some other ailment, especially if that has affected the lungs, the danger to be apprehended will be greatly increased : the same may be said when this disease attacks persons of a scrofulous or a plethoric habit. The following may be considered as the general circumstances which should forewarn us of danger: great violence in the symptoms of the eruptive fever; the eruption appearing too soon or too late ; the approach of pulmonary or abdominal inflam- mation ; severe headache with delirium, suffused eyes, or coma ; a hacking cough, with a hard pulse; extreme dyspnoea ; retrocession of the eruption, which is generally owing to some serious internal derangement; the accession of typhoid symptoms; the appearance of petechiae ; profuse hemorrhages, inducing prostration of strength :f while, on the other hand, a favourable case may be known by the regularity with which the erup- tion appears and proceeds, and its equal distri- bution on the different parts of the Body succes- sively ; by the absence or slightness of the symp- toms of thoracic or abdominal inflammation ; free- dom from headach ; the soft state of the pulse ; the naturally moist condition of the skin ; and the patient obtaining a sufficiency of refreshing sleep. From the London bills of mortality, it * Thenumber of deaths from measles that year amount- ed to 795; while for the three preceding years, taken to- gether, they amounted only to 140. t When females, especially girls, are the subjects of measles, it very frequently happens that during the eruptive stage of the disease the calamenia make their appearance perhaps a week or two before their natural period, and sometimes much more profusely than is natural; this we have repeatedly observed to happen, not only without injury, but we have thought with advantage. 58 RUBEOLA —RUPIA. appears that there died, from December to October 1831, of measles 532, of small-pox 436, and during the same period in 1832 the number of deaths were, of measles 508, of small-pox 532; making a total of measles 1040, of small-pox 968. Morton has given a very highly exaggerated account (Append, ad Exer. de Morb. Acutis, p. 427,) of the mortality during the epidemic of 1672, when he says the deaths from measles were three hundred every week; whereas it appears, from the public bills of mortality, that the whole number of deaths for that year by measles amount- ed only to 118. (See paper by Dr. Dickson in Med. Obs. and Enq. vol. iv. p. 256.) Sequelee.—Measles are very frequently follow- ed by a train of symptoms indicative of serious pulmonary lesions, very generally by a distressing and tedious cough, by chronic bronchitis, chronic pleuritis, pneumonia,* tubercles and phthisis ; chronic diarrhoea, generally of an inflammatory character, sometimes harasses and exhausts the patient; ophthalmia, ear-ach, and running of the ears, occasionally also supervene. There are several cutaneous affections apt to appear after measles; amongst them is a very troublesome eruption of inflamed pustules, sometimes termina- ting in ulceration. In a few instances gangrene of the inside of the cheeks, gums, and lips, in the horrid form of cancrum oris, has been observed ; in other instances the mortification has affected the vulva. Anasarca has been known to appear after measles, as it very often does after scarlatina ; but this is so rare an occurrence, that where anasarca is found, and said to have been preceded by measles, there is much reason to suspect that the previous disease was scarlatina. (Frank, torn. ii. p. 372, op. cit. Guersent, Diet de Med. art. Rougeole.) Dr. Harty, who has had extensive op- portunities of observing this disease, informed the writer that he has very frequently found during convalescence from measles that the pulse became unusually slow, about forty or fifty beats in a minute ; but it did not appear to be connected with any thing unfavourable in the condition of the patients, whose recovery was uninterrupted. William F. Montgomery. RUPIA, from f>irot, sordes, may be character- ized as an eruption of flattened and scattered bulla?, each surrounded with an inflamed areola; the bulla? filled with serous, purulent, sanious or dark bloody fluid, and succeeded by thick dark-coloured scabs covering unhealthy ulcerations. Bateman and Biett describe the varieties of rupia under three species or heads, viz. rupia simplex, rupia prominens, and rupia escharotica. The last of these, rupia escharotica, being the same disease as gangrenous or infantile pemphigus, and as such already fully described in the article Pem- phigus ; the other two species, rupia simplex and rupia prominens, alone demand a place here : moreover, as these differ from one another merely * Laennec thinks that the suffocating orthopncea which sometimes very suddenly carries off young children after measles is produced by an idiopathic cedoma of the lungs. In the greater number of cases examined after death by the writer, the morbid alteration existing was the condensation of the pulmonary structure ordinarily found as the effect of pneumonia. in degree of severity, they may be comprised under one general description. The bulla? of rupia are observed most often on the lower extremities, but are also frequently seen on the loins, the upper extremities, and about the shoulders. They are always few in number, and are generally scattered at some distance from one another. In the mild form, (rupia simplex,) one or more oval bulla? arise with little or no premoni- tory redness of the skin. These bulla? arc flat- tened, and are filled with a sero-purulent fluid, and seldom exceed a sixpence in size. After the lapse of a few hours from their formation, they become partially flaccid ; the contained fluid grows muddy and puriform, and dries into a dark-brown scab, thick in the centre, and thin towards the circumference. Around the scab there is a dusky red areola, the cuticle covering which is slightly raised or separated from the true skin, and con- tinues all round with the thin edges of the scab. The latter is in general easily removed, or falls after a few days, leaving an unhealthy-looking ulceration of the skin, which either becomes crusted with a fresh succession of scabs, or heals, leaving a dark purple mark. In the aggravated degree of the disease, (rupia prominens,) a circumscribed inflammatory redness precedes the formation of the bulla?. The bulla? rise slowly, and, instead of serous fluid, contain purulent matter or a nur- ture of purulent matter and blood, which consti- tutes the blackish fluid already mentioned as some- times found in the bulla?. The contained fluid dries into a very dark-coloured scab, which covers a deeper ulceration, and is surrounded by a wider inflammatory areola than in rupia simplex, and as the ulcerated surface is continually secreting pus, and at the same time enlarging in circum- ference, the scab is increased by successive layers, each wider than the preceding, and at length, at the termination of ten or twelve days, acquires a conical shape similar to a limpet-shell, sometimes extending at the base to the size of a dollar in area, and protruding in the centre an inch above the surface of the skin : hence the name of this variety of the disease — rupia prominens. This scab is superficial, and if removed is either replaced by a fresh scab, or leaves exposed a pale unhealthy spreading ulcer, bleeding on the slightest touch, of a depth proportionate to the duration of the scab, with livid swollen borders, and in old per- sons often very difficult to heal and even when healed leaving a dark-coloured cicatrix. Diagnosis.—Rupia may be confounded with pemphigus, ecthyma, and venereal pustular erup- tion, but the bulla? of pemphigus are large, full, and very prominent, and generally contain a serous fluid, while the bulla? of rupia are small, flattened, quickly become flaccid, and contain a fluid, which, if not sanious or purulent from the commence- ment, very quickly becomes so. Gangrenous pem- phigus pours out a sanious fluid, but does not form scales like rupia. The ulcerations of rupia are deep and indented, while those of pemphigM are superficial, resembling excoriations. The shape of the scab in rupia prominens at once dis- anguishes this variety from pemphigus. Rupia iuriZT { fTd in conJunctio» with ecthyma lundum and cachecticum, and Plumbe has classed rupia and ecthyma together. The two di eases RUPIA — SCABIES. 59 are, however, very distinct in their pathology and appearance. Ecthyma commences as a pustule, rupia as a bulla. The scab of rupia is generally easily removed; the scab of ecthyma is strongly adherent. Around the circumference of the scab of ecthyma there is deep-seated inflammatory hard- ness, extending into the subcutaneous cellular tissue; around the scab of rupia there is only a superficial red areola, the cuticle over which can be traced in continuation with the surface of the scab. The scab formed on some of the pustular venereal eruptions bears a very close resemblance to the scab of rupia; and as both diseases are likely to occur in the same broken-down constitu- tions, there is risk of confounding them. The venereal scab and pustule are, however, found to proceed from pustules with hardened bases, not from bulla? as in rupia, and they are generally surrounded with the peculiar syphilitic copper- coloured areola?. These characters, with the pre- sence of some of the usual constitutional symp- toms of syphilis, will suffice to distinguish the two diseases. Plumbe speaks of having seen evil re- sult from mercury being administered for rupia, under the mistaken supposition of its being a venereal affection. Few practitioners, however, in the present day, after the clear and lucid views laid down for the treatment of venereal affections by Mr. Carmichael, (an Essay on Venereal Dis- eases, and the Use and Abuse of Mercury in their Treatment, by Richard Carmichael, M. R. I. A., &c), would push mercury to any extent for such appearances, even admitting them to be of vene- real origin. Prognosis. — The duration of rupia is very uncertain, running through its course in a few days, or extending to months. The disease is severe in proportion to the age of the patient, or weakness of the constitution. The slowly-healing ulcerations often keep up a low fever in the sys- tem, and thus injure the health, but rupia is scarcely if ever a fatal disease. Causes.—Rupia may be considered as altoge- ther a constitutional affection, being only seen in the aged, or in the debilitated from any cause, but particularly from intemperance, abuse of mercury, or want. Acute diseases affecting the skin, and leaving much debility after them, predispose to it; thus it appears as a sequela of small-pox and scarlatina. The scrofulous are peculiarly subject to it, and it is most prevalent during the winter season among the poor who are badly fed and clothed. Treatment.—From what has been just stated relative to the causes of rupia, its treatment is easily anticipated. The remedies are a light nu- tritious diet, cleanliness, the warm bath, attention to the state of the bowels, and sarsapaiilla or cin- chona, with the mineral acids. Dr. A. T. Thom- son, in his edition of Bateman, says that slight mercurial courses carried so far as to affect the mouth are sometimes necessary. Mercury, when used in this disease, should according to the best observers be used only as an alterative, and in its mildest forms, as in Plummer's pill. As to local applications, the scabs should be removed by a poultice, and the raw surfaces, if painful, are to be stuped with decoction of bran and poppy- heads. Relaxing or emollient applications, how- ever, should be used only for a short time; the surfaces of the ulcers very soon require stimulat- ing applications, and the strength of these must vary, according to the relaxed state of the ulcers, from a weak solution of nitrate of silver to the application of the solid nitrate, the strong nitric or muriatic acid, or ointment of red precipitate of mercury. Rayer recommends the ulcers to be dressed with saturine cerate, pledgets of lint to be placed over this dressing, and all to be confined with a bandage which shall keep up a moderate compression. He recommends the ulcers when indolent to be dusted with powdered supertartrate of potass, or a solution of it to be used as a lotion. In this, as in all skin diseases where there is ul- ceration attended with low irritative fever, internal opiates given at bed-time to procure sleep form an essential requisite in the treatment. D. J. CORRIGAN. [SALIVATION, See Pttaiism.] SCABIES.—This is the classical word now universally used to designate the well-known con- tagious vesicular disease of the skin, called popu- larly, in English, itch, French, gale, German, Kriitze, Italian, rogna, &c. These vulgar appel- lations, except the French, (the etymology of which is doubtful,) are derived from the property which our English expresses, the intense itching and irresistible scratching which it excites. Sca- bies is the word by which the Latins rendered the d/wpa of the Greeks, a term under which the latter comprehended a number of papular and squamous affections, although they at length appropriated it to the disease which we now denominate psoriasis. The confusion which for a long time attached to •Jywpo necessarily involved its synonym scabies, and prevented it from becoming definite in its signification, until they were divorced by Celsus, who restricted the Greek term to scaly diseases, and excluded these from the comprehension of the Latin scabies. The Roman physician and his successors did not, however, confine its significa- tion within its present limits, but included under it other pustular and pruriginous affections, and so caused an inaccurate latitude in its acceptation, which prevailed to a comparatively recent period. The advance of cutaneous pathology at length isolated the disease, but the verbal confusion was revived by Cullen and others, who, when scabies had been definitely fixed, chose for the designation of the itch the term anciently used in so indefinite a sense by the Greeks, psora, which (with a pro- longed termination) Willan, with a greater regard to its old signification, appropriated to the scaly disease. No imputation of inexactness in this instance attaches to the old medical writers, for words must ever be varying and inconstant in their signification until the state of science per- mits the diseases which they represent to be investigated upon enlightened principles, and dis- criminated by a true nosology; but authors are to blame, who, after this period arrives, embarrass the received nomenclature by arbitrarily multiply- ing names, or changing them from their general acceptation. Scabies is one of the cutaneous diseases the distinct identity of which is best confirmed by pe- culiar characters, yet in the description of which SCABIES. such a variety exists as to render it extremely difficult to give a comprehensive account of its history and symptoms. An artificial arrangement would be very desirable for this purpose, but in seeking for such we find how difficult it is to fix arbitrary bounds within which natural phenomena may be circumscribed. " This troublesome dis- ease," says Bateman, " from its affinity with three orders of eruptive appearances, pustules, vesicles, and papula?, almost bids defiance to any attempt to reduce it to an artificial classification." (Sy- nopsis, 7th edition, 1829, p. 278.) A ready illus- tration of this statement is found in the fact that while Willan has placed it in his order "pustula?," Biett and Rayer, who have adopted his system, classify it among the vesicles; and again, Dr. Paget, the author of a late ingenious essay on the classification of cutaneous diseases, (Edin. Med. and Surg. Journal, vol. xxxiv. p. 270,) coincides with others who consider it as appertaining to the papulse. It does not belong to our object to main- tain the credit of the artificial arrangement, but we may remark that this discrepancy, which shows its defectiveness in this particular as a system, by no means detracts from its practical advantages; on the contrary, the purposes of study and description demand more urgently the aid of arbitrary methods of arrangement when the natural appearances are diversified. It is admitted by the majority of observers, that by far the greatest part of the eruption of scabies is composed of vesicles, so that we unhesitatingly agree with the French authors above cited in regarding its- type as essentially vesicular. The transparent apex of the elevation is often so minute or so fugitive as to give the idea of a papula, if not observed attentively and at the seasonable period of its course. With respect to the true papula?, which arc often interspersed amongst the vesicles, it is to be observed that in all eruptions of the skin (whether their real type be vesicle or pustule) there is a period at which the elevation is merely a papula, and it frequently happens that in a vesicular or pustular eruption some pimples proceed no farther in their develop- ment than the state of papula?. Nothing is more common than to see among the pustules of porrigo several which have no purulent apex, having never advanced beyond the papular stage ; but on this account their genuine character is not the less established, being properly regarded as undeve- loped pustules. The papula? which complicate the vesicles of scabies bear a larger proportion to the true type than in the example of porrigo, but they appear to possess a similar relation to it, being as it were abortive vesicles. The occurrence of pus- tules in scabies forms, indeed, a more decided va- riety, as one species of it seems to be truly pustular in its nature. Yet it is not to be overlooked that some of these apparent pustules are also primi- tively vesicles, in which an inflammation of more than ordinary acuteness has produced a purulent secretion instead of transparent serum. Accord- ing, then, to the opinion here stated, we embrace the vesicular as the true type of the eruption, and regard the deviations of papula?, and in part those I of pustules, as caused by casual variations in the intensity of the inflammatory action. On the one ' hand, papula? occur where the inflammation stops j short of maturing vesicles; and on the other, pustules are met with when, proceeding to an immoderate degree, it fills the vesicles with pus in place of serum. The contagious nature of this eruptive disease is the most essential character of its history. Its vesicles are minute and slightly acuminated, with a pearly semi-transparency at their summit. They may arise at any part of the body, and spread until it cover every part except the face, which appears to possess a singular immunity from their invasion. The hands and arms are always prin- cipally affected, and are often so when no other part of the body partakes of the eruption, which is sufficiently accounted for by the fact that infec- tious contact usually occurs in this situation. The vesicles are mostly distinct, but have a dis- position to accumulate at the flexures of the joints; being almost invariably found confluent on the soft fold of skin between the fingers and at the joint of the phalanges and wrist, and often at the larger articulations, if the eruption be more exten- sively spread. The intense itching which is the characteristic feature of this troublesome disease accompanies the first appearance of the eruption, and, indeed, seems generally to precede it, as the inflammatory elevation which generates the vesicle is much promoted by the scratching, which the pruritus irresistibly induces. It increases from the commencement until each vesicle attains a certain degree of maturation, when it decreases. The annoyance which it produces is in proportion to the extent of the eruption; if the vesicles be few in number, are developed slowly, and confined to a circumscribed locality, it may cause little atten- tion ; but when they are numerous and extensive, and come out with rapidity, the pruritus rises to an intolerable height, and produces inexpressible irritation. The patient then seeks to assuage it by scratching, from which, howsoever he may be cautioned against it, he feels it impossible to refrain. Temporary relief may be obtained from this by changing the itching sensation into the pain of laceration, but he only lays up in store a future visitation of greater intensity. The action of the nails increases the inflammation, which causes new crops of vesicles to spring up, and aggravates the pruritus in the old. More or less of the same consequences flow from any other cir- cumstances which give rise to even a transitory excitement of the cutaneous circulation, as the warmth of bed, the digestion of a stimulating meal, or the use of spirituous potations. Several days elapse between the time of infec- tious contact and the manifestation of the pruritus, which period is called in this as in other eruptive diseases the incubation. Its length is much mo- dified by the age of the individual, as connected with the susceptibility of the cutaneous surface to impressions. In childhood, when the skin is soft and active in its functions, the incubation has generally three or four days' duration ; in adults it averages ten to fifteen, and in old age, when the skin is rigid and has lost its vascularity, this period is still more prolonged. I„ the bilious temperament, in which the skin's function is less energetic than in the lymphatic and sanguine it is a so comparatively protracted. The relations of climate and seasons, moreover, have a sensible SCABIES. 61 effect on it, cold and heat respectively retarding and accelerating the first appearance of the dis- ease. The existence of an inflammatory affection of any internal organ is another condition which appears to diminish the susceptibility of the skin to its infection, and to add to the period of incuba- tion. The circumstances connected with this latent period are worthy of attention, not only on account of their intrinsic interest as pathological facts, but because they afford an important prac- tical deduction, which is as follows : the duration of this period has a relation to the actual course of the disease, and the facility with which it may be removed ; when the eruption appears promptly after infection has been contracted, it may be in- ferred that the disease can be speedily conquered by the appropriate remedial applications; but if, on the contrary, the skin has exhibited a tardy inactivity in producing the eruption, when fully developed, the latter will be proportionately in- veterate and less amenable to therapeutic means. When scabies has fully appeared, although it may be modified as to its intensity by circum- stances, it always assumes a progressive course, until arrested by treatment; it has no tendency like the exanthematous eruptions to a spontaneous cure. From its original seat it spreads until the whole surface is affected, but collects especially where the skin is disposed in loose folds, subject to friction, as the axilla, the internal parts of the thighs, and fold of the buttock, as well as the flexures of the articulations. The situation where it may first show itself appears to be entirely de- pendent on the liability of different parts to con- tact with infected persons. This is demonstrable from the consideration of it in different individuals, whose condition in life exposes one part of the body more than the rest : for example, in tailors, sempstresses, and shoemakers, it commences on the hands; in infants in the nurses' arms, the nates are frequently found to be the part first af- fected ; and if, on the contrary, the nurse receive it from the child, it breaks out on the hands, and sometimes (which is more in point) on the breast. An exception to this rule would seem to exist in the case of dyers, smiths, and sawyers, whose hands and wrists are rarely primitively affected, and often escape, while it infests other parts: this is to be ascribed to the rough hardened state which the hands of these tradesmen contract from labour, and doubtless in the first two their im- munity must be in some part owing to the chemi- cal agents with which their employments bring their hands in contact. Sulphuric acid and other powerful astringents form a main ingredient in the dyers' liquors, and the iron and embers of the forge constantly impregnate the smiths' hands with sulphureous vapours, which are at once its best prophylactic and cure. Redi asserts that he knew an instance in which the face became the first part affected, from the contact of the collar of an infected mantle; but its appearance on the face at all is so contrary to experience deduced from innumerable observations, that this has been denied to be a genuine case of scabies by later writers. Willan and Bateman divided scabies into four species, derived purely from the variety of form which the disease assumes. They have not been followed in this by the recent authors who have borrowed their arrangement. As the framer of a system, Willan was disposed to attach too much nosological importance to his divisions, and his followers conceiving that they imply theo- retic error, have in many instances relinquished them. It does not appear, however, that by so doing they have attained either to more simplicity of arrangement or fidelity of description, but rather the contrary. In our opinion, the specific distinc- tions which Willan employed are as valuable as the grander divisions of his system, and to those who are jealous about natural arrangement they are less objectionable, as being the mere expres- sions of facts, which may be received without re- ference to any theory of classification. Artificial subdivisions of cutaneous diseases founded on real differences in external characters, if they have no other advantages, greatly facilitate their study, and without the aid derived from this source their description becomes necessarily either vague or defective. In scabies, these practical means of discrimination are particularly requisite, as its di- agnosis, which is of great importance, is chiefly to be arrived at (where contagion cannot be proved) by an accurate knowledge of its external characters. We now proceed further with its description, and in addition to the general remarks with which we commenced it, we recommend attention to the following divisions, which are the same as those proposed by Willan. Far from being the mere offspring of theory, they were suggested to him by their common use amongst the lower order, whose familiarity with it forces them to be intimately ac- quainted with the various forms in which it ap- pears. Of these they distinguish four, designated the rank, watery, pocky, and scorbutic itch, which Willan adapted to his nomenclature under the fol- lowing titles, viz.:— Scabies papuliformis. ------lymphatica. ------purulenta. ------cachectica. Scabies Papuliformis, or Rank Itch.—In this form of scabies the eruption is generally ex- tensive, and accompanied with slight inflammation in the vesicles, and intense itching. It is found chiefly to infest the fingers and wrists, but also spreads extensively upon the trunk, particularly the front part of the chest and abdomen. The elevations resemble papula?, and thus seem to evince an affinity between this form and prurigo and some varieties of lichen; but where they are fully developed and unbroken by scratching, a close inspection may always detect the transparent apex which indicates its vesicular character. The itching is so troublesome that frequent scratching is resorted to, and the abrasion of the vesicles and even of the skin which ensues, changes the primi- tive appearance of the eruption ; " long red lines are here and there left, and the blood and humour concrete upon the vesicles into little brown or blackish scabs." When it occurs in a sanguine habit, or if it be inordinately exasperated by scratching or other circumstances, some scattered pustules sometimes make their appearance, filled with thick yellow purulent matter. Scabies Lymphatica, or Watery Itch.— The difference between this and the former is in- 62 SCABIES. considerable. The separate vesicles are larger and do not partake of the papular character, being full of serum to the base, which besides exhibits no inflammatory redness. The pruritus is extremely troublesome, and when the vesicles are ruptured, moist excoriations are apt to form, upon which after a certain time dark scabs concrete. The most ordinary appearance which this variety pre- sents is a compound of the three stages just re- ferred to, viz. the entire vesicle, the excoriation succeeding its laceration, and the scab which co- vers this ulcerated part when it begins to heal. It seldom extends like the former variety to the trunk, but is chiefly found collected at the lower parts of the extremities, on the fingers, wrists, back of the hands, and on the feet and toes. Scabies Parnlcnta, or Poclty Itch.—This possesses more the characters of a distinct species than any of the other forms, and evinces the ne- cessity of marking these varieties. As Bateman well remarks, " it is often mistaken by those who con- fine their notion of scabies to the ichorous vesicles of the varieties already noticed." Heberden had divided the disease into two species, comprehend- ing in the first two former varieties under the name of " pustula? exigua?, aqua* plena?." (Com- ment, de Morb. Histor. et Curat. Frankf. ad Moen. 1804. P. 102.) The other he describes as » ma- juscula? cum fundamento rubro, et pure implean- tur, fere tanquam variola?." This resemblance of the round pustules which constitute this species to small-pox, caused the vulgar to denominate it pocky itch. They arise distinct, upon an inflamed base, above which they are considerably elevated: after a few days they maturate and break, having attained frequently to a diameter of two or three lines. The pruritus which they occasion is mixed with a painful tension of the part, different from that which occurs in the vesicular forms. After their breaking they leave a cracked ulceration be- hind, the heat and stiffness of which cause con- siderable pain. The pustules may spread like the vesicular form over the body, but seldom extend far from their original seat, which is usually the hands or feet. In these situations they are largest, and two or three of them sometimes coalesce be- tween the knuckles, especially between the index finger and thumb. The scabby concretions which at length form upon the ulcerations adhere for a considerable time during the healing procesis. The pustular scabies occurs usually in children before the age of ten years. Scabies CacUectica, or Scorbutic Itch.__ This is not distinguished from the forementioned varieties by difference in external character; for it appears under the forms of the other varieties, at one time indiscriminately mixed, at another ex- hibiting them separately in different parts of the body. It mostly occurs in persons of debilitated constitution, brought on by indigence and intem- perance, and is the most intractable form of scabies. It is not unfrequently combined in such individuals with other cutaneous maladies, as lichen, prurigo, ecthyma, and impetigo ; and Bate- man asserts that when the latter disease is super- added, it, as well as the scabies, possess a conta- gious character. He also remarks that the most severe degree of it which his experience made him acquainted with, exhibited itself in persons who came from India, and he had often observed it in children brought from that country. It is there denominated »courap," a term which is equivalent to itch, and is the same which Bontius (De Medicina. Indorum, lib. iii. cap. 17) describes under the name of herpes, seu impetigo Indica, and Sauvages under that of scabies Indica. It was, perhaps, superfluous to make a separate species of this, inasmuch as it possesses no par. ticular form which distinguishes it from the others; vet, as it is so disposed in Willan's divisions, it might be invidious in such a matter to use an arbitrary power in altering an established arrange- ment, which we have taken advantage of for greater facility of description. In whatsoever form scabies manifests itself, it is to be regarded entirely as a local affection, being never like other vesicular eruptions connected with disorder of the internal organs. It gives rise to no disturbance of the circulation, except in severe cases of the pustular scabies, which, from the inflammation sometimes attending it, causes slight febrile action in children. Some authors recount a list of the most formidable diseases as liable to be produced by its retrocession and the metastatic transport of the cutaneous irritation to the vital organs. These notions, however, are now disregarded, being justly considered as the imaginary fabrications of an exploded theory, which pretended that a specific virus residing in the serum of the blood was the cause of scabies. We conceive that the observations of others which assert that important diseases of the internal or- gans have been cured by its eruption are to be equally unheeded. Unprejudiced experience de- monstrates that it exerts little or no pathological sympathy upon the internal organs, and therefore such cases as those narrated by Beer* and others can be only regarded as coincidences. The disease chiefly shows itself amongst chil- dren ; yet on this account it is not to be inferred that it shows a preference for youth more than age. This is to be attributed solely to the fact, that children are more brought in contact with in- fection than adults, from their heedlessness of ex- posure and inattention to cleanliness. It depends upon the same cause that amongst the working classes males are more generally affected with it than females. Climate does not appear to have much effect in modifying its prevalence,—although it is certainly more common in the northern parts of Europe than the southern, an observation which we think must be connected with the fact that in- dividuals of sanguine and lymphatic are much more liable to it than those of bilious tempera- ments. Habits of uncleanliness, however, are more powerful than this predisposition arising from the temperaments, of which its great prew- lence amongst the Polish Jews and Spaniards affords examples ; for amongst these people, as i< well known, the bilious preponderates beyond comparison oyer the opposite temperaments. It prevails in so general and constant a manner in some countries that it may be said to be en- demic. In Poland and Hungary the mass of the r»^GIfrh|Chle £"-es eenciltR" vollkommenen, von »■ Arrfw„\TTfe' K'?™ ^tstandenem. schwarzen Slaar* if if t- . an Amaurosis caused by Retrocession at Itch, which was perfectly cured ) Svo* Vienna!'iTO8. SCABIES. 63 population are constantly more or less infected, and it is equally rife in Galicia and Asturias in Spain, in Lower Brittany in France, and in cer- tain parts of the Highlands of Scotland. It is, however, no stranger amongst the indigent classes of every country, and where it is found to infest one region with peculiar pertinacity, this is not to be attributed to any special influence of the atmo- sphere or the soil, which alone would properly entitle it to be called endemic, but to the habits of the poor population. It has been suggested that salt diet and the neighbourhood of the sea were concerned in maintaining it in some districts, but these circumstances have no influence in pro- ducing it, although they are frequent concomi- tants of that which is its true promoting cause,— inattention to cleanliness of the person, and par- ticularly of the habiliments. Change of linen is the surest protection from it in a family or in a country, and we may with certainty predict its prevalence amongst every people where custom or necessity has precluded this best preservative of the health of the skin. This malady inspires, as might be supposed, no friendly feeling in communities, and it is cu- rious in this respect to remark the difference be- tween it and those contagious eruptions which put life in jeopardy, as small-pox, measles, &c. With whatsoever dread the latter may be contem- plated, they do not produce disgust; but the itch, being free from danger, may be treated more dis- respectfully, and is very generally regarded as contemptible. However, different nations have different opinions on this subject; it is reported of the inhabitants of the Spanish provinces before mentioned, that they retain it often from the cradle to the tomb, and that they are not only careless of its concealment, but regard it as a kind of hereditary possession ; they even refuse to use means to be freed from it, alleging that they are not willing to change the customs of their ances- tors. (Diet, des Sciences Med. t. xvii. p. 183.) But in countries where civilization is more dif- fused, its residence is less tolerated. Here even the imputation of the itch becomes almost inju- rious, and sometimes engages philosophers in its refutation, of which the following is an example. " Laennec was a true Breton, fond of his country and jealous of its honour. It is amusing to ob- serve the high tone he assumes in refuting a charge brought by a certain writer against his native country, for being infamous for an epidemic itch. He solemnly assures us, that if in very truth ' la gale s'observe quelquefois en Bretagne, on en doit moins accuser les localites, que le passage et le sejour des matelots." (Fofbes's Translation of Laennec, Author's Life, p. xxviii.) Equally patriotic renunciations of it have been made in our own islands. Diagnosis. — There is scarcely any disease compromising the general health in so trivial a degree in which it may be more important to the reputation of the practitioner to be able to deliver a categorical diagnosis than in scabies. He is in fact frequently consulted for no other purpose than to decide whether an individual has not brought this contagious affection into his circle ; and as the physician's opinion on the one hand sets him free from this suspicion, and on the other sentences him to a temporary banishment from society or even from his employment, it is obvious how much it behoves him to be able to distinguish it without error. In forming his opinion, he should learn to be as much as possible independ- ent of the criterion furnished by its contagious quality, for it will be generally where this point is yet undecided that his judgment will be sought for. When some evidence of exposure to infec- tion exists in addition to the proper characters of the eruption, there is no difficulty; but if such be unattainable, it will often require all the re- sources which an accurate acquaintance with it and other affections which resemble it supplies to distinguish between them. The eruptions with which it is liable to be confounded are some forms of lichen, prurigo, and eczema. The papular ele- vations of lichen are attended with considerable itching, and are frequently abraded by scratching, so that considerable resemblance may exist be- tween them and scabies, particularly the first va- riety of it above noted, (s. papuliformis.) If the latter be present, the apparent papula?, ex- amined in an unbroken state, will be found to be topped by a vesicular apex, and where they have broken spontaneously, a dark scab remains; but in lichen the papula is solid, even to the summit, and it passes away in a scurfy exfoliation. Lichen occupies the back of the hand, and the external surface of the limbs, and is seldom or never de- veloped in the intervals of the fingers. Moreover the itching is not nearly so intense as in scabies, and is of a more remitting nature, and the papu- lar eruption is commonly attended by some con- stitutional disturbance which is foreign to scabies. In the lichen urticatus the eruption is of a more acute nature, and has occasionally a few vesicles interspersed amongst the papula?, which might confound an observer who relied on any single characteristic; but the diagnosis in this case is still easier than in the simple lichen—the inflamed wheel-like papula?, causing rather a deep tingling than an intense itching, sufficiently distinguish this eruption. Finally, the suspicion of contagion will seldom attach to any form of lichen. The itching of prurigo is of a still more vehe- ment character than that of scabies; they were of old frequently confounded, insomuch that the former was sometimes erroneously denominated scabies sicca. (See Puurigo.) The diagnosis between them is not difficult if these points be held in memory. Prurigo occurs chiefly in elderly individuals; its papula? are flat, and when abraded by the nails no serous fluid is effused, but a dark spot of blood concretes upon their surface. The situation also of the prurigtnous eruption (as that of lichen) is distinguished from scabies by its preference to the surfaces of extension on the ex- tremities, instead of those of flexion, which the latter particularly affects. Prurigo, moreover, is not contagious. In eczema we have a vesicular eruption, which often bears a striking resemblance to scabies in the second variety, (s. lymphatica.) Its vesicles, however, are more flattened and confluent than those of scabies, which are acuminated and dis- tinct. But when the disease is passed to an ul- cerated and scabby state, such distinguishing characters may be wanting, and then other cir- 64 SCABIES. rumstances must be sought out. Eczema is for the most part a local affection, and when the itch lias in any place assumed the ulcerations and soft scabs which resemble it, the eruption has pro- ceeded to a considerable extent, and will doubtless show its proper form in the parts which it has most recently invaded. The irritation of eczema is a stinging or tingling sensation very different from the pruritus of the itch, and its origin may be often traced to the action of irritating causes upon the skin, as sugar, lime, and other acrid substances, or to exposure to the solar rays or great heats. Very lately a female presented herself to the writer with an eruption at the root of the right middle finger, which from its situation and ap- pearance was difficult to distinguish from scabies. She ascribed its origin to milking cows, whose teats were in a diseased state. The pruritus was not that of scabies, and after a careful examina- tion it was concluded to be a vesicular form of impetigo. Bateman calls attention to the possi- bility of confounding the pustular form of scabies with impetigo, and even with ecthyma; and al- though this seems remote, it is yet only a prudent caution to keep in mind every form of cutaneous disease which bears any affinity to it. A circumstance in the history of scabies of the greatest moment, is the simultaneous presence of the diseases which we have just contrasted with it for the sake of diagnosis. This is indeed rare in ordinary cases of itch, but the fact of its occa- sional occurrence forcibly impresses the necessity of cautious examination, and adds much practical importance to the diagnosis, because those com- plications require a line of treatment quite dis- tinct from that of scabies. They are met with in the cases in which much inflammation has at- tended the scabid eruption, and (which serves to illustrate what we have said as to their different treatment) they are very frequently produced by improper applications for its cure, such as power- fully irritant lotions or frictions. The actual complication which may be present will be much influenced by the constitution and age of the subject; in young and vigorous habits, the excess of irritation will mostly take the form of eczema or of impetigo, while in those of an opposite condition pustules of ecthyma may appear, or the inflammation may seize on the cellular tissue, and an eruption of boils be the consequence. Caze- nave and Schedel remark that the same subject may present at once " vesicles of itch, pustules of impetigo, pustules of ecthyma, and boils," (Abrege Pratique des Mai. de la Peau, Paris, 1828. p. 120,) a case which would exercise the diagnostic tact of the physician to discover the primary contagious disease amongst so many complications. Causes.—The universally diffused cause of sca- bies is contagion, and it appears to be the disease which of all is most readily communicated by contact. When it once gains admission into a family, the greatest caution often fails in prevent- ing it from infecting every individual. A question exists undecided among pathologists as to whether it ever originates from any other source than con- tagion. It was observed by Sir John Pringle, that in military hospitals the patients often became the subject of itch after the crisis of fevers, (Bateman « Svnopsis, p. 288, note) ; but there remains little doubt in our mind that this excellent physician in these instances mistook some of the papular erup- lions, as lichen or prurigo, for scabies, for those are not uncommonly observed to occur when the skin recovers its tone in the convalescence from fever. We would make the same remark with respect to a kind of it which Heberden describes as primarily contracted by contagion, hut which being cured by the customary remedies, «tamen non cessat redire semel vel bis quotamnis." (Op, cit. p. 102.) This is rather the description of the lichen simplex, occurring periodically in a person who has been once affected with scabies; for this faithful observer adds, that after its first attack it is no longer communicable by contagion, even to those who lie in the same bed, and that it as often terminated spontaneously as it was removed by any remedy. Bateman thought that it might originate without contagion in crowded, close, and un- cleanly houses, and wherever the means of clean- liness were not obtainable. (Synopsis, p. 289.) These are, however, just the circumstances which facilitate the propagation of contagion. On the whole, there are no facts which contravene the opinion of those who assert that the latter is its sole origin, and it appears to us that it agrees best with every analogy. We have reserved to this head the notice of a very remarkable circumstance connected with the etiology of scabies, the existence of the insect called by Linnseus and by preceding naturalists " acarus scabiei." First in the writings of Avon- zoar, the Arabian physician, and subsequently in those of Ingrasias, Gabusinus, and Joubert, notices of a minute insect occurring in a certain disease of the skin attracted the attention of the English entomologist Thomas Moufet, who examined and described them with considerable accuracy. They are, according to him, minute animalcules similar to the acari of decayed cheese or old wax, which burrow under the cuticle, and excite intense itch- ing, with an eruption of vesicles. His observa- tions were repeated by various naturalists in dif- ferent parts of Europe, and Hyacinth Cestoni, at the end of the seventeenth.century, investigated the characters of this insect with much exactness, and was the first proposer of the theory which regards it as the proximate cause of the itch.* This doctrine gave rise to a controversy which has continued ever since, and seems at the present day to be as far from being settled as ever. In the order of time, two questions are involved in this subject. By the first the acarus, or (as Latreille denominated it generically) sarcoptes scabiei, was universally received ; but issue was joined on the opinion first mooted as a conjecture by Cestoni, that scabies is nothing else than the bite of these small insects, which produces the itching and an extravasation of serum collecting into vesicles; moreover that the contagion is effected by the transfer of those insects from one individual to another. Experiments were made, and opinions were contested negatively and affirmatively, by Si;8^rk3 ii — *™ Stiffs SCABIES. 65 many eminent medical men in different countries. Redi, Wichmann, Osiander, Pringle, and many others, considered the contact of the insect as the only exciting cause of the itch ; while as great a number insisted that the acarus was produced by the disease. Again, a middle opinion was em- braced by the majority, to which Morgagni at- tached himself. They held that in most cases the insect was the product of the disease, but admit- ted that in some instances the latter owed its origin to the insect. M. Gales, apothecary to the Hopital St. Louis in 1812, undertook a series of investigations, which he conducted with the great- est variety and perseverance, and which finally seemed to leave nothing undecided as to the whole subject. He observed with the microscope up- wards of three hundred of the insects taken from the scabious vesicles.* He confined the insect upon his hand with a watch-glass, and observed it penetrating the cuticle, upon which, after a few hours, three vesicles appeared, the intense itching of which left no doubt of their identity with scabies. He inoculated in the same manner three children with the insect, who became covered with the itch. These experiments were testified to by many of the first naturalists in Paris ; and as they appeared to have the force of demonstra- tion, after their publication the opinion that the itch was produced by the insect was ratified by the assent of almost all. They doubtless proved the presence of the acarus, and moreover that its pen- etration of the skin is an occasional cause of scabies; but with all, this may be a very second- ary matter in the production of the disease. In fact, it seems to us somewhat singular that these observations were permitted to prove more than that the insect taken from a scabious vesicle, being charged with the virus, the fluid of the vesicle, by penetration of the cuticle, inserted this virus, and produced the disease, like the inocula- tion of cow-pox. At a later period, however, the opinion supposed to be thus incontestably fixed by M. Gales' ex- periments was not only called in question, but, singular to relate, the existence of the acarus was again doubted. M. Suriray of Havre, and after- wards MM. Lugol and Mouronval, revived the discussion of the subject, and, as the result of their researches, denied that any insect could be found. This extraordinary revulsion of opinion was con- firmed by M. Biett, who, even with the use of microscopes of high power, was unable, in a great number of trials, to discover it in a single instance. Cazenaze and Schedel state that many others have made an equally unsuccessful search for the in- sect ; and rejecting for themselves the idea of its existence, they announce a kind of challenge to M. Gales to transport himself again to the H6pi- tal St. Louis, and demonstrate it anew. It would follow from these negative researches, that while at one period the disease is attended by the acarus, at other times it exists without it. In these countries it is a notorious fact that the insect *His descriptions of the insect agree with those of Linneus and Latreille, but are much more extended and exact. It has six legs, with a few filaments besides pro- jecting from the body, and is not unlike the minute jmlix sometimes accompanying prurigo. It lies in the centre of the vesicle, round the margin of which it de- posits its ova. Vol. IV. — 9 j* j is frequently found. Moufet originally stated that the common people were in the habit of ex- tracting it from the vesicles with the point of a pin ; but that more usually it may be found in a small channel which it frets from the vesicle in ' the adjoining cuticle. We have conversed with those who have frequently seen them, and whose description of their being found not in the vesicle I but in the red streak adjoining it, exactly coincides with Moufet. Bateman and Mr. Plumbe bear the j same testimony; and the latter adopts an hypo- I thesis proposed by Gales and Fournier, (Diet, des I Sc. Med. art. Gale, torn. xvii. p. 109,) by which it is conjecturally affirmed, that when the elevation becomes large and full of lymph, it being no longer possible for the insect to exist in it, in ! obedience to a preservative instinct it makes its way laterally, and is then found beside and not within the maturated vesicle. He supposes, also, that it is sufficient to account for the ill-success of those who have not found it, to presume that they happened to select for their researches vesi- cles which had been evacuated by the acari. This does not occur to us as by any means satisfactory ; but the opinion of Sauvages, adopted by Bateman, seems more plausible, that the insect is generated only in some instances of scabies, of which cases I Sauvages proposes to make a particular species under the title of " scabies vermicularis." This is not irrational; yet we deem it more consonant with the varying history of the researches to sup- pose that there is a variation in the disease itself in this respect at different epochs. This view is more consistent with analogy, as we know how ! often the type of diseases changes at different | epochs in the same locality, without therefore I losing their identity. Of this fever is a familiar example, which it is unnecessary to do more than mention in respect to its change of type; but an , occasional phenomenon which it presents (as was remarked by M. Ranque of Orleans) may be ad- duced, and reflected on in connection with the generation of the acarus scabiei. We allude to | what is occasionally observed when a favourable crisis takes place at the last extremity of typhus ; the head is sometimes swarmed by a sudden pro- duction of lice, so unaccountably numerous as only to permit the supposition that they are se- creted by the skin. According to the view here propounded, and in agreement with the analogy just mentioned, the animalcule of scabies is regarded as a secretory product of the disease, which at certain periods is endemic; but ignorance is professed as to the cir- cumstances which give rise to it at one time more than another; and at the same time we agree with Bateman, that the contagious property of scabies exists in the fluid, and not in the insect, which, however, may be the occasional means of transport of the latter. We would finally remark, with regard to the whole controversy, that it in- cludes a lesson at least to medical theorists: here many ingenious men oppose each other in a mat- ter of fact and observation; with what sobriety, then, should dogmatic opinions be entertained, when it is often so difficult even to lay their foundation in certain facts ! [Most recent writers on the subject are disposed to consider the acarus as the cause of itch (E, 66 SCABIES. Wilson, Practical Treatise on Diseases of the Skin, Amer. edit. p. 235, and W. Horn, art. Sca- bies in Encyclopiid. Worterb. der Medicin. Wis- senschaft. xxx. 138. Berlin, 1843.) Mr. Wilson classes scabies as the only example of inflamma- tion of the skin induced by parasitic animalcules inhabiting the epidermis; yet it is not easy to un- derstand how it is readily communicated by con- tact, under the idea that it must be conveyed by the insects, as it is by no means a matter of faci- lity to extract them from the furrows where they are domiciliated. It was not until the year 1834, and after several distinguished individuals had tried in vain, (Dr. Biett, art. Gale, in Diet, de Med. 2de edit. xiii. 547, Paris, 1836,) that the manner of finding the acarus was clearly demonstrated. A medical stu- dent from Corsica, M. Renucci, had frequently seen the women of his country extract the insect, and had often done so himself; and he showed, that it must not be sought for in the vesicle, but in the furrow which sets out from it, and which is made by the insect beneath the epidermis.] Treatment.—The cure of scabies appears to have been considered a matter of no slight medi- cal interest. Treatises have been written upon it, and a vast variety of means discussed with so much earnestness, that we are led to the conclu- sion, (which we believe coincides with general tradition,) that it was formerly a scourge to the community of greater extent and virulence than at the present day. It is now regarded as of tri- | vial importance. Never in itself dangerous, it gives much annoyance to the individual by its un- appeasable itching; but the fear and restraint which it puts upon him of infecting others often causes as much discomfort to him as its action upon himself. Neglect of the appropriate means may indeed protract it to an indefinite length ; but by their use its treatment is conducted with so much certainty that we have scarcely any other care in the choice of remedies than to select that ■which experience has approved of as effecting a riddance of the disease in the most secure and j speediest manner. A multitude of such has been ' vaunted, but modern practice has contracted the most useful within a small circle ; and it is unne- cessary to enumerate here any of minor efficacy, as we are in possession of some whose virtues are -almost infallible. ! Sulphur is considered in the light of a specific remedy in the cure of itch. It is the basis of the applications which by universal consent are con- sidered its most effectual antagonists. In the or- dinary forms of the disease the common people have long used it as an ointment, mixed with equal parts of hog's lard or butter, with which they smear the parts on which the eruption exists ; once or twice a day. They administer it inter- \ nally at the same time, in doses of from ten grains to half a drachm given in milk at bed-time. By this treatment they scarcely ever fail to cure it ex- peditiously. The internal use of sulphur is adapted for it in children, and is occasionally combined with magnesia ; in adults, however, it is unnecessary to have recourse to any but the ex- ternal use of the sulphur ointment. The assidu- ous use of it for a fortnight is sufficient to cure the common forms of it, if they be attacked with , it speedily after its first appearance, as the dura- tion of the treatment will be longer if long ne- glect has permitted it to gain a certain inveteracy A great improvement was made in the applies tion of the sulphur ointment by the combination of an alkali with it. This adds to the specific effect of the sulphur the advantage of a detergent action, which loosens and dissolves crusts or scabs, and permits the skin to be well penetrated by the ointment. M. Helmerich, a French army surgeon, became famous for a method of using sulphur which cured the itch more promptly, and also per- mitted the greasy stain of the ointment to be re- moved from the linen by washing, obviating an objection to the use of unguents which was very generally felt. He kept it a mystery, but it was analyzed by M. Burdin, and found to consist of the following ointment: Sublimed sulphur, two parts, Sub-carbonate of potass, one part, Axunge, eight parts, intimately mixed.* This deserves a preference over all other methods of applying the sulphur externally. It has the most constant and prompt success, and is seldom attended by the cutaneous affections which some- times result from the use of other stronger but more irritating sulphureous applications. It is the ointment which Biett has exclusively employed at the Hopital St. Louis for several years. He or- ders half an ounce of it to be rubbed, morning and evening, over all the parts occupied by the vesicles. The action of this ointment is favoura- bly promoted by the use of a tepid bath every second day during its application, which will rare- ly have to be continued beyond ten or twelve days. Another sulphureous friction which, in the Paris hospitals, rivals the reputation of the above-men- tioned ointment, is made with the sulphuret of lime. A scruple or half a drachm of this powder is to be triturated with a small proportion of olive oil, so as to render it sufficiently fluid for using as a friction, and this quantity is to be rubbed upon the affected parts twice a day. This is a very ef- fectual cure, but it is not so applicable as the for- mer when the itch has already spread to any con- siderable extent. [In more obstinate cases, the Unguentum Sulphu- ris compositum of the Pharmacopoeia of the United States, which contains — in addition to the sul- phur—ammoniated mercury, benzoic acid, oil of lemons, sulphuric acid, and nitrate of potassa, may be substituted. The writer is more in the habit of prescribing the Unguentum Sulphuris composi- tum of the London Pharmacopoeia, which contains —sulphur, 5hi.; veratr. pulv. gi.; potas. nitrat. 3ij.; saponis mollis, Jiij.; adipis.Six.; ol. berga- mot, fT| xv.] The use of ointments over an extensive surfaW of the skin may be considered unadvisable in some cases, as interfering with the cutaneous transpira- tion. When these objections exist, substitutes of no less efficacy are found in the proper use of lo- tions. None of these is preferable with regard 10 activity to the solutions of sulphuret of potash,or of lime. These^have been long known and a- to ea.:li ounce of the axunJe a fi.iL , "greeable to a« der or bergamo.te, „„"e^rainVofnSf 2f?" otl^\ phuretum rubrum (vermilion) the Mrargyn «* SCABIES —SCARLATINA. 67 tcnsively used in scabies, and a saturated solution of the latter is an excellent remedy in the mange of sheep or doge. The following formula of a lotion was prescribed by M. Dupuytren, and high- ly extolled in France for the promptitude with which it effects the removal of the disease : R.—Sulphureti potassa? ^v. Aqua? pura? lb. iss. Acidi sulphurici ^ss, dissolve ut fiat lotio. Whatsoever part of the eruption has invaded is to lie moistened by a gentle friction with this lo- tion twice a day. It has the advantage of not in- juring the linen of the patient, nor does it compel him to renounce his employment during its use. However, it produces a smarting of the skin, which will sometimes require it to be used in much weaker proportions, and renders it not so appro- priate in some irritable habits. If the individual entertain insuperable objec- tions to the use of sulphur from disgust to its odour, many other external remedies of approved efficacy are at hand. The ointment of white hel- lebore, in the proportion of a drachm of the pow- der to an ounce of lard, is both a safe and expedi- tious application. Solutions of the chloride of lime or of soda have been extolled as highly bene- ficial by some practitioners; they are used as a lotion in the proportion of an ounce to a pint of water. The aqua chlorinii applied in the same manner is also mentioned with applause. Heber- den strongly recommended a lotion composed of a solution of the muriate of mercury, made with one drachm, or two, (according to the inveteracy of the disease,) to a pint of water. This is ac- knowledged to be a remedy of great power in cur- ing scabies, but it is objected to by some as liable to produce the constitutional effects of mercury. We have, however, been assured that these fears are vain, by an esteemed practitioner, who has had a very favourable experience of this lotion, and has used it on his own person with success; and in our own more limited sphere of observa- tion, we never saw any such effects from it. [These ointments are less offensive than the ointments of sulphur, but they are certainly less sure. The same may be said of those of creasote and of chlorinated lime.] Sulphureous baths are an excellent auxiliary means in many cases of scabies. In cases of very irritable skin they are frequently the only form in which general applications of this remedy can be made to the surface; in young children, there- fore, they are a very valuable resource. The arti- ficial are found to answer the purpose equally well with the water of sulphureous springs, and their employment possesses the advantage of-being proportioned according to circumstances. They may be prepared by simply adding to an ordinary sized warm bath six ounces of the sulphuret of potash in powder, and agitating it until it be dis- solved, and the water be reduced to a lukewarm temperature. Sulphureous vapour baths are another means which possess great power in this as well as in 6ome other diseases of the skin. This is evident from the testimony of all who have used them, from M. Gales, who was the first to construct an apparatus for their convenient administration, to I Mr. Wallace, who has also ably illustrated their use. Dr. Bardsley informs us, that he has " al- | ways seen the most obstinate and neglected cases of it yield very speedily to a few fumigations." (Hosp. Facts and Observations, p. 198.) It is hap- pily to such inveterate cases that they are mainly applicable; for even if they did possess the supe- I perior advantages over ordinary methods of treat- ment which are claimed for them, they are too sti- mulating to be employed in many cases except where the disease has become chronic through ne- glect, and has induced an unhealthy torpid condi- tion of the skin. They are particularly contra-in- dicated where there exists any tendency to con- ! gestion in the gastric or pulmonary mucous mem- branes, and in females with complaints depending ■ on morbid conditions of the uterine functions. In the conduct of the treatment the practitioner | has but little to be solicitous about; but, having used his discrimination in the adoption of the most appropriate remedy, he perseveres until the cure is complete. He should inculcate great at- tention to cleanliness and change of linen, espe- cially during the convalescence. A vigilant in- spection must be made for the purpose of detecting [ any of the complications previously noticed as apt to coexist with certain forms of the disease, or to spring up under improper treatment. If any of those be present, it will be necessary to modify his plan accordingly, and often to suspend the use of the stimulating remedies, with which he had commenced to combat the scabies. The state of the alimentary canal now demands particular at- tention; cooling laxatives and alteratives will be proper; and for topical applications recourse should be had to emollient fomentations, and the other soothing means specially adapted to the individual complication, for which we refer to Ecthyma, Eczema, Impetigo, Lichen, &c. James Houghton. SCARLATINA.—-Syn. Morbilli Confluentes, Morton.- Rubeola Rossalia, Hoffmann .- Febris Scarlatina, Sydenham : Febris Rubra, Heberden : Scarlatina, Sauvages, Vogel, and Cullen.- Pur- pura, Shullz, Junck: Enanthesis Rosalia,' Good; Fievre Rouge, Scarlatine, Fr..- Der Scharlachauf- schlag, Germ..- Scarlet Fever. Scarlatina desig- nates a contagious febrile disease, the distinguish- ing characters of which are, a scarlet efflorescence of the skin and of the mucous membrane of the mouth and pharynx, appearing on the second day (though often later) of a febrile disorder, and ter- minating about the fifth; accompanied, in the majority of instances, with inflammation of the throat, either of a phlegmonous or gangrenous character; and occasionally with tumefaction of the cervical absorbents and subcutaneous cellular membrane. Other organs become also sometimes involved in the progress of the disease, giving rise to lesions of greater or less severity. The type of the accompanying fever is various, and modifies remarkably the whole aspect of the malady. In some cases, the constitutional disturbance is so trivial as scarcely to attract notice; in others, the febrile symptoms are those of strong inflammatory excitement; while in individual instances, or dur- ing the prevalence of an entire epidemic, the fever SCARLATINA. is of a low typhoid form, the local inflammation with which it is associated, partaking very much of the same character. The origin of scarlatina is involved in great obscurity. It was evidently unknown to the an- cients; no allusion to it can be discovered in the writings of Hippocrates, or in the early Greek and Roman writers; and, notwithstanding the opinion of some modern authors of the French school, that it was described about the middle of the sixteenth century, it is generally admitted that Prosper Martianus, an Italian physician, who gave a de- scription of the disease as it prevailed in Rome about the middle of the seventeenth century, if not the first, is among the earliest writers on scar- latina. It made its appearance in London in 1689, and was described by Sydenham and after- wards by Morton, though it is evident by com- paring the description given by these two writers, that they had observed different epidemics; the one described by Sydenham being a very mild disease compared with that of which Morton has given an account. From the various names, however, given to scarlatina on its first appear- ance, it is evident, that about the period to which we refer, the notions entertained with regard to it were vague and unsatisfactory ; indeed, it was scarcely distinguished from measles, roseola, or purpura. For example, it was named by Morton morbilli conjluentes,- by Hoffmann, rubeola rossa- lia i by Heberden, febris rubra; and even till within a little more than half a century, both these diseases (measles and scarlatina) appear to have been considered by medical writers as the same, or at least as so closely allied, as only varieties of a common species. Morton, indeed, maintained their identity, and considered their relative con- nection to be nearly the same as that existing between the distinct and confluent small-pox. (De Morbillis et Scarlatina, Exercit. iii.) The description of the epidemic given by Huxham under the name malignant ulcerated sore-throat, which prevailed in the year 1734, resembles in almost every particular one form of scarlatina — that form in which the eruption is accompanied with affection of the throat. The treatise on this subject is a valuable record of the characters of this epidemic, the description being evidently taken from what he had observed in his inter- course with the sick. Dr. Fothergill also has given the history of a " sore throat attended with ulcers," which appeared in London in 1747-8, which there can be little doubt was an epidemic scarlatina; and from the remarks he has made, it is evident, that he had observed various forms of the disease, from the mildest to the more malig- nant. Dr. Withering published an essay on scar- let fever in 1778, a second edition of which ap- peared in 1793; to this author is due the merit of having first accurately described scarlatina as a distinct disease; since that period, various treatises have appeared both in this and other countries. Causes.—Nothing satisfactory is known as to the exciting causes of scarlatina. It appears to be induced, like the other eruptive fevers, by ex- posure to the influence of a specific poison. At- tempts have been made to induce the disease by inoculation, by inserting the thin scales, which are thrown off at the period of desquamation, under the skin of individuals who have never had scar- let fever, but hitherto without success. How far inoculation with the blood might be followed by different results is a question which can only be determined by experiment. That scarlatina may be propagated by conta- gion is, we presume, admitted even by those who profess themselves sceptical on the question of contagion in general. Instances of^the disease spreading in a manner which can only be ex- plained by admitting its contagious origin are so numerous, that practitioners of the most limited observation must have had repeated opportunities of determining the question. We have known, in several instances, convalescents from scarlet fever, on their removal to a considerable distance from the situation in which they had passed through the disease, infect individuals with whom they came in immediate contact, though several weeks had elapsed from the period of desquama- tion. The period of invasion after exposure to sources of contagion is exceedingly various. Some individuals are seized within a few hours; others do not exhibit any of the peculiar symptoms for several days ; and in some more rare cases, five or six weeks have intervened between the period of exposure and the accession of the disease. The poison also appears to affect individuals very dif- ferently. Of a number of persons exposed to the same source of infection, some may escape alto- gether ; others have a mild form of the disease; or it may happen, perhaps, that in several, the disease proves severe. Even in the same family I the various forms which scarlatina presents may occasionally be observed. One or more may have , both the efflorescence and the sore throat; in others there may be fever with the characteristic i rash but without any affection of the throat; an- [ other case may present the characters of the ma- lignant disease; while, again, those who have been in constant attendance on the sick become indisposed with smart inflammation of the throal , and a considerable degree of fever, which lasts for some days, and then subsides with the local affec- tion. In these latter cases, (though there have been no efflorescence), desquamation of the cuti- cle occasionally occurs. Dr. Rush, in an accounl of an epidemic scarlatina which prevailed at Phi- ladelphia, remarks that such was the prevalence of the contagion which produced the scarlatina anginosa, that many hundred people complained of sore throat without any other symptoms of in- , disposition. The slightest occasional exciting cause, particularly cold, seldom failed of producing the disease. (Medical Enquiries and Observa- tions.) The same thing has been repeatedly observed in this country. Although sporadic cases of scarlet fever are met at all seasons, it is more prevalent at the end of summer, and in the autumn, than at other periodi of the year. Epidemic visitations have been most frequently observed after a warm summer, espe- cially when the heat has been accompanied with continued rains; and when the succeeding winter has been open and mild, the disease has continued till it has been checked by frost. It generally d* | appears in the spring months, though it has been observed to continue uninterruptedly for one « j more years. J SCARLATINA. It is necessary to advert in this place to the dif- ference in the characters of epidemic scarlatina, though the causesof such remarkable variation are unknown. For a whole season, the disease may assume a mild aspect, so that a fatal case is rarely met with; in such instances, the danger is gene- rally produced by some local inflammation which has supervened in the progress of the disease, or during the period of convalescence. On the other hand it should be remembered, that during a com- paratively mild epidemic, one or more cases may assume a malignant character, and resist the best directed curative efforts. Sometimes an epidemic of a malignant form, or, as it is popularly termed, a putrid form of scarlet fever suddenly breaks out and proves extremely fatal. From its commence- ment the symptoms often denote a severe form ; at other times on its first irruption the disease is mild, but suddenly, without any apparent cause, the symptoms assume an unfavourable appear- ance, which continues as long as the epidemic lasts. It is therefore of great practical importance to ascertain the prevailing type of the disease, as the character which it assumes must regulate the treatment to be adopted. Dr. Willan observed, (On Cutaneous Diseases, p. 277 and 281,) that when the scarlatina spread widely, it exhibited in the different persons affected every gradation of appearances, from the slightest to the most malignant form of the disease; yet during its diffusion through some large families and schools, he had seen it uniformly retain the series of symptoms which occurred in the first patient, with nearly the same degree of fever. In the autumn of 1786, and occasionally since that period, the scarlatina maligna above described affected the inhabitants of several districts in London, comprising narrow courts, alleys, and close crowded streets, and afterwards extended to 6ome adjoining villages in low, damp, or cold situations. It is, however, more frequently inter- mixed with the other varieties of scarlatina, and it sometimes unexpectedly supersedes the milder forms of the disease on the fourth, fifth, sixth, or seventh day of their course. " It is truly singular," he adds," that the slightest of all eruptive fevers, and the most violent, the most fatal disease known in this country, should rank together and spring from the same origin. Expe- rience, however, decides that the simple scarlet fever, the scarlatina anginosa, the scarlatina (or angina) maligna, and the scarlet ulcerating sore- throat, without the efflorescence on the skin, are merely varieties of the one disease. That all of them proceed from the same source of contagion is evident, because under the same roof in large families some individuals have the disease in one form, some in another, about the same period." Scarlatina occurs more frequently in the early than in the advanced periods of life, and in our own experience females are more liable to the dis- ease than males. Dr. Withering states that the' epidemic which appeared at Birmingham in the year 1778, affected children more than adults, but seldom occurred in the former under two years of age. In children, the number of boys and girls that suffered from it was nearly equal; but in the adults, the number of female patients considerably exceeded that of the male. I In order to determine its relative frequency in the sexes at different ages, we selected from the register of patients admitted into the London Fever Hospital, two hundred cases in the order | of their admission. The following table gives the 1 general results :— From Age. Males. Females. Total. 6 to 10 7 8 15 10 « 15 8 15 23 15 » 20 17 40 67 20 » 25 14 39 53 25 « 30 8 21 29 30 « 35 6 10 16 35 « 40 1 2 3 40 1 0 1 42 0 1 1 48 0 1 1 57 0 1 1 62 138 200 It is proper, however, to state that this table cannot be considered quite complete, the number of children under six years of age who take the I disease not being ascertained, in consequence of the regulations of this hospital precluding the ad- 1 mission of children under six years of age. The table shows the great majority of females at every age, and also disproves the assertion of Sir Gilbert Blane (Select Dissertations, p. 213) and others, that the majority of those who are seized with : scarlatina are under puberty. | Scarlatina in general affects the same individual only once during his life, and in this respect obeys the general law of exanthematous fevers. Occa- sional exceptions have certainly been observed by practitioners, though, from the testimony of Dr. Willan, a second attack of scarlatina in the same individual is extremely rare; he states that he had never seen such a repetition among two thousand patients whom he had visited in scarlatina. We certainly have met with several well authenticated instances of a second attack of scarlatina in the , same person. [Dr. Billing (First Principles of Medicine, 1 Amer. edit. p. 191, Philad. 1842) states, thiA he has known it occur three times in the same indi- J vidual, — frequently twice; in one instance, twice within ten months, in its exquisitely marked form, as to inflamed tonsils, appearance of tongue, erup- tion, and desquamation of cuticle. Recently, the writer attended a lady who, six years ago, was affected with it, for the first time, in childbed,— the child being born with the eruption: three years afterwards, her child had it for the second time, and died; and she also suffered severely from a second attack. Recently, from attending on a young gentleman who died of the disease, she had a third attack. It is by no means uncommon for those who have had the disease, to suffer from sore-throat— scarlatina faucium—when they are in attendance upon one labouring under scarlatina. (See Guer- sant 4 Blacke, art. Scarlatine, in Diet, de Med. 2deedit xxviii. 158, Paris, 1844.)] It is proper to notice the discovery of the sup- posed efficacy of the extract of belladonna as a preventive of the infection of scarlatina. This was first suggested by Hahnemann, of Leipsic, in 70 SCARLATINA. 1807. The belief that this narcotic possesses such a preventive power is gaining ground in some parts of the continent, and lately even in our own country. The following abstract will explain the views of Hahnemann on this subject. A favourite doctrine of this writer is, that diseases are to be combated by remedies, the effects of which are similar to the diseases for which they are given. This is the doctrine to which the ■ term homwopalhia has been given, and which I has of late years gained many proselytes in Germany, France, and Italy. Hahnemann ob- served, that belladonna given in small doses produ- ced heat and dryness in the throat, swelling of the submaxillary glands, and a cutaneous eruption, sometimes an efflorescence only, at other times a papular rash, like miliaria; he therefore inferred that this medicine, from its producing symptoms j analogous to those of scarlatina, might prove a I preservative against its infection. About ten years after Hahnemann had entertained this notion of the anti-scarlatinous power of belladonna, a severe and fatal epidemic appeared in several cities of Germany, and consequently the physicians were naturally desirous of adopting measures calculated to arrest its progress. From the result j of the trials made by Berndt, of Custrin, who j was the first who made a series of experiments, we find, that in an epidemic scarlatina which prevailed in Custrin in 1818 and 1819, he em- ployed the belladonna as a preservative in one hundred and ninety-five children under fifteen years of age; though they were freely and con- stantly exposed to the contagion of scarlatina, only fourteen took the disease, and that after employing a stronger preparation of this drug, every individual escaped. A still stronger testi- mony in favour of its efficacy is given by Duster- berg, a physician of Warburg; he states, that every child who took the belladonna for a sufficient length of time before exposure to infection escaped; that when a child was left in an infected family to nature, (the belladonna not having been ad- ministered with the object of determining its effica- cy) it was invariably attacked with scarlatina, while the others who took the remedy escaped. Behr, of Bernberg, also affirms that of forty-seven persons who took the belladonna as a preservative, only six were attacked. Professor Koreff, of Berlin, after extensive and long-continued trials, asserts that if the belladonna be taken in proper doses for eight or nine days before exposure, and be continued till the period of desquamation, there is little danger to be apprehended from free inter- course with persons affected with scarlatina. Similar testimony has been given as to the efficacy of this narcotic by Hufeland, Kunzman, of Berlin, and others.* [On the other hand, the belladonna has failed to exhibit any prophylactic powers in the obser- vation of many respectable practitioners, (Pereira, Elements of Mat. Med. and Therapeutics, Amer. edit ii. 307, Philad. 1843, and Rilliet and Barthez, Traite Clinique et Pratique des Maladies des En- fants, ii. 641, Paris, 1843.) Dr. Pereira remarks, • Vide Arch. Gen. de Med. Juin, 1824. — Journ. Com- plnment. Juin, 1824. — Hufeland, Journ. der practischen Heilkunde, Nov. 1P15. — Rust, Magazin fur die gesauiuite Heilkunde, xx. i. 182. that whilst the facts brought forward in favour of the existence of the prophylactic fever are only ne- gative, those which can be adduced against it are positive; for twenty cases of failure, he conceives, are more conclusive against it than one thousand of non-occurrence are in favour of it. The writer has repeatedly administered it; and, as elsewhere remarked, (Practice of Medicine, 2d edit. ii. 538, Philad. 1844,) until the winter of 1843, none took the disease. At that time, during the preva- lence of scarlet fever in his own neighbourhood, the belladonna was sedulously administered to his children, five in number,— two of whom, the youngest three years old, and the oldest six, after having taken the belladonna for six weeks, were attacked,—the others escaping. The disease was severe, but it was not attended by any specially alarming symptoms.] The quantity administered is very minute. Three grains of the extract of belladonna are to be dissolved in one ounce of distilled water; of this solution two or three drops are to be given twice a day to a child under twelve months old, and one drop more for every year above that age. In general, no sensible effect is produced by it, but in some instances, it brings out an eruption similar to scarlatina. It is also asserted by those who have tried this remedy, that even when it does not prove a preventive of the infection of scarlatina, which may be in consequence of its not having been administered for a sufficient length of time before exposure, it renders the dis- ease more mild, and even that if it be taken for four or five days before exposure, the disease never proves fatal. As we have never employed the belladonna as an anti-scarlatinous remedy, we can offer no opinion of its merits, though we cer- tainly profess ourselves sceptical as to the powers ascribed to this drug. The subject is, however, worthy of further experimental inquiry. It has one advantage, that of being perfectly harmless, if it do not act as a preservative. Varieties.—Scarlatina occurs under several forms, to which it is necessary to advert. In the first, the afflorescence is attended with mild febrile symptoms, but there is no inflammation of the throat (scarlatina simplex). In the second the fever is of a more severe character, and the efflo- rescence is accompanied with inflammation of the throat (scarlatina anginosa). In the third, the whole character of the disease is more severe than in either of the preceding varieties: the fever is of a low or typhoid type ; the throat is affected with gangrenous inflammation, accompanied with tu- mefaction of the cellular tissue and absorbents of the neck, and in general with an acrid discharge from the nostrils and ears (scarlatina maligna). In other instances, the efflorescence is confined to the mouth and throat, and does not affect the skin. This form (to which no name has been given) is often observed during the prevalence of epidemic scarlatina ; not unfrequently in adulls, when some other form of the disease is prevailing in the family. It may be designated by the name scarlatina faucium. 1. Scarlatina simplex.—In this form of the disease there is only the efflorescence with i moderate degree of fever. The rash is preceded ; by slight symptoms of fever—irregular shivering, SCARLATINA. 71 nausea, sometimes vomiting, thirst, and heat of skin. The degree of fever is by no means uni- form ; the symptoms are sometimes so moderate as scarcely to attract attention, though there is often smart constitutional disturbance, indicated by pungent heat of skin, flushing of the face, suf- fusion of the eyes, pain of head, restlessness, and occasionally delirium. The efflorescence or rash generally comes out on the second day of the eruptive fever, but in some instances it docs not show itself till the third, and accordingly we find authors differing as to the precise period at which it appears. Sauvages and Cullen state that it does not come out till the fourth day after the accession of the febrile symptoms. Plenciz (Trac- tatus de Scarlatina, 1776,) does not limit the period, but affirms that the rash makes its appear- ance on the second or third day, or sometimes later. Heberden restricts it to the first or second day. It is, however, probable that in the majority of instances, the rash comes out on the second day of the fever, and that in cases in which it ap- pears sooner or later, there is some peculiarity in the individual or in the disease to account for the variation. The efflorescence, which is first perceptible on the face, neck, and chest, becomes gradually dif- fused over the body ; in twenty-four hours or less from its first appearance the trunk is covered with the eruption ; on the following day (the third) it extends to the upper and lower extremities, at which period the whole body is of a bright red colour, and pungently hot and dry. On the ex- tremities, particularly the hands and fingers, the rash is diffuse and continuous, but on the trunk it is distributed in irregular patches, the colour being most deep on the loins, buttocks, flexure of the joints, and on those parts of the body which are subjected to pressure; it is generally more vivid in the evening, gradually becoming paler towards the morning. This is the ordinary progress of the efflores- cence in the skin : it is not, however, confined to the cutaneous tissue; the mucous membrane which lines the nostrils, mouth, and fauces being covered with the eruption, so that the lips, the tongue, the pharynx, the velum palati, the nostrils, and even the internal surface of the eyelids are of a bright red colour. The papilla? of the tongue become considerably elongated, the red points shooting through the white fur, and from which it derives its characteristic appearance. In cases where the tongue is clean, it has nevertheless a bright red colour, and the scarlet points may be seen shining through its polished surface. The rash of scarlatina consists of innumerable red points or dots, which are at first of a pale red colour, but afterwards acquire a deeper hue, giving the affected portions of skin not only a uniform red appearance, but a perceptible roughness, which is most evident on the breast and extremi- ties, in consequence of the greater determination of blood to the papilla? of the skin in those situa- tions. The efflorescence on its first appearance some- times closely resembles a papular eruption, and occasionally small miliary vesicles make their ap- pearance, though this latter phenomenon is rarely observed, except when the individual has been subjected to a heating stimulating regimen, or con- fined in a small, crowded and ill-ventilated apart- ment. These papular or vesicular spots, however, are now and then observed when the disease oc- curs under the most favourable circumstances. Dr. Mason Good (Study of Medieine, vol. iii. p. 13,) supposes that they arise from the great deter- mination of blood to the cutaneous vessels pro- ducing an effusion of coagulable lymph, which is not entirely absorbed by the time the efflorescence subsides, hence there is occasionally, though nut often, an appearance of vesicles, sometimes nearly empty, and sometimes nearly filled with a pellucid fluid, according as the effused fluid has been more or less carried off. The occasional appearance of these vesicles during the progress of scarlatina has been noticed by Rush, Withering, Plenciz, and other writers; Sauvages, indeed, under a mis- taken view of their importance, has constituted a distinct species under the name scarlatina vario- lodes. In ordinary cases of scarlatina, the eruption may be regarded at its height on the fourth day ; it begins to decline on the fifth, disappearing in irregular patches *, on the following day it is still more indistinct, and on the eighth day no trace of the rash is discernible. The various symptoms with which the eruption is accompanied gradually disappear with the efflorescence, but the tongue still remains morbidly red and clean. The des- quamation of the cuticle, which begins about the end of the fifth day on the parts on which the eruption first appeared, proceeds, so that about the eighth or ninth, portions of cuticle are thrown off, the thickest and largest being those detached from the skin of the hands and feet. 2. Scarlatina anginosa. — In this form, the fever and efflorescence are accompanied with in- flammation of the throat. The anginose inflam- mation sometimes precedes the fever, but' most frequently appears at the same time with the febrile symptoms, though, in some cases, not until the rash or efflorescence is at its height: in the majority of instances, however, it is felt when the eruption appears, and goes through its progress of increase and decline with the cutaneous erup- tion. The precursory symptoms of scarlatina anginosa indicate a more acute disorder than the scarlatina simplex. The headach is often accompanied with slight delirium ; the heat of skin is more pungent, and the prostration more marked from the begin- ning. In the course of the second day, the patient complains of a sensation of stiffness or pain about the muscles of the neck, extending to the angles of the jaw and under the ears, with feeling of roughness in the throat, painful deglu- tition, and some degree of hoarseness. The viscid secretion from the mucous crypts of the tonsils and pharynx, which takes place in the more se- vere cases, aggravates the patient's sufferings, from the frequent and often ineffectual efforts made to expel it. On examining the fauces, the palate, uvula, and tonsils are red and swollen, and when the local inflammation is severe, coagulable lymph is effused in small irregular masses on the inflamed surfaces. These exudations are very liable, on a superficial examination, to be mistaken for ulcers, or, when the subjacent surface is tender 72 SCARLATINA. and disposed to bleed, the admixture of blood im- parts to them a brown or almost black colour, and thus, more especially if there be fetor of the breath, they may be mistaken for gangrenous in- flammation of the fauces. On attentive inspection, however, after cleansing the throat by acidulated gargles, the entire continuity of the membrane from which the crusts have been detached, at once distinguishes this form of acute symptomatic angina, from the gangrenous inflammation and sub- sequent ulceration observed in scarlatina maligna. These exudations of lymph often extend to the lateral parts of the pharynx, and occasionally as far as the oesophagus, though, according to Rayer, they are never observed after death in the larynx or trachea. This coincides with our own expe- rience, as in the dissections of scarlatina with an- ginose inflammation which we have made, we have not seen an instance of membranous exuda- tion extending to the larynx. As the anginose inflammation becomes devel- oped, the febrile symptoms increase, the pulse rises, the respiration becomes oppressed, the skin more pungently hot and dry, (sometimes rising to 106°, 108°, or even as high as 112° of Fahrenheit,) and the thirst urgent. The mucous lining of the mouth as well as the tongue, especially at its point and edges, assumes a florid red colour, the papilla? being much elongated and protruding their inflamed points over its surface. All these symp- toms are increased towards evening, at which period, the febrile restlessness is often succeeded by delirium. The rash does not appear so early as in the simple form of the disease. It is sometimes per- ceptible on the second, but more generally on the third day, and comes out in irregular patches on various parts of the body, particularly about the elbows and wrists. It has been occasionally ob- served that when the attack is severe, the eruption is sooner thrown out, a circumstance which was noticed by Dr. Clark, who informs us that in an epidemic which broke out in Newcastle-upon- Tyne, in the year 1778, when it began with great vehemence the eruption was often observed on the first day, though commonly it did not make its appearance till the second or third, and sometimes not until the fourth. It evinces also a great ten- dency to recede or entirely vanish the day after it first comes out, and in these cases, it re-appears partially and at uncertain times, but without any perceptible change in the other symptoms, only that the duration of the disorder is protracted. About the fifth or sixth day of the disease, the fever and inflammation of the throat begin to abate; at the same lime the rash declines, becoming faint first on those parts on which it first came out, its disappearance being generally followed by desqua- mation of the cuticle. This process is, however, uncertain. When the rash is slight, or recedes soon after it comes out, desquamation does not take place; in the more severe cases, the cuticle begins to separate after the eruption and febrile symptoms decline, and continues to desquamate to the end of the second or third week, or some- times later, during which large portions are thrown off;, sometimes the cuticle of the whole hand and fingers is completely detached, resembling precisely a glove in shape. Though this is the usual progress of scarlatina anginosa, the disease frequently assumes a still more severe character. Thus we observe, in some instances, acrid discharge from the nostrils or ears, often accompanied with deafness ; enlargement of the parotid or cervical glands, appearing sometimes at the commencement of the disease, at other times about the fifth or sixth day, but occasionally not till the decline of the eruption, and followed in some cases by abscess of the surrounding cel- lular tissue: and towards the decline of the dis- ease, ulceration at the corners of the mouth, or of the tongue. Though these local affections are painful, and keep up or even increase for a time the constitutional excitement, they are seldom at- tended with danger ; and in general, after continu- ing a short time after the prominent symptoms of the disease have disappeared, they subside under judicious treatment. In scarlatina, as in all febrile disorders, the con- dition of the several internal organs demands at- tention. We have often remaiked, in investigating the complications of scarlatina, the great disposi- tion to inflammation of serous membranes ; there- fore, when an organ becomes inflamed during its progress, its investing membrane is much more generally the seat of inflammation, than the sub- stance or parenchyma. In some cases, the general symptoms are accom- panied with evidence of gastro-enteritis. The tongue is morbidly red and clean, and the patient is harassed with sickness, vomiting, and diarrhoea. These symptoms are not uncommon when scarla- tina prevails.in the autumn, at which season bowel-affections generally prevail, and constitute a leading feature of an epidemic. As we have already, in the article Feveb, de- , tailed the various complications which arise, and the symptoms by which they may be detected, it is unnecessary in the present article to enter into more minute details, especially as the exanthemata bear so close a resemblance to the other forms of fever. We deem it, therefore, sufficient earnestly to impress the necessity for minute inquiry into the condition of the several organs in scarlatina, and more particularly for watching the convales- cence. Cases, apparently mild, are often rendered alarming from an attack of inflammation in some organ: the suddenness of the seizure and the ra- pidity with which it often proceeds, prove the ne- cessity for vigilance, however mild the symptoms of the disease may be at its commencement. Dr. Armstrong has well observed, " that scarlatina an- ginosa is sometimes attended with moderate, and at other times with severe symptoms; and it is of great consequence to bear this in mind, more especially as the severe may follow the moderate symptoms at any period of its progress. In those cases where the symptoms are moderate, the in- flammation is chiefly limited to the throat and ' mucous membrane of the nose, and the excitc- ! ment of the arterial system subsides without in- ducing actual inflammation of the viscera; yet where the symptoms are comparatively severe,the inflammation is not limited to the throat and nasal lining, but attacks some of the viscera commonly under a sub-acute character." (Practical Illustra- tions of the Scarlet Fever, &c. by John Arm- strong, M. D.) SCARLATINA. 73 3. Scarlatina Maligna.—This variety has been described by some writers by the name of angina gangrenosa or cynanche maligna. Thus Cullen, in his nosology, places it as a variety of cynanche, and likewise makes it one of the species of scar- latina, from which circumstance much unnecessa- ry confusion has arisen. He was, however, can- did enough to remark, that the scarlet eruption appears on the skin under the same form in both diseases, adding, that he had five or six times seen the angina maligna united with the common scar- latina ; and that in different epidemic constitutions, sometimes one disease predominated, and some- times the other. In fact, two names have been given to one dis- ease, which has almost invariably the same cha- racters, and requires nearly the same treatment, making due allowance for the variation observed in epidemics, and the ever-varying circumstances under which it occurs. Indeed, we are inclined, from our own experience, to affirm that the scarla- tina simplex, scarlatina anginosa, and the scarla- tina or angina maligna, and the sore-throat without efflorescence on the skin, are merely varieties of one and the same disease. Though several Spanish and Italian physicians had described the angina maligna, which raged with great violence and mortality in Spain and Italy in the beginning of the last century, Dr. Fo- thergill was the first writer in this country who described this malignant form of scarlatina as it prevailed in London in the years 1747-8. (An Account of the Sore-throat, attended with Ulcers, by John Fothergill, M. D. 4th edit. London, 1754.) From the description he has given, it is evident, that he witnessed during this epidemic the various forms of the disease, and consequently the malig- nant variety. This is apparent from the following passage: "Thus much, however, seems to be true in fact, that, in some cases, the disease ap- pears to be of so mild a nature, and so benign, as to require but little assistance from art. Persons even recover from it under the disadvantages of unskilful and injurious management, whilst in others the progress of the symptoms is so rapid, and the tendency to corruption so strong, that nothing seems able to oppose it. Just as it hap- pens in the small-pox: the benign and the distinct sort bears ill treatment without injury; in the malignant flux kind, the utmost art and experience are too often insufficient to conduct the distemper to a happy issue. Whether this diversity in the sore-throat we are speaking of is owing to differ- ence of constitution or of seasons, to the different quality or quantity of the contagion, or the man- ner of receiving it, or whether there are in reality distinct species, may perhaps hereafter be more certainly determined." I A few years afterwards Dr. Huxham gavelp faithful account of a similar epidemic as it ap. peared in London from the end of the year 1751 to May, 1753, and was very mortal. It is evi- dent, however, that in this epidemic, as well as in others which have been subsequently described, the malignant form was only occasionally ob- served. In this form of the disease, the symptoms as- sume very early a malignant or typhoid character; to the affection of the throat and skin are super- Vol.IV.— 10 G added great cerebral disorder, and often inflamma- tion of the pulmonary and gastric mucous mem- branes. On the first appearance of the disease, the symptoms may differ little from those of the other forms of scarlatina. The pulse is at first soft and frequent, but soon becomes small, rapid, and often irregular: the patient is restless, and at times delirious, the delirium being sometimes so violent as to require restraint, though more gene- rally it is of the low muttering kind. The rash comes out later and is very uncertain in its dura- tion, often suddenly disappearing a few hours after it is first perceptible ; and, five or six days after- wards, coming out again for a period of perhaps two or three days. It may thus suddenly recede and re-appear several times. The colour of the rash is at first faint, except in a few irregular patches, which assume a deep rose hue, but the whole efflorescence is speedily changed to a dark livid red, and in the worst forms is interspersed with petechia?. The temperature of the skin is generally cool on the trunk of the body, and cold on the extremities ; the eyes are suffused and often covered with a film of mucus; the countenance is pale and dejected, while the cheeks are of a dusky red colour ; the tongue is covered with dry brown, or almost black fur; in other cases, it is smooth, red, and glossy, and often so tender and fissured that it easily bleeds ; the odour from the skin and breath is extremely fetid. The throat is not much swollen, but appears of a dark red hue, and covered with small ash- coloured sloughs surrounded by a livid base; the gangrene often extends with alarming rapidity, destroying the uvula and arch of the palate. A viscid secretion with which the fauces are covered aggravates materially the sufferings of the patient by increasing the difficulty of swallowing, as well as by the obstruction which it offers to the breathing, so that when symptomatic bronchitis occurs during the progress of the disease, there is great danger of fatal asphyxia. The inflamma- tion generally spreads from the throat to the cervical glands, giving rise to enlargement and sometimes abscess; and when the inflammatory action extends to the nostrils, as it almost invari- ably does, there is an acrimonious discharge, at first thin but afterwards thick and yellow, which produces excoriation of the nostrils, lips, and angles of the mouth, which are generally in these instances covered with black crusts. In the more severe cases of malignant scarla- tina, the symptoms are more alarming from the first appearance of the disease: the pulse is smahV rapid, and indistinct: there is more marked cere-\ bral disturbance,—stupor, coma, or violent deli- '■ rium ; the ulcerations of the throat are more ex- tensive, and covered with dark sloughs, and the colour of the rash becomes livid. We frequently also observe pulmonary disease in the form of latent bronchitis, which is often combined with inflammation of the gastro-intestinal mucous mem- brane, giving rise to diarrhoea and its pathogno- monic signs. Some writers mention that hemor- rhage from different surfaces,—from the mouth and throat, lungs, intestines, or bladder, takes place, under which the patient in general rapidly sinks, unless the constitutional powers have been unusually vigorous. 74 SCARLATINA. In a severe epidemic described by Dr. Wither- ing, after detailing the ordinary progress of the disease, he gives the following outline of a fatal form which it frequently assumes :—"In children, the delirium commenced within a few hours after the first seizure. The flesh was intensely hot; the scarlet colour appeared on the first or second day, and they died very early on the third. In others who escaped this rapid termination, when the scarlet colour turned to brown, and their re- covery might have been expected, the pulse still remained feeble and quick, the skin became dry and harsh, the mouth parched, the lips chapped and black, the tongue hard, dry, and dark brown ; the eyes heavy and sunk; they expressed an aversion to all food, and extreme uneasiness upon the least motion or disturbance. Thus they laid for several days, nothing seeming to afford them any relief. At length a clear amber-coloured matter discharged in great quantities from the nostrils, or the ears, or both, and continued so to discharge for many days. Sometimes this dis- charge had more the appearance of pus mixed with mucus. Under these circumstances, when the patients did recover, it was very slowly: but they generally lingered for a month or six weeks from the first attack, and died at length of extreme debility. In adults, the rapidity of the fever, the delirium, &c. was such that they died upon the fourth or fifth .day, especially if purging super- vened. Some survived to the eighth, or to the eleventh day : in all these the throat was but little affected; the eyes had an uncommon red appear- ance, not that streaky redness which is evidently occasioned by the vessels of the cornea being injected with red blood, but an equal shining red- ness, resembling that which we remark in the eye of a ferret. But notwithstanding this morbid appearance in the eye, the strongest light was not offensive. This redness might often be discovered, by lifting up the upper eyelid some hours before it showed itself in the part of the eye that is usually visible : and it was of some consequence to attend to this circumstance, as it greatly in- fluenced the event of the case. These patients were extremely restless, clamorous, and desirous to drink; but after swallowing one or two mouth- fuls, upon taking another they seemed to forget to swallow, and let it run out at the corners of the mouth ; whilst others spurted it out with con- siderable force, and were very angry if urged to drink again. In these cases, the scarlet colour appeared very soon after the attack, but in an un- settled irregular manner, large blotches of red intermixing with others of white, and these often changing places. Besides the full scarlet colour described as above, there were frequently small circular spots of a livid colour, about the breast, knees, and elbows. The pulse from the very be- ginning was so quick, so feeble, and so irregular, that it was hardly possible to count it for half a minute at a time. It is needless to add, that the greater part of those who laboured under these dreadful symptoms died. A few recovered, and others fell into a state of debility bordering upon idiotism, from which they were rescued by time and generous living. In one patient, a man, the jaw was so perfectly locked upon the third day, that it was impossible to get any thing down his throat, and he died early upon the fifth day." (Account of the Scarlet Fever and Sore-Throat, p. 18.) In a few instances, we have seen the large joints suddenly become extremely painful, to which swelling with evidence of fluctuation suc- ceeded, and the patient was destroyed in a very short time. In many instances this malignant form of scar- latina proves fatal on the third or fourth day, though the patient often lingers till the second or third week : it is not uncommon for the patient to die suddenly on the second, third, or fourth day, without the practitioner being able to assign any satisfactory reason, or discover any lesion on the most careful examination of the body. Some- times, on the other hand, recovery takes place under the most unfavourable circumstances, but the convalescence is exceedingly tedious, and often retarded by the recurrence of some local inflammation, which had arisen during the pro- gress of the disease. It should not be overlooked that, when the early symptoms have been comparatively mild, the disease may suddenly assume the malignant character. Indeed this form (scarlatina maligna) is more frequently intermixed with the other va- rieties of scarlatina, and it sometimes unexpect- edly supersedes the milder forms of the disease, on the fourth, fifth, sixth, or seventh day of their course. (Willan.) 4. Scarlatina faucium.—It has been frequently observed, that when scarlatina prevails epidemi- cally, cases occur in which there is no appearance of rash on the skin, the efflorescence being con- fined to the throat and mouth. In some cases, the characteristic red appearance in the throat is unattended with swelling; in others, the efflor- escence in the throat is accompanied with swell- ing of the tonsils, and consequent painful deglu- tition. Dr. Willan states, that this complaint seems peculiar to adults, and is evidently a species of scarlatina, because it affects some individuals of large families, while the rest are labouring under other forms, and because it is capable of communicating by infection all the varieties of that disease. It is sometimes succeeded by an enlargement of the parotid glands, but not by dropsical swellings. Persons who have previously gone through the scarlatina anginosa, experience, while conversant with the sick, very uneasy sen- sations in the throat: in some there is a swelling and inflammation, or ulceration of the tonsils, producing considerable pain and irritation, but without the specific fever and efflorescence. (On Cutaneous Diseases, p. 274.) Similar instances have been related by Dr. Johnstone, in the descrip- tion of the epidemic scarlatina which prevailed at Worcester in 1778. Some individuals, at the first seizure, were more or less severely attacked with the scarlet eruption, with swelling, redness, and ulcers in the throat; yet others in the same family, infected from them, and by them, often had the ulcerated sore throat, without any efflor- escence or eruption on the skin. Again, the first seized sometimes had the simple ulcerated sore- throat only, and yet the others infected by them had the more severe attack of the disease, of fever, and scarlet eruption, as well as sore-throat SCARLATINA. 75 (Memoirs of the Medical Society of London, vol. iii.) In a paper by Dr. Lettsom, entitled Cursory Remarks on the Appearance of the Angina Scar- latina in the spring of 1793, several cases are given of this form of scarlatina. In one case the disease assumed the characters of scarlatina ma- ligna, but without efflorescence. The sister of this patient, a day or two after, became also the subject of the disease; but in this case, the affec- tion of the throat and fever of the malignant kind were accompanied by general florid efflorescence. In another family, one of the children had ulcera- tion of the throat, but no eruption: a second, about a year older, caught the disease, but had both the affection of the throat and the efflorescence. In another family, some had the sore-throat without any eruption, others had the eruption with a very moderate degree of sore-throat; and this was ob- served not only among the children, but also among the servants. (Memoirs of the Medical Society of London, vol. iv.) These statements accord exactly with our own experience of epidemic scarlatina. We had very lately an opportunity of observing in one family the simultaneous appearance of the various forms of the disease. In one of the children, who was the first subject of it, the symptoms early assumed a most malignant aspect; the velum and uvula were destroyed by gangrenous inflammation, and death took place about the fifteenth day. Some days after the disease had appeared in this child, one of the servants became ill, and passed through a mild form of scarlatina anginosa without any untoward symptom. No sooner had this servant recovered than the father of the child began to be indisposed, and in a day or two, considerable fever, with efflorescence of the mouth and throat, and inflammation of the tonsils, came on. The fever and anginose inflammation lasted for several days, and terminated in desquamation of the cuticle. It appears, then, that the various forms of scar- latina may be produced by exposure to the same exciting causes, and that the differences observed depend on some individual peculiarity or idiosyn- crasy, which cannot, a priori, be ascertained. [The blood in scarlatina has been examined by M. Andral, and found to be constituted as in mea- sles,— preserving, in other words, pretty nearly its mean proportion of fibrin—3 in 1000, with an augmentation of the proportion of globules, 127 in 1000. In four patients, he found the ratio of fibrin to be 3, 3£ and 4 ; in two others, that of the globules 136 and 146. (Cours de la Faculte, 1841, cited by Guersant & Blache, op. cit.)] Seqneloe.—Scarlatina is occasionally followed by troublesome local affections—ophthalmia—en- largement and frequently suppuration of cervical ] glands — abscess in the pharynx—laryngitis—] chronic bronchitis—inflammation of the ear, end- ing in purulent discharge from the meatus ex- ternus, or suppuration and consequently destruc- tion of the internal ear. In some instances, dropsical effusion comes on during the convalescence from scarlatina, and always proves an alarming affection. Anasarca is the form in which the dropsy more generally appears, and though the fluid may be ; confined to the subcutaneous cellular tissue, it sometimes accumulates in the different cavities; when this is the case, the patient may be consi- dered in great danger. It is singular, that the dropsy has been remarked to succeed as often to mild as to the more severe forms of the disease ; but it has never been observed to supervene in cases of malignant scarlatina : it would, therefore, appear to be connected with the acute or subacute forms of scarlatina only. It is almost entirely confined to children, rarely occurring after puber- ty ; Dr. Wells, however, had occasion to treat one case which occurred at the age of seventeen. It seems peculiar to some epidemics. We have seen it occur in several children of the same family, who had passed through scarlatina at the same time. Some writers seem to view this secondary affection as of trivial importance; others regard it as more serious than the primary disease. Plen- ciz, indeed, affirms that more persons die of it than of scarlatina. This, however, is not the result of the cases which we have witnessed, though in this country it occasionally proves fatal. It generally comes on ten or twelve days after the period of desquamation, and often without any evident cause: sometimes it does not come on for two or three weeks after the disappearance of the rash ; and in one case which came under our care, the dropsical symptoms did not appear till five weeks after the desquamation. Previous to its appearance, the patient, after perhaps satisfactorily proceeding in his convalescence to a certain point, finds he does not advance, but rather retrogrades: he complains of unaccountable languor and lassi- tude, loses his appetite and strength, his sleep is disturbed, his pulse becomes quick, the bowels costive, and the urine scanty : sometimes there is considerable gastric disorder, indicated by sick- ness, vomiting, and purging. The swelling is first observed in the face and upper parts of the body, to which it is sometimes confined, though more generally it extends over the whole body, and occasionally effusion takes place in the brain, cavity of the chest, or belly. In fatal cases, fluid has been effused in these three cavities in a very short time. In an epidemic scarlatina, described by Dr. Hamilton, which occurred among the boys in Heriot's Hospital, in three cases the disease pro- ceeded with a rapidity which afforded little oppor- tunity for deliberation or action. The stomach gave way; all food, cordials, and medicines were rejected by vomiting. The watery effusion rapidly filled the cellular membrane, and inundated every cavity. Within less than six-and-thirty hours from the occurrence of the ailment, the boys died, labouring under symptoms denoting ascites, hy- drothorax, and hydrocephalus. In this form of dropsy, the urine generally coagulates by exposure to heat or the addition of nitric or muriatic acid, alcohol, or a solution of the chloride of mercury. Sometimes it deposits a dark-red or brown sediment, which seems to arise from the admixture of the red globules of the blood. [Not unfrequently, in these cases, the kidneys exhibit signs of glandular disease; so that a ques- tion has even arisen, whether the anasarca may not be owing to the renal disease. (Guersant et 76 SCARLATINA. Blache, Op. cit. See, also, Rilliet and Barthez, Traite Clinique et Pratique des Maladies des Enfants, ii. 613, Paris, 1843.)] As dropsical effusion is to be regarded only as a secondary affection, it is of importance to ascer- tain its source. We have always regarded the dropsy succeeding to scarlatina as of an acute or subacute kind, arising from increased action in the sanguiferous system ; the consequence of this increased action is the effusion of serous fluid into the external tissues of the body, or when there is a still greater degree of vascular excitement, into one or other of the cavities. That this is the cause of the effusion, if not invariably, at least in the majority of instances, and certainly in all those which have come under our observation, was evi- dent from the character of the pulse as to fre- quency and power, the coagulable urine, the rapidity with which the fluid accumulated if not arrested by prompt treatment, and from the effi- cacy of bloodletting, purging, and other antiphlo- gistic measures, which were generally necessary to remove the dropsical effusion. Burserius, (Instit. Med. Pract. vol. ii.) in the account he has given of an epidemic scarlatina which prevailed at Florence in the year 1717, mentions that on opening the bodies of several persons who had died of this disease, the lungs, pleura, intercostal muscles, diaphragm, kidneys, and intestines, were more or less inflamed : that peripneumony having been considered as the primary disease, and the dropsical swelling only a consequence, blood was taken from the arm in the succeeding cases, once or oftener, as the occasion required ; and that no one afterwards died of the dropsy who was thus treated. [Effusions, of fatal tendency, occasionally take place into the larger joints. Gangrene of the extremities likewise occurs at times. In an ac- count of scarlatina that prevailed in the London Foundling Hospital, Dr. Watson gives one case that died of mortification of the rectum ; and six others that died sphacelated in various parts of the body. In the girls, some had the pudendal region mortified ; two had ulcers of the mouth and cheek, which sphacelated externally ; whilst one had the gums and jawbone so corroded, that most of the teeth fell out before she died. The lips and mouth of many that recovered were ul- cerated, and continued so for a long time.] Morbid Anatomy.—In scarlatina the appear- ances on dissection are by no means uniform; indeed, we have frequently been surprised, in ex- amining rapidly fatal cases, to find no morbid appearances that could explain the cause of death : in such instances, it is more than probable, that the diseased condition of the blood and fluids has had an important share in the fatal issue. The skin runs rapidly into putrefaction : it is generally of a dark red colour, the redness being of a deeper colour in different parts, and frequently inter- spersed with livid spots. When there have been violent delirium and other symptoms of cerebral excitement, the arachnoid membrane is vascular or even opaque, with effusion of a serous or some- times milky fluid underneath. In such cases, the substance of the brain is also unusually vascular. The mucous membrane of the mouth, cavity of the nose, pharynx, and sometimes even of the trachea and bronchi, is often red from sanguineous injection; and when there has been considerable acute anginose inflammation, there is swelling of the tonsils with exudation of lymph. In the ma- lignant scarlatina, there is little or no swelling, but the membrane of the pharynx is sometimes of a dark livid colour, and occasionally in a sloughing state. In some cases, there is a small quantity of puriform fluid in the sacculi of the larynx, and in two or three instances we have seen ulceration of the cartilages. These appear- ances in the throat are, however, by no means uniform or frequently observed, and the state of the throat after death very often presents no ap- preciable morbid appearance, even when there has been considerable anginose affection during the disease. In the chest, redness and thickening of the bronchial membrane, the smaller bronchial tubes and air-cells being/filled with a viscid secre- tion, and a gorged state, with extreme softening and tendency to rapid decomposition of the pul- monary tissue, are the principal morbid appear- ances. In the abdomen, there are seldom any appearances that can be called morbid ; in some cases, the mucous membrane of the stomach or of some portions of the alimentary canal has been slightly injected, though more frequently this membrane throughout the whole tract of the in- testines retains its natural colour. When puru- lent deposits take place in the joints—a compli- cation or sequela which we have occasionally observed—there are not always marks of inflam- mation of the synovial membrane. In the last case of this kind, however, which we examined, in which pus was deposited in the left wrist and in both ankle joints, there was deposition of pus exterior to the wrist joint, among the carpal bones. The synovial membrane of the wrist and ankles was evidently redder than natural, but there was no abrasion. We are therefore inclined to think, that these purulent formations in the joints may occur without antecedent inflammation ; and even in the case alluded to we doubt the co-ex- istence of inflammation : it is more probable that the pus which was deposited was not the conse- quence of the inflammatory action, but that the purulent fluid was deposited from the blood in the same way as it is sometimes deposited in other parts of the body. Diagnosis.—It is seldom difficult to distinguish scarlatina from other acute eruptive diseases. There is some resemblance, in the cutaneous'erfforescence, to measles and roseola. It may be distinguished from measles, 1st, by the period at which the eruption appears; 2d, by the accompanying symptoms; 3d, by the character of the eruption; and 4th, by symptoms which are frequently observed after the disappearance of the rash. In scarlatina the efflorescence generally appears about the second day of the fever, attended (with the exceptions stated) by affection of the throat, and the characteristic appearance of the tongue : in rubeola the rash does not come out till the fourth day, its appearance being preceded by sneezing, coryza, inflamed and watery eyes, cough, and other catarrhal symptoms, which continue during its progress. The eruption in scarlatina consists of innumerable minute dots or points, dif- fused in patches with uneven edges, of various SCARLATINA. 77 sizes and forms, and gives to those portions of the skin on which it appears a diffused bright red colour. In measles, the efflorescence comes out in irregular semilunar or crescent-shaped patches, distinctly elevated, the spots being of a deeper red in the centre than in the circumference, and leav- ing intervening spaces in which the skin retains its natural pale colour. The desquamation of the cuticle is besides more general and more considera- ble in scarlatina than in measles. The sequela? of measles are principally affections of the organs of respiration, croup, bronchitis, or pneumonia, which are more liable to come on towards the decline of the eruption. In scarlatina, there is more frequent affection of the glandular system, and liability to inflammation of the joints and serous membranes, and to anasarcous and dropsical effusion into the cavities. Roseola is always a much milder disease than even the simple form of scarlatina: the efflorescence is more continuous, of a deeper rose colour, and does not terminate by desquamation. Besides, in roseola, the anginose inflammation and appearance of the tongue peculiar to scarlatina are awanting. The whole duration of roseola too is short, seldom exceeding five or six days, and it cannot be propa- gated by contagion. It is also often symptomatic of other disorders. Prognosis and Mortality.—It has been ge- nerally observed, that scarlatina proves more severe to adults than to Aiildren, and that when it attacks pregnant or puerperal women it is often fatal. It has been also noticed, that it is generally mild in spring and summer, but severe during the winter months. Simple scarlatina is in general a very mild dis- ease and seldom proves dangerous unless some local inflammation supervene during its progress ; but thus a form of scarlatina, mild in the begin- ning, may be rendered suddenly and unexpectedly dangerous. Scarlatina anginosa is always a more severe disease than the scarlatina simplex, since to the more acute form of fever there is superadded in- flammation of the throat. The anginose inflam- mation, however, seldom of itself renders the dis- ease dangerous, especially if proper measures be adopted at the beginning. There is in general a manifest disposition in the affection of the throat to terminate in resolution, and it is often surpris- ing how readily it yields to general or local deple- tion. A moderate degree of swelling, with bright red efflorescence in the throat, is a more favoura- ble indication than when there is little or no swelling, and the redness assumes a dark or livid appearance. It was stated in the description of this variety of scarlatina, that the inflammation sometimes extended from the throat to the larynx: when this takes place, the danger is imminent; since if cedematous swelling of the glottis ensue, death almost inevitably ensues. Danger may also arise from inflammation in some of the cavities— cerebral, pulmonary, or abdominal disease being thus superadded to the anginose and cutaneous inflammations. A favourable or unfavourable prognosis may be often, in some measure, inferred from the cutane- ous efflorescence. In the scarlatina anginosa, the rash appears late in the disease, and though in most instances, it is diffused generally over the surface, it is often only partial, coming out in small irregular patches on different parts of the body. In these latter cases, it is more apt to dis- appear suddenly, which is a less favourable cir- cumstance than when the rash is general and re- mains out for several days. The colour of the eruption seems also connected with the general character of the disease. A bright red or scarlet efflorescence is more favourable than the dark red, crimson, or brownish colour which it sometimes assumes. A very pale rash, more especially if it be partial and evanescent, is also unfavourable; and when the eruption, whatever be its colour or the extent of its diffusion, disappears suddenly, and afterwards reappears, or if it do not again come out, more especially if it have receded at the beginning of the disease, the danger is considera- ble. The more perfectly the desquamation takes place, the case is to he regarded as the more favourable, as secondary disorders are less likely to arise. From the description which has been given of the scarlatina maligna, the danger in almost every case must be apparent, though it does not appear to arise from the visceral complications which oc- casionally supervene, as in fatal cases there is sel- dom discovered in the internal organs satisfactory evidence of the cause of death. In estimating the amount of danger and probable issue of the case, however, it should be kept in view, that though this form of scarlatina proves fatal in a much lar- ger proportion of cases than any of the other va- rieties, there is every intermediate shade or grada- tion between the less severe and most malignant cases. In this more severe form of scarlatina some particular symptoms or appearances however modify the prognosis. Children are observed to struggle better against it than adults, though in some epidemics no age seems to be exempt from its ravages. The existence or non-existence of local inflammation in any organ must also be taken into account, in estimating the degree of danger, and it should be kept in mind how little such topical inflammations are under the control of the treatment, which it is necessary to modify accord- ing to the general powers of the patient; if active measures be resorted to in cases of malignancy with the hope of subduing the low forms of vis- ceral inflammation, the powers of the patient would be endangered if not irrecoverably sunk. With regard to the prognosis of malignant scar- latina to be deduced from particular symptoms, a favourable result may be predicted from the fol- lowing circumstances—mild fever and moderate affection of the throat—early and copious eruption succeeded about the third or fourth day by gentle moderate perspiration, and general desquamation of the cuticle—the throat assuming a florid red colour, and if there have been sloughing, the ulcer- ation looking clean and healthy—diminution in the frequency, with firmness and equality of the pulse—the breathing becoming soft and free, while the eye resumes its brilliancy, and the counte- nance its natural expression. On the other hand, the prognosis may be deemed unfavourable, when the following symptoms occur—a partial eruption disappearing suddenly—or assuming a dusky or livid colour, more especially if accompanied with SCARLATINA. 78 petechia? —smallnesa and great rapidity of the i candour would have compelled him to acknow- pulse—frequent sighing with sensation of great ledge, that the views he entertained and promul- faintness-hot dry skin-hurried breathing not gated of the nature of scarlatina had been formed ending on disease of the lungs —acrid dis- on too limited experience of the disease, t nera- depending charge from the nose and ears—ulceration of the lips and angles of the mouth—paleness or shrink- ing of the features—sunken eyes—partial cold sweats—coldness of the extremities—low mutter- ing delirium—coma—hiccup—subsultustendinum —involuntary stools—gangrenous inflammation of those parts subjected to pressure, as the sacrum and hips—swelling and purulent deposits in the larger joints. Huxham observed in some indivi- duals previous to the fatal issue, the face bloated and shining, and the neck swollen and of a cada- verous appearance, the whole body even became in some degree ccdematous, so that the impression of the finger remained pidity with which patients are hurried off is often striking. In an epidemic scarlatina which pre- vailed in Paris in 1743, we are told that every in- dividual who was attacked perished—many indeed within nine hours from its first invasion. That which raged at Bromley, near Bow, in Middlesex, in the year 1746, it is stated by Dr. Fothergill, seemed to yield to no remedies or applications; several of the inhabitants were greatly alarmed by it, some losing the greater part of their children after a few days' indisposition. These are by no means solitary examples of the great fatality of scarlatina, as similar epidemic visitations have been recorded by Huxham, (Dissertation on the [The form of scarlatina, which has been termed ' Malignant Ulcerous Sore Throat,) Cotton, (On a the hemorrhagic, is almost always fatal. It is particular kind of Scarlet Fever, prevalent^.St indicated by the ordinary signs of purpura,—dark spots appearing here and there, followed by ex- udation of blood from the mucous membranes— of the mouth and nose especially, which is occa- sionally so profuse as to cause death. In these cases, if a puncture be made, it becomes the seat of hemorrhage. In a case of the kind referred to by Dr. Morton, (Mackintosh's Principles of Pa- thology, 2d Amer. edit. i. 224, Philad. 1837,) an abscess in the neck suddenly filled with blood, and this, making its way through a leech-bite, flowed out as if from a divided artery, and de- stroyed the patient in a few hours.] The mortality of scarlatina varies much in dif- ferent epidemics, although nothing has.been satis- factorily established as to the causes which influ- ence the fatality of the disease. The difference observed in epidemics is not confined to scarlatina, but occurs in every variety of fever, whether of the continued, periodic, or eruptive form. In some epidemics scarlatina is a very mild disease through- out ; and when it does prove fatal, the cause may often be traced to the supervention of some acci- dental inflammation; or it may happen, that in particular instances, the symptoms may assume a malignant character, though the general aspect of the epidemic be very mild. It is unnecessary to pass under review the histories which have been recorded of epidemic scarlatina which have at various times appeared ; they are alluded to, prin- cipally with the object of directing attention to the influence which certain, though unknown cir- cumstances exert over the character and symp- toms of this disease. It is often sufficient for the practical inquirer to be a diligent and faithful ob- server of nature, without attempting to discover the hidden causes, and invent explanations of her secret operations. The extreme mildness of some Alban's in the year 1748,) De Haen, (Philos. Trans. 1749,) Johnstone, (Remarks on the Angina, and Scarlet Fever of 1788, in the Memoirs of the Medical Society, vol. iii.,) Rush, (Medical Obser- vations and Enquiries,) Lettsom, (Memoirs of the Medical Society, vol. iv.,) Sims, (Ibid. vol. v.,) Willan, (Miscellaneous Works, edited by Ashby Smith, M.D.,) Bateman, (Reports on the Diseases of London,) Blane, (Med. Chir. Trans, vol. iv.,) Macgregor, (Ibid. vol. v.,) Tweedie, (Clinical Il- lustrations of Fever,) Carbutt, (North of England Med. and Surg. Journ., vol. i.,) Sandwith,* and others. Dr. Willan has given the result of his expe- rience of an epidemic scarlatina, from cases which occurred in his own practice in the year 1786. Of 251 cases, there were 152 of scarlatina angi- nosa, 42 of sore throat without eruption on the skin, and 39 of scarlatina maligna. Dr. Clark, in the description he has given of an epidemic scar- latina which prevailed at Newcastle in 1778, ob- served, that of 131 patients, 75 had the eruption with sore throat; in 33 the disease occurred with every distinguishing symptom of scarlatina ma- ligna ; and that in 23 cases it was succeeded by dropsy. He adds, when it is considered that great numbers had the distemper in such a mild manner as to require no medical assistance, and that application was only made for the advice of a physician when the patients were severely attacked, perhaps the malignant cases ought not to be estimated higher than as one to twenty in all who took the disease. No deductions however can be drawn from these averages, as they have reference only to solitary epidemics, and it is well known that in one or several epidemics a large proportion of the cases assume the characters of a malignant disease, epidemics has induced many to assert, that the while, as was formerly stated, a few malignant mortality of scarlatina has been overrated, and even Sydenham from his observance of the disease (its milder forms only having evidently been pre- sented to his notice), came to the conclusion that it scarcely required medical aid, and when it did prove fatal, this result was to be traced to the nimia medici diligentia. Had the attention of this illustrious physician been directed to the epi- demic described by Morton, a very short time after this opinion was delivered to the world, hia cases only may occur out of a large number of in- dividuals affected. We find from the register of cases kept at the London Fever Hospital, that the mortality of scarlatina shows great variation. In the yeara 1822 and 1823, the disease appears to have been extremely mild, as none of the patients died during these years. In 1824, the mortality was one in * Edin. Med. and Surg. Journ., NoTcxvii., fa most ex- cellent practical paper.) v SCARLATINA. 79 twenty-one; in 1825, one in thirteen; in 1826, one in twenty-nine; in 1827, one in forty-one; in 1828, one in ten; in 1829, one in six; in 1830, one in six ; in 1831, the disease was not prevalent, and none of the cases proved fatal; in 1838, the mortality was one in forty ; and during the last year, the average has been about one in twenty-two. Of 644 cases treated at this hospital, the gross mortality was thirty-eight; of these there were thirteen males and twenty-five females. The following table exhibits the comparative ages of the fatal cases:— Males. Females. 7 years of age........ 0 ...... 1 10 ditto.............. 1 ...... 1 11 ditto.............. 0 ...... 2 12 ditto.............. 0 ...... 1 13 ditto.............. 1 ...... 1 18 ditto.............. 0 ...... 1 19 ditto.............. 2 ...... 3 20 ditto.............. 0 ...... 2 21 ditto.............. 0 ...... 2 22 ditto.............. 1 ...... 2 23 ditto.............. 1 ...... 1 24 ditto.............. 2 ...... 2 25 ditto.............. 2 ...... 1 26 ditto.............. 2 ...... 1 27 ditto.............. 0 ...... 2 30 ditto.............. 0 ...... 1 33 ditto.............. 1 ...... 0 40 ditto.............. 0 ...... 1 13 25 in a former part of this article, so that it is suffi- cient merely to advert to it again. 1. In the scarlatina simplex, the symptoms are generally so mild, that it is only necessary to con- fine the patient to bed, to keep the apartment cool, to prescribe occasional aperients, cooling drinks, and abstinence from animal food, so long as there is any febrile indisposition. Should the skin fee! hot at intervals, it is advisable to sponge the sur- face with cold water, by which the morbid heat u rapidly dissipated, and the feelings of the patient are rendered more comfortable. It is seldom ne- cessary in this form of scarlatina to abstract blood, unless it be deemed expedient in cases where the fever runs high. In those cases, it may be pru- dent to take away a moderate quantity of blood, with the view of subduing the vascular excite- ment, and preventing the local inflammations which frequently arise in scarlatina. Whether bloodletting be deemed expedient or not, an emetic is often attended with good effects; after which the bowels should be freely opened by brisk aperients, and the various saline remedies, in combination with antimony, administered as cir- cumstances require. It is necessary to watch every case of scarlatina, however mild at the be- ginning, as the character of the disease is often materially altered by the sudden accession of in- flammation in some internal organ, by which a mild disease may in the space of a few hours be converted into one of severity and danger. 2. We have pointed out the more active nature of the symptoms in scarlatina anginosa. In adults of a plethoric tendency, more especially if [In England and Wales, the number of deaths j the patient be young, bloodletting is sometimes mngst children from scarlatina was in 1838, necessary; and even in 5802; in 1839, 10,325; less than the mortality from measles. (W. Farr, Third Report of the Registrar-General, Lond. 1841.) If, however, the year 1840 be reckoned, the preponderance is on the side of scarlatina:—the deaths during that year being 19,816; whilst those from measles were 9326. In all the Atlantic cities of the United States, so far as statistical examinations have been made, scar- latina appears to be a more fatal malady than mea- sles. In an inaugural " Essay on the Comparative Mortality of Measles and Scarlet Fever," presented to the faculty of Jefferson College in Feb. 1844, Dr. George King Smith makes the number of deaths from measles in Philadelphia, from 1807 to 1841 inclusive, 1376; from scarlatina during the same period, 2226. In New York, from 1819 to 1834 inclusive, the deaths from measles were 1337; from scarlatina, 1500. In Boston, from 1811 to 1840 inclusive, from measles 700 ; from scarla- tina, 970.] Treatment. — From the description which has been given of the various forms of scarlatina, it is obvious that the measures to be adopted for its treatment must have reference to each indivi- dual case, as well as to the various circumstances with which it may be associated. It is also indispensably necessary that the treat- ment should have reference to the prevailing type or character of the fever, an indication which it is of the utmost importance to bear in mind in the management of this disease. We have already endeavoured to impress this circumstance strongly children, a moderate bleed- ing from the arm, when there is much excitement at the beginning, is often useful in moderating the fever, and diminishing the tendency to visceral in- flammation. General bloodletting has been strong- ly recommended by several continental physicians in this form of scarlatina, more especially when there is much cerebral disturbance. Morton em- ployed it with success in the epidemic he has de- scribed ; and in the scarlatina which prevailed at Edinburgh in 1733, we find it stated, that few died who were timely and plentifully blooded, which weakened the fever, relieved the throat, and was the only medicine that removed the vom- iting and diarrhoea. (Edinburgh Medical Essays, vol. iii. p. 27.) Huxham advocates this practice at the commencement of the fever, when the blood was often sizy, but recommends one moderate bleeding only, as patients did not bear a large bleeding, and scarcely any a second. On the other hand, in some epidemics, evacua- tions of blood are less efficacious, or wholly inad- missible, either from the form of fever being of a less acute character, or from the tendency of the general powers to decline, when active depletion has been adopted. The successful treatment of the disease by bloodletting and other antiphlogistic measures at one season, does not warrant the prac- titioner in employing the same plan in another epidemic; the type of the fever, the pulse, and the general aspect of the symptoms must be his guide. In the epidemic described by Dr. Withering, such was the state of the pulse, that bloodletting was inadmissible, unless in the autumn, when the 80 SCARLATINA. colour of the rash was not intense, or did not appear at all, the swelling of the throat great, and the pulse firm. Dr. Willan also states, that during the years 1785, 1786, 1787, and since, when the scarlatina anginosa was epidemic in the metropolis, he never saw a case in which blood- letting appeared to be indicated. Whenever it had been employed, great depression and faintness were the immediate consequences, the pulse be- coming more weak and frequent, and often irregu- lar. Of two adults who had been bled largely, one died before the period of desquamation, the other lingered in a very precarious state upwards of twenty days, but at length recovered. It is therefore almost impossible to lay down general rules for the treatment of a disease which varies so much in its character at different times. At one season, or in one epidemic, bleeding may be required — at another, the lancet is to be em- ployed with the greatest caution, and not unless some urgent circumstance arises to require its use. We have seldom had occasion to bleed from the arm, unless in particular instances of unusual febrile excitement, or when some important organ was threatened with inflammation. We generally prefer the free topical abstraction of blood by cup- ping behind the neck, which is the most effectual mode of relieving the inflammation of the throat, or by the application of leeches under the jaw, or behind the ears. We have seen great benefit also from the free scarification of the tonsils when skil- fully performed, though many patients object to this mode of topical bleeding, which is also often not easily performed in timid persons. We have seldom observed any decided benefit from the use of gargles, indeed the inconvenience felt by the patient in their employment often pre- cludes their adoption. The inhalation of the va- pour arising from warm water gives much more decided relief. The exhibition of emetics in the commencement of scarlatina anginosa as well as of the other forms, has been strenuously recommended by some physicians. Dr. Withering prescribed them not only in the beginning, but even in the later stages of the disease. Their employment, however, should be restricted to the period of invasion, as it has been observed that they are much more beneficial at this stage than when the symp- toms are more advanced. The shock which is given to the system by the action of vomiting in the early stage of eruptive fevers is often followed by most decided improvement in the general symp- toms and feelings of the patient. Dr. Rush exhi- bited an emetic, combined with calomel, in every case he was called to, which, besides inducing vomiting, seldom failed to produce two or three stools; in several cases he was obliged, by the continuance of the nausea, to repeat the emetic, and always with obvious and manifest advantage. The abatement in the symptoms which is gene- rally observed after the bowels have been freely evacuated, has induced physicians to purge freely in the early stages of scarlatina anginosa, and certainly no class of remedies is more entitled to confidence than purgatives, when administered with discernment. Many writers have expressed their doubts of the safety of this practice, from the fear of inducing debility and repelling the efflo- rescence. Dr. Hamilton, however, has adduced powerful arguments in support of it, and has illus- trated his views by an appeal to the result of cases treated in public and private practice. No variety of the disease, as appearing in different epidemics, or in the course of the same epidemic, has hitherto prevented this distinguished physician from fol- lowing out this practice to the necessary extent The pungent heat of surface, violent headach, turgescence of features, and full and quick pulse, the earliest symptoms in some epidemics of scar- latina, and which may have suggested and war- ranted the practice of bloodletting, are often quickly subdued by one or two brisk purgatives. Dr. Ha- milton states, that full purging is not required in the subsequent periods of the disease, in which the sole object is to remedy the impaired action of the intestines ; to secure the complete and regular expulsion of their contents ; and thus to prevent the accumulation of fa?ces, which never fails to aggravate the symptoms and to prove the source of further suffering to the patient. He has added some very useful hints as to the same activity not being required in the exhibition of purgative me- dicines in every case of scarlatina, acknowledging, that he had not ascertained to what this different state of the bowels in scarlatina is to be ascribed, and observing that on whatever cause the differ- ence depends, it is necessary to adapt our practice in the use of purgatives to the nature of the pre- vailing epidemic. In the early stages, when there is nothing to contra-indicate the use of purgatives, a brisk ape- rient may be exhibited daily. We generally pre- scribe a combination of calomel and rhubarb at bed-lime, and on the following morning a moderate dose of castor-oil, or infusion of senna with manna and sulphate of magnesia. When the cuticle begins to desquamate, and the febrile symptoma decline, active cathartics are improper; at this stage of the disease, it is necessary only to ensure the regular evacuation of the bowels, for which purpose the mildest aperients are best adapted. Though we have advocated the employment of purgatives in the more severe cases of scarlatina, they are to be prescribed with the greatest caution, if not altogether withheld, when the mucous mem- brane of the intestines betrays signs of irritation or of inflammation. In such cases, the bowels are generally purged, and the dejections of an unhealthy appearance. Under such circumstances the gastric irritation must be allayed by leeches applied to the abdomen, counter-irritation, and bland nourishment. Aperients, even of the mildest class, must be withheld, until the intestinal derangement is allayed; and should it become necessary to administer an aperient occasionally, the least irritating should be selected ; none is pre- ferable to castor-oil suspended in mucilage, with the addition of a few drops of laudanum. The free application of cold is decidedly benefi- cial in the acute stage of scailatina, and more especially in the anginose form. The bed-cham- ber should always be properly ventilated by fre- quently renewing the air, and allowing a current of cool fresh air to pass round the patient. If the skin be hot, the body should be occasionally sponged with cold water, by which the morbid heat is rapidly abstracted, and the patient refresh- SCARLATINA. 81 ed. The sponging should be repeated when the skin feels pungently hot. The testimony of Dr. Bateman, as to the efficacy of this practice, is very strong: — " We are possessed," he says, " of no physical agent, as far as my experience has taught me, (not excepting even the use of blood- letting in acute inflammation,) by which the functions of the animal economy are controlled with so much certainty, safety, and promptitude, as by the application of cold water to the skin, under the augmented heat of scarlatina, and of some other fevers. This expedient combines in itself all the medicinal properties which are indi- cated in this state of disease, and which we should scarcely a priori expect it to possess : for it is not only the most effectual febrifuge, (the « febrifugum magnum," as a reverend author long ago called it,) but is, in fact, the only sudorific and anodyne which will not disappoint the expectation of the practitioner under these circumstances. I have had the satisfaction in numerous instances of witnessing the immediate improvement of the symptoms, and the rapid change in the counte- nance of the patient produced by washing the skin. Invariably, in the course of a few minutes, the pulse has been diminished in frequency, the thirst has abated, the tongue has become moist, a general free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened; and these indications of relief have been speedily followed by a calm and refreshing sleep. In all these respects, the condition of the patient presented a complete contrast to that •which preceded the cold washing: and his languor was exchanged for a considerable share of vigour. The morbid heat, it is true, when thus removed, is liable to return, and with it the distressing symptoms, but a repetition of the remedy is follow- ed by the same beneficial effects as at first." (Practi- cal Synopsis of Cutaneous Diseases.) [The use of ice internally is the best and most grateful refrigerant. Chlorinated soda, chlorinated lime, or the aqua chlorini, is sometimes added to the water.] Little confidence should be reposed in any of the ordinary saline remedies. We prefer the mineral acids, more especially the saturated solu- tion of chlorine, prepared according to the direc- tions given in the Dublin Pharmacopoeia, which contains about twice its volume of chlorine. Of this remedy a fluid rachm and a half, mixed with eight ounces of water, and two drachms of syrup of lemons, may be taken in divided portions during the day, For children, ten or twelve drops every six or eight hours is a sufficient dose. The solution of chlorine is readily decomposed by exposure to light and air, and in this state it is very apt to disorder the stomach and bowels, pro- ducing sickness, griping pain of the bowels, or diarrhoea. It is therefore necessary, that the remedy should have been recently prepared before it is exhibited. If recently prepared chlorine cannot be readily procured, (though it is obtained by a very simple chemical process,) the diluted sulphuric acid may be substituted. In the advanced stages of scarlatina anginosa, when the general fever has declined, and the efflorescence has disappeared, it is often necessary to give, with due caution, a little support. Mild Vol. IV.—11 nourishment is often sufficient, but should the pulse be soft and rather weak, with a cool skin, small doses of quinine in acidulated infusion of roses are generally very beneficial. It is seldom necessary to administer wine, except under circum- stances of unusual debility after a protracted ill- ness. The moderate use of it in such cases tends much to assist the convalescence. When visceral inflammation arises in the pro- gress of scarlatina anginosa, no time should be lost in endeavouring to arrest it. In such cases, the judgment of the practitioner must direct him as to the extent to which it is necessary to carry the antiphlogistic treatment We have already entered so fully into the management of the various local lesions which arise in the progress of fever, (and the indications to be observed in scarlatina are precisely similar,) that we deem it unnecessary to repeat what has been already advanced, (see Fevee,) though the necessity of watching narrowly the state of the several organs, and of adopting suitable- measures on the first evidence of local inflammation, cannot be too forcibly impressed on those who may not have had much experience in the treatment of this disease. 3. In scarlatina maligna, the acute stage, in which only antiphlogistic measures can with safety be employed, soon passes off, and is succeeded by a low depressed state of the general powers, which renders any form of depletion not only doubtful but hazardous. If the practitioner be called on to treat this form of scarlatina at its very commence- ment, and before it is fully formed, an antimonial emetic is generally very beneficial, more particu- larly when the bowels are afterwards evacuated either by the antimony, or by an active aperient. If, however, those means be insufficient to subdue- the excitement, moreover if the pulse be rapid and firm, the skin hot, and there be much pain in the head, or delirium, a moderate quantity of blood should be taken from the arm, and another aperient given. This treatment, if adopted at the onset of the symptoms, will generally not only moderate the fever, but shorten the duration and violence of the disease. In many cases, however, such is the violence of the symptoms, more especially if they have been neglected in the beginning, that the acute stage is speedily followed by symptoms of a low typhoid character, which requires a cor- dial tonic plan of treatment. It then becomes necessary to support the sinking powers by ani- mal broths, quinine, and a moderate allowance of wine. The volatile alkali has been strongly recom- mended in cases of malignant scarlatina; it was considered by Dr. Peart to be endowed with a spe- cific power over the malignant scarlet fever and sore throat. He directed two drachms of the carbo- nate of ammonia to be dissolved in five ounces of water, of which the dose was two spoonsful every two, three, or four hours, according to the urgency of the symptoms. This remedy was administered in every form and stage of the disease, and were we to judge from the result of the cases in which this remedy was given, it would appear never to have failed even in the worst. We certainly have tried this remedy repeatedly, but our experience of it does not warrant such an inference; nor do 82 SCARLATINA. we deem it preferable to other diffusible stimu- lants. Capsicum is a remedy which appears to have been employed with much success by Dr. Stephens, in an epidemic scarlatina which pre- vailed at St. Christopher's in 1787, and of which an account was published in the second volume of the Medical Communications, and also in Dun- can's Medical Commentaries for the year 1787. This remedy was used in the form of infusion prepared according to the following formula : two tablespoonfuls of small red pepper, or three of the common Cayenne pepper, and two teaspoonfuls of fine salt are to be beat into a paste, to which half a pint of boiling water is to be added. When cold, the liquor is to be strained off, to which half a pint of very sharp vinegar is to be added. Of this mixture, the dose for an adult is one table- spoonful every four hours, the quantity being di- minished in proportion for children. This reme- dy has been commended by several writers who have employed it successfully ; but having never employed it, we cannot offer an opinion of it. When topical inflammations arise in scarlatina •maligna, general bleeding is seldom admissible, unless they supervene in the beginning of the disease : the application of leeches, in numbers proportioned to the age and powers of the patient, is better adapted to the low forms of local inflam- mation which arise in this malignant disease. With regard to the local treatment in scarlatina maligna, we may observe, that in the very begin- ning of the disease, the inflammation in the throat is best managed by the application of leeches under the jaw or behind the ears; but this treat- ment must be confined to the very onset of the anginose affection, since the inflammation in most cases very speedily passes into gangrene. The vapour arising from warm water may be fre- quently inhaled. Some physicians recommend the occasional exhibition of an emetic with the view of dislodging the viscid secretion with which the fauces are clogged, and unless the powers be so feeble as to render the shock of an emetic hazardous, benefit is often derived from their em- ployment. Acidulated bitter effusions, as of cinchona, cusparia, serpentaria, contrayerva, or an infusion of capsicum, prepared as recommended by Dr. Stephens, may be used as a gargle. A weak solution of the nitrate of silver, or of sulphate of copper, applied by means of a proper syringe, after the throat has been well cleansed by warm water, often improves the aspect of the ulceration. Dr. A. T. Thomson recommends the chloroso- diac solution of Labarraque in the proportion of f.gxii of the solution to f.^vss of water and giv of honey, as an excellent gargle. The same solution in the proportion of ^vi to ^v of water, without the addition of honey, if frequently thrown into the nostrils by means of an elastic bottle mounted with a tube, soon removes the coryza. (Bateman's Practical Synopsis of Cuta- neous Diseases, edited by Anthony Todd Thom- son, M. D.) Fumigations by the nitrous acid gas, (separa. ted from pulverized nitre by the strong sulphuric acid,) or the nitro-muriatic acid gas, (chlorine,) (separated from a mixture of equal parts of pul- verized nitre and of sea-salt, by the strong sul- phuric acid,) have been strongly recommended by Willan. It is almost superfluous to state, that proper ventilation is most essentially necessary in this, as in the other forms of scarlatina. The admission of fresh air around the patient generally invigor- ates his powers, and often proves a most excellent tonic. Warm sponging, a tepid bath, or if there be much cerebral disturbance, fomentations to the extremities may be employed in addition to the other means. The treatment of the dropsical effusion which we have described as an occasional occurrence towards the termination of scarlatina, is to be regulated by the condition of the system, and more especially of the several internal organs. The effusion in general speedily disappears under judicious treatment; in all the cases which have fallen under our notice, the dropsy has been evi- dently dependent on general or local excitement, which it was necessary to subdue by bloodletting and purging, after the adoption of which measures the effusion quickly vanished. In some instances, when the state of the pulse did not require the abstraction of blood, a few doses of brisk purga- tives have carried off the fluid: in others, the activity of the circulation, the heat of skin, scanty urine, and oppressed breathing, at once suggested the necessity of bloodletting, from which the most decided relief was immediately obtained, after purgatives and diuretics had completely failed. The efficacy of the antiphlogistic treatment of dropsy succeeding to scarlatina has been corrobo-0 rated by many practical writers in other countries as well as our own ; and though some still hesi- tate to adopt the practice, we are satisfied that in cases accompanied with phlogistic symptoms, it is the only safe and rational mode of treatment. Besides, when we consider the condition in which the internal organs have been occasionally found in fatal cases of scarlatina complicated with dropsy, the propriety of vigorous antiphlogistic treatment is apparent. We admit that in some instances, in which the symptoms are of a less acute character, bloodletting may be dispensed with : we allude more particularly to those in which, though the general powers be feeble, there is congestion or chronic insidious inflammation in some organ. Under such circumstances, topical bleeding, mild purgatives, and diuretics, with a bland diet, will be found more appropriate mea- sures. As to the employment of tonics, on the supposition that the dropsical effusion depends on loss of power or tone in the exhalants, we con- fess we are sceptical as to this being the patholo- gical state of the vessels in any case of dropsy succeeding to scarlatina, and therefore we are dis- posed to place little or no confidence in this class of remedies. When the effusion has been re- moved by suitable measures, pure air, mild nourish- ment, and attention to the bowels will be found the best mode of invigorating the general powers. A. Tweedie. SCIRRHUS.—The term aKipfios, from axtpoi, marble, was given by the Greek physicians to cer- tain tumours characterized chiefly by a great de- gree of hardness ; but the application of the term SCIRRHUS. 83 scirrhus has for a considerable length of time been limited to tumours or portions of organs or tissues which present not only this character, but which terminate in the disease called cancer. Hence the state of induration to which the appel- lation of scirrhus is given is regarded as the first stage of cancer. We shall overlook for the pre- sent the propriety of this distinction, and instead of confining ourselves to the consideration of scirrhus, shall in the present article give a general view of those morbid conditions which have been denominated scirrhus, cancer, fungus ha?matodes, and the several kinds of sarcoma, under the generic term of Carcinoma. The reasons for our group- ing together under the term carcinoma so many diseases which have generally been described as differing widely from that which is commonly known by this designation, will be fully exposed as we proceed. In the meantime, however, the following may be regarded as the more remarkable phenomena which these diseases, considered in a general and anatomical point of view, present in common with one another, and which we con- ceive, while they express in a concise and con- spicuous manner those characters by which they are distinguished, justify our having brought them together under the same general denomination :— 1. They are essentially composed of a solid or fluid substance, different from any of the solids or fluids which enter into the healthy composition of the body. 2. They often present in the early periods of their formation certain characters com- mon to all of them, however much they may differ from each other in the subsequent periods. 3. They all terminate in the gradual destruction or transformation of the tissues which they affect. 4. They have all a tendency to affect, successively or simultaneously, several organs in the same in- dividual. 5. They all possess, although in various degrees, the same reproductive character. Specific Divisions of Carcinoma.—When we examine the several morbid conditions which we have included under the genus carcinoma, we find that they present differences, some of which are of considerable importance, others less so; and therefore it becomes necessary to separate them into distinct groups, and to arrange them into species and varieties. The differences to which we allude are referable to two states of the carci- nomatous substance to which the diseases in ques- tion owe their origin. The first is that in which this substance has little or no tendency to become organized : its form and arrangement appear to be determined chiefly by external circumstances, and its formation and subsequent increase are entirely dependent on the nutritive function of the organ in which it is contained. In the second state this substance exhibits, on the contrary, a greater or less tendency to become organized : although it may at first assume a determinate form and arrangement, in consequence of the influence of external circum- stances, it possessss in itself properties by means of which its subsequent arrangement and develop- ment are effected, independent of the nutritive function of the organ in which it is formed, ex- cept in so far as the materials of its growth may be derived from this source. On account, therefore, of these two opposite states of this particular substance, carcinoma may be divided into two species, the first of which we have called scirrhoma, the second cephaloma. Although neither of these terms expresses the essential characters of the respective states to which they are applied, we have not been able to find or devise others better calculated to accom- plish this object; it is therefore necessary to bear in mind that they indicate only one of the cha- racters of these states, viz. a certain degree of consistence, and which, it may be observed, is far from being constant in either, because of various circumstances, which we shall afterwards endea- vour to explain. In these two species, scirrhoma and cephaloma, the carcinomatous substance presents itself under various forms, which may be regarded as consti- tuting so many varieties of each species. Varieties of Scirrhoma.—The varieties of scirrhoma are determined chiefly by the relative quantity of the carcinomatous substance, the man- ner in which it is distributed, and the difference of colour and consistence which it presents. Thus it may be collected in numerous points in the form of a hard, grey, semi-transparent substance, inter- sected by a dull white or pale straw-coloured fibrous or condensed cellular tissue, and, as such, is commonly denominated scirrhus. When it assumes a regular Iobulated arrangement, so as to present an appearance similar to a section of the pancreas, it forms what was called by Mr. Aber- nethy the pancreatic sarcoma. (Surgical Ob- servations, London, 1804 and 1816.) Again, it may be disseminated uniformly throughout the texture of an organ, which it converts into a solid substance, resembling a slice of raw or boiled pork, and is then called by the French tissu lardace. Lastly, when it presents the appearance of firm jelly, and is collected into masses of greater or less bulk in a multitude of cells, it is the matiere colloid of Laennec, the cancer gilatiniforme or areolaire of M. Cruveilhier. (Anatomie Patho- logique, Dixieme Liyraison.) Varieties of Cephaloma.—The principal va- rieties of cephaloma are derived from the appear- ances which the carcinomatous substance presents either in different organs or at different stages of its development. When it presents the appear- ance of firm coagulable lymph, or fibrine deprived of the red colouring-matter of the blood, possess- ing a uniform, fibriform, or lobuliform arrange- ment, with a certain degree of transparency and vascularity, Mr. Abernethy gave to it the name of common vascular or organized sarcoma. In this state the carcinomatous substance is generally col- lected into a mass of greater or less bulk, in which few or no traces of the proper tissue of the organ in which it is contained are observable. If, on the contrary, it be uniformly disseminated through- out the texture of an organ, so as to transform it into a substance resembling a section of the mam- mary gland, or the udder of the cow when boiled, the appellation of mammary sarcoma was given to it by Mr. Abernethy. When it presents an appearance similar in colour and consistence to the substance of the brain, it was called medullary sarcoma by the same distinguished surgeon ; ma- tiere cerebriforme or encephaloide by Laennec, (Diet, des Sciences Med. art. Encephaloi'des), and spongoid inflammation by Mr. Burns. (Lee- 84 SCIRRHUS. tureg on Inflammation.) The milk-like tumour of Dr. Monro, (Morbid Anat. of the Human Gul- let, Edinb. 1811,) the soft cancer of various au- thors, and the pulpy testicle of Dr. Baillie, (Mor- bid Anatomy, London, 1795,) are names which have been given to the same state. Of all the varieties of cephaloma, the last is that in which a vascular organization is most con- spicuous, and as the coats of the vessels with which it is supplied are remarkably delicate, the circulation of the blood through them is readily interrupted ; hemorrhage from congestive rupture takes place, and the effused blood is mixed in greater or less quantity with the brain-like matter. From this accidental circumstance, together with the protrusion of this substance through the ul- cerated integuments for example, in the form of a bleeding fungus, it has been described by Mr. Hey (Pract. Observat. on Surgery, London, 1803) and also by Mr. Wardrop, (Observat. on Fungus Hsmatodes, Edin. 1809,) under the appellation of fungus hxmatodes. Sir Astley Cooper calls it fungoid disease. Such are, we conceive, the principal varieties of scirrhoma and cephaloma, and the general cha- racters by means of which they may be recognised. But although we have said that the essential differ- ence between the two species of carcinoma consists in the former having little or no tendency, the latter a greater or less tendency, to become organized, it is by no means always easy, nay, it is some- times impossible, to draw a distinct line of sepa- ration between them ; for the carcinomatous de- posit when first formed, and, indeed, frequently for a considerable length of time after its forma- tion, does not furnish us with any signs which show that it will or will not become organized. We cannot determine what those properties are by means of which it is afterwards to assume a definite arrangement, or to possess within itself the powers of contributing to its subsequent de- velopment. These facts may be illustrated by the two following circumstances: 1. the carcinoma- tous deposit may exist as we have described it in the form of scirrhus, pancreatic sarcoma, or the Iardaceous tissue, without its presenting any trace of organization; the textures which it invades being gradually destroyed by its presence, and both ultimately converted into a soft, granular, pulpy, or liquid mass, of the colour and consist- ence of cream or milk. 2. The same deposit may exist under the same forms as those we have just named, but it undergoes changes of an entirely opposite kind; that is to say, it assumes the cha- racters of the mammary or medullary sarcoma, becoming more or less soft and vascular, and fre- quently terminating in hemorrhage by the rupture of its vessels, or in that state called fungus hxma- todes. Numerous examples might be given of scirrhus, medullary sarcoma, and fungus ha?ma- todes, as they are commonly called, originating in the same morbid state, and passing successively from the one into the other in the order in which we have named them. Indeed, we often met with all the varieties which we have enumerated of both species, not only in different organs of the same individual, but even in a single organ. If such are the successive changes observed to take place in carcinoma, the distinction of the dis- ease into species and varieties may be considered by some to be of little importance. Such, how- ever, cannot be the case, for we know that the curability of a disease often depends on the time at which a remedy is employed, or varies with the state or period of the disease; and therefore it is obvious that whatever means may be adopted for the cure of carcinoma, we can form no precise opinion as to their relative efficacy, unless the par- ticular condition or variety of the disease be kept in view. And it is far from being an unimportant fact that several of the varieties of both species of carcinoma differ materially from one another as regards the comparative rapidity of their develop- ment, as well as their reproductive tendency. Thus in both these respects the pancreatic differs from the Iardaceous, the Iardaceous from the mam- mary, and the mammary from the medullary ear- coma; the first often remaining stationary for a long space of time, months or years; the last frequently acquiring its maximum of bulk in a few weeks, and when removed being sometimes reproduced with a degree of rapidity which is never observed in any of the other varieties. It may be said that the more the varieties of both species of carcinoma partake of the characters of those accidental formations which resemble the healthy tissues of the body, as the cellular, cellulo- fibrous, and fibrous, they are, caeteris paribus, the less rapid in their development, and have less tendency to be reproduced. Before proceeding to the description of the physical, anatomical, chemical, and physiological characters of carcinoma, we shall endeavour to establish on the evidence with which out anato- mico-pathological investigations have furnished us, the seat, origin, and mode of formation of this disease; for unless we possess clear and accurate notions on these important points, we should meet with numerous difficulties besides those which are inseparably connected with our subject, under the several points of view in which it is necessary to consider it. Seat) origin, and mode of formation of Carcinoma.—Various opinions have been enter- tained regarding the seat, origin, and mode of formation of carcinoma, some of which have at- tracted notice merely from their novelty, others from their possessing much higher claims to our consideration, and to these we shall more parti- cularly allude. There are several organs subject to carcinoma which, from the peculiarity of their structure or other circumstances, afford us the means of ascer- taining the precise seat of this disease, its origin, and mode of formation. But to derive all the advantages which these circumstances are capable of affording, it is necessary to catch, as it were, the disease at its earliest period, that is to say, when the peculiar substance of which it consists has just been deposited, and has not effaced the texture or structure of the part in which it is con- tained. Investigated in this its first stage, we ascertain with greater or less facility that this sub- stance becomes manifest to our senses either as a product of nutrition or of secretion. In the former case it is deposited in the same manner as the nutritive element of the blood enters into the molecular structure, and assumes the form and SCIRRHUS. 85 arrangement of the tissue or organ into which it is thus introduced. In the latter it makes its appearance on a free surface, after the manner of natural secretions, as on serous surfaces in general. Such are two of the modes in which the forma- tion of carcinoma takes place, and also two of the principal differences in regard to the seat of the disease. Proceeding, however, still farther in our researches, we arrive at the important discovery that the carcinomatous matter exists in the blood under circumstances which can leave no doubt as to this fluid being the primary seat of its forma- tion. As, in our opinion, too much importance cannot he attached to these three positions, viz., the formation of carcinoma in the molecular struc- ture of organs, on free surfaces, and in the blood, we shall endeavour to demonstrate the truth of them by a statement of the evidence derived from our own researches on the subject. 1. The liver and stomach, organs in which car- cinoma is of frequent occurrence, afford us the most striking examples of the formation of carci- noma in the molecular structure of organs. If we make a section of a liver containing what are commonly denominated carcinomatous tumours, that is to say, round or irregular masses of a sub- stance resembling one or more of the varieties of scirrhoma or cephaloma, we shall often be able to detect the first stage of these tumours, and dis- cover the manner in which they are formed. Thus, the first thing which we have frequently been able to perceive in those portions of the liver in which the carcinomatous matter was just mak- ing its appearance was a slight change of colour, observable only in a very limited and well-defined space, and which could be distinctly seen to exist in those minute divisions of the organ denominated acini. This change of colour may take place in a single acinus, or in several of these bodies suc- cessively or simultaneously. The red or yellow colour which they naturally present gradually dis- i appears, and is succeeded by a pale milk-white or straw-colour, accompanied by an increase of the consistence. But the most important circum- stance is, that while these changes of colour and consistence are taking place, the form and bulk of the acini remain unaltered. Now it need hardly be remarked that the form and bulk of the acini could not remain unaltered unless the foreign sub- stance, to which their change of colour and con- sistence must be ascribed, were introduced into them in the same order as the normal element of nutrition, unless it were deposited in the molecular structure of the acini in a manner precisely simi- lar to that in which their nutritive function is carried on. Otherwise, along with the change of colour and consistence which they present, we should have a simultaneous increase of bulk. The more we examine the acini in this state, the more shall we be persuaded that they are thus trans- formed by the molecular deposition of that pecu- liar substance which constitutes the essential anatomical character of the disease in question. By tracing the transformation of the acini from a lesser to a greater degree, we can perceive them forming groups, for example, of three, four, ten, or twenty, the reunion of which constitutes tu- mours varying from the size of a hemp-seed to that of a cherry, in all of which the structure of the liver as characterized by the form, bulk, and arrangement of the acini, is more or less con- spicuously marked, but becoming gradually less so with the increasing bulk of the tumours, until it entirely disappears, being transformed into a uniform Iardaceous mass, or into some one or other of the tissues or substances which belong to either of the species of carcinoma. We have said that a similar mode of formation of carcinoma is observed in the stomach. It is, however, chiefly in the muscular coat of this organ that it is most conspicuously seen, on ac- count of the difference between the natural colour of the muscular fibres of this coat and that of the cellular tissue which enters into its composition. The change of colour which accompanies the presence of the carcinomatous deposit is, there- fore, hardly perceptible except in the muscular fibres. These, however, become pale and acquire an increase of consistence; but their bulk does not appear to be increased at first, and they retain their form and distribution. Such, also, is the state of the intermuscular cellular tissue at the same period, except as to colour, which is not sensibly changed on account of its being naturally pale. By-and-bye both acquire a greater or less increase of bulk, become remarkably distinct, and present that fibriform arrangement, hardness, and transparency which are regarded as so character- istic of scirrhus. At a more advanced period of the disease we no longer trace this nutritive pro- cess of transformation, the muscular and cellular tissues being converted into a homogeneous mass, which is afterwards softened down, or assumes the mammary, medullary, or ha?matoid forms of carcinoma. 2. The fact of carcinoma forming on the free surface of serous membranes is strongly corrobo- rative of the accuracy of the preceding remarks; for although in the former case we refer the pre- sence of the carcinomatous deposit to a modifica- tion of nutrition, and in the present to a modi- fication of secretion, the difference is merely nominal. The distinction, however, between nutrition and secretion is valuable as regards the formation of carcinoma; for considered as a modification of the latter, we possess ourselves of the advantage of studying the disease where it presents itself under, perhaps, the most simple of its forms, viz., on extensive serous surfaces, such as that of the pleura or peritoneum. Here the carcinomatous substance is found to be effused on the free surface of these membranes, without our being able to perceive that they have under- gone any previous change whatever. Multitudes of tumours are sometimes found on these two surfaces, varying in hulk, consistence, and colour. Some of them are as large as a plum or an orange; others of the size of cherries, peas, hemp, or millet-seed, and composed of a substance re- sembling pork, the mammary gland, brain, or a mixture of the latter, fibrine, and blood. We may, in fact, have almost all the varieties of car- cinoma formed in these membranes, and, as we have said, without their having undergone any previous change. Under such circumstances we must refer the presence of these tumours to the separation of the carcinomatous matter from the 86 SCIRRHUS. blood, which, being effused in the form of a secre- tion, afterwards undergoes changes peculiar to itself. 3. The presence of carcinomatous formations in the blood is a circumstance of great import- ance, and unless it be clearly demonstrated that their presence is the consequence of a modifica- tion of the blood itself, in whatever manner pro- duced, we should find it impossible to explain many of the phenomena which the disease pre- sents, and more especially those which accompany its formation in molecular structure and on the free surface of the membranes. The following facts may be adduced as fur- nishing strong evidence that the formation of the carcinomatous substance takes place in the blood, whether it be found in this fluid alone or in other parts of the body at the same time: 1. the pre- sence of this substance in the vessels which ramify in carcinomatous tumours or in their im- mediate vicinity; 2. in the vessels of a portion or of the whole of an organ, to the former of which the carcinomatous substance is exclusively confined, and can be traced from the trunks into the branches and capillaries; 3. in vessels having no direct communication with an organ affected with the same disease, as, for example, when it is confined to a small extent of the vena porta?; and, lastly, in blood which has been effused into the cellular tissue and on the surface of organs. The appearances which the carcinomatous mat- ter presents in the blood are very various : some- times they are perfectly similar to those which mark its presence in the substance or on the sur- face of organs. When contained in large veins, such as the vena porta? and its branches, the emulgent vein, &c. it may present the Iardaceous, mammary, medullary, or ha?matoid characters, all in the same venous trunks. These varieties of the disease may be found mixed together in mi- nute quantities, or isolated into masses so con- spicuous that we can readily distinguish them from one another. Sometimes they lie merely in contact with the internal parietes of the vein ; at other times they are united with these by means of a thin layer of colourless fibrine; or minute blood-vessels pass from the one into the other, and are often very numerous and remarkably con- spicuous in the cerebriform matter. The divisions of the vascular system in which the carcinomatous substance has been observed, are the venous and capillary, — a circumstance which may be ascribed to the contractile power of the arteries preventing, under ordinary circum- stances, the blood from accumulating, and conse- quently this substance from forming within them, and not to any peculiarity of function exercised by the former. The presence of the carcinoma- tous matter in the veins might be, and indeed is, in general, supposed to be owing to its having been absorbed by these vessels; but without entering into minute anatomical details which disprove such to be the case, we shall again repeat the fact that there are cases of carcinoma in which the venous blood alone is found to be the seat of the disease. There is no accumulation of the carcinomatous matter either in the vicinity of the veins in which the blood is thus affected, or in any other part of the body ; and in those cases in which this com- plication exists, as well might we refer the pres- ence of this matter in the veins to the exercise of the function of venous absorption, as that of cel- lular, fibrous, osseous, and cretaceous formations in the same vessels to a similar process, which we know not to be the case. From this view of the origin of carcinoma in the blood, its formation in the intimate structure and in the free surface of organs, after the man- ner of nutrition and secretion, follows as a natural consequence. The material element of the disease is separated from the blood and deposited under a variety of circumstances which modify in a greater or less degree the form, bulk, colour, and consist- ence which it afterwards presents, in the several periods of its development. We cannot therefore limit the seat of the disease to any one tissue, or ascribe its origin to any modification of structure or special organization, as has been done by several pathologists. Perhaps the most ingenious attempt that has been made to explain the local origin of carcinoma is that of Dr. Hodgkin, published in the fifteenth volume of the Medico-Chirurgical Transactions. Dr. Hodgkin has endeavoured to show that the presence of a serous membrane, having a cystiform arrangement, is necessary for the production of carcinoma and some other diseases of a malignant character. The existence of the former precedes, he believes, the formation of the latter, and conse- quently is at once the seat and origin of the dis- ease. That such is the manner in which carcino- matous formations are sometimes formed, we can have no doubt, inasmuch as we have had occasion to see them as they have been described by Dr. Hodgkin. But we have here no new law in ope- ration, nor even an exception established to that the principles of which we have several times al- luded to. Cysts are a very simple modification of a serous membrane ; they partake of the structure and functions of the latter, and, consequently, are subject to similar diseases. If, therefore, such cysts should exist in an individual having the can- cerous diathesis, they may, in the same manner as a natural serous membrane, become the seat of any variety of carcinoma. But although carcinoma- tous tumours, such as those described by Dr. Hodg- kin, are found in cysts, attached, single, or in groups, and covered by a reflected serous mem- brane, these tumours may, and frequently do, not originate in the cysts. They form in the cellular tissue external to the cysts, and during their de- velopment project inwards, carrying before them as their common envelope the internal and serous lining of the latter. Such, in fact, is seen to be the origin of these tumours in most of the cysts represented by Dr. Hodgkin in the work referred to. They are situated external to the cyst, are supplied with vessels which do not belong to the cyst, and are placed in the same circumstances as tumours formed in the cellular tissue where no cyst is present. I As an objection to the general application of | the cystic origin of tumours, it may be observed that there are numerous organs in which the pre- j sence of cysts is not to be detected at any period | of the development of carcinoma; and therefore, when they do occur in other organs, they must be | looked upon as a mere coincidence, or as a conse- SCIRRHUS. 87 quence of the disease, and not as a cause or ne- cessary condition of it. After what we have just said on the cystic origin of carcinoma, it will not be expected that we shall do more than notice the theory which maintained that the formation of this disease depended on the previous existence of an accidental organization, which received the name of hydatid: how far such was the appellation it should have received, must now be a matter of indifference. Mr. Abernethy referred all adventitious forma- tions to the coagulable part of the blood as their origin, and fixed their seat in the cellular tissue, in the parenchyma, and on the surface of organs. This plastic substance was supposed by him to be effused in one or other of these situations, to be- come organized, and to derive the materials of its subsequent growth from the vascular system of the surrounding parts. According to Andral, the cellular tissue is in general the seat of carcinomatous formations; but, that as they depend on a modification of secretion, they may form wherever this function is accom- plished ; the speciality of each being determined by a previous modification of the economy in ge- neral, or of the functions of nutrition, innervation, or hematosis in particular. The only other opinion to which we shall allude regarding the seat and origin of these formations, considered in an anatomico-pathological point of view, is that of Cruveilhier. This pathologist regards all organic transformations and degenera- tions (as he calls them) as exclusively the result of the deposition of morbid products in the cellu- lar element of organs. He believes that the tis- sus propres of organs are incapable of undergoing any organic lesion except hypertrophy and atrophy. Both these statements we have shown to be dis- cordant with facts. The source whence these pro- ducts are derived is, according to the same author, the venous capillary system, to which we formerly alluded, and we assigned a reason for their being found in these vessels, and especially in the venous trunks and their larger branches. [Although cancer in its various forms may be a mere local degeneration, it can scarcely be doubted, at the present day, that such degenera- tion is connected with a special condition of the system, or is a cachexia. Accordingly, this has been made to enter into the definition of the dis- ease by pathologists. One of the most recent, Dr. W. H. Walshe, (Op. cit.) properly defines cancer to be,—" a disease anatomically character- ized by the presence of scirrhus, encephaloid or colloid, originating in a general vitiation of the economy, and possessing the properties of assimi- lation, of reproduction, and of destroying life by a peculiar cachexia." J. Miiller, from his anatomical researches, is disposed to consider, that no division of patholo- gical structures into homologous and heterologous can be established ; and he maintains, that the elementary structures of all morbid growths, hitherto examined, resemble, in every respect, the ' structures presented in the several stages of de- velopment of the elements of the healthy tissues of the body; and as the element in the healthy | tissues is a nucleated cell, so also cells growing j upon nuclei, and developing new cells within themselves, or elongated into caudate or spindle- shaped bodies, or in a still higher stage of develop- ment forming fibres, are conceived to form the main structure of all morbid growths. Blood- vessels are later formations, as they are known to be in the materials that constitute the embryo. It appears clear, however, that even if we admit the nucleated cell to be the same in the healthy and the heterologous tissue, there must be an impulse seated in the one which is not present in the other, and which leads to a different development; and hence we may, with much propriety, regard cancer as a heterodite or heterologous formation. (For the microscopical characters of cancer, see J. Miiller, Op. cit. and Walshe, art. Cancer, in Cyclop, of Surgery, or Amer. edit, by Dr. J. M. Warren, p. 12, Boston, 1824.)] Physical characters of Carcinoma.—The physical characters of this disease comprehend the form, bulk, colour, and consistence which it pre- sents in the different tissues and organs of the body, and in the several periods of its develop- ment. Form.—Carcinoma presents considerable vari- ety of form. In its first stage, and when the material of which it is composed is deposited after the manner of nutrition, carcinoma assumes the particular form or structure of the organ which it affects, as that of the liver and stomach, the acini of the former, and the muscular, cellular, and mu- cous tissues of the latter, determining in these organs respectively the primary form of the dis- ease. In the brain, lymphatic glands, testes, we cannot, however, perceive any particular arrange- ment of the carcinomatous matter at this early stage, either on account of the colour, homogene- ous aspect, or minute structure of these organs, preventing us from detecting its presence, and the manner in which it is deposited. At a more advanced stage of the disease, the forms which the carcinomatous matter derives from the structure of the parts in which it is de- posited disappear, and those which it afterwards presents are determined chiefly by external cir- cumstances. The most important of these forms are the tuberiform, stratiform, and ramiform. 1. Tuberiform carcinomatous matter is by far the most frequent, and presents considerable va- riety. When this matter is deposited in organs possessing a uniform density, and in parts submit- ted on all sides to an equal degree of pressure, it assumes a globular form. Although at first globu- lar, it becomes pyriform on natural and accidental serous surfaces, either on account of the mode of its attachment, or of less resistance being opposed to its growth in one direction than in another. It assumes a fungiform shape when placed in cir- cumstances which facilitate its lateral, and retard its peripheric development, as when it passes from a dense into a soft tissue, or escapes from beneath the skin to the surface of the body. It often pre- sents a lobulated appearance when accumulated in separate portions of the cellular tissue into rounded masses, grouped together and included within a common capsule ; and in the submucous tissue in particular it frequently exhibits the ex- ternal arrangement of the cauliflower or mulberry. That appearance of carcinoma which resembles the structure of the pancreas depends generally on 88 SCIRRHUS. the agglomeration of very small globular or pyri- form tumours, separated from one another by cel- lular or cellulo-fibrous tissue, but enclosed in a common capsule. 2. Stratiform carcinomatous matter is chiefly met with in the subserous cellular tissue. Al- though it may be deposited in layers of various extent, which present no definite arrangement, it more frequently assumes the form of thin circular patches, varying from the breadth of a pin's head to an inch or more in diameter, and presenting an appearance similar to what might be imagined to follow the infusion of a small quantity of milk into a number of isolated points of the subserous cellular tissue. Patches of this kind, which are composed of a substance having the colour and consistence of cream or milk, are most frequently met with beneath the pia mater and pleura pul- monalis, and are remarkably conspicuous in the latter situation, on account of their white pearly aspect contrasting so strongly with the surround- ing dark colour of the lungs. These patches may occur in the situations we have named with- out the substance of the brain or lungs presenting any trace of carcinoma; but we have never met them unless when the disease existed in some other organ, as the breast, eye, liver, stomach, kidney, or uterus. In some cases, lymphatics filled with fluid carcinomatous matter are observed to communicate with the patches; in other cases no such vessels are observed. 3. We formerly alluded to the ramiform ar- rangement, when treating of the seat and mode of formation of carcinoma in the molecular struc- ture of organs and in the blood. This arrange- ment, as well as the seat of the carcinomatous matter in the veins on which it depends, may readily be detected in the liver, where this matter is collected in the form of tumours of various sizes. When such tumours are divided and sub- mitted to pressure, we can often perceive the carcinomatous matter issuing from a number of small circular orifices in the state of a creamy fluid ; and if these orifices are attentively exam- ined by a careful dissection of the tumour from its cut surface towards its circumference, we find that they are the cut extremities of veins filled with this matter to a greater or less extent beyond the tumour. But there is no organ in which the ramiform arrangement of the carcinomatous mat- ter is so conspicuously seen as the kidney. The whole of the venous system of this organ, in- cluding the emulgentvein to its termination in the vena cava, is sometimes found completely distended with this matter, either in a fluid state, of the con- sistence of brain, or as firm as the pancreas. When the kidney thus affected is divided, it ap- pears as if it were formed of a multitude of encysted tumours of various sizes, on account of the carcinomatous matter being contained within, and bounded by the walls of the cut extremities of the veins. This form of carcinoma of the kidney is easily ascertained by dissection, or by the introduction of a probe from the emulgent vein into its branches. A similar arrangement is also remarkably con- spicuous in carcinoma of the stomach. Not only are the minute veins, which ramify beneath the mucous membrane in the vicinity of the disease, filled with the carcinomatous matter, but also the larger branches seen on the external surface of the stomach, and the coronary veins in which they terminate. The abdominal division of the vena porta? furnishes us with a remarkable exam- ple of the ramiform arrangement of carcinoma, isolated from any organ affected with the disease. There is another variety of form of the carci- nomatous matter which may be noticed in this place, as it may be regarded as a modification of the preceding. It is that which is observed when this matter is contained in the lymphatics and lacteals, and which is derived from the particular form of these vessels. The lacteals, more frequently perhaps than the lymphatics, contain this matter, and are sometimes seen in great numbers quite filled with it on the surface of the stomach and intestines, and between the folds of the mesentery, in carcinoma of these organs. Such are the principal forms of carcinoma, whether we consider the disease in a general or special point of view. They are certainly not equally prevalent, nor precisely the same in both species, viz. in scirrhoma and cephaloma, nor in the several varieties of each ; but they are found to occur in all of them ; and as the modifications which they present in this respect are very unim- portant, it is not necessary to allude to them more particularly. Bulk. — The quantity of the carcinomatous matter deposited in the molecular structure or on the free surface of organs is extremely various, but it is perhaps never so great in the former as in the latter. In the liver it may vary from the size of a pin's head to that of an orange. In softer or more yielding organs, as the lungs, testes, and even the mamma, it may equal in bulk the head of an infant or of an adult; and in the intermus- cular and subcutaneous cellular tissue its bulk is sometimes still more considerable. We now speak of individual tumours, and not of those masses formed by the aggregation of tumours, during their progressive development, as occurs in the liver, lungs, &c. nor of those produced in a similar manner in the abdominal cavity, posterior to the peritoneum, in carcinoma of the mesenteric glands. The influence of pressure in favouring or re- tarding the development of carcinomatous tumours, and consequently in modifying their bulk, is most conspicuously seen when they are situated near the external surface of the body. So long as their progress outwards is obstructed by an un- yielding fibrous membrane, they often remain for a considerable time nearly stationary ; but so soon as this obstacle is removed, they acquire a rapid increase of bulk. This rapid increase of bulk on the removal of all pressure is still more remarkable when these tumours project through the ulcerated integuments in the frightful form of bleeding fungi. But the best illustration of the influence of pressure on the development of these tumours is met with in carcinoma of the eye. A tumour which may have required several months before it reached the external surface of this organ, will, after it has been removed, together with the whole contents of the orbit, reappear, and in the course of one or two weeks acquire a much greater bulk than before the operation. SCIRRHUS. Independently, however, of this physical circum- stance, which modifies so conspicuously the bulk of these tumours, there is another of an opposite nature, which requires to be particularly noticed on account of its constituting the distinctive cha- racter of the second species of carcinoma. We allude to the physiological properties of the cephal- omatous tumours, by means of which they possess within themselves the power of increasing their development to an almost unlimited extent. It is to the vascular organization, which we shall after- wards describe, of the tumours of this species, that the rapidity of their growth and the great bulk which they attain are to be attributed, and which renders them less subject to the influence of pres- sure than those of the species scirrhoma. How- ever, unless we were aware of the modifying in- fluence of pressure, we should often be unable to explain why tumours possessing the same charac- ters are subject to differences both as regards the rapidity of their development and the bulk which they acquire. Colour. — The colour of carcinoma differs greatly from that of any of the other adventitious formations. It is, therefore, a character of consi- derable importance, inasmuch as it frequently ena- bles us to distinguish this disease from others of the same class ; and we have already seen that it is chiefly by the same means that we are led to a knowledge of the seat and forms of carcinoma in the early stages of its formation. It is most fre- quently white, with a shade of grey or blue; sometimes it inclines to yellow, brown, or red, in consequence of the colour of the organs affected with the disease, of the presence of blood, bile, pus, or other fluids in various proportions, or of some other accidental circumstance. But the principal modifications of colour of carcinoma are seen in the several varieties of both species of the disease, these varieties, as we have already stated, resembling more or less in colour that of the organ or tissue whence have been derived their respective appellations ; as that of cartilage, of the pancreas, of fresh boiled pork, of coagulated albumen or fibrine, of the mammary gland, of the substance of the brain, or a mixture of the latter and blood. Consistence.—To none of the physical charac- ters of carcinoma has so much importance been attached as to that of consistence, but more espe- cially to an increased degree of this property when considered in relation either to the disease itself or the tissues of the affected organ. Hence the term scirrhus, which implies a state of induration, in consequence of its being frequently not only one of the first, but likewise one of the most marked changes which we are capable of perceiving in the affected organ, has been employed to characterize the early or occult stage of carcinoma. The op- posite condition of carcinoma, that in which this disease presents a degree of consistence less than that of the organ which it affects, has been consi- dered as a change succeeding to the state of indu- ration or scirrhus, and the result of a process of softening; consequently, as indicating a more ad- vanced period of the disease. But the degree of consistence of the carcinomatous formations is not an invariable character of a particular stage of their development; for these formations may, when first perceivable, be as hard as cartilage, soft Vol. IV.—12 h» as brain, or fluid as cream ; or they may become soft or fluid after having remained for a greater or less length of time in a state of hardness. This variety in the consistence of the carcinomatous for- mations depends on the following circumstances : —1st. the nature of the organ in which the car- cinomatous deposit is contained ; 2d. the ele- mentary composition of the deposit; 3d. the sub- sequent changes occurring either in the deposit it- self, or in the tissues with which it is in contact. 1st. The structure, situation, connection, and greater or less density of organs and tissues, greatly modify the consistence of the carcinomatous de- posit, either in consequence of a difference between the quantity of this substance relative to that of the tissues in which it is contained, or of a differ- ence in the degree of resistance opposed by the latter to its accumulation or development. Thus it is more consistent in the liver than in the lungs or brain ; in the skin than in the cellular tissue or a mucous membrane; in a tumour situated beneath a dense covering than on a free surface. 2d. Modifications in the composition of the carcinomatous deposit exercise a considerable in- fluence over the degree of consistence which it presents, for we often meet with it possessing va- rious degrees of consistence, when examined at the same stage of its development, and in the same or in different organs. Examples of this kind, although common in almost every organ of the body, are best seen where the deposit is col- lected into isolated masses containing little or none of the natural tissues, and where consequently its consistence must depend on the nature of the ele- ments of which it is composed. It is found in this state in cellular tissue and in serous mem- branes, and more especially on accidental surfaces, such as those of sores formed by the destruction of the protruded portion of tumours, or after the removal of an external organ affected with carci- noma. In these situations this substance may, at the same stage of its formation, present the oppo- site extremes of consistence, being in one case as hard as cartilage and more or less transparent, and in another as soft as brain, or quite fluid and opaque. But these opposite extremes of consist- ence are most strikingly manifested in those fungi- form tumours which arise from the bottom of the orbit after the extirpation of the eye, or from the cicatrix of the integuments after the removal of the breast in consequence of carcinoma. In these two instances it is obvious that the stage of de- velopment of the tumours is the same in both; and that the difference of consistence which they present is no evidence of their being different In their nature, is equally obvious, inasmuch as the hardest of them often assume, after a certain length of time, the consistence of the softest, a part or the whole of the dense transparent substances of which they are composed being gradually trans- formed into a soft, brain-like, pulpy mass. This process of transformation is also most conspicuous in those tumours which constitute the vascular or organized sarcoma of Mr. Abernethy. They are at first more or less transparent, presenting the appearance of a solid mass of albumen, coagula- ble lymph, or fibrine, but become gradually opaque, soft, and pulpy, resembling foetal brain, and are then not to be distinguished from those carcino- 90 SCIRRHUS. matous tumours which, from their commencement j possess the cerebriform character. These exam- ples will suffice to show that the carcinomatous deposit, besides being modified in its consistence by the tissues in which it is contained, is equally so in consequence of a difference in its composi- tion ; that its consistence may or may not be the same when first formed ; that it may be either hard or soft at this period ; and, consequently, that the latter state is not necessarily preceded by the former, as was maintained by Laennec and the greater number of pathologists who have published on this subject since his time. 3d. The last modification of consistence of the carcinomatous formations is that to which the at- tention of pathologists has almost exclusively been directed. It depends on a series of changes taking place either in the carcinomatous matter itself, the tissues with which it is in contact, or in both at the same time. But in order that these changes may be more fully understood, we shall first de- scribe the chemical and anatomical characters of carcinoma. Chemical characters of Carcinoma. — In order to ascertain the chemical composition of the several varieties of scirrhoma and cephaloma, it would be necessary to procure a sufficient quantity of the carcinomatous matter isolated from the tis- sues with which it is so frequently more or less intimately united or combined. The difficulty, and in many cases the impossibility of obtaining it in several of these varieties in a separate state, has prevented the pathologist from determining accurately its chemical composition. Indeed, the results of the analyses that have been published may be regarded as indicating the chemical compo- sition of particular organs and tissues affected with carcinoma, rather than of the carcinomatous mat- ter itself. The most recent analysis of carcinoma in the scirrhomatous and cephalomatous states, is that published by Lobstein in his " Traite d'Ana- tomie Pathologique." Seventy-two grains of scir- rhous breast were found to contain— Albumen.................. 2 grains Gelatine..................20 Fibrine...................20 Fluid fatty matter..........10 Water...................20 72 Seventy grains of the uterus in a state of scirrhus contained— Gelatine..................15 grains Fibrine..................10 Fatty matter..............10 Water...................35 70 According to the same author, it would appear that the chemical composition of cephaloma is not the same at different periods of its development. Thus in the first stage of the disease, or that of crudity, it was found to contain a greater propor- tion of gelatine than of albumen ; and in the se- cond stage or that of softening, that is to siy, when the carcinomatous matter is of the consist- ence of soft brain, the albumen is in much greater quantity than the gelatine. [Other observers enumerate, also, gelatin among the constituents of encephaloid and scirrhous ; in an analysis, however, by M. Foy, not a particle of that principle was detected in either. (Walshe, Op. cit.)] For the reasons already stated, it must be ob- vious that no great importance can be attached to these results of the chemical analysis of the carci- nomatous matter; and, independent of the differ- ence of composition which it must present from its admixture, in various proportions, with the same or different tissues, it is highly probable that it is likewise modified, in this respect, by the phy- siological influence of the organ in which it is formed, and the constitution of the individual in whom it exists. Anatomical characters of Carcinoma.;— We have already pointed out the most important circumstances illustrative of the anatomical cha- racters of carcinoma, when treating of the specific divisions of the disease, its varieties of form, bulk, and consistence; its seat and mode of formation. We shall, therefore, now examine more especially the structure or anatomical arrangement of the carcinomatous matter itself. We formerly stated that the carcinomatous matter may exist in two states; that in the first state it has little or no tendency to become organ- ized, its form and arrangement being determined chiefly by external circumstances ; and that in the second it exhibits a greater or less tendency to be- come organized, possessing in itself properties by means of which its form, arrangement, and deve- lopment are effected. The carcinomatous matter may, as we have seen, exist in three situations, viz. in the molecular structure of organs on free surfaces, and in the blood. It is, perhaps, only in the two latter situations that we can submit it to minute anatomical investigation. When, there- fore, we examine anatomically a mass of carcino- matous matter contained in a large vein, or situated on the surface of a serous membrane, in loose cellular tissue, on the surface of a sore or cicatrix after the removal of an organ affected with carci- noma, we find it composed of the following ele- ments in various proportions, viz. carcinomatous matter; cellular, fibrous, and serous tissues; and blood-vessels. The carcinomatous matter, whatever may be its consistence, almost always forms by far the greater bulk of the disease. If, however, its con- sistence be considerable, it generally presents a uniform, granular, or radiated, and, when soft, a lobulated arrangement. These three varieties are sometimes met with in the same tumour, and in- dicate the progressive development of the disease, the radiated arrangement being seen at the basis, the uniform and the lobulated towards the cir- cumference. The cellular tissue is often small in quantity, and sometimes so fine and loose, as not to be per- ceptible till after the carcinomatous matter has been separated from it by pressure and maceration. It encloses that matter, separates it into granules, bundles, or lobules, intersects these in various directions, and serves to conduct the vessels which administer to the nutrition and growth of the dis- ease. The fibrous tissue is not often met with as an SCIRRHUS. 91 anatomical element of carcinoma in the situations in which we are now considering this disease. The serous tissue, on the contrary, is frequently present, and may form either a capsule to the car- cinomatous substance, which is then said to be encysted, or give rise to the formation of cysts of various sizes, containing gelatinous, albuminous, or other fluids. When the carcinomatous matter is deposited in the molecular structure instead of on the surface of organs, as we have just been considering it, the quantity of the cellular and fibrous tissues which intersect it in various directions is sometimes very considerable. In carcinoma of dense organs, such as the breast, uterus, ovaries, liver, walls of the stomach, &c. these tissues are often very abundant. Indeed, in the early stage of carcinoma of these organs, a firm, pale, compact, cellulo-fibrous-look- ing tissue is not unfrequently the only anatomical element discoverable, and which on this account, and from the increase of bulk with which it is ac- companied, has been described by Andral as hyper- trophy of the cellular tissue, an appellation which does not appear to us to be warranted by analogy or by the changes which this tissue subsequently undergoes. For hypertrophiated cellular tissue, such as we find in elephantiasis Arabum or Bar- badoes leg, has no tendency to terminate in carci- noma; nor does hypertrophy of the heart from disease, or of the muscles of voluntary motion from frequent exercise, ever present any other change than that implied by this term, except a certain increase of consistence, generally in pro- portion to the increase of bulk which has taken place. Besides, admitting that a certain degree of hypertrophy may precede the presence of car- cinoma, the facts which we have already brought forward in illustration of the mode of formation of the disease, its seat and origin, clearly show that no such change is necessary, inasmuch as all the varieties of carcinoma may form in situations in which the cellular tissue is either extremely small in quantity or does not at all exist. What, therefore, appears to be hypertrophiated cellular tissue must he regarded a tissue sui generis, pro- duced by the uniform distribution and molecular deposition of the carcinomatous matter, either in the cellular tissue of an organ, or in an accidental tissue of a similar kind, formed at the same time, and deposited along with the carcinomatous matter. Such is, in fact, the manner in which the cellular and fibrous tissues which enter into the composi- tion of the carcinomatous matter are generally formed. These tissues are most conspicuous in the early stage of the disease, becoming gradually less apparent as it advances, and ultimately disap- pearing in consequence of their undergoing the carcinomatous transformation, or other changes which we shall afterwards describe. The blood-vessels which enter into the compo- sition of the carcinomatous matter vary greatly in number, and sometimes also in bulk. They are rarely perceptible in any of the varieties of scir- rhoma; are generally few in number in the first and second varieties of cephaloma, or in the or- ganized and mammary sarcoma of Abernethy; but in the last variety or medullary sarcoma, they are often so numerous as to form the greater por- tion of the brain-like tumour in which they ramify. When these vessels are examined in cephaloma, they are found to vary in diameter from the breadth of a hair to a line, and present that peculiarity of distribution, always more or less conspicuous in newly-formed blood-vessels; that is to say, the ramifications of which they are composed communicate with a common trunk at its opposite extremities in the same manner as the hepatic and abdominal divisions of the vena porta? do with this vessel. They are frequently varicose, their walls are remarkably delicate, and they have altogether much more a venous than arterial cha- racter. They appear to be formed apart from the vascular system of the surrounding tissues, as they can be seen forming from small specks of blood situated at the centre or at the circumference of the carcinomatous mass, in the form of stria?, or slender streaks of blood, and gradually assum- ing a cylindrical arrangement and ramiform dis- tribution, and thereby constituting what may be called the proper circulation of cephaloma. The communication which exists between these vessels and those of the organ in which the carcinomatous substance is contained, is frequently very imper- fect,—a circumstance which, together with the de- licacy of their structure, renders them extremely liable to congestion and rupture. The most mi- nute divisions of these vessels terminate by peni- cillated extremities in the carcinomatous matter, where they communicate with veins and arteries belonging to the affected organ. The latter ves- sels, which may be said to form the collateral cir- culation of cephaloma, are seldom so numerous as the former, but there are cases in which they appear to constitute the greater part of the vascu- lar structure of the disease. They proceed in a radiating direction, from the pedunculated attach- ment of a tumour for example, or arise along its circumference in the cellular tissue which sepa- rates it from the neighbouring parts. It is by means of these vessels that the materials required for the nutrition and growth of such tumours are supplied ; and, as we shall afterwards see, the partial or even complete destruction of these and other tumours similarly situated, is occasioned by causes which interrupt this their collateral circu- lation. The blood-vessels which are seen in scirrhoma appear to be no other than branches of those which belong to the neighbouring tissues, and which have become inclosed within the substance of which its several varieties are composed. Physiological characters of Carcinoma. —The anatomical characters just described are the most unequivocal circumstances by means of which we are enabled to perceive the existence and estimate the degree of those properties termed vital or physiological which manifest themselves during the developement of carcinoma. But it is more especially the formation of cellular tissue and blood-vessels in the carcinomatous matter which shows it to be in possession of these properties. We have already seen that the functions of circu- lation and nutrition are actively carried on in the carcinomatous matter. Of these functions, that of circulation is far the most important, inasmuch as many of the more remarkable phenomena which present themselves during the progress of carcinomatous formations depend on changes 92 SCIRRHUS. which take place either in the proper or collateral circulation which we have described. Thus, the quantity of blood contained in a carcinomatous tumour, and consequently various shades of colour of the substance of which it is composed, will de- pend much on the degree of facility with which the circulation is performed in either or both sys- tems of vessels. An imperfect communication between these vessels, owing to the manner in which they are connected, or the presence of a mechanical obstacle in the situation of the colla- teral veins preventing the return of the venous blood, frequently gives rise to congestion of the whole or a portion of a carcinomatous tumour, the colour of which becomes more or less red, purple, brown, or black. The congestion thus produced may be such as to give rise to rupture of the vessels, and internal or external hemorrhage. In the former case the carcinomatous substance, when situated externally in the form of a tumour, is seen to acquire a rapid increase of bulk, pro- portioned to the extent of the effusion, and, when examined afterwards, is found to be infiltrated with blood, or broken down and mixed with clots of this fluid, and irregular masses or layers of fibrine, thereby producing, when the tumour pos- sesses the cerebriform character, appearances very similar to those observed in cerebral apoplexy from sanguineous effusion. If the obstacle interrupt entirely the circulation in the tumour, nutrition ceases, and death ensues in all those parts of it from which the obstructed vessels proceeded. The termination of carcinoma in mortification from obliteration of veins is far from being a rare occur- rence. It sometimes occurs in whole tumours, but is most frequently observed in portions of them, or in some of the small tumours of which larger ones are frequently composed, that are at- tached by narrow pedunculated extremities. The unequal development of one of these small tu- mours may give rise to compression of a neigh- bouring one ; or the tissue to which they are attached may, from its unyielding nature, act as a ligature on their pedunculated extremities, and intercept the return of the venous blood through them. The same thing sometimes happens to tumours that have perforated fascia? or even the skin. The protruding portion, now relieved from the pressure to which it was before subjected, in- creases rapidly in bulk ; but the dimensions of the opening remaining the same, very soon exercise a degree of constriction which arrests the circula- tion through the vessels of the neck of the tumour, and it dies and sloughs. Changes of a similar kind result likewise from the presence of the carcinomatous matter acting as a stimulus, and exciting various degrees of con- gestion. In consequence of the congestion thus produced, and the modification of nutrition which necessarily follows, softening takes place, not only of the carcinomatous substance, but likewise of the tissues which enter into its composition. Softening of this kind is sometimes effected with great rapidity, and tumours which before felt firm or even hard, acquire a soft, pulpy feel, and, when laid open, are found to contain a fluid of the consistence of cream intermixed with shreds of cellular tissue, detached blood-vessels, blood, and sometimes pus. This process of softening is frequently seen taking place in carcinomatous tumours that have perforated the skin, and when considered in connection with the state of the cir- culation which has given rise to it, enables us to explain the peculiar appearance of those frightful solutions of continuity by which it is followed, such as their projecting everted edges, and rugged central excavation. It is well known that it » the most projecting part of a tumour situated be- neath the skin in which a solution of continuity commences, and the reason of this is, that it is here the circulation is first arrested from the greater degree of compression to which the blood-vessels are subjected, together with the increased influx of blood caused by a greater degree of excitement The most elevated portion of the skin becomes atrophiated during the first stage of compression and irritation, that is, when the circulation of the blood through it is only impeded ; but so soon as this all-important function has ceased, which is announced by a change of colour from bright to dark-red, purple or black, and a diminution of sensibility and temperature, it begins to soften, soon sloughs, and exposes the subjacent portion of the tumour whose circulation had been similarly modified, softened, and deprived of its vitality, to a greater or less depth. The edges of the solution of continuity of the skin when first formed are sharp and irregular; they are not everted; they are, on the contrary, sometimes inverted; and their thickness is in proportion to the depth of the slough. The peculiarity of form assigned to them is produced by the subsequent development of the carcinomatous substance situated beneath them, which, being entirely freed from pressure all round their internal margin, necessarily projects forward, as it grows, towards the centre of the tumour hollowed out by the softening and slough- ing process, and, consequently, carries them gra- dually upwards and backwards. They acquire at the same time a great accession of bulk, and form a rounded undulating border, beneath which the skin is found doubled upon itself, encircling the carcinomatous excavation. All these changes, viz. congestion, hemorrhage, softening and sloughing, which we have described, take place in both species of carcinoma. In scirrhoma, however, they originate in the vascular system of the tissues included within the carcino- matous substance, but are not on that account less frequent and destructive than those which arise in the proper and collateral circulation in cephaloma. In general the softening is less com- plete, the hemorrhage not so considerable, and the sloughing more extensive in the former than in the latter. Softening may take place in any portion of a carcinomatous tumour, although it has been main- tained that the central portion is the primary seat of this change. Instead of being softer, the centre of the tumour is often much harder than any other portion of it. In such cases it consists of a nucleus of firm, grey, semi-transparent substance and obliterated blood-vessels, forming a central depression, around which the rest of the tumour presents a radiating structure. The depression ia not observed unless when the tumour is divided, or is situated on the surface of an organ, as the liver, where tumours of this kind are generally SCIRRHUS. 93 met with. In the former case the depression arises in consequence of the softer substance, after the division of the tumour, raising itself by its elasticity above the unyielding nucleus; in the latter it is produced by the peritoneum adhering to the surface of the tumour when small, and pre- venting its development in that direction. If the tumour does not come in contact with the perito- neum until it has acquired a considerable size, it presents no such depression, or only a very small one. Hence the reason why, in carcinoma of the liver, we meet with some tumours having a smooth globular surface, and others with a central depression of greater or less extent. Nerves have never been detected in any of the varieties of carcinoma as a new formation. They are sometimes included within agglomerated tumours, or even in a single tumour that has hap- pened to form in a situation through which they pass. It is on this account that some pathologists have supposed the carcinomatous matter to be supplied with nerves : and M. Maunoir of Geneva (Loc. cit.) hazarded the opinion that cephaloma, no doubt from its frequently resembling the sub- stance of the brain, is in reality this substance effused by the nerves when under the influence of some peculiar morbid state ; an opinion to the accuracy of which the facts related in the preced- ing pages do not leave even the semblance of pro- bability. The last circumstance connected with the pathological anatomy of carcinoma to which we shall allude, is the development of the subcutane- ous venous system sometimes so conspicuous when the disease affects the breast in the form of a tumour, or any other external part Where the skin is capable of considerable extension. The dilated and varicose state of these veins is simply the consequence of the mechanical obstacle occa- sioned by the tumour to the venous circulation in its vicinity, and not the result of any special in- fluence exercised by the disease. It is produced by tumours of every description, similarly situated, —fatty tumours and even cysts, and canaot there- fore be considered as furnishing any evidence of the existence of carcinoma in particular. The great difficulty generally experienced by physicians in distinguishing carcinoma under the various forms which it presents in the different stages of its development, and in different organs of the body, will, we trust, furnish a sufficient ex- cuse for our having given such a lengthened de- scription of what strictly relates to the anatomy of the disease. If we have not succeeded in con- veying a clear impression of this part of our sub- ject, much assistance may be derived by consult- ing the coloured plates of the second and third fasciculi of the author's work on the Elementary Forms of Disease. [In a recent work, already referred to, Dr. Walshe has thus classified the genus cancer or carcinoma: GENUS CANCER OH CARCINOMA. Species. Varieties. Abernethy. Common vascular sarcoma. Mammary sarcoma ? ' Solanoid. Recamier. Zano. Nephroid. Idem. Encephaloid -j Napiform. Idem. Carcinoma fasciculatum vel hyalinum. Mokl- LER. Fungus {nematodes. Hey. Hematode cancer. Auct. Gall. Scirrhus [ Pancreatic sarcoma ? Abernethy. Napiform. ) „„„ „.„„ Jchondroid.|RECAMIER- j Lardaceous tissue. Acct. Gall. Carcinoma reticulare. Mueller. Colloid t S Pultaceous cancer. ' ' 1 Pearly alveolar ditto. ■ Cruveilhier. Syvonyms of the Specif s. Spongy or ossivorous tumour. Ruysch. 1 LETTa. Struma fungosa (testis). Callisen. Spongoid inflammation. Burns. Milt-like tumour. Munro. Medullary sarcoma. Adernethy. Cerebriform disease or cancer. Laennec. Pulpy testicle. Baillie. Carcinus spongiosus. Good. Carcinoma spongiosum. Young. Fungoid disease. A. Cooper. Hodgkin. Medullary fungus. Maunoir. Chelios. Acute fungous tumour. C. Bell. Medullary cancer. Travers. Cephaloma. Hooper. Carswell. Carcinoma medullare. Mueller. Soft cancer. Auct. Var. Carcinomatous sarcoma. Abernethy. Carcinoma scirrhosuui. Young. Scirrhus cancer. Travers. Scirrhoma. Carswell. Carcinoma simplex hbrosum. Mueller. Stone cancer. Auct. Var. Areolar gelatiniform cancer. Cruveilhier. Carcinoma alveolare. Mueller. Gum cancer. Hodgkin. These three species of carcinoma are thus described in a tabular manner by Dr. Walshe: Encephaloid. Resembles lobulated cerebral mat- ter. Is commonly opaque from its ear- lied formation. U of dead white colour. Contains a multitude of minute vessels. Is less hard and dense than scir- rhus. Is frequently found in the veins issuing from the diseased mass. The predominant microscopical elements are globular, not always distinctly cellular, and caudate cor. puscula. Scirrhus. Resembles rind of bacon traversed by cellulo-fibrous septa. Has a u semitransparent glossi- ness. Has a clear whitish or bluish yel- low tint. Is comparatively ill-supplied with vessels. Is exceedingly firm and dense. Has not been distinctly detected in this situation. The main microscopical consti- tuents are juxtaposed nuclear cells; caudate corpuscula do not exist in it. Colloid. Has the appearance of particles of jelly inlaid in a regular alveolar bed. The contained matter is strikingly transparent. Greenish yellow is itspredominant hue. (Its vessels have not been suffi- ciently examined as yet.) The jelly-like matter is exceedingly soft; a colloid mass is, however, firm and resisting. The pultaceous variety has been detected in the veins. Is composed of cells in a state of tmboitcment. 94 SCIRRHUS. Encephaloid. Occasionally attains an enormous bulk. Has been observed in almost every tissue of the body. Very commonly coexists in several parts or organs of the same subject. Is remarkable for its occasional vast rapidity of growth. Is frequently the seat of intersti- tial hemorrhage and deposition of black or bistre-coloured matter. When softened into a pulp, ap- pears as a dead white or pink opaque matter of creamy consistence. Subcutaneous tumours are slow to contract adhesion with the skin. Ulcerated encephaloid is frequently the seat of hemorrhage, followed by rapid fungous development. The progress of the disease after ulceration is commonly very rapid. Is the most common form under which secondary cancer exhibits it- self. Is the species of cancer most fre- quently observed in young subjects. Scirrhus. Rarely acquires larger dimensions than an orange. Its seat, as ascertained by obser- vation, is somewhat more limited. Is not unusually solitary. Ordinarily grows slowly. Is comparatively rarely the seat of these changes. Resembles, when softened, a yel- lowish brown semitransparent gela- tinous matter. Scirrhus thus situate usually be- comes adherent. Scirrhous ulcers much le^s fre- quently give rise to hemorrhage, and fungous growths ^provided they re- tain the scirrhous character)are now more slowly and less abundantly de- veloped. There is not such a remarkable change in the rate of progress of the disease after ulceration has set in. Colloid. Observes u mean in this respect ' Has so far been seen in a limited number of parts only. Has rarely been met with in more than one organ. Grows with a medium degree of rapidity. Undergoes no visible change of kind. Is much less common before pu- berty. Has so far been observed in adults only.] Local and other relations of Carcinoma. | organs, such as both eyes, the mamma;, testes, or —There are no organs, and few tissues, which I kidneys, are affected at the same time. We have may not become affected with carcinoma. Among never met with carcinoma of the pancreas, muscu- the former, the stomach, liver, uterus, breast, and testes, are much more frequently the seat of the lar, venous, and arterial tissues, serous, mucous, and fibrous membranes, without the disease being disease than any of the other organs of the body, present in a neighbouring organ or tissue, and It k also worthy of remark that it is met with from which it was communicated to the former. more frequently in certain portions of organs and I The greater liability of some organs and tissues systems than in others. Thus, when it affects than others to become affected with carcinoma is the uterus, it is almost always the os tincae in a circumstance of considerable practical import-; which it commences ; in the stomach it is much' ance. So, likewise, is its occurrence as a primary more frequently the pyloric than the cardiac ori-| and secondary affection. In this latter respect the i fice; it much more often affects the stomach than disease may be secondary only as regards the order the oesophagus or intestines ; the large than the of its appearance, the same morbid condition of .■: small intestines. In the latter, it is rarely met; the economy which gave rise to it in one organ r with, and perhaps only in the duodenum and com-| giving rise to it in the others, which become suc- mencement of the jejunum ; and in the former it, cessively affected ; or it may be secondary in one is exclusively confined to the rectum, sigmoid1 organ in consequence of the intimate physiologi- : flejeure of the colon and ileo-cacal valve, unless! cal connection existing between it and another when propagated from a neighbouring organ by' previously affected ; and, lastly, it may be secon- contiguity of tissue. j dary from mere contiguity of tissue. If we pass in review the several tissues subject In the first case the secondary appearance of to carcinoma, we find that the cellular is infinitely the disease is recognised partly by the extent more so than any of the other tissues in which which it occupies, and partly by the physical and the disease occurs, although we have proved that; anatomical characters which it presents in the it is far from being so frequently the seat of the | different organs in which it is present. By the disease as was, and still is, generally believed, same means, and more especially in consequence , The mucous and cutaneous tissues are the next in of two or more organs being found to be much ■ the order of frequency, and lastly the osseous, ve-j more frequently than others affected with the dis- nous, and arterial. We have never observed the ease, we infer that its propagation in the former disease in cartilage, tendon, or ligament; but we is influenced by the intimate physiological con- have shown, when treating of the mode of its! nection which is known to exist between them, aa formation in the stomach, that, contrary to the [is exemplified in carcinoma of the uterus and general opinion, the muscular tissue of this organ mamma;, and of the liver and stomach succeeding is frequently the seat of it. i to each other. The secondary production of car- The number of organs that may become affected cinoma from contiguity of tissue, whether of a with carcinoma in the same individual varies j similar or dissimilar kind, is frequently observed; considerably. In some cases there may be only' such as the gradual extension of the disease from one organ or tissue affected with the disease, as the walls of the stomach to those of the intestines, the stomach, intestines, oesophagus, liver, lungs,! and from the latter to the parictes of the abdomen; kidney, uterus, testis, breast, brain, eye, tongue, from the stomach to the liver; from the uterus to chin, cellular tissue, lymphatic glands, bone, capil-; the bladder or rectum, and vice versa. But in all laries, and veins. In other cases it may be found these cases the contiguous tissues am', organs be- in a great many organs and tissues in various come united or continuous before the°disease stages of its progress. It is seldom that double! passes from the one to the other which is then SCIRRHUS. 95 propagated by the gradual molecular deposition of the carcinomatous matter, in the same manner us we see it accomplished in the skin during the ulcerative stage of the disease. An opinion very different from that we have now given respecting the secondary production of carcinoma has long been entertained, chiefly by surgeons. Finding, as they frequently must have done, cancer in an internal organ which had given no signs of its presence until after it had existed for a greater or less length of time in some exter- nal part, they considered the production of the disease in the former situation to be subsequent to that in the latter, and to arise in consequence of the absorption of a specific virus from the sup- posed primary disease, and its transmission into the system. This opinion was strengthened by the fact that symptoms of cancer of an internal organ frequently make their appearance soon after the breast, testicle, or other external part has been removed by a surgical operation, and was consi- dered as fully confirmed by another fact, viz. that the lymphatic glands situated in the vicinity of a cancerous tumour or ulcer are seen to become affected during the progress of the primary dis- ease. We shall only remark with regard to this view of the secondary production of carcinoma, that the facts adduced are far from justifying the application which has been made of them; for they furnish no proof that the occurrence of the disease internally, at any period subsequent to its existence externally, may not depend on the same morbid condition of the economy producing its effects successively or simultaneously, in a greater or less number of organs, inasmuch as we know that carcinomatous tumours may exist for a con- siderable period, even in the most important of the internal organs, without giving rise to any appre- ciable modification of function calculated to lead to their detection. Hence, under whatever cir- cumstances the signs of carcinoma may present themselves for the first time in an internal organ, we cannot determine either the length of time it may have existed, or the relative order of its suc- cession. Besides, the extension, a3 it is called, of carcinoma from the breast or testis, for exam- ple, to the neighbouring lymphatic glands, affords no proof that it takes place through the medium of absorption ; for we have found these glands in the axilla, and in the lumbar region, extensively diseased in carcinoma of the breast and testis, without any of the carcinomatous matter of which all these were composed being visible in the lymphatic vessels passing from the one to the other. The more natural explanation of the oc- currence of the disease in these glands in such cases is, that, being subjected to the irritation which accompanies the latter stage of the disease, (the period at which the lymphatic glands are generally observed to become affected,) they be- come the seat of congestion, and, as we have already endeavoured to show, the material ele- ment of carcinoma being contained in the blood, it is separated from this fluid and deposited in their substance. We are, however, well aware that there are cases in which this matter is absorbed and accu- mulates in the lymphatic glands; but from the circumstance just stated, and from the fact already noticed that these glands may be the only organs in the body in which, after the most careful ex- amination, the disease is found to exist, we are surely not entitled to say that they are always secondarily affected, whatever signification we may attach to this term. We have seen several instances of cephalomatous tumours formed exclu- sively in the mesenteric glands and abdominal lymphatic glands; and in one case the latter glands of the principal regions of the body, on both sides of the neck and under the jaws, in the axilla? and groins, in the chest and abdomen, were extensively affected with the disease, and forming tumours varying from the size of a cherry to that of an egg. The spleen was the only other organ which presented any trace of the disease. Carcinoma is a disease which is far from being equally frequent at the different periods of life. It is observed to make its appearance most fre- quently in the male from between thirty to forty or fifty years of age, and in the female after the cessation of the menstrual discharge, than at any other period of life. It is also on account of the more complicated nature of the organs of repro- duction in females that they are more subject to the disease, generally considered, than males; for the uterus and mammse are the organs which, in the former, are most frequently the seat of the disease. In the latter it rarely makes its appear- ance in the breast, and not so frequently in the testes as in the uterus. The stomach and liver are, according to our own observations, the most frequent seat of the disease in males, although these organs are, perhaps, equally so in females. The tongue, and especially the lips, are often affected in the former, and rarely in the latter. It is also worthy of remark that from childhood up to the age of puberty, and even to twenty or twenty-five years of age, we seldom meet carci- noma unless in particular organs or regions of the body. Thus it is chiefly the lymphatic and me- senteric glands, the great joints, as the elbow and knee joints, the brain, and cellular tissue, where it is considerable in quantity ; whereas the sto- mach, intestines, uterus, and mammaj are almost exempt from the disease till a later period of life. And it is interesting to observe that the exceptions to its non-occurrence in these latter organs within the period alluded to are met with in such of them only the exercise of whose functions are suscepti- ble of being prematurely and preternaturally ex- cited, particularly the testes and ovaries. These remarks on the relative frequency of car- cinoma under the circumstances of age and sex apply to the disease generally, and not to both species and their varieties; for while scirrhoma is rarely met with within the period which we have specified, cephaloma is of frequent occurrence, and seldom proceeds to such an extent or with such rapidity in advanced as in early life; a circum- stance which may probably depend on the greater activity of nutrition and the more plastic quality of the blood in the latter than in the former condi- tion of life ; and thus also a corresponding charac- ter may be given to the morbid products which manifest themselves in each. The frequency of carcinoma is said to be con- siderably influenced by temperament. Thus out of forty-four cases of the disease in which the origi- 96 SCIRRHUS. nal temperament was sufficiently characterized, Breschet and Ferrus found the lymphatic to pre- vail twenty times, the sanguineous twelve, the bilious eight, and the nervous two; and in almost all the patients submitted to their observations, the lymphatic temperament had acquired a marked predominance during the progress of the disease. (Diet, de Med. t. iv. art. Cancer.) The observation of carcinoma in individuals of different habits and modes of life submitted to the influence of various external agents arising out of locality, profession, or climate ; in the mar- ried and unmarried; in women who have or who have not had children; in the poor and wealthy; in the temperate and debauched, ore. &c. has not led to very satisfactory results regarding the rela- tive frequency of the disease. It is, however, said that it is as rare in peasants and country-people in general, as it is common among the inhabitants of large cities; and that it is more frequent in the lower and higher than in the middle classes of society. Causes and nature of Carcinoma.—The observations which we have made on the relative frequen9y of carcinoma as to age, sex, tempera- ment, and condition of life, contain the greatest part of what we have to say on the predisposing causes of the disease. Among these have long been enumerated the frequent and direct operation of irritating substances ; external injuries, espe- cially blows; the abuse of stimulating potions ; immoderate indulgence in venery ; the depressing influence of moral afflictions; bad food, conjoined with the debilitating effects of cold and otherwise unhealthy habitations; the injurious influence of one or more of these predisposing causes on par- ticular organs being determined or modified by the individual or accidental circumstances of the case. The frequent occurrence, however, of car- cinoma in individuals in whom none of these predisposing causes seem to have co-operated in the production of the disease, as well as its non- occurrence in many who have been subjected to the influence of these causes, has led many pa- thologists to consider it as having an hereditary origin. They believe that the germ of the malady, or cancerous virus, is transmitted from the parent to his offspring, and cite, in favour of their opinion, the occurrence of the disease in several members of the same family. This opinion, however, has few advocates, particularly since Alibert, (De- scription des Maladies de la Peau, p. 118,) Biett, and Dupuytren (Diet, des Sciences Medicales, t. iii. p. 677,) have shown that the carcinomatous matter may be introduced in the form of inocu- lation into the digestive organs, the serous cavi- ties or veins, without giving rise to the disease; experiments, it may be remarked en passant, to which no more importance can be attached than to the fact that the disease may occur in several individuals of the same family. A more generally received opinion, and one much more in accord- ance with the results of accurate observation, is, that the manifestation of the disease is at all times, and under all circumstances, dependent on the previous existence of a peculiar state of the con- stitution, either congenital or acquired, termed diathesis. The evidence on which this opinion rests we have in great part already exposed when treating of the seat, local origin, and mode of j formation of carcinoma. We have shown that | the material element of the disease — without which it can have no existence—is contained in the blood, is separated from this fluid after the manner of nutrition or secretion, either in the molecular structure, or on the free surface, of organs ; and that, while the formation of the dis- ease is thus going on, there may be no apprecia- ble physical or physiological modification of the part in which it is observed. It is thus that we meet with carcinomatous tumours in the brain, which, from their bulk and other characters, must have existed long before the functional disturb- ance of the organ gave signs of their presence; and we have an equally striking example of the silent development of these tumours in the eye, until, acting simply as a foreign body, they ob- struct the rays of light, and render vision more or less imperfect. In persons, too, apparently in the enjoyment of the most perfect health, we often see the disease making its appearance in the form of a small pimple, proceeding more or less rapidly in its course, extending in breadth and in depth, and terminating ultimately in death, in spite of all the means which art has devised. In others, a similar pimple arises under similar, or even un- favourable, circumstances, proceeds like the former to ulceration; and although it may have been neglected, irritated, and excited from time to time, and maltreated in every possible way, disappears, and leaves the patient in perfect health. There is, indeed, no form of inflammation which may not exist for any definite length of time, and in every organ of the body, without being followed by carcinoma. Of the truth of this position every candid inquirer must be fully aware, although it is still attempted to support the unphilosophical theory which maintains that this disease is always preceded by chronic inflammation. It would, however, be a great practical error were we to overlook the influence of this pathological state on a constitution predisposed to carcinoma; for this disease does make its appearance in organs which we have every reason to believe would not have become affected with it, had they not been previously modified by the former. We must, therefore, conclude that, if carcinoma makes its appearance in individuals, however they may have been placed in regard to the operation of what are called predisposing and exciting causes, there must be present in such individuals a pecu- liar condition or disposition of body, previous to the manifestation of the disease. In what thia disposition consists, we are entirely ignorant. Its very existence is made known to us only by means of the peculiar characters of the products to which it gives rise. We have certainly seen that the great function of nutrition is that which is more especially affected, and that, as the mate- rial element of carcinoma is contained in the blood, it is highly probable that a modification of this fluid constitutes the primary if not the essen- tial condition of the formation of the disease. But, unacquainted as we are with the nature of nutrition as a physiological function, we can offer no explanation of the nature of the change ef- fected in the blood, nor, consequently, of the nature of carcinoma. It is, however, an interest* SCIRRHUS. 97 ing fact,—the result of our anatomical researches in particular,—that, as carcinomatous formations derive the materials of which they are composed from the blood, instead of their being local trans- formations or degenerations of pre-existing tis- sues, they do not, in this point of view, form an exception to the law, viz. that the natural and healthy solids, as well as the fluids of secretion, derive also their respective materials from the same source ; and, therefore, we are led to hope that a more intimate knowledge of the manner in which these two functions are performed will enable us, at some future period, to determine the nature of a disease which hitherto has only been rendered more obscure by the attempts which have been made to explain it. [For some excellent observations on the etiology of Cancer, see the work of Walshe, already cited.] Symptoms of Carcinoma. — Considered in a general point of view, the symptoms of carci- noma refer to changes taking place during the progress of the disease, as they occur in the carci- nomatous substance itself, in the organs in which it is contained, and in remote organs or the con- stitution generally. The symptoms are therefore local or general. The former are referable to changes in the bulk, consistence, form, colour, temperature, sensibility, circulation, nutrition, and special functions of the organ affected ; the latter to changes in the functions of circulation, nutri- tion, and innervation in general. Both series of phenomena are greatly modified by the seat, stage, or period of the disease. They present also marked differences in the two species of carcinoma, those observed in the first species being often absent in the second ; or, being present in the former from the commencement, either do not occur in the latter at all, or only towards its termination. We shall pass in review the local and general pheno- mena which accompany the presence of carcinoma in those organs the disease of which belong more especially to the province of medicine. Local symptoms. — Few of the changes to which we have referred the local symptoms of carcinoma are discoverable in internal organs, and all of them may be absent in the early stage of the disease. Changes in the colour, temperature, circulation,, and nutrition of the affected organ, cannot be detected by direct observation; and those of bulk, consistence, and form, can be de- termined only in certain organs, and at a more or less advanced period of the disease, such as the stomach and intestines, liver, spleen, kidneys, ovaries and uterus, lungs, and mesenteric glands ; in all of which organs these changes may be re- cognised either by the touch, percussion, or aus- cultation. But it is more particularly the change of bulk which is detected by these means, and which, as a local symptom of the presence of car- cinoma, is that to which the greatest importance is to be attached. The increase of bulk which accompanies the presence of carcinomina is not perceptible till the disease has made some pro- gress. It is most considerable in solid organs, such as the liver, kidney, ovary, &c, and is sel- dom very marked in hollow organs, such as the stomach or intestines. Considerable increase of bulk may, however, have taken place in the walls of the stomach and intestines, without our being Vol. IV.—13 I able to detect its presence, which happens when the carcinomatous matter accumulates in the direction of the internal surface of these organs. In such cases an increase of bulk of a different kind is produced, viz. dilatation, in consequence of the obstacle presented by the carcinomatous matter to the passage of the food or faeces. When dilatation of the stomach is thus produced, the obstacle is situated at the pylorus; when of the small intestines, it is, in the great majority of cases, situated at the termination of the duodenum or commencement of the jejunum, and caput cae- cum coli; and at the sigmoid flexure of the colon and rectum, when the dilatation occupies the large intestines. The increase of bulk which the stomach and intestines acquire in consequence of an obstacle of this kind is sometimes very great. In some cases of scirrhus pylorus, the stomach has been found to occupy the greater part of the ab- dominal cavity, stretching down to the symphysis of the pubis, and from one lumbar region to the other; and the large intestines sometimes measure from four to six inches in diameter, when similarly affected. We have seen the small intestines equal in size to the ordinary dimensions of the stomach. It is important to know that the extent of the dilatation is not to be taken as the measure of the extent of the disease. The greater the dilata- tion the greater we may infer is the obstacle by which it is occasioned; but this obstacle may con- sist in a slight scirrhous enlargement, which pre- vents the passage of the food or faeces as effectu- ally as when it is occasioned by one or^more tumours of considerable size, or great thickening occupying several inches in length of the whole circumference of the walls of the stomach and in- testines. There are two circumstances connected with the dilatation of these organs from carcinoma which merit particular notice. The first is the disappearance of the dilatation at a particular period of the disease. This may happen a con- siderable time after the dilatation was first per- ceived, and is the consequence of the destruction of the carcinomatous substance from softening, ulceration, or sloughing. The obstacle being thus removed, a free passage is opened to the accumu- lated contents of the stomach and intestines, and the dilated walls of these organs are allowed to contract, and in some instances regain their na- tural dimensions. The second circumstance is the re-occurrence of the dilatation, which we have observed to take place only in the intestines. It does not occur, unless the mucous and muscular coats have been destroyed by ulceration, after the destruction of the carcinomatous substance, and not until cicatrization has commenced. The cica- trix being formed of cellulo-fibrous tissue, contracts and produces stricture of the intestine. The pas- sage of the faeces is again obstructed, and the intestine acquires an increase of bulk much greater than before the destruction and removal of the carcinomatous substance. We shall again allude to these changes in bulk when speaking of the modifications of function, and the diagnosis of carcinoma in the digestive organs. The increase of bulk which accompanies car- cinoma of the liver is often very considerable. Cases have been met with in which the left lobe 98 SCIRRHUS. of the liver extended into the left hypochondrium, and the right down to the iliac fossa on the same side. It is always produced in this organ by the accumulation of the carcinomatous matter in the form of tumours, which may often be felt pro- jecting above its surface. It is chiefly from this latter circumstance that we are enabled to detect carcinoma of the liver. It is, however, necessary that the tumours should occupy the convex sur- face of the liver, and that this organ should pro- ject beyond the false ribs. In one instance only have we found the spleen, when affected with carcinoma, much increased in size; it was nearly six times larger than natural. We have also found the kidney enlarged to the same extent in a young person, but it is seldom more than twice its natural size in this disease. Carcinoma of the uterus is not accompanied by any perceptible increase of bulk, unless examined per vaginam, when, in the early stage of the dis- ease, the os uteri is found enlarged and projecting into the vagina. The ovaries acquire the size of the fist or even of the head of a child, but never become so large as when they are the seat of ■dropsy, or contain fibrous tumours. We have never seen the bulk of the lungs so increased by the presence of the carcinomatous deposit as to give rise to dilatation of the walls of the chest. We have already noticed the great increase of bulk which accompanies carcinoma of the mesen- teric and lymphatic glands. The only modification of the sensibility which, as a» local symptom, accompanies carcinoma, is that of pain. There is, however, no symptom of •carcinoma more deceptive than pain. The im- portance attached to it, more particularly when it possesses a lancinating character, must have ' originated in the study of the disease in external parts of the body, as the face, breast, or the skin and subjacent tissues in general; for there are several organs in which the pain is either very slight or seldom acquires the lancinating character ascribed to it: such is the case in carcinoma of the liver, spleen, kidneys, ovaries, stomach and intestines, (with the exception of the rectum,) the mesenteric glands, and even the brain. It is also to be remembered that pains, described by patients as lascinating, may occur without any trace of carcinoma being found in the organs to which they are referred. Of all the varieties of carcinoma, it is that of scirrhus which is most frequently accompanied with pain; and it is also in this variety that the pain is most severe, acute, and lancinating. In medullary sarcoma this symptom is less frequent and severe than in any of the other varieties. But it is not according to the several varieties of carcinoma that we are to form an estimate either of the frequency or severity of the pain. For this symptom may, in both these respects, be said to vary with the degree of induration of the car- cinomatous substance ; of the distension or com- pression, and of irritation to which this substance gives rise in the neighbouring tissues. Under the influence of the two former of these conditions, pain would seem to result from compression of the nerves which happen to be included within the dense carcinomatous substance, or that are distributed in its immediate vicinity. Pain from irritation may also be produced under similar cir- cumstances, but it is much more frequently when softening and sloughing of the carcinomatous substance, and ulceration of the neighbouring tissues, have taken place, that pain from this cause makes its appearance, and acquires a degree of severity which gives rise to the most intolerable suffering. It is in this stage of the disease that pain occurs in internal organs, in consequence of the extension of the irritation to the nerves of sensation. The pain may be intermittent, remittent, and continued, whatever may be the organ affected with carcinoma. The intermittent character is most frequently observed during the early stage of the disease ; and the remittent and continued during the progress of softening, sloughing, and ulceration. Numerous circumstances concur to produce these varieties in the duration of the pain in carcinoma ; but in the great majority of cases they appear to depend on varying and opposite states of the sensibility and circulation of the af- fected organs. For we know that the direct application of those means which increase the sensibility and circulation excite, in an organ affected with carcinoma, pain when absent, and increase it when present; whilst those remedies which are known to diminish the sensibility and the action of the vascular system, effect also a diminution or an entire cessation of the pain in this disease. The symptoms which depend on the modifica- tions of the functions of organs affected with carcinoma, are far from being so conspicuous as the fatal character of the disease would lead us to suppose. We allude to the special modifications of function observed in carcinoma of internal organs. Before taking a general view of these modifications of function, we may remark that there is not one of them which may not be found to accompany other diseases than carcinoma. They nevertheless require to be studied with great care, because of the effects to which they give rise being sometimes more intolerable than the disease itself, and requiring a separate mode of treatment. The modifications which are observed to occui in the special functions of organs, present great variety not only in different organs, but also in the same organ, according to the stage, extent, and situation of the disease. Thus the function of digestion is not so frequently disturbed in the early as in a more advanced stage of the disease, nor is the disturbance so great in the former as in the latter case. This difference in the effects of carcinoma on the function of digestion may be explained on the following principles, viz. that the carcinomatous substance, when first deposited, acts merely mechanically, and therefore does not inter- fere with the function of digestion, unless it oc- cupies a great extent of the walls of the stomach, or prevents the egress of the digested food; whereas during its subsequent development, this substance undergoes those changes which we have already described, viz. softening, sloughing, and ulceration. The absence of irritation in the former case, and its presence in the latter, fur- nish an obvious reason why digestion is seldom disturbed in the one case, and more frequently and SCIRRHUS. 99 to a greater degree in the other. The influence of carcinoma as to extent and situation, over the function of digestion, is very great. A carcino- matous tumour of from three to four inches in diameter, and projecting from one to two inches above the mucous membrane of the stomach, if situated at the small or large curvature, may be accompanied by but a very slight derangement of the function of digestion ; whereas a tumour not larger than a filbert, situated at the pyloric orifice, may disturb this function to an extreme degree. It is, indeed, very often in consequence of the mechanical operation of carcinoma pre- venting the egress of the food or chyme, that we are first led to detect disorder of the function of digestion, and to suspect the nature of the disease on which it depends. In such cases more or less of the digested food is retained; the succeeding meal is partially or imperfectly digested ; the sto- mach becomes distended, and being irritated by the continual contact of its contents, rendered more stimulating by decomposition or fermenta- tion, contracts forcibly, and they are rejected by vomiting. Vomiting is an invariable consequence of carcinoma of the pylorus, accompanied with a diminution of bulk of the orifice of this part suf- ficient to interrupt or impede the exit of the chyme or indigested food. Perhaps the most fre- quent cause of vomiting is the mechanical obsta- cle occasioned by the carcinomatous substance in the pyloric portion of the stomach. This modifi- cation of the function of the stomach as a me- chanical effect, we have never observed in carci- noma of any other portion of this organ. Vomiting, however, frequently occurs, whatever may be the situation of the disease, in consequence of the irritation which accompanies the softening pro- cess, and the ulceration by which it is followed. Vomiting from irritation may, in general, be dis- tinguished from that occasioned by a mechanical obstacle situated at the pylorus. The former takes place however small the quantity of fluid taken into the stomach -, the latter, only when the quantity is considerable. Vomiting from irrita- tion is sudden, and accompanied by a disagreeable or painful effort; that from a mechanical obstacle gradual, and instead of being accompanied by pain, frequently affords relief from this state or a considerable degree of uneasiness. It is in this case a kind of passive act, the consequence of the great dilatation of the stomach, and sometimes of the inferior portion of the oesophagus also. The presence of dilatation of the stomach, which is easily detected by percussion, will enable us to distinguish vomiting from a mechanical obstacle from that occasioned by irritation. The periodical character of vomiting is, in the great majority of cases of carcinoma of the sto- mach, to be attributed to the presence of a me- chanical obstacle at the pylorus. The vomiting occurs at certain intervals, which vary with the extent of the obstacle, the quantity and kind of food taken, and other necessary and accidental circumstances, as the susceptibility of the patient and the state of those organs which exercise a sympathetic influence on the function of digestion. In some cases of this kind, the vomiting, after having continued for several weeks or months, disappears for a considerable time before it recom- mences, and in other cases ceases entirely. We have met with examples in both cases, referable to opposite physical conditions of the pyloric ori- fice. In both cases the vomiting depended on the pyloric orifice being obstructed by thickening of its walls, or the presence of projecting or pendu- lous tumours; and the partial or permanent ces- sation of this symptom, to the patency of this ori- fice being restored, in consequence of the destruc- tion of the carcinomatous substance. The return of the vomiting in the former case was owing to the return of the disease in such a form as to obstruct anew the exit of the contents of the sto- mach ; and in the latter, the entire cessation of this symptom was to be attributed to the progres- sive extension of the ulcerative and sloughing processes, and, consequently, the complete removal of the obstructing cause. The quantity and quality of the matters vom- ited are variable. Both will be modified by the quantity and quality of the food and drink; the former by the capacity of the stomach, and the absence or presence of irritation; the latter by the nature of the ingesta, the state of digestion, and the stage and variety of the disease. It is only at the early stage of carcinoma, or at least before softening and ulceration have taken place, that the vomiting consists of a watery or mucous secre- tion. At a more advanced stage, the rejected food is less altered by the digestive process than before, and is often accompanied by a quantity of gas of a disagreeable odour. In the great majority of cases, and always towards the termination of the disease, the contents of the stomach rejected by vomiting contain a substance resembling the lees of wine, a mixture of chocolate, or soot and water. This substance may appear in the form of little particles, patches, or streaks, among the other matters vomited, or it may be in such quantities as to give to the whole contents of the stomach a deep brown or black colour. Its appearance al- ways indicates the effusion of blood into the cavity of the stomach from hemorrhage, either in conse- quence of the softening of the carcinomatous sub- stance, or the sloughing of this substance and of the contiguous parts. It is on this account re- garded as a fatal symptom, and as indicating the speedy termination of the disease. (The cause of the black colour of the effused blood we have already explained in the articles Mortification and Perforation.) It is also at this period that the odour of the breath and the rejected matter is most offensive ; and that the appetite, if not pre- viously much affected, is entirely lost, perverted, or replaced by a morbid craving for peculiar kinds of food. There is only one other circumstance connected with vomiting to which we shall allude, viz. the rejection of the food taken the previous day or even at a later period, whilst the last meal is retained. This kind of choice, as it would seem, of the stomach between fresh and digested food, is not frequently observed. We do not recollect to have observed it except in cases of carcinoma of the pyloric portion of the stomach. The modifications of the special functions of the intestines produced by carcinoma are in many re- spects very similar to those which we have described as occurring in the stomach. We have already noticed the mechanical influence of the disease in 100 SCIRRHUS. preventing the passage of the food and faeces, the accumulation of the latter, and the subsequent dilatation of the intestine. In no other respect does carcinoma interfere with functions of the intestines, except when it gives rise to great irri- tation or inflammation of the mucous membrane and subjacent tissues, or when it terminates in sloughing and ulceration. Diarrhoea is the con- sequence of the former, and hemorrhage a frequent attendant on the latter of these morbid conditions. The rejection of faecal matter by vomiting is not often observed in carcinoma of the intestines. The stools sometimes present the same melanotic character as the matters rejected by vomiting in the last stage of carcinoma of the stomach. They also indicate the last stage of the disease in the intestines, coincide with the appearance of the hemorrhage, and depend on the subsequent dis- coloration of the effused blood. Carcinoma of the liver may occur without any appreciable derangement of the special function of the organ being observed. We are disposed to believe that a suspension of the secretion of the bile very seldom occurs in the disease. In the great majority of the cases of jaundice which we have seen to accompany carcinoma of the liver, we have found the ductus communis choledochus, the hepatic duct or its principal branches, much compressed or obliterated by the carcinomatous substance in the form of large tumours. The same mechanical operation of these tumours on the trunk of the vena portae or its larger divisions in the liver, prevents the return of the blood of the chylopoietic viscera to this organ ; hence that form of ascites which always accompanies this state of the portal vessels. There is often no apparent alteration in the quantity or quality of the bile, even in the most extensive forms of carcinoma of the liver. This fact is determined not only by the colour of the faeces during life, but by the examination of the organ afteT death; the substance of the liver pre- senting no unusual colour, and the gall-bladder being filled with bile of the natural consistence and colour. There is no apparent modification of the secre- tion of the urine in carcinoma of one of the kid- neys, although the disease may be so extensive as to leave no trace of the natural structure of the organ. We have never found both kidneys af- fected. On the contrary, the sound one is gene- rally larger than natural, and appears to supply by its increase of bulk or energy the place of the other, as the quantity of urine voided in a given time is not sensibly diminished. The much more frequent occurrence of carci- noma after than before the cessation of the men- strual discharge, prevents us from estimating accu- rately the influence which this disease exercises on the special function of the uterus and ovaries. Impregnation, however, has been known to take place in carcinoma of the os uteri, and of one of the ovaries. For farther information on carcinoma of the female organs of generation, see Uterus, Diseases of. Only a few remarks are necessary on the modi- fications of function which accompany carcinoma of the spleen, pancreas, mesenteric and lymphatic glands, epiploon, and serous membranes in gene-1 ral. With regard to the spleen, we have only to remark that its cellular organization may be com- pletely effaced by the presence of the carcinoma- tous matter, and consequently it is rendered inca- pable of receiving more blood than is necessary for the nutrition of its solid parts, and the growth of the disease. Carcinoma of the duodenal ex- tremity of the pancreas, in consequence of the compression of the duct which passes in this direction, gives rise to an accumulation of the secretion of this organ, and great dilatation of the duct throughout its whole extent. It is in conse- quence of the increase of bulk of the pancreas which accompanies such cases, that we are some- times led to suspect retention of the secretion of this organ. Diminished or suspended absorption are the occasional consequences of carcinoma of the mesenteric and lymphatic glands. Emacia- tion, when attributable to no other cause, may be regarded as indicating the modifications of func- tion alluded to, of the former glands, and oedema of some external part, of the latter, both of which are rare occurrences, particularly oedema. An accumulation of the secretion of serous mem- branes, and a greater or less degree of obstruction to the motions of the contained organs, arc the functional derangements which accompany carci- noma of these membranes and of the epiploon. The latter, when affected with carcinoma, is gene- rally drawn up in the form of a thick irregular mass, and fixed to the stomach along its great curvature; or it is sometimes split into several portions attached above to the stomach, and below to the uterus, ovaries, or walls of the abdomen, forming so many thick bridles, which not only interrupt the motions of the intestines, but some- times pull the stomach downwards, giving rise to an uneasy dragging sensation in the latter organ, and a sense of tightness or constriction in the former. The function of respiration may be interrupted to such a degree by the mechanical presence of the carcinomatous matter, as to terminate in fatal asphyxia. We remember one case in particular of this kind. It occurred in a young man about twenty-five years of age, who, six weeks previous to his admission into hospital, performed the active duties of a soldier. He complained only of diffi- culty of breathing; he had a slight cough, fol- lowed occasionally by the expectoration of a small quantity of mucus. The difficulty of the respira- tion rapidly increased, and terminated in asphyxia, without the occurrence of fever or emaciation. Both lungs were nearly filled with large masses of the medullary sarcoma. The remaining pul- monary tissue was compressed, but not otherwise altered. This case affords a striking example of the mechanical effects of carcinoma, and the rapid and extensive development of the medullary va- riety of the disease. Carcinoma of the heart has been seldom met with to any great extent, and so far as we know, no particular modification of function has been observed to accompany its pre- sence. We have already minutely detailed the changes effected by this disease in the capillary and venous circulation. The functional lesions which accompany carci- noma of the brain, cerebellum, and spinal cord, i vary considerably with the seat of the disease re- SCIR lative to these organs individually, as well as to particular portions of them. But in neither of these respects does it give rise to any symptom which can be regarded as pathognomonic of its presence. As a foreign body, it gives rise some- times to a degree of compression sufficient to pro- duce partial or complete paralysis; loss of memory, or difficulty of speech; and derangement of the intellectual faculties. But these latter changes depend principally on the irritation and softening of the substance of the brain in contact with the carcinomatous mass. Even paralysis is more frequently produced by these subsequent changes than by compression. We have met with two cases of medullary sarcoma of the cere- bellum, characterized by a remarkable develop- ment of the function ascribed to this organ by Gall. Both patients, young men, were between 18 and 19 years of age. The left lobe of the cerebellum in one of them contained a carcino- matous tumour, of the variety mentioned above, as large as a hen's egg ; in the other the tumour was less, and projected from the centre of the cerebellum into the fourth ventricle. We could not ascertain how long they had practised the act of pollution, but both were emaciated and weak when admitted into hospital. One of these pa- tients was left to himself, and died about two months after his admission, in a state of extreme debility. The other lived nearly three weeks. When warned of the fatal consequences which must soon follow the practice which had already reduced him to a state of great misery, he declared that although he was conscious of the nature of his situation, it was not in his power to resist the influence under which he felt himself compelled to act. His hands were secured, but without the desired effect. As' a last resource, the whole of the prepuce was removed, yet in this mutilated state he attempted to gratify the fatal propensity. He died a few days afterward, having had several severe convulsive attacks. Paralysis of the superior and inferior extremities, of the muscles of respiration, of the bladder and rectum, have been observed in carcinoma of the spinal cord. It is hardly necessary to observe that the seat and extent of the paralysis depend on the portion of the spinal cord occupied by the disease. General Symptoms.—The general symptoms of carcinoma do not make their appearance before the last stage of the disease. Their severity de- pends much on the nature of the organ, and the extent to which it is affected ; but it is principally the irritation produced by the presence of the car- cinomatous substance during the period of soften- ing, sloughing, and ulceration, that determines the gravity of these symptoms. It is in this, the last stage of the disease, that the circulation and inner- vation become deranged, and that fever and a diminution of the nutritive function are first ob- served. It is likewise at this period, but more frequently a few days or weeks before death, that the skin assumes a pale earthy, or dull ochry tint; that debility and emaciation make rapid progress ; and all the functions of the economy become im- plicated in the deteriorating influence of the dis- ease. It is this group of the general symptoms which constitute what is called the cancerous ca- i* RHUS. 101 chexia. The febrile symptoms, as well as the diminution of nutrition, in general are greatest when the seat of carcinoma is the uterus or sto- mach ; and least in those organs, as the brain and lungs, in the former of which softening, and in the latter compression, may terminate in death, before either of these symptoms has become con- spicuous. General dropsy does not often occur, and is never great. Ascites frequently accom- panies carcinoma of the liver, for the reasons which we have already stated. Dropsy of the inferior extremities occurs more frequently in car- cinoma of the ovaries and uterus than of any other organ. It is the consequence of compres- sion of the iliac veins, but it may also be occa- sioned by the extension of the inflammation which accompanies the ulcerative stage of the disease to these vessels. Compression of the vena cava by tumours in the liver, or by the enlarged mesen- teric glands, may also give rise to the same state of the inferior extremities. Diagnosis. — It is not until carcinoma has made considerable progress, that we are sometimes able to recognise its presence in internal organs, by means of a careful consideration of the local and general symptoms which we have enumerated. We have had frequent occasion to remark how little importance is in general to be attached to any one of these symptoms taken individually. But when the local signs, viz. the changes in the bulk, form, and situation of organs, occasioned by the disease; its relative frequency in different organs and in particular portions of the same organ, are taken in connection with the special and general modification of function which may be present in individual cases, the greatest pos- sible assistance is afforded us in establishing the diagnosis. The degree of facility with which this important object may be accomplished, will de- pend on the number of the signs and symptoms present, and the possibility of detecting them by the means of investigation in our possession. Thus it is more easy to detect carcinoma of the stomach than of the lungs, of the latter than of the brain; because of our being able to ascertain the presence of the greater number of the local signs of the disease in the first case, only a few of them in the second, and none at all in the third. And when the sense of sight can be ap- plied with that of touch and hearing, the diag- nosis seldom presents much difficulty, as in the case of carcinoma of the os uteri and rectum. It is necessary to observe that too much reliance is not to be placed on the presence of those general symptoms which constitute the cancerous cachexia; for there are morbid conditions of the stomach and duodenum, associated with derangement of the biliary secretion, which give rise to a state of de- bility and emaciation, accompanied with discolora- tion of the skin, which so closely resembles the cancerous cachexia, that the one is not to be dis- tinguished from the other. The difficulty of estab- lishing the diagnosis in such cases is likewise increased by the circumstance that the same chronic character prevails in both. There is, therefore, no possibility of distinguishing between carcinoma of the stomach and such morbid condi- tions of the same organ, unless the local phenome- na of the former be very conspicuous. 102 SCIRRHUS. It is hardly necessary to remark that the presence of carcinoma in an external part of the body is to be regarded as a diagnostic sign of great importance, in all cases of a doubtful character in which functional derangement of an internal organ has existed for some time. In such a case we should regard the frequent occurrence of vomiting after meals as indicating the existence of carcinoma of the pylorus, even should no tumour be felt in this situation, or dilatation of the stomach. If the presence of a tumour were detected in any part of the abdominal cavity, we should not hesitate to say that it was of the same nature as the external affection; and the-occurrence of paralysis, under the same circumstances, would justify us in attri- buting it to carcinoma of the brain or spinal cord. We shall not, in this general article, attempt to determine how far it may be possible to distinguish carcinoma from other diseases to which internal organs, considered individually, are subject. Be- sides, in the description which we have given of the signs and symptoms of carcinoma, we have already endeavoured to point out those which more especially characterize the presence of this disease in individual organs. Prognosis.—In no disease is a fatal termina- tion so universally admitted as in carcinoma. The possibility of the cure of carcinoma of internal organs has never been supported by substantial evidence; and the examples are few indeed in which we are disposed to believe that the disease has been removed from an external part by surgi- cal or other means, without its recurrence in the same or some other part of the body at some other future period. Treatment.—A host of remedies have been proposed for the cure of carcinoma; the greater number of them have been tried in almost every form of the disease, but they have nearly all failed to justify the high praises formerly bestowed on their curative virtues. Some of them, however, have been found to retard, if not to arrest the progress of the disease; and, what is of great im- portance, to alleviate the sufferings and prolong the life of the patient. We shall notice those remedies only, the successful administration of which has been rendered evident in carcinoma of external organs, as under such circumstances the nature of the disease is less likely to have been mistaken. We shall speak first of those remedies which effect a salutary change in the nutritive function of the affected organ, and thereby retard or arrest the progress of the disease; secondly, of those best calculated to prevent, remove, or mitigate the local and general effects to which it gives rise. 1. The remedies which retard or arrest the pro- gress of carcinoma consist of those which exercise a direct or indirect influence on the nutritive function of the affected organ. Among the former, or those which operate directly, the local abstrac- tion of blood by means of leeches, and compression, hold the first rank. The first of these means should be employed for a considerable length of time, at intervals of one, two, or three days, and the quantity of blood taken should be regulated chiefly by the strength of the patient. The dimi- nution of bulk of the original tumour which follows this mode of treatment, is sometimes very consider- able. In the great majority of cases the tumour is not entirely removed. It may be reduced from the size of a hen's egg to that of a nut, and in this state remain stationary for years without giving rise to pain or any inconvenience whatever. The alternate use of local bleeding and compres- sion effect more rapidly the reduction of bulk just noticed than when either is employed separately; but the former should, as a general rule, be always employed so as to produce a certain degree of indolency in the tumour, before the latter is had recourse to. The beneficial effect of pressure, first employed by Mr. Young, (Cases of Cancer, &c. London, 1816,) has been satisfactorily determined by M. Recamier, one of the physicians of the Hotel Dieu of Paris. The following are general results obtained by this physician:— 1st. Of one hundred patients treated by M. Recamier for carcinomatous affections, sixteen ap- peared to be incurable, and underwent only a palliative treatment. Thirty were completely cured by compression alone; and twenty-one, submitted to the same means, derived considerable benefit from it. Fifteen got rid of the affection radically, by means of ablation alone, or chiefly by ablation combined with pressure; and six by means of compression and cauterization. In the twelve remaining patients, the disease resisted all the means employed. 2d. Tumours similar, or at least analogous to those which degenerate into incurable cancer, are cured by methodical compression, and some other internal and external remedies. 3d. When a tendency towards resolution of a swelling of the mammary gland, which has not yet degenerated, has been produced for a considera- ble length of time by means of compression, the resolution of the swelling continues even after the compression is no longer employed: but if the swelling has degenerated, and, after having ob- tained a great diminution of its bulk, compression be laid aside, the swelling may resume its former bulk, and its degeneration proceed with greater rapidity than before. 4th. Compression may assist in preventing the return of cancer after ablation. 5th. The resolution of chronic inflammation ia greatly favoured by compression alone, or com- bined with local bleeding, &c. 6th. Various tumefactions of the neck of the uterus are resolved by compressing this part by means of a pessary in the form of a hollow cone terminating in an open olive-shaped extremity. 7th. It is reasonable to hope, that if compression were employed at an early period, that is to say, before the degeneration of those tumours suscepti- ble of this mode of treatment, the resolution of a greater number of them would be obtained, and the necessity of the ablation of cancer of the breast, so frequently followed by a return of the disease, when not encysted, be greatly diminished. (Recherches sur le Traitement de Cancer, par M. Recamier, t. i. p. 474.) Although compression and local bleeding can- not be employed in the treatment of carcinoma of internal organs, properly so called, we have thought it proper to notice the results which M. Recamiei states he has obtained by their external applica- SCIRRHUS. 103 tion, as encouraging to the physician, and as af- fording a strong presumption that the cure of this disease, even in internal organs, is not altogether beyond the resources of his art. It is also in consequence of a modification of nutrition in general, and consequently of that of the affected organ, that the beneficial effects of some general remedies, in carcinoma of external organs, are chiefly to be attributed. Some of these remedies appear to modify nutrition by effecting some unknown change in the composition of the blood, as aconitum, conium, and arsenic ; others, by acting on the capillary circulation and absorp- tion, as mercury, in alterative doses, and various preparations of iodine. The beneficial effects of tonics, as preparations of iron, the fixed and volatile alkalies, mineral waters, such as those of Plombieres, Bareges, and Vichy, and all other remedies which increase the vital energies, invigorate digestion, and promote absorption and secretion, may also be referred to a favourable change induced in the nutritive func- tion of the affected organ, by the introduction of these remedies into the circulating system. The salutary operation of these local and gene- ral remedies is much increased by a judicious com- bination of both, regulated according to the cir- cumstances of individual cases. But while em- ploying any of these remedies, it is of the utmost importance to regulate the diet and regimen of the patient in such a manner that neither of them may interfere with the operation of the remedy em- ployed. M. Recamier, in the work already referred to, has shown that the curative virtues of conium, for example, depend greatly on the quantity of food consumed by the patient; that is to say, the operation of this remedy was more or less power- ful when only a small quantity of food was allowed, and hardly perceptible when the quantity was con- siderable. While using the conium, he therefore restricts the patient to a severe diet; and in this way he says he has succeeded in curing several cases of carcinoma of the uterus, lifer, spleen, mammae, testes, and of the extremities. The fol- lowing are the principles of the treatment:— 1st. The patient takes a dose of the extract of conium, evening and morning, two hours before the first and two hours before the last meal. The amount of the first dose is half a grain, which is gradually increased to six grains each time. This dose is continued for a fortnight in order that the organs may become habituated to its operation, and is afterwards increased to twelve grains each time, beyond which it is not necessary to carry the remedy because of its influence being sufficient. The twelve-grain dose is continued for from two to three or four weeks. 2d. After each dose of the conium, as well as at meals, the patient uses a decoction of sarsapa- rilla, (composed of two ounces of the root to two pounds of water,) instead of water. 3d. Only the third of the ordinary quantity of food is allowed, which ought to be very simple, and divided into three small meals. 4th. If the conium disagree in one form, it should be given in another, or the aconitum may be used instead, but in lesser quantity than the conium. Towards the end of the tieatment the ] dose of the conium is gradually diminished, and the diet gradually increased. M. Recamier ascribes the success he has ob- tained in the use of the conium not only to the strict observance of these dietetic rules, but also to the method he has employed in the preparation of the extract. The plant is submitted to the ac- tion of the vapour of vinegar or alcohol, before the juice is expressed from it; the juice is after- wards exposed to the heat of a sand-bath, and evaporated to the consistence of an extract. The extract thus obtained has not the nauseous odour of that usually employed, while it possesses all the deobstruent virtues, and sits better on the stomach than the latter. [The only class of remedies, that can be expected to afford any essential benefit, are those that are capable of inducing a new condition in the sys- tem, by modifying the function of nutrition; such as the various preparations of iodine, combined with a thorough change of every thing surround- ing the individual. The cachexia is the real mor- bid condition, and the cancerous affections in par- ticular organs are but so many evidences of it, as tubercles in the lungs are mere expressions or indications of another form of cachexia, equally possessing the whole system. Hence it is, that cancerous tumours on the external parts of the body are so apt to recur after they have been re- moved by the surgeon. Still it must be admitted, that in cases of scirrhous tumours, when they have been removed early, there has very frequently been no return of the disease. In such cases the ca- chexia has been less strongly marked, and time, apparently, has not been permitted for the local mischief to increase the morbid disposition. It would seem, too, that the particular species of cancer influences the probability of recovery. There are few examples of permanent recovery after the removal of encephaloid tumours. Recent statistical inquiries by M. Leroy d'Eti- olles, offer no great encouragement to the surgeon to attempt to remove by the knife the local evi- dences of systemic mischief. Of 2781 cases oc- curring in the practice of 174 surgeons, 1227 happened in persons above 60 years of age. The cases of cancer of the uterus were about 30 per cent, those of the heart 24 per cent. Cancer of the mouth was in women only as I to 1£ per cent.; whilst in men, probably—he suggests—from the use of the tobacco-pipe, it was as much as 20 per cent. Of 1172 patients not operated on, 18 lived more than thirty years after the first appear- ance of the disease; whilst of 801 operated on by excision or caustic, the existence of only 4 was prolonged for a similar time. 14 patients operated on, and 34 not operated on, lived from twenty to thirty years; and 88 in the first category, and 228 in the second, lived from six to twenty years after the first appearance of the disease. The or- dinary duration of life after this period, amongst persons not operated on, is said to be five years for men, and five and a half for women ; whilst among those operated on, it is no more than five years and two months for men, and Six years for women. Hence it would seem, that setting aside the immediate danger from the operation, the re- moval of cancerous disease by the knife had but i little influence in prolonging life. Further observa- 104 SCIRRHUS —SCORBUTUS. tions are necessary, however, before these influ- ences can be regarded as generally applicable. (See on the whole subject of cancer the excellent Essay by Dr. Walshe, especially the Amer. edit. by Dr. J. M. Warren.)] II. The remedies best calculated to prevent, re- move, or mitigate the local and general effects of carcinoma of internal organs, vary with the nature of these effects and the seat of the disease. The state of irritation and fever, and pain, at whatever period of the disease they may occur, may be greatly moderated by the use of the conium, aco- nitum, opium, hyoscyamus, the acetate or muriate of morphia ; whilst at the same time the use of all kinds of stimuli is to be avoided, particularly if the digestive organs be the seat of the disease; and the patient himself kept as much as possible in a state of quiet of body and mind. If the os uteri be the seat of the disease, additional benefit may be derived from the use of leeches applied to this part, and also sedative injections. It is only in this latter situation that sloughing and ulcera- tion can be detected, and local remedies applied to remove some of the disagreeable effects of the one, or retard the progress of the other. The chloru- rets of lime and soda are, perhaps, the best reme- dies we can employ in this case, as they not only destroy the disgusting odour which accompanies this stage of the disease, but remove the putrid and irritating fluids which are then discharged. The retention of the contents of hollow organs, from compression or obstruction, is an occurrence which ought to be guarded against by regulating the quantity and quality of the food, for negligence in this respect may be followed by fatal consequences, if the obstacle be situated in the intestines. It is not in our power to prevent the occurrence of ascites from compression of the vena porta?, nor of oedema of the inferior extremities from com- pression of the cava in carcinoma of the mesen- teric glands, or of the iliac veins when the ovaries or uterus are affected with this disease. But the quantity of the effused fluid may be prevented from becoming so great as to affect the respiration, or give rise to painful distension of the integu- ments, by the use of those remedies usually em- ployed in dropsy from obstruction to the return of the venous blood. (See Dropsy.) When carcinoma has arrived at that period when the cancerous cachexia announces the ex- tension and fatal termination of the disease, the efforts of the physician must be directed solely to the mitigation of the sufferings of the patient. It would indeed be a valuable discovery — a remedy capable of removing pain without producing any injurious effects on the economy ; for if this symp- tom were removed, there are many cases in which carcinoma would run a much longer course, and give rise to comparatively little functional derange- ment. Wc have not in the course of this article alluded to the perforation of hollow organs from carcino- ma. With regard to this termination of carcino- ma, we shall only remark that it most frequently takes place in the uterus and stomach, the rectum and urinary bladder, the transverse arch of the colon and jejunum, and the peritoneum. The perfora- tion of the rectum, bladder, and peritoneum, is the consequence of the extension of the disease from , the uterus; that of the transverse arch of the colon, the consequence of its extension from the stomach. (See Perforation, Peritonitis, Stomach and Uterus, Diseases of.) Robert Carswell. SCORBUTUS. —This is the general appella- tion of nosologists for the disease long known in our own country by the name of scurvy. The lat- ter term, however, in professional as well as in popular use, has had an extended and very vague signification, embracing various morbid conditions of the skin which differ often essentially from each other, and are unallied to the subject of the pre- sent article. Illustrations of this remark might be adduced from various sources. As an instance, in J the English translation of the Pentateuch the word scurvy is twice used synonymously with scabies in the Latin. (Lev. xxi. 20, xxii. 22.) This and similar applications of it we think may be traced to its early use in an adjective sense; the substantive scurf having its literal prototype in the Saxon language, and referring, as is well known, to exfoliations of small particles of the cuticle; an occurrence not uncommon in the disease now called scurvy, but which has no title to a charac- teristic symptom. The word scorbutus, as Good observes, is nei- ther Greek nor Latin, nor belongs to any language whatever, but is an intolerable barbarism, deduced probably from the Sclavonic word ' scorb,' the identical disease of which we have to treat having been frequently endemic in Russia and other northern countries : it has gratuitously received a sort of Latin termination. It has also been re- ferred to < schorbert' in the Danish language, and 1 scorbeck,' i. e. sore mouth or «scheurbuych' in the Dutch. Most authors, says Lind, have traced it to «schorbock,' a griping or teazing of the belly, by no means a usual symptom, but so stated by a mistake in the etymology of the word. Scorbutus has also been called gingibrachium and gingipe- dum, from its affecting the gums, arms, and legs. It is probable also that the word « stomacace,' (from BToparos and KaKos, disease of the mouth) and ' sceletyrbe' (from ckcXos, the leg, and -rvpfin, disor- der) have by the ancient writers been employed to designate this affection. It may be well also to mention here that ' scorbutus' has two derivatives, which have had the same extensive and corre- sponding misapplication as the original, viz. the terms scorbutic and antiscorbutic, the former re- ferring to a peculiar virus supposed to be the com- mon root of a large class of diseases, the latter to the substances employed for their removal, consti- tuting a very formidable and extraordinary cata- logue. To prevent misconception, it seems necessary for us to premise that the following discussion re- lates to a peculiar disease, distinct, so far as we know, from the papular, pustular, squamous, and other diseases of the skin which have been un- fortunately confounded with it; a confusion which has given rise to evils of the greatest magnitude, as exemplified not only in the errors of the care- less and illiterate, but in their endless dissemina- tion with all the force of authority from the written doctrines of the respected and erudite. It may not be without its use to mention, that from the SCORBUTUS. 105 confusion of terms above adverted to, the best me- dicine for the prevention and cure of scorbutus was for a very long period overlooked and ne- glected, to the immense sacrifice of human life; and from the same cause it is stated that on the recommendation of Bderhaave, mercury was em- ployed by the medical officers of the imperial army of Hungary in 1720, in the treatment of four hundred soldiers suffering from real scorbu- tus ; every one of whom having been subjected to a course of this medicine died in consequence. (Elements of Medical Logic, by Sir Gilbert Blane, M.D. p. 217.) Scorbutus, or true scurvy, is a disease which pervades the whole of the human frame, and is characterized by general debility, fcetor of the breath, sponginess and turgidity of the gums, livid subcutaneous spots, particularly at the roots of the hairs, ecchymoses, spontaneous hemorrhages, and frequently contraction of the limbs. Cullen has placed it in the class Cachexia: and order Impeti- gines, and has thus defined it: " In regione frigida post victum putrescentem, salitum, ex animalibus confectum, deficiente simul materia vegetabili; asthenia, stomacace, in cute maculae diversi coloris, plerumque livescentes, praesertim ad pilorum radices." Mason Good has arranged it in his class Hxmatica and order Dysthetica, as one of three species under the generic name Porphyra,- including under it every variety of petechial eruption not depending on fever. The first species, viz. « P. simplex—petechial scurvy," he has defined " spots numerous but small and flea-bite shaped, chiefly in the breast, arms, and legs, paleness of visage." The second » P. hae- morrhagica—land scurvy," in which the spots are circular, of different sizes, often in stripes or patches irregularly scattered over the thighs, arms, and trunk ; occasional hemorrhage from the mouth, nostrils, or viscera ; great debility and depression of spirits. In the third species, viz. : " P. nautica —sea scurvy," the spots are of different hues in- termixed with some which are livid, principally at the roots of the hairs, teeth loose, gums spongy, and bleeding, breath fetid, debility universal and extreme. The first and second species having been particularly discussed in the article Purpura, in conformity with the usage of modern writers, require no further comment in this place, than that they have been so distinguished from the circum- stance of their having frequently occurred in young persons living in the interior of the coun- try, and previously enjoying good health with all the necessaries and comforts of life, but who, nevertheless, having failed to derive benefit from the diet and regimen usually found adequate to the cure of sea-scurvy, have not unfrequently been recovered by opposite means; circumstances which appear to indicate some essential differences in the pathological conditions under which they occur. This opinion has been further strength- ened by the blood drawn from the veins being also dissimilar; under the former circumstances being livid and very loosely coagulable, and under the latter having the usual appearances character- istic of an inflammatory disease. It is to be re- marked, however, that the scurvy as it is developed at sea is a form of disease in its characters pre- cisely similar to that which was commonly termed Vol. IV.—14 land-scurvy long prior to the distinction of Mason Good above adverted to; the only difference being that of the situation of its occurrence and the class of persons (mariners) who have been most frequently its victims. In our own country, though now happily a rare disease, it was formerly, even in the inland parts, of great frequency ; and in other northern states, particularly on the shores of the Baltic, where the products of vegetation, at least in their fresh state, have formed a very in- significant portion in the diet of its inhabitants, it is now even occasionally endemic. Its former frequent occurrence in besieged towns and garri- sons, under the combined circumstances of defect in the quantity and quality of food, fatigue, anxi- ety, disappointment, and exposure to the united influence of a cold and damp atmosphere, further prove that any particular influence from the sea is not essential to its generation. A memorable in- stance in point presents itself in the account of the siege of Thorn ; where we find that between five and six thousand of the garrison, besides a great number of the inhabitants of the town, were cut off by the disease, when the Swedes, who were the besiegers, were altogether exempted from it; and it is further remarkable that no sooner were fresh vegetables admitted to their use than the mortality subsided, and the disease dis- appeared. (Lind on Scurvy, Part III. ch. ii. p. 395.) Considerable discrepancy of opinion has pre- vailed as to the origin of scorbutus; whether it be of recent date, or referred to in the earliest pro- ductions of medical literature. It has been con- tended, chiefly by the continental writers, though some of high estimation in our own country have coincided in the opinion, that the ancient physi- cians were acquainted with it, although it has not been accurately described by them. On the other hand, there are authors of great celebrity, amongst whom are to be found Friend, Lind, and Trotter, who have maintained that the Greeks, Romans, and Arabians never could have witnessed it; con- sidering it indigenous to the colder regions of the globe, and chiefly incidental to the privations consequent to long voyages, which from their ig- norance of the compass and the science of navi- gation generally, they never undertook. Sieges, however, and seasons of dearth have been com- mon to every period and country, the former of much longer duration in ancient than in recent times ; and though experience has determined that the climates, or at least the vegetable pro- ductions of tropical latitudes, and their consequent use in the diet of the inhabitants, would in gene- ral insure its prevention, we have abundant proof that its existence is not incompatible with high temperatures. The ancient physicians, too, it is contended, have left us details more closely cor- responding to the symptoms of scorbutus in our present acceptation of the word than any other disease with which we are acquainted. Thus Hippocrates, in his description of disorders of the spleen, has noted the occurrence of the following assemblage of symptoms. " The abdomen is dis- tended, and subsequently the spleen is enlarged, becomes hard, and the seat of acute pain ; the complexion is changed and has a dusky (/"Xaj) pallid appearance, like the colour of a pomegra- 106 SCORBUTUS. nate; a disagreeable odour is exhaled from the ears and gums; the latter recede from the teeth, and ulcers break out on the tibia? like nocturnal pustules or blotches, (oKoia ntp cirivvKTiSec;) the limbs are attenuated and the bowels costive." Again, in his second book of Prognostics, he ob- serves that in those who have tumid spleens, the gums are diseased and the mouth emits a fetid odour, but those whose spleens are enlarged with- out any consequent hemorrhages are attacked with ill-conditioned ulcers in the legs and black scars, His description of the convolvulus sanguineus (EiXeoj attiarirns) more nearly represents the scurvy than that of the cit\nv p.eyas. » A bad odour is emitted from the mouth, the gums recede from the teeth, and blood is effused from the nostrils : but sometimes ulcers break out on the legs, and while some are healing others break out afresh, the skin about them is of a dark colour, thin and tender, and the patient is not disposed to walk or use any exertion." In the original the affirmative is as- serted, that the patient is disposed to exertion, a circumstance so inconsistent with ulcerations of the legs, hemorrhages, and other symptoms, that commentators agree that the negative particle (ov) must have been omitted : this derives further con- firmation from some additional remarks of the same writer, referring to a former description of another kind of convolvulus for the remaining symptoms, in which it is said that the patient's legs are wearied, and if he walk they tremble, and if he should ascend an acclivity that he breathes with difficulty, the elbows being raised as if they were suspended, &c.; the causes of which, he states, are heating food taken by persons using little or no exercise, and who, thus weakened, were suddenly forced to take long and fatiguing jour- neys in very cold weather; the tiXtoj, it must be remembered, being a term not confined by the ancients to express affections of the smaller intes- tines, but applied to denote also pains in the other parts of the abdomen. (Enquiry on Scurvy by Francis Milman, M. D. Lond. 1782, p. 179.) Cclsus has given a similar character of the ulcera- tions attending scurvy to that of Hippocrates: " Ulcera autem omnino non sanescunt, aut certe cicatricem vix recipient;" and in another part seems to have translated the observations of Hip- pocrates : " At quibus magni lienes sunt, his, gingivae malae sunt, et os olet, aut sanguis aliqua parte prorumpit; quorum si nihil evenit, necesse est in cruribus mala ulcera et ex his nigrae cica- trices fiant:" (Lib. ii. c. vii.), and in another pas- sage, on tumefactions of the spleen, he has almost confirmed the' conjecture above mentioned, ex- pressly observing, " in intenta ambulatione cur- suque dolor et quaedem difficultas est;" and he thus proceeds : " hoc vitium quies auget, itaque exertione et labore opus est, habita tamen ratione, ne febrem ista, si nimium processerint, excitent." (Liv. iv. c. ix.) Aretaeus, (lib. i. c. 14,) Paul of ^Egina, (lib. iii. c. 49,) and Avicenna, (lib. iii. c. 2,) as well as other Greek and Arabian physicians, have described the same chain of symptoms. It seems highly probable also that the true scurvy has been referred to both by Strabo and Pliny; by the former of whom we are told that the Roman army, sent into Arabia under ^Elius Gallas in the reign of Augustus, underwent great hardships and fatigue from difficult marches, sometimes in a marshy unhealthy country, and at others from long and troublesome navigations, which Syllaeus purposely protracted. " Proinde," says he, " ad Album Pagum perVenit, jam exer- citu oris et crurum vitiis (qui morbi sunt ei regioni peculiares) tacto stomacacen et sceletyrben dicunt; quorum ilia circa os, et circa crura resolutio qua?.. dam est ex aquis et herbis proveniens." (Stra- bonis Geograph. lib. xvi.) Pliny has left an ob- servation which seems to bear on the same point. He states that the Roman army under the com- mand of Caesar Germanicus, having encamped in Germany beyond the Rhine, near the sea-coast, met with a fountain of sweet water, by the drink- ing of which in the space of two years the teeth drop out, and the joints of the knees became para- lytic (compages genubus solverentur). The phy- sicians, he adds, called the disease stomacace and scelotyrbe, and discovered a remedy for it, viz. herba Btittanica, " a salutary medicine not only in disorders of the mouth and nerves, but for the quinsy, bite of serpents," &c. (Plinii Histor. Naturalis, lib. xxv. c. iii.) It has been denied, however, that the scelotyrbe was an indication of scurvy, because Galen has spoken of it as a kind of paralysis,* by which the patient is disabled from walking straight; but such an effect does not seem at all inconsistent with the detail of the symptoms. It has been argued, also, that the stomacace may have stood for aphthous and similar disorders of the mouth; and that other concomitant symptoms equally constant and remarkable, particularly the petechia? and ecchymoses, could not have failed to elicit the notice of the early writers, if the disease they described had been scurvy. On the other hand, from the comparative rarity of the occurrence of scurvy in the southern climates, it is not to be presumed that the attention of the ancient phy- sicians should have been very particularly directed to it. There is, besides, a peculiarity in the com- bination of the symptoms, a difficulty in referring them to any other known disease, and an apparent identity of circumstances under which they had been induced. It is likewise an established fact that in many instances the presence of scurvy has been acknowledged, and it has been expressly noticed, without the appearances which have been supposed to constitute the deficiency in the descrip- tion of the ancient writers. Thus Sennertus ob- serves, "In aliquibus nulla? erumpunt macula; aliis tola crura violaceo pinguntur ut tibialia ejus coloris superinducta jurares." To cite another authority, Nitzeh, who had very extensive expe- rience of the disease as physician in the imperial Russian armies, and published an elaborate ac- count of it in the year 1747, has noticed the occasional appearance of the other symptoms of scorbutus without the petechia? which usually ac- company it. (See Lind on Scurvy, p. 423.) From a consideration of all the circumstances of the question at issue, it appears a reasonable conclusion that the conjecture of the antiquity of the disease is well founded, and that the slight diversity of the effects, if any, by which it has * Mason Good imagines that Galen referred to chores, under the name scelotyrbe. — Study of Med. vol. iii. p, 432. First Edition. SCORBUTUS. 107 been manifested at different periods, is to be ac- counted for by the infinity of varying circum- stances which exert their modifying influences on disease, rather than by any essential differences in the actual morbid condition under which it has been induced. It will be sufficient to mention the diversity of periods, of seasons, of climates, of localities, of occupations, of diet, besides number- less others of a moral nature. It is further corro- borative of the antiquity of scorbutus, though we mention it in continuation of its history, rather than with the view of dwelling on incidents from which no deductions of practical value are to be drawn, that with the revival of literature after the siege of Constantinople, we find an undoubted record of its occurrence. It is characterized in the most particular manner by the Sieur Joinville, from the appearances it presented in the Christian army under St. Louis IX. in Egypt, about the year 1260. They had only one sort of fish, viz. the bombette, and their religion would not suffer them to eat meat during Lent; circumstances which, together with bad air and great scarcity of water, were supposed to have induced the dis- ease. (Histoire de Louis IX. par le Sieur Join- ville.—Milman on Scurvy. Lond. 1782. p. 184.) In the year 1486, it is stated by Fabricius in his account of the antiquities of his own country, Misnia,) to have been a new and unheard-of isease, spreading as supposed by contagion, and proving extremely dangerous. (Op. supra cit. p. 186.) In 1497 it was the acknowledged occasion of dreadful havoc in the crew of Vasco de Gama in his passage of discovery by the Cape of Good Hope, (Hackluyt's Collection of Voyages, vol. iii. p. 225) ; and its destructive ravages have since been awfully pourtrayed in the narratives of the early English navigators, particularly in those of Carrier, Sir Francis Drake, Davis, Cavendish, and Dampier. Sir Richard Hawkins mentions that within his naval experience, he had known of 10,000 men having perished by the scurvy ;* and from the same cause Commodore Anson, in the course of his voyage round the world, lost more than four-fifths of his men. Until the year 1796, scorbutus may be said to have been the universal scourge of our maritime connections; and it is supposed to have destroyed more sailors than the various accidents incidental to a sea life, united with the terrific consequences of naval warfare. Happily, however, since the above-mentioned period it has been of very rare occurrence in our ships of war and naval hospitals; so rarely, that on the high authority of Sir Gilbert Blane, the year adverted to may be regarded as the era of its extermination. The accomplish- ment of this he attributes in an unqualified man- ner to the curative as well as preventive use of citric acid ; no instance of the disease having oc- curred in his extensive experience which resisted its influence. To such testimony, perhaps, it behoves us to yield our implicit assent; but, satis- fied as we are with the immense mass of evidence adduced in favour of the wonderful efficacy of the remedy referred to, we cannot but take into the account the co-operative influence of the great • The Observations of Sir Richard Hawkins, knt. in his Voyage to the South Sea, A. D. 1593. — Purchas's Pilgrim, part iv. p. 1374. improvements in naval economy, successfully commenced with a view to the prevention of scorbutus by the justly esteemed navigator Cap- tain Cook, and brought to comparative perfection under the happy auspices of the enlightened and venerable director of the medical department of the navy, Sir Gilbert Blane himself. The records of medicine abundantly prove the prevalence, and even the great fatality of scorbutus on our own shores at a former period, although its appearance at the present day is most rare, as is well known to every practitioner of medicine. This salutary change is fully accounted for by the drainage of the country ; by the introduction of fresh vegeta- bles as a considerable proportion of the habitual diet of the people; and those improvements in our national economy by which the use of fresh meats has been rendered available at all seasons of the year, and substituted for the dried and salted provisions formerly a principal article of sub- sistence throughout the winter. The want of fresh vegetables at former periods is plainly evinced by the historical fact, that as late as the commence- ment of the sixteenth century, the art of garden- ing was so little understood in our country, that Katharine of Aragon, queen of Henry VIII., to procure a salad, was obliged to despatch a mes- senger to the Netherlands for it; and it was near the close of Henry's reign before the necessary vegetables for the purpose, as well as cabbages, turnips, carrots, and some other edible roots, were produced; the small quantity of this kind of food previously used having been imported from Hol- land and Flanders. (Hume's History of England, ch. xxxiii.) But to return to the general history of scor- butus. Krantz, the historian of Saxony, is sup- posed to be the first writer whose works are extant who calls it scurvy; and the next, Euritius Cordus, in his Botonologicon, published in 1534, wherein the chelidonium minus, called by the Saxons schorbock root, is extolled as a remedy. It is mentioned, also, in the same manner in the Me- dicina Herbaria of J. Agricola, published in the year 1539. But in an intermediate period, in 1535, we find that the most decisive and deplora- ble effects of it were evinced in the crew of James Cartier in his second voyage to Newfoundland, when we are informed of the providential disco- very of a remedy (in previous use amongst the people of Stadacona,) viz. the decoction of the bark and leaves of the ameda or hanneda, after- wards gratefully designated by them " the tree of life."f In 1555, the History of Northern Na- tions, by Olaus Magnus, contained, amongst the diseases peculiar to them, a long description of scorbutus. Soon afterwards we find three cotem- porary physicians of eminence treating expressly of it, viz. Rousseus, Wiems, and Ecthius. The works of the two former, in the opinion of the learned Astruc, were not published until the year 1580, and the epitome of Ecthius, which, accord- ing to Forrestus, was the transcript of a letter t" I am inclined to believe, from the description given by Cartier of the ameda tree, that it was the large swampy American spruce. Some have supposed it to be the sassafras, others the white-thorn ; but in his third voyage he mentions the white-thorn, and makes the ameda to be three feet in circumference." — Lind. on Scurvy, p. 178. 108 SCORBUTUS. dated 1541, not until 1583. In 1604 appeared a work on the subject by Engelanus, which for many years was regarded as the standard of pub- lic opinion. This was succeeded in 1624 by that of Sennertus, and in 1627 by the description of Vander Nege, drawn from personal observation of its extensive prevalence at the siege of Breda. In 1667 Willis published a systematic treatise on the disease, which, like that of Engelanus, continued for some time to be the prevailing au- thority. In 1708, however, it gave place to the observations of Boerhaave, and to him succeeds a long list of writers ; but, as of those who pre- ceded him, we shall mention such only as have been held in estimation, attaching the dates to their several publications. (Lind's Treatise on Scurvy. Lond. 1757.) Mead, in 1749; Russell and Huxham, in 1750; Addington, in 1753; Bisset, in 1755; Lind, in 1757; Macbride, in 1767; Hulme, in 1768; Milman, in 1782; Trot- ter, in 1797; and Blane, first in his work on the Diseases of Seamen, published in 1785, and sub- sequently in a paper on the health of the navy, inserted in the sixth volume of the Medico-Chi- rurgical Transactions of London, in 1815, and transcribed in a pamphlet of the same title printed for private circulation in 1830. Besides the above mentioned, there are doubtless others which merit attention ; and much valuable information on the subject is to be found in the periodical miscella- nies, chiefly of a remote date. Symptoms.—The symptoms which constitute scorbutus having rarely if ever appeared except when there has been an obvious exposure of the subject of them to the concurring influence of several of those termed its predisposing causes, other indications of the approach of the disease will be confirmed, or the suspicion of it diminish- ed, in proportion as such a connection of circum- stances can or cannot be ascertained. Of the predisposing causes the most uniformly present has been the combination of cold with humidity of atmosphere, either general or partial; whilst at the same time the diet has consisted of food de- fective in its nutritious qualities, and particularly of provisions rendered dry and hard by the pro- cess of salting as usually adopted to preserve them for sea use, together with a total privation, or the use of a comparatively insignificant quan- tity of succulent vegetables in their fresh state. Under this privation, as it has frequently occurred at sea, a craving desire for them, particularly for such as are of an acid taste, and also for pure water, when the supply of that article has been scanty, has been so often observed to precede the disease, that practical authorities have considered such desires as premonitory symptoms. Their operation has been feelingly portrayed in the nar- rative of Lord Anson's voyage, on the occasion of the approach of his ships to the island of Juan Fernandez : the scenery of which having been depicted, the writer observes, « Such a scene, so beautifully diversified, must have been delightful to an indifferent spectator; but in the distressed condition of the Centurion's men, who were in a manner languishing for the land and its vegetable productions, a situation of mind which always attends the scurvy, it is not to be conceived with what transport and eagerness they viewed the shore, and how impatiently they longed for the greens, the fresh water, and the other refreshments then in sight." And it is further observed, " that those only who have endured a long series of thirst, and can readily recall the desire and agita- tion which the ideas alone of springs and brooks have at that time raised in them, can judge of the emotion with which they eyed a large cascade of the most transparent water, which poured itself from a rock near one hundred feet high into the sea at a small distance from the ship." " Those who had been long confined to their hammocks now exerted all the strength they had left in crawling up to the deck to feast their eyes with the reviving prospect. Thus they coasted along the shore, contemplating the enchanting land- scape, which improved as they advanced; but the night closed upon them before they had dis- covered a proper bay. At four the next morning the third lieutenant was despatched with the cut- ter to discover the bay they sought for, and at noon he returned with the boat laden with seals and grass; for the boat's crew did not stay to search for better vegetables, as they well knew that even grass would prove a dainty, and indeed it was soon eagerly devoured." (Anson's Voyage round the World, 1740-4, ch. iii.) Another indication of the scorbutic diathesis, unnoticed by preceding writers, says Sir Gilbert Blane, is a soft indolent tumour, which arises under the skin on a part which has received a slight blow or contusion, so slight as not to break the skin. It most commonly appears about the elbow or forearm, and generally disappears with- out inconvenience, its contents being absorbed. (Observations on Diseases of Seamen, 1785, p. 465.) Scratches and wounds which under other circumstances would scarcely elicit attention, are apt to proceed to troublesome ulcerations, and betray their real character with the further de- velopment of the disease. Amongst the more obvious symptoms, the ear- liest is usually a change of colour in the face, which, as well as the rest of the skin, becomes pale, and has a bloated appearance. When nar- rowly examined, it is seen that the lips and carun- cles of the eye, where the blood-vessels lie most exposed, are of a greenish hue. The countenance denotes the state of the mind, which is depressed. The patient complains of lassitude, and is averse to all kinds of bodily exercise ; the inability to use it is soon manifested by stiffness and feeble- ness of the knees, and excessive fatigue and breath- lessness or panting are the consequences. The gums soon become itchy, swelled, and are apt to bleed upon the gentlest friction. On inspection they present a livid red appearance, are soft and spongy, and become extremely putrid and fun- gous. The odour of the breath is, as may be supposed, excessively offensive, and hemorrhages are apt to occur from the gums, as also from other parts of the body. The skin at this time feels dry, and continues so through the whole course of the disease. If the patient be feverish, it is extremely rough, sometimes resembling that which is vulgarly called goose-skin. But most frequently it is smooth and shining, with suffusions of reddish, bluish, or ra- ther black and livid spots. These are of different SCORBUTUS. 109 sizes, occupying spaces from the smallest possible to that of a handbreadth or more, increasing gene- rally with the progress of the disease. They are to be seen chiefly on the legs and thighs, often on the arms and trunk, but more rarely on the head and f ice. The legs are apt to be cedematous, the swelling at first being confined to the ankles, and conspicuous only in the evening, but gradually extending to the whole limb, and becoming less and less transient. Such are the most constant and essential symp- toms of the disease in its first stage; but a diversity is sometimes observed in the order of their appear- ance. Thus, when there has been great debility from previous illness, the gums for the most part are first affected; whereas, when the individual has been deprived of exercise in consequence of a fractured bone or other injury, the parts so affected become first scorbutic. As for example, if a pa- tient is suffering from a strain of the ankle, the first indication of scorbutus will be pain, swelling, and cedema of the leg, with the purple subcutane- ous spots and ecchymoses which more especially characterize the disease. It is remarkable, also, that if there have been previous disease, particu- larly rheumatism, chronic pains from bruises, and other effects of local injuries, these are apt to be renewed, and the disease on which scorbutus may have supervened to appear in a more aggravated form. (See Lind on Scurvy, chap, ii.) A strik- ing instance in confirmation of the preceding re- mark is mentioned in the account of Lord Anson's voyage. The individual spoken of had been wounded, about fifty years before, at the battle of the Boyne, but had speedily recovered, and had continued well for a great number of years pre- ceding an accession of scorbutus; but upon this, and during its progress, the same wounds broke out afresh, and appeared as if they never had been healed ; nay, what is still more astonishing, the callus of a broken bone, which had been com- pletely formed for a long time, was found to be destroyed, and the fractured part as if no consoli- dation had ever taken place. The subjects of scorbutus frequently suffer from shifting pains : some complain of them, according to a common expression, throughout their bones, being particularly severe in their limbs and lum- bar region, and in the joints and legs when they are swelled. But the most frequent seat of pain is the thorax; a sense of constriction in it with stitches on coughing being usual symptoms. " I believe indeed," says Lind, " it will universally be affected unless the bowels are very open. The pain shifts from one part of it to another, often to opposite sides, and is at first perceived upon coughing only; but in a more advanced stage it commonly fixes in a particular part — most fre- quently in the side, where it becomes extremely severe and pungent, so as to affect the breathing— a dangerous symptom." As scorbutic pains often change their position, so they are always exaspe- rated by motion of the body, especially the pain of the back, which on such occasions proves very troublesome. The next thing observable is, that if any epi- demic should prevail at the same time with scor- butus, the subjects of the latter are in consequence predisposed to be attacked by it, even if there K should appear to be no correspondence between the two diseases. Such a concurrence, however, Lind considers much more fortunate than when the new disease may be, as he terms it, of a putrid nature, as small-pox, measles, dysenteric fever, &c.; «it is then," he adds, " that co-operating with the scorbutic acrimony, they produce most fatal and malignant symptoms." The head is seldom or never affected with pain, unless when fever is present, which may be considered altoge- ther an adventitious circumstance. When fevers supervene on scorbutus, they usually prove fatal; but that species which at a former period was most destructive, more so even than the plague, was the petechial or gaol fever, of which we read in works of the last century, contracted in large, crowded, and sickly ships or prisons. According to the habit and constitution of the patient, there will be some diversity in the performance of the alvine function. In some patients it is natural, in others there is extreme constipation ; but generally the bowels are in a relaxed state, and the dejec- tions are extremely fetid. The appearance of the urine is very variable at different times, even in the same patient, except that it is generally high- coloured, and soon becomes rank and fetid. It is said, also, to turn blue vegetable infusions to a green colour. The pulse varies according to the habit of the patient and stage of the disease, being in general slower and more feeble than in health. After a time the patient is commonly deprived of the use of his inferior extremities, the flexor ten- dons of the ham being contracted and the joints swelled ; livid spots and ecchymoses are to be observed, particularly on the legs, and frequently hard and very painful swellings in different parts. " In some," says Lind, " I have seen, without any swelling, the calf of the leg quite indurated." There is great proneness to syncope upon exertion, and not unfrequently upon occasions of this kind, or any sudden exposure to a fresh atmosphere, scorbutic patients have instantly died. The ten- dency to profuse hemorrhages increases with the progress of the disease, and these are apt to take place from the nose, gums, lungs, intestines, &c, as well as from any ulcers which may be present. Besides the morbid appearances of the gums already mentioned, they are liable to be affected with deep ulcerations, the teeth most commonly are loosened and often fall out; but caries of the jaw rarely ensues, nor is this affection of any of the bones a usual consequence, but has probably been considered so from the occasional complica- tion of scorbutus with syphilis; as ptyalism has also from its synchronous occurrence when mer- cury has been exhibited for the cure of the latter disease. When scorbutus approaches its fatal termina- tion, the painful and livid swellings above referred to often break, and assume the fungous appear- ance characteristic of scorbutic ulcers. The he- morrhages become more profuse and general; the increasing dyspnoea is accompanied in some cases with pain under the sternum, but most frequently in one of the sides. In others, however, without any complaint of pain, the respiration becomes suddenly quick and laborious, and death unex- pectedly puts a period to the disease. The mind throughout is depressed and anxious, but at last 110 SCORBUTUS. there is generally a total indifference and apparent torpor of every faculty. The appetite for food is rarely impaired, and death has even seized the sufferer in the act of eating. Nyctalopia is an occasional occurrence in the progress of scorbutus, though rarely noticed in the descriptions of it. Dr. Hulme recorded its appearance in his inaugu- ral dissertation printed in 1765; and Sir Gilbert Blane states that it had been reported to him by Mr. Telford. It was also a common occurrence amongst the scorbutic patients in the garrison of Gibraltar, during the siege of that plate. (See Nyctalopia.) To the complications of scorbutus with other diseases is to be attributed the Protean character which has frequently been ascribed to it, and which, from a comparison of descriptions, it would seem to have manifested. The conjoined diseases have been most frequently such as are incidental to the same predisposing causes, namely, fevers, continued, intermittent, and remittent; rheuma- tism, diarrhoea, and dysentery. It has often also been complicated with syphilis, and occasionally with catarrh and ophthalmia. Besides these, numerous other diseases are mentioned by writers as having preceded its occurrence ; but scorbutus always exerts the predominating influence, and sometimes even has simulated the worst form of idiopathic disease, as phthisis pulmonalis,* the symptoms of which have subsided on the treat- ment appropriate to the removal of the former. Scorbutic ulcers are to be recognised by the following characteristics : instead of pus they ex- crete a thin, fetid, sanious fluid, mixed with blood ; their edges generally are of a livid colour, and as it were puffed up ; a coagulum is soon formed on their surface, which can with great difficulty be wiped away or separated from its subjacent parts. These are soft, spongy, and putrid. When, how- ever, the removal of this coagulum has been effected, the same appearance presents itself again after the lapse only of a few hours, and soon con- stitutes a soft bloody fungus of considerable size, formerly familiar to sailors, and commonly called by them bullock's liver, which in its boiled state the former resembles both in colour and consist- ence. " It often rises," says Lind, " in a night's time to a monstrous size, and although destroyed by cauteries actual or potential, or cut smooth with a bistoury, in which case a plentiful hemor- rhage generally ensues, at the next dressing it is as large as ever." Pathological Anatomy.—Although scorbu- tus, as we have already stated, was until the latter end of the last century a very fatal disease, and has been the subject of numerous dissertations, few accounts have recorded the post-mortem ex- aminations of individuals who have died of it. On this part of the subject the essay of M. Pou- part, from observations made at the hospital of St. Louis, in Paris, (Memoires de l'Academie des Sciences, 1699, p. 237; also Lind on Scurvy, p. 255,) is the most minute and explicit we pos- sess. Added to the external appearances of the body as described in the living subject of the dis- ease, extravasations of dark-coloured blood have * Me.lico-Chir. Review, for June, 1824. On scurvy in his Majesty's ship Leander, on a voyage from Trinco- malee to the Cape of Good Hope. been found very generally under the integuments in the muscles, so as to render them hard and rigid, and in some of the glandular parts of the body, particularly the spleen. The brain was always in its natural state. Serous fluid was fre- quently found in the thorax, stated to have been of various colours, and so corrosive as to excoriate the hands which have been wetted with it. In some who had suffered from dyspnoea, and had died suddenly, the cavity of the chest and also the lungs were void of serum,- but there were adhe- sions of the pericardium to the latter, and of the lungs to the pleura costalis and diaphragm. In some who died suddenly without any obvious cause, the auricles of the heart, it is stated, were as large as a man's fist, and full of coagulated blood. The glands of the mesentery were gene- rally obstructed and swelled. Some of these were found partly corrupted and imposthumated. In the liver of some few, the extravasations were hardened. The spleen was three times bigger than natural, and fell to pieces as if composed of coagulated blood. Sometimes the kidneys and lungs were studded with imposthumes. The ligaments of the joints were corroded and loose, and instead of the synovial fluid there was only a greenish liquor, to the causticify of which the cor- rosion of the ligaments was attributed. The epi- physes were found entirely separated from the shafts of the bones, the cause in the living subject of a crepitating noise on motion, which was some- times distinctly audible. In some, the cartilagi- nous portions of the ribs were separated from the bone, and the bony part, at the point of separation from the cartilage, was carious to the breadth of four fingers. In some subjects, on squeezing the sternal extremities of the ribs, the spongy portion was separated in a corrupted state, leaving only the external and internal bony plates. In some were found abscesses of the glands of the groin and axilla. Dr. Mead tells us, that upon opening the abdomen of a scorbutic patient, he was struck with amazement at the monstrous size of the spleen, which weighed five pounds and a quarter, whereas the liver weighed but four pounds and a quarter; but its bulk seemed to be its only defect; for it retained its natural shape and colour, and had not the least scirrhosity or other hardness. Its interior parts were as usual of a dark livid hue, with lax fibres and deep-coloured blood. (Medi- cal Works of Richard Mead, M.D. Dublin, 1767, p. 421.) In the beginning of the disease, according to the observations made by the surgeons of Lord Anson's expedition, (Mr. Ettrick and Mr. Allen,) the blood as it flowed out of the orifice of the wound might be seen to run in different shades of light and dark streaks. As the disease ad- vanced, it ran thin and seemingly very black, and after standing some time turned thick and of a dark muddy colour; the surface in many place« of a greenish hue, without any regular separation of its parts. In the third degree of the disease it came out as black as ink, and though kept stirring in the vessel many hours, its fibrous parts had only the appearance of a quantity of wool or hair floating in a muddy substance; and when it issued from the body, as in hemorrhages, the ap- pearances of this fluid were the same as to coloM SCORBUTUS. Ill and consistence, whether it was discharged from the mouth, nose, stomach, intestines, or any other part. In dissected bodies, the blood in the veins was so entirely broken, that by cutting any con- siderable branch, the part to which it belonged could be emptied of its black and yellow liquor. The extravasated blood was also precisely of the same kind. Diagnosis.—The symptoms already detailed as characteristic of scorbutus, considered in con- nection with the circumstances under which they are stated to occur, or in other words its immedi- ate causes, are sufficient data to render it distin- guishable from every other disease; but in the present state of our knowledge a consideration of the latter is necessary to prevent it from being confounded with certain forms of purpura, viz. purpura simplex and purpura hemorrhagica; both of which until a recent period were regarded as manifestations of the disease under discussion. Good, as already stated, has classed the three to- gether as species of the same genus, under the name Porphyra, Scurvy,—an arrangement which was sanctioned by the opinion of Willan, who viewed them as allied. A comparison of the symptoms alone would seem to warrant the con- clusion that they are constituted by diversities of degree only of the same morbid condition. But that this uniformity does not exist, particularly as regards purpura hemorrhagica and scorbutus, has been inferred from the successful issue of the treatment of the former by the pursuance of the antiphlogistic system, especially by the exhibition of purgatives, and in some instances even by bloodletting, when the occasional causes of the latter have not been found to exist, and the reme- dial measures appropriate to its removal had been resorted to in vain. In many instances a pletho- ric state of the system and a febrile disposition have pointed out the divergence from the line of symptoms which characterize scorbutus, and the peculiarity has been further marked by the nature of the diet and the previous condition of the pa- tient. But it must be acknowledged that it is often impossible to recognise the distinction be- tween purpura and scorbutus, or appreciate any difference in their occasional causes, except that amongst those of the latter the influence of a cold .and humid atmosphere appears almost, if not always, essential to its production. When the state of the pulse and the condition of the patient have suggested the advantage of bloodletting in purpura hemorrhagica, the appearance of that fluid on being allowed to stand has been that of blood drawn in inflammatory diseases, presenting on its surface a thick and tenacious coat of coagulated lymph. The cruor has also been firm and cohe- sive, and difficult of diffusion when shaken in the serum, and altogether different, (as will be seen by comparison with the description already given,) from blood drawn in scorbutus. Prognosis.—Although scorbutus has "slain its tens of thousands" on land as well as at sea, and from its former fatality was not inaptly classed amongst pestilential diseases, the means of treating it have been so well ascertained and established, that for the most part, having citric acid at com- mand, and still more certainly an abundant supply of fresh and succulent vegetables, with the power of protecting the patient from a continuance of the operation of its occasional causes, its cure may be much more certainly anticipated than that of any other disease in which the visible effects are as general and as threatening to the extinction of life. When deprived of the means above spe- cified, as formerly often happened at sea, and as is even now frequently the case as regards fresh vegetables, citric acid may in general be depended on as a very efficient antidote; but without it the probabilities of arresting the progress of the dis- ease will-be infinitely diminished, and the recovery of severe cases rendered hopeless. The first favourable symptom in the advanced stages of the disease, when fresh fruits and vege- tables have been obtained, is a change from a con- stipated to a lax state of the bowels ; the skin becomes moist and soft; some increase of bodily power follows; a tranquil pulse together with an improvement in the appearance of any ulcers which may be present; and a change in the aspect of the petechia? and ecchymoses, their livid colour gradually assuming a yellow hue from the centre to the circumference, the skin at the same time resuming its natural colour, is then observed. The most unfavourable symptoms are dyspnoea, stitches in the side, frequent faintings, a weak and quick pulse, involuntary evacuations, and exces- sive hemorrhages. An unexpected and fatal ter- mination of scorbutus has occasionally, we have said, taken place upon any unusual exertion, or on sudden exposure to a fresh atmosphere. When complicated with other diseases, as dysentery or diarrhoea, the unfavourable aspect of scorbutus is rendered still more so, in proportion to their severity and the difficulties there may be to en- counter in checking their progress. Diseases, also, of an incurable nature, the tendencies to which have been previously established, may be developed by the presence of scorbutus, such as phthisis, and other organic lesions productive of hydrothorax, ascites, &c. But at the same time, in forming a prognosis, it must be borne in mind that phthisis itself and other organic lesions have been simulated by this disease, and that their symptoms have subsided when the peculiar affec- tion which constitutes scorbutus has been sub- jected to its appropriate treatment; and that the most unfavourable sequela? will sometimes disap- pear when solely consequent upon the disease under discussion. Causes.—The predisposing causes, or those which induce an aptitude in the body to be at- tacked by scorbutus when exposed to its usual excitants, are numerous, and vary in their nature, but concur to occasion debility whatever they may have been. Thus we find that preceding diseases, whether acute or chronic, have been very common precursors, and that persons recovering from fevers, or who have been previously weakened by fre- quent relapses, have been often subjects of it. Indolence and inactivity appear also to have con- tributed to produce the susceptibility. The per- sons in a ship's crew termed skulkers or sluggards have been usually the first attacked ; and it has been observed that those whose condition on board-ship exempts them from much exercise, have also been early amongst the number affected. We are told that in one of Lord Anson's ships, 112 SCORBUTUS. the Centurion, out of fifty cases of scorbutus four only survived, and of the whole number of ma- rines attached to the squadron (seventy), all but eleven died of it. It has been observed also in the Dutch service, that if there were seven on board that had the scurvy, four of these were marines, though the number of the latter was, of course, proportionately much less than that of the sailors. Corpulent persons have appeared to be peculiarly prone to it, and on shore it has been observed to affect individuals of sedentary occupations more frequently than those engaged in the active duties of life; and where it has been endemic, very fre- quently to attack the sedentary mechanics whilst the rural population have entirely escaped. On the other hand, however, excessive fatigue, over- exertion, and want of necessary rest, induce the same predisposing condition. Thus, it has not unfrequently occurred after long and harassing marches, and at sea succeeded occasions of much laborious duty; numerous instances of which might be adduced, if space were allowed us for the detail. But of all the predisposing causes, none has been observed to have more frequently, if not in- variably, exerted its influence, than cold combined with moisture either from the atmosphere gene- rally, or from the equivalent influence of a humid apartment or damp clothes. When scorbutus made such havoc in Lord Anson's squadron on doubling Cape Horn, the weather had been very tempestuous, the wind cold and cutting, accom- panied with snow and sleet. At the siege of Azof, when the Russian army suffered from it severely, the same circumstances existed. In the account of his voyage round the world, La Perouse states that he was very fortunate in preserving his crew from scorbutus, an effect which he attributed entirely to maintaining a dry state of the atmo- sphere between the decks. Captain Cook's suc- cess in this respect seems to have depended con- siderably on similar precautions. In Captain Parry's first voyage for the discovery of a North- West passage, the influence of humidity in this particular was very conspicuous. " Mr. Scallon," he states, " had been complaining for some days of pains in his legs,—first considered by the sur- geon as rheumatic, but which he was soon con- vinced by the appearance of the gums depended on scorbutus. This occurrence, so uncommon amongst the officers of a ship, led to a particular inquiry as to its cause, and it was discovered that Mr. Scallon's bedding was in so damp a state in consequence of the deposit of moisture in his bed-place, as to render it no longer questionable." In Captain King's expedition in 1826, the crews of the two ships which he commanded, viz. the Adventure and the Beagle, continued healthy until May 1828, when scorbutus began to show itself whilst in the straits of Magellan, notwith- standing they were plentifully supplied with lemon-juice, sugar, preserved meats, pickles, cran- berries, fish, wild fowl and wild celery. There was, however, excessive moisture of the atmo- sphere, and great mental depression prevailed in the crews from want of occupation, which in this instance would seem to have been excitants of the disease. Mental depression, indeed, appears on most occasions to have had a powerful influence in predisposing persons to scorbutus. During its endemic prevalence, the timid, the discontented, and the inactive, have been frequently the first attacked. From this cause probably it is that newly impressed seamen have been particularly liable to it, and that it has often shown itself among the inhabitants of besieged towns. Hy- pochondriacs and persons of a melancholic tem- perament have been so commonly its subjects, that the hypochondriacal disorder, the atrabilious habit, and scorbutus, have by many of the old writers been considered as different degrees of the same disease. (Enquiry into the source of Scur- vy, by Francis Milman, M. D. 1782.) Amongst a variety of other deBilitating circumstances con- ducive to scorbutus, exposure to the impure air of crowded apartments and the free use of ardent spirits have been so commonly its precursors, that they require to be especially perticularized. It has also been observed that individuals of un- cleanly habits, both with regard to their persons and clothing, have been more liable than others to the disease. Various opinions have been entertained as to the immediate or exciting causes of scorbutus, and, as frequently has occurred in reference to epidemic or endemic diseases, its propagation has been attributed to contagion. Sennertus, Boer- haave, and Hoffmann, are of the number of those who have advocated this opinion ; and in Sir Gilbert Blane's work, published in 1785, we find that it was not discountenanced by him. It has been so completely subverted, however, by subse- quent experience that it would be needless to dis- cuss the question. Its hereditary transmission has also been asserted, but of this there is no satisfactory proof or even plausible argument. At all times it has been an accredited opinion that its origin has been referable, with the con- currence of the predisposing circumstances al- ready mentioned, to an insufficiency of nutriment, or to some noxious qualities of the ingesta, and these for the most part included in the following particulars—in certain impurities in the water or other liquids used for drink; in a preponderating proportion of farinaceous substances ill-fermented, or which have not undergone that process, or otherwise in a faulty state; in the use of animal' food in a state of putrefaction, decomposition, or hardened and changed in its nature by the process of salting, as for sea use; simultaneously with privation or an insufficient supply of fresh vege- tables, or a scanty allowance of such dietetic drinks as contain their elementary principles. The connection of scorbutus with the use of such diet has to a certain degree been rendered obvious, by the successful issue of changes in the dietary of our own navy, determined on in con- sequence of the numerous facts corroborative of the supposed influence of the former system on the generation of this particular disease. The necessary concurrence of so many circumstances apparently essential to its production renders it impossible to estimate their individual operation, and this knowledge can be obtained only (if the opportunity should ever occur) by a more full and exact inquiry into the coexistent condition of the blood and other fluids of the body than SCORBUTUS. 113 has ever yet been made. From its former preva- lence principally amongst sea-faring people, an idea has been entertained that the large quantity of salt used in their food was exclusively an ex- citant of scorbutus; but Dr. Lind has shown that the daily use of considerable quantities of sea- water has in no degree aggravated it, and that an entire abstinence from salt or salted meat has had no mitigating effect on its symptoms. (Page 52.) It is certain also that scorbutus has prevailed where the operation of this article could not even have been suspected ; as, for instance, on the oc- casion of Lord Anson's ships leaving the coast of Mexico, when they were plentifully supplied with fresh meat. The soldiers in the Russian armies, who suffered from scorbutus at the siege of Azof, had no salt provisions. During a scarcity of corn it raged amongst the poor inhabitants of the colder districts of Italy near the Alps, who subsisted chiefly on the decoction of roots, and often passed whole days without any food at all. In the Transactions of the College of Physicians, Dr. Milman has related two cases of the disease appearing in a very severe form in individuals who had lived for three months on tea, without milk or sugar, or any other article of diet except bread. (Milman on Scurvy, ch. ii.) From its occurrence also in prisons, and so lately as the year 1819 in the Milbank Penitentiary, under a dietary of fresh animal and vegetable food com- bined, it may be inferred that the prejudicial effect of salted meat depends either on its being deprived of its nutritious qualities, or upon its being other- wise rendered indigestible. It is also somewhat corroborative of this view, that the direct effect of the addition of salt to blood out of the body is a change of its colour from black to red, the reverse of which is the consequence of scorbutus in the blood of the living body. With regard to diet, however, the most constant peculiarity which has apparently caused the occurrence of scorbutus, has been a deficiency in the proportion or an entire privation of fresh vegetables, or rather, it should be said, of those which are of a succulent nature,—as an instance in point, may be men- tioned the occurrence of scorbutus in Porchester Castle and at Norman Cross, about the beginning of the late revolutionary war, before those ar- rangements were put into practice which after- wards so effectually secured the health of the pri- soners. Under similar circumstances it appeared in a prison-ship near Porchester Castle. (See a paper on the health of the Navy, by Sir Gilbert Blane, in the London Med. Chir. Trans, vol. vi. p. 502. 1815.) In these situations, however, it is to be remembered that there was a co-operation of several circumstances conducive to the disease, viz. deteriorated air, a dull uniformity of life, de- pression of spirits, want of exercise, &c. &c. It is scarcely necessary to observe that the saline effluvia in sea-air has been alleged as the cause of scorbutus. It is obvious that a circumstance so constantly prevailing at sea and on its shores could never have had so partial a consequence, and that the disease has almost entirely disap- peared, though the cause alleged remains the ■ame. It has been moreover remarked that there are few artificers so healthy as those who prepare salt from sea-water, and are thus continually ex- Vot. IV.—15 k.* I posed to the impregnated vapour which rises in the processes of drying and purifying this article. j (Lind, ch. i. p. 53. Stevens on the Blood, p. 311. Lond. 1832.) The hypotheses which have been promulgated j in explanation of the physical condition on which scorbutus, or, in technical language, its proximate cause, depends, have accorded with the revolving doctrines of general pathology, but have been chiefly founded on those principles which refer disease to morbid changes in the fluids, or else to i a corresponding condition of the properties of the living solids. For the most part, and up to the present day, scorbutus has been attributed to the former, even by those who have ably advocated the opposite opinions with regard to disease in general. Much further investigation, however, into the elementary components both of the solids and fluids of the body in their healthy and morbid state, and into the influences of external agents upon them, than has hitherto been made, is requi- site to clear up the difficulties of this intricate question. The peculiar opinions on the subject which from time to time have elicited attention, require to be noticed in this place ; but it must be premised that the principles of treating the disease founded upon them have been very inadequate to the end in view, which has been achieved most completely by observation alone, or, in other words, by that enlightened empiricism, which suggests the right application of established facts in the art of therapeutics, although much knowledge may be wanting to elucidate the nature of the changes produced in the body by which the object is effected. The early writers on scorbutus have applied the general doctrines of the humoral pathology to the explanation of its various phenomena ; more espe- cially ascribing them to a putrid state of the blood, occasioned, as it was supposed, by defect in the function of the spleen, this organ at the period having been considered essential to the process of sanguification. Willis, (Tract, sec. de Scorbuto,) consistently with his pathological speculations in general, referred scorbutus to a state of dyscrasy of the blood, which he fancifully described as of two kinds, under the terms of the sulphureo-saline and the salino-sulphureous; the former to repre- sent a supposed superabundance of sulphur, for the correction of which he taught that the deplet- ing system was requisite, and above all things the avoidance of the hot and acrid antiscorbutics; whilst, on the contrary, in the salino-sulphureous, when the salts of the blood were supposed to pre- dominate, he considered the warmer medicines were proper, and such as contained a volatile salt, together with preparations of steel and other tonics. The dyscrasy of the blood, he further presumed, was the occasion of a corresponding state of the nerves, or, according to his system, of the liquor nervosus,- which thus secondarily, he imagined, conduced to the manifestation of some of the symptoms. The opinions of Boerhaave (Opera, cap. De Scorbuto) on this subject appear to have been equally hypothetical: he contended that scor- butus was occasioned by that part of the blood which constitutes the crassamentum being inordi- nately thick and viscid, and the serous portion too thin, salt, and acrid. The acrimony of. this fluid 114 SCORBUTUS. he imagined was either acid or alkaline, according I to the nature of the food by the use of which the ] disease appeared to be induced : if, as at sea, it had consisted of salted meats, or of such as yielded little nutriment, as a consequence that there would be an acid, or, to use his own phrase, a muriatic acrimony ; but if the food had been in a putrid state, that the acrimonious principle would be al- kaline. Although Hoffman exposed the fallacy of the humoral pathology in general, his views of the nature of scorbutus coincided for the most part with those of Boerhaave; and Cullen, who first and most successfully controverted the same sys- tem of pathology, admitted its influence in giving rise to this disease. Presuming from the appear- ance of the blood, from that of the secretions and excretions, and from the fetor of the breath, that a morbid condition of the blood does give rise to it, he contends that a putrefaction or a nearer ap- proach to it than is consistent with health, is a necessary consequence of living entirely upon ani- mal food, without a frequent supply of vegetable aliment, and thereby of producing and evolving a larger proportion of saline matter. In confirma- tion of this, he observes that every interruption of perspiration, that is, the retention of the saline matter, contributes to the production of scurvy, whether produced by the direct application of cold, or by any other circumstance which might weaken the force of the circulation, such as the neglect or want of exercise, fatigue, and despondency of mind. It will be sufficiently obvious, he adds, that if the preternaturally saline state of the blood in scorbutus be admitted, the throwing into the body along with the aliment an unusual quantity of salt may have a great share in producing the disease. Even (he proceeds) supposing such salt to suffer no change in the animal body, the effect of it may be considerable ; and this will be ren- dered still more probable, if it may be presumed that all neutral salts consisting of a fixed alkali are changed in the animal body into an ammonia- cal salt, which he apprehends to be that especially prevailing in scurvy. (First Lines of the Practice of Physic, by William Cullen, M. D.) Sir John Pringle supported a similar doctrine, that scurvy was the result of "a gradually accumulating pu- trefaction" in the blood, from the putrescency of salted food, which he deemed the chief cause of the disease. (Obs. on Diseases of the Army, Ap- pendix, p. xci.) The theory of fixed air, which was considered the principle of cement or bond of union on which the firmness, soundness, and cohesion of bodies depends, was advanced by Macbride in support of the opinions which referred scorbutus to a putrescent tendency in the blood; the loss of that principle appearing to him to account for the altered state of this fluid, and the method of cure depending on its restoration, which he proposed to effect by conveying it to the body by the free use of the infusion of malt and essence of wort. Dr. Trotter differed from his predecessors in his application of the pneumatic doctrines of pathology to this disease, the remote causes of which, in his view, tended to deprive the blood of oxygen; and to the restoration of this principle through the medium of the acid fruits he attributed their antiscorbutic efficacy. " We are of opinion," he remarks, •< that the citric acid is decomposed by the organs of digestion and assimilation, after which the oxygenous principle is blended with the circulating mass." This supposition Dr. Trot- ter considers as further confirmed by the black- ness of the blood discharged, and by the speedy change to a florid hue which the fungous ulcera- tions assume within a few hours after the acids have been administered. (On Scurvy, p. 141.) Dr. Beddoes adopted the same hypothesis, but extended it to the abstraction of oxygen from the whole system, in explanation of the phenomena of the disease. i Lind disputed the idea of putridity of the blood in scorbutus, and referred the primary changes to | a relaxation of the tone of the animal fibres, a I weakening of the powers of digestion, together with a stoppage of perspiration, the tendency of | which, he admits, was to produce spontaneous | putrefaction, the process of nutrition being sus- pended. (Lind on Scurvy, p. 234.) This view of the subject was followed up and most ably ad- vocated by Dr. Milman, in an essay remarkable also for the elegance of its composition, published in 1782. "Whether," says he, " I consider the nature of the causes producing scorbutus, or the actual state of the blood in the disease, or the se- cretions which occur in its progress, they all con- cur to make me believe that it does not consist in a putridity of the blood. Nor does there appear to be any quality which can be discerned or de- fined in the blood of scorbutic persons by which the nature of their disease can be characterized." The theory which Dr. Milman has substituted, it would exceed our limits to enter into in detail, but it consists of the following propositions:—that scorbutus is not a disease of the fluids, but of the solids ; that its seat is in the muscular fibre; that its proximate cause consists of a gradual diminu- tion of the vital power; and that the subsequent diminished cohesion between the particles of the muscular fibres, and the tendency of these to pu- trefaction, are links of the chain. In reference to the action of salt provisions, he considers, with Lind, that they tend to excite scorbutus not by their saline, but by their indigestible nature, and through defect of nutriment occasion an enfeebling of the vital principle productive of languor in all the functions of the body, and ulteriorly of a general disposition to putridity. (Milman on Scurvy, chap, vi.) This view of the proximate cause of scorbutus is supported by the argument that all its predisposing causes are of a debilitat- ing nature, and by the extraordinary influence of mental impressions in favouring its occurrence as well as its prevention and cure, such impressions being considered inadequate to the occasion ol a sudden change in the chemical condition of the fluids. The agency of such impressions, how- ever, through the medium of the nervous system, is supported by numerous illustrations in the phe- nomena of health and disease. On the other hand, it must be acknowledged that those means which appear to contribute in general to the strength and activity of the solids, such as fiesh animal food, soups, wine, bark, and a vaiiety of other tonics and stimulants, have been found to , exert very inferior powers over the disease in com- SCORBUTUS. H5 parison with the vegetable acids; w,hich, never- theless, are well known to produce an attenuating effect on the body, and this not unfrequently whilst they are accomplishing its cure. Broussais contends that in scorbutus, whatever may be its cause, there is first an irritation of the internal membrane of the digestive canal; 2dly, an imperfect assimilation of the elements, especially of fibrin and gelatin, either in the tissues formed out of them, or in the blood which directs them to different parts of the body ; 3dly, that in conse- appeared in consequence of the dietetic consump- tion by all classes of persons of fresh vegetable food at every season of the year, of drinks which contain their elementary principles, of water in a pure state, of milk, of fresh animal food, and the disuse, as an article of daily subsistence, of dried and salted meats, together with the general drain- age of the country, the greater security, dryness, and warmth in the dwellings, the improvements in clothing, and greater attention to cleanliness, it would be superfluous to enter into a formal de- quence of defect of nutrition a diminished cohe- tail of measures for its prevention on land; more sion of fibre ensues, which accounts, in his view, for the imperfect contractility and fragility of the muscular fibre, for the rupture of vessels and the escape of their fluids, and finally, for the easy disorganization of the issues on the occurrence of scorbutus. (Treatise on Physiology applied to Pathology, Transl. Philadelphia, 1832.) We shall conclude this part of the subject by noticing some observations of Andral, which ap- pear to us to be most consistent with all the facts on which an opinion of the nature of scorbutus can be established. In the threefold respect of the vital phenomena, intimate structure, and chemical composition, no line of demarcation can be drawn with strictness and precision between the blood and the solids. Physiologically speaking, it is impossible to conceive that one of these two parts of the s.une whole could be modified without the other being so likewise. On the one hand, inas- much as the blood nourishes the solids, and as without its presence they cannot support life, the state of the solids cannot but be influenced by the state of the blood. The chemist might as well say that the nature of a body does not depend on the nature of the elements that compose it. On the other hand, the solids, considered with respect to their relations to the blood, form but two classes, the one contributing to make the blood, such as those concerned in the processes of absorption, digestion, arterial circulation, and respiration ; the other contributing to unmake it, those, namely, concerned in the processes of venous circulation, secretion, and nutrition. No one solid, therefore, can undergo the slightest modification without producing 6ome derangement in the nature or quantity of the materials destined to form the blood or to be separated from it. Physiology, then, leads us to the conclusion that every alteration of the blood must be succeeded by a modification of the solids. Viewed in this light, there is no longer any meaning in the disputes between the solidists and the humorists; and the system appears to especially as the process of civilization advances us so much the farther from the sources of this and other epidemic diseases. But, although im- provements comparatively as great have been ef- fected in our naval economy, and have been suffi- cient to lead to the general extermination of scor- butus, yet under particular circumstances the greatest vigilance has been frustrated by the supe- rior power of its occasional causes, and their unceasing operation at sea renders unremitting attention to certain prophylactic measures neces- sary to ensure security against its occurrence. These consist of the removal, if possible, or, at least, of the counteraction of the predisposing and occasional causes of the disease; and in the daily use of a certain quantity of lemon-juice, the pre- ventive efficacy of which is well established al- though its operation has not been satisfactorily explained. The application of such preventive measures has for the most part been happily illus- trated in the narrative of the memorable voyage of Captain Cook. To his sagacity we are indebted for the first impulse to those regulations by which scorbutus is so successfully prevented in our navy. It will be remembered that the crew of his prede- cessor Lord Anson, in a similar voyage of disco- very, had experienced the most dreadful havoc from this disease, and the prevention of it seemed to present as great difficulty to himself as any circumstance of his projected voyage. The main- tenance of the general health of his men he dis- cerned was the main point of security, and to command this he was especially careful that they should not be subjected to excessive or unneces- sary fatigue, and as much as possible that they should be protected from the noxious influence of a cold and damp atmosphere. In the first place he instituted three instead of two watches,* by which eight hours of uninterrupted rest were allowed to his men for four of duty; their strength was consequently more recruited, and they were also less exposed to the weather than if they had constitute but one great whole, indivisible in the been at watch and watch, and if necessary they 6tate of health as well as in that of disease. With had dry clothes to change. The hammocks and regard to scorbutus in particular, he observes that bedding every fine and dry day were not only or the causes under which it is developed epidemi cally, the symptoms that characterize it, the re- markable state of the blood itself, and the nature of the lesions discovered on examining the bodies, all combine to prove that this disease depends on a primary alteration of the blood. (Andral's Pathol. Anat. translated by Townsend and West, vol. i. p. 641 and 678.) Prevention of Scorbutus.—The prevention * Dr. Trotter disputes the advantage of this arrange- ment. " We," he observes, " who see things on the spot, and are daily accustomed to reason on the disci- pline of ships, are clearly decided in favour of two watches; our most accomplished and intelligent officers have also from experience put it beyond dispute."—Me of scorbutus in this and in some other countries dical and Chemical Essays by Thomas Trotier, M.D., p dcred upon deck, but each bundle was unlashed and so spread out that every part was exposed to the air. Besides the ordinary modes of white- washing and scraping the decks, stoves were kin- in which it formerly prevailed having been com- pletely effected, or rather the disease having dis- 25. We believe, however, that three watches are now the more general custom in our navy, at least in large ships. 116 SCORBUTUS. died and carried successively through them, which not only served to dry the ship, but, by heating the impure air below and rendering it specifically lighter than the common air, to make it rise and pass through the hatchways. In the torrid zone he shaded his people from the scorching sun by an awning over the deck, whilst in his course within the Antarctic circle they were provided with coats of woollen stuff, furnished with hoods to cover their heads. He attended also particu- larly to their diet, taking care that there should be always a plentiful supply of water both for this purpose and for the promotion of cleanliness. He prohibited the custom of using the fat which was boiled out of the salted meats in lieu of other food; having observed that symptoms of indigestion were the common consequence, and the latter not unfrequently a preliminary of scorbutus. (Mil- man, p. 33.) Captain Cook begins his list of preservative stores with malt. " Of this," he says, " was made sweet wort,* and given not only to those men who had manifest symptoms of the scurvy, but to such also as were considered most liable to it." This article, although he did not consider it adequate to the cure of scurvy, he praised as one of the best antiscorbutic medicines known in his day. Sooins or sowens.j- an article of diet well known in Scotland, was also consi- dered by him of great antiscorbutic efficacy, and was dealt out to his men in messes sweetened with sugar and flavoured with some French prize wine, which, though sour, was thought to improve the flavour. Captain Cook was provided with lemon-juice prepared for sea use, but the neces- sary quantity not being understood, it was ne- glected and erroneously underrated. But the arti- cle of most extensive use for the same purpose was sour kroute (sour cabbage), well known in German diet. Sour kroute or croute (Saures Kraut, German ; literally sour herb or pickled cabbage,) is prepared by slicing the soundest and most solid cabbages in the way cucumbers are used in this country. In this state they are put into a barrel in layers, hand high, and over each is strewed a handful of salt and caraway seeds; in this manner it is rammed down, stratum super stratum, till the barrel is full, when a cover is put over it, and it is pressed down with a heavy weight. After standing for some time in this state, it begins to ferment, and it is not till the fermentation has entirely subsided that the head is fitted to it, and the barrel is finally shut up and prepared for use. Vinegar, as some have sup- posed, is not employed in its preparation. It was * Infusion of malt, proposed as a preventive as well as a remedy for scorbutus, was recommended by Dr. Macbride on the supposition that it would ferment after being taken into the stomach, and give out carbonic acid gas—its alleged remedial principle. Laying aside all regard to the theory on which it was suggested, expe- rience seem3 to have determined that it is a nutritious beverage, and that it has been productive of considerable advantage in the objects for which it was proposed. It has been used rather as an article of diet than medicine, and has been generally directed in the quantity of from one to four pints daily. f This food is prepared by putting some oatmeal into a wooden vessel, pouring hot water upon it, and continu- ing the infusion till the liquor begins to taste sourish, i. e. till a fermentation comes on, which, in a place mo- derately warm, may be in the space of two days. The water is then poured off from the grounds, and boiled down to the consistence of a jelly. recommended to the use of the British navy by Dr. Lind, the great freedom of the Dutch from scorbutus having been attributed to the free use of it. The quantity allowed was two poundi weight to each man per week, besides a pound and a half to two pounds with every gallon of peas, for making soup. He was supplied also with portable soups, which, as far as possible, he made the vehicle of vegetable aliment; and by such means, and by diminishing the quantity of salted provision, to his honour be it said, he pre- served his crew from scorbutus, although the pe- riod of his voyage had extended to three years and eighteen days, passed in all latitudes from 52° N. to 71° S. It is still more remarkable that of a company of 118 men he lost but one, who there is reason to suppose was labouring under phthisis previous to his departure from England. The comparative exemption of our own navy from scorbutus during the last thirty-five years, is, we conceive, to be attributed in no small degree to the regulations enforced for the maintenance of the general health of the sailors, together with the improvements by which this object has been ad- vanced. A frequent inspection of the men's clothing is made, to ascertain whether there is a sufficiency for the purposes of personal cleanliness and of protection from the effects of the weather, both as regards their bedding and wearing apparel. The strictest attention is given to the ventilation, cleanliness, and dryness of ships. For what are called windsails (which were found to be imper- fect and inconvenient ventilators, from their use being inadmissible with hatches closed in bad weather when they are most wanted, and when the men were asleep, on account of the large volumes of cold air which they admitted) has been substituted a contrivance free from those ob- jections, borrowed from a French frigate : this consists of square wooden trunks (for which brass tubes have since been used) running from the hold or lower deck and terminating in the open air. A contrivance which has still more recently been preferred, is a funnel placed vertically near the middle line of the ship, before the foremast, leading through the forecastle-deck where there is neither hatchway nor ladder, and under which are the sleeping-places. The removal of all offen- sive substances by sweeping and scraping has been much more particularly attended to than formerly ; but instead of washing the decks, par- ticularly in cold or damp weather, the preserva- tion of dryness, so essential to comfort and health, as well as to the prevention of scorbutus, has been carefully studied, and rubbing with hot sand, scraping, and portable fires, have been generally substituted. By these precautions, also, the de- teriorating agency of moisture on the ship's pro- visions, as well as on other articles in common use, has been prevented, and thereby a source cut off, which otherwise might have been largely con- ducive to the generation of this disease. This important point has been further promoted by having portable fires in iron stoves carried all oyer the ship. Formerly a prolific source of foul air and bad smells in ships were the putrescent matters absorbed and retained by gravel, sand, and other earthy substances used for ballast, for which are now substituted small masses or pigs SCORBUTUS. H7 of iron; and iron tanks, instead of the lower tier of water-casks, are placed over the iron ballast. The tanks adverted to are cubes of four feet in dimensions, each capable of containing about two tons of water: as they are not corruptible, like wood, they impart no bad quality to it, and by their durability insure an ample supply; whereas the decay of casks in long voyages and in remote parts of the world where they cannot be replaced, has occasioned the utmost distress. The improvement suggested by Sir Robert Seppings, Surveyor of the Navy, and explained by him in the « Philosophical Transactions" for 1814, the object of which was to add to the strength, solidity, and durability of ships, has been highly conducive to the purity of the air in them; first, by the obliteration of those cavities under the floor of the hold which used to be the receptacle of filth and vermin, and the perpetual sources of offensive and noxious exhalations; secondly, from commanding at all times the most perfect ventila- tion, the timbers of the frame which run up the side of the ship maintaining a constant communi- cation with the open air, with the hold and spaces between the decks; thirdly, by virtue of this new construction, a ship being less liable to leakage, together with the new method of ballasting, all the unwholesomeness and offensiveness belonging to bilge-water is done away. The promotion of the general health of seamen, and consequently the prevention of scorbutus, is further effected by the superior quality of all the articles of victualling; by the plentiful supply, when in port or within reach of it, of fresh meat, succulent vegetables and fruits; and when at sea, by the daily use of cocoa for breakfast, or of tea, coffee, sugar, &c. and a less proportion of ardent spirits. To these are to be added the more liberal allowance as to quantity of the diet at sea ; and, under circumstances particularly conducive to the generation of the disease, an increased allowance of farinaceous articles in lieu of the necessary diminution in the rations of salted meats. The former consist for the most part of biscuit, wheat- flour, oatmeal, peas, and pearl barley, and, as sub- stitutes for fresh vegetables, though of infinitely inferior antiscorbutic efficacy, dried raisins, cur- rants, prunes, preserved fruits, spices, pickles of various kinds, vinegar, molasses, and as much wine for each man as is equivalent to one-half of the allowance of spirits, the latter being suspended. (See Paper by Sir Gilbert Blane on the Health of the Navy.—Med.-Chir. Tr. vol. vi.) But to the genera] supply of lemon-juice, judi- ciously dispensed to ships of war since the year 1795, Sir Gilbert Blane ascribes the complete eradication or rather the prevention of scorbutus. Usually, after ships have been a fortnight at sea, to every individual in them a fluidounce of lemon- juice mixed with an ounce and a half of sugar is served out daily, which, with tho addition of water and of wine or spirits, affords a grateful beverage, the use of which is enforced when the neglect of it is suspected, or under particular apprehension of the invasion of the disease. It is in conse- quence of this prophylactic, Sir Gilbert Blane in- fers, that there are now many surgeons in the navy of long standing who have never seen a case of the disease ; and, as appears from the inspec- tion of a great number of journals, that it has either not appeared at all, or else in so slight a degree that it was speedily checked by an increase of the quantity of the antidote. No other remedy yet known can ward off, he observes, this dreadful scourge of mariners under the use of salt provi- sions for an indefinite length of time ; nor does it 1 produce, he adds, any bad effects on the constitu- tion like some specifics in other diseases. The decisive superiority of lemon-juice has led to the disuse of a variety of articles formerly in repute for the prevention of scorbutus, such as sour kroute, infusion of malt, essence of spruce, elixir of vitriol, &c. Of the sour kroute we have already spoken; and we have alluded to the use of the infusion of malt. « Although," says Dr. Trotter, " I have no idea of impeaching the veracity of those who established the credit of the malt pre- paration, yet I must beg leave to observe that in my own practice I have not seen it attended with any good effects. Lind speaks of it only as a very nourishing liquor, well adapted for scorbutic patients." The essence of spruce,* or rather spruce-beer, the form in which it has been com- monly used, seems to possess, says Sir Gilbert Blane, similar and equal antiscorbutic virtues with fermented malt liquor, as beer or porter; and it has this advantage, that the materials for pre- paring it can be readily carried about and used as occasion may demand. (Observations on Diseases of Seamen, p. 302.) The use of elixir of vitriol in the cure of scorbutus was of very early date, and, on the principle that what will cure will prevent, it was recommended to the use of the navy by Dr. Huxham, who states that it had been found « greatly serviceable." The assertion, how- ever, is not corroborated by general experience, and the converse of the proposition seems more applicable to the circumstance in question; at most, probably, it had been useful in correcting the unwholesome qualities of impure water, for which purpose it has been occasionally added to it in very minute proportion. We have yet to mention the necessity, in a pro- phylactic point of view, of regular exercise. Al- though often called upon for extraordinary exer- tion, it occasionally happens with seamen that there are long intervals in which systematic atten- tion to this branch of hygiene is especially requi- site. Independently of its direct influence on the maintenance of the general health, it may be made subservient to an equally important object in the prevention of scorbutus, viz. to occupation of mind, and in sailors, its diversion from those gloomy views to which, under suspension of duties, they are peculiarly prone; a fact which, however as- tounding it may at first appear, reflection will as- sent to be consistent with his condition. To separate, as his duties require him, under perilous circumstances, from those to whom he is linked by the bonds of affection; to be peculiarly subjected to disappointment, and to unexpected delay in schemes to which the brightest hopes are attached ; to have been taught by reason and experience that ♦Captain Ball states that the essence of spruce a little diluted did wonders at St. Domingo, both in prevention and cure. It acted as a purgative, and was therefore carefully administered; it sat on the stomach when every thing else was rejected. — Med. Naut. by T. Trot- ter, vol. i. p. 349. 118 SCORBUTUS. the perils which he has no fear to encounter are frequent and more than ordinarily liable to frus- trate them; and in many instances the necessary system of moral discipline being wholly inconsist- ent with the physical condition, are circumstances sufficient to account for the state of mind above mentioned. The despotic system, formerly in force, of impressing seamen, doubtless had a pow- erful influence in predisposing them to disease. Their country, says Dr. Trotter, has taken ad- vantage of their situation, and their service is in- dispensable to the safety of its commerce and terri- tory. It is only therefore mild treatment that can reconcile an impressed sailor to his fate, and if he be so unfortunate as not to overcome it, some fatal disease, as scurvy, will be the consequence ; among people of this description it first makes its appear- ance. An officer, therefore, cannot too minutely study the genius and the temper of those he has to command; but the good effects of it and the satisfaction he will experience, will more than repay his assiduity. In the narrative of Captain Parry's voyage al- ready referred to, it appears that that able officer was fully impressed with the expediency of amuse- ment as well as of exercise for the preservation of the health of his men, and was particularly aware of the antiscorbutic efficacy of occupations being afforded to them. The mode of their pursuance must depend on the circumstances which are pre- sent, and much of the advantage must arise from the ingenuity and address with which the means are devised. The narrative of Captain Parry's expedition to the Polar seas affords a happy illus- tration in point, many circumstances of it having been congenial to the production of scorbutus, but which, nevertheless, by salutary precautions, was most successfully opposed. Although some of these have been already discussed, their practical application with that of others is so advantageously set forth in the following passage, that no apology, we conceive, is necessary for transcribing it. " The commander finding himself shut in for a long and dreary winter, devoted his attention, with judicious activity and a mixture of firmness and kindness, to mitigate those evils which even in lower lati- tudes had often rendered an arctic winter so fatal. His provisions being very ample, he allowed the sailors weekly a pound of Donkin's preserved meat and a pint of concentrated soup, instead of a pound of salt beef; beer and wine were served instead of spirits; and a certain allowance was made of sour krout, pickles, and vinegar. The sailors were also called together daily and made to swallow a quantity of lime-juice and sugar in presence of the officers; their improvidence being such as to afford otherwise no hope of their spon- taneously imbibing this salutary draught. Their gums and skins were also regularly examined, in order to detect scurvy in its earliest symptoms. It was necessary to be very economical of fuel, the small quantity of moss and turf which could be collected being too wet to be of any use. By placing the apparatus for baking in a central posi- tion, and by several other arrangements, the cabin was maintained in a very comfortable temperature; but still, around its extremities and in the bed- places, steam, vapour, and even the breath settled, first as moisture and then as ice; to dry and re- move these annoyances became therefore a part of their daily employment." Exercise, it is stated, was enforced on the men when they were prevented from leaving the vessel, by obliging them to run round the deck to the tune of an organ; this they did not at first en- tirely relish, but no plea against it being admitted, they converted it at last into a matter of frolic. To keep their minds agreeably occupied, schools, masquerades, and plays, were adopted ; in refer- ence to the latter it is observed that the very ex- pectation thus raised among the seamen, and the bustle of preparing a room, were extremely salu- tary, and when the North Georgian Theatre opened, with " Miss in her Teens," these hardy tars were convulsed with laughter, not a little excited perhaps by viewing their officers in the singular and novel position of stage performers. At all events the Arctic management was extremely popular. As the small stock of plays contained in one or two chance volumes was soon exhausted, original compositions were produced and afterwards formed into a collection. The officers had another source of amusement in the North Georgian Gazette, of which Captain Sabine became editor, and all were invited to contribute to this chronicle of the frozen regions. Even those who hesitated to ap- pear as writers enlivened the circle by severe and good-humoured criticisms. Treatment.—Recovery from scorbutus, to use an expression of Lind's, presents a remarkable in- stance of the quick diminution of the effect from the cessation of the cause ; an observation which has been so amply confirmed by experience that it may be regarded as a most important axiom in the therapeutic consideration of the disease. There are remedies, nevertheless, which expedite and even effect its removal under disadvantageous cir- cumstances, and this with a degree of rapidity which, considering its apparent ravages, seems most extraordinary and peculiar to itself, the more so from our knowledge of its nature being very imperfect, and the salutary operation of such re- medies by no means obvious. We reject theory, therefore, from our consideration of this part of the subject, in the spirit of the following remark of one who has well appreciated its importance in practical medicine : " Cujus autem rei non est certa notitia, ejus opinio certum reperire remedium non potest. Verumque est, ad ipsam curandi ra- tionem nihil plus conferre quam experientiam." ( Celsus, lib. i.) It has been found an essential step to the relief of a person suffering from scorbutus that he should have the advantage of a dry atmosphere, both as regards the apartment which he inhabits, and the various articles of his bedding and wearing apparel. Next to this, to gratify the cravings of his appe- tite, an instinctive index, apparently, to the chief corrective of his disease by a satisfying supply of esculent fruits and fresh vegetables .- «be they of any sort," says Lind, and all experience has veri- fied the remark, « they will for the most part prove effectual." At different periods, however, a spe- cific virtue in the cure of scorbutus has been at- tached to particular articles of the vegetable king- dom, and those which are succulent and possessed of an aromatic quality, especially the alkalescent plants of the class tetradynamia, have been re- SCORBUTUS. H9 garded as powerfully antiscorbutic;* but that their power in this respect does not depend on their alkalescent property is proved by the fact that the vegetables and fruits in which the acid principle abounds have been alike efficacious, and even in a still higher degree. Of the latter, those of the genus Citrus, and of the natural order Hes- perida?, viz. the Citrus medica, lemons—C. auran- tium, oranges — C. acida, limes — C. decumana, shaddocks — particularly the three first, have ob- tained pre-eminent repute, even to the extent of being considered specifics — a denomination to which they appear to be as much entitled as me- dicines adapted to the cure of any disease. Their efficacy, however, having been gainsayed by a physician whose writings have attracted considera- ble notice,-}- and their claim to therapeutic estima- * Formula: for the preparation of medicines for the cure of scurvy were formerly inserted in the Pharmaco- poeias of London, Edinburgh, and Dublin, under the titles of Succi Scorbutici and Succi ad Scorbuticos; these were compounded of the juices of garden scurvy grass (coch- Iearia officinalis); brookliine (veronica beccabunga); water-cresses(nasturtium officinale); and Sevilleoranges. Besides these, of the infinite number of anti-scorbutics which have been in great popular estimation, and com- monly recommended by medical writers until within the last half century, the chief are the horse-radish (cochlea- ria armoracia); garden purslane (portulaca oleracea); black and white mustard (sinapis alba et nigra); the biting stone crop (sedum acre); celandine (chelidonium minas); marsh trefoil (trifolium palustre); common and Roman wormwood (absinthium latifolium et tenuifo- lium); fumitory (fumaria purpurea); hemp agrimony (eupatorium cannabinuml; the garden radish (raphanus sativus); the garden lettuce (lactuca sativa); the garden endive (cichonium endivia): common juniper (juniperus communis); dandelion (Jeontodon taraxacum); the com- mon onion (allium cepa); garlic (allium sativum); the leek (allium porum); squill (scilla maratima); the po- tato, sliced and raw in vinegar (solanum tuberosum); the fir (pinus abies); sorrel (rumex acetosa); &c. Bishop Berkeley wrote a treatise, in 1744, to insist on the cura- tive efficacy of tar water in scorbutus; and Alston, (1750) another on the superiority of lime-water for the same purpose. t Dr. Stevens; see his Observations on the Healthy and Diseased properties of the Blood. 8vo, London, 1832. Dr. Stevens's denunciation of the treatment of scorbutus by the administration of vegetable acids, seems to rest on the general effect observed of their admixture with the blood out of the body—viz. that of changing its colour from red to black, and by consequence, on the supposi- tion that in this as well as in some other diseases in which the latter quality has particularly characterized the appearance of that fluid, such means would be found not only to keep up but to aggravate the disease. This morbid appearance Dr. Stevens attributes to its priva- tion of its saline constituents, and hence in scurvy, and in other diseases in which it is in a black and vitiated condition, he asserts that " the natural saline waters, or the active non-purgative alkaline salts, act like a charm" (p. 309)—it being the property of these substances (con- trary to that of the vegetable acids) on their addition to black blood out of the body to change its hue to red. On this principle Dr. Stevens explains the good effect attri- buted to the nitrate of potash in the treatment of scor- butus, and on the same ground would administer the mu- riate of soda, to the excessive use of which its production ias observed in the text) has been commonly attributed. )r. Stevens, however, in another place (p. 451), has stated that during a residence of twenty years in the West Indies only one ease of scurvy had come under his notice, and that case, he asserts, was decidedly brought on hy the excessive use of citric acid which an American gentleman had been recommended to use as a preventive against yellow fever; consistently with his theory too, that on its being laid aside and the carbonate of soda substituted, the patient was completely cured in three weeks. " To those," he observes, " who are disposed to see the contrast betwixt the effects of the neutral salts and the citric acid in the treatment of scurvy, I would recommend the perusal of Mr. Cameron's paper on this disease, which they will And in the Medico-Chirurgical Review, for 1829"—more conveniently, perhaps, for that purpose inserted in our text, and which, if considered with that degree of candour which the cause of thera- peutic science demands, would only serve to prove what little credit is due to the following remark of his own, tion resting entirely on experience of their effects and deference to authority confirmatory of it, we conceive it necessary to enter into detail of evi- dence in support of the treatment of the disease by the remedial agents the efficacy of which has been denied. The earliest notice we can find in reference to this point is in the third epistle of Rousseus, dated 1564, wherein it appears that some Dutch sailors who were suffering from scurvy, and the cargo of whose ship on their return from Spain consisted of lemons and oranges, accidentally dis- covered that their use was the means by which they recovered their health. " And if people," observes Lind, (p. 160,) "had been less assidu- ous in finding out new remedies, and trusted more to the efficacy of these fruits for preventing this fatal pestilence to seamen, the lives of many thousand sailors, and others, especially during the last war, might in all probability have been pre- served. But some have been misled to recom- mend many other things, as of equal, if not su- perior, antiscorbutic qualities to these; and have reduced them to a level with other acids, and many falsely supposed antiscorbutic medicines; from whence the many unhappy disappointments hitherto met with in preventing this disease at sea seem to have arisen." In 1593, Sir Richard Hawkins experienced the antiscorbutic efficacy of lemon-juice in his crew, who were attacked by it in its virulent form within three or four degrees of the equinoctial line. In a work of considerable merit, entitled the Surgeon's Mate, or Military and Domestic Medicine, by John Woodall, master in surgery, dated London, 1636, we find an excellent disquisition on scurvy, and the following apposite remarks : " further expe- rience teacheth, which I have oft found true, that where a disease most raigneth, even there God hath appointed the best remedies for the same grief, if it be his will they should be discovered and used ; and note, for substance, the lemmons, limes, tamarinds, oranges, and other choice of good helps in the Indies, which you shall find there, do farre exceed any that can be carried thither from England, and yet there is a good quantitie of juyce of lemmons sent in each ship out of England by the great care of the merchants, and intended only for the reliefe of every poore man in his neede, which is an admirable comfort to poore men in that disease. Also I finde we have many good things that heale the scurvy well at land, but the sea chirurgeon shall do little good at sea with them, neither will they indure. The use of the juyce of lemmons is a precious medi- cine, and well tried; being sound and good let it have the chiefe place for it will deserve it, the use whereof is: It is to be taken each morning, two or three spoonfuls, and fast after it two houres, and if you add one spoonful of aqua vita: thereto to a cold stomack it is the better. Also if you take a little thereof at night it is good to mixe therewith some sugar, or to take of the syrup (p. 264.) " With respect to scurvy it would not be diffi- cult to prove, from the writings of Trotter and others, that this disease, which at one period was so distressing in the British navy, was frequent and fatal almost ex- actly in proportion to the quantity of citric acid which was used as a preservative, and unfortunately also as a cure for the disease." 120 SCORBUTUS. thereof is not amisse. Further note, it is good to be put into each purge you give in that disease. Some chirurgeons also give of this juice daily to the men in health as a preservative, which course is good if they have store, otherwise it were best to keep it for need." In want of these he adds, " use the juice of limes, oranges, citrons, or the pulp of tamarinds, and in want of all these use oyle of vitrioll, as many drops, as may make a cup of beere, water, or rather wine if it may be had, onely a very little as it were sower." In another place he writes, " And generally note that bitter and sower medicines prevail most to the cure of this griefe, amongst which you have that are ap- proved goode thereto, those that follow as chiefe, juyce of lemmons, of limes, of citrons, and oranges." In the account of his voyage to the East Indies, published in 1683, Dellou, a French physician, recommends for the prevention of scurvy, that each person on board should provide himself with the juice of citrons, lemons, and dried fruits, especially prunes. The same reme- dies we find recommended in the treatise of Mar- tin Lister, published in 1694. It is remarkable, however, that epidemic scurvies were allowed to rage in various parts of the world, and in none more than in the British navy, for more than a century and a half after Woodall had pointed out the usefulness of lemon-juice, without its being generally employed. So com- plete was this neglect, that in 1740, when Lord Anson proceeded on his circumnavigation, no provision of any kind appears to have been made against the disease, and we find Mr. Walter, the chaplain of the expedition, and discriminating historian of it, declaring that " in some instances the prevention and cure of the malady could not be effected by any management or remedies which could be made use of at sea :" (p. 113.) But it is mentioned that on nearing the island of Tinian, lat. 15°. 8'. north, and in 114°. 50'. west longi- tude from Acapulco, it was part of a very grateful account of it they obtained from a Spanish pri- soner, that it afforded plenty of lemons, limes, sweet and sour oranges, cocoanuts, and bread-fruit. We are informed also that on making shore their sick amounted to 128, and notwithstanding the extreme debility of the greatest part, twenty-one of them dying on the day of their arrival and the following day, yet during the whole two months in which they staid there, they did not lose above ten more, and that the remainder reaped such benefit from the fruits of the island, and "in particular those of the acid kind, that within a week most of them were so recovered as to be able to move about without assistance." The calamities of this unfortunate expedition, and the sufferings they underwent, created a ge- ■ neral interest, not only with medical men, but with the public at large, on the cause and nature of the disease, and the most likely means of con- trolling its ravages. The stamp of correct observation founded on most extensive experience, which Dr. Lind's treatise on the subject, published in 1753, has been always acknowledged to bear, renders his testimony of the highest worth. "The result of all my experiments was," says he, »that oranges and lemons were the most effectual remedies for this distemper at sea. I am apt to think oranges preferable to lemons, though, perhaps, both given j together will be found most serviceable." In | another case, " I cannot omit upon this occasion observing what caution is at all times necessary in our reasoning on the effects of medicine, even in the way of analogy, which would seem the least liable to error. For some might naturally con- clude that these fruits are but so many acids, for which tamarinds, vinegar, sp.salis., elixir, vitriol. and others of the same tribe would prove excel- lent succedaneums. But upon bringing this to the test of experience, we find the contrary. Few ships have ever been in want of vinegar, and for many years before the end of the late war all were supplied sufficiently with el. vitriol. Not- withstanding which the Channel fleet often put on shore a thousand men miserably overrun with this disease, and many hundreds besides died in their cruises. Upon those occasions tar-water, salt-water, vinegar, and el. vitriol, especially, with many other things, have been abundantly tried to no purpose; whereas there is not an instance of a ship's crew being ever afflicted with this disease where the before-mentioned fruits were properly, duly, and in sufficient quantity administered." Again, says this observer, " in seemingly des- perate cases the most quick and sensible relief was obtained from lemon-juice, by which I have re- lieved many hundred patients labouring under almost intolerable pain and affliction from this dis- ease, when no other remedy seemed to avail." Finding the acid to operate violently upon the stomach and bowels of those who were much weakened, he recommended the addition of wine and sugar, as constituting the best antiscorbutic, and was in the practice of ordering about four ounces and a half of lemon or lime-juice, and two ounces of sugar, to be put into a pint of Malaga wine, which he thought sufficient for any weak patient to take in twenty-four hours. Dr. Trotter, however, states as the result of his experience that any such preparation was unnecessary, and that the happiest effects were produced by allowing the patients to suck the juices immediately from the fruits themselves. In another place Dr. Lind says, " summer fruits of all sorts are here in a manner specific, viz., oranges, lemons, citrons, apples, &c.;" he more- over devised a method of preserving the juice of the two first-mentibned, so as to render them available at all times and in all climates, whether in the midst of the ocean or under the arctic circle. The testimonies of Sir Gilbert Blane and Dr. Trotter in favour of the antiscorbutic efficacy of these fruits are equally strong, and when we con- sider the extensive opportunities of observing this disease which fell to the lot of these three eminent physicians, their qualifications for forming correct opinions, and the immense mass of evidence ad- duced by them in support of the remedies in ques- tion, the conclusion is irresistible that their adapta- tion to the removal of this disease is established on as firm a basis as that of any article of the materia medica to any disease whatever. The late venerable and talented director of the medical de- partment of the navy, has in the year 1830 con- firmed the opinion he gave to the world of these remedies in 1785, by the triumphant fact that the SCORBUTUS. 121 scurvy has been prevented, subdued, and totally rooted out of the navy by the general use of lemon- juice, supplied for the first time at the public ex- pense in the year 1795, and which operated so speedily that in less than two years afterwards it became extinct and has remained so. (Brief State- ment of the Improvement of the Health of the Navy, by Sir Gilbert Blane, M. D., London, 1830.) Of all the articles either for medicine or diet he had observed for the cure of scurvy, lemons and oranges are of much the greatest efficacy. They are real specifics, if anything deserves that name ; but upon what principle their superior efficacy depends, and in what manner they produce their effect, he acknowledges that he was wholly at a loss to determine, the only sensible effect being a small increase of some of the secretions. In an- other place he says that he has never seen the scurvy resist the juice of these fruits, and in the perusal of several hundreds of surgeons' journals that he had met with only two cases which seemed to resist it. " It is sui generis—nil simile nee se- cundum." " It may be affirmed with truth that it performs not only what no other remedy will perform in this disease, but what no known remedy will effect in any known disease whatever." (Me- dico-Chirurgical Transactions, vol. vi., p. 500. London.) Dr. Trotter, in his account of the health of the fleet in 1795, remarks, " from the middle of March to the 12th of June, upon comparing notes from the reports of surgeons, it appeared that not less than three thousand cases of scorbutus (the sub- jects of which were unfit for duty) had been cured on board ship by the fruit or preserved juice, and that twice that number with slighter symp- toms were relieved by the fruit, the juice, and sa- lads." (Medicina Nautica, vol. i. p. 134.) Mr. Moffat, surgeon to H.M.S. Triumph, 1796, in which scurvy had prevailed to a considerable ex- tent, reported to Dr. Trotter, " that the scorbutic cases as usual yielded to the lemon-juice in every instance. So general," he adds, " was the ten- dency to it, that almost every case of contusion or ulceration was attacked with the disease, nor could their cure be accomplished without a few doses of the acid." (Ibid. p. 157.) In p. 151, vol. i. of the Medicina Nautica we find the fol- lowing entry:—"Jan. 2, 1796. This day the squadron under Rear-admiral Harvey arrived at Spithead, after an absence of eighteen weeks from England, bringing three thousand soldiers from Isle Dieu. This squadron had been repeatedly supplied with refreshments from Plymouth and Cork. The scurvy appeared nevertheless in all the ships, but was quickly cured by lemon-juice." In the report of Mr. Kenning, surgeon, of the In- vincible, dated June 8, 1795, (Med. Nautica, vol. i. p. 411,) in which ship there had been in all one hundred and sixteen cases of scorbutus, it is stated that of twenty-eight attacked in the month of April, the worst were supplied with three lemons and one orange daily, the others with two lemons, and that in every instance after the third day, and sometimes sooner, they began to recover, and were shortly well. In May fifty-six fresh cases were treated with the same remedies with equal success. In the latter end of the month the fruit was all expended, but there still remained a few ! Vol. IV.—16 l gallons of lemon-juice, which lasted until the 2d of June. Patients continued to apply, and two of those that had been recovering before the le- mons were expended, got worse in the short inter- val from the 2d to the 5th day, the day on which a fresh supply of lemons was received. Their complaints were soon checked by the fresh fruit, but not so fast by the juice, though it was given in some cases to a pint per day." In Lord Brid- port's squadron, which (in 1795) had suffered severely from scorbutus, there was not a case in which lemon-juice was given where it did not produce a cure in the space of a few days. (Ibid. vol. i. p. 417.) Dr. Baird, surgeon of the Hector, a ship in which scorbutus prevailed to a considerable extent, gives the following account: «I began with giving the lemon-juice in the quantity of an ounce and a half daily, and encouraged by the material change I perceived in about four days, I increased it to three or four ounces per day, always taking care to join a sufficient quantity of sugar to prevent it from irritating the bowels; in twelve or fourteen days the worst of them were able to return to duty, every symptom being then removed, except some slight degree of stiffness in the hams, which gradually wore off." "When I consider," he adds, " the alarming progress which the scurvy was making among the Hector's ship's company previous to the administration of lemon-juice as a preventive, the sudden check given to it after- wards and its powerful effect in very bad cases, I think I shall not be accused of presumption when I pronounce it, if properly administered, a most infallible remedy, both in the cure and prevention of the disease." (Ibid. vol. i. p. 426.) Mr. Walker, surgeon of the Hannibal in 1795, writes, "during our late cruise, numbers were afflicted with the disease (scurvy) ; the citric acid to the quantity of three ounces per day cured many, and always stopped its progress. It was given with wine in the following manner: R Vin. rub. gii. Succi lim. £i. Sacchari, gii. m. fiat haustus ter die sumendus." (Ibid. vol. i. p. 407.) Dr. Trotter himself remarks that the superior efficacy of the acid fruits in the cure of scurvy is so well ascertained, that it might seem superfluous to add any fresh remark to what is so fully admit- ted. These articles are certainly more beneficial as they approach to the nature of the citric acid, which is that abounding in the lime, lemon, &c. Our summer fruit in this country, such as the apple and gooseberry, lose their acidity as they come to maturity, so that in their immature state they contain most of that principle valued in the cure of scurvy. «In all cases of scurvy," he adds, " which I have attended, I have remarked the longings and desires of the patient for acids, which also have been mentioned by some of the earliest writers on the disease, and more or less by others since that time. It is one of the strongest instincts in nature we are acquainted with.— Having repeatedly observed the scorbutic slaves throw away the ripe guavas, while they devoured the green ones with much earnestness, I resolved to try if there were any difference to be remarked in their effects. For this purpose I selected nine 122 SCORBUTUS. blacks, affected in nearly a similar degree with scurvy. To three of these I gave limes, to three green guavas, and to three ripe guavas. They were kept under the half-deck, and served by my- self twice or thrice a day. They lived in this manner for a week, which was about the time we left the coast of Africa, and it is to be remarked that the three negroes restricted to the ripe guavas continued in much the same situation, while the others were almost well." Whenever the fresh fruit, i. e. oranges and lemons, can be procured, they should be preferred to their juice prepared by evaporation for sea use according to the methods devised by Dr. Lind, and to the crystallized citric acid obtained according to Scheele's formula by combining the fresh vegetable acid with lime, and then precipitating by means of sulphuric acid. (See Pharm. Lond.) The former by keeping is somewhat liable to spoil, though as stated by Mr. Moffat, a naval surgeon of experience, he found it fully adequate to the purpose of the fresh juices at the end of fifteen months. The crystallized acid, reduced to the strength of lemon-juice by solution in from sixteen to eighteen parts of water, is, however, an excel- lent substitute for the fresh juice. This solution should not be prepared long before it is required for use, being apt to undergo decomposition, but in its recent state it has proved equally efficacious, according to the testimony of Dr-. Trotter and others, with the fruits themselves. (Med. and Physical Journal, vol. iv. p. 154.) Although all the esculent fruits and fresh vegetables have been found effective in the cure of scorbutus, and par- ticularly, as we observed before, those in which an acid principle prevails, it seems impossible to estimate their relative powers in this respect. The vegetable acids which have had trial, viz. the acetic and tartaric, appear to have exerted little if any power over the disease, nor have we any proof that the sulphuric, the nitric, and the muriatic acid, though frequently tried, have been at all beneficial. Mr. Patterson, a surgeon in the navy, published a treatise in 1794, in which he infers that a solu- tion of nitrate of potassa in vinegar is preferable to lemon or lime-juice as an antidote to scorbutus; its good effects he ascribes entirely to the oxygen contained in the former. At first he used a solu- tion of two ounces of nitre in one quart of the ship's vinegar, and gave half an ounce of the solu- tion, to some twice, to others thrice in the day, and as frequently bathed the local affections with it. From the good effect it produced, which was unattended either by nausea, colic, or diarrhoea, he was induced to increase the dose of the above- mentioned solution to an ounce, and to repeat it as before. At length, instead of two, he dissolved four ounces of nitre in a quart of vinegar, and used it in the same quantities and manner as be- fore. He adds, "some patients cannot bear the solution without the addition of water, whilst others without the least inconvenience bear it un- diluted. The discharge by stool, or the presence of gripes and nausea, guide me with respect to in- creasing or diminishing the dose ; but, at the fame time, it is not a slight degree of nausea, colic, or diarrhoea that renders an alteration in the quantity of the medicine necessary. To a great number of scorbutic patients eight ounces of this strong solution, containing one ounce of nitre, have, in the course of the day, as long as such a quantity was necessary, been administered to each with the greatest success. Also, a circumstance no less curious than pleasing, large and frequently re- peated doses of this medicine have been given in cases of scorbutic dysentery, and instead of in- creasing I have always found it remove the dis- ease. Sometimes, notwithstanding the free use of the nitric vinegar, I have known constipation take place to a considerable degree, in which case I have found intermediate doses of the potassae supertartras necessary and highly advantageous. This very constipated state generally occurred where the disease was far advanced ; but in a few particular cases in delicate habits, and where the disease was not far advanced, I perceived even small doses of the nitric vinegar ruffle the sto- mach and intestines; to prevent or remove which, I have found two, three, or four grains of camphor with each dose of the medicine very effectual." The beneficial effect of the nitrate of potash in scorbutus has been more recently testified by Mr. Charles Cameron, surgeon in the Royal Navy, in a letter, dated December 10, 1829, to the Com- missioners for Victualling. The Fergusson, he states, sailed from Ireland on the 16th of Decem- ber the preceding year, with two hundred and sixteen male prisoners, amongst whom scorbutus, in several instances combined with dysentery, pre- vailed to a considerable extent Before reaching Rio Janeiro, their state was such that he had rea- son to fear he should lose several, and others were fast approaching the same lamentable condition. Having on several occasions experienced the ex- cellent effects of a " solution of nitre," as recom- mended by Patterson, he was induced to employ it. "From the moment I commenced the use of it," he observes, " many, although almost hopeless cases, began to improve rapidly, and before we accomplished one-third of our voyage, I found the health of the sick improve so fast under the new treatment, that I did not think it necessary to go into any port, and on our arrival at Sydney the general health of the prisoners was much better than when they embarked in Ireland. I am willing," he adds, " to ascribe much of this favourable change to the effect of climate, but I feel assured that a solution of nitre in vinegar or lemon-juice is the best remedy ever proposed in the treatment of scurvy." Two of the patients who recovered exhibited symptoms of the last stages of phthisis, and ex- pectorated large quantities of purulent matter. With regard to the patients in general, he sayB, the most distressing symptoms which they com- plained of in the early stages of the disease were, a sense of oppression and sinking at the pit of the stomach, which a few doses of medicine invariably relieved or totally removed. Mr. Cameron's pre- paration consisted of eight ounces of nitre dis- solved in so much vinegar as made the solution amount to sixty-four ounces. Sometimes equal parts of vinegar and lime-juice were used, a little sugar was generally added to render it more palatable, and about four drops of ol. menth. pipe- rita!, diffused in a small portion of alcohol, was added to the whole, which rendered it more grate- SCORBUTUS. 123 ful to the stomach. An ounce of this solution was a dose, and from three to eight doses, accord- ing to the stage of the disease and the severity of the symptoms, were given at equal intervals during the day, from six o'clock in the morning till eight at night. Mr. Cameron, at the conclusion of his letter, observes that he has previously tried nitre in several bad cases of scurvy, where neither vine- gar nor lemon-juice could be obtained, and, ex- cept that sometimes it did not appear to sit so easy on the stomach, with the same beneficial effects. With the view of restoring the supposed defi- ciency of oxygen to the scorbutic system, it has been proposed to impart it to the body through the medium of the lungs; but the attempt which was made in cases of the disease as it appeared in the voyage of La Perouse round the world, was wholly unsuccessful. From the salutary effect in cases of scorbutus produced by vegetable matter in general, peculiar efficacy has been ascribed to particular articles, the use of which accident or analogy from time to time has suggested ; it may be that future disco- veries will determine their relative title to the esti- mation in which they may have been held, and the precise principle on which it depends, but the superiority of lemon-juice as an expeditious and certain remedy being well established, other arti- cles of the vegetable kingdom, and the drinks pre- pared from them, are to be regarded rather as use- ful auxiliaries, and may be selected from those in popular repute as the inclination or particular habit of the patient may dictate. It will be no in- considerable advantage also to introduce them to use according to the dietetic form most grateful to the taste, instead of prescribing the nauseating compounds which until the last half century were supposed to possess especial virtues conducive to the removal of this disease.* [Of late, the antiscorbutic effect of raw potatoes has been frequently deposed to.] Beer, porter, simple infusion of malt, cider, perry, spruce-beer, various wines made from the subacid fruits, and even pure water, will present useful and agreeable beverages to scorbutic pa- tients. The Lisbon diet drink (decoctum sarsa: compositum) and the compound decoction of guaiacum, have also been found serviceable for the recovery of patients from this disease. Of the dietetic vegetable substances, those which have been commonly preferred and considered to be most especially adapted to the removal of scor- butus, have been the various subacid fruits, and the several herbs used in salads, a form in which with their usual additions, vinegar and mustard, they have been considered especially efficacious. Dr. Trotter, in his Medicina Nautica, has adduced numerous instances of their efficacy, and the popular favour they elicited serves to corroborate *"A vegetable substance called nopal, the stalk of the cactus opuntia, which keeps well at sea, has been lately discovered in India to be an extremely salutary article of diet, and to resist scurvy: but the author read in the surgeon's journal of one of the East India Company's ships, that in spite of the use of this and of spruce-beer at the same time, sixteen cases of scurvy arose, in one of which it was so severe as to prove fatal."—Paper by Sir Gilbert Blane, on the Health of the Navy; Medico- Chir. Tr. vol. vi. p. 501. the opinion entertained of them by professional writers for this particular purpose. Another agreeable method of supplying the system with vegetable aliment, and which has been advantageously adopted in scorbutus, has been the combination of it with fresh animal mat- ter through the medium of broths and soups, as well as in the ordinary forms in which they are commonly prepared for dinner use. Lind states that milk is useful to scorbutic patients, with whom it generally agrees, but that whey, " by reason of its more diuretic and cleansing quality, is preferable." " Thus," says the last-mentioned writer, " we have numberless instances of people after long voyages, miraculously, as it were, recovered from deplorable scurvies without the assistance of many medicines, for which, indeed, there is no great occasion, provided the green herbage and fresh broths keep the belly lax, and pass freely by urine, sweat, or perspiration." Since scorbutus has become a very rare disease, the materia medica has been enriched by the ad- dition of some valuable articles, the general pro- perties of which suggest their- adaptation to the purposes of its treatment; these are the chlorides of lime and soda, and the sulphate of quinine. At sea, the chloride of lime will doubtless be advan- tageously applied to the preservation of water and to the correction of such as may be putrescent, to the prevention of unwholesome exhalations, and to the general purification of the air. Solutions of it as gargarisms and lotions for ulcers give promise of considerable advantage, and from the little experience already had of its internal use, encouragement is given to its further trial. Dr. Robertson informs us that he has used the chlo- ride of soda in one instance—with the benefit he anticipated. (See Dublin Hospital Reports, vol. v. 1830.) With some other remarks with which he has been so kind as to favour us on this dis- ease, he observes,—«I had occasion, in the year 1831, to see a case resembling scurvy in all its phenomena, (indeed, had it occurred in a seafaring person instead of a person living in a midland county, I should have pronounced it a well- marked case of that complaint,) where the liquor chloridis sodse, given in doses of half a drachm in conjunction with the decoctum lichenis Islandici, had a strikingly beneficial effect. The patient was speedily brought by it from a state of cachexia threatening death to a very tolerable degree of health and enjoyment. Were it ever my fortune to treat scurvy extensively again," he adds, '• I should trust chiefly to quinine or the chloride of soda internally, and to the chloride of lime pro- perly diluted as a topical application ; with, of course, a liberal supply of vegetable matter where it could be obtained." The costive state of the bowels which occasion- ally prevails to an extreme degree must be coun- teracted by aperient medicines, or, if need be, by the stronger purgatives. In many instances the advantage derived from the operation on the alvine canal of a single dose has led to their frequent repetition, and the most beneficial results have ensued. Lind was favourable to the combination of medicines of this class with diuretics, or to the 124 SCORBUTUS. use of such as embraced the twofold property. Selections have accordingly been made from the supertartrate, acetate, and sulphate of potash, the tartrate and sulphate of soda, and the sulphate of magnesia, dissolved in the infusion of senna, of tamarinds, or of prunes, with the addition of some aromatic tincture, and further combined if requi- site with jalap, rhubarb, aloes, scammony, colo- cynth, or some of their preparations. The complication of inflammatory disease with scorbutus in constitutions naturally robust and not much debilitated, will sometimes require vene- section and the general adoption of the antiphlo- gistic treatment, according to the nature and degree of the supervening disease; but diarrhoea, dysen- tery, pneumonia, and other morbid conditions which have been coexistent with it, have not un- frequently resisted modes of treatment peculiar to them, and have disappeared together with scor- butus when the remedies appropriate to the latter disease have been had recourse to. In reference to the concurrence of scorbutus and dysentery, Dr. Trotter observed that they frequently disappeared together, and readily yielded to a diet of fresh meat, citric acid, and esculent vegetables; without requiring any of those reme- dies more particularly adapted to the last-men- tioned disease, as it occurred under other circum- stances. (Med. Nautica, vol. i. p. 377.) The same remark has been illustrated by Sir James M'Gregor, in his reference to a case of severe ophthalmia, which appeared conjointly with slight symptoms of scorbutus where the latter disease was endemic. It resisted a variety of applications, both external and internal, for five months, when the acid of limes was thought of, which in twelve days effected a cure. (Edin. Med. and Surg. Journ. vol. i. p. 283. 1805.) In some cases of apparent phthisis accompany- ing scorbutus, we find in the observations of Mr. Cameron, already cited, that the disappearance of both forms of disease was evidently effected by the remedies appropriated to the removal of scor- butus alone. It has been commonly observed, that however promising and speedy recovery from scorbutus may be, to prevent its recurrence it is necessary for a considerable time to persevere in the coun- teracting regimen, and to avoid as much as possi- ble the predisposing and occasional cause of the disease. When fresh vegetables can be procured, and the object is not to cure, but to guard against a relapse, the use of acids will be advantageously suspended. Practical authorities have expressed opposite opinions as to the general effect on the constitution of their continued use, but on the whole there is good reason to believe that, when long continued, they have produced injurious effects on the digestive organs. Great care should be taken that scorbutic pa- tients be not too suddenly exposed to an atmos- phere differing in its temperature or other qualities (except in point of dryness) from that which they have breathed for some time previously. Any sudden exertion should also be avoided, for nume- rous instances might be adduced in which inatten- tion to these particulars has been immediately followed by death, in cases in which it was not in the least to be expected. We read in the narra- tive of Lord Anson's voyage, that in the removal of his crew from the Centurion to the island of Juan Fernandez, twelve of them died on being exposed to the fresh air; and on the first breaking out of the disease many of the people, though confined to their hammocks, were cheerful, talked in a loud strong tone of voice, and eat and drank heartily, but on being only moved in their ham- mocks from one part of the ship to another imme- diately expired. Others, trusting to their seeming strength, resolved to get out of their hammocks, but died before they could reach the deck, and it was common to see the men drop down dead upon a violent effort of duty. The local affections which are manifested in scorbutus are often extremely distressing, but, it must be remembered, are always secondary to the constitutional disorder, increasing in malignancy with its progress, and manifesting a contrary dis- position whenever a salutary change has been effected in it: this correspondence, too, takes place with an almost incredible degree of rapidity, and such as is rarely, if ever, exemplified under any other circumstances of disease. The constitu- tional disorder, therefore, should be the first object of regard in the cure of every local lesion which depends on scorbutus : a contrary procedure only can account for the numerous and complicated formulas which are to be found in the early treatise) upon it, all of which, it may be inferred from ac- cumulated experience, will be nugatory whilst their immediate cause is allowed to continue uncorrected. Local applications, however, with the contemporaneous use of constitutional reme- dies, are not unproductive of advantage. To re- lieve the spongy and rotten state of the gums and of the mucous parietes of the mouth and pharynx, astringent gargles, particularly those containing sulphate of alum, have been found very service- able. Two drachms of this substance, or more, may be dissolved in half a pint of water or of a decoction of cinchona for the purpose. Lind re- commends also the tincture of cinchona, which may be used alone, or mixed with port wine or camphor mixture. The tinctures and other pre- parations of myrrh, of kino, of catechu, may like- wise be selected from the class of astringents for the same purpose, and will be advantageously diluted with water or with camphor mixture, to be sweetened and inspissated with honey. In the advanced stages, the mineral acids have been found more efficacious ; water, barley-water, the infusion of roses, or other vegetable substances acidulated with the sulphuric or muriatic acids, and made agreeable with the addition of honey or simple syrup, will form convenient gargles. " The quan- tity of the acid," says Lind, " must be proportioned to the greater or less degree of putrefaction. The fungus must be often removed, or if needful be cut away; and by frequent gargarizing the mouth kept as clean as possible. Where the ulcers ap- pear deep and spreading, they are to be checked with a touch of vitriol, or sp. salis, either by itself, or diluted according as the patient bears it." Analogical reasoning leads us to infer that a solu- tion of chloride of lime is peculiarly adapted to the purposes of this disease, whether in the form of gargle for the mouth, or as an immediate appli- cation to ulcers in other parts. To the latter the SCORBUTUS—SCROFULA. 125 astringent applications already mentioned as use- ful in the corresponding condition of the mouth and gums have been advantageously' employed. »Sulphate of alum, in the proportion of two drachms to a quart of water," says the experienced and talented writer of the Medical Topography of New Orleans, Dr. Robertson, of Northampton, (Edin. Med. and Surg. Journal, vol. xii. p. 146,) in his observations on < the Sloughing Scorbutic Ulcer,' as it appeared extensively in that place, » was upon the whole an admirable local remedy, and seemed to possess wonderful powers in stop- ping the ravages of sphacelus, and giving a healing tendency to spreading ulcers. In the same cases equal parts of basilicon and oil of turpentine (melted and applied warm to the ulcer), mixtures of lime-juice, or rum and water, charcoal cata- plasms, common poultices, bark decoctions, and bark in powder, were employed ; but though they kept the sores cleaner, they were often of no avail to arrest the sloughing process." Several of the early writers, and Lind amongst the number, particularize the unguentum Mgyptiacum* as adapted to the ulcerations of this disease. Mr. Murray, a naval surgeon, in a communication to Dr. Lind, observes," I have applied a strong tinc- ture of bark lately to scorbutic ulcers, and have found it highly beneficial. The powder of the hydrargyri nitrico-oxydi sprinkled on the fungoid ulcerations, and the ointment of this substance, after the sloughs have been removed and the ulcers cleansed by carrot and other detergent poultices, have also been of some use; but no permanent benefit is to be anticipated from any other treat- ment than a diet of nutritious food of which fresh' vegetables constitute a considerable proportion, the : efficacy of which will be materially augmented by including amongst them the acid fruits or their . juices, such as lemons, times, shaddocks, apples, - pears, gooseberries, &c. whilst at the same time the patient is secured from the influence of the predisposing and occasional causes of the disease." The latter remarks apply also to the cedematous swellings of the legs and the rigidity of the ham- strings, for which local relief also is often de- manded. Frictions with warm flannels, (which for this purpose were formerly medicated with the -j fumes of benzoin, amber, and warm aromatic _ gums,) have answered this end, and have been ;- advantageously followed up by gentle compression . with bandages. But in extreme cases, warm , fomentations, local steam-baths, or, as Lind has recommended, sweating the limb " by burning of t spirits," (the local vapour-bath of the present t day,) with some of the various other contrivances . in common use for the promotion of heat locally, are better calculated to afford relief. An important part of our duty would be unper- formed were we to limit ourselves to the detail of those means by which scorbutus has been success- fully treated, for we know not what additional '. light may be reflected on the obscure parts of this '. subject by a knowledge of such as have been found unsuccessful. The cost of the experience, too, by which it has been gained forbids its waste, and in * Gray, in his Supplement to the Pharmacopceias, gives the following as the formula for this ointment:—Rough verdigris ppd. v. oz. honey xiv. oz. vinegar vii. oz.; boil to a proper consistence. practical medicine it must be acknowledged that a beacon is often of not less use than a guide. In the first place, " it is to be observed," says Lind, (page 216,) "that this disease, especially when advanced, by no means bears bleeding,-even although the most acute pains upon the mem- branes, a high degree of fever, and dangerous hemorrhages would seem to indicate it. The pa- tient generally dies soon after the operation. Nor does it bear strong cathartics, which are often injudiciously administered in its commencement. From blisters there is danger of a gangrene. As to vomits, though I have never had any great ex- perience of their effects, yet by the observation of others squill vomits have been found serviceable. 2dly. Persons in the advanced stages of this dis- ease are not, without great caution and prudence, to be exposed to a sudden change of air. On such an occasion they are to be given a glass of generous wine well acidulated with lemon or orange-juice, which is likewise the best cordial in their fainting fits. The sloth and inactivity be- longing to the disease are not to be mistaken for wilful idleness. This," continues Lind, " has proved fatal to many, some of whom, when obliged by their officers to climb up the shrouds have been seen to expire and fall from the top of the mast. 3dly. After a long abstinence from green vegeta- bles and fruits, scorbutic persons should be treated like those nearly starved to death; that is, not permitted for a few days to eat voraciously, or surfeit themselves ; otherwise they are apt to fall into a dysentery which often proves fatal. " Lastly, medicines of the fossil or mineral kind, such as steel, antimony, and especially mer- cury,! do manifest harm. Opiates occasion an unaccountable depression of spirits, with a sense of oppression on the chest, and when absolutely necessary, as in fluxes, should be of the warmest kind," (i. e. we presume combined with aromatics and cordials.) W. Kerr. SCROFULA. — The term scrofula is derived from the Latin scrofa, a hog ; and %oipas, the cor- responding word in Greek, plainly acknowledges a similar origin, (xoipos, a pig:) but whether this etymology has arisen from the filthy condition in which scrofulous children are often found, or from the hog being subject to a similar disease, or from the appearance presented by scrofulous glands lying in clusters under the skin, or from the tumid throat and neck of such subjects, is not so easy to determine and seems of small importance to in- quire. It is sufficiently evident, however, that a strong association existed in the minds of the Greeks and Romans between scrofula and the animal in question. Another term by which this malady has been designated is struma. Celsus very distinctly describes the disease as it affects the absorbent glands under this name ; and adds that it occurs also in the female breast. Among t Sir Gilbert Blane stated to the select committee of the House of Commons appointed to inquire into the state of the Penitentiary at Milbank in 1823, that if he had found, when he was in office as commissioner, a navy surgeon who by his journal had administered a particle of this medicine in the treatment of sea scurvy, he should have felt it his duty to move that such surgeon be struck off the list.—Edin. Med. and Surg. Journ. vol. xxii. p. 142. I* 126 SCROFULA. modern nations the French have named the dis- ease les ecronelles* probably a corruption of scrophules; the Germans der Kropf, from the swelling under the chin; and the English the kind's evil. This last term commemorates the imaginary virtues of the royal touch, to which, from the time of Edward the Confessor till the reign of Queen Anne, multitudes of cases of scro- fula were submitted, and very many of them were supposed to have been cured. A similar practice existed in France, with equal belief in its success; and miraculous powers for the cure of scrofula were likewise claimed for different Romish saints, for the heads of certain noble families, for the seventh son, and for many consecrated springs in different parts of Christendom. It may be truly asserted that no original tem- perament, complexion, or frame of body, confers complete immunity from scrofula ; yet a little ob- servation will convince us that individuals pos- sessing certain characteristics are more frequently the subjects of this malady than others. The scrofulous constitution is often indicated by a fair complexion, light silky hair, long shining eye- lashes, large, watery, and often blue eyes, with dilated pupils, and a red patch on either cheek, contrasted with a dazzling whiteness of the skin, which is itself usually thin, smooth, and readily irritated by slight causes. Thus scrofulous indi- viduals are more liable to chilblains, which appear often on their hands; and in such persons the ap- plication of a blister is generally followed by an eruption of pustules on the skin around, and the formation of successive crusts. The insertion of a seton, the wounds of leeches, and even simple venesection sometimes produce the same effect: so great, indeed, have we known the irritability of the skin in scrofulous children, that washing with scented soap has caused the immediate ap- pearance of a papular eruption. Scrofulous per- sons often present the look of florid health and a full habit; but the soft parts are flabby, and easily shrink away under fatigue, privation, or disease; and when the operation of these causes is com- pletely at an end, such individuals are restored with the same rapidity to their former plethoric condition. The scrofulous habit is, in short, cha- racterized by a deficiency of what has been termed stamina, and enduring tone. Children who pos- sess this constitution are familiarly known as fever- ish children ; a very slight irregularity of diet or exposure to cold or moisture throwing them im- mediately into a state of febrile excitement. Their frames possess an undue proportion of irritability, and they are peculiarly prone to attacks of inflam- mation. The mucous membranes of the scrofu- lous, like the external integument, aie also deli- cate, and their vessels readily give way and pour out blood: thus bleeding from the nose is a com- mon occurrence in persons of this constitution; and in them hemorrhage is more frequent from the urinary passages and ramifications of the wind- pipe. The conjunctiva in scrofulous individuals is very liable to inflammation, and the mucous membrane of the intestines is readily irritated and diarrhoea induced. In such subjects the mucous * In some parts of Scotland the disease is called by the common people "thecruels;" an evident corruption of the French woid. secretions are very abundant and often acrid, and the membranes themselves frequently become thickened : hence arise excoriations of the nostrils and of the upper lip, which becomes in conse- quence chapped and swollen; and the half-open mouth is a common characteristic of scrofulous persons, owing to the partially obstructed state of the nasal passages. Most scrofulous persons are of small stature, and have slender limbs; norisil very uncommon in such individuals to find some member or organ imperfectly developed, defective in its power, or curtailed of its proportion: yet multitudes of scrofulous persons are met with of a very different description—individuals remarkable some for their lofty stature and apparent strength, and others for the surpassing symmetry and beauty of their persons. The moral and intellectual qualities of the above, which is the largest class of scrofulous sub- jects, correspond with, and in all probability are derived from those of their bodies : the temper is quick and irritable ; the desires and passions are ardent; the perception is keen, the imagination is predominant over the judgment; and the mind is characterized by a want of firmness and solidity, and an inability to persevere steadily in the pur- suit of any one object. To this observation, how- ever, there are many brilliant exceptions, where the strumous constitution is seen combined with mental qualities of the highest order. In a second class of persons who are disposed to scrofulous disease, the complexion is dark, the skin harsh, and the habit indolent; the counte- nance is swollen and pasty, and all the functions of the body are sluggish and imperfect: the nerv- ous energy is feeble, the feelings are obtuse, and the moral and intellectual powers occupy a very low rank. Scrofulous cases of this character are not by any means uncommon in Britain, although far more rare than those first described; but ex- treme instances are frequent in some districts of Switzerland and France; and in these human nature appears reduced almost to the level of the brute creation, assuming forms which awaken feel- ings of humiliation and disgust. Scrofula, which is always tedious and difficult of cure, becomes still more obstinate and unmanageable when it makes its appearance in those of a dark com- plexion and sluggish temperament [The writer's experience leads him to say, that scrofulosis occurs quite as frequently in the dark complexioned. The negroes of the south are very subject to it, and in its most severe forms. (Guer- sant, art. Scrofule, in Diet, de Med. 2de edit. xxviii. 207. Paris, 1844.)] This disease exhibits itself under a great va- riety of symptoms, according to the part of the body which it happens to affect: hence the diffi- culty of framing any definition of it which is at onc# accurate and comprehensive. The most certain evidence of the existence of scrofulous disorder is afforded by the production of a soft, brittle, unorganized matter, resembling curd or new cheese, which is found mixed with the purulent contents of scrofulous abscesses, or deposited in rounded masses of different degrees of firmness, and varying in bulk from the size of a millet-seed to that of a hen's egg: sometimes it is contained within the natural cavities and canall SCROFULA. 127 of the body, sometimes it is enclosed in cysts, and occasionally it is diffused, as if by infiltration, through the natural texture of a part. To the rounded masses of this substance, which, as they enlarge, often acquire the irregular form of a tube ous root, the name of tubercle has been as- signed, and the substance itself has been named tuberculous matter. We venture to assert that the presence of tuberculous matter is a satisfactory proof of the existence of scrofula; but we do not by any means maintain that scrofula cannot exist without the deposition of this substance. The researches of pathological anatomy have satisfac- torily shown that scarcely any living texture of the human body is altogether exempted from tu- berculous deposits. This morbid production has been observed on the free unbroken surfaces of mucous membranes, within mucous follicles, and forming the contents of lymphatic vessels the tunics of which were themselves sound, (Andral, Precis d'Anat. Patholog. torn. i. p. 419, and torn. ii. p. 446) : granules of tuberculous matter, some- times insulated, sometimes clustered together, have also been detected within the clots of blood con- tained in the cells of the spleen. (Andral, op. cit. torn. ii. p. 431. Carswell's Illustrations, &c. Fascic. 1, plate iii.) The history of tubercle cer- tainly entitles us to consider it as a morbid secre- tion ; but when it is thus found lying free within a healthy lymphatic vessel, or enveloped in the coagula of the splenic cells, we are led to suspect that in such cases it has probably been formed by some change in the constitution of the lymph or blood, from an alteration in the proportions of their ingredients, or the addition of some coagu- lative substance, or the withdrawal of something which these fluids usually contain. The cellular tissue has been hitherto considered as of all others the most common seat of tubercle; but Dr. Cars- well has stated that it is far more frequently met with in contact with mucous surfaces; and he has certainly adduced very strong arguments in support of this opinion, which he has also illus- trated by most beautiful engravings. (See Fas- cic. 1.) For a particular history of this substance in its etiological, pathological, and chemical relations, we must refer the reader to the articles Tubercle and Tubercular Phthisis, and content our- selves, in this place, with noticing such circum- stances as have more especial reference to the subject of the present article. According to Dupuy, (De 1'Affection tubercu- leuse,) all the domestic animals of France, not excepting the dog, as well as those imported from warmer countries, are subject to tuberculous de- posits: his researches further show that this dis- ease in the inferior animals is much more fre- quently combined with the presence of vesicular worms than it is in man. He has traced the con- version of the cysts containing these animals into collections of tuberculous matter, and has thus given a degree of support to the opinions of Dr. Baron, who maintains that all tuberculous disease originates from vesicular worms or minute serous cysts. But although we admit that such adven- titious cavities often become, at least in the inferior animals, the nests in which the matter of tubercle is deposited, the assertion that all tubercles arise in this manner may well be disputed when we find that such cysts or vesicular worms, or traces of them, are by no means always co-existent with tuberculous disease, and that they often attain a very great magnitude without exhibiting any symptoms even of incipient transformation. Opinions directly opposed to each other have been held by writers of great eminence as to the immediate cause of tubercles ; one parLy ascribing their origin in every case to inflammation, (Brous- sais, Examen des Doctrines Medicales, torn. i. Alison, Edin. Med. Chir. Trans, vol. i. and iii.); another as exclusively asserting that they are in no instance dependent on inflammatory action, and that when inflammation co-exists, it does so as the consequence, and not the cause, of tuber- J cles.* After carefully reviewing the discussions on this question, we have come to the conclusion, that on some occasions tubercles have been found where no symptom of previous inflammation could be recollected, nor any trace of it dis- i covered on inspection after death, (Andral, Precis d'Anat. Pathologique. Lombard, Essai sur les Tubercules) ; while in other instances the deposi- tion of tuberculous substance seems to have been distinctly connected with the development of in- flammatory action. But as inflammation often ! occurs without the formation of tubercles, it is obvious that this alone is not sufficient for their production, and that the addition of something ' else is required to that end. Inflammation, there- fore, may be viewed as an occasional cause of tubercles, producing this effect only in frames of a scrofulous disposition. Some organs are more liable to tuberculous deposits than others, and the liability differs at different periods of life : the organs which are most frequently affected with tubercles in children are not those in which they are oftenest met with in adults. In children the disease tends more to implicate several organs at once ; and in them it is more common to find the lungs unaffected, although tubercles be discovered in other parts of the body. (Lombard, op. cit.) The existence of tubercles in the fetus is certainly rare, but it has been proved beyond question by the dissec- tions of Langstaffe, (Lloyd on Scrofula,) Lom- bard, West, Orfila, (Velpeau, Thesis ad aggreg. p. 10,) and Chaussier, (Proces verbal de I'Hospice de la Maternite, 1812, p. 62) : they continue in- frequent from birth till two years, after which they are often met with; and during the fifth year their occurrence appears to be much more com- mon than at any period before puberty. From eighteen till forty, tubercles very frequently occur; affecting, however, chiefly the lungs, intestines, and some parts of the lymphatic system. * O. L. Bayle, Recherches sur la Phthisie. — Laennec, Auscult, Mediate.—Oendrin, Hist. An atom des Inflam- mat.—Lobstein, Anat. Patholog. torn. i. This able advo- cate of these opinions admits the production of what he terms miliary granulations on the surfaces of inflamed serous and mucous membranes, but denies their identity with tubercles. In this manner he endeavours to set aside the arguments drawn from such cases as those of Dr. Alison, and also the results of the experiments of Cruveilhier and others, who produced the appearance of myriads of small tubercles by injecting mercury into the bloodvessels and lungs of animals ; each minute globule being found enclosed within an effusion of tuberculous- like matter. These experiments we have always con- sidered as any thing but conclusive : for where is the evidence that the effused matter is truly tuberculous ? 128 SCROFULA. These results are drawn from the researches of pathological anatomy ; but to speak merely from symptoms, independent of the verifications of dis- section, scrofula has been observed by us in the form of enlarged axillary glands within the first fortnight after birth: it is not usual, however, for the absorbent glands to be affected till the period of the first dentition ; the occurrence is still more frequent during the second. At puberty the dis- ease often disappears spontaneously, and after this age external scrofula is very rarely observed to originate; but instances are not wanting in which persons well advanced in life have been attacked for the first time by scrofula, more especially among those who have been long confined in prisons or workhouses. To show the various ages at which the disease may develop itself, La- louette (Traite des Scrophules, Paris, 1780) states that in a scrofulous family one daughter was af- fected at fourteen, another at sixteen, a third at twenty-six, and the father at sixty-six. Cases have occurred to the writer where scrofula has appeared in youth, undergone an apparent cure, and again manifested itself in advanced life, when it proved fatal. In former times it was believed that scrofula was communicable from one individual to ano- ther ; and the occurrence of the disease in many members of the same family, and its diffusion among the inhabitants of particular districts, seemed, through a loose mode of reasoning, to afford ground for this opinion. Positive experi- ments have been made by Kortum, (De Vitio Scrofuloso. Lemgov. 1798,) Goodlad, (On the Lymphatic System,) Hebreard, (Dissertat. sur les Tumeurs Scrofuleuses,) Le Pelletier, (Sur la Ma- ladie Scrofuleuse, p. 16,) and others, to propagate the disease by rubbing in scrofulous matter, and by inserting it under the skin of animals, and even of the human subject; while Pinel, Alibert, and Richerand, (Nosograph. Chirurg. torn. i. p. 161,) have carefully watched the effects of allow- ing scrofulous and healthy children to associate together without restraint; but in no instance was there the least reason for believing the malady to be communicable by any of these modes of infec- tion. The observation of British practitioners fully corroborates the opinion of the non-conta- gious nature of scrofula, although the writers of this country have not directed so much attention to the subject; because a belief in the contagion of scrofula was abandoned by our physicians long before it ceased to be current among those of the continent. In this respect scrofula differs remarkably from that form of tuberculous disease in animals which has been named glanders : for this last is not only communicable from one animal to another, but also to man.* It would be curious to inquire whether glanders in man is itself communicable to other human beings : that it is so is by no means improbable, for it has been proved by expe- ment to be capable of being communicated from man to the inferior animals. (Coleman, in Tra- vels on Constitutional irritation.) It is proper * Eliotson, in Lond. Med. Chir. Trans, vol. xvi. p. 171. Travers, On Constilut. Irritat. 2d edit. p. 398. Schilling and Weiss, in Rust's Magazin. fur die gesammte Heil- kunde, 1821. Also Remer, in Hufeland'e Journal, March 1822. here to state that M. Dupuy has expressed strong doubts of the contagious nature of glanders, and has asserted that he knows of no well-conducted experiment in favour of this doctrine, but some against it. He is disposed, on the contrary, to refer glanders to hereditary transmission, and to various unfavourable circumstances in the rearing of horses, similar or analogous to those which are admitted as predisposing to scrofula, such as cold, damp, and shady pastures, insufficient nourish. ment, and the debilitating effects of castration. (De l'Affection Tuberculeuse.) Daily observation must convince us that a scro- fulous constitution is often transmitted from pa- rent to child; therefore the disposition to the dis- ease may be truly said to be hereditary ; nay, the dissections already referred to prove the actual de- velopment of scrofula even before birth, in the progeny of a strumous mother. Like other here- ditary gifts, it may miss one generation and re- appear in the succeeding ; just as some individuals are observed to resemble in external appearance their grandfathers more than their fathers. A striking example of the hereditary nature of scrofula was lately presented to the writer by a family respecting whom he was consulted. The father was a tall, thin, and sickly man, who suf- fered much every year from winter cough; the mother a person of full relaxed habit, with a look of florid health, and in fact not often affected with illness. Of nine children to whom she had given birth, two females and six males had died with phthisical or mesenteric symptoms, between the ages of three and fifteen months; the survivor was a boy nearly twelve years old, who enjoyed moderately good health. The last of these little victims of transmitted disease died just as he had completed his third month, after having suffered under symptoms of phthisis. On inspecting the body, the lungs were seen mottled with many yellow spots, and when cut into they exhibited myriads of tubercles, varying from the size of a small mustard-seed to that of a pea : all of them were opaque, and many converted into pus. The glands at the root of the lungs were enlarged, in- durated, and some of them converted into ab- scesses, the walls of which were lined with firmly adherent fibrin, and their contents were a thick purulent fluid. The mesenteric glands were en- larged, hardened, and many of them contained softened tuberculous matter. The spleen con- tained some small granules of a white colour and cheesy consistence. There was a good deal of subcutaneous fat, but none in the omentum. A very few weeks after the death of this child, the father, who had been eager to learn whether his offspring drew their fatal disease from himself or from their mother, declined rapidly in strength, and fell a victim to phthisis. Scrofula is supposed by most writers to be of more frequent occurrence among females than males; and Le Pelletier (Sur la Maladie Scrofu- leuse,) has stated, as the result of a comparison of the cases in the Parisian hospitals, that the proportion of strumous females to males is as five to three. In all inquiries into the relative prevalence of disease in the two sexes, it must be recollected that the female population, especially of large towns, considerably exceeds the male; and SCROFULA. 129 hence it is to be expected that a great number of scrofulous females will apply for medical relief. But on reviewing the matter carefully, and refer- ring to an examination of hospital patients made for another purpose, we are convinced that the disease is really more frequent in the female sex. Dr. Cullen was of opinion that scrofula was oftener transmitted from the father than the mother, which he conjectured might arise from the circumstance that more scrofulous men than women enter the married state; but he has nowhere explicitly as- serted that males are more liable to the disease than females. (First Lines. Scrofula.) We proceed now to pass briefly in review the various parts and organs of the human body in which scrofula most commonly appears, and to point out the modifications of this disease induced by the different properties and textures of the parts affected. The first which presents itself is the common integument; and here several forms of cutaneous disease are distinctly referable to the class of scrofulous affections. The three species of porrigo named favosa, larvalis, and furfurane, together with eczema impetiginodes and rubrum in their chronic forms, may be fairly enumerated among strumous diseases; at least if we are entitled to draw any inference from the facts that these erup- tions are found in combination with the generally admitted symptoms of scrofula, and are as often benefited by anti-strumous remedies as the symp- toms just mentioned are usually observed to be, Eruptions of this description, when they affect the scalp, ears, and face, are very apt to occasion swelling of the glands at the back part of the head, on the sides of the neck, and under the jaw ; at first from simple irritation, or perhaps the absorption of morbid fluids ; afterwards, the swelling becomes permanent, from the deposition of tuberculous matter. Other causes of an irrita- ting or inflammatory kind, as dentition and expo- sure to cold, are known to produce such glandular tumours, terminating like the others, where the habit is strumous, in the deposition of the same curdy substance. Thus we have a second order of parts more deeply seated than the skin affected with scrofula, often from the causes stated above, and sometimes, it would seem, spontaneously. The absorbent glands, indeed, are the parts of the body which have long been regarded as the peculiar seats of scrofula, and their enlargement and indu- ration are still considered as affording more une- quivocal evidence in the living body of the presence of that disease than any other circumstance except the discharge of tuberculous matter. A lymphatic gland, when first affected with scrofula, is soft and fleshy, and its size is increased; the texture, as proved by inspection, then becomes firmer, and the colour paler than in health: as the disease proceeds, portions of the gland are observed to have altogether lost their flesh-colour, and acquired a degree of semi-transparency, and a texture ap- proaching to that of cartilage ; at length a deposi- tion of soft white or yellowish curd-like substance is found to have taken place, and the true scrofu- lous tubercle is now manifest. (Abercrombie, Edinb. Medico-Chir. Trans, vol. i. p. 683.) The size to which strumous glandular tumours Vol. IV. —17 attain is in some instances enormous. The lower jaw and upper part of the neck are occasionally seen hung round with such voluminous swellings as completely to deform the countenance; and we have seen, in the case of a strumous middle-aged male, both gToins occupied by vast glandular tumours, the larger of which equalled in size the half of a child's head at birth. These inguinal swellings were firm, nodulated, and without pain ; they had commenced only six months before as clusters of hard kernels, which by degrees enlarged and coalesced into the enormous morbid masses now described. It has been stated by a very able and accurate observer that scrofulous glands always possess a higher temperature than the healthy parts in the vicinity ; but the trials which we have made, and they were often repeated, did not detect any greater heat in such swellings, unless when they were actually inflamed. Scrofulous glands are commonly supposed to be obstructed and impervious to the fluids which are naturally transmitted through them, but it is certain that they are in many instances capable of being injected with mercury from the intrant lym- phatic, (Soemmering, De Vasis Absorbentibus, sect. 37, p. 90); and hence we may infer that, though partially changed, some portion of them may still give passage to their proper fluids. Scrofulous tumours do not uniformly originate from the degeneration of lymphatic glands, but arise in many cases from the deposition of tubercu- lous substance in the subcutaneous cellular tissue, in different parts of the body, quite independent of any absorbent gland : their resemblance, how- ever, to glandular swellings is such as to deceive the inexperienced ; nay, they were named even by Wiseman, the first surgeon of his day, adventi- tious glands. When these scrofulous tumours are cut into, they are found to be composed of cysts varying in size and density, usually lined with a fibrinous exudation, and filled with tubercu- lous substance, sometimes crude, at others soften- ed, or converted into curdy pus. Absorbent glands affected with scrofula, and cysts of tuberculous matter in the cellular tissue, may remain for a long time without exciting any irritation; but their tendency is to become soft by the secretion of purulent fluid from the internal surface of the cavity, which is soon followed by inflammation of the integuments. Ulceration suc- ceeds, and the morbid contents are discharged from the body, sometimes by one, at others by many small apertures: but a cure does not follow; either fistulous openings remain, discharging a thin glutinous fluid mixed from time to time with curdy particles, or an indolent ulcer succeeds, or both may result from the expulsion of tuberculous matter. The contents of scrofulous glands and tumours on the surface of the body occasionally undergo the cretaceous transformation ; after re- maining long indolent, suppuration at last takes place, and masses of earthy substance, sometimes of considerable bulk, are extracted from their cavities. On macerating these calculous concre- tions in water, we have found them to separate readily into a multitude of gritty particles like dried mortar. In some instances, strumous glands are converted into prominent spongy tumours of a 130 SCROFULA. red colour, and covered by a silky cuticle, which frequently breaks, and gives issue to small super- ficial collections of purulent matter. Scrofulous ulcers are characterized by their flabby and often pale granulations, and the thin unhealthy integument which usually overlaps their margins. This undermined skin is of a purplish or livid hue ; showing the languor of its capillary circulation, and its proneness to be destroyed by gangrenous erosion. Such ulcers, though usually productive of little uneasiness, sometimes become exceedingly irritable and painful, requiring the employment of powerful narcotics to give relief to the patient. The thin discharge which scrofulous sores yield often concretes upon their edges into straw-coloured crusts, under which the ulcer, if small, sometimes heals. Scrofulous cicatrices pos- sess a peculiar wrinkled and puckered appearance, with small portions of projecting skin, and even complete bridges admitting a probe to pass beneath them; features by which their real origin, long after a cure, may be readily discovered. These appearances of scrofulous scars seem to be pro- duced by the great attenuation and irregular de- struction of the integument, and the slow and in- terrupted mode in which such ulcers heal; and they may always be in a great measure prevented by careful and judicious surgical treatment. When scrofulous cicatrices are cut into and ex- amined after death, the affected glands are found wasted away, no vestige of them being left ex- cepting a few bands of condensed cellular tissue attached to the cicatrized integument. The heal- ing of a scrofulous ulcer is often followed by the advance of other tumours to suppuration, or per- haps the formation of new ones in some adjoining or distant part of the body. Thus one train of evils succeeds another, till the constitution of the patient begins to yield to the debilitating effects of the irritation and discharge, or the disease fastens on some organ of greater importance in the economy, and life is at length destroyed by 'hectic fever, colliquative perspirations, and diar- ihoea. Another form in which scrofula sometimes attacks the integument is that of lupus, the usual seats of which are the lips and nose; but we have also seen it affecting the genitals. Scrofulous lupus commences by the appearance of small red button-like prominences, which usually remain indolent for some time, then become excoriated and form eroding ulcers, with pale shining spongy . granulations and encrusted margins; or, perhaps, the work of destruction goes on under a thick in- crustation, which drops off from time to time, to show the ravages which have been committed. The progress of the disease is sometimes hastened by the formation of sloughs, especially when the parts are cartilaginous ; and in this way perfora- tions are made into the nostrils, and sinuses scooped out within the thickness of the lips. In lupus of a well-marked scrofulous character, the face usually becomes swollen and raised into .pallid flabby prominences, which deform the coun- tenance, and give to it a very sickly and disgust- ing aspect. Sec the article Noli me Tajtgere. Scrofulous individuals are subject to the forma- tion of large chronic abscesses, which sometimes arise with great rapidity, as if from a sudden de- position of fluid rather than as the consequence of regular suppuration. The usual seat of such abscesses is in the cellular tissue connecting the large muscles, or within their sheaths, and under fascia?; and their contents are at first a serous effusion, afterwards sero-purulent fluid, with curdy flakes; and more rarely a thin pus. In such cases, sloughing of the cellular tissue is not un- common ; spongy masses of it, like wet tow, coming away along with the discharge, or plug- ging up the lancet puncture. These abscesses are named by French writers abces froid and abces par congestion ,• and their origin is usually the irritation of some diseased joint or bone in their immediate vicinity. It does not appear that abscesses of this description result from the soft- ening of tuberculous matter previously deposited, but that the curdy flakes arc thrown out from the internal surface of the abscess during the forma- tion of its more fluid contents. The lymphatic system has been generally con- sidered as the primary, and by some the only seat of scrofula ; and in all treatises on the diseases of the absorbent vessels, this malady occupies a pro- minent station. In almost every case of advanced scrofulous disease of the mesenteric glands, the lac- teals connected with them will be found affected, and more or less filled with tuberculous matter; but the absorbents in other situations have not been very often observed to be the seats of stru- mous disease. Several well-authenticated cases, however, are recorded, in which tuberculous mat- ter was found deposited within these vessels, and that in such quantity as completely to obstruct them.* The following instance of scrofulous affection of the lymphatic, vessels occurred to the writer. A gentleman, after applying an astringent lotion to a simple excoriation of the cervix glandis, was affected with indurated swelling of the prepuce, and the appearance of hard tortuous cords within the integuments of the penis, which after a few days could be traced all the way to the pubes. A glandular swelling took place in one groin, which after a considerable interval suppurated, burst spontaneously, and at length healed. No per- ceptible benefit accrued from a slight mercurial and purgative plan of treatment; but amendment commenced under the use of sarsaparilla and iodine, and the disease wholly disappeared after a tour of several weeks' duration, since which the individual has continued to enjoy good health. The inflammation of the superficial lymphatics in the horse, is believed by the best writers on veterinary medicine to constitute the disease named farcy, (Percival, Lectures on the Veterinary Art, vol. hi.), and M. Dupuy (De la Maladie Tuber- culeuse) regards the small tumours termed farcy buds as tuberculous deposits. The sublingual and submaxillary glands are often the seat of scrofula; the parotid more rarely, but a chronic swelling of that organ is occasion- ally seen in scrofulous subjects of a dark com- plexion. Tumefaction of the tonsils is seldom • i* f'r •*• C<">Pcr- Medical Records and Researches, vol. i. 1st and 3d Cases.-PafcMa, Exercitat. Patholog. p. 109, ri 1' ~ni,lCU*U,d' "£'■ Aflat- m<*- vo>- »• obs. 770, 771, I'JL, Z°"°-^llei,e Be"bachlung. Theil ii. No.33.--*n- dral, Precis d'Anat. Patholog. t. i. pp 41&-421 SCROFULA. 131 absent, when the strumous constitution is strongly marked: this exists from an early period of life, and is perhaps in some instances congenital. The tonsils so affected jut out in rounded tumours from between the arches of the fauces: they are pecu- liarly prone to inflammation, and when it occurs, the swelling is often such as to threaten suffoca- tion, especially when stimulant astringent gargles have been incautiously employed. The inflamed tonsils become speedily spotted with aphthous crusts, which are succeeded by superficial ulcera- tions, always indolent, and sometimes ending in brown excavated ulcers, which we have known to exist for weeks without any remedy being used, and then to yield rapidly to cinchona. Scrofula occasionally attacks the tongue,* the disease alternating with strumous eruptions, espe- cially in the face : it sometimes assumes the form of aphthous ulcerations and fissures of the mar- gin ; but its most characteristic features are small knots or nodules superficially imbedded in the substance of the organ, varying in size from a grain of small shot to that of a horse-bean. They cause no uneasiness unless when firmly pressed, and then the pain is slight and pricking. The mucous membrane covering them is red and pro- minent, and soon breaks in the centre, giving rise to an ulcer, which spreads and destroys by sloughy erosion, with much pain, profuse salivation, furred tongue, and fetid breath. The ulcers under proper treatment become clean, contract, and heal; but the hardness remains, fresh nodules form in other parts of the organ, and the same train of suffering is gone through after a longer or shorter interval, according to the state of the patient's health and the regularity of his mode of life, until a decided improvement be produced on the constitution by time, change of climate, or the employment of remedies. The mucous membranes are frequently affected with scrofulous disease: allusion has just been made to the aphthous exudations and superficial sores which appear on the tongue and tonsils of strumous individuals; in other instances there are small blisters and excoriations on the inside of the lips and cheeks, and on the fauces, and that wholly independent of any syphilitic disease, or the pre- vious exhibition of mercury. The pituitary mem- brane in scrofulous subjects is easily irritated, and the secretion of mucus is usually copious and often acrid : nay, in some instances the morbid condi- tion of the part proceeds so far as to induce small ulcerations, constituting one form of ozoena. If the progress of this affection be not arrested, the fine long laminae within the nostrils become in part denuded, and at length necrosed; and it is from the decomposition of dead osseous substance that the horribly offensive odour is produced which renders this malady so peculiarly disgusting. To those around the patient it is always so ; but he himself is sometimes unconscious of the odour, in consequence of the diseased condition of the pitu- itary membrane, and the loss of smell resulting from it. The most frequent cause of ozcena is, without doubt, syphilis; but it occurs chiefly in those syphilitic cases where the habit is strumous, and it is met with also as the effect of scrofula * Mr. Russel has alluded to this affection, but without describing it. See Russel on Scrofula. alone. It has not been ascertained whether ozcena ever originates from the deposition of minute tu- bercles on the pituitary membrane; but that this sometimes occurs is far from improbable. In the glanders of horses, which is an analogous affec- tion, the existence of tubercles in the lining mem- brane of the nostrils has been satisfactorily shown by Dupuy to form a leading feature. (De 1'Affec- tion Tuberculeuse, pp. 30 & scq.) Scrofulous children are more liable than others to inflammatory affections of the windpipe, and to that fibrinous exudation on its mucous surface which occurs in croup; yet this cannot properly be classed among strumous diseases. But the ultimate terminations of the respiratory mucous membrane are frequently the seat of scro- fula: some eminent pathologists, indeed, are of opinion that the air-vesicles of the lungs are the usual situations in which tuberculous matter is originally deposited in cases of scrofulous phthisis. Dr. Alison informs us that he has repeatedly found tuberculous matter in the air-vesicles, these minute cavities being partly filled with air and partly with this substance, (Edin. Medico-Chir. Trans, vol. i. p. 427) ; and the dissections of Dr. Carswell, (Illustrations of the Elementary Forms of Dis- ease, Fascic. 1,) which he has so happily per- petuated by his drawings, appear to us to have set this point completely at rest. M. Gendrin, how- ever, asserts that the substance effused into the air-vesicles is nothing more than the product of common inflammation, and not at all tuberculous; but he candidly admits that Laennec expressed a contrary opinion while the subject was before them, and he is ready to acknowledge that inflam- mation is a powerful occasional cause of the pro- duction of tubercle. (Hist. Anatom. des Inflam- mations, torn. ii. pp. 310, 601.) The digestive mucous membrane is subject through its whole extent to scrofulous disorder of function, and in its intestinal portion at least to extensive scrofulous transformations. A feeble action of the stomach is an almost uniform ac- companiment of well-marked strumous disease ; and the mucous lining of the alimentary canal is in such cases either torpid or unduly irritable, the food remaining lodged as a source of oppression and disturbance, or being hurried rapidly forward, and expelled before it has had time to afford ade- quate nourishment to the system. Tubercles are met with in the walls of the intestinal tube in children, and still more frequently in adults: Louis states that in his examination of more than 350 phthisical subjects above the age of fifteen, he found tubercles in the small intestines of one- third, and in the large intestines of one-ninth of the whole. (Recherches sur la Phthisic.) The subsidiary organs of digestion and assimi- lation suffer also from scrofula; but the spleen and the pancreas are more frequently the seats of tubercles than the liver; yet the last of these organs is more or less functionally deranged in almost all strumous cases, which the chalky and various-coloured motions of such patients suffi- ciently demonstrate. The great irritability of tho mucous tunic of the intestines in many scrofu- lous cases, and the tubercles which so often form within the mucous follicles and walls of the tube, naturally lead to ulceration, and hence arise many 132 8CR0FULA. cases of disease of the mesenteric glands. At first they become merely swelled, but ultimately tuberculous deposits take place within their sub- stance, constituting what has been named mesen- teric consumption, or tabes mesenterica. For a full account of this affection, we refer the reader to the article Tabes Meseicterica. Scrofulous disease of the mucous membrane of the female genital organs is of frequent occur- rence, and forms the most obstinate description of leucorrhcea, producing languor and debility, disor- dering and sometimes putting a total stop to men- struation, and in very many cases preventing con- ception. The morbid discharge in this disease is interrupted on the appearance of menstruation, and is increased in quantity before and after that occurrence. It varies in character from an opaque white mucus to a greenish yellow or blood- streaked purulence; and the surface which fur- nishes it is not limited to the vagina, but appa- rently extends throughout the whole internal lining of the uterus. It does not appear that tubercles have been detected in the vagina, but scrofulous ulcers have been seen there, probably arising from the destruction of tubercles, while the cavity of the uterus itself and the Fallopian tubes were found filled with tuberculous matter. (Carswell, Op. cit. pi. ii.) Tubercles have also been found imbedded in the walls of the uterus, and still more frequently in the ovaria. (Meckel, Handbuch der Pathol. Anat. B. ii. Theil. ii. 8. 386. Louis, Recherches sur la Phthisie. Lom- bard, Essai sur les Tubercles.) In men, scrofulous disease of the mucous mem- brane of the urinary channels and cavities is not unfrequent; and it is an affection particularly obstinate and unmanageable. The writer has known it to continue in the urethra for five years, at the end of which time it came under his care. The urethral membrane was then so soft and spongy that the most cautious attempt to intro- duce an instrument occasioned a profuse hemor- rhage : after a lengthened treatment, the discharge at last yielded to tonics, the cold plunge-bath, and astringent injections. Chronic, or mucous cystitis, is often of a scrofulous character, (see Ctstitis;) and there is ground for believing that the same affection passes up along the ureters, and even extends itself within the chambers of the kidney. Tuberculous deposits have been found within the coats of the bladder, (Louis, Op. cit. Lombard, Op. cit. Delaroche, Bulletin de la Societe de Med. t 13. 14,) and lining the interior of the ureters, (Laennec, Auscult. Med. t. i. p. 556. Lout's. Also Carswell, Op. cit. pi. ii.); very fre- quently also in the cavities and substance of the kidneys, and sometimes in the renal capsules. (Baillie, Morbid Anatomy.) The glands of Cow- per, the prostate, vesicuUe seminales, and testicles, have all been found the seats of tuberculous de- posits. They occur most frequently in the pros- tate gland and testicles, particularly in the latter; and the symptoms to which they give rise render them objects of considerable importance to the practical physician as well as to the surgeon. See Prostate Gland, Diseases of. The changes produced in the testicle by scro- fula vary considerably, according to the degree of attending inflammation, and the rapidity with which the disease has formed. We have, most commonly, a hard solid enlargement of the organ, usually affecting first the large head of the epidi- dymis, slow in its growth, and obstinate in resist- ing the operation of remedies. It may remain indolent for some time, but at length abscess forms, the scrotum inflames, adheres, and gives way, discharging a curdy substance mixed with pus. The disease now extends to other parts of the epididymis and to the body of the testicle; sinuses form under different parts of the inflamed integument; and fistulous openings take place, which give issue to a tbin, ill-conditioned fluid, mixed with curdy particles. At other times a more rapid inflammation occurs, and an abscess forms, which on bursting discharges scrofulous pus; a fistulous opening succeeds, the gland wastes away, and at length nothing remains but a small, shrunk, and hardened mass. On dissect- ing a strumous testicle, the natural fabric of the organ is found more or less indurated by the de- position of dense organized substance; tuberculous matter is discovered in different spots, in the tubuli seminiferi epididymis, and sometimes even in the vas deferens. Small scrofulous abscesses are also occasionally found disseminated through the sub- stance of the gland. (Sir A. Cooper, On the Testis. Carswell's illustrations, pi. ii.) This disease is much more common after puberty, when the actions of the testicle are awakened, and it has become exposed to numerous causes of irritation and injury ; but we have known it occur at a very early age, in the case of a child which exhibited other strong marks of the strumous constitution. In almost every instance only one testicle is at- attacked at first, but after a time the other is usu- ally affected; and it is not uncommon for both to continue suffering from the disease at the same time. Andral has well remarked the frequency of scrofulous affection of the testicle, and has pointed out the palpable omission of Louis, who has assigned no place either to the testicle or the bones in his enumeration of parts in which scro- fulous deposits have been found. Another organ which is subject to scrofula is the mamma; scrofulous disease of which occurs both before and after puberty, but much more fre- quently after that period, and often during the ex- citement of the first lactation. Scrofula of the mamma appears under different shapes, and in its earlier stages is not always easily distinguished from disease of a more formidable character. Some- times a hard lump forms in the breast, and re- mains nearly quiescent for several years ; at others the whole gland is affected with scrofulous en- largement ; but in every case of the disease its ten- dency is to suppuration, and the purulent matter discharged is more or less mingled with curdy flakes : instances likewise occur in which large masses of tuberculous substance come away. (Lloyd, On Scrofula.) In the progress of such cases the integuments become inflamed, assume a livid colour, and are extensively detached from the parts beneath; new abscesses and aperture> form, and the adipose and glandular tissues are traversed by many fistulous passages, while the contiguous parts are condensed and hardened. In strumous disease of the breast, there is always an enlargement of the gland instead of that contiac- SCROFULA. 133 tion which occurs in one form of carcinoma: the tumour is tender when squeezed, never possesses the stony hardness which exists in the disease just named, and there is never, we believe, re- traction of the nipple. The mucous membranes of the eye and lachry- mal passages are peculiarly liable to scrofulous disease; its influence on the latter is indicated by the long-continued discharge of puriform mucus, varying in its colour and consistence; while stru- mous inflammation of the conjunctiva constitutes a very large proportion of all the inflammatory affections to which this organ is subject. Beer asserts that in Vienna nine-tenths of all the dases of ophthalmia in children are of a scrofulous cha- racter, (Jos. Beer, Lehre, &c. b. i. s. 588) ; and Benedict of Breslau estimates the proportion in that city as high as ninety-five in the hundred. (Handbuch, &c, b. ii. s. 165.) The eruption of the minute vesicles, (phlyctenular) or pus- tules, which occurs in scrofulous inflammation of the conjunctiva, seems to approximate it to other diseases of the same class, when nume- rous crops of very small tubercles are seen on the investing membranes of various organs; but it does not appear that true tuberculous matter has ever been detected in any part of the eye.* Scro- fula likewise attacks the margins of the palpebrae and Meibomian follicles, causing the appearance of vesicles and ulcerations named ophthalmia tarsi; and it is believed by Mr. Todd to occasion chronic enlargement of the lachrymal gland. (Dublin Hospital Reports, vol. iii.) The organ of hearing, like that of sight, is the frequent subject of scrofula, which in many in- stances is productive of early deafness, and, there is reason to believe, is the cause of that imperfec- tion of hearing which is sometimes seen to per- vade several members of the same family. The lining membrane of the external auditory passage is in most instances the seat of the disease, which is usually marked by profuse watery, then mucous, and at length purulent discharges, forming what may be named strumous otorrhoea. It is in gene- ral unattended with danger, but it rarely exists without producing a greater or less imperfection of hearing. In some instances, however, the dis- ease spreads more deeply; the membrane of the tympanum becomes inflamed and is perforated, the small bones of the ear are discharged, and irre- mediable deafness ensues; or perhaps caries of the petrous portion of the temporal bone takes place, and the result is fatal. (See Oualgia and Otitis.) Strumous otorrhoea has been known to alternate with other mucous discharges, such as leucorrhcea and chronic cystitis, (Lallemande, Recherches sur I'Encephale, lettre quatrieme) ; and its disappear- ance has been followed by enlargement of the cervical glands, swelling of the testicle, and vari- ous diseases of the eyes and skin, (ltard, Mala- dies de l'Oreille.) Like other scrofulous affections it sometimes resists all remedies, and at length disappears at puberty. The synovial membranes of joints are un- doubtedly much more liable to disease, in scro- * Strumous disease of that organ seems to exist also among animals. M. Dupuy considers the specific oph- thalmia of horses as one of the consequences of the tuber- culous affection. fulous subjects, than others; inflammation is more readily excited, and effusion of fluid into their cavities is more easily induced. In such persons we frequently observe several joints affected at the same time. In a case of six years' duration, lately placed under the writer's care, the left hip- joint, the right knee, and the joints of the right great toe were all suffering under disease, with displacement of the head of the femur and shaft of the tibia; there were, besides, many ulcers and sinuses around the joints, and indurated cervical glands : this patient had a strongly marked stru- mous countenance. The secretion of scrofulous pus into synovial cavities is not uncommon, but the existence of tubercle within the substance of the membrane itself appears to be of rare occur- rence. Dr. Craigie states his belief that tubercle has been found in the synovial membrane of the hip-joint (Elements of Patholog. Anatomy, p. 810.) There is indeed a remarkable change of structure, which takes place slowly in the synovial membranes, particularly that of the knee-joint, and which, as it occurs most frequently in the scrofulous, some may be inclined to regard as of scrofulous origin. This morbid alteration of tex- ture, which was first accurately described and illustrated by Mr. Brodie, (Pathological Observa- tions on the Joints,) consists of the conversion of the synovial membrane, and afterwards of the adjacent soft parts, into a pulpy substance of a light brown colour, intersected by white mem- branous threads, and traversed by minute red vessels. But there is another affection of the joints, in which the characters of scrofula are unequivocally exhibited; in this the disease originates in the cancellous structure of the bones, which is found to contain deposits of tuberculous matter: and the cartilages and syno- vial membranes are affected secondarily by the spreading of the inflammation. In scrofulous persons the bones are more slen- der throughout; their cortex or outer wall is much thinner, and their interior more soft and vascular than the bones of persons of sound and vigorous constitution : in the inferior animals affected with tuberculous disease, according to Dupuy, (De 1'Affection Tuberculeuse,) this pecu- liarity is still more strongly exhibited. Scrofulous children sometimes fracture the thigh or leg merely by falling on the carpet; and in other instances the bone does not snap across, but bends like a piece of tin ; and the injury may be remedied by straightening it as we do a rod of that metal. The effects of scrofula on the bones are considerably different, according to the comparative density of their texture; but in all instances the process of disorganization appears to commence by an in- crease of their vascularity, or a greater or less degree of inflammation. In the dense fabric of the bones of the skull and the shafts of the long bones, scrofula is a frequent cause of necrosis; while in the spongy heads of bones, the small bones of the hand and foot, and the bodies of the vertebra?, this disease manifests itself, first by in- creased vascularity and softening of the cancellated structure while the firm exterior remains entire and unchanged ; then a deposit takes place of a clear yellow fluid, which is succeeded by or pro- bably converted into a soft cheesy substance or 134 SCROFULA. true tuberculous matter. (Brodie, Patholog. Ob- serv. on the Joints.—Lloyd, On Scrofula.) This alteration in the texture of the bones is slow in its progress, and its existence is not indicated by any decided symptoms until it is considerably ad- vanced. A dull and deep-seated pain gives the first warning of the disease, the soft parts then become swelled, the motions of the neighbouring joint are restrained and painful, and abscesses now form around it, containing a scrofulous pus; the investing cartilages and synovial membrane next suffer, effusion takes place into the articular capsule, and perhaps a high degree of inflamma- tion is induced by the escape of tuberculous mat- ter or a portion of necrosed bone into the cavity of the joint In the progress of the disease the destruction of the head of the bone or edge of the socket, and of the ligaments which preserve the bones in their places, enables the more powerful muscles to draw the lower one from its situation, and produce what is named secondary luxation. The writer has repeatedly observed dislocation of the tibia produced by the separation of the epi- physis from the shaft of the bone; the leg being in this manner completely displaced, although the articular surfaces of the knee-joint were in proper apposition. Not only the bones but also their investing membrane of periosteum is subject to tubercular deposits,* giving rise to swelling, inflammation, suppuration, detachment of the periosteum from the bone, and ultimately to necrosis, or absorption of the osseous tissue, which is replaced by dry tuberculous substance without softening of the bone. To this form of tuberculous disease we would refer some of those cases which have been named osteo-steatoma. This morbid deposition, which we have seen lying in contact with the bone in large angular masses, bears a striking resemblance to suet or adipocire; but its nature is truly that of coagulated albumen, for it emits, under a strong heat, the odour of burnt cheese or horn, and produces no greasy stain when rubbed on paper. Scrofula manifests itself by unequivocal proofs both in the bodies of the vertebra? and the fibro- cartilaginous substance which is interposed be- tween them. The former become more vascular, are softened by the partial absorption of their earthy and saline constituents, and afterwards receive a deposit of yellow, cheesy, or true tuber- culous matter. These changes naturally lead to caries and destruction of the bone, which yields to the superincumbent weight; and the spine bends at an angle more or less acute according to the number of vertebra? which are diseased. The bend is in general directly forward; but when the sides of the vertebra? have suffered most, the curve is of course lateral. (Brodie, Opus cit. p. 289.) In the progress of this disease the soft parts around become affected, and collections of purulent mat- ter form, which, passing down in front of the spine and along the course of the psoa? muscles, ultimately make their appearance under Poupart's ligament at the upper part of the thigh, and some- times on both sides, nearly at the same time. On *Otto has found tubercle within the tissue of the periosteum. See Compend. of Pathol. Anat. translated by South, vol. i. p. 240. other occasions the matter points in the loins, or near the anus ; and in some rare instances it has burst into the spinal canal, with an immediately fatal result. When chronic disease has thus been producing such extensive disorganization in the osseous sub- stance of the spinal column and in the soft parts around, it is not to be expected that the membranes of the spinal cord, the medullary substance itself, and the nerves which branch from it, should es- cape injury; accordingly we find that the first symptoms of caries of the spine are, a feeling of weight and aching in the part, itching and numb- ness, pains shooting round to the front of the trunk; and, when the disease is farther advanced, pains and twitchings of the limbs, succeeded by palsy of all the parts below the affected vertebra?, and of the sphincters of the bladder and rectum. The nervous symptoms are not always limited to the parts below the seat of the disease: in some cases we have pains of the arms, although the disease be situated in the middle dorsal vertebra?. (Copland, on Diseases of the Spine.) On in- specting the contents of the spinal canal, where death has occurred during the existence of caries of the bones, effusions of serum or plastic lymph are found between the osseous surface and the dura mater, and sometimes they are found firmly adherent; plastic lymph and pus are also dis- covered within the arachnoid, or the membranes are found glued together. Tuberculous deposits have been observed within the substance of the spinal dura mater, and between that membrane and the arachnoid ; most commonly connected with scrofulous disease of the bones, but some- times wholly independent of it. (Ollivier, De la Moelle Epiniere, t. ii. pp. 760-764.) The me- dullary substance itself has in such cases been found softened or attenuated ; sometimes entirely destroyed for a short space, and the vacuity filled up with a sanious pus. When scrofulous disorganization of the bones has been effectually checked, it is astonishing to mark the efforts made by nature to repair the loss and support the fabric hy new osseous growths: we have even occasionally seen them formed in the vicinity of the disease, even although its activity was still unabated. Scrofulous affections of the spine often conv mence in the intervertebral substance, which be- comes soft in the centre, and is then destroyed by ulceration and absorption ; the disease afterwards extending to the bodies of the vertebra?. There is no reason to doubt that ulceration of the inter- vertebral substance is in most cases of a scrofu- lous nature; yet it must be admitted that tubercu- lous matter has very rarely been observed in this texture; partly, perhaps, because it has not often been carefully sought for. Andral states that he once met with a mass of tubercles within the sub- stance of the intervertebral cartilages. (Precis d'Anat. Patholog. t. i. p. 424.) Lateral curvature of the spine has been sup- posed by some writers to be in almost all cases produced by strumous disease of the bodies of the vertebra?. Certain it is that scrofulous indi- viduals are most liable to lateral curvature of the spine; but this may with more propriety be ascribed to a general debility and relaxation of the SCROFULA. 135 frame, and of the muscular and ligamentous sys- tem in particular, than to any positive softening of the osseous texture. Were the bones softened from scrofula in every case of lateral curvature, how is it possible that so many cures should be effected, or that such multitudes of females should be met with in comparatively good health, yet having permanent lateral flexure of the spine 1 Scrofulous disease of bones in other cases re- quires powerful counter-irritation to check its progress; but in this form of spinal disease, rest in the horizontal posture, friction, a regulated ex- ercise of the muscles, and attention to the general health, are sufficient, in a great majority of in- stances, to accomplish a cure. Lateral curvature of the spine not unfrequently precedes angular projection from caries: hence it has been.inferred that the latter is but the second stage of the former disease: of this, however, there is no proof; nor is it at all unnatural that a feeble in- dividual, whose spine sinks readily into a serpentine bend, should afterwards become the subject of a more formidable disease, affecting the bones them- selves. The vertebra? after death, in cases of serpentine curvature, are most commonly found free from disease,* which would seem to show that scrofulous softening of the bones is rarely the cause or this deformity ; for it is highly improba- ble that so great a change in the texture and form of the vertebra? should be repaired without leaving behind it some traces of its previous ex- istence. The serous membranes in different parts of the body often exhibit decided marks of scrofulous disease, myriads of minute tubercles or tubercu- lous granulations being found adhering to their surfaces or imbedded in their tissue; and some- times enveloped in the false membranes connect- ing them, which have formed during inflammation. Thus the pleura, the arachnoid, the pia mater, the peritoneum, are frequently found affected with scrofula ; and a few instances are recorded where tubercles have been observed in the pericardium. (Baillie, Morbid Anatomy, p. 9.) When this disease attacks the membranes of the brain, its symptoms are usually the same as those of acute hydrocephalus; and its termination takes place by effusion within the skull or spinal canal, to which sometimes is superadded softening of the medullary substance. The children of scrofulous parents are well known to be more prone than others to cephalic disease ; and in this manner the whole offspring of such individuals are some- times cut off in succession during infancy. When tuberculous disease affects the peritoneum, it seems, whether originally induced by inflamma- tion or not, to produce, after a time, that state: dropsical effusion then follows. As the disease proceeds, the fluid is absorbed, and the opposite surfaces, loaded with tuberculous matter, become glued together, obliterating the cavity of the peri- toneum, and fixing the floating viscera in their places. We have seen this disease in a boy of twelve years pervading the whole trunk, gluing the contiguous viscera to each other, to the pa- *Shav>, Diseases of the Spine. We have lately ex- amined a number of preparations with a view to this point, and the result fully corroborates the assertion of Mr, Shaw. rietes of the chest and abdomen, and to the dia- phragm, filling up the anterior mediastinum, and presenting numerous white cheesy tumours within the substance of the viscera themselves. The heart alone was free from disease. A separation of the lowest part of the sternum, which was much softened, had taken place, and the point of the ensiform cartilage was directed forwards and upwards ; a consequence apparently of the swell- ing of the abdomen, and the restraint imposed by the strong adhesions on the motions of the chest in respiration. Such cases are always compli- cated with scrofulous disease of the mesenteric glands, and usually with ulceration of the coats of the intestines, which have thus been perforated, allowing a free communication through the ad- herent sides of the contiguous tubes. In some cases it has appeared that the ulceration had com- menced in the peritoneal surface; (Gregory, Lond. Med.-Chir. Trans, vol. ii. p. 269;) while in others the mucous lining of the bowel seems to have been the first eroded. (Howship, Prac- tical Observations in Surgery and Morbid Ana- tomy, p. 269.) The same result will follow from both processes; but certainly the ulceration from within outwards is what we consider most likely to happen from the greater proneness of mucous membranes to that state. The frequent occurrence of scrofula within the central organs of the nervous system has been satisfactorily ascertained. Wiseman, whose know- ledge on this subject greatly surpassed that of most of his contemporaries, appears to have suspected the fact; but it was reserved for modern patholo- gists-j- to show how frequently tubercles are formed within the encephalon and spinal cord. Before the age of two years they are not common ; but from this period onwards till puberty they are of frequent occurrence. Their most usual scat in the brain is the upper part of the hemispheres; and in the spinal cord they occur much oftener in the cervical than in the dorsal or lumbar portions: according to the most accurate observers, they are very often enclosed in cysts. (Andral, Precis d'Anat. Pathol, torn. ii. p. 841.) It is singularly deserving of notice that tubercles have been re- peatedly found in the nervous centres where no symptom during life had induced any suspicion of their existence; and the scalpel has as fre- quently been unable to disclose any deviation from healthy texture in the substance immediately surrounding them. The thyroid gland was long believed to be pe- culiarly subject to scrofula; and the chronic en- largement of that organ, named bronchocele, was at one period regarded by the best writers of their day as a distinctly scrofulous disease; (Sennertus, Medicina Practica.—Laurentius, Hist. Anat cor- poris humani;) nay, it is remarkable that even in recent times the introdtfction of iodine as a gene- ral anti-strumous remedy originated in the sup- posed connection of bronchocele with scrofula. But on reviewing the history of the two diseases, we shall find so many points of difference as to convince us that they are altogether distinct and t Leveilli. Bechercbes sur les Tubercules du Cervau, 1824. a thesis.—Oendrin, Sur les Tubercules du Cervau et de la Moelle Epiniere, 8vo. — Ollivier, Sur la Moelle Epiniere. 136 SCRO FULA. independent. (See article Bronchocele.) In support of this opinion it may be sufficient here to state that bronchocele is of rare occurrence in the large manufacturing towns of Britain ; while scrofula prevails throughout their population, cut- ting off thousands in infancy, and scattering among the survivors the germs of debility and protracted disease. The thyroid body, though rarely the seat of true scrofula, is not wholly exempt from it, more than one instance of its occurrence having come under our observation. The disease com- mences with a moderate degree of swelling, which is followed by the formation of a small indolent abscess : this after a time bursts spontaneously, discharging a thin pus mixed with curdy flakes; the apertures remain fistulous for a considerable time, while the tumefaction of the gland subsides. The lungs have long been known to be particu- larly liable to scrofulous deposits ; and so rare is it to find tubercle in any other situation without also finding it in the lungs, that Louis states he never met with an instance in all his numerous dissections excepting once, in the case of a man who had died of fever. (Recherches sur la Phthisie.) Scrofulous disease of the lungs con- stitutes what has been named tubercular phthisis; to the article on which, the reader is referred. [Scrofulosis is very analogous to, although not identical perhaps with, tuberculosis. They both occur in persons who have like habits and general appearance; but there is this difference, as regards at least tuberculosis of the lungs, that it is most frequently developed after puberty,—the period when the tendency to scrofulosis is usually dimin- ished or arrested. Moreover, scrofulous disease manifestly exists where there is no reason to be- lieve in the existence of tuberculous matter. (Scro- fula, its Nature, Causes and Treatment, by W. Tyler Smith, M. D. p. 6. Lond. 1844.) A person having scrofula, however, in early life, would seem to be more liable to tuberculosis at an after period. Some recent observers, however, argue strenuously for the identity between scrofulosis and tuberculosis. MM. Riiliet & Barthez (Traite Clinique et Pratique des Maladies des Enfans, iii. 5. Paris, 1843,) affirm, that having examined the bodies of a large number of scrofulous chil- dren, at the Hopital St. Louis, they met with no instance in which tuberculous deposits did not exist in some part or other. Many affections, commonly termed scrofulous, as ophthalmia, they consider of a secondary nature, accidentally com- plicating the original scrofulous or tuberculous habit, but not essentially scrofulous in their na- ture. They propose to banish the term scrofula from medical nomenclature, as being vague and apt to mislead, and to substitute for it the term tuberculization. M. Bredow, of St. Petersburg, (Ueber die Scrofelsucht, Berlin, 1843,) seems to entertain a similar view ; i>ul he proposes to re- tain the word scrofula, to designate tuberculous disorganization of the lymphatic glands; and the terms tubercle and tuberculous disease for the same affection existing in other organs. (Dr. West, Brit. 4 Fur. Med. Rev. April 1844, p. 565.)] The heart has been found affected with scrofula but rarely : Dr. Otto, (Compendium of Pathologi- cal Anatomy, translated by South, p. 290,) of Breslau, a very learned and able pathologist, never once met with a case of this sort; yet several cases of its occurrence are on record from Fabri- cius Hildanus, (Observ. Chirurg.) and Needham, (Wiseman's Surgery, vol. i. p. 404 ; at the apex of the heart,) down to Andral, (Andral c\ Bayle, Revue Med. Fran?, et Etr. 1821,) Lobstein,* and Macmichael.-f- Tubercle of the heart never occurs except when the system is strongly imbued with strumous disease; and its existence in this situa- tion does not appear to have been indicated by any peculiar diagnostic symptom. The occurrence of scrofulous disease in the voluntary muscles appears to be not less uncom- mon than in the heart: instances, however, have been met with of tuberculous deposits in these or- gans, both in the human subject and the monkey.$ The effect of scrofula in modifying the symp- toms of a large proportion of the diseases to which the human frame is subject, has been long known to medical observers, and meets us daily in the course of our practice. Inflammatory affections, in a particular manner, exhibit the effects of this influence ; losing the acuteness of their character, and becoming tardy and indolent, difficult of cure, and requiring for its accomplishment the use of stimulants and tonics. Frequent and striking ex- amples of these facts are presented to us by many of the early consequences of syphilitic infection, and by the extensive tribe of ophthalmic diseases. Injuries of the soft parts, particularly where there has been much loss of blood, also often afford un- equivocal evidence of the presence of a strumous habit: hence it is common for persons who are jealous of the imputation of scrofula to declare that their wounds are always readily healed. So strong sometimes is the modifying power of scro- fula, that the writer has known the stump of a strumous girl's arm, which was removed on ac- count of an extensive laceration, to discharge dis- tinct curdy matter at the second dressing. Scrofula appears to possess a certain degree of connection with several other diseases. Some con- genital affections, such as hare-lip, spina bifida, and external hydrocephalus, are more frequently met with among scrofulous children than others; and it is worthy of remark that in many cases of congenital peculiarity or defect, the same have been observed in ancestors, or near collateral rela- tives of the patients. Of all the diseases allied to scrofula, perhaps the most closely connected is rickets, (see art. Rickets ;) yet the distinction between the anato- mical characters of the two diseases is sufficiently well marked. In rickets the whole texture of the bone is softened, though not exactly in the same manner in both species of that disease; but in scrofula, tuberculous matter is deposited in the can- * Anat. Patholog. At the apex of the heart, as large as the point of the thumb, and apparently formed in the substance of a false membrane. t Lond. Med. and Phys. Journal, 1826, p. 119. The tu- uf.r,°le?'".'^ heart were connected with others in the lungs, yet they may have been originally distinct. t Otto, Opus cit. p. 252, in the sterno-mastoid of a girl mnnkPvt ? " °f.'he "eCk and ,bigh «<" scrofulous ?Z$?*~Laenn^ Auscult- Mediate, torn. i. p. 556. Is eft KrVr.^M0'* Phthisical ">an. Lombard, Opus cit Intercostal Muscles.-Reynaud, Archive Gen. de e venCa"verv0!n,"V; 1831' Pp-149" ^ This write? h« fions Sa?t^. i.r1re',."15 aCC°Unl 0f the "">erculous """ec- S,T ,plaan,t,eysP,,lll,S,8' °CCUrrin» in monkey9 at »* SCROFULA. 137 ccllous structure, the outer wall remaining entire, or becoming necrosed: or tubercle invades the bone from the periosteal surface, the osseous sub- stance being removed by absorption. Encepha- loid or medullary tumours may also be enumerated among the affections connected with scrofula; they occur chiefly in individuals of a strumous habit, and the materials of which they are com- posed bear, in their last stage of softening, a con- siderable similitude to those of tubercle.* There is a fungous tumour, occurring in the lips and cheeks of young scrofulous subjects, which we have repeatedly met with; in its external charac- ters it bears a very close resemblance to encepha- loid ; but it is formed with much greater rapidity, and admits of cure by a well-directed alterative and purgative treatment, and the application of leeches, astringents, and escharotics. It is the opinion of some experienced practitioners, that carcinoma occurs more frequently in persons of a strumous constitution than others; and our own observation inclines us to entertain a similar be- lief. The concurrence of scrofula with urinary calculus has led to the supposition that the two diseases are intimately connected; but it does not appear that they are in any way dependent on each other: the same causes, however, are likely to induce both. (See art Calculous Diseases.) The greater sensitiveness of most scrofulous individuals renders them more prone to diseases of the nervous class: hence an aggravated form of hysteria is more frequent in such persons; and we think with Dr. Cheyne, that epilepsy affects strumous subjects oftener than others. (See Epi- lepsia) The diseases of the mind claim an alli- ance with scrofula, which has not attracted the attention of writers on this subject so much as it seems to merit An eminent physician of great knowledge and experience in the treatment of in- sanity has stated to us his belief that more than one-half of those who are subject to mental de- rangement are of a scrofulous constitution, having some manifest indication of its existence in their persons. With the view of elucidating this sub- ject, we examined all the paupers of a lunatic establishment Of forty-four females, exactly one- half presented indurated or enlarged glands of the neck or throat, and several had extensive scrofu- lous cicatrices. Of forty-six males, twenty-eight had no decided symptoms of scrofula, though several of these had the strumous aspect; sixteen presented the marks already mentioned in refer- ence to the females ; and two belonged to families known to be afflicted with scrofula in an aggra- vated form. All of these ninety lunatics were adults, and not one of them exhibited any active symptoms of scrofulous disease. It has been remarked to the writer by the physician already referred to, that he has often observed active scro- fulous symptoms to alternate with attacks of ma- nia. In several cases he has known the purulent expectoration of phthisis to cease during the urgent symptoms of insanity; and, on the other hand, reason has been seen to return before the pulmo- *The earliest distinct account of encephaloid as it affects the extremities, is to be found in Ruysch, Obser- vat. Analomico-Chirurgic. No. 81, where he describes it under the title of the spongy or ossivorous tumour, and states that it was known to the Germans under the name of schitamm, and to the Dutch under that of been eter. Vol. IV.—18 M» nary disease proved fatal—soothing the feelings of affectionate relatives, and shedding a calm over the last days of the consumptive lunatic. In ac- cordance with what has just been stated, the seve- rity of the symptoms of scrofula does not appear to promote the development of mental disease, but rather to impede it; for in families eminently scrofulous, we have sometimes observed the indi- vidual least afflicted with that malady to be the victim of insanity; while those who suffered most from scrofula possessed sound minds; as if the local irritation, or the drain from the body afforded some protection against mental derangement It has often been remarked by medical writers, and the observation of every physician must confirm the accuracy of the statement, that precocity of mental development, and superior genius, are in a great majority of instances the accompaniment of the scrofulous constitution. Causes. — In considering the causes of a dis- ease so deeply rooted in the constitution as scro- fula is universally acknowledged to be, it is neces- sary to direct our attention to circumstances very remote in the history of those who are its subjects. The foundation of a scrofulous habit is frequently laid during the foetal state, by the transmission of that peculiar organization of the frame from pa- rents who themselves possess it Nothing, indeed, can be better established as the result of general observation than the hereditary nature of scrofula. This peculiarity of constitution may also be com- municated to the foetus by some defect of energy in one or both of the parents, arising from extreme youth, or very advanced years, or great disparity of age, or that premature decay which is induced by a life of dissipation, or the debilitated states ' resulting from protracted illness; or, on the part of the mother, repeated miscarriages, and by defec- tive nourishment and other similar causes. Va- ' rious occurrences, likewise, may take place during gestation — such as accidents, frights, prolonged disease, mental distress,—which interfere with the proper development and growth of the embryo, and entail upon the child that feebleness of con- ■ stitution which, if not identical with scrofula, leads to its appearance on the application of causes not adequate under other circumstances to pro- duce that disease. The writer was recently called upon to examine a boy of six years, labouring under a complication of scrofulous ailments; the history of whose case may serve to illustrate the influence of injuries received by the mother during gestation. In this instance the mother was a tall and rather slender woman, apparently enjoying good health; the boy was puny for his age, his movements were quick and restless, his articula- tion very imperfect, and his mind in a state ap- proaching to idiotcy : the lips were seamed with the scars of former ulcers, the conjunctiva? relaxed and injected, the tarsi inflamed, ulcerated and almost without cilia; the countenance pale and bloated; the skin dry and scaly; many of his teeth were gone, and most of those which remained were in a state of decay ; the cervical glands were indurated, but not much enlarged. The last pha- lanx of one thumb was double, and each extremity of the fork had a perfect nail. He had always been a very sickly child, had had repeated suppu- rations in the groins, and was then labouring 138 SCROFULA. under chronic diarrhoea, part of his food passing undigested. During the time that his mother was pregnant with him she had suffered many severe falls, the first towards the end of the third month. Scrofula is also observed to originate in the healthy offspring of healthy parents under certain circumstances, the principal of which are habitual exposure to cold and damp, privation of free air and light, and want of healthful exercise. In- stances are recorded where persons previously in good health have been affected with scrofula after being confined in the dungeons of a prison, and there scantily fed. (Pinel, Nosog. Philos. t. iii. pp. 380, 385.) The influence of such causes in producing tuberculous disease in the inferior ani- mals has been made the subject of experiment by Dr. Jenner, (Jenner, in Beddoes on the Med. Use of factit. Airs), Dr. Baron, (Delineations, &c, pp. '25 et seq.,) and others ; and the results have satis- factorily shown both the great extent of that in- fluence, and the power which we possess of re- moving the factitious disease by replacing the animals in healthy situations, and supplying them abundantly with wholesome food. The operation of cold and damp, as causes of scrofula, is greatly augmented even by a slight local injury. A moist, cold, and variable climate, like those of Great Britain and Holland, is particularly favourable to the development of scrofula; in proof of which it is sufficient to adduce the great prevalence of the malady in both of those coun- tries. A very cold or a hot climate, on the other hand, serves rather to protect us against scrofula; the former, dry and bracing, invites to exercise and promotes digestion, and thus strengthens the system ; while the latter favours the excretions, particularly that of the skin, and preserves the body from those sudden changes of temperature which in our island so often lay the foundations of scrofulous affections. But when an individual whose constitution has been formed in a warm climate is removed to a cold and variable one, the occurrence of scrofula is exceedingly frequent; convincing proofs of which are every day afforded by those natives of warm climates who reside in our island, as well as by the diseases of birds, monkeys, and other animals which have been brought to us from warmer latitudes. (See Rey- naud, on the Diseases of Monkeys at the Jardin des Plantes. Archives Gen. de Med. t. 25.) In- deed it is not necessary for the inhabitants of warm climates to leave their native countries to experience the effects of a cold and variable atmo- sphere in the production of scrofulous disease : it is sufficient for them to ascend their own moun- tains, when they will be exposed to the same influences, and suffer the same evil consequences as if they had removed to a more northern cli- mate.* The information communicated by Dr. Ferguson regarding the diseases of the black troops in different situations in the West Indian islands, illustrates this point in a very interesting and satisfactory manner. (Alison, in Edin. Me- dico-Chir. Trans, vol. i. p. 398.) * In every latitude there is a point of elevation above the plains where the thermometer never sinks below 32° Fah. Even at the equator this exists at a height of 15,207 feet. See Suppl. to Encycl. Brit. art. Climate; also Humboldt, Geography of Plants. Among the causes which appear to give rise to scrofula in children, are the practices of rearing them by the hand and suckling them too long- two extremes, both of which often lead to the same result, the imperfect nourishment of the child. The former of these is a fruitful source of scrofula in England, the latter in Scotland, where it is usual among the labouring classes for children of sixteen and eighteen months to be still at the breast: in some instances we have known them suckled for upwards of two years. A similar injurious effect will be produced by allowing the same wet-nurse to suckle several children in suc- cession, which we have known to be pursued as far as three, when debility and symptomatic amaurosis forced the woman to resign her charge. Imperfect nourishment of the child, and consequent tendency to scrofula, is also likely to be induced in those cases where the wet nurse menstruates regularly during lactation. It is an opinion pro- fessed by Wiseman and other writers of great ability and experience, that a scrofulous wet-nurse may occasion the disease to appear in the child to whom she gives the breast; and the idea appears consistent with reason, not on account of the exis- tence of any scrofulous poison, capable of being imbibed by the infant, but because it is natural to suppose that the milk of a scrofulous female will not afford the same substantial nourishment as that of a woman in sound and vigorous health. [When a close investigation is made, it will be seen, that infants of the scrofulous habit display evi- dences of imperfect formation—Dr. Stokes says— of arrest of development. Their development re- sembles, in some respects, that of the foetus prior to the seventh month of intra-uterine existence: the abdomen is prominent; the liver large; the head large ; and the extremities small. The writer has always entertained the view, that the condi- tion of the system is such as to require an in- crease of the plastic powers ; and a radical error appears to him to have been incurred by those who apply to all scrofulous inflammations the rigid system of regimen and therapeutics which arc adapted for ordinary phlegmasia?. These views have been strengthened by the observations of recent histologists. It has been remarked by Gerber, ( General Anatomy, by Gulliver, London, 1842,) that "albuminous or unorganized tuber- cles (which with great propriety are called scrofu- lous tubercles,) can only be produced from exuda- tions abounding in albumen, poor in fibrin," and such exudations, it need scarcely he said, are more likely to take place from blood itself defective in the fibrinous or essentially plastic element] Another case of this disease is confinement in ill-ventilated apartments; for the deficiency of pure atmospheric air cannot be long endured, i especially during youth, without the most injuri- ous consequences. While the frame is building up and the constitution acquiring that character which is to distinguish it through life, all the processes of the economy are peculiarly active, and any defect of what is to perfect the animal fluids and give energy to the nervous power, is felt with greater force, and is productive of much more injury than at an after period. Ill-aired apart- ments are in general imperfectly light, and the want of this vivifying influence of light favours SCROFULA 139 the formation and development of scrofula; for the human body requires a certain exposure to light for the proper performance of its function, little less perhaps than plants, although in them the loss of colour renders the effects of seclusion more strikingly manifest. The experiments of Edwards on the spawn of frogs and on tadpoles clearly j demonstrate the agency of light on the formative processes of living organization. He found when the light was excluded that the eggs were never fully hatched, and that tadpoles did not undergo their transformation at all, or did so after a con- j siderable delay ; but their size increased, although \ they were kept in darkness. (De l'lnfluence des Agens Physiques sur la Vie, p. 398 et seq.) In ' accordance with the results of these experiments,' it has been observed that monstrous births are exceedingly frequent among the miserable occu- pants of the dungeons under the fortifications of Lille. (London Medical Gazette, Sep. 29, 1832.) We may in part ascribe to the deficiency of light the prevalence of scrofula among the inhabitants of cellars and of narrow alleys, where the beams of the sun never gain admittance. We are even inclined to think that the custom now so general among the wealthier classes in this country of sitting in darkened rooms during the day is far from being conducive to vigorous health; and where the young are concerned, we do not hesi- tate to say that it must be injurious. It is a custom borrowed from the luxury and effeminacy of warmer latitudes, and one which is calculated to enervate the body and induce a tendency to strumous disease. In a great metropolis like London, where the moving crowds of human beings and the number of carriages are such that children cannot be allowed to go abroad in the streets, they grow up feeble and often scrofulous ; while in villages and even in some populous towns, where they are almost constantly at play in the open air, they prove healthy and vigorous. The mischievous effects of the want of air, and sun-light, and healthful exercise, may be seen among the rich as well as the poor, though not to the same extent. The confinement, mental fatigue, and anxiety to which female children in particular are so unre- mittingly subjected during their education, prove fertile sources of scrofula in boarding-schools, and even in the families of the higher classes: bodily health is too often sacrificed to the idol of accom- plishment, and the intellectual powers, perhaps originally of excellent quality, are forced into a state of extreme culture and morbid precocity, destructive of all genuine soundness and vigour. Acute diseases, especially those accompanied with cutaneous eruptions, as small-pox, measles, and scarlet-fever, are often observed to have the effect of producing the development of scrofula ; and the more tedious the convalescence, the more frequently do symptoms of this disease ensue. Various other causes of debility prove the means of developing scrofula — as long watching, pro- tracted anxiety of mind, severe study, especially in the young, habits of dissipation, excess in sexual indulgences, solitary vice, profuse discharges of all kinds, repeated syphilitic disease ; the abuse of mercury, of narcotics, of warm bathing, and of powerful evacuants. Different local irritations have the effect of causing the neighbouring lymphatic glands to swell, and where a strumous tendency exists, to become the seats of tubercu- lous deposits, as we see exemplified in the con- sequences of difficult dentition, and of the in- flammatory affections of the mucous membranes of the respiratory and alimentary canals. Too great indulgence in sleep has been enumerated among the causes of scrofula, and excess in this particular will certainly debilitate and thus dis- pose to the disease; but we are inclined to believe that the indulgence in sleep which appears to in- duce scrofula is, in fact, usually occasioned by that feeling of weakness and exhaustion which is among the earliest symptoms of the approaching development of the disease. [Nature.—The pathology of scrofula, and the definition of the term, are differently expressed by different authors. Some define it to consist essen- tially of inflammation of the lymphatic ganglions, especially of those of the neck. This acceptation, however, is too incomprehensive, and expresses but imperfectly the grand characters of the disease. Although inflammation of the ganglions, and chiefly of the cervical, is very common in scrofu- losis, it is often absent; and it can only be re- garded as a functional expression of the morbid diathesis. The disease, as has been shown, often expresses itself elsewhere, as in coxalgia, white swelling, vertebral caries, &c. &c. Scrofulosis is a morbid condition of the whole system of nutri- tion ; and hence, ought to be classed amongst the cachexia?—the inflammation and enlargement of glands, like the eruption in variola, rubeola, &c. being merely attendant phenomena. The lymphatic ganglions are liable to simple inflammation from ordinary irritation. A thorn, run into the finger, may cause enlargement of the ganglions in the axilla ; inflammation or irritation of the mucous membrane of the intestines may give rise to mesenteric ganglionitis, owing to the extension of 1 the irritation to the lymphatic ganglions that are seated between the irritated part and the centre of the lymphatic system. In like manner, nutri- tive irritation, occurring in one of a scrofulous diathesis, may occasion inflammation of the same glands ; but, being general in its influence, scrofu- losis may express itself in various other forms besides ganglionitis. With some, it has been a question, whether it be not dependent upon a morbid state of the blood. This is not probable, inasmuch as the disease, or rather a tendency to it, must exist prior even to the formation of blood. An impulse to it must be present in the materials furnished by one or both parents at a fecundating copulation; which impulse may persist and be developed at an after period of the individual's existence. This tendency may not be received in sufficient force from the parents to be developed in their immediate progeny; but, like facial re- semblances, may be strongly exhibited in the grandchildren. Some writers, among whom is Dr. Stokes, (Lectures on the Theory and Practice of Physic, 1st Amer. edit. p. 311, Philad. 1837,) place scrofulosis in the system of white vessels; in which, according to them, the lymphatics exe- cute the function of veins. This view, however, implies a something which probably has no ex- istence—white blood. The want of colour in cer- 140 SCROFULA. tain of the tissues, as in the conjunctiva and serous membranes, is probably due to the thin stratum of red blood circulating in their vessels, which tenders the colour inappreciable. A very thin stratum of any coloured liquid, viewed by transmitted light, appears to be colourless ; but if the quantity of liquid be increased, the colour becomes manifest. This is what occurs in in- flammation of the white tissues : the quantity of red blood in the vessels is increased sufficiently to render its colour perceptible—not that there is an enlargement of arteries, destined in health to con- vey white blood, so that they now admit red cor- puscles, as supposed by some. There would, in fact, seem to be no white arteries, and, conse- quently, no white veins. Were such vessels to exist, they would be liable to constant obstruction from the red corpuscles. The function executed by the lymphatics would seem to be to break down the old tissues and convert them into lymph —a fluid essentially the same in every part of the lymphatic system—which eventually enters the circulation. They are engaged in the great pro- cess of assimilation, or in the decomposition and renovation of the tissues. Scrofulosis, then, must be regarded as a peculiar morbid condition of the whole system of nutrition.] Treatment.—The treatment of scrofula natu- rally divides itself into the preventive and cura- tive, the former of which is the more generally successful, and obviously the more important. All children are liable to become scrofulous, and those more especially whose parents or near rela- tives are the subjects of this disease. Hence par- ticular attention is required to prevent the forma- tion of the strumous constitution in children, and the development of the disease in those who may from birth be marked by this peculiarity of organ- ization. Indeed, it will not be undeserving of our care to influence as far as we can the sound and perfect formation of the embryo, by more than ordinary attention to the health of the mother during her pregnancy, wherever there is reason to apprehend the existence of a scrofulous disposition. When the child of a scrofulous father is born, the infant, unless the mother is free from all traces of the disease, ought to be consigned to a wet- nurse of sound and robust constitution, having an abundant supply of milk. This alone ought, for some months, to be sufficient for the nourishment of the child; but after a time, should it appear delicate, a little isinglas jelly may be allowed in addition, or liquid yolk of egg, or beef-tea, to- gether with some preparation of wheaten meal or flour, or pure starch. Daily immersion in cold water, and gentle friction of the whole body will be found of great utility. The child ought to bo warmly clothed, to be carried about in the open air as much as possible, and the apartment in which it sleeps ought to be kept at a steady mode- rate temperature, and perfectly well ventilated. All rooms occupied as nurseries for children ought to be spacious and lofty, never situated in a sunk floor nor in an attic, and, if possible, considerably above the level of the ground—directions which will be readily understood, when it is recollected that low rooms arc ill ventilated and often damp, while those in the attic story are particularly liable to variations of temperature. I As the child grows up, a similar plan of man- ! agement will be found to avert, as far as it can be | accomplished, the formation of a scrofulous habit, and the development of the disease in those who I exhibit that tendency. A plain and nutritious ' diet, containing a larger than usual proportion of ' animal food, warm clothing, daily exercise in the ' open air, the cold plunge-bath, cool and well-ven- tilated rooms, moderation in the pursuits of plea- sure, of study, and of business ; strict temperance 1 and virtuous habits; may be said to comprise all that is most likely in our mode of living to give protection throughout life against the occurrence of scrofulous disease. To those in affluent cir- cumstances who can be removed to a climate more genial than that of Britain, such a change, if judiciously made in early life, will confer a still greater security from scrofula. (Dr. James Clark, On the influence of Climate. See also art. Cli- mate, in this work.) When a well-marked strumous tendency ex- ists, the management of the mind urgently de- mands our attention; and attempts ought to be made at a very early age to correct whatever is deficient or excessive in its operations. Children who are of a dull and apathetic character ought to be roused by presenting to them objects which are likely to interest and enliven, while the ardour of others in the pursuit of knowledge should be cautiously repressed; and when the genius gives promise of unnatural precocity, means should be used to retard the unfolding of the mind, and allow the faculties to mature themselves by slow degrees. The moral feelings, in an especial man- ner, require a strict control for the purpose of giving them a just direction, and preserving indi- viduals of a sensitive character from indulging in those extravagant manifestations of sensibility which, if permitted, are apt to endanger the soundness of the mind. Before proceeding to consider the cure of scro- fula, it will be necessary to direct our attention to the different conditions of those who are afflicted with this disease. It is frequently engrafted on a feeble and attenuated frame; but it exists also in combination with a plethoric habit, perhaps deceiv- ing with a false show of strength; the first of these forms being often exemplified among the poor, the second among the rich, although not by any means uniformly so. Hence a broad line of distinction arises between the methods of treat- ment adapted to such different types of the dis- ease. In the former a generous diet and stimulat- ing remedies are required; in the latter spare living, moderate evacuants, and local depletion are necessary : both, however, demand the em- [ ployment of those tonic means which tend to j communicate vigour to the constitution, and which increases that power of resisting the occasional j causes of disease and repairing the injuries of the ■ frame, a power which it is the remarkable | characteristic of the scrofulous constitution to be devoid of, or to possess in a very imperfect degree. | To consider in detail, the method of treating each of the extensive class of strumous affections would involve us in the repetition of what will be found under various specific heads of disease, and swell the present article far beyond its due limits. It will be sufficient, after premising a few general SCROFULA. 141 remarks, to pass in review the chief of the numer- ous remedies which have been held in estimation for the cure of scrofula ; pointing out, as we pro- ceed, the particular circumstances under which they have appeared to produce most benefit. The management of scrofulous patients, in respect of air, exercise, clothing, and diet, must be conducted upon the principles already laid down, but varied according to the exigencies of each individual case, still keeping steadily in view the improvement of the constitution. On the subject of diet it is deserving of notice that, besides those varieties before alluded to, a very nourishing food may be prepared by boiling a small bag filled with suet in cow's milk. We have made trial of it on the recommendation of Dr. Paris, (On Diet, 2d edit.,) and found it to answer remarkably well in cases of scrofulous marasmus when almost every other article of diet caused irritation of the bowels, and passed through undigested. It bears a near resemblance to goat's milk, but has the advantage of being more as- tringent. Some eminent writers have not hesitated to state their belief that air, exercise, and proper clothing and diet, comprise the best and only method of controlling and removing scrofula. To such an opinion we cannot subscribe, although we fully acknowledge the vast importance of attending to these particulars, and the natural progress of cases of external scrofula towards a cure, after the age of puberty. An amusing in- stance of the effect of air and exercise alone in the cure of a scrofulous sore in the leg is afforded by the case of a young nobleman, who, after suffer- ing under a variety of regular treatment, had a hole cut in his stocking, and was sent to range the fields, when a crust soon formed, and the ulcer healed. It is worthy of remark that this indivi- dual became afterwards insane. I. Evacuants. — Although it be true, in a general sense, that scrofula is a disease of debility rather than of strength, and that profuse dis- charges, whether natural or artificial, prove among the most powerful of its exciting causes; yet in the early stage of many scrofulous diseases, and sometimes during their progress, a cautious em- ployment of evacuants is found to be productive of the best effects; but it is only by a careful study of the existing symptoms of inflammation in each individual case that we are enabled to make use of depletory means with confidence and success. In strumous persons the occurrence of inflammatory symptoms is to be watched with unceasing care, and above all those of the respira- tory mucous membrane, as well as of the serous membranes of the head and abdomen: a well- timed venesection in such cases may be the means of cutting short symptoms which would speedily induce the eruption of a crop of tubercles ; on the fatal consequences of which, whether slow or rapid in their progress, it is unnecessary to en- large. Leeches are often preferred from the timidity of patients and their friends, and some- times perhaps from the indolence of medical Attendants; but their effects are frequently irritat- ing and exhausting, and, even in children, far inferior to those of the lancet. Cupping is also preferable to leeching, the ease and rapidity with which blood can be taken by this method placing it nearly on a level with venesection. The de- traction of blood from the vicinity of parts suffer- ing from scrofula, or in danger of becoming the seats of scrofulous affections, is in very many cases necessary; and in these both leeches and cupping may be employed, but under the guidance of a wise discretion, for which no general rules can be given. To promote the efficacy of san. guineous depletion, and supply its place when circumstances render it unsuitable, the tartrate of antimony may be exhibited in small doses, as a nauseant and diaphoretic; and it will sometimes be necessary to have recourse to this remedy during the progress of the tonic plan of treatment when it appears, as often happens, to be pro- ducing too much excitement The tartrate of antimony or ipecacuan is also used, with excellent effects, in emetic doses, for the purpose of pre- paring the stomach for the reception of tonic medicines in many scrofulous cases. Long-continued nausea, whether produced by sea-sickness or by the persevering use of tartar- emetic, has a powerful effect in dispersing indolent tumours, and has been successfully employed for that purpose. Two cases of this nature, and one of presumed tuberculous phthisis, cured by the use of nauseants, have been communicated by Dr. Jenner ; and he has expressed a hope that by such remedies we shall be enabled to affect the absorption of tubercles. (Baron's Inquiry, pp. 158, et seq.) All that we know of the action of the absorbents leads us to believe that they are capable of removing tubercles; and that such an operation, to a certain extent, does really take place, is proved by the changes which that sub- stance undergoes in its progress to the cretaceous transformation. If tuberculous masses of long standing are thus changed, what reason have we to doubt that the soft curdy matter of which they are at first composed is often absorbed and carried back into the circulation, to be converted into some less noxious constituent, or altogether ex- pelled from the system ? The action of strong purgatives is sometimes, though rarely, required in scrofulous diseases; but the neutral salts combined with the administration of mercurials are very useful, as we shall presently point out. Moderate aperients, and those which tend at the same time to improve the powers of digestion, are required in the treatment of almost all scrofulous cases. Rhubarb and soda, and rhu- barb and magnesia are well adapted to such cases; and as a mild evacuant, when the bowels are loaded, castor oil is very serviceable. 2. Mercurials.—Of all the remedies employed in the treatment of scrofula, perhaps none have enjoyed a greater reputation than mercurials; but it is only from their purgative and alterative effects that they prove beneficial, and not when they pro- duce that powerful influence on the frame which so rarely fails to ensue from their free exhibition. In the forms of calomel and blue-pill, mercury enables us to relieve the bowels from those morbid accumulations which are so apt to collect in stru- mous cases, and to restore to the liver its healthy action, which is rarely preserved, at least for any length of time, during the existence of scrofula. The success of a mild alterative plan of treatment, 142 SCROFULA. aided by the use of saline purgatives with senna, has been admirably illustrated by Mr. Abernethy (On the Constitutional Origin of local Diseases) ; and more exclusively in reference to the disease now before us by Mr. Lloyd. (On Scrofula.) Other mercurial preparations are also employed with benefit in different forms of scrofula: thus the hydrargyrum cum creta will be found very serviceable when the secretion of bile is faulty or deficient, whether combined with a torpid or re- laxed state of the bowels, as in the early stages of mesenteric disease. The internal use of corrosive sublimate is also valuable, particularly in scrofulous ulcerations and leucorrhceal discharge; provided it be administered cautiously and in minute doses such as the eighth of a grain three times daily. It seems to act rather by stimulating the mucous membrane of the alimentary passages, and pro- moting perspiration, than by any influence it exerts over the secretion of the liver. Mercury has like- wise been employed in the form of ointment, rubbed on the skin for the relief of scrofula, and, according to the report of Mr. Brandish (On the Use of Caustic Alkali in Scrofula, &c), with the most beneficial effects. It was his practice to use it in small quantities, continued nightly for months, but never during the cold season; it is proper to add that he avoided the full operation of the mineral, and combined its employment with the internal exhibition of liquor potassa?, with a gener- ous diet, and the occasional use of vegetable tonics. Of this practice in cautious and experienced hands, we are inclined to think favourably, although it must be admitted that medical opinion in the pre- sent day is adverse to the employment of mercu- rial frictions in scrofulous cases generally. But the local application of camphorated mercurial ointment to diseased joints and indurated testicles is now acknowledged to be in very many instances highly efficacious. (Scott, Observations on the Treatment of Chronic Inflammation, &c.) As a sequel to the subject of mercurials, it will not be out of place to mention another remedy, less hazardous in its operation, but not of less ap- proved efficacy in scrofula,—namely, sarsaparilla. We find it recommended by Wiseman (Vol. i. pp. 410 et seq), and after a period of neglect it has been again restored to merited favour. It is a mild tonic, and well adapted to those cases where the skin is in a harsh and unkindly state: it proves a restorative to the stomach, and is found very use- ful in the chronic diarrhoea of strumous children. The decoction is the usual form in which this drug is exhibited, but the bulk of this preparation often renders it objectionable, particularly for chil- dren ; and in most cases, both of children and adults, a much more concentrated preparation, such as the solid or fluid extract, will be found to possess many advantages. Powdered sarsaparilla, conjoined with soda, is an excellent form, though much less palatable than the extracts: it has been given with marked benefit in scrofulous disease of the tongue. A feeble digestion, and prevailing acid condition of the stomach and alimentary tube, are the fre- quent concomitants of scrofulous disease; hence the employment of the alkalies and alkaline earths, but particularly the former, has been attended with very beneficial effects in its treatment All the alkalies have been used with advantage in scro- fula; but the liquor potassa? is that which in our hands has proved the most decidedly useful. The dose must be large, as Mr. Brandish has shown— from half a drachm to a drachm and a half three times daily, for an adult; given in malt tea, mild ale, or infusion of hops. (Brandish, Op. cit.) Carbonate of soda is generally more agreeable to patients, and may be given freely with good effect, especially when combined with sarsaparilla, cin- chona, or bitters. The volatile alkali (carbonate of ammonia) has also been administered in scro- • fulous cases ( Charles Armstrong, on Scrofula), and with excellent results. But its stimulant and dia- phoretic properties render it suitable only for cases in which there exist torpor, languid circulation, impaired appetite, and a dry husky state of the skin, such as we often meet with among the poor, and in that form of the disease so well character- ized by Alibert (Nosologie Naturelle), under the designation of scrofule nomie. A considerable number of the remedies which have enjoyed reputation in the treatment of scro- fula, have belonged to that class which increase the secretion of urine. The alkalies which we have just considered are of this description; and besides these, we may enumerate the muriate of lime, the muriate of barytes, and nearly all the mineral waters to which scrofulous patients are in the habit of resorting. These saline remedies not only promote the secretion of urine, bnt act gently on the bowels, and thus, especially when conjoined with the exercise and free air enjoyed at a water- ing-place, increase in a remarkable degree the powers of digestion, and so prove beneficial to the scrofulous invalid. In their specific effects we have no confidence. Muriate of barytes is now very rarely prescribed; and muriate of lime almost. as seldom, excepting in the combined form in which it is furnished by nature at various mineral springs. The opinions which we have already expressed regarding the nature of scrofula may have pre- pared our readers to look for the most valuable remedies in this disease under the head of tonics. Even inflammation, which in most cases requires depletory measures, is, when combined with scro- fula, and thus rendered indolent in character, often successfully treated by tonic remedies; this ii especially true of those inflammatory affections which are attended with little or no constitutional disturbance, as in strumous inflammation of the conjunctiva, where the efficacy of cinchona has so long been acknowledged. This admirable drug is, without doubt, the most efficacious of all the tonics used in scrofula, and, from the concentrated form in which it can now be exhibited, the roost generally available. The virtues of cinchona in strumous diseases were first brought into notice by Dr. Fordyce, (Medical Obs. and Enquiries, vol. i. p. 184 ; see also Fothergill, ibid. p. 303,) and from that time until now it has enjoyed more or less favour. Sulphate of quinia has now very generally superseded it, having become a remedy of every day prescription. It is one, however, which requires to be carefully watched and imme- diately intermitted when it produces, as it often does, a degree of feverishness. Other vegetable tonics and bitters have been administered with SCROFULA. 143 advantage in scrofula, such as calumba, gentian, and hop; and in Germany, coffee made from roasted acorns has found many advocates, although, as Benedict (Handbuch der Practish. Augen- heilkunde) informs us, it often proves consti- pating and induces a feverish state. [Of late, different preparations of the leaves of Juglans Regia, walnut tree, and especially the extract, have been highly extolled by M. Negrier as anti-scrofulous remedies. (Archiv. Gdneral. de Med. x. 399, Paris, 1841.)] Of the metallic tonics used in scrofula, iron is that which has been found the most beneficial. The best forms of exhibiting it are the vinum ferri, the muriated tincture, and the subcarbonate in powder : the chalybeate mineral waters also have often proved eminently serviceable in this disease. Arsenic is a metal of much more questionable efficacy; but we have known it productive of great benefit in allaying the pain attending stru- ' mous affections of the bones and periosteum. Gold was given by Lalouette in scrofula, and its use has lately been revived by Chrestien as a remedy for syphilis. [From recent trials, it would not seem to be possessed of such efficacy as to re- commend it to great confidence.] In the advanced stages of scrofulous affections, one of the most permanent and exhausting symp- toms is profuse perspiration ; for the purpose of checking which, the mineral acids, particularly the sulphuric and nitric, have been given with great benefit: their use, however, is apt to cause irritation of the bowels, and thus we are forced to alternate them with opium, or altogether to aban- don their employment. The root of the tormentil has been recommended as a substitute, but it seems, to possess very feeble powers of repressing either perspiration or diarrhoea. The mineral acids are also useful in restoring the tone of the stomach, and thus they frequently prove of great service in the treatment of scrofula. Scrofula as a chronic disease, often accompanied with febrile action of the stomach, and indeed, of all the assimilative organs of the system, seems naturally to require the exhibition of stimulating remedies. In regard to dietetic stimulants, ani-i mal food, as we have already stated, is proper in a large proportion of strumous cases, and in some ale and wine may be given with great advantage. Of these, ale is the more nutritious and less heat- ing, and when sound and well seasoned with ' hops, it proves in many cases a valuable auxiliary ; to the medicinal treatment of scrofula,—an opinion which is not given on theoretical grounds, or the mere authority of others, but from what we have had frequent occasion to observe. Bitter tinctures have been prescribed in this disease, and that of Peyrhile, which contains also a proportion of alkali, was long a favourite among the French. ' Its effects, however, are known to have been often injurious, because too stimulating ; and in the pre- sent day it is seldom or never employed. Iodine, a powerful stimulant of the alimentary mucous membrane, and of the whole absorbent system, has lately been added to the catalogue of anti-strumous remedies ; and as yet it can scarcely be said that a just estimate has been formed of its j real virtues. The evidence contained in the writ- ings of numerous authors, and the results of our own experience, prove satisfactorily that iodine possesses a very considerable efficacy in removing scrofulous swellings of the lymphatic glands; and there is some reason even to believe that it is capable also of inducing the absorption of tuber- culous deposits. (Gairdner, On Iodine, pp. 52 & seq.; also, Baron's Inquiry.) This remedy is successfully employed both internally and locally, in each of which modes it increases the action of the absorbents ; and in the latter it likewise often induces suppuration of strumous tumours, and thus hastens their removal. After attracting for a time the attention of the medical profession, iodine was beginning to experience a degree of neglect, when the appearance of M. Lugol's Memoirs re- stored its reputation. (Lugol, Memoires sur I'lode, Paris, 1829, 1830; and Dr. O'Shaugh- nessy's Translation, with Appendix.) His exten- sive series of experiments in the employment of this substance have placed in a very clear and convincing light the powers which it possesses of controlling and even curing scrofula. The trials which we have made of it serve to confirm the representations of M. Lugol; but we are ready to admit that his strong partiality in its favour may in some instances, perhaps, have led him a little beyond the limits of legitimate induction. For farther information regarding the employment of iodine in scrofula, we beg to refer to M. Lugol's last memoir, where a full account will be found of his most improved method of administering this powerful drug. Iodine, like arsenic and some of the mercurial preparations, is apt to cause pain of stomach, and in some instances headach; and when taken in excess, to produce an inflamma- tory condition of the alimentary mucous mem- brane, diarrhoea, and even bloody motions. The first of these symptoms is relieved by wine of cin- chona, but the others require that the remedy be discontinued; and when resumed, that the dose be reduced. In cases where iodine has produced debility and loss of appetite while manifestly re- ducing the scrofulous swellings, we have obtained a return of health and continued diminution of the tumours, by administering in its place sulphate of quinia with extract of sarsaparilla and aromatic sulphuric acid. The evidence of many practi- tioners, whose veracity and correctness of observa- tion are above suspicion, proves that iodine, when long continued in full doses, frequently produces great weakness and emaciation ; but M. Lugol is disposed to throw doubt on this opinion, and he even asserts that in his experience, thin females have not become emaciated, nor corpulent ones lost flesh. It ought to be remarked in explanation of this discrepancy, that the doses which he pre- scribes are usually small, always moderate, and much diluted ; and that he endeavours to accom- plish by long perseverance what others have at- tempted by rapidly pushing the remedy to its utmost limit. In these particulars, we conceive, consists the superiority of M. Lugol's mode of treatment. It is proper to state here, that he also avails himself in the treatment of scrofula, of tho auxiliary means of air, exercise, warm clothing, and good diet; and employs, besides, baths of watery vapour, of iodine, and of sulphureous water. 144 SCROFULA. [The general condition of the system in scro- fulosis might appear to suggest more especially the iodide of iron, in which eutrophic and tonic properties are combined. Accordingly, it has been extensively used, and with valuable results. Of this, a grain may be given three times a day, and the dose may be gradually raised to three grains. Codliver oil—oleum jecoris aselli—which has been found to contain iodine, has been given largely in various forms of scrofulosis, and there is much testimony in favour of it. One writer, Schenck, (Hufeland's Journalder Praktisch. Heil kunde, May, 1838,) esteems it as certain a remedy in scrofula and rickets, as cinchona is in intermit- tent fever. The writer has had no experience with it. Recently, skateliver oil has been recom- mended as preferable to codliver oil. In Holland and Belgium, the oils obtained from the livers of Raia clavata and R. batis have been used in place of the latter, on account of their being less dis- agreeable to the taste, and even more efficacious as a therapeutical agent It is said by MM. Gi- rardin and Preisser to contain a per centage more of iodide of potassium; and in point of purity and other properties, appeared to be superior to it. (Edinb. Med. and Surg. Journ., Oct 1842, p. 504.) Dr. Ure has suggested the use of codliver as a diet for those for whom the oil is considered to be indicated. (Pharmaceutical Journ., Nov. 1, 1842, or Braithwaite's Retrospect, vi. 104, Lond. 1843.) Bromine, whose properties resemble those of iodine, has been given in the same cases, but it pos- sesses no advantage over the other, and is by no means as easily attainable.] The use of baths in the treatment of strumous affections is of great value, the kind of bath made choice of being determined by the existing state of the patient. Sudden immersion in cold water, and especially sea-water, has long been an ap- proved remedy in scrofula ; but when the strength of the patient is so reduced that no kindly glow follows, and when there is decided feverishness, the cold plunge bath is not admissible. In such cases the warm-water bath, and still more that of vapour, will be found highly soothing and resto- rative. To weak scrofulous invalids, the well- managed application of steam has very often proved signally beneficial. A greater degree of excitement may be communicated to the cutane- ous surface, when the general torpor of the system or the indolence of the diseased parts demands it, by the employment of warm saline water, or im- pregnating the water or steam with irritating gases, such as sulphuretted hydrogen, carbonic acid, (see the Remarks of Prof. Osann on the Ga- seous Baths at Eger. Osann und Trommsdorf Die Mineral Guellen, etc., Berlin, 1822,) chlorine or iodine. The use of baths of every kind ought al- ways to be followed by friction, and this alone is a valuable mean of restoring the healthy actions of the skin, and furnishing a substitute for that bodily exercise which the condition of the scrofu- lous patient often disables him from using. In cases of abdominal obstruction and affections of the spine and joints of the extremities, the great benefit derived from friction is attested by all who have seen it carefully practised. Other modes of stimulating the scrofulous pa- tient are afforded by electricity and galvanism: hitherto these have been employed principally as local remedies for the dispersion of strumous swell- ings, and with excellent effects; (Underwood, Surgical Tracts.—Birch, on the Medical Applies- tion of Electricity;) but they will be found equally, if not more beneficial, as general means of exalt- ing the nervous energy, and improving the tone of the whole frame. Like all diseases occasionally attended with pain, scrofula requires at such times the use of narcotics, and, among these, opium under various forms of preparation certainly holds the first place. Hyoscyamus, belladonna, and conium, are also used with advantage ; and the last obtained at one period, through the writings of Dr. Stoeck, a parti- cular celebrity for its anti-strumous virtues. It has both as an internal and external remedy a consider- able power of relieving pain ; but none which we have observed of a truly discutient nature. Topical Treatment.—Of the local treatment of scrofula, it may be supposed that the physicians ought not to speak ; but, although this branch of ' the subject falls immediately within the province [ of surgery, we may yet be permitted to state ge- nerally our views regarding this matter. Long observation of scrofulous diseases has convinced I us that much active surgical interference is usually | injurious, and that mild and soothing modes of j treatment are, on the whole, more generally suc- cessful. Thus the laying open of sinuses, the cutting away of undermined integument, and the application of strong escharotic ointments, often exasperate instead of improving the case; while small counter-openings, moderate pressure, brush- ishing the integuments around ulcers and fistulous | openings lightly with nitrate of silver; and. the I application to strumous sores of bread-and-water poultices, astringent washes, lime-water, and the black mercurial lotion, proves very serviceable. When a scrofulous ulcer is highly irritable and | painful, the bruised fresh leaves of the hemlock applied as a poultice seldom fail to give relief. In ulcers of the tongue, carrot pulp and Peruvian | balsam are the best applications. [ Indolent scrofulous tumours, when the health is little reduced, may be dispersed or made to sup- purate by continued pressure or by blistering, which can be employed when the situation of the swelling will not admit of pressure. As soon as : suppuration has taken place, and the matter ap- [ proaches the surface, it ought to be evacuated by a small puncture, which will hasten the cure and diminish the chance of an unseemly scar. When the parts continue inflamed and hardened, poul- tices of bread and water, or rags dipped in cooling lotions, are the best applications; but when the discharge is considerable, finely carded cotton with gentle pressure checks the profuse secretion, and gives comfort to the patient. In those sudden depositions of fluid which sometimes occur in strumous cases, it is not always prudent to make an opening as soon as fluctuation can be detected; for by a little delay and soothing means we have not unfrequently known the fluid to be wholly absorbed. [When the strumous swellings are very indo- lent, along with the internal remedies, and re- SCROFULA —SEDATIVES. 145 giraen inculcated above, many local applications may be made use of to discuss them. Chlorinated lime has been applied with advantage in the form of ointment, as well as the aqua chlorini. Iodine has been used advantageously in the form of tincture, applied repeatedly by means of a camel's-hair pencil. The ointment of iodine, of iodide of potassium, of the ioduretted iodide of potassium, and of the iodide of lead, have likewise been used with advantage, rubbed on the part night and morning, and the iodo-hydrargyrate of potassium has been prescribed both internally and externally. An ointment of veratria has likewise been strongly recommended, but it has not been much employed.] The eczematous and impetiginous eruptions which occur in scrofulous individuals are greatly benefited by astringent applications, such as the liquor subacetatis plumbi and liquor aluminis compositus ; and when these diseases have proved obstinate, the unguentum picis will often com- pletely remove them. This last application we have found particularly efficacious in those crops of psydracious pustules and extensive exfoliations of the cuticle which are so frequently seen on the fingers of scrofulous females and delicate children. The tumid upper lip, so distinctive of scrofula, and often amounting to a deformity, may be greatly reduced or altogether removed by the re- peated application of nitrate of silver. When the ulcerated fissures of the lip are very painful, relief will be obtained from the hemlock poultice, and nitrate of silver can be afterwards had recourse to. Strumous enlargements of the tonsils were formerly treated by excision, and cases requiring this procedure do sometimes occur: the practice is as old as Celsus, and is still a favourite with the Baron Dupuytren; Dr. Hosack of New York has also lately borne testimony to the safety and advantage of this operation, [and it is now fre- quently — perhaps too frequently — practised.] When it is not absolutely demanded, the employ- ment of iodine, leeches to the throat, the light ap- plication of nitrate of silver to the tumours, and a gargle of oak-bark, will generally prove sufficient, if not fdr a complete cure, at least to keep the swellings within moderate bounds. Scrofulous diseases of the bones and joints require, in their first stage, local depletion, and at a more advanced period counter-irritation by croton oil, blisters, tartar-emetic ointment, caustic issues, or moxa. The warm-water douche and careful friction are also eminently useful in indolent cases. A very successful plan of managing dis- eased joints has of late been made public by Mr. Scott, (Observations on the Treatment of Chronic Inflammation, &c.,) — consisting of the applica- tion of camphorated mercurial ointment, pressure, and complete rest of the affected articulation with- out confinement of the patient. When all hope of recovering a diseased portion of the body is at an end, the question immediately presents itself whether such part ought not to be removed by an operation, and the patient thus freed from what is in itself useless, perhaps burden- some, the cause of constant irritation, and in many cases of exhausting discharge. Scrofulous bones and joints are peculiarly of this description, and Vol. IV.—19 s the question of their amputation is seldom deter- mined without the concurrence of the physician. It has been asserted that amputation in such cases merely puts off the evil day, and that the patient, at no distant period, is destroyed by scrofulous disease of some other and more important organ ; but the futility of this opinion is daily attested by the numerous living instances, not only of those who have suffered amputation for scrofulous affec- tions in early life, but of multitudes of others who have survived with contracted and distorted limbs from the ravages of the disease. In considering the propriety of amputation, it is necessary to de- termine how far the continuance of the affection brings the patient's life into hazard, and whether he has still sufficient strength left to undergo the operation. It is truly surprising to observe how small a degree of vital force is adequate to carry a patient safely through an operation under such circumstances; but it must be remembered that amputation, severe as it certainly is, removes the very sources of irritation and exhaustion which are rapidly undermining life. This operation is nugatory when another joint, or a vital organ, as the lungs or bowels, is already the seat of incurable disease; and in such cases unquestionably it should not be performed. Great caution, however, is required in making our final decision ; for every practitioner of experience has seen instances where the symptoms of visceral disease appeared almost to preclude hope, and yet have yielded on the removal of the local irritation, and a cure has been the happy result. Trr ~ W. Cumin. SEDATIVES, from sedare, to calm. These are medicines which directly depress the energy of the nervous system, and diminish preternaturally increased action. They exert an immediate in- fluence over the nervous system, by which its energy is either greatly weakened or wholly de- stroyed. They thus have a twofold action, first, upon the nervous system, and, secondly, through it upon the muscular: if the dose be large, the indi- vidual quickly loses his volition and becomes vertiginous; the nerves of sensation cease to respond to ordinary impressions ; consciousness fails; syncope supervenes, and in a few seconds life is extinct. With the exception of Dr. Young (Introduction to Medical Literature,) and Dr. Billing,* medical authors in general have confounded sedatives with narcotics. There is no doubt, however, that the distinctive characteristics of both classes are well marked, and that the boundaries of each may be readily traced. The only circumstance, indeed, which has prevented the distinction from being at all times perceived, is the transitory nature of the excitement which follows a large dose of a narco- tic, and the rapidity with which the symptoms of diminished sensibility and mobility supervene, as if they were induced without any previous in- creased action. In the operation of every narcotic the depressing effect, therefore, is preceded by in- creased action; and both the degree of the col- lapse and the rapidity of its appearance depend on the extent of the previous excitement. In * First Principles of Medicine, p. 44. [The separation is made by the writer in his General Therapeutics, Phila- delphia, 1836 & 1843.] 146 SEDATIVES. small or moderate doses, narcotics augment the force and increase the frequency of the pulse, pro- mote the secretions, and elevate the powers both of .the body and the mind, and if these doses be repeated at proper intervals, this excitant effect is maintained ; but, if the dose be not repeated, the transitory nature of this excitement becomes con- spicuous, and a state of depression or collapse fol- lows, in which languor, dullness of sensation, and sleep ensue. Such are the effects of a narcotic. The admin- istration of a sedative, on the contrary, whatever be the dose, is not followed by any perceptible quickening or augmentation of the pulse, but by an immediate diminution both of its force and frequency, and by a general feeling of depression, too decided to be overlooked. It is, indeed, evi- dent that this effect is exactly the opposite of that of an excitant: and if the dose be large, not only is the sensibility diminished, but the whole power of the srnsorium is at once completely paralyzed. We are perfectly aware that Magendie and others regard the sedative influence of one of the most efficient of this class of medicines, the hydrocya- nic acid, as that of transient excitement, followed by an immediate state of collapse; but the result of our own experiments on living animals is ad- verse to this supposition : the instantaneous dimi- nution of the general powers of the system, the prostration of strength, the stupor, numbness, sleepiness, vertigo, and depression of the animal spirits, all indicate an immediate influence on the nervous energy. With these observations in view, and with the experiments of Mr. [Sir B.] Brodie on some poisonous substances before us, we may venture to assert that it is upon the nerves of sen- sation chiefly that direct sedatives operate. When sedatives are taken into the stomach, if they do not destroy life, their influence is much weakened after a certain time has elapsed, and soon afterwards it altogether ceases. It may, however, be maintained in the same manner as that of narcotics, by the repetition of the dose at moderate intervals ; but the impression becomes weaker after each renewal of it, until it is almost lost, unless the dose be greatly augmented. If these statements be correct, it is evident that seda- tives operate directly on the nerves of sensation, and that this effect is not the result of a stimulus rapidly exhausting the excitability of the nerves, but of a direct impression of a peculiar kind on the nervous system, which instantaneously de- stroys the susceptibility of the nerves for receiving impressions from external stimulants. Owing to the ideas which we acquire in early life, the effects of excitants are connected with mechanical impressions, and, therefore, the mind has less difficulty in admitting the hypothesis that every instance of collapse must be preceded by a previous state of excitement, than that something is either abstracted from the nerves, or that some alteration takes place in these organs, which di- minishes their faculty of receiving impressions, It is true that no organic change can be detected in the nerves of animals killed by sedative poisons, and we are equally unable to affirm from inspec- tion that any thing has been abstracted from them, yet that some change has occurred is undoubted, as they are no longer susceptible of being excited. Whether we can assume that the sedative effect is immediate, not secondary, is questionable: but wc imply its direct character from the local effect of powerful sedatives where they are applied in small quantity to a limited portion of the surface of the body ; as for example, if the finger be held over the mouth of a bottle of hydrocyanic acid, it is numbed, and it continues so for a considerable time without any extension of this effect to the rest of the body. When the quantity is larger, their influence ceases to be partial, and is extended over the system : and when it is very large, the same rapid destruction of life follows as when the sedative is taken into the stomach. Sedatives con- sequently differ from many of the other classes of medicines, in their effects being more regulated by the extent of the dose than by the state of the body. Upon the whole we conceive that there are sufficient reasons for separating sedatives from narcotics, and allotting to each a distinct place in the arrangement of the materia medica. Let us examine their influence, as physiological agents, on the different organs of the living sys- tem. 1. On the Digestive Organs.—No sensation in the stomach is experienced when a sedative is taken into it, except occasionally that of nausea: the influence of the sedative is rendered obvious rather by the change which follows in the state of the digestive function than by anything which can be referred to the condition of the organ itself. If the viscus be morbidly irritable, the influence of the sedative is acknowledged by the diminished susceptibility of the gastric nerves, by the improve- ment of digestion from the lessened irritability fa- vouring the formation of a more healthy, because more slowly secreted, gastric juice. In this respect, when the dose is moderate, the direct influence of the sedative is local and con- fined to a certain set of nerves, although the gene- ral system ultimately benefits by the change thus affected, a fact daily illustrated in the administra- tion of hydrocyanic acid in dyspepsia; whereas the influence of narcotics is invariably propagated over the system, even when they are administered in small doses. If the dose of the sedative, however, be in- creased, the impression then extends to the brain, and is manifested by slight vertigo, transient in- sensibility, sinking of the pulse, failure of the muscular energy, particularly in the thighs, gene- ral lassitude, and mental depression. If the dose be larger, but within the limit of a poison, it must be admitted that sensations, for example weight and an obtuse pain in the forehead, are super- added, which seem to indicate previous excite- ment ; but that this has not existed is highly probable, since we know that coma may proceed from inanition as well as from increased action in the brain, and that stimulants are frequently re- quisite to relieve symptoms closely resembling those requiring venesection and depleting reme- dies. Taken into the stomach, therefore, sedatives operate directly upon the nerves of that organ, and, within a certain limit with respect to dose, the effect which follows is strictly local. 2. On the Circulating and Respiratory Organs—When the influence of a sedative ex- tends to the general system, the action of the SEDATIVES. 147 heart and arteries is diminished, but not in the ratio of the impression on the nervous system. Schubarth asserts that the heart loses its con- tractility, but the experiments of Coullon, (Re- searches, &c. p. 146,) with which those of the author accord, lead to an opposite opinion. In poisoning by hydrocyanic acid, the heart contin- ues to pulsate, and the intestines continue to dis- play their peristaltic and vermicular movements after the death of the animal, and they do not lose their contractility for some time; at least such is the case when hydrocyanic acid is taken, and it is probable that the same occurs when other seda- tives are employed. As far as relates to the lungs, if sedatives be applied directly to them either in the form of gas or of vapour, the effect is both more rapid and more decisive than when they are swallowed ; the respiratory function is almost instantaneously suspended ; no change takes place in the blood, which retains its venous character, and, on examining the organs, nothing is perceived which can authorize the idea of ex- citement having existed : death, in fact, is the result of the complete destruction of muscular irritability. When taken into the stomach, the action of sedatives on the lungs is greatly modi- fied ; the blood, however, remains dark-coloured and retains its fluidity. 3. On the Nervous System.—It is unne- cessary to repeat that the nerves are the organs on which the influence of sedatives is chiefly and directly exerted ; but little is known with regard to the nature of the impression, except that it is different from that of any exciting agent; and after the most minute inspections of the brain, the spinal cord, and the nerves, in cases of death from poisoning by sedatives, no other conclusion has been arrived at Whatever may be the impres- sion, it is assuredly not that which is followed by excitement 4. On the Secerning System. — Sedatives produce effects which, to an ordinary observer, might seem almost at variance with the foregoing opinions : thus, salivation has occasionally fol- lowed the employment of hydrocyanic acid; (Lond. Med. Journ. Feb. 1823, p. 128,) and the secretion of urine is not unfrequently greatly augmented by whatever produces a sedative effect on the system. But such results do not necessa- rily imply previously increased vascular action in the salivary glands and the kidneys : thus we know that in the lowest condition of the nervous excitability in fatuity, salivation is one of the most ordinary attendants, and under the influence of fear and other depressing passions, nothing is more common than a sudden and copious secre- tion of urine. Upon the whole, we have suffi- cient reason for concluding that there are powers which can destroy excitability and life without causing previous excitement, or, at least, without any signs of its being discoverable. This is not the result of the administration of narcotics, and therefore we feel authorized in forming a distinct class of sedatives. In treating of sedatives employed as therapeuti- cal agents, we may arrange them under two heads ; 1. direct, or those which operate by their immediate influence on the nervous system; and, 2. indirect, those which operate through the me- dium of the vascular system. 1. The first and most powerful of the direct sedatives is hydrocyanic acid.* This acid, as prepared for medicinal use, is one-sixth only of the strength of the concentrated acid, but it dif- fers from it in no other particular. It is colour- less, limpid, and has a penetrating odour, which causes headach, nausea, and fainting, when in- haled in considerable quantity by the nostrils. This odour has been erroneously compared to that of the peach-blossom,—an error originating from the odour of the volatile oil, which is, in some instances, as in the peach kernels, blossom, and leaves, and in the bitter almond, mingled with this acid. The odour of the free acid, when well ex- amined, cannot be confounded with that of the peach-blossom.-]- The pure acid is extremely volatile, and even the diluted or medicinal acid is so much so as to be greatly weakened when not carefully preserved. It is also spontaneously decomposed when it is not kept in a cool place: the best method of pre- venting this decomposition is to place the bottles containing it in water, or in porous jars saturated with moisture. In prescribing hydrocyanic acid, it is essential to know that it is decomposed by the aqueous solutions of chlorine and the oxides of antimony, and is precipitated by nitrate of silver and sulphate of copper. These substances are, therefore, incompatible in prescriptions with hydrocyanic acid, but it may be combined with the salts of iron if no alkali be present. This acid is the active principle of laurel-water, the distilled water of the leaves of the prunus lauro-cerasus ,- cherry-water, distilled from the bark of the cluster cherry, prunus padus,- the kirsch-wasser of the Germans, which is a spirit distilled from the fruit of the same species of prunus; and the oil of * This name is a compound of bSdp, water, and cyan- ogen, (a compound substance, named from Kvavoc, blue, and yevvaia, to produce,) signifying a produce of blue, as it gives the blue colour to the ferrocyanate of peroxide of iron, or Prussian blue. tThe plan of this work forbids any detailed account of the various methods proposed by Vauquelin, Gay, Lussac, Robiquet, Pessinau, Frantwain, and others, for preparing the medicinal hydrocyanic acid ; but it may be useful to describe the following processes, by which any practitioner can readily prepare it for himself. 1. Put into a wide-mouthed phial a solution of one part of bicyanide of mercury, dissolved in eight parts of distilled water, and pass through it a stream of sul- phuretted hydrogen gas, extricated in another phial from a mixture of equal weights of sulphuret of iron, and strong sulphuric acid, diluted with two parts of water. The gas must be passed as long as any sulphuret of mer- cury in the form of black powder is formed; the fluids then filtered, and any excess of sulphuretted hydrogen removed by agitating the solution with a little carbonate of lead, and filtering a second time. 2. Put into a phial twenty-two grains of cyanuret of potassium, and pour over it a solution of fifty grains of pure tartaric acid in six fluidrachrns of distilled water, and eight of rectified spirit. After agitating the phial occasionally, secure the stopper, and set it aside until the precipitate falls to the bottom : then decant the clear acid. The acid thus formed should contain one grain of hydrocyanic acid in every fluidrachnj, which is easily ascertained by adding in small quantities to a given portion of it peroxide of mercury finely levigated, as long as agitation enables the acid to take it up. By di- viding the weight of the peroxide dissolved by four, the quotient expresses the quantity of real acid contained in the diluted acid. No heat should be employed. [See the form for the preparation of hydrocyanic acid, in the Pharmocopceia of the United States.] 148 SEDATIVES. bitter almonds, now occasionally employed as a medicine, and very generally in confectionary.* But along with the acid in these and similar pre- parations, there is a volatile oil, the odour of which, as we have already stated, is very distinct from that of the hydrocyanic acid, is stimulant, and possesses poisonous properties nearly equal to those of the acid.f It is, however, not a direct sedative, but resembles a narcotic in its operation: thence the effects of the oil of bitter almonds and laurel-water differ considerably from those of free hydrocyanic acid. Concentrated hydrocyanic acid cannot be em- ployed as a medicine.^ The same circumstance, the powerful influence of this acid on the nerves of sensation, which renders it so awfully formida- ble when it is taken in doses sufficient to produce its poisonous effects, renders it in the hands of the prudent and well-informed practitioner, when its dose is judiciously regulated, its. administra- tion properly timed, and its effects are carefully watched, a remedy possessed of powers which cannot be obtained from any other substance, and it is therefore extensively employed. The use of hydrocyanic acid is indicated in diseases connected with a state of excessive or morbid sensibility, and those depending on a highly irritable state of the nervous system. This general statement is not solely influenced by the opinion which we maintain of its direct sedative power, and were the assertion that it produces at first a transient excitement capable of demonstra- tion, it would not affect in any degree the ad- ministration of the acid ; for as this excitement is said to be of a very transitory nature, it need not be taken into account in estimating the sedative powers of the remedy. In idiopathic fever, hydro- cyanic acid has been rarely if ever employed : it has, however, been supposed to act beneficially in hectic, moderating the force of the circulation and suspending the night-sweats which always accom- pany this symptomatic fever ;§ but, in reference to phthisis, the eulogy bestowed by some practi- * Hydrocyanic acid is found in the leaves and kernels of almost all the plants of the natural order Amygdalese, and in the pips of some of the Pomacete and Auranti- aceae; it is formed when copaiba is distilled with diluted nitric acid. f When the volatile oil of bitter almonds is redistilled, the first portion which comes over smells strongly of hydrocyanic acid, and affords indications of its presence when tested ; but it smells very faintly of the peach- blossom : the second portion exhales a more powerful odour of the peach-blossom than the first, but less of that of the hydrocyanic acid. The first portion operates as a powerful direct sedative in the same manner as free hydrocyanic acid ; the second, besides operating prima- rily as an excitant, produces violent convulsions when it poisons. What remains in the retort, if the distilla- tion have been carried far enough, crystallizes on expo- sure to the air, and absorbing oxygen, acquires all the properties of an acid: this is completely inert on the living system. Vogel has suggested that these changes depend on the process, and he supports his opinion by the fact that a quantity of bitter almonds, which, if made into an emulsion, may be swallowed with impuni- ty, when distilled would yield a product more than suffi- cient to destroy the life of one individual. T For an account of its poisonous influence on the animal system, as well as that of the diluted acid, the oil of bitter almonds, and laurel-water, with the modes of detecting these poisons and of counteracting their effects, we must refer our readers to the article Toxi- cology. § Historical and practical Treatise on the Internal Use of the Hydrocyanic Acid, &c. By A. B. Granville, M. D. &c. p. 5'J, 1*20. tioners on this acid has not been merited. Neither, with the exception, perhaps, of phrenitis, is it cal- culated for the relief of the diseases classed by nosologists under the title Phlegmasia?: even in phrenitis we have had no experience of its utility, but knowing that the inflammation of the mem- branes of the brain morbidly augments the general sensibility, as illustrated by the impatience of light and of sound, we are disposed to recommend its employment as an adjuvant to other remedies in this state of the brain. In pleurisy it has been found beneficial in moderating the cough, one source of exasperation of the inflammation of the serous membrane; but beyond this it has no pretensions to be regarded as a remedy in this disease. In the exanthemata, except as an external ap- plication, hydrocyanic acid holds forth no prospect of benefit In the state in which it is found in the bitter almond, it was employed as an external sedative so early as the time of Celsus in several external diseases; his formula in a painful pustu- lar disease, which he describes as peculiar to in- fants, is the following: " Iapidis, quern pyriten vocant, partes octo, cum quinquaginta amaris nucibus miscetur, adjiciunturque olei cyathi tres." (De Medicina, lib. v. c. 28, § 16.) But even as an external application, the volatile oil of bitter almonds requires to be used with much caution, and Coullen has recorded the case of a child killed by the leaves of the prunus lauro-cerasus, applied to a sore on the neck. (Researches, &c.) The free acid has been recommended by the author of this article in the proportion of f/jiii to f.Jviof bitter almond emulsion, as a lotion in impetigo or running tetter. In such cases also, when the irri- tability is very considerable, it may be combined with the acetate of lead according to the following formula : R. Acid, hydrocyan. f-^iv. Acet. plumbi, gr. xvi. Alcoholis, f.^i. Aqua? destillata? f.^viiiss. M. This lotion not only soothes the irritability of the diseased surface, but also disposes the skin to renew its healthy action, and is productive of the greatest comfort to the patient: it has been found very useful in prurigo inveterata, in the various forms of psoriasis, and several other skin diseases attended with itching and tingling. In passive hemorrhages no advantage can be expected from hydrocyanic acid ; but in active forms of the disorder, much confidence may be placed on the internal use of it. In hemoptysis, by rapidly augmenting the dose from three minims (the medium dose) to twelve minims, or until the pulse begin to afford indications of the deleterious influence of the medicine, we have seen the most happy results in the absence of any organic affec- tion. In phthisis, as we have said, the powers of hydrocyanic acid have been much overrated; nevertheless as a palliative it is not without its value. In small doses frequently repeated, it di- minishes the hardness and frequency of the cough, and lessens the general hectic tendency: but more is not to be expected from it in this respect than from some of the narcotics. It has, however, one advantage over narcotics, namely, that, besides moderating the cough, it frequently favours sleep SEDATIVES. 149 without exciting those sweats which are too often augmented when opium is employed. At the same time, as its tendency is to lower the powers of the system, it is in the early stages only of this disease that it can be regarded as likely to prove beneficial even as a palliative. Its employment in phthisis, in the combined state in which it is found in laurel-water, is, indeed, of no recent date, most of the old works on consumption enumerat- ing laurel-water amongst the means to be em- ployed for soothing the cough. From some ex- periments made by M. Jorg, at Leipsig, we might infer that it would prove injurious in the early stage of the disease, as well as in every inflamma- tory affection. This physician exhibited the cherry laurel-water in doses progressively increased from five to twenty-five, and finally to one hundred and twelve minims. He states that the symptoms were those of concentrated action of the brain, a sensation of weight in the head, drowsiness and torpor of the intellectual functions, lassitude, re- tardation of the pulse, and headach, preceded by a dull pungent pain of the head, chiefly in the region of the optic nerve. It also was attended with symptoms not unlike those of bronchitis. M. Jorg refers these symptoms to plethora of the cerebral vessels, but they may depend on paralysis of the brain itself. These observations are at va- riance with our own experience. We have found the laurel-water and also free hydrocyanic acid almost specific in that affection of the trachea which has been termed phthisis trachealis, and which is often as fatal as tubercular phthisis. The natural combination of hydrocyanic acid in the bitter almond emulsion is also an excellent vehicle for the administration of the compound powder of ipecacuanha in the above-mentioned disease. In affections of the mucous membrane, hydro- cyanic acid is a much less equivocal remedy than in the diseases already mentioned. In chronic catarrh, and under certain circumstances in dysen- tery, sufficient proofs of its efficacy have been recorded. In the latter disease, when given at the same time with full doses of calomel, to the extent of four or five minims for a dose, in the bitter almond emulsion, and repeated at short intervals, it allays irritation and improves the secretions and excretions of the intestinal canal. On the same principle its power of allaying irritability, and thereby favouring a slower and consequently more healthy secretion of the gastric juice, the author of this article was induced to recommend its em- ployment as a sedative in dyspepsia. (See Gran- ville's Historical and Practical Treatise on the Internal Use of the Hydrocyanic Acid. First Edition, 1819.) Dr. Elliotson prosecuted this suggestion, and laid the results of a very extended trial of its powers in St. Thomas's Hospital before the profession. (Numerous Cases illustrative of the Efficacy of Hydrocyanic or Prussic Acid in Affections of the Stomach, &c. 8vo. 1820.) In dyspeptic affections it may be combined with the decoction of Iceland liverwort, infusion of calum- ba, or the extract of sarsaparilla; or it may be administered in water, from three to five minims for a dose, with the addition of f.gi of tincture of calumba or of any simple bitter. In pyrosis it affords relief on the same principle, by allaying the morbid irritability of the stomach. It is in spasmodic affections, however, as may be readily conceived, that the sedative powers of the hydrocyanic acid are most conspicuous. In spasmodic asthma, even when the pulse is small, irregular, and often not easily distinguished, we have seen it act almost instantaneously, relieving the oppressed state of the pulmonary circulation, and restoring the free action of the respiratory organ. In hooping-cough, also, this acid displays the most striking influence when early resorted to and judiciously administered. After emptying the stomach with an emetic, and purging briskly, it may be immediately administered three or four times a day, in doses of one or two minims, ac- cording to the age of the patient, in f.Jiss of the bitter almond emulsion, sweetened with a few drops of syrup of tolu. It is seldom necessary to change the prescription, except to increase the dose of the acid, until the cough ceases, which generally occurs in less than a month or six weeks after commencing the* use of the remedy. It is requisite to confine the patients to a graduated temperature, and to restrict them to a milk and vegetable diet. [The writer has often used hydrocyanic acid in hooping-cough, and endeavoured to observe its effects carefully ; but the results have not been such as to enable him to place much reliance upon it. It certainly has not answered, in his hands, in the very cases mentioned by Dr. Thomson, half as well as narcotics employed so as to pro- duce a sedative influence.] In epilepsy, chorea, hysteria, and tetanus, the results of the trials of hydrocyanic acid have been of a description which do not admit of any deci- sive opinion of its value in these diseases. In hydrophobia it has been tried both in this country and on the continent; in few instances it appeared to allay the violence of the paroxysms; (see Transactions of the Medico-Chirurgical Society of London, vol. xiii. p. 298;) but, as may be sup- posed, the effect was transitory, and in no instance has it warded off the fatal termination of the attack. The essential oil of bitter almonds has been proposed as a substitute for hydrocyanic acid, on the plea that the strength of the medicine can be more certainly determined, and that it is less likely to suffer decomposition than the free acid from the influence of air, light, and variations of tempera- ture. Twelve minims of the volatile oil of bitter almonds, dissolved in a fluidrachm of olive oil, and formed into an emulsion with mucilage, are regarded as equivalent to four minims of the or- dinary medicinal hydrocyanic acid. An objection, however, to the use of this oil is the excitant pro- perty of the volatile oil with which the hydro- cyanic acid that it contains, is mixed; it also produces an uncomfortable effect on individuals of a peculiar idiosyncrasy. Some people cannot eat even a single bitter almond without suffering severely from nettle-rash, attended with vomiting and vertigo; a circumstance, as we have already stated, depending on something in the kernels independent of the hydrocyanic acid, which is further demonstrated by the fact that the sweet almond sometimes causes the same inconvenience, although no hydrocyanic acid has been detected in it. A more useful substitute for the hydrocyanic 150 SEDATIVES. acid than the volatile oil of the bitter almond, is the cyanide of potassium, which, although it does not hold a place in any of the British phar- macopoeias, yet possesses sedative properties equal to those of the free hydrocyanic acid. In solution it is a hydrocyanate; but in this change it loses none of its sedative properties. One part of the cyanide and eight parts of water form a solution which may be administered in the same doses as the hydrocyanic acid ; and in this state it has been successfully employed in neuralgic affections by Dr. Buttigny and Dr. Lombard of Geneva. They have also used in the same disease an oint- ment compounded of five grains of the cyanide and one ounce of lard. The cyanide has also proved useful in rheumatism.* In closing our account of this powerful seda- tive, candour obliges us to notice some experi- ments and facts which have been published on the opposite side of the question, with regard to the mode in which its influence on the nervous system is effected. The author of this article supports the opinion that it operates directly on the nervous system, whilst Magendie, Orfila, and others contend that it is previously absorbed. The only experiments we shall notice are those of Dr. Krimer of Aix-la-Chapelle, who found that when it is applied directly to the neurilema of the nerves, or to the surface of the brain and spinal cord, it displays no activity. He also supposes that he has ascertained that it does not kill, even when applied to the tongue, until it is evaporated by the heat of the mouth, and is absorbed into the pul- monary circulation ; destroying life first by di- minishing the action of the heart and arteries, and then by extinguishing the energy of the spinal cord. Dr. Krimer found that when the arteries and veins of a part are tied and the nerves left free, if the acid be applied to a wound it pro- duces no effect; but the instant the ligatures are removed, it displays its power: on the other hand, also, death occurs when the nerves are divided if it be introduced into the vessels. When all the vessels of the stomach, says Dr. Krimer, are tied, although the nerves remain entire, hydrocyanic acid when introduced into the stomach does not produce its usual effect; but it operates imme- diately when placed on the tongue, and in thirty- six minutes it can be detected in the blood by re- agents : such is the case, also, when it is inhaled, without the vapour coming in contact with the nerves of the tongue. Notwithstanding the apparent conclusiveness of these experiments, we cannot accord with the inferences deduced from them. For instance, we cannot conceive how the acid can be taken into the pulmonary circulation, and yet not act on the nerves in its vicinity; and an assumption is made respecting pulmonary absorption, which requires to be proved. On these accounts, and from hav- ing witnessed the instantaneous effect of this acid when taken in large doses, we see no reasons sufficient to alter our formerly expressed opinion regarding its mode of action. Tobacco is another sedative of great power. The experiments of Mr. [Sir B.] Brodie have rendered it probable that there are two efficient principles in * A method of obtaining this cyanide in a state of great purity has been lately discovered by Mr. R. Laniins. tobacco ; one an empyreumatic volatile oil, which operates directly on the brain and the nerves of sensation, or on the sensibility of the system ; the other a saline substance, (nicotina,) which appears to influence chiefly the motor nerves, confining its sphere of action particularly to the heart, which it renders insensible to its natural stimulus, the blood, and thereby causing death. In whatever manner this volatile oil is procured, its effects are so powerful on the animal economy, that, when it is applied to an abraded surface, or introduced into the rectum, it causes almost instant dealh.j When tobacco is infused in boiling water, this volatile oil is partially taken up by the liquid, and produces the sedative effects which always more or less result from the exhibition of tobacco enemata; but the greater part of the influence of the tobacco clyster is due to the nicotina, which, in the to- bacco, is probably combined with some acid that increases its solubility. The sedative influence of nicotina is such that the action of the heart ceases even before that of the diaphragm,—an effect directly the opposite of that which occurs from the administration of hydrocyanic acid. The influence of both the components of tobacco is evidently directly sedative, without even the most transient stimulant effect, whether the infusion be introduced into the stomach or into the rectum. It is remarkable, with the knowledge which the profession possesses of the sedative influence of the tobacco clyster, that it should ever have been employed in cases of suspended animation : it is indicated and has been successfully used in cases of incarcerated hernia. If one drachm of the dried plant infused in a pint of boiling water and strained, be thrown into the rectum, great muscu- lar debility, partial insensibility, and sometimes cold clammy sweats almost immediately super- vene; relaxation of the spasms follows, during which the gut is replaced. But occasionally the aid thus afforded to the taxis is not unattended with hazard ; and in certain states of the system of some individuals which are not obvious, but greatly influence the action of the remedy, it is evident that it must not be inconsiderately re- sorted to, nor indeed at all whilst the least chance of any other means proving useful remains.^ When it does not succeed, and the operation must be performed, the patients do not recover so well as those who have not been subjected to its use. The sedative influence of tobacco has also been taken advantage of, in smoking the plant for the relief of spasmodic asthma, violent tooth-ache, and some painful affections of the face. [Digitalis, classed by Dr. Thomson under Nahcotics, (q. v.) is more worthy of a place among sedatives. It is an important agent with t This oil is gradually deposited in the wooden stems of the pipes of the Hottentots, who employ it for destroying serpents. Mr. Barrow mentions having »rit- nessed its ellects when applied to the tongue of a poison- ous snake ; the reptile stretched itself out, became stiff, and died in an instant. 1 When the tobacco clyster produces deleterious effects, they should be immediately obviated by throwing intn the rectum a strong infusion of nut-galls, or anyothei substance containing a large proportion of tannin and HP-tmv^„ '■?0a8.t2-J50,l,bine witl1 tne nicoUna.aml bj * !l! solubility, to render it inert. Brandy. Sin- "iVh °Hier fctimulants, should also be adminis- ai ,,,! U ? ",0,,•th• a"d an arti"cial respiration main- ained for some nine, or until the sedative influence of the medicine begins to disappear. uuuve ,nnuellle SEDATIVES. 151 the contra-stimulant school. Colchicum, veratria, album, veratrum, viride, cimicifuga, and perhaps ergota might likewise be considered, with pro- priety, under this head, as their main action is one of sedation.] The hydrosulphuret of ammonia, although less frequently employed than either hydrocyanic acid or tobacco, is a most powerful sedative, depressing the action of the heart and arteries by operating directly on the nervous system. In very moderate doses, namely five minims in a tumbler of water, it causes nausea and vomiting; and, when the dose is increased, drowsiness and vertigo super- vene. It was employed and strongly recom- mended by Mr. Cruickshanks in diabetes mellitus, for destroying the ravenous appetite and morbid action of the digestive organs which always ac- company that disease; but it has been very little used. Two gaseous compounds of hydrogen, sulphu- retted hydrogen and carburetled hydrogen gas, exert a powerful sedative influence on the animal economy, which proves rapidly fatal to animal life, if breathed, even when largely diluted with air. The former is noticed here rather with the view of alluding to the share which it has in causing the depression that always occurs in those febrile affections in which it is extricated largely in the intestinal canal, than to refer to its thera- peutical properties, although its employment in phthisis has been suggested. There is undoubtedly a copious evolution of it in all low fevers, and its direct sedative influence on the intestinal nerves is the chief cause of the collapse which attends these diseases; to obviate this, is therefore, of much consequence, and the influence of chlorine in decomposing this gas by forming muriatic acid in combining with the hydrogen whilst the sul- phur is deposited, points out an easy and effectual method of doing so. Either the aqueous solution of chlorine, or of the chloride of soda, should be administered in these cases. The presence of the gas is detected by the extremely offensive odour of the fa?ces; and still more decidedly by holding slips of paper covered with carbonate of lead over the vessels containing them. If sulphuretted hy- drogen be exhaled, the carbonate will be immedi- ately blackened. The second of the above-mentioned gases, car- buretled hydrogen, has been employed for medi- cinal purposes, as a sedative in phthisis ; but its use requires much caution, as even when diluted with twenty or thirty times its bulk of common air, it cannot be respired for more than a minute or two without causing nausea, dizziness, and other symptoms of dangerous nervous depression. Although so destructive to animal life that it can- not be taken into the lungs undiluted without producing instantaneous death, yet to no gas does the system become so soon habituated; conse- quently the degree of dilution which is at first re- quisite, may be gradually reduced with impunity. The trials, however, which have been made of it as a remedy in phthisis are as yet far from suffi- cient to determine accurately its influence in that disease. 2. The indirect sedatives operate on the nervous system through the medium of the blood, either by altering the properties of that fluid so as to unfit it for affording the requisite stimulus to the brain and nervous centre, or by extracting it in quantity sufficient to bring the brain into a similar state from defect of stimulus, or, as it were, from inanition. The first of the sedative agents belonging to this division of the class which requires to be no- ticed, is carbonic acid gas. The influence of this gas in causing suffocation when it is attempted to be breathed undiluted, as it never enters the lungs, but causes a constriction of the muscles of the glottis, so that no air can enter the lungs, and no change take place in the blood passing through them, is supposed to be negative ; thence the ques- tion, whether this gas is positively or negatively sedative 1 But although this gas is never admit- ted into the lungs in attempts to respire it, and therefore may be regarded as negatively sedative, yet there are facts which demonstrate its positive sedative properties. Thus, if the body of an ani- mal be immersed in an atmosphere of carbonic acid gas, whilst atmospherical air is freely admit- ted to the lungs, sedative symptoms occur, such as weight in the head, dimness of sight, singing in the ears, vertigo, &c.; and that it even exerts a local influence on the nerves, was demonstrated by an experiment of Dr. Priestley, who, having excited pain in a blistered hand by immersing it in oxygen, relieved the pain instantly by plunging the hand into a jar of carbonic acid gas. It is also a well-known fact that the pain of a cancer- ous ulcer is allayed by directing upon it a stream of carbonic acid gas which has passed through water; and it is to the presence of this gas in the carrot and other fermenting poultices, that they are indebted for their sedative properties. On these accounts, although we have arranged car- bonic acid gas among the indirect sedatives, yet it in some measure belongs also to the former divi- sion of direct sedatives. Carbonic acid gas was at one time much cm- ployed as a sedative in phthisis: Dr. Percival in- troduced it as an antiseptic, and from the result of thirty cases concluded that it abates the hectic and improves the expectoration; (Percival's Es- says, vol. ii. p. 308 ;) and Dr. Withering, who also looked upon it merely as an antiseptic, found that similar effects resulted from its administration. Favourable opinions of it were given by Dr, Dob- son, (Medical Commentary on fixed Air. London, 1779,) Dr. Hulme, Dr. Beddoes, and Dr. Fcnwick of Durham : on the contrary, the experiments of Dr. Muehry, (Inaugural Dissert. Gott. 1797,) who gave it a fair trial in five cases without material benefit, and our own experience, have led us to place little confidence in it, even as a sedative. When it is employed, it should be largely diluted with common air; the best proportions are four parts of the air to one part of the gas. The only other indirect sedative which requires to be noticed is bloodletting. It is scarcely neces- sary to remark that a certain quantity of the cir- culating fluid is required to be present in the blood- vessels, in order to support the energy of the brain and nervous centres ; and, therefore, that when this proportion is diminished, the result is a sedative effect on the system. In man the aver- age quantity of blood in proportion to the weight of the body, in a healthy adult subject, is as one 152 SEDATIVES. to five ; when a greater relative proportion exists, a diseased state of the body, plethora, takes place ; when a smaller, the body becomes emaciated. If blood be suddenly abstracted from the vessels, a series of phenomena occur which demonstrate a diminished state of vitality ; and if the quantity taken away be greater than a certain proportion of the whole, then death almost immediately en- sues. But these effects do not depend altogether upon the quantity of blood contained in the ves- sels or abstracted from them, but partly upon other circumstances, which ought always to be kept in view when bloodletting is intended to operate as a sedative. If these phenomena depend on the state of the vascular system in health, it is evident that a pow- erful effect must result, in disease, from the ab- straction of blood, whether this be effected by opening a vein, by cupping, or by leeches. The immediate depression of the vital powers which follows this abstraction must have been early ren- dered obvious, from the effects of hemorrhages arising from the accidental rupture of vessels ; and thence artificial means were adopted to dimin- ish excitement by opening a vein. The syncope which succeeds is much regulated by the habit of the patient, the nature of the disease, and the manner in which the blood is abstracted; but as a particular inquiry into the morbid effects of bloodletting and the methods of obviating these are given in detail in other parts of this work, we think it unnecessary to enter into minute details, referring the reader to the articles Bloodletting, Fever, Inflammation, and Plethora. A. T. Thomson. [Under the head of sedatives may be included a set of therapeutical-agents, now much used, in Italy more especially, but also adopted in France and in Great Britain,—rarely in this country;— agents which, by removing excitation, might be termed sedatives, but which, by their propounders, have been called contra-stimulants, and the theory which suggests them, the theory of contro-stimu- lus or contra-stimulus,—the new medical doctrine of Italy,—La nuova Dottrina, cij-c. Prior to the termination of the last century, the doctrines of Brown were universally embraced in Italy, and they continued in vogue until Rasori, on the occasion of a petechial fever making its appearance in Genoa, subjected the prevalent views to considerable modification ; and, as in most similar cases, ended by embracing views dia- metrically opposite. Rasori maintained that most diseases, to which mankind are liable, are owing either to an augmentation of excitability, or to an excess of stimulus; and he conceived that there are certain medicinal agents which possess a pecu- liar debilitant power, and which act upon the ex- citability of the frame in a manner directly opposed to that in which stimulus acts upon it. To this power he gave the name contro-stimulus. The mode in which the different contra-stimu- lants have acquired their reputation, appears to have been as simple as it must frequently have been fallacious. Every agent which succeeded in removing a sthenic disease, could do so only, it was presumed, by diminishing the excitability, or removing the stimulus. Accordingly, it was a contra-stimulant. Substances were therefore cla-sod together, which bore no relation to each other, either in their immediate properties, or in their secondary effects—as regarded the physiolo- gical phenomena they induced. We find, in the lists, emollients—as milk and gum ; astringents— as acetate of lead ; tonics—as gentian, simarouba, iron, and, according to some, even cinchona ; ex- citants—as turpentine, squill, and arnica; emetics —as tartrate of antimony and potassa, and ipeca- cuanha ; narcotics — as stramonium and bella- donna; acrid poisons — as arsenic, nux vomica, cantharides; and a host of other animal, vegetable, and mineral substances, which had no kind of analogy to each other. It has been properly ob- served, that this manner of considering the effects of medicines tends essentially to bring together the most dissimilar substances, as well as to sepa- rate such as are closely allied, and, consequently, to confound all. In the case of this theory, however, as of every other, the practice built upon it has added valuable facts to therapeutics ; and not the least of these is the knowledge, that tartrate of antimony and po- tassa may be administered in large doses in in- flammatory affections, not only with impunity, but with marked advantage. This potent emetic may be given to the extent of ten or twenty grains or more, in divided doses, during the day, without either producing vomiting or purging; or, if the first doses prove emetic, a tolerance is soon ac- quired, and the subsequent doses may be followed by no marked effect, except the diminution of the febrile symptoms. At other times, the urinary and cutaneous depurations appear to be largely augmented, and rapid emaciation succeeds to its administration. The contra-stimulant physicians maintain, that the exaltation of the vital manifes- tations in febrile and inflammatory diseases, en- ables the system to bear the large doses of this and other contra-stimulants, and they say that the tolerance vanishes with the disorder that commu- nicated it; but this assertion is not confirmed by experience. There is certainly a greater resist- ance to the action of these agents, as there is to bloodletting, when all is exaltation, but the powei of resistance does not cease, although it is dimi- nished, when the exaltation ceases. Some indi- viduals, too, never possess the necessary tolerance; so that with them the tartrate of antimony and potassa does not produce its contra-stimulant effects; and it would seem that there are, also, what the French term medical constitutions or epidemic conditions, which forbid its employment Thus, according to Bricheteau, (Clinique Medi- cale de l'Hopital Neckar, Paris, 1835 ; or the writer's translation in the Amer. Med. Lib. Philad. 1838,) although it was so successfully used in 1831, it could not be beneficially admi- nistered at the end of 1832, and the beginning of 1833. Not until the autumn of this last year, could it be resumed advantageously. On one occasion it was given in the hospital, by an Elevt de garde, during the choleric epidemy. The most violent symptoms supervened, and the patient died of cholera morbus, no sign of which existed before the tartrate was taken. Of the different phlegmasia?, acute rheumatism and pneumonia are those that are considered to SEDATIVES.—SEX, (DOUBTFUL.) 153 have been most successfully combated by this agent, in a large dose. (See art. Inflammation, vol. ii, p. 795.) "Emetic tartar," says M. Bri- cheteau, " should generally be preceded by blood- letting ; and commonly it is advisable not to have recourse to the former, unless the latter is insuffi- cient, except in cases in which bloodletting is contra-indicated or impossible, owing to some special circumstances, — as happened to me once in the case of a rickety individual, who had no veins proper for phlebotomy. The medical con- stitution of the season is, also, occasionally op- posed to the abstraction of blood : in such cases, the tartrate of antimony and potassa is a valuable agent. Recourse may, likewise, be had unhesita- tingly to tartar-emetic at the very first, when the patient is exhausted by age or other causes, and appears to be too weak to bear the abstraction of blood ; or in cases where a positive refusal is given to the proposition for phlebotomy." « This agent," he adds, " must also be of great advantage and of convenient employment in country situa- tions, where the physician can rarely pay his visits at an early period. It may be practicable, by this method, and with the aid of an intelligent person, to regulate the treatment of a case of pneumonia or of rheumatism for several days after having premised a copious abstraction of blood, if it be considered desirable." The fact, however, referred to by Bricheteau — that it is not every one who presents the necessary tolerance—would render this agent by no means as easy of applica- tion by the laity as he presumes. Granting — and it would seem it must be granted — that the tartrate of antimony and po- tassa is a sedative agent, it becomes interesting to inquire into the mode in which such agency is exerted. It is, as is well known, one of our best suppurants, when we are desirous of establishing a centre of fluxion on some part of the cutaneous surface, with the view of removing an internal disease. Experience, too, has sufficiently shown that, when given in large doses, it produces pus- tulation in the mouth and fauces, if not lower down in the alimentary tube. In a case which occurred under the author's care in the Baltimore Infirmary, this effect of the antimonial was sig- nally evidenced. Bricheteau—who has adminis- tered it largely as a contra-stimulant—says its local action is exerted more particularly on the mouth, tongue, and pharynx, where false mem- branes and pustules are occasioned by it; but these lesions, he thinks, are by no means common. The oesophagus, he says, never participates in them, and they are more frequent in the intestinal canal than in the stomach : and in the former, the lower part of the small intestines, and the com- mencement of the large, exhibit themselves more sensible to the action of the antimony than other portions of the tube ; but it cannot be said that sufficient opportunities have occurred for testing the effects of the remedy, and for separating the morbid appearances which have presented them- selves, and which may have proceeded from other causes. Bricheteau is of opinion, that the lesions which may be referred, with the greatest proba- bility, to the use of the tartrate of antimony and potassa,—although he admits they are frequently owing to other inappreciable causes,—are, injec- Vol. IV. —20 tion or infiltration of the submucous tissue of the intestines, and softening of the mucous membrane. In the mouth, considerable inflammation—either pustular or ulcerous — is sometimes observed, which speedily disappears after the discontinuance of the antimony. The contra-stimulant virtues of tartrate of anti- mony and potassa may, then, be dependent upon its revulsive properties ; this revulsion being pro- duced in the lining membrane of the alimentary canal; so that when it is accomplished, the ex- cited actions, going on elsewhere, may become diminished, and more or less nervous and vascular concentration takes place towards the seat of the artificial revulsion. Rasori thought that the re- medy lessens stimulation, or augmented excita- bility, directly: Laennec maintained that it in- vigorates the action of the absorbents; whilst Vaidy,—a French practitioner, who embraced the precepts of the followers of the " Nuova Dot- trina,"—is of opinion, that its influence extends immediately to the circulation of the blood, restor- ing its harmony, and subduing the febrile excite- ment. Begin (Traite de Therapeutique, Paris, 1825) asserts that none of these hypotheses can stand the test of attentive inquiry, and that they are not founded on well-observed facts. " They are all in contradiction to experiments made on living animals, which prove that tartar-emetic, whilst it stimulates, and tends to inflame the mu- cous coat of the alimentary canal, from the cardia to the lower portion of the rectum, irritates the nervous system, and produces more or less inflam- matory engorgement of the lungs:" and he adds— " this remedy acts chiefly as a revulsive in the treatment of pneumonia, and we shall have occa- sion to develop this truth, when treating of the revulsions produced on the gastro-intestinal sys- Robley Dunglison.] SEX, DOUBTFUL, [Sexual Ambiguity.]— Among the freaks of nature, there is none which has given rise to more erroneous ideas or more barbarous practices than those varieties in the formation of the organs of generation, which have given origin to the term hermaphrodite. This word, derived from 'Epurjs, Mercury, and 'A-Qpodirn, Venus, conveys the notion of an individual par- taking of both sexes, and capable of both begeW ting and conceiving. The ancients believed.'Jn the possibility of such a combination in tfie hu- man body; and enactments existed, both/in Greece and Rome, ordering the destruction/ of infants born with confusion of the sexual organs. At Athens all the unfortunate beings considered to be hermaphrodites were thrown into the sea, and at Rome into the Tiber. In modern times it is admitted that no such phenomenon ever existed in the human species as a perfect hermaphrodite; although there are numerous instances of preter- natural structure which gives the appearance of a double sex. In the lower orders of organized bo- dies, hermaphrodism is common ; thus in vegeta- bles it is so prevalent as to have led some to sup- pose it to be an attribute of the order; and the more nearly the other classes of beings approach the vegetable, the more common is this combina- tion of sex among them. Of this zoophytes, mol- lusca, acephali, and gastcropodes are examples. 154 SEX, (DOUBTFUL) In these animals two kinds of hermaphrodism exist: in some it is absolute, that is, the animal is capable of impregnating itself, as in some of the bivalves, as oysters and mussels ; but in others, as the univalves, this power is not possessed, but a union of two individuals is necessary, both, however, becoming impregnated at the same time. We look in vain for any such admixture in the higher orders of animals, though some extraordi- nary approaches towards it are recorded. Accor- ding to Sir. E. Home (Phil. Trans. 1799,) and J. Hunter (Anim. Econ.,) such combination is most frequently met with in neat cattle, the indi- viduals so circumstanced being known by the name of free martins. In these, however, the testes and ovaria are always too imperfect to per- form their functions. Instances are not wanting in the human species in which, either from mal- formation of the genital organs in one or other of the sexes, or from a real attempt at mixture of the two in the same individual, considerable difficulty arises in deciding on the proper sex. This is the point to which the present article is more particu- larly directed, and it should be recollected that it is one of material importance; for upon the opinion pronounced by medical examiners may depend the employment in life of an individual, the right of inheritance to property, and the judicial deci- sions concerning impotence and sterility. [In an able article by Dr. J. Y. Simpson, (Heh- MAPimoniTisM, in Cyclopaedia of Anatomy and Physiology, ii. 685, Lond. 1839,) hermaphroditic malformations, considered as a class, are divided into two orders—spurious and true,—the spurious comprehending such malformations of the genital organs of one sex as make these organs approxi- mate in appearance and form to those of the opposite sexual type ; and the true comprising all cases in which there is an actual admixture or blending together, upon the same individual of more or fewer of both the male and female organs. The following is Dr. Simpson's classification : ClASSIFICATION OF HERMAPHRODITIC MALFORMATIONS, ' Spurious. Hermaphroditism. ] L True. From excessive development of the clitoris, &c. From prolapsus of the uterus. From extroversion of the urinary bladder. From adhesion of the penis to the scrotum. From hypospadic fissure of the urethra, &c. Testes on the right and ovary on the left side. Testes on the left and ovary on the right side. External sexual organs female; internal male. External sexual organs male; internal female. Ovaries ancj an imperfect uterus with male vesicuUe seminales, and rudiments of vasa deferentia. Vertical or Double-(. Testicles, vasa deferentia, and vesiculae seminales, with an imperfect female uterus and its appendages. Ovaries and testicles coexisting on one or both sides, &c] In the male.. Lateral...... Transverse ... I, Sir E. Home (Loc. cit,) considers that all the monstrous productions hitherto noticed and de- scribed as hermaphrodites may be reduced to one of the four following classes:—1. malformations of the male ; 2. malformations of the female; 3. males with such a deficiency in their organs that they have not the character and general proper- ties of the male, and may be called neuters ; 4. where there exists a real mixture of the organs of both sexes, although not sufficiently complete Xo constitute the double organ. .Malformation of the Urinary and •' v -ulva, and the similarity is he.^ stance of the urethra being u '■..■■-'■■ in these cases, and. opening in . which having a red and tender appeu,. easily mistaken for the vagina. In consequeii. of the urethra terminating at the perineum, the penis is imperforate; and thus, if it be of small size, it may be supposed to be the clitoris. It is this malformation of the male organs which more than any other has given origin to mistakes respecting the mixture of the sexes. The case of the negro described by Cheselden (Anat. of the Human Body, p. 314,) was of this kind. In him the scrotum was divided into two separate bags, with a deep slit between them, representing the labia majora and commencement of the vagina. Over these hung down the penis; the imperfec- tion of the scrotum extended to the canal of the urethra,—a circumstance appropriately compared to the fissure of the hare-lip being continued through the bony palate. The penis was united by its under surface, through its whole length, to the folds of skin containing the testicles, resem- bling an enlarged clitoris, to which resemblance the absence of the urethra contributed. The urethra opened with a large aperture in the peri- neum, between the divisions of the scrotum, and from its size was mistaken for a vagina. Chesel- den describes another case similar to the preceding, which he met with in the person of an European. Persons afflicted with such malformation as we have described have not only been taken for females but have been married as such. Adelaide Preville was married, and lived the last ten years of her life in Paris, and died in the Hotel Dieu that city. Giraud discovered by examination Kody after death that it was of the mascu- except a false vagina, which con- -,c placed between the rectum a'- ' ""»1 presented no resem- blance .. ..oueil periad. de la Soc. de Med. Paris.; x Here is a very remarkable case related by Marc, (Diet, des Sciences Med. t. xxi.p. 91 et Jour, de Med. Chirurg. et Pharm. Paris, Feb. 1806,) in which an individual after having passed for a female for many years, was at length disco- vered to belong to the male sex, and was restored SEX, (DOUBTFUL) 155 by public ordinance to his proper station. On the 19th of January, 1792, the cure of the parish of Ber certified the birth of a girl, and gave her the name of Marie Marguerite. This child arrived at the age of 14 without having particularly at- tracted the attention of the parents. It shared the bed of a younger sister, and grew up among other young persons with whom it was associated by education, exercise, and childish amusements. At this time Marie complained of pain in the right groin, where a tumour soon manifested itself. The village surgeon took it for a hernia, and applied a truss. This instrument gave too much pain to be borne, and was soon laid aside. The tumour descended and the pains ceased. Some months afterwards, the left groin was affect- ed in a similar manner, and on the supposition of the tumour in it being also a hernia, a double truss was put on, which was as speedily thrown off as the former. At 16 years of age an offer of marriage was made, but refused by the parents as an unsuitable match for their daughter. Three years afterwards another proposal was made and broken off' after having been accepted of. Never- theless, as Marie advanced in age, the graces of her person began to disappear; her clothes did not fit as well as before; her air and carriage had some- thing extraordinary ; from day to day her tastes changed and became more masculine ; indoor oc- cupations seemed to interest her less, and she pre- ferred field-work to her former duties. These masculine dispositions, and the report of the surgeon that Marie had been hurt in such a man- ner as to prevent her ever marrying, did not pre- vent a third lover from aspiring to her hand. This match was much desired by the friends on both sides ; but the parents of Marie, knowing that she was not formed as other women, and recollecting that she had never menstruated, did not wish to deceive the son of an old friend, and determined on having a medical examination of their daughter. Worbe was requested to perform this office. The surprise of all was great indeed when he declared Marie to be a man. She (or he) shed tears at the announcement, and was for some months before she could be reconciled to the idea of not being a woman. At last he took the resolution of petitioning the authorities to alter the registry, and declare him of the male sex. A commission was accordingly appointed consisting of three medical men, to inquire into the circumstances of the case, who reported that on examination they found the scrotum divided through its whole extent, each division containing a rounded body, which they recognised as true testicles. Between these parts a fleshy prolonga- tion was observed, having a cleft at its extremity, but imperforate, covered by a process of skin, which was in reality the prepuce. The penis was but little developed ; and beneath it, at about an inch and a half from the margin of the anus, an opening was discovered, caused by the abrupt termination of the urethra in the perineum. As to the rest of the body they found nothing remark- able, except a considerable development of the breasts, resulting, as they imagined, from the form of clothing usually worn. They therefore gave it as their opinion that Mario belonged to the male sex ; and the authorities declared it to be so, and ordered that the registry of birth and baptism should be altered. Dr. Worbe states that in 1816, this individual was 23 years of age, hair and eye- brows auburn, a light beard appearing on the upper lip and chin, the sound of the voice mascu- line, height four feet eleven inches French mea- sure, skin very white, constitution robust, and the limbs round but muscular. The form of the pelvis did not differ from that of a male, the knees were not inclined inwards, and the hands and feet were large and strong. A year had not elapsed from the time of his metamorphosis when he was considered as one of the best farmers in the canton. On being questioned with respect to what he felt when sleeping with females, whether he had not desires different from those of others, and if curiosity had not prompted him to discover what opportunity permitted him so easily to observe, he answered, blushing, " quelquefois, mais je n'osais pas." Dr. Schweikard (Hufeland's Journal, t. xvii. No. 18,) has published the history of an indivi- dual who up to the age of manhood was esteemed to belong to the female sex. He had been bap- tized as a girl, and regarded as such, until to the astonishment of all he demanded permission to marry a girl then pregnant by him. He sub- mitted to an examination, when it was found that the penis was situated lower than ordinary, not quite two inches long, and a little less bulky than usual. The impetforate glans offered a slight curve towards the lower part; the inferior sur- face of the corpora cavernosa was deprived of urethra, but presented a channel or groove along its middle line. Behind and under the corpora cavernosa, between their root and the anterior superior part of the scrotum, a prominent oval opening was remarked ; this was the orifice of the urethra, through which the urine flowed, and in consequence of its vicinity to the penis, the stream was conducted along the under surface of that organ so as to appear to issue from its orifice. The scrotum, situated below this opening, con- tained the right testicle only, that of the left being probably retained in the abdomen. In all other respects the physical constitution of this individual was perfectly masculine. According to his ac- count, the desire for women and the secretion of semen were observed at puberty. He had fre- quently performed coition, and had, besides a child born before marriage, two other children well formed, born in wedlock. This case was evidently only an instance of hypospadias, of which malformation we have already spoken in the article Impotence ; and it is a further con- firmation of the opinion there advanced, that per- sons labouring under it are not to be considered as incompetent to procreation. It is most pro- bable that the semen during the act of coition was conducted along the penis, as the urine is stated to have been, at least so far as to enter the vagina. A case similar to that just mentioned is detailed by Dr. Wageler. (Annales de Med. Politique de Kopp. v. 129.) The malformation of which we have now spoken is that which most frequently causes mis- takes in the male, but by a careful examination of the individual the obscurity must be easily re- moved. There are other degrees of imperfection 156 SEX, (DOUBTFUL) which are sometimes observed, but can never lead to much confusion. One of these consists in a close application of the penis to the anterior sur- face of the scrotum, by a continuation of the skin of the latter over the former. In such a case the penis is bound down in its unnatural situation, and the urine passes downwards ; the erection of the organ cannot take place; it may become turgid, but never erect, and intromission is of course impossible. A case of this description oc- curred to Mr. Brand, (Vide Brewster's Edinburgh Encyclop. art. Hermaphrodites, and Beck's Med. Jur. by Darwall, p. 45,) in the person of a child seven years of age, who had been baptized and brought up as a girl; he found a malformation of the male sexual organs consisting of the pre- sence of such an unnatural integument. By a slight incision he liberated the restricted part, and proved to the parents that they had mistaken a hoy for a girl. Another form of lusus which has given rise to mistake of sex, is that in which the urinary blad- der, or rather the rudiment of it, opens directly above the pubis, through a deficiency of the ab- dominal muscles and integuments at that part. In these cases the bladder can scarcely be said to exist; all that appears of it is a red fungous mass protruding through the integuments, consisting of the mucous lining of the viscus, with the uterus opening on it together with the vesicula? seminales and vasa deferentia. The penis is always very short, scarcely exceeding two inches, and, from deficiency of the urethra, imperforate. The testi- cles are generally well formed, but are sometimes retained in the abdomen. Persons with this mal- formation are observed to vary in their sexual appetites ; some being totally deficient in sexual desire, others exhibiting it in a trifling degree, while others have it strong. It may readily be supposed that persons constructed in this manner are impotent; but it sometimes happens that the vasa deferentia open in a small tubercle at the root of the penis, in which case it is possible that impregnation may be effected by the individual. It is only by such a disposition of parts we can explain the pregnancy of a young girl in Lin- lithgow in Scotland, stated to have resulted from her sleeping with a young person, who from a malformation, such as we have described, was supposed to be a female. (Vide Piscottie's His- tory of Scotland, p. 104.) It is plain that if the seminal ducts opened externally above the pubis, such an event could not have taken place. 2. Malformation of the Female Genera- tive Organs.—There are two sorts of malforma- tion in women which may lead to error in judging of the sex. The first consists in excessive dimen- sions of the clitoris. Although hypertrophy of this organ occurs most frequently in warm coun- tries, it has also been observed in cold. Sir E. Home doubts that it ever takes place in these latitudes, and also is of opinion that even in those situations where it is most frequently observed, the enlargement never proceeds to such a length as to lead to any serious doubt. There are, how- ever, some instances on record in which the in- crease in size was such as to cause the clitoris to resemble and be mistaken for the male organ. Columbus notices an instance in which it was the size of a finger. Haller observed one case in which he states that it was seven inches in length; and it has been said to reach the extent of twelve inches. (Diet, des Sciences Med. art. Clitoris.) However, notwithstanding any excessive dimen- sions of the clitoris, an attentive observer will readily discover the difference between the genital organs of a female with such a development, and those of a male. Thus, for instance, in a celebrated hermaphrodite exhibited in Paris and London in 1777, named Marie Auge, the clitoris was found to resemble perfectly the male organ, but it was unprovided with a urethra, and imperforate: ,it was situated above the other parts of generation, which presented no peculiarity, except an unusual contraction of the vagina. Schneider met with an instance in a child of two years old still more likely to mislead ; he examined it after death, and found neither labia majora nor minora, nor the usual cleft between them; the clitoris was an inch and a half long, resembling a penis, with a well-formed glans and prepuce' but it was imperforate, a small spot occupying the situation at which the male urethra terminates. Some lines below this organ there was an opening, by which the urine was transmitted ; but this passage seemed also des- tined to perform the functions of a vagina, for it led directly to the uterus, and was of a length proportionate to the age of the subject; the vagi- nal ruga? were distinct, and at the upper part of the orifice a small opening was observed which led to the bladder, and was in fact the orifice of the true urethra. In Sir E. Home's (Loc. cit.) paper on hermaphrodites he gives an account of a Mandingo negress whose clitoris was two inches long, and of the thickness of an ordinary thumb: at first view the extremity seemed formed like a glans, but on more minute examination it was found imperforate, and not so round as a true glans, but more pointed ; the clitoris was capable of erection, during which state its size increased to three inches. The other parts of generation were well formed, the urethra was situated just beneath the clitoris, which obstructed the flow of urine so much as to compel her to raise it when about to evacuate the bladder. Her person was very masculine, the mamma? were little developed, the voice was rough, and the countenance resem- bled that of a man. Beclard (Jour, de Med. Chir. et Phar. Mars, 1815,) has given a very detailed account of a female who was exhibited in Paris, in 1814, as an hermaphrodite, from which we extract the following. Marie Madeline Lefort was the name of the individual; she was then sixteen years of age, and in the general form of her body resembled a male; the voice was mas- culine, a beard appeared on the upper lip and chin, the breasts were developed, and the limbs were slightly hairy. The external genitals pre- sented a rounded mons veneris, covered with hair, but the symphisis pubis was elongated as in the male; beneath it protruded a conoid-shaped body, twenty-seven centimetres in length, when flaccid, but more when erect; this was surmounted by an imperforate glans, covered for three-fourths of its extent by a prepuce. Inferiorily this enlarged clitoris was furnished with a canal, which, how- ever, did not run the whole length, but was pierced in the middle line with five small holes, SEX, (DOUBTFUL) 157 capable of admitting a small probe. Beneath and behind the clitoris, there was a sulcus, bordered on each side by a narrow and short labium, which on being handled gave no sensation of containing any body like a testicle. This sulcus or fissure was very superficial, being blocked up by a dense membrane, hut which gave, when pressed by the finger near the anus, the idea that it was spread over a cavity. At the anterior superior part, near the clitoris, this membrane was pierced by a round opening, which readily admitted a moderate-sized catheter. The external abdominal rings were very small, and gave no indication of containing testi- cles. The urine was passed partly through the opening in the membrane described, and partly through the small cribriform openings in the canal extending along the under surface of the clitoris. This was taken from her own account, as she found it impossible to void urine in the presence of the examiners. The bladder could not be reached by a catheter introduced through the large opening, but the instrument could be easily passed upwards and backwards, and in this manner it glided along the posterior surface of the membrane closing the vagina, which, being felt between the point of the instrument and the finger, seemed about twice as thick as the skin. She had men- struated regularly from the age of eight years, and on one occasion when Beclard examined her during menstruation, he observed the fluid to pass through the opening already described, and the catheter then introduced was withdrawn full of menstrual blood. She considered herself a woman, and preferred the society of men, and was per- suaded that a trifling operation would render her fit for matrimony. This individual belonged decidedly to the female sex; she had many and the most essential of the female organs of generation, the vagina and uterus, the latter organ moreover per- forming its natural function with regularity ; and those characters of the male which she exhibited were only of a secondary class, such as the pro- portions of the limbs and body, shoulders and pelvis, the size of the larynx, tone of voice, deve- lopment of hair, and the prolongation of the urethra beyond the symphisis pubis: this, how- ever, was not complete, for the canal did not ex- tend to the extremity of the mimic penis. The second kind of malformation of the female generative organs likely to mislead as to the sex of the individual, is a protrusion of the internal parts. The uterus when prolapsed has at times assumed so close a resemblance to the penis that it has actually been mistaken for it by medical men of the highest character. The following case came under the observation of Sir E. Home, who has given the particulars in his paper on hermaphrodites. " A French woman had a pro- lapsus uteri at an early age, which increased as she grew up. The cervix uteri was uncommonly narrow, and at the time I saw her (when she was about twenty-five years old) projected several inches beyond the external opening of the vagina: the surface of the internal parts, from constant exposure, had lost its natural appearance, and re- sembled the external skin of the penis; the orifice of the os tinea? was mistaken for the orifice of the urethra. This woman was shown as a curiosity in London, and in the course of a few weeks made four hundred pounds. I was induced by curiosity to visit her, and on the first inspection discovered the deception, which, although very complete to a common observer, must have been readily detected by any person intimately ac- quainted with anatomy. To render herself still more an object of curiosity, she pretended to have the powers of a male : as soon as the deception was found- out, she was obliged to go away." There is in the Philosophical Transactions the history of an hermaphrodite which seems to be exactly similar to this, as is fully proved by the menses flowing regularly through the orifice of the supposed penis. The French physicians were, however, so perfectly convinced of her manhood, that they made her change her dress and learn a trade. To this she readily submitted, and the account says she could perform very well the functions of a man, but not those of the other sex. 3. Males with such a deficiency in their organs that they have not the character and general properties of the male, and may he called Neuters. This form of hermaphrodism usually takes place in individuals originally intended for the male sex, and is nothing more than the effect pro- duced by atrophy, or absence of the testicles,—a circumstance to which is frequently joined a de- fective development of the penis. The genital organs do not appear to grow with the rest of the body, but continue iu the same state as at birth. In many the characters of both sexes seem mixed ; in others there is a slight predominance of one or the other, discoverable chiefly by moral circum- stances, such as the kind of life, habits and pur- suits of the individual. An instance of this kind of deformity occurred to Hufeland at Koningsberg. An individual narned Marie Dorothee Duriee, aged twenty-three years, was examined by him and Mursinna, who both declared the sex to be female, while Stark and Martens were of opinion that the same person belonged to the male sex. A marine soldier, aged twenty-three years, in the year 1779 was admitted a patient into the Royal Naval Hospital at Plymouth, under the care of Sir E. Home. He had been there only a few days when a suspicion arose of his being a woman, which induced Sir E. Home to examine into the circumstances. He proved to have no beard, his breasts were fully as large as those of a woman at that age ; he was inclined to be cor- pulent; his skin uncommonly soft for a man; his hands fat and short; his thighs and legs very much like those of a woman; the quantity of fat upon the os pubis resembled the mons veneris; the penis was unusually small as well as short, and not liable to erections; the testicles were not larger in size than we commonly find them in the fcetal state; and he had never felt any passion for women. In this case the testicles had been im- perfectly formed, and the constitution was deprived of the influence which it naturally receives from them. The two following cases show a still greater degree of imperfection in the male organs; they are mentioned by Sir E. Home. A woman near Modbury, in Devonshire, the wife of a day-labourer, had three children ; the first was considered to be an hermaphrodite; the 158 SEX, (DOUBTFUL) second was a perfectly-formed girl; and the third an hermaphrodite similar to the first. In the year 1779 the eldest was thirteen years of age, and of a most uncommon bulk, which seemed to be almost wholly composed of fat; he was four feet high ; his breasts as large as those of a fat wo- man ; mons veneris loaded with fat; no penis; a prepuce one-sixth of an inch long, and under it the meatus urinarius, but no vagina. There was an imperfect scrotum with a smooth surface, with- out a rapha in the middle, but in its place an in- dented line; it contained two testicles of the size they are met with in the foetus. The younger one was six years old, uncommonly fat and large for his age : the external parts of generation dif- fered in nothing from those just described except in the prepuce being an inch long. Both were nearly idiots. The immense accumulation of fat, and the uncommon size of these children, accords with the disposition to become fat so commonly met with in the free martin. 4. Where there exists a real mixture of the Organs of hoth Sexes, although not sufficiently complete to constitute the Dou- ble Organ.—Cases of this description which most nearly approach the absolute hermaphrodite are less common than those we have mentioned. A remarkable instance is mentioned in Dr. Bail- lie's Morbid Anatomy, (3d edit. p. 410.) The person was twenty-four years of age, and bore the name and dress of a woman, had the breasts of a female, and no beard, and yet had a very mascu- line appearance. The clitoris and meatus urina- rius had the natural appearance, but there were no nympha?, and the labia pudendi were unusually pendulous, resembling a split scrotum, and con- tained a testicle each. The vagina was found to terminate in a cul-de-sac, two inches from the ex- ternal 'surface of the labia. She had no partiality for either sex, and had never menstruated. The Memoirs of the Academy of Dijon con- tain the following case, communicated by M. Ma- ret. (Mahon, t. i. p. 190, and Beck by Darwall, p. 13.) Hubert J. Pierre died at the hospital in Oc- tober 1767, aged 17 years. Particular circum- stances had led to a suspicion of his sex, and these induced an examination after death. His general appearance was more delicate than that of the male, and there was no down on his chin or up- per lip. The breasts were of the middle size, and had each a large areola. The bust resembled a female's, but the lower part of the body had not that enlargement about the hips which is usually observed at his age. On examining the sexual organs, a body four inches in length and of pro- portionate thickness, resembling the penis, was found at the symphisis pubis. It was furnished with a prepuce to cover the glans, and at its ex- tremity, where the urethra usually opens, was an indentation. On raising this penis, it was ob- served to cover a large fissure, the sides of which resembled the labia of a female. At the left side of this opening there was a small round body like a testicle, but none on the right. However, if the abdomen was pressed, a similar body descended through the ring. When the labia were pushed aside, spongy bodies resembling the nympha? were seen, and between these and at their upper part the urethra opened as in a female, whjle below these was a very narrow aperture covered with a semilunar membrane. A small excrescence, placed laterally, and having the appearance of a carun- cula myrtiformis, completed the similarity of this fissure to the orifice of the vagina. On further examination the penis was found to be imperfo- rate ; the testicle of the left side had its spermatic vessels and vas deferens which led to the vesiculaj seminales. By making an incision into the semi- lunar membrane, a canal one inch in length and half an inch in diameter was seen, situated be- tween the rectum and bladder. Its identity with a vagina was, however, destroyed by finding at its lower part the verumontanum and the seminal orifices, from which, by pressure, a fluid, resem- bling semen in all its properties, flowed. The most remarkable discovery was, however, yet to be made. The supposed vagina, together with the bladder and testicles, was removed. An inci- sion was made down to the body noticed on the right side. It was contained in a sac, filled with a limpid and red-coloured liquor. From its upper part on the right side, a Fallopian tube passed off, which was prepared to embrace an ovarium placed near it. It seemed thus proved that the body in question was a uterus, though a very small and imperfect one, and on blowing into it, air passed through the tube. In April 1807, an individual was exhibited at Lisbon, uniting the organs of both sexes in the highest degree of perfection that has probably been ever seen. This person was twenty-eight years of age, and possessed of the male oigans, a penis, or what represented one, capable of erec- tion, covered by a prepuce, and pierced for a third of its length by a canal, and testicles. The air and appearance were masculine, the colour dark, and a light beard covered the chin. The female organs were labia, vulva, and vagina, well formed, but very small; the larynx and voice were femi- nine, and so were all the dispositions; she men- struated regularly, and was twice pregnant, but was prematurely delivered each time, once at three, the other at five months. (Diet, des Sc. Med., art. Hermaphrodite.) This, if the account respecting the testicles be correct, is the nearest approach to a true hermaphrodite with which we are acquainted in the human subject. In the Memoirs of the Royal Academy of Sci- ences of Paris (An. 1720) there is a very accu- rate description by M. Petit, of a similar mixture of organs. The person had wholly the character of a man, but was of a delicate constitution; he was a soldier, and died of his wounds. The ap- pearance of the penis is passed over ; but the scro- tum not containing testicles drew M. Petit's at- tention, and in the dissection he found testicles in the situation of the ovaria, attached to two pro- cesses, continued from an imperfect vagina, but having vasa deferentia, which passed in the usual manner to the vcsicula? seminales; the vagina communicated with the urethra between the neck of the bladder and of the prostate gland. [A number of cases in which there was a mix- ture of the organs of the two sexes are now on record. (Simpson, op. cit. See also, Guy, Prin- ciples of Forensic Medicine, p. 36. Lond. 1843; and the writer's Human Physiology, 5th edit, ii- 351. Philad. 1844.)] SEX, (DOUBTFUL). —SMALL-POX. 159 With respect to the formation of such monsters as we have spoken of, Sir E. Home was of opinion that the only mode in which it can be explained is by supposing the ovum, previous to impregna- tion, to have no distinction of sex, but to be so formed as to be equally fitted to become a male or a female foetus ; and that it is the process of im- pregnation which marks the distinction, and con- duces to produce cither testicles or ovaria out of the same materials. The following circumstances are in favour of this opinion. The testicles and ovaria are formed originally in the same situation, although the testicles even before the foetus has advanced to the eighth month, are to change their situation to a part at a considerable distance. The clitoris in foetuses under four months is so large as to be often mistaken for a penis, and serves to explain an erroneous opinion at one time main- tained in France, that the greater number of mis- carriages between three and four months have been remarked to be males; which mistake arose from the above circumstance. The clitoris origi- nally appears, therefore, equally fitted to be a cli- toris or a penis, as it may be influenced by the ovarium or testicle. In considering this subject, it is curious to observe the number of secondary parts, which appear so contrived that they may be equally adapted to the organs of the male or female. In those quadrupeds whose females have mamma? inguinales, the males have also teats in the same situation ; so that the same bag which contains the testicles of the male is adapted to the mamma? of the female. In the human species, which has the mamma? pectorales, the scrotum of the male serves the purpose of forming the labia pudendi of the female, and the prepuce makes the nympha?. The male has pectoral nipples as well as the female ; and in many infants, milk, or a fluid analogous to it, is secreted, which proves the ex- istence of a glandular structure under the nipple. This view of the subject throws some light on those cases where the testicles are substituted for the ovaria; since, whenever the impregnation fails in stamping the ovum with a perfect impression of either sex, the part formed will neither be an ovarium nor a testicle, sometimes bearing a greater resemblance to one, sometimes to the other ; and may, according to circumstances, either remain in the natural situation of the ovaria, or pass into the situation proper to the testicle, whether it is the scrotum of the male or the labia pudendi of the female. [On the causes of hermaphroditic mal- formation, see J. St. Hilaire, Hist, des Anomalies de rOrganiz. ii. 58; and Simpson, op. cit.] Means of ascertaining the true sex of a supposed Hermaphrodite. — We say sup- posed, because, as has been already stated, we do not acknowledge the existence of a true herma- phrodite in the human species. Some cases no doubt have occurred in which it was very difficult to assign the proper sex ; but even the most per- fect of these complications of the genital organs did not give the individual in whom they existed the power of double copulation. Thus in the case of Hubert Pierre it is not easy to decide to which sex he really belonged: again, we must admit that great difficulty existed in coming to a conclusion when we find such men as Hufeland, Mursinna, Stack, Martens, and Metygcr disagree- ing. From these and other cases that might be quoted, we must agree that cases do occur in which the greatest difficulty must be felt, and tho greatest caution should be used in forming an opinion. These cases of great difficulty all belong to the last class of malformations : in the other classes the solution is not so difficult. In pro- ceeding to make an examination for the purpose of ascertaining the sex of an individual, the great- est care should be taken not to mistake appear- ances, and these should be all accurately noted down. The different openings that present them- selves should be all explored with appropriate instruments, (taking care not to inflict any wound or cause pain,) in order that their direction may be ascertained. An accurate inspection of the whole body should be made, to elicit any predomi- nance of the constitutional characters of either sex that may exist. These examinations should not be made hurriedly, but should continue for a length of time, and be frequently repeated, before a positive opinion is given ; for the tastes, habits, and propensities of the individual must be taken into account, as well as the physical conformation in doubtful cases. It is of importance to be in. formed whether a discharge of blood has ever escaped from any of the openings, and if repeated, whether it has been periodical; as that circum- stance alone will be sufficient to decide us in coming to a conclusion. In the case of young children, it is best to wait until the parts become more fully developed, as it has happened that in- stances of confusion of sex when young have at the age of puberty taken a decided leaning to one or the other sex. Above all, it is necessary to be most cautious in believing all that is stated by the individual or the friends, as, from interested mo- tives, they may misrepresent facts in such a way as to lead us into error. T. E. Beatty. SMALL-POX. — The most approved authors concur in the belief that the disease known to us by the name of small-pox or variola, was not de- scribed by any of the writers of antiquity. From their silence, therefore, respecting a disorder so fatal, and possessing such very peculiar characters, we may reasonably presume that its origin was subsequent to their times, and that the world had existed some thousand years before it was visited with this dreadful pestilence. Etymology comes here in aid of history. The first authentic pas- sage in which the words variola and pocca occur is to be found in the Bertinian Chronicle of the date 961. (Moore's History of Small-pox, p. 87.) There being no term for the disease in the Greek or Roman authors, variola was coined in the mid- dle ages from the Latin varus, a pimple, or varius, spotted, and for several succeeding centuries was applied to designate measles as well as small-pox. From variola are derived the Italian vaiuolo, and the French verole. The term poc is of Saxon origin, and signifies a bag or pouch. The Anglo- Saxons early adopted this word, which was vari- ously spelt, and became pock, pocks, and pox. The epithet small in England, and petite in France, were added in the fifteenth century. From very early times attempts have been made to prove the antiquity of small-pox, and even in 160 SMALL-POX. our days this doctrine has found supporters. Dr. Baron, of Gloucester, the latest writer on the sub- ject, entertains the opinion that small-pox is to be traced in the earliest writings of the Hebrews and Greeks; that it was seen by Hippocrates, and commented upon by Galen. According to this author, the account of the plague of Athens, as given by Thucydides, "presents as accurate an account of the leading symptoms of variola as could possibly be expected from any historian not medical." (Life of Jenner, p. 177.) In this opinion Dr. Baron is countenanced by Salmasius, Hahn, and more recently by Dr. Willan, in a pos- thumous dissertation " On the Antiquity of Small- pox." Rhazes, an Arabian physician, and the first acknowledged writer on this disease, laboured to prove that Galen had seen it, but with all his en- thusiasm for his master, he acknowledged and was surprised at the unwonted brevity and inaccuracy of his description. This alone may be considered as decisive of the question; but we may further state that Friend and Mead, authors of the highest repute, after devoting great attention to the sub- ject, agreed that there was no foundation for such a notion. We shall be fully justified, therefore, in adhering to the generally received opinion that small-pox is a disease of modern origin. The first notices of a disorder which exhibits the well-marked features of small-pox, are to be found in the historical writings of Procopius (De Bello Gothico, lib. ii.), who flourished during the reign of Justinian the First. The obscurity of its origin, the difficulty of its cure, the universality of its devastations, and above all, the complete immunity from second attacks which are mentioned as characteristic of this epidemic, bespeak it to have been truly small-pox. It began A. D. 544, at Pelusium in Egypt, from whence it spread to Constantinople. This corresponds closely with the era commonly assigned in medical books to the first appearance of small-pox, viz. A. D. 569, the year of the birth of Mahomet. In that year an Abyssinian army, under Abrahah the viceroy, appeared before Mecca, and was unexpectedly compelled to raise the siege. Several circumstances concur to render it probable that the sudden retreat of the army was owing to the breaking out of small-pox, and the dreadful mortality which it oc- casioned. Bruce, in his travels (Travels to dis- cover the Source of the Nile, vol. i. p. 514), met with a manuscript account of this war, which confirms this story, and strengthens the opinion that small-pox first appeared in Egypt and Arabia about the middle of the sixth century. A further question has been raised and keenly agitated, whether the small-pox really began in Egypt, or was conveyed to the shores of the Red Sea from India. Attempts have been made to establish the existence of this disease in China and Hindostan at very remote periods. Mr. Moore, in his history of small-pox, advocates this opinion. He finds in the mythology, the religious institu- tions, the sacred and historical records, the medical works, and uniform tradition of those countries, abundant proofs that small-pox existed there at a period antecedent even to Hippocrates. (Moore's History of Small-pox, p. 35.) He then enters into an investigation of the circumstances which may have prevented the spread of the infection from Asia to Europe and Africa. It must be ac- knowledged, however, that the facts on which Mr. Moore relies in support of this opinion rest on very questionable authority ; and as the opinion itself has not met with many supporters, it is not necessary in a practical work like the present to bestow on it more particular examination. The small-pox, and with it the measles, cer- tainly burst forth in Arabia under circumstances most fatally favourable to their dissemination. It was in the year 622, when Mahomet began to collect the wandering tribes of Arabs whom he led forth, inflamed with religious zeal, against the neighbouring nations. To the devastations of war were now added the ravages of a new and most intractable disorder. But if we owe the in- troduction of small-pox to the Arabian armies, it is to the physicians of the same nation that we are indebted for the earliest accounts of it. Rhazes, an Arabian physician, who practised at Bagdad about the beginning of the tenth century, is the first author who treats expressly of small-pox. He quotes, however, several of his predecessors, of whom the most ancient is Ahron, a physician of Alexandria, who is supposed to have flourished about the year 622, the era of the Hegira, when Mahomet first went forth as a conqueror and a prophet. The treatise of Rhazes " De Variolis et Morbillis," deserves especial mention for the accu- rate description which is given of the several kinds of small-pox. His theory of the disease, however, is childish and scarcely intelligible, and his treat- ment lamentably deficient. He abounds, indeed, with directions for the management of every symptom, and more especially for that of the pus- tules in their several stages, which is very compli- cated, consisting of fomentations, fumigations, dry powders, ointments, and other applications chiefly intended to prevent pitting. In most of those in- stances his prescriptions are harmless, but this merit does not belong to his recommendation of free bloodletting and of the most powerful nar- cotics in all stages, and even in the confluent forms of the disease. Avicenna, another Arabian physician, gives also a very full and excellent ac- count of the symptoms of small-pox, and he im- proves upon the treatment suggested by Rhazes, by restricting bleeding to plethoric habits, and to the three first days of the disease. Both Rhazes and Avicenna concur in the opinion that measles and small-pox are only modifications of the same disorder. Avicenna considered measles as a sort of bilious small-pox. Hali Abbas, a third Arabian author on small- pox, deserves to be mentioned as having made an approach to the doctrine of contagious origin. The theory of small-pox adopted by him, as by all the Arabian physicians, was founded on the commotion and putrefaction of the humours of the body ; but Hali observed that one of the accidental causes which excited the movement of the distempered humours to the skin was being in the same place with persons affected with the small-pox, or breathing air contaminated with the pestilential vapour of small-pox pustules. All the Arabian authors believed in the occasional occurrence of small-pox twice in the same person. The successes of the Saracen arms in Spain and Sicily, during the eighth century, contributed SMALL-POX. doubtless to the gradual extension of small-pox through the different countries of Europe, but on this subject very little is known. We read that on several occasions a pestilence of fire raged, the body dissolving away as if burnt, with an intole- rable fostor of the putrid flesh. It is reasonable to suppose that some at least of these epidemics were the small-pox: others may have been the true Egyptian plague with buboes. The researches of antiquarians lead to the be- lief that small-pox reached England early in the tenth century (907). There is preserved in the British Museum a curious Anglo-Saxon manu- script, supposed to have been written in that cen- tury, containing an exorcism or supplication against the small-pox. (Moore's History of Small- pox, p. 94.) Nicasius was the saint especially addressed on these occasions. All that we read serves to show how great were the terrors in- spired by the small-pox in every period of its career. The discovery of America by Columbus, which so wonderfully extended the boundaries of human knowledge, was the occasion also of scenes of desolation at which the heart sickens. Among all the calamities incident to that event none can surpass the introduction of small-pox into that continent, which took place in 1517, twenty-five years after its discovery. It is stated, on the authority of the Spanish historians, that in a very short time after the infection reached Mexico, three millions and a half of people were destroyed by it in that kingdom alone. Among the victims was the emperor, the brother and successor of the brave but unfortunate Montezuma. (Robertson's History of America, vol. iv. b. viii.) From the revival of learning to the present period, no subject has attracted the attention of physicians, both speculative and practical, more than small-pox. Every medical writer has treated of it, and some have devoted themselves exclu- sively to its study. It would be vain, therefore, to attempt more than a brief allusion to those who have distinguished themselves in this department of medical inquiry. The humoral doctrines which prevailed in the schools during the sixteenth century led to the universal adoption of the hot or alexipharmic mode of treating pestilential and malignant dis- eases, including small-pox. Sennertus gives the following account of the practice pursued in his time (1628). The great object was to expel the noxious humour by perspiration, to accomplish which various decoctions of warm seeds are di- rected, containing mithridate, bezoar, and other drugs, denominated alexipharmic and sudorific. " While using these, every attention is to be paid, especially in winter, to prevent the admission of cold air. The patient is therefore to be tended in a warm chamber, and carefully covered up, lest by closing the pores of the skin the efforts of nature should be impeded, the humours driven upon internal organs, and matters which ought to be expelled retained within the body, to the im- minent danger of the patient, and the certainty of increasing restlessness, fever, and other symp- toms." (De Variolis et Morbillis, t. vi.) Such had long been, and such was the state in which Sydenham in 1667 found the theory and Vol. IV. —21 o* practice of small-pox. Bad as that practice was, it yet had the support of all the learning and all the prejudices of the age. It required, therefore, talent and boldness successfully to oppose it. Sydenham began by separating for ever small-pox from measles, with which, from the days of Rhazes, it had been so strangely yet so obstinately associated. He divided small-pox into two kinds, the distinct and confluent, traced with the greatest accuracy the usual course of both, and added many important remarks to the detail of symp- toms given by others, particularly with reference to prognosis. Of the intimate nature or essence of small-pox he professed his ignorance in com- mon with the rest of mankind, but adds immedi- ately afterwards his suspicion that it consists of a specific inflammation of the blood and other humours, and that the inflamed particles, when duly digested and concocted, are expelled from the body in the form of little abscesses. The chief merit of Sydenham consists in his criticisms on the prevailing treatment of small-pox. These, though worded with the most scrupulous care, and an anxious wish to avoid hurting the feelings of his professional brethren, yet exposed him to much obloquy, and he was calumniated as an in- novator and a homicide. He introduced what is now called the cooling regimen, including fresh air, light bed-coverings, and abstinence from wine and all cordial and sweating medicines. The remedies on which he chiefly relied were mode- rate bleedings, acidulated drinks, and opiates. His principal faults consisted in the timid em- ployment of purgatives, and his fondness for blisters. Boerhaave, who was born when Sydenham was at the height of his fame (1668,) entertained the highest admiration of him, and was contented to adopt almost without alteration the description and treatment of small-pox given in his works. But Boerhaave has the great merit of first putting prominently forward contagion as its direct excit- ing cause. He acknowledges " that as the first man who suffered from small-pox must necessarily have received it without contagion, so may it still be occasionally engendered by causes of which we are ignorant. Nevertheless, as a general law it may be stated that the contagion once generated multiplies itself without any assignable limit, as the smallest spark may spread the widest confla- gration." (Van Swieten's Commentaries, vol. v. p. 18.) The theory and treatment of natural small-pox, placed thus, by the combined labours of Syden- ham and Boerhaave, upon their proper footing, underwent no important changes during the last century; the attention of authors was then di- rected almost exclusively to the new discovery of inoculation, of which we shall treat more fully in a subsequent page. We now proceed to give a description of small- pox, and have to remark, in the first place, how singularly diversified are the appearances which it presents. A variety of causes contribute to this, but none more remarkably than the previous habit or condition of the body with reference to the contagion of small-pox. It will be useful, therefore, to begin by considering the disease under three different aspects :—. 162 SMALL-POX. First, as it occurs, casually and for the first time, to those who have undergone no preparatory process. This is called the casual or natural small-pox. Secondly, as it occurs to those who in early life have undergone the process of vaccination. This is called the mitigated or modified small-pox. Thirdly, as it occurs to those who have been inoculated with the variolous virus : the inocu- lated small-pox. Natchal S>iali.-pox. This disease is characterized by a long train of phenomena, some of which are peculiar to it, while others are common to it with other acute disorders. From very early times it was observed that these admit of a division into three stages. Such an arrangement is strictly natural, and admits of no improvement. These are, the stages of incuba- tion, maturation, and decline ; and they will re- quire separate investigation. I. Stage of Inclination. — Under this head is included the whole period that elapses from the reception of the variolous germ, or virus, into the human body, until the appearance of eruption. Rayear (Treatise on Diseases of the Skin, trans- lated by W. B. Dickinson, p. 108, London, 1833) subdivides it into the two stages of incubation and invasion, the former comprising the interval be- tween the reception of the germ and the sickening,- the latter extending from the sickening to the ap- pearance of eruption. In very many cases, how- ever, this distinction cannot be made, the two periods running into each other by insensible de- grees. The reception of the variolous poison into the human body casually by the mode of infection, (that is, through the medium of respiration,) takes place in most instances imperceptibly and without symptoms. Occasionally, however, the patient experiences at the moment of imbibing the germ of disease some unpleasant sensation, such as a disagreeable odour, or a feeling of giddiness, or sickness at stomach, or, what is perhaps more common still, an inward sense of alarm or fright. The duration of this stage is subject to some va- riety. Fourteen days may be stated as the ave- rage period that elapses from exposure to conta- gion to the appearance of eruption. The extremes may be set down as one week and three weeks. This interval is passed differently in different cases. Sometimes the patient, during the whole or greater part of this period, has been weak, lan- guid, low-spirited, and inactive, with impaired digestion and unquiet nights. He has felt poorly, without any assignable cause. In the greater number of instances, however, no uneasiness what- ever is experienced until the eleventh or twelth day after exposure to contagion, when an unex- pected and perhaps severe rigor announces the commencement of the initiatory, or, as it is some- times called, the eruptive fever. This is accom- panied in some cases with severe pain or weakness of the back, so that the patient has dropped down ; in other cases with acute pain of the epigastrium, aggravated on pressure, and hence sometimes mistaken for gastritis; with nausea, vomiting, gid- diness or headach. Children are often very drowsy at this period. The nervous system some- times participates in a more marked manner. There is extreme prostration of strength. The patient staggers in his walk, and the expression of countenance is anxious and haggard: children have an epileptic fit: adults become delirious. These more urgent symptoms generally indicate the approach of a severe form of the disease. Of this there can be no doubt, when, in addition to the symptoms already enumerated, we observe such as denote that the fluids of the body are im- plicated in the mischief which is going on—that is to say, when petechia? appear in different parts, or large patches of subcutaneous ecchymosis, with hemorrhage from the nose, mouth, stomach, bow- els, or uterus. Under these circumstances death has been known to take place prior to any unequi- vocal appearances on the skin. Here the real nature of the disease must always remain in some degree doubtful, but it can often be inferred by tracing carefully the history of the case. It will be found to have succeeded exposure to small-pox contagion within the reasonable limit of time, or it may in its turn have communicated contagion to others. Several well-marked instances have occurred, rendering it almost certain that conta- gious emanations are thrown off from the lungs and skin even at this early period of the disease. The duration of the initiatory or eruptive fever of small-pox has been a fruitful source of discus- sion among authors. Prior to the time of Syden- ham the object of physicians was to shorten the period as much as possible, and to promote an early eruption, which they attempted to effect by powerful diaphoretics. Sydenham, on the other hand, maintained that the more tardy the eruption the lighter was the subsequent disease. This ob- servation is not borne out by the results of our own experience ; and it is not improbable that Syden ham's judgment might have been in some degree warped by his anxiety to dissuade from that heat- ing regimen of whose injurious effects he was so well convinced. The fact appears to be that the period of the initiatory fever is most remarkably uniform. The eruption in a vast majority of cases shows itself at the end of forty-eight hours from the occurrence of rigor or headach, whether the subsequent disease be mild or malignant, con- fluent or distinct: in other words, one complete day intervenes. Sometimes, from accidental cir- cumstances, (such as great weakness of constitu- tion,) this period is protracted to seventy-two hours, but never, so far as we have observed, is it shortened. This may be looked upon as a re- markable law of the variolous disease, and a most important means of distinguishing small-pox from other exanthemata, particularly scarlatina, lichen, and measles. In the two former disorders, the duration of the premonitory symptoms is less than in small-pox ; in measles it is greater. II. Stage of Maturation.—The eruption of small-pox shows itself in the first instance in al most all cases on the face and wrists, and thence gradually extends over the rest of the body. In a very few cases only has it been first observed on the inferior extremities. It consists of minute papula? sensibly elevated above the general sur- face of the skin. In some instances the eruption is fully developed over the whole body in the course of twenty-four hours. In other cases, two and even three days elapse before the process is SMALL-POX. 163 completed on the legs and feet. When the papula? are few in number, and separate from each other, the disease is called distinct,- when the eruption is close set and profuse, confluent. To the inter- mediate varieties the old authors gave the name of contiguous or coherent, but the term semicon- flucnt is preferable. We apply it to designate those cases where the eruption is confluent in one 'part and distinct in another, as well as those where the papula? are numerous without actually running into each other. Arrangement and structure of the pock.— This branch of the subject has excited much at- tention at various times, and in particular was investigated diligently by Cotugno, (better known under his Latin name of Cotunnius,) an Italian physician, in the year 1771. (De Sedibus Vario- larum. Vienna, 1771.) When the papula? are few in number, they will not be found indiscrimi- nately diffused over the body, but arranged in groups of three or five, and assuming a crescentic or semicircular form. When two groups coalesce, a complete circle of papula? may sometimes be observed. The papula? have their seat in the true skin ; and upon the third or fourth day from their first appearance are converted into vesicles, containing a thin transparent lymph. These vesicles are very curiously organized, being divided into six or eight cells tied together in the centre, which for several days is depressed. This central depression, or umbilicated form of vesicle (as it is sometimes called), is very characteristic of small-pox. It is exhibited only in one other dis- ease—cow-pox. The specific matter or poison of small-pox is secreted by the parietes of the minute cells, and the progress of inflammation in the papula is denoted by the inflammatory circle (called areola) which about the fourth day begins to surround it. As the colour of this areola changes to a bright crimson, the lymph in the vesicle is converted into a thick opaque matter, of a white or straw colour. This distends the cells, and gradually increasing in quantity, breaks down the central band, in consequence of which the pustule acuminates. In favourable cases this process is usually completed in seven, or at furthest in eight days : occasionally it occupies only five or six days. During the maturation of the pustules there is always some degree of fever present, varying, of course, in violence, with the quantity of eruption, the habit of the patient, and the circumstances in which he may happen to be placed. If the habit of body be good, the season mild, the apartment cool, the diet duly restricted, and the mind free from anxiety, there will be very little fever, even though several hundred pustules are in the pro- cess of maturation. There is generally more or less tenderness of the skin present. Occasionally this tenderness is excessive, and productive of the greatest distress. Confluent form of small-pox. — When the eruption is very copious over the whole or greater part of the body, this, its regular or normal pro- gress, undergoes several important modifications, which are next to be described. In some cases, indeed, the confluent small-pox runs the same course as the mildest forms of the distinct disease. The vesicles are small, and each is surrounded by a minute areola, while the constitutional excite- ment is moderate. Such a form of small-pox may be characterized as the confluent superficial. The most familiar instances of it are presented when the disease is taken after vaccination, but it is sometimes witnessed among persons wholly unprotected. Analysis of the symptoms of confluent small- pox.— 1. The first peculiarity of confluent small- pox, as generally met with, is, that from a very early period it involves not only the cutis vera, but the subjacent cellular membrane in extensive and often violent inflammation. The eye-lids are swollen, and by the fifth day the patient is unable to see. The scalp is tense and tender. The pa- rotid glands participate in the increased action of the surrounding cellular membrane, and salivation takes place, with great turgescence of the cheeks. The limbs are tumid, and an erythematous red- ness often occupies such parts as are free from variolous papula?. In the most aggravated cases, buboes form in the groin, often with intense pain. The skin being almost wholly occupied with vesi- cles, there is no areola. The pustules do not acu- minate, but appear flat and doughy, and upon the face especially they coalesce into one large sore, which discharges a copious thin ichor. The con- stitutional symptoms accompanying this kind of small-pox are very severe. The pulse is rapid, with extreme debility, restlessness, and total want of sleep. 2. The second peculiarity of the confluent small-pox is, that the eruption occupies not only the skin but the mucous expansions of the mouth, nose, pharynx, larynx and trachea to below its bifurcation. The tongue is also occupied with vesicles. The precise structure of the mucous vesicle has not been determined with the same ac- curacy as that of the cutaneous vesicle; but it runs a course in all respects similar. This com- plication of mucous inflammation adds immea- surably to the danger of the disease, besides that it modifies some of the other symptoms. Heat of the mouth, pain of the throat, difficulty of swallowing, hoarseness, dyspnoea, and more or less mucous expectoration, are the first symptoms that it occasions. These increase in severity until the eighth day, from which time a copious secre- tion takes place from all the structures so affected. In a large proportion of cases the swelling occa- sioned by the inflammation so narrows the open- ing of the larynx, and the effused matter so blocks up the air-passages, that suffocation is produced. Before this takes place, however, the respiration has been impeded to such a degree as materially to interfere with the due oxygenation of the blood. Hence arises a long and frightful train of symp- toms, among which we may particularly enume- rate gradually increasing dyspnoea, coldness and paleness of the extremities, lividity of the areola, especially in parts distant from the centre of cir- culation, a swelled and purple tongue, great rest- lessness, and a low muttering delirium. Cases of the confluent form of small-pox are sometimes met with, which are altogether devoid of mucous complication, but they are very rare. The extent of mucous and of cutaneous inflam- mation, however, are not always and necessarily proportioned to each other. A case may be very 164 SMALL-POX. confluent on the surface, with but few vesicles in the throat. A. A third circumstance influencing materially the character of the symptoms in the confluent / variety of small-pox, is the early and deep impli- cation of the brain and nervous system. This fortunately is but a rare occurrence. The chief (' symptom by which it is characterized is early and violent delirium, (the delirium ferox of old au- thors,) attended in many cases with such a strong Vdisposition to self-destruction that the utmost care should always be taken to guard against the pos-^ sibility of accident. Variolous delirium is accom- panied with redness of the conjunctiva, contrac- tion of the pupil, and a wild expression of coun- tenance. It generally shows itself at the very commencement of the initiatory fever, but is some- times delayed until the second or third day from the appearance of the eruption. Excessive rest- lessness, anxiety, and despondency may be viewed as lighter evidences of the same specific affection of the brain. Nothing indicates its absence so certainly as a calm and collected manner, with a succession of quiet nights, and a confident hope of recovery. Variolous delirium is always most violent in the early periods of the disorder. When the areola begins to form, still more when external inflammation is fully developed, delirium for the most part ceases. Cases of confluent small-pox complicated with delirium are extremely danger- ous. A large proportion of them terminate unfa- vourably, sometimes by affection of the head, (coma,) sometimes by acute inflammation of some other internal part, especially the, pleura, brought on or determined by the general derangement of the nervous system. We have stated, as a gene- ral rule, that the peculiar affection of the brain and nervous system now adverted to, is associated with a full confluent form of eruption, but occa- sionally it is found to accompany, and of course very materially to aggravate the danger of distinct and semi-confluent cases. 4. The fourth circumstance which characterizes and modifies the phenomena of the confluent forms of small-pox, is the implication of the fluids of the body,—in other words, the concurrence of that state of the blood called by the old writers dissolved or putrescent. To these, the most ag- gravated of all cases, the terms malignant or petechial small-pox are generally applied. They are thus distinguished. From the earliest period of the disease, petechia? are observed in different parts of the skin. Sometimes the extent of sub- cutaneous ecchymosis is immense. As the vesicles advance to maturation, they fill, not with pus, but with a thin ichor tinged with blood. Hemorrhages break forth from all the mucous structures of the body. The gums bleed often very profusely. There is epistaxis, spitting of blood, vomiting of blood, and the passage of blood by stool. Fe- males suffer from violent menorrhagia, and abor- tion never fails to occur to such as are pregnant. There is bloody urine in some cases. All this occasionally happens without delirium, or any other well-marked evidence of cerebral affection. More commonly, however, these conditions, viz. disturbed brain and dissolved fluids, are found asso- ciated together. From this appalling variety of small-pox, recovery is scarcely ever met with. Death usually takes place between the fifth and seventh days of the eruption. Complications.—Such are the ordinary phe- nomena of the natural small-pox in its distinct and confluent forms, when it occurs to persons Previously in good health and of sound constitu- on. But it must be remembered that this dis- order may attack those who may be labouring, at the time of seizure, under some other disease, tuch as pneumonia, hooping-cough, hepatitis, or consumption; and further, that these and othei disorders may come on, unexpectedly, at any period, early or late, during the progress of small- pox. An infinite variety of accidental symptoms may thus be superadded to those regular symp- toms now enumerated. Besides which, small-pox may occur to persons of a weak habit, or in con- stitutions exceedingly exhausted, and unable to cope with a disease of such severity. It may occur, for instance, to those who have but recently recovered from a severe typhous or scarlet fever. Under these circumstances, we observe a very tardy eruption; collapse without advance of erup- tion ; or in cases somewhat more favourable, an abundant formation of large blebs, containing a thin ichor, with a very tedious and hazardous period of convalescence. To this latter form of the disease the old writers gave the name of the watery or bladder pock. III. Stage of Decline. — If the maturating stage of small-pox exhibits great diversity of symptoms, so also, even in a more eminent de- gree, does the stage of decline. The mildness and rapid progress to recovery which some cases present, contrast strongly with the severity, obdu- racy, and varied dangers of others. In the distinct and mild form of small-pox the pustules burst and discharge their contents on the sixth, seventh, or eighth day. A scab succeeds, cicatrization commences, and in vigorous consti- tutions is completed in about eight or ten days. In the very mildest cases of all, which approach to the character of chicken-pox, there is very little discharge of matter, but the pustules harden, and the small portion of pus which they do contain is apparently absorbed. This variety of the disease has been called the dry or horny pock, and it is the most common form in which small-pox shows itself after previous vaccination. In cases of greater severity, as well in the truly confluent as in those which we have distinguished as the semi-confluent variety, where the eruption is copius, but where the vesicles do not actually coalesce except in a few places, the decline of the disorder is attended with some remarkable phe- nomena, of which the most important are pitting and secondary fever. Cicatrization is tedious and ultimately effected with such a loss of substance in the true skin as occasions pits and scars, which continue during the remainder of life. From the great vascularity of the face, there is always greater confluence and a higher degree of inflammation there than in other parts. Hence, pitting is chiefly met with in the face, disfiguring and often completely altering the countenance of the suf- ferer. Secondary fever.—The febrile symptoms sub- side entirely in all cases where the pustules have maturated kindly over the whole body; but in all SMALL-POX. 165 severe cases, that is to say, where the cellular membrane and glands which it envelopes have become involved with the skin in inflammation, the fever, so far from subsiding on the ninth or tenth day, when the maturative stage has closed, is aggravated. The surface of the skin at this time becomes hot and dry, the tongue white, the pustules hard and scaly, the pulse increases in fre- quency, the patient is tormented with a great, sometimes inextinguishable thirst. Secondary fever is now said to have set in, and the variety of symptoms observed during its progress almost baffles description. The following attempt to enumerate some of the leading phenomena of se- condary fever will serve at least, to point out the character of this very singular condition. 1. In a large proportion of cases, secondary fever is accompanied with some form of inflam- matory action on the surface. An efflorescence identical with that of scarlatina occupies the trunk and extremities. Trails of erythematous redness appear in several parts, or a genuine erysipelas attacks the head, trunk, or limbs. In other cases the cutaneous and cellular inflammation is more circumscribed, leading to the formation of ab- scesses, often of great extent, of boils and car- buncles, and ulceration of those parts which are especially liable to pressure, such as the elbows, hips, and sacrum. In those situations sloughing sores are often met with, which from their extent and depth bring life into danger. In some cases the scalp is the part which receives the violence of the fever. Abscesses form there, or a diffuse cellular inflammation takes place, which is fol- lowed by purulent infiltration. Lastly, in a few instances the whole surface is occupied with pus- tules of ecthyma cachecticum, accompanied with fever of the hectic kind, which is with great diffi- culty subdued. 2. Secondary fever is accompanied in a certain proportion of cases with ophthalmia. The sub- ject of variolous ophthalmia is one of great extent and importance. In the early periods of the dis- ease it is not uncommon to observe a considerable degree of conjunctival inflammation, and some- times a pustule forms at the edge of the cornea ; but it is reserved for the decline of the disease to exhibit the aggravated form of this affection. In some desperate cases an intense form of ophthal- mia sets in about the tenth day, which rapidly involves all the structures of the eye, and in the course of a few days destroys its entire organiza- tion. In other cases the sloughing is confined to a portion of the cornea, and this is followed by a slaphylomatous protrusion of the iris. It is rare to observe more than one eye involved in this very destructive form of inflammation, but still in all countries, and from the earliest periods at which we read of this disease, a large proportion of the blind have been found to owe their misfortune to the secondary fever of small-pox. 3. Another frequent occurrence in the progress of secondary fever is gangrenous inflammation of the genitals. This shows itself in the first in- stance on the scrotum or prepuce, runs on rapidly to mortification, and in almost all instances ends in the loss of life. 4. The destructive effects of secondary fever, however, are by no means confined to the suiface of the body. It frequently happens that without any obvious cause some internal organ receives the violence of the febrile shock. Acute inflam- mation is set up, and the result is in almost all cases suppuration. The pleura is the part pecu- liarly disposed to suffer under these circumstances. Variolous pleurisy comes on about the eleventh or twelfth day of eruption, for the most part very suddenly, and proceeds rapidly to empyema. We have seen it prove fatal in thirty-six hours. In general, the pleuritic symptoms are violent and well marked. The pain of side is excruciating, and the shortness of breath equally unequivocal; but sometimes there is a latent form of pleurisy. The patient dies without making any complaint of the side, and on dissection one of the cavities of the thorax is found gorged with a sero-purulent fluid. In all cases of secondary fever, a strict attention to the respiratory organs, with such aid as the stethoscope can afford, should never be omitted. In a few cases the substance of the lungs is the seat of an intense form of inflamma- tion, tending to abscess. Children are sometimes attacked with symptoms indicating laryngitis or croup. 5. Affections of the abdominal viscera are very uncommon. Inflammation of the liver and of the mucous membrane of the bowels have been no- ticed, but they are among the rarest forms of in- ternal disease observable in the progress of small- pox. 6. The brain sometimes suffers during the pre- sence of secondary fever. Phrenitis with delirium occurs in children ; and in adults of plethoric habit a state of coma or lethargy is not unusual. But what is most worthy of attention in this respect, is that singular state of the nervous system which accompanies the destruction of large portions of skin, and which is so well known to surgeons as a consequence of extensive burns and scalds. It is characterized by severe and repeated rigors, succeeded by general tremors, low delirium, a weak and rapid pulse, a dry brown tongue, and collapse of the features terminating in death. 7. The evils attending secondary fever are ag- gravated by the concurrence of the strumous habit. Nothing develops it more certainly than protracted small-pox. Accordingly, in scrofulous constitu- tions we see secondary fever complicated with strumous ophthalmia, characterized as well by its complete intolerance of light and abundant secre- tion of tears as by its obstinate resistance to every kind of remedial treatment. Irritable ulcers form under the lower eyelid, and around the knee, ankle, and elbow-joints, and are found very diffi- cult to heal. Glandular enlargements of the neck take place, which sometimes suppurate, but oftener continue indolent and of stony hardness. Chil- dren frequently suffer from otitis. 8. To all this must be added the danger of con- tracting during the stage of decline, common fever of the typhoid or erysipelatous kind. At the Small-pox Hospital, it is not uncommon to find even the milder cases attacked during apparent convalescence, with fever, irritable stomach, sore throat and erysipelas of the face or extremities. This superadded disease has in many instances brought life into hazard, and in some has proved fatal. The great peculiarity of it is the concur- 166 SMALL-POX. rcnce of severe inflammation of the tonsils and subjacent cellular membrane with erysipelas of the head, neck, or back. It appears to have its origin in that vitiation of the air which is almost insepa- rable from the very nature of an hospital, and which any accumulation of malignant cases, more especially in a disease like small-pox, must neces- sarily tend to augment. This form of disease might be appropriately designated hospital fever. When it has once shown itself, there is abundant reason for believing that such a fever, whether exhibiting anginose or erysipelatous symptoms or their combination, is truly contagious. Prognosis. — The following are the chief grounds on which the prognosis in small-pox should rest 1. Confluence is always unfavourable, because it necessarily occasions a large drain on the sys- tem ; ,but if the pustules acuminate well, and the areola on the extremities be of a good, that is, crimson, colour, a reasonable ground of hope exists. Confluence on the face is more to be dreaded than in any other part. When the vesi- cles on the trunk of the body are flat, when the eruption on the face is white and pasty, when the extremities appear of a clarety or livid colour, little or no hope of recovery can be entertained. 2. With reference to prognosis, great attention is due to the state of the larynx. Hoarseness, with copious spitting, occurring at an early period is very unfavourable, as indicating the extent of mischief in that important organ. On the other hand, a natural tone of the voice is a favourable sign, and with a good constitution gives a fair ground of hope, even though the eruption be full and confluent. 3. Quiet nights, composure of mind, a collected manner, and confident hope of recovery are good omens, because they indicate the comparative free- dom of the brain and nervous system from all serious complication. Patients who from an early period of the disease are restless, delirious, moan- ing, and desponding, rarely recover. There is not a worse symptom in children than grinding of the teeth: very few recover in whom it is ob- served. 4. In estimating the danger of confluent and semi-confluent cases, the age of the patient merits particular attention. Persons above forty years of age seldom recover from any of the severer forms of small-pox. Infants also are in danger even from a moderate quantity of eruption. In both cases the reparative process is attended with great exhaustion of nervous power, the result of which is that the brain, larynx, or some other important organ loses its tone, takes on acute inflammation, and by its disorganization life is destroyed. The most favourable age for taking small-pox is from the seventh to the fifteenth year, when the powers of life are in the greatest vigour, with the least chance of plethora. 5. The habit of body is likewise to be taken into account. In the middle periods of life the danger of small-pox is much increased by its con- currence with a plethoric habit. Great weakness of constitution is equally a source of danger. Of the additional risk which a strumous habit entails, we have already had occasion to treat. 6. Every thing indicating a dissolved or putres- cent state of the fluids is of course most unfavour- able, such as petechia?, menorrhagia, and epistaxis. Recovery from the petechial or malignant form of small-pox, indeed, is so rare as scarcely to enter into calculation. Mortality of Small-pox. — It is commonly stated that one-fourth of those who are attacked by small-pox in the natural way perish. The records of the Small-pox Hospital indicate a somewhat higher proportion. The deaths during the last fifty years at that institution have averaged thirty per cent, the extremes being eighteen and forty- one per cent. The days of greatest mortality, or critical days, as they are called by the old authors, have been much commented upon, and in all ages it has been observed that the eighth (counting from the day of eruption) is the day of greatest danger. The following table, extracted from the register of the Small-pox Hospital for the years 1828 and 1829, illustrates this fact, while it shows at the same time that small-pox proves fatal at various periods, from the third to the thirty-eighth days of eruption. From this table it also appears that nearly two-thirds of the total number of deaths take place during the second week of erup- tion. Table of the critical days in Small-pox, showing the period of eruption, at which 168 cases proved fatal. (From the Records of the Small-pox Hospital for 1828 and 1829.) There died on the cases. 3d day of eruption. 4th ............ 1st week. f 3 4 < 5 3d week. 32 > 99 21 Total. 16 168 [Prior to the introduction of vaccination, ac- cording to Dr. Gregory, (Tweedie's Library of Practical Medicine, 2d Amer. edit. ii. 324, Philad, 1842,) tho deaths by small-pox were, to the total deaths in town and country, in the ratio of 16 to 100, or about one-sixth. Of those attacked, the mortality is usually stated at 1 in 4. This, SMALL-POX. 167 according to Dr. Stewardson, was the mortality at the Small-pox Hospital of Philadelphia during the years 1840, '41, and '42,—a much smaller propor- tion than in the epidemic of 1823 and 1824, de- scribed by Drs. J. K. Mitchell and J. Bell, (North American Med. and Surg. Journal, vol. ii. 1826,) in which more than one-half the unprotected cases died. In an epidemic small-pox, which visited Malta and Gogo in 1830 and 1831, the mortality amongst those not vaccinated was, according to Dr. John Davy, 1 in 4.7. (Notes and Observa- tions on the Ionian Islands, c\c, Lond. 1842.) The numerical method has not, however, been extensively and rigorously applied to this subject. The mortality seems to vary in different places; thus, from primary small-pox in London it has been estimated by Dr. George Gregory at 36 per cent.; whilst in Germany, according to Heim, it was only 20 per cent. From accurate statistical accounts, taken by the Registrar-General of Eng- land, it would appear that, in 1837, there were only five diseases more fatal in England; and that the deaths by it throughout England and Wales amounted to about 12,000 annually, .Since then, the number has fluctuated from 16,268 in 1838, to 9,131 in 1839. (Mr. W. Farr, in Third Re- port of Registrar-General, 1841.) At times, during special epidemic influences, the mortality from small-pox is terrific] Causes of death in Small-pox. — It may not be irrelevant to recapitulate the several causes of death in small-pox. 1. Prior to the maturation of the pustules, that is, between the second and seventh days of eruption, patients die of malignant fever ; of that peculiar condition of the fluids and nervous system to which the name of acute ma- lignancy may properly be given. 2. Between the eighth and thirteenth days of eruption, the chief cause of death is to be found in affection of the throat, and consequent suffocation. 3. In the state of secondary fever, that is, between the four- teenth and twenty-first days of the eruption, death may take place in three ways—either by violent febrile excitement with effusion on the brain; or by sloughing, gangrene, and destruction of large portions of the surface ; or lastly, by supervening pleurisy, peripneumony, or laryngitis. 4. At a still later period, that is, after the third week from the appearance of eruption, death may take place from mere exhaustion, or from erysipelas and superadded fever. Morbid Appearances.—It has been remarked from the earliest periods that the internal organs do not suffer in small-pox so extensively or so frequently as might be expected. In a large pro- portion of cases, the condition of the surface is the sole cause of death. In the throat, however, some very characteristic appearances present them- selves, provided death has taken place between the seventh and twelfth days of the eruption. The pharynx, larynx, and trachea are then found covered with a copious, viscid, puriform, or puru- lent secretion of a grey or brownish colour, thrown out by the numerous vesicles which had formed upon the mucous membrane of those organs. The mucous membrane itself appears thickened, pulpy, and in the worst cases black and sloughy. There is no point wherein pathologists have more widely differed than in this, whether the specific inflammation of small-pox invades the in- ternal parts 1 The phenomenon has been asserted as a matter of fact by some, while others have, with equal confidence, denied it. Cotunnius (De Sedibus Variolarum, passim) made a vast number of dissections with a special view to ascertain whether any of the viscera were the seat of vario- lous pustules. His conclusion is, that they are exclusively confined to the skin, and those mucous membranes which are in direct contact with the external air. There can be no doubt that this opinion of Cotunnius is strictly correct. Inflam- mation may originate from accidental causes in any internal organ during the progress of small- pox, and its effects will be seen after death; but these are not to be confounded with, or mistaken for, the specific effects of small-pox on the skin, and mucous expansion of the throat and chest. When death has taken place in the third week from the appearance of eruption, the pleura will sometimes be found inflamed, and coated with layers of coagulable lymph, while in the corre- sponding cavity of the thorax, purulent matter or a sero-purulent fluid will be collected, often in enormous quantity, compressing by its bulk the lung of that side into a small space. Occasion- ally a portion of the lung itself is found infiltrated with pus. In some cases, where great determination of blood to the head has been indicated during life by swelling of the head and face, delirium, head- ach, and high fever, the blood-vessels of the brain and its meninges are found turgid, with more or less of effusion into the ventricles. Nothing is more worthy of notice than the freedom of the abdominal viscera from all traces of disease in those who die of small-pox. Among the numerous dissections made at the Small-pox Hospital, we have never been able to detect vario- lous pustules on the mucous membrane of the intestinal canal. Ulceration of the bowels indeed sometimes takes place in children during the vio- lence of the secondary fever, but differing in no respect from that which occurs in other and more familiar forms of hectic fever. [See, on this subject, Dr. Petzholdt, in Brit. and For. Med. Rev. v. 479.] Pathology.—For more than a thousand years after the first appearance of small-pox, this dis- ease was considered by physicians to have its origin, like other fevers, either first, in some state of the atmosphere, or secondly, in some vitiated condition of the humours of the body. A large portion of the community at the present day are of the same opinion, and confidently believe that the small-pox is, to use their own expression, bred in the blood. The pathologists of the last century, however, from the time of Boerhaave, reasoning from the very peculiar train of symp- toms observed in small-pox, and from the com- paratively recent date at which it became known, adopted the notion that this disease is in all cases the product of a specific poison or contagion, re- ceived into the blood from without. Such is still the general opinion of the best informed phy- sicians. It cannot indeed be denied, that great difficulties are experienced in tracing the source of contagion in numberless cases, and that the doctrine of spontaneous origin admits of being 168 SMALL-POX. supported by some ingenious and plausible argu- ments ; but the weight of evidence is decidedly in favour of the invariable origin of small-pox by contagion. How the variolous poison was first generated is wholly unknown. A tradition has been handed down by the Arabian physicians (See Baron's Life of Jenner, p. 522,) that it was originally derived from the camel, but no substan- tial reasons for such an opinion have ever been advanced. The peculiar miasm or morbid matter of small- pox is receivable into the human body in three modes: first, by the lungs through the medium of the respiration: this is called the mode of in- fection. Secondly, by application of the matter to the unbroken surface of the skin or mucous membrane of the nose. This is properly denomi- nated contagion, although the terms infection and contagion are generally made synonymous. Thirdly, by application of matter to the wounded surface, which is the mode of inoculation. The diffusion of small-pox by the air in the mode of infection, as thus defined, presents many interesting peculiarities. It takes place much more energetically in certain states of the air than in others. Occasionally the atmosphere appears to be altogether incapable of disseminating the poison. That peculiar, or as it is sometimes called, epidemic, constitution of the air which is so favourable to the propagation of small-pox is not at all understood. It is neither appreciable by the thermometer, the hygrometer, nor the barometer. Small-pox spreads sometimes in a dry and warm, sometimes in a cold and moist state of atmosphere. The phenomenon may pos- sibly depend upon some electrical state of the air, which has hitherto eluded the researches of philo- sophers, but which time and closer observation may perhaps eventually succeed in discovering. It has been supposed that the peculiar condition of the atmosphere predisposing to the dissemina- tion of the variolous germ recurs every five or seven years, but no adequate grounds for this opinion appear to exist. Dr. Haygarth (Inquiry how to prevent the Small-pox, p. 78, 1801,) has taken great pains to ascertain the sphere of con- tagious influence in the case of small-pox—in other words, the distance to which the contagion extends beyond the person of the individual af- fected. He inclined to the opinion that it was very limited, not exceeding a few feet. There is reason to believe, however, that some fallacy ex- ists in the experiments made to determine this point, and that the distance at which the poison ceases to be energetic is much greater, varying, however, according to the condition of the atmo- sphere. Effluvia capable of communicating small-pox are generally considered to be given off by the lungs as well as by the skin, and at every period of the disease from the earliest to the latest. Drs. Haygarth and Heberden maintained (Ibid. p. 47 and 216,) that prior to the appearance of eruption, and even for the first two or three days after, a patient is seldom if ever found to communicate infection. We have already, however, expressed our belief, founded on facts within our own know- ledge, that even prior to the occurrence of erup- tion, while the body is labouring under the pre- monitory fever, the secretions are infectious. It is admitted by all that the contagious property hangs about the body as long as any scabs remain, which may be said to contain the poison in a con- centrated form. Again, it has been well ascer- tained (see cases detailed by Mr. Hawkins, in the London Medical Gazette, vol. iii. p. 282,) that for some considerable period after death the matter of the pustules continues energetic, and that a con- fluent case will so taint the air as to spread the disease, by infection, for at least ten or twelve days after death. All mankind, with few exceptions, are sus- ceptible of the variolous poison at some period of their lives. It has been received by the foetus in utero, by the infant immediately after birth, and by the adult up to the most advanced period of human life. As a general law, it may be stated that the susceptibility of small-pox is equally great at all ages, but it often happens that a par- ticular individual shall resist infection at one period of his life and receive it at another. Some constitutions imbibe this morbid germ mildly, others with great alarm. In such cases the nerv- ous system may truly be said to be poisoned by it. A full and plethoric habit predisposes to a confluent and malignant form of the disease. Huxham has well remarked that the ebullition of the fluids consequent on the circulation of the poison in such persons is, cxteris paribus, most severe and dangerous. (On Fevers, p. 126 et seq.] Hence the great mortality of the disease in that class of adults who indulge in full living, with a large allowance of ale and porter. At the same time it must be remembered that the opposite state of body, extreme weakness, is equally unfavour- able for the quiet reception and safe elimination of the variolous poison. The quantity of eruption is sensibly influenced by the state of the surface at the period of its development. Great heat of the apartment, the warm bath, the use of strong diaphoretics, abund- ance of bed-clothes, and the local irritation of blisters, all favour confluence. It might be ex- pected that cold would possess some power in diminishing the number of papula?. It must be confessed, however, that though by injudicious measures we may often aggravate the quantity of eruption, we possess few or no means of lessening it. The character of the disease is not with any certainty influenced by the source whence the in- fection was derived. The mildest form of what is called varioloid eruption will communicate to another the most confluent and malignant dis- order. Variolous effluvia are very volatile. A free ventilation, therefore, is the most effectual means which we possess of diminishing the danger of contagion. The clothes and bedding of a small- pox patient, if closely wrapped up, will retain and give out the disease to others at great distances of time; while medical men who visit small-pox patients and subsequently go into the open air, seldom if ever communicate the disorder. Dr. Haygarth is of opinion that they never do. Be this as it may, variolous effluvia are rendered comparatively innocuous by dilution. A few persons pass through a long life, ap- parently insensible to, or unsusceptible of, the SMALL-POX. 169 small-pox virus. It is a curious and important circums-tance that, so far as is yet known, such constitutions exhibit a like inaptitude to receive and nourish the vaccine disease. (See London Medical Gazette, vol. viii. p. 494.) Recurrent Small-pox. — Few facts in me- dicine are better ascertained than that once under- going small-pox gives to the individual through life complete immunity from future attacks. Ex- ceptions to this law, however, have undoubtedly occurred. They have been noticed in all ages, and stand recorded in the writings of almost all authors who have treated of small-pox. (See Medico-Chirurgical Transactions, vol. ii. p. 31. Also Edin. Med. and Surg. Journal, vol. iv. p. 460.) They are, nevertheless, comparatively rare occur- rences, and many persons practising extensively, have never seen even a single case of the kind. There is no instance recorded of a patient being received twice into the Small-pox Hospital. Second attacks of small-pox, when they do occur, are ge- nerally, so far as our own experience extends, different in their character from the first: when the first attack, that is to say, has been severe and unequivocal, the second has been light and tri- vial, and vice versa. Sir Gilbert Blane remarks, (Blane's Select Dissertations, p. 209,) that "al- most all the well-authenticated cases of second small-pox have been of those persons who in the first instance had undergone it in its most severe and dangerous form." This would seem to con- nect the occurrence of small-pox with a peculiar proneness in such a constitution to suffer under the variolous germ. Others, again, have attempted to explain this phenomenon on the supposition that the first attack did not perfectly saturate the system. Instances of death from recurrent small- pox are not common, but they are to he found recorded in authors of undoubted veracity. It has been alleged that second attacks of small-pox are more frequent after the inoculated than after the casual disease; but Baron Dimsdale, a high authority on such matters, denies this. A pre- disposition to receive small-pox more than once has been stated to exist in certain families. Concurrence of Small-pox with other Exanthemata.—Among the peculiarities of the contagion of small-pox, the possibility of its simul- taneous occurrence with other exanthematous dis- eases deserves mention. Several cases have been recorded wherein measles and small-pox have appeared together,* and both diseases have run their regular course uninfluencing each other. Such cases, however, are very rare. It has oc- curred to us to see at the Small-pox Hospital several unequivocal cases of the simultaneous existence of small-pox and scarlatina anginosa. Small-pox and cow-pox may sometimes be seen together, each running its natural course, but in general, under such circumstances, one or other disease is modified. This subject will be more fully discussed when treating of vaccination. Communication of Small-pox to the foe- tus in utero. — A number of facts illustrating this very curious subject have been collected toge- * Dr. Russell in Transactions of a Society for the Im- provement of Medical and Chirurgical Knowledge, vol. i. p. 90.—Mr. Dclagarde in Medico-Chirurgical Transac- tions, vol. xiii. p. 163. Vol. IV. —23 r ther by Dr. George Pearson. (Duncan's Medical Commentaries, vol. xix. p. 213.) From them it appears that the small-pox does not often extend from the mother to the fcetus; that whenever it is so taken, it is fatal in almost all cases to the fcetus; that inoculating a pregnant woman generally de- stroys the life of the fcetus, and, lastly, that the disease in the fcetus and mother is scarcely ever in the same degree of intensity. Dr. Jenner has published two cases (Medico-Chirurgical Trans- actions, vol. i. p. 269) in which the fcetus in utero took the disease from the mother, without the mo- ther being herself affected, though exposed, of course, to the contagion. Mead entertained the fanciful notion, that if a pregnant woman under- went small-pox without aborting, the child would remain through life unsusceptible of small-pox. Treatment.—1. It is seldom that opportuni- ties offer of treating this disease in its initiatory stage, for its existence is generally unsuspected until the eruption manifests itself. The eruptive fever of small-pox, therefore, supposing its nature unknown, would be managed like other forms of inflammatory fever. Blood would be taken from the arm, when the pain of the epigastrium or of the head were urgent. Saline medicines in a state of effervescence would be given to lessen the fever- ish excitement and to allay the irritable state of the stomach. Coldness of the extremities would be met by hot bottles to the feet, sinapisms, and the pediluvium. When from concurrent circum- stances, especially a known exposure to contagion, the real nature of the disease should be ascertained or very strongly suspected, the plan of treatment would not be materially different from this. Blood- letting would not then be repeated under a confi- dent expectation that the appearance of eruption would speedily relieve the symptoms. Leeches to the temples would be advisable, provided the head- ach continued urgent. The bowels should be relieved by injections and the milder kinds of aperients. All drastic purgatives should be then avoided. The saline diaphoretics might be advan- tageously directed, with the addition of an opiate at night, in cases accompanied by much delirium. Bleeding from the arm is not found to afford relief to that specific affection of the brain and nervous system which ushers in a certain proportion of the severe cases, and accompanies their matura- tive stage for the first three or four days. Leeches cold lotions to the head, aperients, and an ano dyne at night, offer a better prospect of relief. The antiphlogistic regimen is to be pursued in all its details. 2. During the period of maturation the follow- ing plan of treatment is to be recommended. When the stomach remains irritable with a tardi- ness of eruption on the extremities, a blister may be applied to the epigastrium, and frequent pedi- luvia administered, made more stimulating by the addition of mustard-powder. Pain of the fauces with difficulty of swallowing is benefited by the application of leeches to the throat, followed by fomentations made of camomile-flowers or poppy- heads. The bowels are to be duly regulated by aperient draughts, consisting of senna and salts, castor oil, or jalap with cream of tartar, in suffi- cient doses to insure one motion daily, or two motions, if the degree of fever requires it. Tho 170 SMALL-POX. action of the kidneys in like manner is to be en- couraged by frequent doses of the citrate of potash, the liquor ammonia? acetatis, or any similar mild diuretic. An opiate consisting either of laudanum, of the liquor opii sedativus, or of Dover's powder, may be given at bedtime, if there be any conside- rable degree of restlessness or of irritation of the skin. When the surface is tender and painful to the touch, with much heat, cooling lotions may be applied with considerable advantage. Under all circumstances the diet is to be regulated as in other cases of inflammatory fever. Lemonade may be given for common drink, and Sydenham's strong recommendation of small-beer may be un- hesitatingly adopted. Symptoms indicating local inflammation must be met by appropriate means. When cough and copious expectoration of a puriform mucus occur, and give evidence that inflammatory action has spread to the smaller branches of the bronchi, blood should be taken from the arm to the extent of twelve ounces, and repeated according to the exigencies o£ the case, bearing always in mind the drain upon the system which an extensive pustu- lation will ultimately occasion. When headach, a flusJied face, redness of the eye, and activity of the carotid and temporal arteries denote the pre- sence or probable approach of phrenitic inflamma- tion, particularly in persons of plethoric habit, blood must be taken from the arm freely. In the same habit of body it is sometimes advisable to take blood from the arm to moderate the violence of inflammatory action upon the surface, and to lessen the danger during the state of secondary fever. In all these cases the blood will be found buffy, and generally in a high degree. Ophthal- mia occurring during the maturative stage is gene- rally relieved by leeches to the temples, a strong purgative of calomel and rhubarb, and lotions con- taining Goulard and the extract of poppies. In all cases of small-pox it is desirable to keep the chamber darkened to guard as far as possible against this occurrence, and for the same purpose, as well as for the general comfort of the patient, the hair should be taken off at an early period of the disease. 3. The treatment of small-pox during the stage of decline and secondary fever is to be regulated on the following principles. When the disease is mild, a few doses of purgative medicine are useful, to keep down feverish excitement, and to carry off foul secretions, or, in the language of the vulgar, to get rid of the dregs of the disorder. Where the disease has been more severe, and secondary fever has set in, the excitement is to be allayed by occa- sional doses of antimonial powder with calomel, followed by an active aperient. The propriety of purging during the secondary fever of small-pox was for a long period the subject of keen contro- versy, but the question was satisfactorily settled in its favour. Calomel and rhubarb, senna and salts, and castor oil are the forms of purgative which will generally be found to answer best. Bleeding from the arm is seldom advisable in the course of secondary fever, unless accidental and superadded symptoms, such as pleurisy or coma, occur to render it necessary. When the face continues swollen, with tendency to delirium and a very dry skin, leeches should be applied to the temples. In those aggravated cases accompa- nied with the destructive form of ophthalmia al- ready described, little can be done for the assist- ance of the patient. The loss of blood which the intensity of the symptoms indicates would be fol- lowed by great and rapid exhaustion. To save the patient's life, therefore, the eye must sometimes be sacrificed. The period of secondary fever is frequently ac- companied with symptoms of debility, which call for the employment of tonic and cordial remedies. If there be a cold surface, a trembling hand, and dry tongue, wine should be administered, together with cordial draughts, consisting of camphor julep, ether, and the subcarbonate of ammonia. When the pustulation is profuse over the whole body, and the consequent drain upon the system great, beef-tea should be given freely, with a liberal allowance of porter, wine, or brandy. In this condition of the surface, it is extremely useful to absorb the matter by frequently and largely sprinkling the body with some simple dry powder, such as hair-powder, dried flour, the powder of starch, or of calamine. Starch-powder is the best. When sloughy and gangrenous sores have taken place upon the hips or extremities, reliance must chiefly be placed on the administration of wine and brandy, assisted by cordial draughts containing quinine, camphor, the aromatic confection, and laudanum. Particular symptoms must be met, as they arise, by appropriate remedies. Pains of legs are best relieved by warm fomentations made of the decoc- tion of poppy-heads. Extreme debility and night- sweats call for the administration of bark and acid. An ecthymatous state of the surface, with languor and loss of appetite, will sometimes yield, and cicatrization advance, under the use of sarsaparilla and small doses of the pilula hydrargyri. In many cases, however, this troublesome sequela of the disease will not give way except to change of air, the beneficial influence of which is very manifest in the convalescence from all the severer forms of small-pox. Erysipelas is to be treated by purga- tives of calomel and rhubarb, followed by castor oil; by lotions to the surface, applied either warm or cold according to the feelings of the patient, and the internal administration of saline diuretics, aided towards the decline of the complaint by the decoction of bark. When small-pox has called into activity the dormant seeds of scrofula, the tonic and alterative treatment usually pursued in the management of that disorder is demanded, although the most sci- entific efforts of the physician will then too fre- quently be baffled. The abscesses and ulcers, as well indolent as irritable, which are so often left by small-pox, are to be treated according to the ordinary rules of surgery. There is no peculiar method which can be devised for the prevention of pits and scars. The masks and ointments for- merly in use for that purpose, and so highly vaunted, are in reality more hurtful than benefi- cial. The application of a little cold cream to the hardened scabs is all that can be recommended. The greatest attention should be paid during the latter stages of confluent small-pox to the state of the scalp. The matting together of the pus- tules is apt in this situation to occasion extensive SMALL-POX. 171 abscesses, which are very troublesome and difficult to heal. To obviate these evils, the hair should be kept close cut, the scalp, when hot, should be covered with cold lotions, and purgative medicines administered, to relieve that determination of blood to the head on which the occurrence mainly depends. [The " ectrotic method" of treating the eruption has been much recommended of late years. (Ril- liet & Barthez, Traite Clinique et Pratique des Maladies des Enfants, ii. 544, Paris, 1843.) It has been advised to cauterize the pustules, within the first two or three days, or even somewhat later, with the view of abridging their duration, and preventing pitting. The best mode of apply- ing the caustic is to cut it to a fine point, and pierce the centre of each pustule with it. Mercu- rial plasters, composed of calomel or corrosive sub- limate, are said to have the power, when applied to the skin, of so modifying its condition as to prevent the maturation of the pustules; and wet- ting the face frequently with spirit of hartshorn is said by Dr. Morton, (Amer. edit, of Mackintosh's Principles of Pathology, &c.,) to have kept down the inflammation, and prevented the pustules from becoming either large or irritable. Keeping the patient with his face covered with a linen mask smeared on the under surface with mercurial oint- ment, seems to have prevented pitting. (See, on this subject, Dr. Stewardson, in Amer. Journ. of the Med. Sciences, Jan. 1843.) Baron Larrey, however, affirms, that he has found nearly the same benefit to follow the repeated anointing of the patient's face with olive oil. In addition to the plans already mentioned, it has been proposed, of late, to pass over the erup- tion a pencil dipped in a solution of nitrate of sil- ver in the proportion of from 15 to 45 grains to the ounce of distilled water. It would seem to be necessary, that the plan should be adopted before the fourth day, or before the eruption assumes the pustular form. Frictions with sulphur ointment, made of from a drachm and a half to two drachms to an ounce of lard—the first proportion for vario- loid,—the second for cases of confluent small-pox —over the face and the other parts that are co- vered with pustules, have been followed by equally favourable results. Light has certainly an effect in favouring the development of the pustules : hence, the patient has been kept with advantage in a dark room. With the view also of preventing the contact of light, the face has been masked with advantage; and, according to Baron Larrey, the Egyptians and Arabians are accustomed to cover the exposed parts of the body—as the face, hands, and feet— with gold-leaf, as soon as the eruption makes its appearance.] Modified Small-pox. Small-pox taken casually by those who have undergone no preparatory process of any kind, is sometimes of an exceedingly mild character. The pustules, though perhaps very numerous and close set, do not run into each other, but maturate sepa- rately, and turn, as it is called, on the fifth day. The eruption feels hard to the touch, and is of the kind commonly denominated seedy or horny. In the works of the oldest authors on small-pox, a description of the variety called horn-pock or stone-pock may be found. (Van Swieten's Com- mentaries, vol. v. p. 10.) It is a fair presumption that such natural mildness of disorder is attributa- ble to some fortunate peculiarity in the constitution of the patient. When small-pox occurs a second time, whether after inoculation, or after the disease casually taken, the second attack is very often of a spurious or anomalous kind. The papula? are prematurely surrounded with an imperfectly-formed areola; some are developed and pustulate ; others harden and die away. The eruption is limited to the face, or, at furthest, extends only to the face and trunk. Such instances of a spurious or modified small-pox are recorded in all the old writers, and do not appear to have been of unfrequent occur- rence. Their close resemblance to cases of com- mon chicken-pox gave occasion to much ambiguity, and even dispute concerning the identity and re- lations of these diseases. Since the discovery of vaccination, the milder varieties of small-pox have greatly increased in frequency, so as at the present time to be familiar to every one engaged in practice. Vaccination may be said to have multiplied prodigiously the number of constitutions that imbibe the small-pox mildly. It has generated a sort of artificial habit favourable to the peaceful reception of the vario- lous virus. It becomes now, therefore, an object of considerable importance to investigate carefully the phenomena of the mitigated or modified small- pox [ Varioloid.] It is reserved for a future oppor- tunity (see Vaccination,) to explain the circum- stances under which small-pox occurs after cow- pox, and the presumed causes of such an occur- rence. All that we now propose is to state the appearances which small-pox presents at some considerable interval of time after vaccination, as for instance, ten or twenty years. In a certain limited number of such cases, even when the proofs of correct vaccination have been most undeniable, the small-pox has been found to run its regular course unaltered in its symptoms, and unmodified in any of its features. We can- not, therefore, be surprised if it has sometimes, when so occurring, proved fatal. In an infinitely larger proportion of cases, however, the small-pox, when it attacks an individual who in the early period of life has felt the full influence of vacci- nation, is altered or modified, as well in its primary aspect as in its subsequent development and pro- gress. No reasonable doubt can be entertained, from the abundance of facts now before the world, that such modification is the law of the animal economy, and that the regular or normal progress is the exception. It does not appear, however, that the modifying power of vaccination displays itself in the incu- bative stage. In the modified, as in the natural disease, the same interval of time elapses between the reception of the variolous germ, the first de- velopment of symptoms, and the subsequent ap- pearance of eruption. The same pain of back attends the initiatory fever. The same constitu- tional disturbance, as well in kind as in degree, precedes the eruption. But though the primary fever rages uncontrolled by vaccination, its influ- ence is often perceptibly seen at the very first ap- pearance of the papula?. The eruption is both 172 SMALL-POX. less in quantity, and more limited in extent than in the common forms of the disease. It shows itself in the face and breast, and not at all, or very scantily, on the extremities. In many cases, indeed, this description does not apply. The eruption is profuse, and equals, both in extent of surface affected and in quantity, the worst cases of natural confluent small-pox. The modifying power, however, begins to show itself almost immediately afterwards. The feverish ex- citement, which with such a state of surface might be expected to run high, subsides entirely. Some of the papula? never advance at all towards matu- ration, while around others an imperfect attempt to form areola? may be observed as early as the second or third day. The course of the disease is then so rapid, that by the fifth day the pustules on the face have maturated. The pocks are horny and speedily desiccate, leaving, however, for a con- siderable time afterwards, tubercular elevations of the skin surrounded often by a mottled redness. During the progress of this imperfect maturation the patient is generally able to walk about. He enjoys a good appetite and sound sleep. The un- sightliness of the eruption alone disturbs him. No inflammation of the cellular membrane interrupts the period of convalescence. No pits remain to attest the violence of the disorder. We are warranted, as well by etymology as by the custom of old authors, in applying to this mild form of small-pox the term varicella; but to distinguish it from another disease which has received the same name, (the genuine or infantile chicken-pox,) we may with propriety call this the varicella variolodes. It resembles the true chicken- pox in the mildness of the external inflammation and the absence of all severe constitutional excite- ment. It differs from it, however, in its undoubted origin from the variolous germ, and in its power of communicating the most perfect small-pox to others, as well by inoculation as by infection. In some cases, especially where the interval from the date of vaccination has been short, small- pox in the vaccinated shows itself in a form so singularly mild that the real nature of the disor- der can be with difficulty ascertained. In fact, none but those who are in the constant habit of seeing such cases, of tracing them to their source, and observing the minute gradations by which the several kinds of small-pox run into each other, could recognise them. A few scattered pimples perhaps are all that exist to attest the fact; but these pimples, in their progress to maturation, will be found to exhibit (with or without the aid of the microscope) that great and undoubted criterion of variolous origin, depression of their centres. The diagnosis is aided by carefully inquiring into the history of the initiatory fever, and observing if forty-eight hours had elapsed between the occur- rence of rigor and the development of papula?. It is put beyond dispute by tracing the source of the disorder to some case of undoubted variola, at the distance of eight to fourteen days, or by its simul- taneous occurrence with other cases in which the character of the disease is unequivocally displayed. Such are the phenomena of small-pox as it usually presents itself in those who have under- gone regular vaccination in early life. It remains to state that every intermediate degree between the thoroughly confluent and the mildest vanoloid will sometimes be seen. l( is seldom, however, that any severe affection of the bronchial passages is witnessed. A few vesicles may be observed on the tongue and soft palate, but they seldom extend to the larynx. Affection of the brain and nervous system is more common. Intense delirium may often be found accompanying a very modified aspect of eruption, giving rise to much anxiety and some real danger. The cause of this anomaly generally exists in the peculiar habit of the indi- vidual. He will be found to be a person of an irritable or nervous temperament, and who has probably displayed, on some former occasion, a similar occurrence under the pressure of acute disease. Small-pox after vaccination very rarely exhibits dissolution of the fluids, hemorrhages, and the other phenomena of malignancy. Such an occur- rence has been witnessed, and followed too by a fatal result, but it must be looked upon as the most rare of all observed deviations from the ordi- nary course of the modified disease. Inoculated Small-pox. Small-pox existed in the world, and had been studied by physicians for at least a thousand years, before any idea prevailed that its course could be controlled and its virulence assuaged by any arti- ficial means. When, where, and by whom this great discovery was first made is not accurately known. It has been conjectured that it had its origin in the countries bordering on the Caspian sea, Circassia, and Georgia ; but the opinion Tests upon no adequate authority. Nor can we place much more reliance on the statements which have been made as to the antiquity of inoculation in China and Hindostan. Our first accounts of it are derived from Constantinople, and there, towards the close of the seventeenth century, inoculation must be considered as having had its origin, About the year 1703, rumours of the great success of this operation attracted the attention of Dr. Emanuel Timoni, a Greek physician, who had studied and graduated at Oxford. He subse- quently settled in Constantinople, and being con- vinced of the importance of the discovery, wrote an account of it in 1713 to his English corre- spondent Dr. Woodward, which in the following year was published in the Philosophical Transac- tions. In 1715, Dr. Pylarini, the Venetian consul at Smyrna, having also learnt the success of this Turkish practice, published an account of it at Venice. A notice of this work appeared in the Philosophical Transactions for 1716, and these favourable accounts were fully corroborated by the reports of Mr. Kennedy, (an English surgeon, who had travelled in Turkey) in his " Essay on External Remedies," published in London in 1715. No notice, however, was taken of these impor- tant facts by any English physician, and the idea of transplanting or engrafting small-pox (as the process was called) was well-nigh forgotten in London when the celebrated letter of Lady Mary Wortley Montagu appeared, which described the practice in so lively a manner as to attract public attention. (Vol. ii. Letter 31, dated April 1,1717.) " The small-pox," she writes, « so general and so fatal amongst us, is here entirely harmless by the SMALL-POX. 173 invention of engrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation. Every year thousands undergo it, and the French ambas- sador observes pleasantly that they take the small- pox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died in it, and you may believe I am well satisfied of the safety of the experiment, since I intend to try it on my dear little son. I am patriot enough to take pains to bring this careful invention into fashion in England." She kept her word, and to the spirit and enterprise of this lady the introduction of inoculation into this country is altogether due. It was not until her return to London that any attempt was made to profit by a discovery which had been announced for five years ; and her own daughter was reserved to be the first example of inoculation in England. This event occurred in April 1721, and as its success was complete, Dr. Keith, who had been witness to the experiment, submitted his child to the same process, and with a like happy result. Several months elapsed, but the medical profession in London still remained sceptical ; some, because the practiceoriginated with ignorant old women, and others from inability to understand the rationale of the process. The next step was to obtain a pardon from King George I. for six condemned criminals, on condition of their submitting, by way of experi- ment, to inoculation. This was effected through the agency of the Princess of Wales, who was anxious to follow Lady Mary's example, and to secure her own children by the new process. These and some other trials having been deemed satisfactory, the Princesses Amelia and Caroline were inoculated on the 19th April, 1722, the former being then eleven and the latter nine years of age. Both of them passed through the small- pox favourably; but the new practice, begun under such brilliant auspices, received a severe check in the death of three persons, (one of them a child of the Earl of Sunderland,) which hap- pened within a few days afterwards. Contemporaneous with these experiments in London were those performed at Boston in North America, by Dr. Boylston, on the authority of Timoni and Pylarini. 244 persons were inocula- ted by him in Boston and its neighbourhood between June, 1721, and January, 1722, of which number six died. The subjects, however, were ill chosen, and the operator betrayed both igno- rance and rashness. Dr. Boylston, however, deserves credit for having been the first to remark that the period of incubation is shorter in the inoculated than in the natural small-pox, and that the former may be employed to supersede the latter. When these occurrences at Boston became known in London, the clamour against inoculation increased. Objections were made to it both in a medical and moral point of view. By Dr. Wag- staffe it was declared to be unsafe, and by the Rev. Mr. Massey impious. Under these discour- aging circumstances, it is hardly to be wondered at that the practice of inoculation advanced but slowly. Prejudice and mismanagement combined to throw obstacles in its way. It was calculated that during the first eight years only 897 persons were inoculated throughout the whole of Great Britain, of whom seventeen died. By slow degrees the medical profession became convinced of the advantages of inoculation, but it was not until the middle of the last century that it was practised in England to any considerable extent. Several circumstances contributed about this period to bring it into repute. In the year 1746 the Small-Pox and Inoculation Hospital of London was founded, for the express purpose of extending to the poor the benefits which had hitherto been almost exclusively confined to the rich. The results of the practice in the hospital were eminently favourable to the cause of inocu- lation. In 1747, Dr. Mead, then in the zenith of his fame, published his work De Variolis et Mor- billis, and in a chapter expressly treating of inocu- lation, adduced many cogent arguments in sup- port of it. In 1754, the Royal College of Phy- sicians of London put forth a strong approbation of inoculation ; but the popularity which it ulti- mately acquired is mainly attributable to the im- provements which, in 1763, the Suttons introduced in the mode of conducting the process. Robert and Daniel Sutton were sons of Mr. Robert Sutton, surgeon, of Debenham, in Suffolk, who had acquired some celebrity as an inoculator. Both followed their father's profession. The for- mer established himself as a professed inoculator at Bury St. Edmunds, and the latter at Ingate- stone in Essex. The success which attended Daniel (the cleverest of the family) at Ingatestone was unparalleled, but he fairly earned it by the boldness and dexterity of his management. The peculiarities in his system of inoculation were chiefly the following:—he reduced the preparatory- process from a month to a week; he employed very freely, during the whole period, a strong pur- gative powder, containing calomel and emetic tar- tar: he inoculated by means of a single puncture; he exposed his patients freely to the coldest air prior to and during the eruption, and prescribed cooling drinks and a spare diet There was no- thing new in the plan. Lady Mary Wortley Montagu had stated that the Turkish children were suffered to play about in the open air during the period of eruption ; Sydenham taught the value of the cool regimen; and the purgative powder had been introduced from North America. The merit of the inoculator consisted in the skill with which he selected what was beneficial in the seve- ral plans already known. The system of Daniel Sutton was ably followed up by Baron Dimsdale, who enjoyed a high re- putation and extensive practice, and whose admi- rable treatise on inoculation (The present Method of Inoculating for the Small-Pox, by Thomas Dimsdale, M.D. seventh edition, 1779) contains every thing then known on the subject. Nor was any further improvement attempted. For twenty years the mode of practice recommended in Dims- dale's work was adhered to, and the result was, that in every succeeding year inoculation became both more popular and more successful. The close of the century, however, which saw the rise of inoculation, was destined to witness its fall. In 1798 Dr. Jenner announced the discovery of vac- cination, almost immediately after which the ge- 174 S M A L L - P O X. neral practice of inoculation declined, and has never since been revived. Theory of Inoculation.—The object of inocu- lation is to secure a mild form of the disease, and this result follows in a very large proportion of cases. No adequate explanation has ever been offered of the singular fact, that mildness of the disease should be occasioned by the germ being received into the system by means of the cutane- ous vessels. Something, it has been said, may be attributed to the influence of the preparative process, but this explanation will not go far when we reflect that the same means applied during the incubation of the natural disorder are not pro- ductive of the same effects. The beneficial influence of inoculation is dis- played not only in moderating the quantity of eruption, but in determining the whole force of the disease upon the surface. In a very large proportion of inoculated cases, the eruption is of the distinct sort, and moreover widely scattered. An efflorescence (roseola exanthematica) fre- quently precedes for one or two days the develop- ment of the true variolous papula?. Sometimes a full and confluent crop is produced, but under these circumstances it is very seldom that the mu- cous membrane of the pharynx and larynx be- come implicated to any dangerous extent. The cellular membrane, in like manner, is rarely in- volved in the inflammatory action, so that the dis- ease is then properly characterized as confluent superficial. Secondary fever, therefore, is rarely met with in the latter stages of inoculated small- pox ; and further, that affection of the fluids which constitutes the leading feature of acute malignancy is almost or altogether unknown as a consequence of inoculation. The result of all this is, that the mortality by inoculated small-pox is very small indeed, and bears no sort of propor- tion to that of the casual disease. The average number of deaths at the Inoculation Hospital was only three in a thousand. In the wards appro- priated to the casual disease the deaths were (and continued to be) three in ten. Practice of Inoculation. — According to the statement of Lady Mary Wortley Montagu, the old women of Constantinople " opened with a large needle one or more of the veins of the arm or leg, and put into the wound as much matter as would lie on the head of the needle, afterwards binding it up with a hollow bit of shell. This simple mode was first followed in England, but it was afterwards supposed more desirable to have large wounds, which might ensure a more plenti- ful discharge of matter. For this purpus inci- sions were made three quarters of an inch in length, and deep enough to penetrate through the skin ; and some cotton charged with variolous matter was laid on them for twenty-four hours, and retained there by means of a plaster. (Wood- ville's History of Inoculation, p. 99.) Another mode of giving the small-pox, said to have been first practised in China, consisted in inserting crusts or cotton charged with variolous matter in the nostrils. These rude practices were very in- jurious to the cause of inoculation, and they have long since yielded to the simple expedient of mak- ing a single wound with a lancet armed with fresh variolous matter in any convenient part; and, by a sort of general consent, the arm, at the insertion of the deltoid muscle, has been selected for the purpose. It is of little moment at what period of the dis- ease the matter for inoculation is taken ; but thin, limpid, or crude lymph of the fourth and fifth days is generally preferred to the purulent or well concocted matter of the eighth and ninth days, It is of as little importance whether the matter be supplied by a distinct or a confluent, a casual or an inoculated case. The Suttons preferred the crude lymph of a primary inoculated vesicle. Common sense would dictate the propriety of re- jecting a case of extreme malignancy. The best age for inoculation is from the third to the sixth month from birth, and again, after the period of dentition is passed. Adult persons in the middle periods of life may be inoculated with perfect safety, due attention being paid to the habit of body. Season has but little influence upon the results of inoculation, but, cseteris paribus, the extremes of heat and cold should be avoided. The spring season was generally preferred by the pro- fessed inoculators in England. At Constantino- ple the month of September was the period usually selected. The circumstance chiefly to be dreaded in in- oculated small-pox is an inflammatory state of the blood. Hence it is that the only preparatory mea- sures of any importance are such as have for their object to repress this tendency. A dose of pur- gative medicine should be given prior to the ob- servation, and two or three more during the period of incubation. The purgative should consist of calomel, combined either with antimonial powder, emetic tartar, or powder of jalap. The patient is to be restricted to a spare vegetable diet. He should sleep in a large airy apartment, without a fire, and during the day should be exposed freely to the cold air. The influence of cold in repress- ing the quantity of eruption.was strikingly mani- fested in the practice of the'Suttons, and consti- tuted, in fact, the principal peculiarity of the Sut- tonian system. Phenomena of Inoculation. — On the second day after the operation, if the part be viewed with a lens, there appears an orange-coloured stain about the incision, and the surrounding skin seems contracted. On the following day a minute pa- pular elevation of the skin is perceptible, which on the fourth day is transformed into a vesicle with a depressed centre. The patient perceives an itching in the part. On the sixth day, some pain and stiffness are felt in the axilla, proving the absorption of the virus into the general mass of blood. Occasionally on the seventh, but oftener on the eighth day, rigors occur, accompanied sometimes with faintishness, sometimes with pain of the back, headach, or vomiting. The patient complains of a disagreeable taste in the mouth, and the breath is offensive, soon after which the eruption shows itself. The incision in the arm, when viewed through a glass, now appears surrounded with an infinite number of small confluent papula?, which daily increase in size. On the tenth day an areola or circle of inflammation forms around the inoculated point, now distended with matter. This areola a irregular in shape, and in its progress become* SMALL-POX —SOFTENING OF ORGANS. 175 interspersed with numerous minute vesicles. By the fifteenth day the primary pustule has scabbed, and the eruption on the body generally has begun to maturate. By the twenty-first day, in the great majority of cases, the disease is wholly at an end. The number of papula? dispersed over the body is subject to great variety. In some cases not more than two or three are perceived. It is important to know that an eruption is not indispensable to the success of inoculation. In some cases the full change has been produced upon the frame, and a complete insusceptibility to future attacks given, by means of the single pustule excited ar- tificially upon the arm. Treatment of inoculated small-pox.—In mild cases nothing is required but one or two doses of simple aperient medicine, such as the infusion of senna, with manna and Epsom salts. In cases of greater severity, we are to proceed in the man- ner already directed for the natural small-pox. The objections which have been urged against inoculating for the small-pox, and which have caused the abandonment of the operation, are the following. Although in many instances the sub- sequent disorder be slight, still it is sometimes severe, and occasionally brings life into hazard. It often proves the exciting cause of other disorders, and more especially calls into activity the scrofu- lous taint. But more than all, it is urged against small-pox inoculation that it adds to the danger of the public by multiplying the foci of variolous contagion,—that it preserves one life at the risk of many. This objection to inoculation, which has been so strongly insisted on of late years by almost all writers, was long since fully appreciated. Dr. Watkinson, Dr. Schwencke, and others, in the year 1777, attempted to obviate it by showing that the diffusion of variolous contagion takes place only in certain epidemical states of the air; that when such a condition of atmosphere pre- vails, the disease would propagate itself quite as widely, independent of all cases artificially ex- cited ; and when it was not present, inoculation would be perfectly harmless. The argument is ingenious, and certainly calculated to show that this charge against inoculation has been over- stated. It might seem easy to determine the point at once by reference to the Bills of Mor- tality, where a gradual augmentation of deaths, in proportion as the practice of inoculation extended, will at first sight appear. Dr. Adams, however, very justly remarks (Inquiry into the Laws of dif- ferent Epidemic Diseases, by Joseph Adams, M. D. 1809, p. 144,) that this argument is more plausi- ble than solid; for in the first place, admitting the fact to be as stated, there has been a corresponding increase in other diseases, not communicable by inoculation; and, secondly, the statements may be so put as to show a diminution rather than an in- crease. Thus, in the thirty years between 1741 and 1770, there died of small-pox, according to the Bills of Mortality, 63,308; whereas in the next thirty years (viz. from 1771 to 1800,) there only died 57,268. Although, then, it would be difficult to support this objection against inoculation by a reference to statistical tables, it is obvious that it must ne- cessarily contribute to diffuse the contagion, and so far therefore is an evil. Notwithstanding this defect, however, and others already adverted to, inoculation must still be viewed as a most valua- ble discovery, and a merciful provision of nature against the ravages of a dreadful pestilence. George Gregory. SOFTENING OF ORGANS. —The term softening [Ramollissement] is employed to de- signate a diminution of the natural and healthy consistence of organs. It is only of late years that this change has been investigated and de- scribed as a special morbid condition ; and whether we consider the frequency of its occurrence, the variety which it presents as to degree and extent, the serious and often fatal effects to which it gives rise, or the wide difference of its nature in the same or in different organs, it constitutes a sub- ject of great interest and importance. Before proceeding to describe softening of par- ticular organs and tissues, we shall take a sum- mary view of the opinions which are entertained regarding the nature of this lesion. Two opinions prevail regarding the nature of softening of the brain, an organ in which this change of con- sistence frequently occurs and often proceeds to a great extent. The first of these opinions is, that it is always a consequence of inflammation ; the second, that it is a disease sui generis, entirely opposite in its nature to inflammation, and, con- sequently, that it ought to have a distinct place in the nomenclature of diseases. It is surprising that opinions so opposite should have received the exclusive support of pathologists of great merit, and whose extensive opportunities of studying the disease put them in full possession of the means of determining how far one or both of these opinions should be received as the truth. It may not be altogether out of place to notice here what we conceive to have been the circum- stances which led to the adoption of these two opinions on the nature of softening of the brain. M. Rostan, who may be regarded as the first who directed the attention of pathologists to softening of the brain, was one of the physicians of the Salpetriere of Paris, an hospital destined exclu- sively for the reception of females, the greater number of whom are very old. These old women, varying from sixty to upwards of eighty years of age, were the patients in whom he observed soft- ening of this organ. In such patients, ossification and other diseased states of the arteries of the brain which give rise to obliteration of these ves- sels, and consequently to cessation of nutrition in the part to which they are distributed, may be said to be a frequent occurrence. The conse- quence of this state of the arteries is, as we shall afterwards endeavour to show, softening of the cerebral substance. But M. Rostan having over- looked this pathological state of the arteries, and not observing in the greater number of his patients, either the phenomena which generally accompany acute inflammation of the brain during life, or some of its least equivocal effects, such as various degrees of vascularity, and the presence of pus or coagulable lymph in this organ, after death, was led to believe, and to announce it as his belief in the work which he published on softening of the brain, that the disease in question is not the consequence of inflammation, but, as 176 SOFTENING OF ORGANS. we have already said, a disease sui generis, re- sembling gangrena senilis more than any other disease with which we are acquainted. (Re- cherches sur le Ramollissement du Cerveau.) The facts brought forward by Rostan in support of this opinion are far from being conclusive. He maintains rather than proves that the disease is not the consequence of inflammation, and has not attempted to elucidate its nature, with regard to which he seems satisfied by saying that it resem- bles gangrena senilis, which disease is the result of cessation of nutrition from ossification of the arteries ; but what is most remarkable is, that, after having made such a statement, he brings forward no evidence to show that softening of the brain is produced by a similar state of these vessels. Nay, among the great number of cases of softening of the brain, the histories of which are detailed in his work, there is not one in which ossification of the arteries of this organ is men- tioned as having been observed at the autopsy. Such being the case, the opinion of M. Rostan on the nature of softening of the brain is at most but a plausible conjecture, in so far as the evidence which he has brought forward in support of it is concerned. But the fact is, these researches were imperfect; for we have had frequent opportunity of examining the state of the arteries of the brain in softening of this organ in the old women of the Salpetriere, and in the great majority of cases we have found ossification or other morbid states of these vessels. Had this anatomical fact been stated by M. Rostan, and shown to have the same relation to softening of the brain as it has to gangrena senilis, he would have proved that there is at least one form of softening of this organ, the origin of which is independent of inflammation : —that it is the consequence of a cessation of nutrition from an interruption to the arterial cir- culation, a state of gangrene or local death from this cause. The chief supporter of the opposite opinion is Lallemand of Montpellier. This able pathologist seems to have studied softening of the brain for the most part in young and middle-aged persons, and in several of his cases it occurred in conse- quence of external injury. Under these circum- stances he had a full display of the inflammatory phenomena which precede softening of this organ. He has traced, if not in all, at least in the greater number of the cases he has related, its inflamma- tory origin and progress; that is to say, he has shown its connection with vascular injection of various degrees, with the presence of coagulable lymph, or with pus either infiltrated or collected in the form of an abscess. (Recherches Anato- mico-Pathologiques sur l'Encephale et Ses De- pendances. Paris, 1820.) Indeed, the researches of Lallemand on the nature of softening of the brain are so conclusive, that even Rostan himself tacitly admits, in the second edition of his work already referred to, that this lesion may occur under two forms—the inflammatory and the non- inflammatory, or that which he compares to gangrasna senilis. [A similar opinion has been strongly expressed of late by Durand-Fardel, (Traite du Ramollisse- ment du Cerveau, Paris, 1843.)] Dr. Abercrombie describes softening of the brain as the consequence of chronic or acute inflamma- tion, but he thinks it may also occur from oblit- eration of the arteries, as supposed by Rostan. (Pathological Researches on Diseases of the Brain and the Spinal Cord. Edin. 1828.) Softening of the mucous membrane of the di- gestive organs, a much more frequent occurrence than softening of the brain, has for a long time engaged the attention of pathologists. But it is more especially softening of the mucous mem- brane and other tunics of the stomach which has been made the subject of pathological investiga- tion. The great extent to which softening often proceeds in this organ, and its occurrence under conditions of the most opposite kind, as relates to the state of the stomach individually or to that of the economy in general, are circumstances which have given rise to great diversity of opinion regarding the nature or softening of this organ. The following are the chief opinions which have prevailed on this point. 1st. That softening of the stomach is the consequence of irritation or inflammation. 2d. That it is produced by the operation of an acid and corrosive fluid, formed in consequence of irritation of the mucous mem- brane of the stomach. 3d. That it is a change effected after death by the gastric juice, this fluid having been previously modified by disease of the stomach. 4th. That it is produced after death by the dissolvent property of the gastric juice, this fluid as well as the stomach itself being in the natural state. Of these opinions, two only appear to us to merit attention, viz. the first, which ascribes softening of the stomach to an inflammatory con- dition of this organ ; and the fourth, which refers this change to the natural dissolvent property of the gastric juice acting on the stomach after death. We have, therefore, the same lesion said to be produced by two agents, and under circum- stances of the most opposite nature. In the first case, softening of the stomach is a pathological condition—a disease; in the second, it is not a disease, it is merely a post-mortem lesion. But although occurring after death, softening of the stomach from the chemical action of the gastric juice requires to be particularly noticed in the present article, because of its having been described by many eminent pathologists as a diseased state. We shall, therefore, endeavour to demonstrate in another part of this article the separate existence of these two forms of softening of the stomach, and more particularly the characters by means of which the one may be distinguished from the other. The forms of softening which we have noticed are confined to particular organs or tissues. But there are other forms of this lesion of a much more general character, and which are also very different in their nature from the former. In the first of these forms the softening occurs in almost all the textures of the body at the same time, although it may be so slight in some as hardly to be observable ; whilst in others, even the hardest, it may be greatly marked. It is never observed unless in individuals in whom nutrition in gene- ral is strongly modified. The modification of nutriment which precedes the softening process is, however, very different in kind in different in- SOFTENING OF ORGANS. 177 dividuals—a difference which obviously exercises I a great influence in determining the seat and ' severity of the disease. Thus, in children born in a state of debility and emaciation, and in those who have been long deprived of the wholesome necessaries of life, we find all the tissues and organs of the body more or less soft, and easily injured by external causes. This general dimi- nution of cohesion is always accompanied by universal pallor, a watery, scanty, and aplastic state of the blood. Such, also, is the case in ad- vanced stages of scrofula and scorbutus; the bones as well as the other textures being found in those who die of these diseases, soft, spongy, and infiltrated with a sero-albuminous or sero-sangui- nolent fluid. In another class of patients, the softening, while it pervades to a certain extent all the tissues of the body, exists in a much greater degree in the bones, and from the superincumbent weight which they have to support, or the impulse which they receive from the action of neighbour- ing muscles, they lose their natural forms, and become bent or flattened to an extraordinary de- gree. It is this form of softening which has been termed rachitis, mollities ossium, or osteo-malacia. Great softening and pliancy of the bones consti- tute what is most frequently termed mollities ossium, whereas a degree of fragility, a want of cohesion, accompanied with softness, are more generally regarded as constituting rachitis. (See Rickets.) There is another form of softening, or rather flaccidity, which only requires to be noticed. It is best seen in the skin and cellular tissue when these textures, after having been greatly distended by an accumulation of fluid in the abdomen, are left unsupported by the removal of the distending cause. The looseness and flaccidity of these tis- sues is also very conspicuous in old people : in persons who, from a state of obesity, become lean, and in persons in general who become rapidly emaciated, particularly from disease. Lastly, softening of organs and tissues may take place from maceration and putrefaction after death. With regard to softening produced by these causes, we shall only observe that it should be kept in mind by the physician in his post- mortem researches, lest it should be confounded with the pathological forms of this lesion. From these general considerations, it would ap- pear that the several forms of softening to which the different tissues and organs of the body are subject, may be ranged under two groups, the first comprehending those forms which occur during life; the second, those which arc effected after death. I.— Occurring during life. 1. Softening from inflammation. 2. Softening from obliteration of arteries. 3. Softening from a modification of nutrition. II.—Occurring after death. 1. Softening from the chemical action of the gastric juice. 2. Softening from maceration and putrefaction. We shall treat of three only of these forms of softening,—viz. the first and second of the first group, and the first of the second group,—because of the two former being special pathological states, Vol. IV. —23 and because of the latter occurring under circum- stances which have often deceived the practical pathologist, and led him to describe it as a morbid alteration of the gravest character. I. Softening from Inflammation.—Before proceeding to describe inflammatory softening, it may be well to make a few remarks as to the man- ner in which the consistence of a tissue becomes diminished or entirely destroyed by inflammation. Two causes appear to co-operate in producing this change. The first is of a mechanical, the second of a physiological nature. Serosity or pus, when in considerable quantity, appear to effect, mechanically, a diminution of the cohesion of the tissue in which they are contained. The pressure which they exercise arrests the circulation, and it would appear, absorption also ; for if this func- tion were performed, we should have an excava- tion or ulcer formed instead of a mass of soft pulpy tissue. The circulation being thus arrested, nutrition ceases to be accomplished, and the mole- cules of the tissue are disunited and detached. If, while these changes are going on, or at some subsequent period, the function of absorption be resumed, the softened tissue is partially or wholly absorbed, and solutions of continuity of various extent are formed. The physiological cause of softening is referable to a change in the vital pro- perties of the affected tissue. We are unable to say in what this change consists, but its effects on circulation and nutrition are sufficiently obvious, both these functions ceasing to be performed at an early period of the inflammatory process. Soft- ening or dissolution of the affected tissue then takes place in the same manner as when produced mechanically. It is necessary to observe that the presence of serosity in a tissue from a mechanical obstacle to the return of the venous blood, as oedema of the inferior extremities from disease of the heart, does not give rise to softening ; and for this reason, that it does not arrest, but only im- pedes the capillary circulation. Locality of inflammatory softening.—There is no tissue in which softening may not occur as the mediate or immediate consequence of inflam- mation. It occurs in tissues which are never the seat of inflammation, as cartilage, tendon, Gbrous tissues, &c. Thus, when inflammation exists in the immediate vicinity of these tissues, they are soon deprived of the materials of their nutrition, and, consequently, lose their natural consistence, become soft and pulpy, and even slough. The cellular tissue is by far the most frequent seat of inflammatory softening. The diminution of co- hesion which follows inflammation of parenchy- matous organs, is owing to softening of the inter- stitial cellular tissue. Slight pressure with the point of the finger lacerates or breaks down a portion of hepatized lung. Muscular tissue is also easily torn or separated into shreds in conse- quence of softening of the interstitial cellular tex- ture by which its fibres are united, examples of which are sometimes met with in the heart, but more frequently in the muscles of voluntary mo- tion. Softening of the subcutaneous, submucous, and subserous cellular tissues, is often great in degree and extent in erysipelas phlegmonodes, enteritis, and peritonitis. The easy separation of these 178 SOFTENING OF ORGANS. coverings, particularly the serous and mucous,' from the subjacent tissues after death, is always the consequence of inflammatory softening of their cellular tissue, and the degree of facility with j which their separation is effected affords a ready means of determining the degree and extent of the inflammation to which this tissue had been subjected. Cases of peritonitis and meningitis occur which would escape the post-mortem re- searches of the pathologist but for this state of softening of the cellular tissue. In such cases there may be little increase of vascularity, and perhaps only a slight serous effusion, both of which may be overlooked, or, if observed, can afford no idea of the degree or extent of this morbid condi- tion of the cellular tissue. Softening of mucous membranes from inflam- mation is a frequent occurrence, and is often great in degree and extent. Softening of this tissue is more frequently met with in the digestive organs than in the respiratory, urinary, or generative or- gans. It is not, however, either so frequent or extensive in the mucous membrane of the diges- tive organs as has been supposed, for the reasons to which we have already alluded, and which we shall afterwards explain. Softening of the osseous tissue is seldom observed as a consequence of in- flammation, unless in surgical diseases. It is, however, a change which always follows inflam- mation of this tissue, and is frequently so con- siderable that the hardest bones become as soft as cartilage or muscle. Softening of the blood-vessels as a consequence of inflammation does not take place till after the destruction of their cellular sheath from the same cause. Softening of this sheath is a serious acci- dent in surgical diseases of the arteries requiring the application of the ligature. It has often been said that softening of the spleen, which is sometimes so great that this organ is transformed into a uniform pulpy mass, is the consequence of inflammation. We are, however, -of the opinion of those who ascribe this state of softness of the spleen to a morbid condition of the blood with which it is filled, this fluid being in a state of extreme fluidity. Inflammatory softening is no where so conspi- cuous, either as regards its physical characters, or the functional derangement to which it gives rise, as in the brain and spinal cord. Obvious func- tional derangement, as the direct consequence of inflammatory softening, is indeed not observed, unless when the brain or spinal cord is the seat of this lesion. We shall therefore commence with the medical pathology of inflammatory soft- ening as it occurs in these organs. Physical characters of inflammatory soft- ening of the Drain and spinal chord.—The degree of softening of the cerebral substance may vary from a slight diminution of the natural con- sistence of the part affected to that of cream or even of thin milk. The first stage of softening of this substance is often so slight, that it is hardly perceptible to the touch, and may, even when con- siderable, if not accompanied by some peculiarity of colour, be altogether overlooked. In the first case a gentle stream of water allowed to fall upon the cerebral substance, is the best means of deter- mining whether a portion of it has lost its natural consistence; and in the second case, the only way of detecting the presence of softening unaccompa- nied by any obvious change of form or colour of the affected part, is to submit the whole of the cerebral substance to a careful inspection, by re- moving it piecemeal in the form of thin slices. In the first stage the cerebral substance is not yet broken down ; it has only lost a certain degree of its cohesion, for it is still continuous with that by which it is surrounded. In the second stage the diminution of consistence is so great that it may be recognised at first sight, owing to trie change of form by which it is accompanied. The cerebral substance is so soft that it sinks by its own weight beneath the level of the cut surface; and prominent parts, such as the thalami, corpora striata, and convolutions, become more or less flat- tened. In the third stage, a solution of continuity has been effected by the separation of the softened cerebral substance. It is now of the consistence of cream or milk, contained in an excavation of variable extent, situated in the substance of the brain, or confined between the membranes and convolutions of this organ. The colour of inflammatory softening of the j cerebral substance presents considerable variety. j The principal varieties of colour depend on the i quantity of blood contained in the affected part, ! on changes which this fluid undergoes some time j after its accumulation or effusion, and on the presence of serosity and pus. Redness and vas- ! cularity are, in general, greater in the first than in | the second stage, but the degree and extent of i either greatly depend on the quantity of blood in the cerebral vascular system. In some cases a gradual increase of redness and vascularity can be traced to a considerable extent beyond the softened part; in others, these changes are limited to the immediate vicinity of the latter. The vascularity of the softened cerebral substance has frequently a hemorrhagic character. When this substance is divided, it presents a number of I red points, streaks, or patches, produced by the blood accumulated in the veins, or effusion of this fluid. In some cases the effused blood is small in quantity compared with the extent of the soften- ing ; in others it pervades the whole of the soft- ened substance, and presents the same appearance j as hemorrhagic apoplexy. The redness, vascu- j larity, and hemorrhagic character of inflammatory softening, are never so conspicuous as when this i lesion occupies the brown substance, as that of the ! corpora striata, thalami, and convolutions. In- | flammatory softening of the cerebral substance is | not always accompanied by those changes of co- lour which we have just described. The affected part may have preserved its natural colour, or it may be much paler than natural. Thus the sep- tum lucidum may be converted into a mere pulp, without its colour being perceptibly altered ; and the same degree of softening may take place in the brown or cortical substance, which has become so pale as hardly to be distinguished from the medullary substance in its vicinity. Pale soften- ing in either of these situations, viz. in the medul- lary or cortical substance of the brain, is a fre- quent occurrence in hydrocephalus, and it is also this variety of softening which is sometimes met with in those fevers in which the brain is prima- rily or secondarily affected. Mons. Recamier de- scribed this pale softening of the brain in his SOFTENING OF ORGANS. 179 clinical lectures at the Hotel Dieu of Paris, long before Rostan, Lallemand, or Abercrombie pub- lished on softening of this organ. This author regarded the pale softening as a primary condition of nervous or malignant fevers, and therefore he called it ramollissement ou deginerescence ataxi- que,- foyer ataxique. In such cases of softening of the medullary or cortical substance, we always find the brain in general pale, its vascular system containing but a small quantity of blood, and its membranes infiltrated with serosity. It is, in fact, owing to the pressure which the effused serosity exercises on the blood-vessels, that the ana?mic condition of the brain in general, and of the soft- ened portion of it in particular, is to be attributed. When the redness which accompanies softening arises from the presence of effused blood, it may always be regarded as evidence that the softening is of recent occurrence. But there are other modifications of colour which accompany soften- ing of the cerebral substance, and which for various reasons require particular notice. They indicate that the disease has existed for a considerable time — several weeks, or two or three months. The principal modifications of colour consist of brown, yellow, and orange colours, either sepa- rately or combined, and occupy either the softened substance, the part of the brain contiguous to it, or both at the same time. They are not observed unless the softening has been accompanied by effusion, and originate in changes taking place in the effused blood. Such are the modifications of colour to which we allude, so frequently observed to take place in the blood effused in the subcuta- neous cellular tissue in consequence of external violence. The brown colour appears first, and is very limited in extent when compared with the orange and yellow, by which it is succeeded,— circumstances which enable us to form a tolerably accurate opinion regarding the extent of the san- guineous effusion by which the softening had been accompanied. Knowing that these colours accompany cerebral softening, the pathologist will be put on his guard, and not confound this disease with hemorrhagic apoplexy, in which the same colours are present. A pale yellow straw-coloured tinge of the soft- ened cerebral substance arises also from the pre- sence of pus. But this is rarely observed unless the softened substance be in contact with the membranes of the brain. The presence of sero- sity in the softened cerebral substance produces, as we have already observed, a diminution of the red colour alluded to; but it likewise communicates a glossy albuminous aspect to softening, which it does not present in any other circumstances. When softening of the brain is accompanied by an increase of bulk, it is generally owing to the softened part being infiltrated with serosity. The situation of softening, or those portions of the bruin in which this change of consistence oc- curs, requires to be pointed out. Thus, it has been found in the central portions of the medullary substance and in the convolutions of the anterior, posterior, and middle lobes of the brain; in the corpora striata and thalami; in the corpus callo- sutn, septum lucidum, and fornix ; in the pons Varolii, crura cerebri and cerebelli; in the cere- bellum and the surface of the lateral, third and fourth ventricles. It is much more frequent in the brown than in the medullary substance, and more so in the brown substance of the convolutions than in that of the thalami or corpora striata. Soften- ing may occur in both substances at the same time, which is generally the case when it occupies the two latter situations. It may also occupy several portions of the brain at the same time, as the septum lucidum, fornix, and walls of the lateral ventricles; the corpora striata and thalami; one or more lobes ; a portion of one or both hemi- spheres ; the brain and cerebellum ; and is rarely met with in the latter organ without its being pre- sent in the former, — circumstances which give great variety and complexity to the functional de- rangement by which it is accompanied. In all the portions of the brain which we have named, the softening may be confined to a very limited spot, or pervade the greater part of their entire substance. There are examples of nearly the whole of one of the hemispheres of the brain having undergone this change of consistence; and in children, probably on account of the natural softness of this organ in them, both hemispheres have been found reduced almost to a pulpy or fluid consistence. [Softening of the brain occurs with nearly the same frequency in both hemispheres. In 169 cases, the right hemisphere was concerned 73 times; the left, 63 times ; and both hemispheres, 33 times. (Andral, Clinique Medicate, v. 545.) In 150 brains, the softening of the whole of the hemispheres was observed 4 times; of almost the whole of one hemisphere, 13 times; of the con- volutions, 14 times; of the convolutions and other parts, 9 times ; of the anterior lobes, 27 times; of the middle lobes, 37 times ; of the posterior, 16 times; of the corpora striata, 28 times; of the thalami optici, 15 times; of the parietes of the ventricles, 2 times; of the peduncles, once; and in disseminated points, 5 times. M. Durand-Fardel (Op. cit.) found acute soft- ening by far most frequently in the convolutions. Of 33 cases, 31 were examples of this seat of the disease; and in 9 the convolutions were alone affected. Fifty-three cases, collected from various sources, gave the following results as regards the seat of the lesion :— Convolutions and medullary substance, .. 22 Convolutions alone, ................. 6 Medullary substance alone,............ 5 Corpus striatum and thalamus opticus, .. 6 Corpus striatum alone,...............11 Thalamus opticus alone,.............. 4 Pons varolii,....................... 3 Crus cerebri,....................... 1 Corpus callosum,.................... 1 Walls of the ventricles, septum,....... 1 Fornix, ........................... l Cerebellum,....................... 1] Such is a general description of the physical characters of inflammatory softening of the brain. Whatever may have given rise to the inflamma- tion of the cerebral substance or its membranes, which terminates in softening, the physical cha- racters of this lesion are always such as we have described them. It is, however, of great practical importance to make a distinction between soften- ing from idiopathic inflammation, and that which follows the presence of foreign bodies, such as 180 SOFTENING OF ORGANS. bony and fibrous tumours, tubercles, carcinoma, melanoma, hydatids, &c, formed in the brain or its membranes, and foreign bodies forced into it from without, which, at some period of their deve- lopment, or after their introduction, excite inflam- mation and softening. The description which we have just given of inflammatory softening of the brain, applies gene- rally to the same lesion of the spinal cord. In this organ the softening may be confined to the medullary or cortical substance, or may occupy both at the same time. The whole of the cord may be softened, or only particular portions of it, as the cervical, dorsal, and lumbar,—differences of situation which are accompanied by correspond- ing differences in the seat of the functional derange- ment to which this lesion gives rise. The nature of the functional derangement, especially of sensa- tion and motion, it is now well known depends on the situation of the softening, the former being deranged when the softening occupies the poste- rior surface, and the latter being affected when it occupies the anterior surface of the cord. Soften- ing of the cord may, like softening of the brain, be the consequence of idiopathic inflammation, or of this pathological state succeeding to the presence of foreign substances, or arising from external injury. The simultaneous occurrence of inflammatory softening in the brain,—cerebrum, cerebellum, and spinal cord, is rarely observed, unless in infants. Of thirty cases of softening of the cerebral sub- stance observed by M. Billard in infants, in ten these three divisions of the nervous system were simultaneously affected. In these children, soft- ening of the cord was rarely observed to occur without softening of the brain; and on the con- trary, softening of the brain was frequently con- siderable without any similar change being pre- sent in the cord. (C. Billard, Traite des Mala- dies des Enfans, &c. Paris, 1828.) Before proceeding farther in the description of inflammatory softening of the brain, we shall point out the physical characters of this lesion when produced by obliteration of the arteries, as it will be more advantageous to treat of the causes, symp- tomatology, diagnosis, prognosis, and treatment of both forms of the disease at the same time. Softening of the brain from obliteration of the arteries of this organ.— This form of softening depends on the presence of osseous, cartilaginous, and' fibrous substances formed in the interior of the arteries or between their coats. These acci- dental products may exist in the form of cylinders occupying the entire calibre of arteries of consi- derable size, and also the smaller branches; or they may form patches or small masses projecting internally, which obstruct the circulation of the blood. The obliterated arteries may occupy the softened cerebral substance, and can be seen rami- fying through it; and when this substance is removed by pouring water upon it, the solidified vessels retain their situation, and feel sometimes as hard as fine wires. If the obliteration be con- fined to a limited portion of an artery whose branches terminate in the softened part of the brain, the cause of the softening may be over- looked. In the case of obliteration of minute arteries, or of a single small arterial trunk, the softening is generally limited to a space not ex- ceeding an inch or two inches in breadth ; but if several large contiguous branches be obliterated at the same time, the extent of the softening is con- siderably increased ; and if the obliteration takes place in the carotid or one of its principal divi- sions within the brain, the greater part or the whole of a hemisphere may be completely soft- ened. This form of softening is, like the inflam- matory, not confined to any particular portion of the brain. Like it also, it occurs far more fre- quently in the brown than in the medullary sub- stance, or in those parts most abundantly supplied with blood-vessels, as in the optic thalami, corpora striata, and cortical substance of the convolutions. If the obliteration has taken place in the minute arteries or small branches, the softening is gene- rally confined to the brown substance ; and when a large trunk or several small trunks are oblite- rated, both the brown and medullary substances are softened. Softening, from obliteration, of the corpus cal- losum, septum lucidum, and fornix, is extremely rare, and we have only met with one example of it in the pons Varolii. We have not observed it in the spinal cord. The degree of softening from obliteration, as well as the various colours which this change pre- sents, are very similar to those observed in inflam- matory softening. It is necessary, however, to observe that redness is seldom considerable, and vascularity and effusion of blood are generally wanting on account of the impervious state of the arteries. When it does happen that blood is effused, it is probably the consequence of rupture of the obliterated vessels, or some of the small arteries in the softened part having remained per- vious, and yielding to the increased momentum of the blood. Before concluding this part of our subject, it may be well to observe that the sanguineous effu- sion which succeeds to softening of the brain is sometimes so extensive that it is extremely diffi- cult to distinguish such cases from sanguineous apoplexy. Nor should it be overlooked that soft- ening of the brain is occasionally the cause of apoplexy, as apoplexy may be the cause of soft- ening, although some authors have maintained that apoplexy is always preceded by softening. It is only when the softening extends considerably beyond the effused blood, or when this fluid has been thrown out in several points of the softened cerebral substance, that we can feel authorized to say that apoplexy has occurred subsequently to the softening. That apoplexy may occur without previous softening is as true as the occurrence of hemorrhage in other tissues, such as the cutane- ous, mucous, and cellular, where it is not preceded by any such alteration. That hemorrhage may take place under similar circumstances in the brain is obvious from what is observed in many cases of apoplexy, in which the only change consists in the presence of effused blood. Nor are the por- tions of brain which have been broken down and mixed up with this fluid always softened. In those cases where death has taken place suddenly, such portions of brain are found to have lost very little of their natural consistence. [It appears to the writer, however, to be taking too restricted a view of softening, when we refer SOFTENING OF ORGANS. 181 it either to an inflammatory process or to oblitera- tion of arteries. It certainly remains to be proved, as M. Calmeil has remarked, (Art. Ramollisse- ment Cerebral, in Diet, de Med., xxvii. 220, Paris, 1843,) that white softening, with ana?mia, and without purulent infiltration, has been really pre- ceded by active hyperemia of the softened tissue. It is clearly an altered state of nutrition of the organ, occurring under the influence of morbid causes of very different character. «To endea- vour," says M. Andral, " to discover these various conditions is the great but difficult object,— an object of far more importance than that on which observers have exhausted themselves in recent times, when they have been desirous of referring every cerebral softening to some form or degree of inflammation of the nervous centres," (Clinique Medicate, iv. 527). In the obscurity of the subject M. Calmeil (op. cit.) suggests, that the softening may be owing to the action of some kind of menstruum, which, he supposes, may be formed by the reaction of the chemical elements upon each other,—" a menstru- um, which hereafter perhaps the chemists may be able to demonstrate to the pathologist!"] To distinguish softening from obliteration from softening produced by inflammation, it is only necessary to ascertain the presence of the morbid state of the arteries which we have described. We shall conclude the pathological anatomy of softening of the brain with a short description of the changes which occur in those cases in which this lesion does not prove fatal. It is now well known that blood effused into the substance of the brain may be absorbed, and the solution of continuity which it had occasioned become cica- trized. The softened cerebral substance may also be removed by absorption; but we have never seen a case in which its removal was followed by cica- trization. The first change which indicates the removal of the softened cerebral substance is the formation of an excavation containing a milky, greyish, red- dish, or yellowish fluid matter, with sometimes a small quantity of loose cellular tissue. By-and- bye this matter becomes fluid and limpid, and the cellular tissue is found transformed into a serous membrane which lines the surface of the excava- tion. This cystiform membrane is very delicate, and when the excavation which it lines is situated near the surface of the brain, it may acquire a large size. We have met with a cyst of this kind which would have contained an orange. It oc- cupied one of the thalami and a portion of the corpus striatum on the same side, and extended to the surface of the brain, where it was covered only by the pia mater and arachnoid. It is only in the inflammatory form of softening that we have met with examples of this mode of cure. In three cases in which we have seen it, the patients, from thirty to forty years of age, could not afford us any particulars of their respective cases, but they had been paralytic of both extremities of one side from an early period of life. Causes of softening of the cerebral substance. —The exciting causes of the two forms of soften- ing which we have described are, as we have seen, inflammation and obliteration of the arteries of the brain. The predisposing causes of the first form of this lesion will be found enumerated under the article Brain. Those of the second form have as yet received no elucidation, further than that the ossification which gives rise to the obliteration of the arteries and softening, consists in a modifi- cation of nutrition peculiar to an advanced period of life. It is, therefore, between seventy and eighty years of age that softening from ossification and obliteration of the arteries of the brain is most frequent. The inflammatory softening occurs at every age. It has been met with in infants a few days after birth, in children, adults, and old persons. Symptoms and progress of softening of the brain and spinal cord.—In both forms of soften- ing of the brain it is necessary to distinguish two periods; the first period comprehending the symptoms which accompany or follow the exist- ence of this lesion. 1. Symptoms of inflammatory softening of the brain and spinal cord.—As the symptoms of the first period of inflammatory softening of the brain must necessarily be those of inflammation of this organ, its membranes, or both, it would be superfluous to describe them here. (See Brain, Inflammation of.) It may, however, be ob- served that the severity of these symptoms does not always indicate a corresponding condition as to the degree and extent of the softening which they precede; nor do they present any one charac- ter which can be regarded as a sign that the in- flammation on which they depend will terminate in softening. When, however, they are taken in conjunction with those of the second period, they are frequently of great value, as they afford us the means of establishing our diagnosis in cases where it would otherwise be impossible. We shall, therefore, as we proceed, allude to the more im- portant of these the precursory symptoms of soften- ing of the brain. The symptoms of the second period of inflam- matory softening of the brain are, generally speak- ing, of an entirely opposite character to those of the first period. Those of the first depending on the presence of irritation or a morbid stimulus, are characterized by a state of excitement; whereas those of the second being the consequence of the softening or disorganization of the cerebral sub- stance, are necessarily marked by a state of pros- tration, collapsus, or paralysis. They are an- nounced by the gradual or sudden diminution of the intellectual powers; by the occurrence of stupor or coma ; by paralysis, difficulty or loss of speech, and diminution of the sensibility of the skin, eye, and ear. The relative frequency, degree, and extent of these symptoms, as well as the order of their occurrence, present considerable variety. Thus, the derangement of the intellectual facul- ties, such as their diminution, suspension, or abolition, is always present at the commencement of the second period, that is, so soon as the soften- ing of the cerebral substance has taken place. In some cases the derangement which they manifest is at first slight, increases gradually or rapidly, and terminates in their entire abolition. In others, these faculties are, from the commencement, gravely compromised and give no signs whatever of their existence. It is not rare to meet with cases in which their derangement is marked by 182 SOFTENING OF ORGANS. remissions and exacerbations, or the occurrence of lucid intervals succeeded by profound stupor. The delirium which accompanies the first period of inflammatory softening either disappears or diminishes greatly in intensity when the second period is announced by the derangement of the intellectual faculties to which we have alluded. It diminishes with the diminution of these facul- ties, and ceases when their suspension or abolition is indicated by the presence of coma and complete paralysis. An imperfect state or the entire loss of memory and speech are necessary consequences of these latter conditions of the intellectual faculties. But the absence of any derangement of these faculties is not necessarily unaccompanied by derangement of memory and speech, particularly the latter, for a patient may recover the consciousness of his existence, perceive and comprehend what is pass- ing around him, and yet be incapable of express- ing himself in words, on account of paralysis of the muscles by means of which the act of speech is accomplished. The diminution, suspension, or abolition of the intellectual functions, are always accompanied with paralysis of the muscles of voluntary motion, and the degree of the paralysis is, generally, in the direct ratio of the extent of the derangement manifested by these functions. The paralysis is rarely complete at the com- mencement. It is generally progressive, with oc- casional alternations of increase and decrease, before it becomes ultimately complete. The situa- tion and extent of the paralysis present consider- able variety, and in many cases seem to correspond with the situation and extent of the softening, in the same manner as in apoplexy. The paralysis occupies one or both extremities of the same side, when the softening is limited to one of the hemi- spheres of the brain, and paraplegia or universal paralysis is produced when both hemispheres, the pons Varolii, &c, are the seat of this lesion. It has been said that paralysis occurs more frequently in the superior than in the inferior extremities; that the seat of the lesion in paralysis of the for- mer is the corpus striatum, and of the latter, the optic thalamus of the opposite side of the brain. Softening of certain parts of the brain may, however, exist without occasioning paralysis. Such cases are observed in softening of the sep- tum lucidum, fornix, and corpus callosum. [Still, according to M. Calmeil, (Op. cit.) the most precious symptom in the diagnosis of local softening of the brain is local paralysis seated in the side of the body opposite to the softened hemi- sphere. » Without being invariably present, the abolition or quasi-abolition of motion is so rarely absent, that, whenever the premonitory symptoms of softening are noticed, we should hasten to ex- plore the movements of the limbs." In 32 cases of acute softening, recorded by M. Durand-Fardel, (Op. cit.) paralysis was present in 23 cases. In two, it was general; in one there was simply weakened powers of motion; in 6 the paralysis was limited to the arm, and in 14 it af- fected one entire side.] Paralysis of the muscles of the face, of the eye, of the tongue, and of deglutition, depends likewise on the situation of the softening. Paralysis of the bladder and rectum is a frequent consequence of softening of the brain, and gives rise, in the first place, to an accumulation of the contents of these organs, and afterwards to their involuntary escape, more particularly of the urine, from the distension of the bladder and the subsequent dila- tation of its sphincter. The difficulty with which vomiting is sometimes effected in this affection of the brain is also, no doubt, owing to a similar state of the muscles which participate in the ac- complishment of this act The state of stupor of the intellectual faculties will, however, explain, in great part, why the urine and fa?ces are retained, and why emetics as well as purgatives frequently fail to produce their usual effects. For in this state of the brain the impressions of external ob- jects are feebly or not at all perceived. It is under similar circumstances of the brain that the organs of hearing and of sight, which in the first or in- flammatory period of softening are highly suscep- tible, are rendered obtuse to a degree that a strong light or loud sounds impressed on the eye and ear pass unperceived. One of the most constant symptoms of inflam- matory softening of the brain is a state of perma- nent contraction of the flexor muscles of the ex- tremities. This state is well described by Lalle- mand. (Loc. cit. p. 252.) In some cases the contraction of these muscles amounts only to a slight degree of stiffness ; in others it is carried to such an extent that the hand is clenched and re- mains pressed against the shoulder, and the heel against the hip. The spasmodic contraction of the muscles is sometimes so great that it is not possible to extend the affected limb. The mus- cles themselves are prominent, feel hard, and the projecting tendons resemble cords stretched be- neath the skin. Acute pain is frequently the im- diate consequence of an attempt to overcome the contraction of the muscles. A prickling sensa- tion or even lancinating pains, more marked in the superior than in the inferior extremities, some- times precede the contraction of the muscles, which, according to Lallemand, always com- mences in one of the superior extremities, in which, unless it be already carried to the utmost extent, it is always greater than in the inferior extremities. It is sometimes limited to the for- mer, or does not extend to the latter until a con- siderable time after. It is of importance to note the presence of this state of the muscles of the face and eyes, as it produces changes peculiarly characteristic of pa- ralysis from softening. We have seen that a paralysed extremity may be contracted and held in a state of permanent flexion. The same thing happens in the paralysed side of the face. The muscles of this side, spasmodically contracted, are drawn upwards and backwards, and produce that deviation in the form and situation of the mouth observed in this disease as well as in apoplexy. But the fact to be noticed in the present case is the deviation of the mouth to the paralytic side, the opposite of what is observed in apoplexy, in which disease it is drawn towards the healthy side. When, however, the spasmodic state of the muscle has ceased, the mouth immediately as- sumes the position which it occupies in the latter disease. As the spasmodic contraction of the muscles depends on the presence or irritation SOFTENING OF ORGANS. 183 around the softened cerebral substance, the former coincides, diminishes, increases, or disappears with the latter. Hence it is that these contractions have an intermittent character, precede the para- lysis, and seldom accompany it till the fatal ter- mination of the disease. The paralysis is not otherwise recognised during the spasmodic con- traction than by the immobility of the paralysed limb, which is not under the command of the will. When the contraction ceases, the limb becomes flaccid, and remains in a state of immovable ex- tension. If the spasmodic state of the muscles returns, the limb is again contracted, and thus the stiffness and flaccidity, the flexion and extension of the muscles, occur at irregular intervals of time. Slight convulsive motions, referable to the same cause as the contractions, viz. the presence of irri- tation of the brain, the degree of which is sud- denly increased and diminished, accompany some- times the contraction of the muscles, or agitate the paralysed limb. The spasmodic contraction of the orbicular muscle of the eye is also not unfrequently very marked. When the eyelids are raised by the finger, they immediately return to their former position, and cover the entire surface of the eye- ball ; and when the motor muscles of this organ are affected, there is strabismus. The pupil, too, undergoes marked changes of contraction and dilatation. It is contracted only during the first period of the softening, or when this change is accompanied by irritation of the brain ; and dur- ing the second period, or when there is softening without subsequent irritation, it is dilated. This state of the pupil is also intermittent, and its per- manent dilatation does not occur until the paraly- sis is complete. It is observed by Lallemand that the pupil is contracted only in those patients in whom the muscles are spasmodically contracted; that when the disease exists only on one side of the body, it is the eye of the same side that is affected ; that when the spasmodic convulsions make their appearance by successive attacks, it is during these attacks that the pupil is contracted ; and lastly, that in proportion as the paralysis in- creases, the pupil becomes more and more dilated ; and, as we have seen, that as patients are unable to use their limbs although the action of the mus- cles is increased, so are they incapable of perceiv- ing external objects, although the contraction of the pupil announces an augmentation of the sen- sibility of the retina. In some cases the spasmodic contractions are confined to the paralysed extremity, a circumstance which depends on the irritation being limited to the same portion or side of the brain in which the softening exists. In other cases, the paralysed and healthy extremities are both spasmodically contracted from the irritation occupying both hemispheres of the brain. Such is frequently the case when the softening occupies the convolutions of the brain, or when it is preceded by meningitis of both hemispheres. In this latter instance too, the rigidity, contraction, and convulsive move- ments of the muscles, precede the paralysis. Lastly, one side of the body may be in a state of complete paralysis, and the other the seat of spasm or convulsive contraction, when one hemi- sphere of the brain is affected with softening, and the other or its membranes in a state of inflam- matory excitement. The precedence of spasmodic contractions to paralysis is not a constant character in inflamma- tory softening. We have seen two marked cases of paralysis from inflammatory softening which, so far as information could be obtained from the relatives of the patients regarding the previous history of both, appeared to have taken place sud- denly without any precursory symptoms, such at least as were calculated to prevent the patients from carrying on their daily occupations. The last symptom of inflammatory softening of importance to be noticed, is pain. It is obvious that this symptom cannot depend on the state of softening of the cerebral substance. It is the consequence of irritation or morbid excitement of the brain, the disorganization of which has not yet taken place. It is therefore generally most severe when it occurs as a precursory symptom; but it frequently accompanies the first period of the disease, and presents remissions and exacerbations, variable in duration and degree. It is seldom that it exists to the same extent in the second period as in the first; on the contrary, it generally diminishes or disappears as the paralysis and the derangement of the intellectual faculties increase. The depressed state of these faculties not unfre- quently prevents the patient from manifesting the existence of pain ; and it is not until he is roused from the state of stupor in which he is plunged, that he gives signs of suffering by carrying the hand to that part of the head which is the seat of pain. We have already alluded to the pain which accompanies the spasmodic contraction of the muscles. It is hardly necessary to remark that pain can be present in those cases only in which the sensibility of the paralysed part remains unaffected. Such are the modifications of function which are generally observed to accompany inflammatory softening of the brain, and which appear to be the immediate consequences of this lesion. We shall now notice briefly those which are observed in the functions of respiration, circulation, and diges- tion. Respiration is seldom much affected till near the termination of the disease, when it be- comes embarrassed, afterwards hurried or irregular, and lastly stertorous. The pulse is sometimes frequent, full, and strong ; sometimes quick, or feeble and intermittent, but more frequently it does not present any very remarkable alteration. There is in general little or no appetite; some- times nausea or even vomiting ; thirst, and, as we have already noticed, difficulty or even impossibility of swallowing. The temperature of the skin is sometimes not much increased ; at other times it is considerably so; the tongue and lips become dry, fissured, and covered with a brown or black sordes. It is at this period that the respiration becomes stertorous, the pulse sinks and intermits, and announces the approaching death of the patient, which takes place in the midst of the most profound stupor, and in a state of universal paralysis and prostration. The progress of inflammatory softening of the brain is generally rapid. It is seldom stationary except during the first period. The second period is marked by a progressive increase of the principal l^i SOFTENING symptoms, which, although sometimes observed for a short interval, re-appear under a worse form, and hasten towards a fatal termination. The average duration of the disease, or of the second period, is from five to seven days; death may supervene on the second or third day, or not until the third or fourth week, or even at a later period ; but cases of the latter kind are extremely rare. The symptoms of inflammatory softening of the j spinal cord consist in modifications of sensation : and motion, as the increase, diminution, or aboli- tion of the former, the diminution or cessation of j the latter. If the posterior portion of the cord be i softened, sensation only is modified ; if the anterior, i motion only is modified ; and when both portions are the seat of this alteration, both sensation and motion are modified. The lesion of sensation and motion, separately, does not so frequently happen as that of both : and when it does occur is seldom of long continuance, both soon becoming affected. The situation, degree, and extent of the functional derangement are determined chiefly by the seat of the softening. If the softening has taken place in the cervical region, the functions of all the organs situated interiorly, in so far as their accomplish- ment depends on the integrity of the cord, are ! altered. Paralysis of the superior and inferior ] extremities of one or both sides ; diminution or in- I crease of the sensibility in the same parts; difficulty of respiration; retention or involuntary discharge J of the faces and urine, are produced, according as the softening occupies the anterior or posterior portions of the cord or both. The latter symp- toms only are present when the dorsal or lumbar region of the cord is affected. Pain may or may not be present in the affected portion of the cord. I It may exist as a consequence of the disease, or may not be perceived until it is developed by pressure or the direct application of heat or cold. We formerly alluded to the simultaneous occur- ! rence of softening of the brain and spinal cord. This complication rarely happens, however, in adults; and in the cases which we have seen, the softening of the cord being confined to the lumbar region, the general symptoms did not present any i peculiarity worthy of notice. The same may be said of softening of the cerebellum, which we have never seen unaccompanied by softening of the brain. 2. Symptoms of softening of the brain from obliteration of the arteries.—This form of soften- ing of the brain has, like the former, been divided into two periods. The symptoms of the first pe- riod consist of pain referable to a particular part of the brain. The pain may be slight or severe, of short or long duration, generally remittent or intermittent. The intellectual functions are often sensibly modified ; memory is impaired, speech embarrassed; there is frequently drowsiness, an unwillingness to every exertion ; sometimes numb- ness or stiffness of the extremities, a prickling sensation or an increase of the sensibility to such a degree that even slight pressure occasions acute pain. The functions of the organs of sense are generally impaired ; sight in one or both eyes may be less acute or entirely lost, and the pupil may retain its natural dimensions or be dilated; hearing may also be more or less imperfect, and taste and smell, when altered, are less acute than OF ORGANS. natural. The state of the digestive functions does not present any remarkable alteration, except in- appetence, or constipation ; the latter symptom being generally accompanied with retention or a difficulty of voiding the urine. These are the symptoms which generally occnr during the first period, but they are not constant; they are seldom all equally manifest; several of them may be absent, or only one, two, or more of them may be so marked as to attract the attention of the physician, or excite the fears of the patient. The local symptoms, or those of the brain, may prevail, particularly pain, loss of memory or con- fusion of ideas; or it may be the general symp- toms, or those which indicate derangement of the functions of those organs which we have enume- rated, especially the sensation of numbness and prickling felt in the muscles of the extremities or face, and difficulty of speech. It is, however, im- portant to note that all the symptoms of this pe- riod may be regarded as denoting a diminution rather than an increase of function, the opposite of what is observed in the first period of inflam- matory softening of the brain. The symptoms of the second period are gene- rally ushered in by a sudden aggravation of those of the first period, but chiefly by the occurrence of complete paralysis and the suspension or abo- lition of the intellectual faculties. The extent and situation of the paralysis, the modifications of the sensibility and contractility of the affected parts, and the ulterior progress of the disease, are so similar to those observed in the second period of inflammatory softening, that a description of them would be nearly a repetition of the latter. The important exceptions which they present will be more appropriately introduced when treating of the diagnostic symptoms of both forms of soften- ing. The progress and duration of softening of the brain from obliteration of the arteries do not essen- tially differ from those of inflammatory softening. In its progress it is, perhaps, less rapid than the latter. Although it may sometimes appear sta- tionary, it is essentially progressive. The para- lysis, if not complete at the commencement, in- creases till it becomes so, and the recovery of speech or of the intellectual faculties seldom insures more than a short suspension of the progressive increase of this form of softening. The duration of this lesion is very various. We have seen death take place as early as the second day, and not before the fourth or sixth week. Diagnosis of softening of the brain and of the spinal cord.—We have here to distinguish, first, the symptoms of softening of the brain produced by inflammation, from those which accompany softening from obliteration of the arteries; and, secondly, the symptoms of both these forms of softening from those of other diseases between which and the former there is a greater or less resemblance. First, the necessity of distinguishing between the two forms of softening of the brain can arise only when this disease affects persons after the decline of life. We shall not enter minutely into the description of the distinctive characters of the two forms of softening, as the treatment required in both is essentially the same, and as the irapor- SOFTENING OF ORGANS. 185 tancc of an accurate diagnosis diminishes in pro- portion as the disease approaches to that stage or period which constitutes the lesion of which we are now treating. We have already observed that the two forms of softening of the brain are distinguishable from each other more by the phenomena of the first than by those of the second period ; by the symp- toms which precede rather than by those which accompany the state of softening. Inflammatory softening is preceded by local and general excite- ment ; there is present, from the commencement, an increased development as it were of the func- tions of the brain, and of those organs comprised within the sphere of its morbid activity. This state of local and general excitement does not oc- cur in the non-inflammatory softening at the com- mencement. It takes place after this lesion is produced ; is, in general, slight at first, and after- wards increases in severity, the opposite of what happens in the former. The delirium, the spas- modic contractions and convulsions, the contrac- tion of the pupil, and increased sensibility of the eye and ear to their natural stimuli, which precede the former, are absent at the commencement of the latter, and do not occur until some time after the softening has taken place and is followed by irritation or inflammation of the substance of the brain or its membranes. When the second period of softening of the brain has arrived, there are few if any symptoms which indicate the kind of softening on which they depend, if those of the first period cannot be ascertained, or, as sometimes happens, have been wanting. The spasmodic contraction or convul- sive twitchings of the muscles of the extremities and contraction of the pupils are, under these cir- cumstances, the symptoms on which most reliance is to be placed. The presence or absence of these symptoms may, as a general rule, be regarded as indicating the presence, the former of inflamma- tory, the latter of non-inflammatory, softening. Secondly, the diseases the most likely to be confounded with softening of the brain are serous effusion, congestion, and apoplexy. The serous effusion which gives rise to symptoms resembling those of softening of the brain, occurs as a termi- nation of meningitis. The delirium, derangement of the intellectual faculties, and febrile excitement which accompany the first stage of the latter dis- ease, together with gradual and sometimes sudden supervention of paralysis occasioned by the effused serosity, render it, in some cases, very difficult to distinguish this termination of meningitis from inflammatory softening. There are, however, two features in particular, in the symptoms of menin- gitis, of considerable diagnostic value, — namely, the prevalence of convulsions during the first stage, and the general character of the paralysis in the second stage, the latter symptom being seldom confined to one extremity or one side of the body in this disease. Paralysis from this cause is not likely to be confounded with non-inflammatory softening. The symptoms of congestion are, generally speaking, very characteristic of the kind of lesion on which they depend. The ringing of the ears, dimness of the sight, the sensation of a weight within the cranium, giddiness, stupor, and the Vol. IV. —24 o. * turgidity of the veins of the face and neck and conjunctiva, followed by the sudden diminution or suspension of the intellectual faculties, of sensa- tion and motion, are symptoms referable to a rapid accumulation of blood in the vascular system of the brain. And if this disease does not suddenly prove fatal, the disappearance of all these symp- toms under the use of the ordinary remedies, and the rapid recovery of the patient, very soon put its nature beyond doubt. The difficulty of distinguishing between inflam- matory softening of the brain and apoplexy from sanguineous effusion is, in the great majority of cases, by no means great. The progressive cha- racter of the former, and the sudden invasion of the latter, constitute, in a general point of view, a marked difference between the two diseases. The state of excitement which precedes and accompa- nies inflammatory softening occurs in apoplexy only as a consecutive symptom, and is, perhaps, never equal in degree or extent to that observed in the former disease. The state of coma and collapse does not make its appearance till towards the termination of softening from inflammation, whereas it is the first symptom which indicates the existence of apoplexy. Inflammatory soften- ing tends progressively to this state; whereas in apoplexy the most profound stupor may be of short duration ; consciousness and the exercise of the intellectual faculties return, and, if the disease be curable, may regain the same degree of integ- rity which they possessed before the attack. The subsequent contraction and convulsive motions of the muscles, and the contraction of the pupil — conditions the opposite of those observed at first, namely, relaxation and dilatation, — present the same differential importance as the symptoms just alluded to. It is in those cases of apoplexy in which the stimulus of the effused blood gives rise to irritation of the cerebral substance with which it is in contact, that the difficulty of distinguishing between this disease and inflammatory softening is greatest, particularly if the inflammation which has preceded the latter has been slight, and con- fined to the cerebral substance. It would be difficult to lay down even a general rule whereby to determine the distinctive charac- ters of softening of the brain originating in ob- literation of the arteries, from those of hemorrhagic apoplexy. Apoplexy is certainly, in general, more sudden in its occurrence and less frequently pre- ceded by precursory symptoms than non-inflam- matory softening. But it must not be forgotten that the former may be preceded by symptoms similar to those which precede the latter; and, vice versa, the latter may occur with all the ra- pidity of the former, and without its being an- nounced by any marked modification of func- tion. Softening of the spinal cord will not readily be confounded with apoplexy of this organ. Apo- plexy is a rare affection of the cord compared with softening; and its effects, loss of sensation and motion, are sudden, from the first complete, and without being announced by any precursory symp- toms. In inflammatory softening, sensation and motion are gradually lost, are preceded by excite- ment, generally by local pain, although it may be slight; by an increase of the sensibility and con- 186 SOFTENING OF ORGANS. tractility of the affected extremities, and sometimes by convulsions of the same parts. Prognosis of softening of the brain and spi- nal cord.—We formerly observed that we had not met with a case of cure of non-inflammatory softening of the brain, and that, on the contrary, we had seen cases of the inflammatory kind in which the evidence of complete recovery was ren- dered obvious by the state of the brain examined some years after the attack. Rostan (Loc. cit. p. 462,) says that the cure of softening of the brain, when it has attained the second period, must be regarded as problematical, and if he alludes to the non-inflammatory form of the disease, his opinion is in accordance with our own. Lallemand (Loc. cit. p. 287,) and Abercrombie (Loc. cit. p. 158,) both agree in opinion as to the curability of in- flammatory softening of the brain, or, more cor- rectly, of the curability of inflammation of this organ when the symptoms have been of the worst kind, and those too which accompany the second period. But at the same time they remark that this favourable termination of the disease is, under such circumstances, of rare occurrence. When, therefore, the symptoms of the second period of inflammation of the brain, or those ascribed to softening of this organ, manifest themselves, our prognosis must always be unfavourable, and the more so in proportion to the rapidity of the pro- gress of the symptoms of the second period, and the degree of coma and paralysis by which they are succeeded. The progress of softening of the spinal cord is, if possible, more unfavourable than that of the brain. Treatment of softening of the brain and spi- nal cord.—It would appear from the preceding remarks that the fatal termination of this disease has seldom been prevented by any mode of treat- ment hitherto adopted. There are no successful cases recorded of softening from obliteration of the arteries, and in the few cases of the inflammatory form of the disease which have terminated favour- ably, it is more than probable that the softening was very limited in extent, and affected the super- ficial or less important parts of the brain. As regards the state of softening, which, in point of fact, consists in a solution of continuity of the cerebral substance, it must be obvious that we pos- sess no remedial agent capable of obviating such a change. The diseased state, therefore, of which we are treating, is incurable; that is to say, the solution of continuity which it constitutes will remain, even though the patient should recover. The essential part of the treatment of softening of the brain relates, consequently, to the local morbid conditions which immediately precede this change,—namely, the diseased state of the arteries on the one hand, and inflammation of the brain on the other. This state of the arteries, like the softening to which it gives rise, is, so far as we yet know, beyond the control of remedial agents. When, therefore, it is ascertained that the soften- ing is the consequence of this state of the arteries, the only hope that can be indulged is partial re- lief, and the prolongation of life for a short period beyond that at which the disease would have proved fatal had it been allowed to run its natural course. It is possible that the attack may be de- layed by judicious treatment, employed when the first symptoms of cerebral derangement nre per- ceived, such as pain in a particular part of the head, confusion of ideas, giddiness or unusual drowsiness and listlessness, together with a prick- ling sensation, or numbness in the muscles of the extremities, face, or tongue. Bleeding from the temples, cupping in the nape of the neck, or small general bleedings, repeated from time to time as circumstances may require, may, by diminishing the quantity of the blood, facilitate the circulation of this fluid through the brain. But, perhaps, greater advantage would be derived by keeping the bowels freely open without inducing excitement or debility, chiefly by means of the neutral salts. The compound aloetic pill will be advantageously employed in those cases in which the disease occurs after the cessation of the catamenia, or suppression of a hemorrhoidal discharge. A diminution of the circulating fluids, as well as their equalization, will be effected like- wise by promoting all the secretions, particularly the secretion of the urine and bile. The food and drink of the patient should be particularly attended to. His diet should consist of those kinds of food which are most easily digested by him, and which affords the greatest quantity of nourishment in the smallest bulk. Ardent spirits, strong wines, fermented liquors, even strong coffee or tea, and all stimulating potions should be avoided as more or less injurious. The occasional use of warm and rubefacient pediluvia, constant warmth to the feet and lower extremities, an elevated posture of the head, residence in a cool atmosphere, and tranquillity of mind, will greatly favour the ope- ration of the other means, and afford the patient a chance of escaping the fatal termination of the disease. It is with reluctance that we allude to any kind of treatment to be employed when softening has once taken place. Rostan recommends that the use of all debilitating means be avoided, when the softening does not present the inflammatory cha- racter, which kind of softening, we presume, is that of which we are now treating. He recom- mends the prompt use of rubefacients, irritating lavements, and those internal medicines which exert their influence on the large intestines; and the administration even of tonics, aromatics, and internal stimuli. It is also by the early, prompt, and vigorous application of those means which have been found most efficacious in arresting the progress of in- flammation of the brain and its membranes, that the termination of this pathological state in soft- ening is to be prevented. As the treatment of inflammation of the brain and its membranes has been given in detail in another article, (see Bhaik AND ITS MEMBRANES, INFLAMMATION OF,) We shall, in this place, only allude to it generally. The principal are bloodletting, purgatives, and cold. The bloodletting may be either local or general, or both ; and in this respect, as well as quantity, we must be regulated by the violence of the attack, the age, habits, and constitution of the patient Drastic purgatives have been found the most beneficial, but in their employment the physician must be guided by the state of the stomach and intestines. With these, the tartar-emetic may be SOFTENING OF ORGANS. 187 combined, or given alone in such quantity as to keep up a state of nausea, but ought never to be carried so as to produce vomiting. As a purga- tive, Dr. Abercrombie strongly recommends the croton oil. The same author highly extols the beneficial effects of cold applied to the head, by means of pounded ice contained in a bladder; or a stream of cold water directed against the crown of the head, and continued until the desired effect be produced: but this is so powerful a remedy that it requires to be used with much discretion. The treatment of the second period, or that of softening from inflammation, is the same in prin- ciple as that of the former, in so far as it regards the state of excitement with which this morbid change is generally accompanied. But if the paralysis be fairly established, and, notwithstand- ing the depletory and sedative measures which have been employed, continues to increase, neither our own observation nor the recorded experience of others would recommend a hardy perseverance in the means, the debilitating effects of which have not been sufficient to overcome the inflam- matory excitement of the first period. Bleeding and active purgatives should now be laid aside ; blisters or sinapisms should be applied to the in- ferior extremities, the nape of the neck, and supe- rior part of the spine; the head should be kept cool by the constant application of evaporating lotions; the bowels evacuated once or twice a day by means of castor oil or any mild aperient if it can be swallowed, or by injections ; the secretion of the urine and the cutaneous perspiration should also be promoted by remedies of the least stimu- lating qualities. The retention of the urine is a complication which must be sedulously watched, that this fluid may be removed before it accumu- lates to a degree to prove injurious. Stimuli or tonics should now he employed with a view to support the strength of the patient, but they ought never to be employed to such an extent as to pro- duce excitement, as the powers of life are already greatly exhausted by the stimulus of the disease. Should the patient recover from this dangerous and so frequently fatal disease, every attempt to restore the functions of the paralysed limb should be deprecated in the strongest terms. There are, however, cases in which the paralysis is extremely slight, consisting in a slight degree of weakness, which disappears gradually of itself in the course of a few weeks. But in the former, the paralysis is from the commencement complete, the member remains in a state of flaccidity and immobility, from which it does not recover until after a con- siderable length of time, and, perhaps, never to such a degree as to be of much use to the patient. In such cases there must be a solution of con- tinuity, which being permanent and the cause of the paralysis, the paralysis must be permanent also. With regard to the treatment of inflammatory softening of the spinal cord, it is only necessary to observe that it is in every respect the same as that of softening of the brain. Topical blood- letting, however, the actual cautery or the moxa, may be employed according as the disease may be acute or chronic in its progress, and the more so that it is much more frequently the conse- quence of disease of the spine, which also re- quires this treatment, than of idiopathic inflam- mation. Softening of the Mucous Membranes.— Softening of the mucous membranes may, as we have already remarked in the introductory part of this article, occur either as a pathological or post-mortem lesion. The first, being the conse- quence of inflammation, is met with in mucous membranes in general; but the second being the effect of the chemical action of the gastric juice, is observed only in the digestive organs. It is a remarkable fact that softening of the mucous membrane is much more frequent and infinitely more extensive in the stomach and intestines than in any other organ ; a circumstance deserving of particular notice, inasmuch as it indicates some peculiarity in this portion of the mucous system considered in itself, or in its relations with exter- nal agents. It is, therefore, not surprising that softening of the mucous membrane of these organs should have attracted in a special manner the at- tention of pathologists, but more particularly after it was discovered that this membrane undergoes so frequently this change in various forms of fever, or when the seat of inflammation as a primary or secondary disease. Before proceeding to describe softening of the mucous membrane of the stomach and intestines from inflammation and from the chemical action of the gastric juice, we shall make a few general observations on the natural consistence of this membrane in these organs, and the diminution of consistence which it undergoes from maceration and putrefaction. The importance and intricacy of this part of our subject render it absolutely necessary to possess an accurate acquaintance with the modifications which the mucous mem- brane presents in these respects. The natural consistence of the mucous mem- brane of the digestive organs is always in propor- tion to its thickness. Thus it is found to be thickest in the duodenum and pyloric portion of the stomach, and in these situations it is most consistent: it is thinnest in the colon and fundus of the stomach, and there also its consistence is least. Its thickness progressively diminishes in the rectum, jejunum, and ileum, and in the same descending ratio its consistence. If where it is thickest it be cut through, it may be torn from its connection with the cellular tissue, in pieces vary- ing from a quarter of an inch to half an inch in length. This can be done in the pyloric portion of the stomach and rectum, but not in the duo- denum, on account of the mode of attachment of this membrane in this portion of the intestinal tube. At the fundus of the stomach and in the colon it can be detached in very small portions only; and in all cases of great emaciation, this membrane becomes so thin throughout the whole of the stomach and intestines, that it breaks whenever an attempt is made to raise it. The relative degrees of the normal consistence of the mucous membrane in different portions of the digestive tube are nearly the same at every period of life. It is hardly necessary to remark that the consistence of this membrane, as well as that of the other tunics of the stomach and in- testines, is much less in the infant than in the adult. 188 SOFTENING When a portion of intestine is submitted to maceration, the mucous membrane does not lose its consistence until after a considerable lapse of time. Billard made this experiment, and found that softening did not commence till towards the expiration of two months. (De la Membrane MuqueuseGastro-Intestinale. Paris, 1825.) When exposed to the air, it does not begin to soften until about the commencement of the third week. But in both cases it would appear that putrefaction always precedes the softening, as the latter is not perceived until the former is announced by the peculiarity of its smell. Hence it has been sug- gested that as softening of the mucous membrane, from these causes, does not take place until at a period greatly beyond that at which the body is usually submitted to inspection, we ought not to regard as post-mortem examples of softening those which are met with in this membrane, say twenty or thirty hours after death. This, however, we shall find, is far from the truth, as we shall after- wards show that complete softening of all the tunics of the stomach and intestines may take place in a much less space of time. With regard to the influence of putrefaction in producing softening, it would not by any means be correct to say that it does not produce this change of the mucous membrane till after the expiration of weeks or months. Such appears to be the expression of the fact as regards the in- fluence of putrefaction in modifying the consist- ence of healthy mucous membrane; but when this membrane has been the seat of disease before death, and more particularly when the disease has been of such a kind as to deprive this membrane suddenly of its vital properties, a few hours will suffice for its complete decomposition. This fact is illustrated in a general point of view by those cases of sudden death in which the nervous sys- tem, the blood, or both, are the vehicles of the destructive agent or of its influence, as in death from lightning and certain poisons. In such cases all the tissues run rapidly into putrefaction. Having made these general remarks on soften- ing from maceration and putrefaction, we shall now confine our attention to softening of the mucous membrane from inflammation and the chemical action of the gastric juice. Softening of the Mucous Membrane of the Stomach and Intestines from Inflam- mation.—It is said that the mucous membrane of the stomach is much more frequently affected with softening than that of the intestines. Now this statement is true only in so far as expressive of the occurrence of softening without reference to its nature. It is not true as regards inflamma- tory softening, while it is quite true if applied to softening as a chemical effect of the gastric juice. It is also said that the mucous membrane is most frequently found softened where it lines the fun- dus of the stomach. This circumstance does not, however, decide the locality of inflammatory soften- ing in this organ. For it is precisely at the fun- dus of the stomach that the mucous membrane is almost always acted upon by the gastric juice after death. Softening of the mucous membrane from inflammation is, we should say, most fre- quently observed at the termination of the ileum; in the depending or fixed portions of the colon, OF ORGANS. or the coecum, in the right and left hypochondriac regions and sigmoid flexure of this intestine. Although such are the parts in which inflamma- tory softening is most frequently observed, it may occur not only in any definite portion of the in- testinal tube, but also throughout its whole extent, that is to say, from the cardiac orifice to the anus; but such cases are very rare. These remarks apply to inflammatory softening of the mucous membrane considered as a whole; but as this membrane is composed of distinct elements,—the mucous tissue properly so called, villosities and follicles,—this morbid alteration may take place in each of these parts separately, or in all of them at the same time. Softening of the mucous mem- brane in general, or of these its elements in parti- cular, presents various degrees. In the first degree the mucous membrane, instead of possessing that degree of cohesion which permits of its being detached from the submucous tissue, breaks as soon as it is seized between the fingers or forceps; in the second degree the edge of a scalpel or the finger passed lightly over its surface converts it into a soft, somewhat opaque, creamy-looking pulp; and in the third or last degree it is so soft that it is removed by a stream of water poured upon it from the height of a few inches. In this stage portions of it are found partially or entirely destroyed, and, having been removed by the fluid contents of the stomach or intestines during life, the submucous or cellular tissue is thus found deprived of its mucous covering. It is in this manner that various forms of softening are pro- duced, as irregular or round patches of various sizes. It is important to notice this circumstance, for when the softening is limited to the glandule solitaria?, particularly in the large intestines, as is frequently the case in dysentery, it might be alto- gether overlooked. These bodies being very small, and their entire destruction from softening being often unaccompanied by any obvious alteration of the mucous membrane itself, the seat and nature of the intestinal affection might not be ascertained were it not for the presence of a number of minute circular patches, which, when narrowly examined, are found to be the result of softening of these follicles; for it often happens that enlarged folli- cles are seen intermixed with the patches, and which, when a scalpel is carried over the surface of the mucous membrane, break down or are removed, and thus other patches are formed similar to the former. These circular patches, which have the submucous tissue for their basis, are often described as ulcerations of the mucous membrane ; but in all cases of doubt the use of the scalpel, as noticed above, will enable us to determine their nature. Softening of the mucous membrane in the form of stripes and bands has been described with great care and precision by Louis, and has been much insisted upon as characteristic of inflammatory softening. But for reasons which we shall afterwards assign, we are disposed to ascribe a very different origin to these forms of softening of the mucous membrane of the stomach, viz. the chemical action of the gastric juice. Softening of the mucous membranes of the di- gestive organs may present various degrees of red- ness, or it may be quite pale. The redness may SOFTENING OF ORGANS. 189 be confined to the softened part, or it may extend to the neighbouring parts at the same time, or the latter may be red and the former pale. The red- ness of the softened membrane may vary from a slight rose red, bright or dark red, to purple or brown,—varieties of colour, the value of which it is by no means easy to estimate, inasmuch as the quantity of blood in an inflamed tissue cannot be taken as the measure of the degree of inflamma- tion which had caused the accumulation of this fluid. The pale inflammatory softening presents also some variety of tint which requires to be no- ticed. The softened mucous membrane is of a pale greyish or yellowish grey tint, being little altered from its natural colour; or it may be paler than natural, when it generally presents a milky aspect, owing to the colour of the submucous tis- sue being seen through it. The pale softening is very common in phthisical subjects, in tubercular disease of the mesenteric glands, as in all diseases followed by great emaciation, although the exis- tence of this important lesion was not known to pathologists till very lately, owing to the imperfect mode of examination to which the digestive mu- cous membrane was subjected. Instead of constituting the only disease of the mucous membrane, softening may be complicated with various other diseased states, such as thick- ening of this membrane, enlargement of its fol- licles, and ulceration ; but its general characters do not, under these circumstances, differ from those we have just described. Inflammatory softening has been described as affecting all the tunics of the stomach and intes- tines. It is said to proceed from the mucous mem- brane to the submucous tissue, and from the lat- ter to the muscular coat and peritoneum, all of which it destroys in succession, and terminates in perforation of these organs. We, however, disbe- lieve this statement. Softening of all the coats of the stomach or intestines, carried to the extent of perforation of these organs, does not arise in inflammation. It depends on the chemical action of the gastric juice. Much has been said of the symptoms of soften- ing of the gastro-intestinal mucous membrane, but it would serve no useful purpose to give an exposition of them in this place, inasmuch as when this lesion is the consequence of inflamma- tion, the symptoms are those of gastritis or gastro- enteritis, and which will be found detailed under these heads respectively. It need hardly be ob- served that there are no symptoms referable to the states of softening which we have described, con- sidered in itself, and as a termination of inflam- mation of the mucous membrane. It may, however, be reasonable to suppose that, if a person recovers from gastritis or enteritis, fol- j lowed by complete softening of the mucous mem- ] brane to a considerable extent, nutrition will be considerably modified, at least in degree. But how far this actually takes place has not been as- certained ; and although we find the mucous membrane in some individuals, after death, pre- senting a very indistinct villous structure, either generally or in particular parts, it is easy to con- ceive how great must be the difficulty of deciding on the nature of such an appearance, the more especially as it has not been found to be connected with any peculiar modification of function. The description, therefore, which we have given, of softening of the digestive mucous membrane, is valuable only in so far as it becomes a test of the previous existence of inflammation. It is, in fact, only in this point of view that we can consider it in this place. It is a lesion of the mucous mem- brane which belongs exclusively., to the patholo- gist, as it furnishes the physician with no sign of its existence. It puts him, however, in possession of the important facts to which we have alluded, viz. the frequency, extent, and consequences of inflammation in organs to which it had so long escaped his researches, thereby leaving him with- out the means of judging of the propriety of his practice, or of giving to it that stability and scien- tific character which it is more capable of receiving. 2. Softening of the stomach and intestines from the chemical action of the gastric juice.— The chemical dissolution of the mucous membrane and other tunics of the stomach was discovered by John Hunter, while engaged in a series of ex- periments on digestion. (J. Hunter, on the diges- tion of the stomach after death, Phil. Trans, vol. lxii. p. 444 ; and Observ. on certain Parts of the Animal Economy, 2d edit. p. 226.) He described it as digestion of the walls of the stomach after death, and as the immediate consequence of the solvent property of the gastric juice. As he had observed it only in healthy animals, and in per- sons who had been suddenly deprived of life by external violence, he believed that a perfect state of health, immediately before death, was abso- lutely necessary to its production. The opinions of Hunter on the dissolvent property of the gas- tric juice after death, were soon after confirmed by Spallanzani (On the Natural History of Ani- mals and Vegetables, Dissert. 5,) and Dr. Adams, (On Morbid Poisons, &c. and London Med. Jour. vol. xxiii. p. 399) ; and Mr. Allan Burns (Ob- servations on the Digestion of the Stomach after Death ; Edin. Med. & Chir. Jour. vol. vi. p. 129,) contributed some important information on the subject, more particularly relating to the chemical dissolution of the stomach in individuals who had died in a state of great debility and emaciation from chronic disease, and also the occurrence of this lesion in portions of the stomach in which it had not before been observed. Although the experiments and observations of Hunter, modified and extended by the contribu- tions of Spallanzani, Adams, and Burns, clearly demonstrated the occurrence of softening and per- foration of the walls of the stomach in certain animals, as fishes, rabbits, and dogs, and in man, in consequence of the chemical action of the gas- tric juice after death, British pathologists appear to have entirely overlooked the importance of the subject in relation to those morbid conditions of the stomach which bear a greater or less resem- blance to the post-mortem effects of the gastric juice upon this organ. In France, the opinions of Hunter were at first received with doubt, after- wards turned into ridicule, and the most vague and absurd hypotheses set up in their place. French pathologists, instead of regarding the lesions pointed out by Hunter as post-mortem effects of the gastric juice, described them as grave 190 SOFTENING OF ORGANS. alterations of the stomach during life by the direct operation of morbific agents. Chaussier (Bulle- tins des Sciences Medicales du Departement de 1'Eure, No. 53, p. 7,) whose description of the appearances produced by the gastric juice accords with that of Hunter, ascribes the softening and perforation of the walls of the stomach to the presence of an acrid and corrosive fluid produced by a special irritation of this organ, and which turns its activity even against the tissue whence it is derived, as well as other tissues with which it is brought in contact. Morin (Consider, generates sur I'Erosion, Paris, 1806,) Laisne (Consider. Medico-legales sur les Erosions et Perforations spontanees de l'estomac, dans le recueil intitule Med. Leg. No. 104, p. 135,) and several others referred the same alterations of the stomach to the sudden development of a high degree of local irritation, terminating in the partial or complete destruction of the affected part of this organ, by a process similar to that of erosion or ulceration. The researches of Jaeger* in Germany revived the opinions of Hunter, and directed the attention of pathologists anew to the experimental investi- gation of this interesting subject. The experi- ments and observations of this author led him to the conclusion that the softening and perforation of the stomach occur after death, but that these changes are not the result of the chemical action of the healthy gastric juice. He believes, on the contrary, that this fluid must have been altered by disease, the nature of which he does not explain, but supposes it to consist in some peculiar change taking place in the functions of the nervous sys- tem, and a consequent modification of the secre- tion of the digestive organs. Dr. J. Gairdnerj- has arrived at the following conclusions as the result of his observations on softening and perfora- tion of the alimentary canal, viz. that these lesions are produced after death by the action of the fluids contained in the stomach and intestines ; that these lesions probably occur in some cases without previous disease of the parts in which they are found to exist; but that they also take place in consequence of a peculiar disease of the alimentary canal, whereby portions of it are rendered more easily soluble by the action of its contents. Such are the principal opinions of those who have adopted, rejected, or modified the views of John Hunter on softening and perforation of the alimentary canal. We may now allude briefly to those of Cruveilhier and Louis, who have described these post-mortem lesions as pathological altera- tions of the stomach and intestines, and as consti- tuting a disease not hitherto observed by patholo- gists. Louist has detailed, with great precision and accuracy, the symptoms and post-mortem ap- pearances observed by him in a considerable num- ber of cases in which the mucous membrane of the stomach was found more or less softened or * Dber die Erweichung des Magengrundes, oder die Sogennante Verdauung des Magens nach dem Tode. Hufeland's Journal, 1811; and in Lond. Med. Reuos. vol. x. p. 4)0. f Cases of Infantile Disease, in which Erosions and Perforations of the Alimentary Canal were found after death. Trans, of Edin. Med. Chir. Soc. vol. i. p. 311. \ Ramollisseinent avec Amincissement, et de la De- struction de la Membrane Muqueuse de PEstomac, Ar- chiv. G^ner. de Med. torn. v. p. 5; and, Recherches Ana- tomico-Pathol. sur diverses Maladies, Paris, 1826. destroyed. He considers this state of the stomach as produced during life, and referable to a state of irritation of the mucous membrane, the symptoms of which, although generally conspicuous, are sometimes wanting. In Cruveilhier's (Medecine Pratique eclairee par 1'Anatomie et la Physiologie Pathologique) memoir, we find this author de- scribing the same lesion of the alimentary canal as it occurs in infants and children, and ascribing it to a high state of irritation of the mucous mem- brane, which, being followed by the repeated effu- sion of serosity, the delicate textures of the sto- mach and intestines become infiltrated, distended, and ultimately disorganized, thus producing, as it were mechanically, what he calls the ramollisse- ment gelatiniform of the walls of this organ, and perforation. Such is a brief outline of the several opinions which have been entertained regarding the nature of the lesion now under consideration. Impressed with the importance of the subject when considered in connection with several morbid conditions of the stomach, more especially those produced by inflammation of this organ, the author of the present article instituted a series of experiments, modified in every possible way, with a view to obtain a satisfactory solution of the following questions. (Journ. Hebdom. de Med. Nos. 87 and 91, 1830.) Are the lesions described by various authors under the appellations of softening, ero- sion, perforation, gelatiniform softening, and diges- tion of the walls of the stomach, the same or dif- ferent lesions ? Are these lesions produced during life or after death ? If in the latter case, are they the effects of the chemical action of the gastric juice 1 and what are the conditions and properties of this fluid to which they are to be ascribed 1 The following summary of the experiments alluded to ajppears to us to afford a satisfactory solution of these queries. Softening, erosion, and perforation of the stomach and intestines from the chemical action of the gastric juice after death, in inferior ani- mals.—When an animal, such as a rabbit or dog, in the most perfect state of health, is killed during the act of digestion, the following appearances are observed in the stomach if examined four, six, or eight hours after. In one series of cases, the mu- cous membrane of the most depending portion of the stomach, or this membrane, the submucous, and muscular coat, are softened or broken down into a pulpy substance. In a second series, the serous or peritoneal covering is also destroyed, oi the stomach is perforated, and a quantity of di- gested food projects through the opening, and lies in contact with the liver, spleen, diaphragm, or intestines, one or all of which may present, to a greater or less extent, the same kind of softening as that observed in the stomach. In a third series, the diaphragm or oesophagus is perforated, and the liquid part of the digested food has passed into the cavity of the thorax, and all the parts with which it is in contact, as the pleura pulmo- nalis and costalis, and even the substance of the lungs, are softened or entirely dissolved. The colour of the softened parts was generally pale, sometimes of a yellowish tinge ; and whenever vessels filled with blood traversed these parts, this fluid presented a brown or black colour. The SOFTENING softened mucous membrane of the stomach, when removed by passing a scalpel over its surface, ap- peared like a solution of starch in hot water. It was frequently found in this state covering the submucous coat like a thin layer of jelly, and could be carried away by a stream of water, leaving a large irregular grey or pale coloured patch, formed by the denuded submucous coat. Sometimes several of these patches were observed, ' and presented those appearances termed erosions. These alterations of the mucous membrane were always limited to, or most marked in, the fundus or most depending portion of the stomach; they became gradually less perceptible towards the body or pyloric portion of the stomach, where they were lost in the healthy state of this mem- brane. The same characters were observed in the other tunics of the stomach, and the borders of the perforation were irregular, ragged, thin, pulpy, and transparent, and consisted principally of the peritoneum. The fundus of the stomach was the part pri- marily and exclusively affected. It was also in this portion of the stomach that the food was found most completely digested,—a circumstance which depended on the depending position of the fundus, at least in those cases in which the food was in a state of fluidity, or the gastric juice considerable in quantity. The same may be said of those organs alluded to, those of them being most softened that were nearest the fundus of the stomach, or in the direction in which the fluid contents of this organ were made to pass, from the position given to the body of the animal after death. From these facts it will not be difficult to perceive in these changes the effects of a common cause, having its seat in the stomach, and ex- tending its influence to other organs in the man- ner we have described. That this cause was the healthy gastric juice must be obvious, since this fluid was formed in animals in a perfect state of health. It was, besides, only when these animals were killed during the act of digestion, or when the stomach contained gastric juice, that any lesion of this organ was observed. We shall not at present attempt to identify the effects of the healthy gastric juice with those described by Cruveilhier, and others observed in children, as we shall afterwards have an opportunity of show- ing that the gelatiniform softening of the stomach and intestines met with in children is of the same nature as that we have just described. The next fact satisfactorily determined by these experiments was the property of the gastric juice, by means of which the dissolution of the stomach or other organs is effected after death. On laying open the softened or perforated stomach of a healthy animal, we are at once struck with the sour smell that arises from its contents. It is precisely similar to that which we perceive on opening the stomach of a living animal contain- ing a quantity of digested food. When litmus paper is placed in contact with this food, or the more fluid contents of the stomach, it becomes immediately red, the degree of redness, or the rapidity with which it takes place, varying with the stage of the digestive process and the fluidity of the contents of the stomach. The acidity of the gastric juice always accompanied the soften- OF ORGANS. igi ing and perforation of the stomach in the animals subjected to our experiments; and hence we con- cluded that it is to this property—acidity, that the production of these changes is to be attributed ; a conclusion, the accuracy of which was con- firmed by introducing into the stomach of a rabbit that had just been killed, a quantity of magnesia sufficient to neutralize the acid contents of this organ. In this experiment there was no appear- ance of softening. In order to show that the softening and perfora- tion of the stomach are the immediate effects of the gastric juice, or, more correctly speaking, the gastric acid, and in no way dependent on any morbid state of the stomach or other organ of the body, the stomach of a healthy rabbit, containing digested food, was removed, and placed under a glass globe. It was kept moist by a little tepid water placed beneath it. In a short time the fundus became pale, afterwards soft, thin, and transparent, and at the end of four hours dissolu- tion of all the coats of this depending portion of the stomach took place, and was followed by the escape of the food. Softening and perforation of the stomach, intestines, and urinary bladder, are produced under similar circumstances—that is to say, when the gastric acid or digested food is taken from the stomach of a healthy animal, and introduced into one or other of these organs, re- moved from another animal, or left in situ. We have repeatedly observed, and reproduced as stated above, all the varieties of softening, erosion, per- foration, &c. described by the authors whose opinions we have quoted as pathological states. Softening, erosion, and perforation of the sto- mach from the chemical action of the gastric juice after death, in persons suddenly deprived of life while in the enjoyment of perfect health. — It were weak and futile to argue that the post-mor- tem effects of the gastric acid, although observed to take place in inferior animals, do not prove their occurrence in man ; for the gastric acid has been found to be of the same nature in all animals in which it has been examined, as in man. More- over, all the chemical post-mortem effects of this acid have often been observed to occur in indi- viduals suddenly deprived of life soon after a meal, and at the time in the enjoyment of perfect health. We have seen one case of this kind which oc- curred in a healthy young man who fell from a considerable height soon after breakfast, and died a few hours after. All the coats of the fundus of the stomach, except the peritoneal, were converted into a soft gelatinous pulp, resembling in every respect the same change observed in our experi- ments on rabbits, as well as the contents of the stomach in this case, these having been found, by means of their smell and the chemical test, to be acid. There cannot, therefore, remain the slight- est doubt that softening of the walls of the stomach occurs after death from the chemical action of the healthy gastric acid in individuals suddenly de- prived of life. Softening, erosion, and perforation of the sto- mach, of this organ and the intestines, the oeso- phagus, diaphragm, c\c.from the chemical action of the gastric acid after death, in persons who die of various diseases.—These lesions have been met with of every possible degree, extent, and 192 SOFTENING OF ORGANS. form, whatever may have been the nature of the disease by which they had been preceded. Thus they have been observed in the bodies of those who have died of acute and chronic diseases, whether of one or of several organs, whether the stomach and intestines have manifested any signs of disease during life or not; in the most robust as in the most feeble and emaciated, and at every period of life. Before alluding farther to the symptoms ascribed to the present form of softening of the stomach, by those who regard it as a pa- thological lesion, we shall point out the situation which it occupies in this organ, the degree and extent to which it proceeds, and the form and colour which it presents, in order to determine how far it resembles in these respects this change of consistence, such as we have described it to occur in animals and in man, as the consequence of the chemical action of the healthy gastric juice after death. The situation of softening, as well as that of erosion and perforation of the stomach, in indi- viduals who die from disease, is precisely the same as in our experiments, viz. the fundus of that organ. It is to this part of the stomach that these lesions are almost always either exclusively con- fined, or in which they are greatest in degree. Their occurrence in any other portion of the sto- mach may be explained by the presence of certain physical conditions of this organ, which we shall presently notice more particularly. The degree of softening presents the same va- riety observed in our experiments. The mucous membrane or other tunics of the stomach present, in the first stage, a slight diminution of consist- ence, and have acquired a certain degree of trans- parency. When seized, they break immediately, or are .crushed between the fingers into a soft pulp. In the second stage, the mucous membrane is seen lying like a quantity of albumen covering the submucous coat, and can be wiped off or removed with a bit of cloth or a stream of water. In the last stage, this membrane has entirely dis- appeared in several portions of the stomach, thus leaving the submucous coat denuded, and present- ing the grey silvery aspect by which it is charac- terized. The extent of the softening is very various, being either limited to a small portion of the fun- dus, or occupying the whole surface of the sto- mach. When perforation either of the stomach or oesophagus has taken place, we find, as in our experiments, softening of the liver, spleen, intes- tines, diaphragm, pleura, and lungs, all of which organs may be affected in the same individual, and present various degrees of dissolution. The form of softening presents several import- ant varieties. If the softening be confined to the mucous membrane of the fundus, the form which it presents is that of small or large patches. These are generally irregular, the borders of them being formed by the mucous membrane, and the bottom of each by the submucous coat. The edges of the patches, besides being irregular, are thin, soft, and somewhat transparent. If the softening has penetrated the submucous and muscular coats, the edges of these are beveled outwards, and terminate in thin irregular prolongations, which are seen to float like shreds of transparent coagulable lymph when water is poured upon them. Softening and perforation of the peritoneal coat present precisely the same characters as to form and consistence. These, then, are the varieties of form of softening observed in the fundus of the stomach, and when this lesion extends beyond the fundus, it still pre- sents the same appearances so long as the mucous membrane is smooth or stretched out. But when this membrane is thrown into folds or forms plica, the softening no longer occurs in patches, but pre- sents those remarkable appearances so minutely and accurately described by Louis, as indicating the existence of pathological alterations. The forms of the softening in this case are those of stripes or bands of various dimensions, having the situation and distribution of the plica?. Wherever these stripes and bands exist, we find that the mucous membrane has been completely destroyed, and the submucous coat laid bare. They have thus a bluish or silvery grey aspect, while the mucous membrane which they enclose may be of its natural colour, red or otherwise modified, and appears in isolated patches of various forms and extent. It was the isolated and defined character of this form of softening which made it be con- sidered as indisputably of a pathological nature. But the following explanation will show that it is a post-mortem lesion, and the consequence of the chemical action of the gastric juice. The mucous membrane possessing only in a very limited de- gree the power of diminishing its bulk, is always thrown into the form of plica? when the muscular coat has contracted so as to diminish considerably the capacity of the stomach. When a quantity of gastric acid is collected on the surface of the mucous membrane in this state, it is obvious that the dissolvent property of this fluid will be exerted principally, if not exclusively, on the borders of the plica?, their lateral surfaces being in contact with one another, or covered with mucus. Hence it follows, that when the stomach is removed from the body, emptied of its contents and spread out, the plica? are effaced, and the stripes and bands, not before observed, make their appearance. That such is the manner in which this form of soften- ing is produced is demonstrated by the following experiment, which we have frequently repeated. If the stomach of an animal, or of the human subject, in which the plica? are well marked, be taken, and a quantity of gastric acid or digested food be placed over its mucous surface, we find that after a few hours the projecting borders of the plica? are dissolved, while their lateral surfaces remain unchanged. We have said that softening of the stomach, the erosion and perforation by which it is fol- lowed, almost always takes place in the fundus of this organ, in consequence of its depending position favouring the accumulation of the gastric acid. But there are various circumstances which, operating after death, give rise to important va- rieties in the situation, form, and extent of the softening of the mucous and other coats of the stomach. Great enlargement of the spleen may elevate or compress the fundus of the stomach so as to prevent the gastric acid from collecting within it, while at the same time this fluid accumulates in some other portion of the stomach, as the pyloric, which may have become the most depending part; SOFTENING OF ORGANS. 193 great distension of the transverse arch of the colon may throw the great curvature of the stomach up- wards and forwards, when the fluid contents of this organ collect along the small curvature; or tumours in the liver, retro-peritoneal cellular tissue, &c. may be so situated as to produce considerable variation in the position and form of the stomach, and, consequently, in the situation of the soften- ing. Under all these circumstances the form of soft- ening is likewise considerably modified. But the presence of gas in the stomach gives rise to a par- ticular variety of form of softening which requires to be noticed. The softening terminates in a well- defined, abrupt margin, beyond which the mucous membrane is found to present (so far, at least, as the gastric acid is concerned) its natural colour and consistence. This regular and defined margin of the softening is determined by the gas acting as a foreign body, equalizing the distribution of the gastric acid, and confining its operation to a cir- cumscribed portion of the mucous membrane. The quantity of the gastric acid generally regulates the extent of the softening of the mucous membrane. If considerable, the whole of the gastric mucous membrane may be destroyed, and it is also in cases of this kind that the cardiac orifice becomes dilated, and the gastric acid passes into the oesophagus, the cuticular lining, mucous and muscular coats of which it dissolves, and forms a communication between the cavity and this tube and that of the chest. The colour of the mucous membrane in soften- ing, erosion, and perforation of the stomach, pre- sents several important modifications, and which depend essentially on the quantity of blood con- tained in this organ after death. If the quantity of this fluid be very small, or such as it is gene- rally found to be in what is considered the healthy state of the stomach, the natural colour of the mu- cous membrane is not altered except where it is softened, where it is of a dull-yellow or orange- tint. This colour increases with the quantity of blood, and is accompanied with shades of brown and black, which assume a variety of forms, the description of which will be found in the article Melanosis, and also the experimental evidence which demonstrates that these changes of colour are produced by the gastric acid. An opposite state, or extreme paleness of the softened mucous membrane, is that form of post-mortem softening which is generally observed in infants and young children, and in emaciated, cachectic, and leuco- phlegmatic persons, in whom the blood is not only small in quantity, but contains a great dispropor- tion of serum. In such individuals the whole stomach appears as if macerated ; is, indeed, some- times infiltrated with serosity, and is so completely deprived of blood that no trace of this fluid is perceived except in some of the large venous branches. Redness of the softened mucous membrane is never observed. Its existence is incompatible with the chemical action of the gastric acid, and the red colour of the blood is instantaneously destroyed by this fluid. Although the general characters of the chemi- cal dissolution of the intestines agree in every re- spect with those which accompany this lesion of Vot.IV. —25 K the stomach, there are a few circumstances which require to be noticed, in order to refute the opin- ion that softening of this part of the digestive appa- ratus is, in an especial manner, the consequence of disease. We have already stated that soften- ing of the intestines was a frequent occurrence in those animals submitted to our experiments. The portions of intestines softened or perforated were invariably those situated in the epigastric or left hypochondriac region ; and it is most important to note that complete dissolution of the coats of the intestines was sometimes observed, even when the stomach was not perforated, and, consequently, when the former were not in immediate contact with the gastric acid contained within the sto- mach. As the intestine occupied the superior surface of the stomach, presented no trace of dis- ease, nor contained any acid fluid, the softening must obviously have been produced by the gastric acid having been transported from the stomach by imbibition. Hence it follows that softening, and even perforation, from without inwards, of the intestines, may take place after death from the chemical action of the gastric acid, and without perforation of the stomach as a previous and ne- cessary occurrence. It is an interesting fact that in almost all the cases of softening, (gelatiniform softening,) or softening with perforation of the in- testines that have been published, the large intes- tines, situated in the epigastric or left hypochon- driac region, were exclusively the seat of one or both of these lesions. Such, also, has been the result of our own observations in all the cases of softening of the intestines which we have exa- mined in the dead body. The locality of this lesion and its physical characters being precisely the same in man as those observed in animals, and having traced it in both to the mediate or im- mediate influence of the gastric acid, we must necessarily regard it in the former, as it was shown to be in the latter case, a post-mortem alteration- Cases of softening and perforation of the intestines, from within outwards, occur after death, from the presence of an acid fluid, either formed within them, or brought into them from the stomach. From the evidence we have brought forward to prove that the softening, erosion, and perforation of the stomach and intestines, described as patho- logical lesions by the authors to whom we have referred, are the effects of a chemical agent—the healthy gastric acid—and produced after death, it would, in our opinion, be a waste of time to at- tempt a refutation of the several theories which have been offered on this subject. We have already remarked that all these lesions have fre- quently been found to occur in individuals, what- ever may have been the seat or nature of the functional derangement by which they may have been preceded, whether death may have been the consequence of disease or of accidental injury. But why, it may be asked, do these lesions fre- quently occur, particularly in children, in whom the only symptoms observed arc referuble to a greater or less derangement of the functions of the stomach and intestines ? This question may bo met by the following. How does it happen that these lesions do not occur in cases in every re- spect the same as the former as regards the de- rangement of function and the organs affected ? 194 SOFTENING OF ORGA NS— SOMN AM B ULISM . The answer is simply this—the presence in the former, and the absence in the latter case, of the chemical cause of these lesions. Gastritis or gastro-enteritis is the disease which exists in both cases, and would never have been described as any thing else but for the presence of those post- mortem lesions which we have described. It is, indeed, surprising that any divergency of opinion should exist on this subject, seeing that no such changes exist in any other organ supplied with a mucous membrane ; seeing, on the contrary, that inflammation produces quite a different kind of softening of the mucous membrane from that which we have described. The mucous membrane softened by inflammation, instead of being trans- parent, is more or less opaque, and even when it is completely disorganised, it resembles a mixture of flour and water or milk, rather than an albu- minous or a gelatinous fluid. Such is, in fact, the principal character of inflammatory softening of the mucous membrane, in whatever organ it occurs ; whereas the transparent gelatiniform soft- ening is never observed except where the chemi- cal agent is formed by which it is produced, viz. in the alimentary canal, and in some of the neigh- bouring organs, for the reasons which we have already given. We shall only further observe, that were the gelatiniform softening, erosion, and perforation of the stomach the consequences of inflammation, we should in every case find, either in the stomach or external to it, one or more of the products of this pathological state. But this we never find ; even the perforation of the sto- mach, of the intestines, diaphragm, with the ac- companying destruction of the spleen, liver, &c, may exist all in the same individual without any trace of serous effusion, of coagulable lymph or pus. There is no trace of peritonitis, even when the contents of the stomach, of the most stimulat- ing quality, are lying in contact with the perito- neum. Lastly, the stomach is frequently found perforated without its contents having escaped into the cavity of the abdomen. From all the facts brought forward on this part of our subject, the following principles may be established :— 1st That the softening, erosion, and perfora- tion of the walls of the stomach, attributed by the greater number of pathologists to morbid condi- tions of this organ, may be produced, whatever may be their form, degree, extent, or situation, by the gastric acid. 2. That no pathological condition of the sto- mach or of any other organ is necessary to the production of these lesions. 3d. That all of them are met with in individuals who, in the full enjoyment of health, are suddenly deprived of life; and in those who die from vari- ous diseases. 4th. That all of them are met with, after death, in healthy and diseased stomachs, which contain gastric acid. 5th. That they are produced by introducing this fluid into a healthy dead stomach. 6th. That the varieties observed in the form, degree, extent, and seat of these lesions, depend on modifications of the gastric acid, the action of which on the stomach is regulated by a certain number of physical conditions in which this organ may be placed. 7th. That softening, erosion, and perforation from the action of the gastjic acid, are observed in other organs besides the stomach, viz. in the oesophagus and intestines, from the direct com- munication which exists between them and the former organ; and the peritoneum, liver, spleen, diaphragm, pleura?, and lungs, in consequence of the perforation of the stomach and oesophagus. 8th. That all these lesions of the stomach, intestines, and of the other organs, are produced after death. R. Carswell. SOMNAMBULISM AND ANIMAL MAG- NETISM. I.—Of Proper Somnambulism. Somnambulism or sleep-walking is one manifes- tation of a state of the nervous system which, in dif- ferent degrees and under several forms, coexists with various general conditions of the living body. It is characterized by a suspension more or less complete of external feeling, while the imagina- tion is in activity, but the individual is not con- scious of his real state, and fancies himself to exist under different circumstances from those which actually surround him. Dreaming is one modification of this state, but it does not afford so great a variety of phenomena as somnam- bulism, or display so many peculiar signs of the real condition of the faculties. Many forms of delirium, catalepsy, trance or ecstacy, and some cases of madness— those, for example, in which the patient on recovery is found to have lost sud- denly all recollection of what had passed daring the period of his disease — belong to the same class of affections, for which we have as yet no collective term. An inquiry into the real charac- ter and pathology of somnambulism may afford us an opportunity of throwing some light on a variety of obscure phenomena which display themselves in the state of the system above de- scribed, and it will be found interesting, and, as we trust, useful in some other points of view. There is an obvious relation between the state of the faculties in somnambulism and that which exists during dreams. It is, indeed, probable that somnambulism is dreaming in a manner so modi- fied, that the will recovers its usual power over muscular motion, and likewise becomes endued with a peculiar control over the organs of sense and perception. This power, which gives rise to the most curious phenomena of somnambulism, is of such a kind that, while the senses are in general obscured, as in sleep, and all other objects are unperceived, the somnambulator manifests a faculty of seeing, feeling, or otherwise discovering those particular objects of which he is in pursuit, towards which his attention is by inward movement direct- ed, or with which the internal operations of his mind bring him into relation. The near connection between somnambulism and dreams is established by the following con- siderations :— 1. Sleep-walkers, after they have awakened from the slumbers which ushered in and continued after somnambulation, have sometimes remembered the circumstances or adventures of the period, and SOMNAMBULISM. 195 have correctly related them as the impressions of a dream. This fact has been noticed by Sylvius and by Hoffmann : «< Somniantibus et somniorum ratione obvcnire hominibus somnamhulorum affec- tum patet exipsorum evigilantium relatu, putanti- um se somniasse duntaxat, qua? actu fecerunt." A striking instance of this kind is related by Horstius. A young nobleman in the citadel of Brenstein was observed by his brothers, who occupied the same room, to rise in his sleep, put on his cloak, and having opened the casement, to mount, by the help of a pulley, to the roof of the building. There he was seen to tear in pieces a magpie's nest, and wrap the young birds in his cloak. He returned to his apartment, and went to bed, having placed his cloak by him with the birds in it. In the morning he awoke, and related the adventure as having occurred in a dream, and was greatly surprised when he was led to the roof of the tower and shown the remains of the nest, as well as the magpies concealed in his cloak. A similar observation as to the occasional remembrance of the impressions made on the mind during somnambulism, was made long ago by Muratori, to whose work we shall again have occasion to refer. 2. As in dreams, so likewise in somnambulism the individual is intent on the pursuit of objects towards which his mind had been previously di- rected in a powerful manner, and his attention strongly roused; he is in both states impelled by habit, under the influence of which he repeats the routine of his daily observances. A somnambulator is a dreamer who is able to act his dreams. Many facts may be cited in proof of this remark. A man (known to the writer of this article), who was accustomed to attend a weekly market, rose from his bed, saddled his horse, and actually pro- ceeded on his journey as far as a turnpike, which Doing closed during the night, he was awakened by the circumstance. Another individual who had been in the habit of frequenting a public promenade, where he used to meet his acquaint- ances, was seen to rise from his bed at night and walk in his shirt along the same path, which extended for a mile on the brow of a hill, stopping very frequently and greeting different individuals whom he had been accustomed to see in the same place. Hoffmann relates the case of a somnambulator who dreamed that he was going to set out on a journey, rose and put on his clothes, shoes, and spurs, and then striding across the sill of an open window, began to kick with his heels and to exert his voice, supposing that he was exciting his horse to speed. Henricus ab Heer mentions another person, a student at an university in Germany, who having been very intent on the composition of some verses which he could not complete to his satisfaction, rose in his sleep, and opening his desk, sat down with great earnestness to renew his attempt. At length having succeeded, he returned to bed, after reciting his composition aloud, and setting his papers in order as before. Martinet gives the case of a man who was accustomed to rise in his sleep and pursue his business as a saddler. M. Bertrand considers it to be a peculiar fea- ture of somnambulism that the individual, though on waking he is generally found to have lost all recollection of what passed during his sleep, yet recalls, when the periods of this state return, the whole train of obliterated ideas. « Somnambu- lism," as the same writer says, " thus constitutes really a new life, returning at unequal intervals, connected together by a new species of memory." (Traite du Somnambulisme, par A. Bertrand, Paris, 1823.) We may observe that something of this kind is perceived in the instance of dreams. A person strongly impressed by a dream, on again falling asleep, experiences not unfrequently a recur- rence of the same impressions, and the imagina- tion will even take up the dream at the precise point where it was before interrupted. These observations seem to prove that somnam- bulism is a modification of dreaming, and this conclusion appears so probable, that it will per- haps be admitted without hesitation; yet there are many writers of great research and ability who maintain a different opinion. Bertrand, who has investigated the circumstances connected with the history of sleep-walking with great pains and accuracy, considers the state in question to be something entirely different from dreaming. The same opinion is expressed in the most positive manner by Professor Heinroth, who says that somnambulists are to be reckoned as awake, since their perceptive power is in some respects even more acute than during the ordinary waking state; and that this condition bears no relation to dream- ing, inasmuch as dreamers exist in an ideal world, whereas night-wanderers are conversant with ac- tually existing and material objects. (Lehrbuch der Stoerungen des Seelenlebens, und ihrer Be- handlung, von Professor J. C. A. Heinroth, Leip- zig, 1818, B. ii. p. 270.) Both of these writers maintain an opinion which is very prevalent in France and Germany, that somnambulists have the ordinary channels of sensation entirely closed, that they neither see with their eyes nor hear with their ears, but are endowed with a peculiar mode of sensation, which, in its highest degree, consti- tutes what is termed clairvoyance. This is sup- posed to be diffused over the whole surface of the body, but to be especially seated in the epigas- trium and fingers' ends. It is not exactly sight or hearing, but fulfils all the functions of both these modes of perception. An opinion so improbable will be thought by some scarcely worthy of consideration. Its ex- tensive reception, however, among a large number of continental writers, together with some other reasons which will become apparent, must prevent our passing it over as an idle speculation. The facts, also, of somnambulism are, as we have above remarked, deserving of further attention on account of their relation to a variety of obscure pathological phenomena, with which we shall have to compare them. For these reasons we deem it necessary to call the attention of our read- ers to some of the most remarkable of the cases of somnambulism which have been recorded in different countries, and which are occasionally appealed to as affording evidence on controverted points. Somnambulism was known to Hippocrates and Aristotle, and to Galen by his own experience, but is briefly mentioned by them. Diogenes Laer- tius has recorded two cases of this affection. One 196 SOMNAMBULISM. was that of a stoic philosopher, who in this state used to compose works, read, and correct them. Such actions, as M. Bertrand observes, under the ordinary circumstances would imply the possession of sight; still this writer is inclined to maintain that somnambulists have rather a new faculty which supplies the place of sight, though he ad- mits that the supposition should not be adopted without incontestable proof. Gassendi has related in a more detailed manner several cases of som- nambulism. These are extracted by Muratori in his work on The Imagination, in which are also to be found some of the most interesting facts on record connected with this and other mental phe- nomena.* One of Gassendi's somnambulists used to rise and dress himself in his sleep, go down to the cellar and draw wine from a cask: he ap- peared to see in the dark as well as in a clear day ; but when he awoke either in the street or cellar, he was obliged to grope and feel his way back to his bed. He always answered his wife as if awake, but in the morning recollected nothing of what had passed. It often seemed to him as if there was not light enough, and he thought he had risen before day. He then struck fire, and lighted a candle. Another sleep-walker, a countryman of Gassendi, passed on stilts over a swollen torrent in the night, but on waking was afraid to return before daylight, or until the water had subsided. Two of the most curious and best related cases on record are those of Signor Augustin Forari and John Baptist Negretti; both of these are given by Muratori, from whom we shall take a brief ex- tract of them. " Signor Augustin was an Italian nobleman, dark, thin, melancholic, and cold-blooded, addicted to the study of the abstract sciences. His attacks occurred at the waning of the moon, and were stronger in autumn and winter than in the sum- mer. An eye-witness, Vigneul Marville, gave the following description of them. " One evening towards the end of October, we played at various games after dinner; Signor Augustin took a part in them along with the rest of the company, and afterwards retired to repose. At eleven o'clock his servant told us that his master would walk that night, and that we might come and watch him. I examined him after some time with a candle in my hand. He was lying upon his back, and sleeping with open, staring, unmoved eyes. We were told that this was a sure sign that he would walk in his sleep. I felt his hands and found them extremely cold, and his pulse beat so slowly that his blood appeared not to circulate. We played a trictrac until the spectacle began. It was about midnight, when Signor Augustin drew aside the bed-curtains with violence, arose, and put on his clothes. I went up to him and held the light under his eyes. He took no notice of it, although his eyes were open and staring. Before he put on his hat, he fastened on his sword-belt, which hung on the bed-post: the sword had been removed. Signor Augustin then went in and out of several rooms, approached *L. A. Muratori, della forza della Fantasia Umana, Venez. 17156. It is singular that this treatise has not been translated into either French or English. The Ger- man translation is a very valuable work, containing various notes and additions by the editor, Richertz of Gottingen. . the fire, warmed himself in an arm-chair, and went thence into a closet where was his wardrobe. He sought something in it, put all the things into disorder, and having set them right again locked the door and put the key into his pocket. He went to the door of the chamber, opened it, and stepped out on the staircase. When he came below, one of us made a noise by accident: he appeared frightened, and hastened his steps. His servant desired us to move softly and not to speak, or he would become out of his mind ; and some- times he ran as if he were pursued, if the least noise was made by those standing round him. He then went into a large court and to the stable, stroked his horse, bridled it, and looked for the saddle to put on it. As he did not find it in the accustomed place, he appeared confused. He then mounted his horse, and galloped to the house door. He found this shut; dismounted, and knocked with a stone which he picked np, several times at the door. After many unsuccessful efforts he remounted, and led his horse to the watering- place, which was at the other end of the court, let him drink, tied him to a post, and went quietly to the house. Upon hearing a noise which the servants made in the kitchen, he listened atten- tively, went to the door, and held his ear to the keyhole. After some time he went to the other side, and into a parlour in which was a billiard- table. He walked round it several times, and acted the motions of a players. He then went to a harpsichord on which he was accustomed to practise, and played a few irregular airs. After having moved about for two hours, he went to his room and threw himself upon his bed clothed as he was, and the next morning we found him in the same state; for as often as his attack came on, he slept afterwards from eight to ten hours. The servants declared that they could only put an end to his paroxysms either by tickling him under the soles of his feet, or by blowing a trumpet in his ears." The history of Negretti was published sepa- rately by two physicians, Righellini and Pigatti, who were both eye-witnesses of the curious facts which they relate. The former corresponded with Muratori, and gave replies to his questions as to particular circumstances. Negretti was about twenty-four years old, was a sleep-walker from his eleventh year, but his attacks only oc- curred in the month of March, lasting at farthest till the month of April. He was a servant of Marquis Luigi Sale. On the evening of the 16th of March, 1740, after going to sleep on a bench in the kitchen, he began first to talk, then walked about, went to the dining-room and spread a table for dinner, placed himself behind a chair with a plate in his hand, as if waiting on his master. After waiting until he thought his master had dined, he uncovered the table, put away all the materials in a basket, which he locked in a cup- board. He afterwards warmed a bed, locked up the house, and prepared for his nightly rest. Be- ing then awakened and asked if he remembered what he had been doing, he answered, no. This, however, was not always: he often recollected what he had been doing. Pigatti says that he would awake when water was thrown into his face, or when his eyes were forcibly opened. Ac- SOMNAMBULISM. 197 cording to Maffoi, he then remained some time faint and stupid. Righellini assured Muratori that his eyes were firmly closed during the paroxysm, and that, when a candle was put near to them, he took no notice of it. Sometimes he struck himself against the wall, and even hurt himself severely. Hence it would seem that he was directed in his movements by habit, and had no actual perception of external objects. This is confirmed by the assurance that if any body pushed him he got out of the way, and moved his arms rapidly about on every side, and that when he was in a place of which he had no dis- tinct knowledge, he felt with his hands all the objects about him, and displayed much inaccuracy in his proceedings; but in places to which he had been accustomed, he was under no confusion, but went through his business very cleverly. Pigatti shut a door through which he had just passed : he struck himself against it on returning. The writer last mentioned was confident that Negretti could not see. He sometimes carried about with him a candle, as if to give him light in his em- ployment ; but on a bottle being substituted, took it and carried it, fancying that it was a candle. He once said during his sleep that he must go and hold a light to his master in his coach. Righellini followed him closely, and remarked that he stood still at the corners of the streets with his torch in his hand not lighted, and waited a while in order that the coach which he supposed to be following might pass through the place where light was required. On the 18th of March he went through nearly the same process as be- fore, in laying a table, &c. and then went to the kitchen and sat down to supper. Signor Righel- lini observed him in company with many other cavalieri very curious to see him eat. At once he said, as recollecting himself, < How can I so forget ? To-day is Friday, and I must not dine." He then locked up every thing and went to bed. On another occasion he ate several cakes of bread and some salad, which he had just before de- manded of the cook. He then went with a lighted candle into the cellar and drew wine, which he drank. All these acts he performed as usual, and carried a tray upon which were wine-glasses and knives, turning it obliquely on passing through a narrow doorway, but avoiding any accident. Our limits prevent us from extracting the further details which relate to the history of this night- wanderer. The preceding relations, to which we shall incidentally add a few other particulars from the same sources, furnish a body of facts sufficient for displaying, as far as these individual cases are concerned, the state of the faculties in somnam- bulism. In the analysis of these we shall now attempt to discover some general principle which may serve as a clue to the variety of analogous phenomena on record. To begin with the infe- rior senses. Pigatti says that Negretti sat down to eat a bowl of salad which he had prepared. It was taken from him, and some strongly sea- soned cabbage put in its place ; this he eat with- out perceiving the difference, as he did also some pudding which was presently substituted. At another time, having asked for wine, he drank water which was given to him. He sniffed ground coffee instead of snuff, which he had de- manded. Other sleep-walkers are well known to have detected similar deceptions, as it will appear from a case hereafter to be related. The difference appears to be in the degree of attention: a more lively perception as to the qualities of the object desired existed in one case than in the other, the mind being more directed to particular sensations in the one case, and more distracted or diverted from them in the other. The sense of hearing presents similar variations. In general, somnambulists do not hear persons who talk aloud in their presence. It has often been observed that very loud noises are unper- ceived by them,—that a trumpet must be sounded in their ears before their attention can be forcibly withdrawn from reverie to the perception of the real world, and to the waking state. At other times they converse and hear the lowest sounds. Signor Augustin repeatedly listened and hea'rd slight noises at a distance. The difference seems here to depend upon the same principle as in the preceding instances which refer to smell and taste. When attention is by a voluntary act directed to the particular operations of sense, the perceptive faculty of the sleeper is perfect, even remarkably acute. But when his mind is distracted, his reverie presenting different objects, even loud sounds are imperceptible to him. Perhaps from the same consideration we shall obtain a clue to unravel the perplexing varieties of phenomena connected with the state of vision in some cases which will be presently mentioned. Negretti, as it seems, had his eyes shut and saw not. Habit guided him in places with which he was familiar, and in other places he frequently showed the want of accurate perception, and assisted himself by feeling and groping about. Etmuller observed that sleep-walkers go about " oculis clausis," but he adds that some have acted " oculis conniventi- bus." Haller says decidedly, that they get out of their beds fast asleep, their eyes being either firmly closed or otherwise sightless, since a strong light is unperceived, though held near. (Elem. Physiol, lorn. v. p. 626.) The fact is doubtless, yet why may we not avail ourselves of the analo- gy presented by the sense of hearing, and allow the insensibility to light under the ordinary cir- cumstances of sleep-walking to be compatible with the use of the same faculty in other instances where we can find no other explanation of the phenomena] Such cases will presently come under our notice. Negretti and Augustin did not see, and Richertz well observes that the want of vision seems to have been supplied by various means. Habit, as we have observed, is the prin- cipal guide. The sense of feeling, when under the guidance of attention, and even that of hear- ing in similar circumstances, appear to be remark. ably acute. Then as to the hypothesis to which in the sequel we shall have further to advert, viz. that somnambulists have a new kind of sight in- dependent of the eyes; — although we are not called upon to disprove such a position, yet many facts may be found in the history above related which would enable us to do so. The defect was not supplied in such a degree and manner as the hypothesis implies. Negretti stood behind his master's chair supposing him to be at dinner; he fancied that the torch which he held to guide 198 SOMNAMBULISM. his coach was lighted, when it was not. In a variety of cases he displayed the total want of any sensation analogous to sight; he stumbled when he walked in places to which he had not been accustomed, felt his way on various sides, struck himself against a wall. In attempting to pass through a closed door, he hurt himself. Other histories of somnambulists supply parallel remarks. Galen mentions of himself that he once walked about a whole night in his sleep till he was awakened by striking himself against a stone which happened to be in his way. (De Motu Musculorum, lib. ii. cap. 5.) There are facts which prove that even the sense of feeling, which is the principal guiding faculty in somnambulism, is limited in its sphere of action, and exists under a modification similar to that which affects the other perceptive powers, and which, according to the opinion above stated, explains the anomalies of their operation. Ne- gretti seems not to have distinguished accurately even objects of feeling when they were not par- ticularly the objects of attention. When struck a blow by a stick on the leg, he fancied that a dog had touched him, and scolded it. Being again struck, he threw a bit of bread, calling the hound by name. A muff was thrown at him, which he again took for the dog. (Muratori, ubi supra, p. 323.) In other instances somnambulists have been known to write, and even to correct their compo- sitions, and to do other acts which could not pos- sibly be performed without sight. Castelli, a sleep-walker, whose case is one of the most remarkable, was a pupil of Porati, an Italian apothecary. His history has been published by Francesco Soave, a physician, who personally ob- served him. He was found one night in the act of translating from Italian into French, and looked for words in a dictionary as usual, being asleep. His candle being extinguished, he found himself to be in the dark, groped for the candle, and went to light it again at the kitchen fire. Bertrand thinks that Castelli did not really experience the want of light, because the room was, as we are informed, actually illumined at the time by other candles. This is a most improbable supposition, and seems irreconcilable with the fact just related, that he perceived his candle to become extin- guished. There are, indeed, many circumstances related of this somnambulist which prove to our entire conviction that he not only saw, but had his other organs of sense in a state capable of per- ception whenever his attention was excited, and he wished to avail himself of their operation. He used to leave his bed, go down to the shop and weigh out medicines to supposed customers, to whom he talked. When any one conversed with him on a subject on which his mind was bent, he gave rational answers. He had been reading Macquer's Chemistry, and somebody altered his marks to try if he would notice it. This puzzled him, and he said, " Bel piacere di sempre togliermi i segni." He found his place and read aloud, but his voice growing fainter, his master told him to raise it, which he did. Yet he perceived none of the persons standing round him, and " though he heard," says Soave, " any conversation which was in conformity with the train of his ideas, he heard nothing of the discourse which those persons held on other subjects." His eyes seemed to be very sensible to objects relating to his thoughts, but ap- peared to have no life in them, and so fixed were they, that when he read he was observed not to move his eyes but his whole head, from one side of the page to the other.* Facts which appear even still more strongly to evince the possession of accurate sight, are related in a very curious case of somnambulism, which was published in the French Encyclopedia. The account has been copied by Bertrand, who endea- vours to turn aside the evidence afforded by it, or to reconcile it with his own hypothesis. We shall conclude this part of our inquiry with an abstract of the most remarkable facts contained in the nar- rative, and request our readers to bear in mind the explanation of the phenomena which we have pro- posed. This somnambulist was a young priest in a Catholic seminary ; the witness and reporter of the facts, the archbishop of Bordeaux, who used to go into his chamber after the priest was gone to sleep, and observe his proceedings. He some- times arose from bed, took paper, and wrote ser- mons. After finishing a page, he read (if the act was properly reading) the whole aloud; and, if necessary, erased words and wrote his corrections over the line with great accuracy. " I have seen the beginning of one of his sermons whicn he had written when asleep; it was well composed, but one correction surprised me : having written at first the words ' ce divin enfant,' he had after- wards effaced the word divin, and writtten over it adorable. Then perceiving that ce could not stand before the last word, he had dexterously in- serted a t, so as to make the word cet." The wit- ness, in order to ascertain whether he made use of his eyes, put a card under his chin, so as to in- tercept the sight of the paper which was on the table ; but he continued to write without perceiv- ing it. Wishing to know by what means he judged of the presence of objects which were under his eyes, the witness took from him the paper on which he was writing, and substituted others repeatedly. He always perceived this by the difference of size, for when a paper of exactly the same shape was given to him, he took it for his own, and wrote his corrections on places cor- responding to those on the paper which had been taken away from him. The most astonishing thing is that he would write music with great ex- actness, tracing on it at equal distances the five lines, and putting upon them tho clef, flats, and sharps. Afterwards he marked the notes, at first white, and then blackened those which were to be black; the words were written under, and once happening to make them too long, he quickly per- ceived that they were not exactly under the cor- responding notes; he corrected this inaccuracy by rubbing out what he had written, and putting the line below with the greatest precision. On one occasion, in the midst of winter, he fancied himself to be walking on the bank of a * Riflessioni sopra il Soinnambolismo ; di Francesco Soave. Many of the particulars relating to this case of Castelli have been inserted by Mr. P. B. Duncan,fellow of New College, in a very ingenious essay on somnam- bulism. SOMNAMBULISM. 199 river, and to see a child fall into it, in danger of drowning. He leaped into the river, as he thought, in order to rescue the child, and actually threw himself upon his bed with the action of a man swimming. He imitated the movements of a swimmer for some time, and at length feeling in a corner of the bed a bundle of the clothes, fan- cied that he had seized the child, held it in one hand, and with the other swam, as he supposed, to the bank of the river; he there put down the bundle, and came out shivering and chattering with his teeth, as if he really had just emerged from a cold stream. He said to the persons near him that it was freezing, and that he was almost dead with cold, and asked for a glass of brandy to warm him; as there was none at hand, they gave him water, but he knew the deception, and again demanded brandy, expressing the risk which he incurred. He drank a glass of strong liquor, and seemed refreshed, but, without awaking, lay down, and continued to sleep soundly. The reporters of this curious story suggest, by way of comment, the following queries: —« 1. How is it possible for a man buried in profound sleep, to hear, speak, write, see, and in short en- joy the use of his senses, and perform correctly different movements ? To facilitate the solution of this problem, we shall add," say the writers, "that the somnambulist sees only those objects which he seeks, or which are present to his ima- gination. This individual composed sermons, saw his paper, his ink, pens, could distinguish whether they marked or not the paper. For the rest he did not suspect that any person was in his room, neither seeing nor hearing any body, unless when he had asked for any thing. " 2. How any person can experience sensation without the assistance of the organs of sense ? The somnambulist above mentioned appeared evidently to see those objects which had relation to his own ideas. When he traced the notes of music, he knew exactly those which ought to be black and those that were to be left white, and without mis- take blackened the former and omitted the others, and if the lines were not dry, he took the precau- tion to avoid blotting them. There is no reason to suspect that the other channels of sensation were less interrupted than the ordinary one of vision. This might have been ascertained by stopping his ears, &c. " 3. How did it happen that during the paroxysm of somnambulism he remembered what had oc- curred during former paroxysms, although, when awake, he lost all traces of such matters ? "4. How is it possible that, without any real J cause, he was strongly affected by agents of which he had only imagined the existence, as by the coldness of the water, in which he supposed him- self to be immersed ?" We shall leave these inquiries to the considera- tion of our readers, and now proceed to another division of the subject. II.—Ecstatic or cataleptic Somnambulism. A morbid affection analogous in many of its phenomena to sleep-walking, but occurring under different circumstances, has been well known to medical writers since the time of Sauvages and Lorry, who first described it. Sauvages gave it the designation of cataleptic somnambulism. Ac- cording to this writer the attack is ushered in and followed by a complete fit of catalepsy. This hap- pened in the case described by him, but in other instances the preceding symptoms are not so strongly marked : coma, or insensibility in various degrees, may, however, be considered universally present. The most correct idea of the phenomena of this affection will be conveyed by some exam- ples. The following is the first case published by Sauvages. "In the month of April 1737, a fe- male who had been for some time affected with fits of hysterical catalepsy, experienced in con- junction with these attacks other symptoms, of which she had more than fifty returns. The fits were divided into three periods; the beginning and termination had perfectly the character of catalepsy; the intermediate period, which some- times lasted from the morning till the evening, was occupied by what the girls in the house called the live fit, while they termed the catalepsy the dead fit. I shall now describe the phenomena," says Sauvages, " which I should certainly have believed to be feigned if I had not become con- | vinced of the contrary by numerous proofs. What I shall say respecting one attack may be under- I stood to apply, with the variation of some circum- stances, to all the rest. On the 5th of April 1737, visiting the hospital at ten o'clock in the morning, I found the patient in bed, which she kept on account of her debility and the pain in her head : the fit of catalepsy had just seized her, j and it quitted her after five or six minutes ; this was perceived by her yawning and raising herself into a sitting posture, the prelude to the following scene. She began to talk with a degree of ani- mation and esprit never observed in her except when in this state. She sometimes changed her subject, and appeared to converse with some friends whom she saw around her bed. Her dis- course had relation to what she had said during her attack on the preceding day. She repeated word for word an instruction in the form of a catechism, which she had heard on the evening before, and she made pointed applications of it to persons in the house, whom she took care to de- signate by invented names, accompanying the whole with gestures and movements of her eyes, which she kept open, and alluding to the circum- stances and actions of the preceding evening. Yet she was all this time in deep sleep; a fact which was strongly averred, but which I should never have ventured to declare if I had not obtained satisfactory proof by a series of experiments on the organs of sense: when she began to talk, a blow of the hand inflicted smartly on her face, a finger moved rapidly towards her eyes, a lighted candle brought so near to the organ of vision as even to burn the hair of her eyebrows, a person unseen uttering suddenly a loud cry into her ear, and making a stunning noise with a stone struck forcibly against her bedstead, brandy and a solu- tion of ammoniacal salt placed under her eyes and introduced into her mouth, the feather of a pen, and afterwards the extremity of a finger applied on the cornea, Spanish snuff blown into the nostrils, pricking by pins, twisting her fingers; all these means were tried without producing the least sign of feeling or perception. Soon after- wards she rose, and I expected to see her strike 200 SOMNAMBULISM. herself against the neighbouring beds ; but she passed between them and turned corners with the greatest exactness, avoiding chairs and other fur- niture that happened to be in her way, and hav- ing walked about the ward, returned between the beds without feeling her way, lay down, covered herself, and in a few minutes became again cata- leptic. She afterwards awoke as if from a deep sleep, and perceiving by the looks of those about her that she had been in her fits, she became very confused and wept all the rest of the day, not hav- ing the least idea of what had passed during the pa- roxysm." Sauvages adds that this patient reco- vered ; her fits became less frequent; she had some relapses, but the disorder at length nearly left her.* Lorry has described the phenomena of two re- markable cases of ecstasis, of which he was an eye-witness. A woman in a state resembling somnambulism used to converse aloud with absent persons, supposing them to be present. She was so insensible to external impressions, that she could not be excited by pricking or pinching her body, yet she perceived objects to which the cur- rent of her thoughts directed her, or to which they had relation. Her arms and fingers retained the positions in which they were placed till they were changed by a voluntary movement of the limb. After the paroxysm she had lost all recollection of what had passed. The other case given by Lorry was that of a female who had deficient catamenia. During her paroxysms she used to address herself to some individual actually present, whom she evidently saw, while all that she said to him turned upon the subject of her reverie. In the mean time she appeared unconscious of the presence of others, and could not be made to hear them or perceive them. " This fact," says Lorry, " I witnessed with the utmost astonishment, but many other persons are living who can attest it The mother of this female died unexpectedly; after which the daughter used to hold conversa- tions with her as if she were present." A remarkable circumstance in these cases is the fact that while the individual is insensible to all other impressions in a wonderful degree, he re- tains perception of all objects which fall in with the course of his ideas, or connect themselves with the thoughts and feelings which occupy his atten- tion for the time being. This feature is common to the cases of ecstasis and somnambulism. It was observed in an example of the former kind, of which an account was published several years ago by the writer of this article. A boy, about thirteen or fourteen years of age, suddenly ex- claimed that somebody was beating him on his head, and fell into a state of insensibility; he be- came subject afterwards to similar attacks. He first perceived a mist or darkness before his eyes, and would say that he was then going off. He became then unconscious of external impressions; had his eyes open, but did not perceive objects; ■used to hold conversations with absent persons, repeat his lessons, supposing himself to be at * Histoirede l'Academie des Sciences, an. 1742. Traite even °f greater thickness. -, T I ^n acousUc instruments, we avail ourselves of STERILITY, (see Impotence.) I the conducting power of similar bodies, and the STETHOSCOPE, from oTrjOos, pectus, and reflecting quality of dissimilar substances, to direct ukovIui, exploro, contemplor,) is the name of an sound into any particular channel. It is with instrument invented by the late M. Laennec, to regard to these principles, in the first place, and assist the ear in examining the acoustic signs of with a certain respect to portability and conve- various diseases, especially of those of the chest. nience, that the best stethoscopes are constructed. The use and indications of the stethoscope have As the sounds which they have to transmit to the been so fully explained in the article Ausculta- ear are various in origin and intensity, so these Tiox.that it remains for us here only to study the instruments have modifications in their make, stethoscope as an instrument, and the physical which, with a view to avoid the multiplication of principles of its adaptation to the object to which apparatus, were contrived by Laennec in a single it is applied. When we bring to the aid of our | instrument of convenient portability. Thus to senses artificial instruments, we can neither perfect j convey the sounds originating in the denser con- their construction nor fully avail ourselves of their tents of the chest, such as the heart, a cylinder uses, without a knowledge of the laws by which | of light but rigid wood, as free as possible from they assist our organs. No one can satisfactorily knots and inequalities, answers perfectly. To use the microscope or telescope without under- : transmit the sounds produced in the more aerial standing the laws of optics; and we hold that the ' contents of the chest, this cylinder is perforated easiest, the most agreeable, and the surest road to longitudinally, so as to contain a column of air, a knowledge of stethoscopic phenomena, is through which being perfectly closed from external com- a study of acoustics. It was by a happy applica- munication by the ear at one end, and the chest tion of a general law that Laennec was led to the of the patient at the other, readily conducts the discovery of this instrument, and he never could sounds of the voice, or of the respiration, pro- have enriched his description of its use with such duced in the spot which the aperture covers. To a number of interesting and valuable facts, if his ', concentrate the diffused sound of respiration, and experience had not been guided by a familiar I--------------------- knowledge of natural philosophy. | * Many other illustrations might be adduced; and we The first instrument used by Laennec was ' ^'irnV^mhni'^H1'^ "for esP'™»'ion °f/h,i Pri£- /• , r iL . c J ., „ , ci pie of sounding-boards of musical instruments is to be formed of three quires of paper, compactly rolled ; found in the same law. 238 STETHOSCOPE, to expedite the examination by making the ste- thoscope take in as large an extent of surface at a time as possible, the cylinder is hollowed out at the pectoral end into a conical cavity, the apex of which terminates in the central canal; so that all the sounds that enter the excavated end are re- flected through this canal into the ear. To re- convert this into a simply perforated cylinder for the uses before mentioned, a perforated plug or stopper is adapted, of size and form exactly filling the conical excavation. The instrument last re- commended by Laennec was a cylinder of walnut, a foot long and an inch and a half in diameter, with the longitudinal perforation three lines in diameter, and the excavation and stopper of a parabolic form, with a metallic tube to fix the lat- ter into the central bore. For the sake of porta- bility, and to render it applicable in a shorter form, the instrument is divided in the middle, with an excavation into which the stopper can be fitted as at the other end. We have found rea- sons, in both principle and practice, to prefer a conical to a parabolic cavity; and we would re- commend, as the best and most easily used ste- thoscope, a cylinder of cedar nine inches long, of the diameter and bore prescribed by Laennec, with a conical excavation tapering at least an inch and three quarters, so that its sides do not subtend an angle of more than twenty-five degrees. The stopper must be made to fill this cavity completely, and it may be held in it either by a flute-joint at the base of the cone, or by a thin ivory or horn tube projecting an inch from the apex of the stopper and fitting into the central bore. The flute-joint is in principle the best of these, but as it is with difficulty made accurately, and from its requiring ivory or ebony ferules, is liable to get out of repair, the tube may be preferred. The general excellence of this instrument will depend on the smoothness and true turning of the inte- rior, and the perfect adaptation of the stopper to the cavity; but to be fully available to the auscul- tator, the auricular end should be made wide or narrow, flat or concave, to fit comfortably to his ear. Generally it will be found useful to make this end slightly concave, and somewhat wider, by a ferule of ivory or ebony, than the general diameter of the instrument, or this width may be formed in the wood itself. A beginner should not choose a stethoscope hastily, but when one is found exactly to fit the ear, a more perfect tact will be acquired by keeping to the same instru- ment than by using a variety. [Almost any of the stethoscopes, offered for sale, will answer the purpose of the ausculta- tor, provided, that the ear part can be easily adapted to the ear. It is proper, however, to ob- serve, that the writer has found those which are wholly conical, or which, in other words, consist of the funnel part only, the least satisfactory, in consequence of the confusion of sounds, re- sembling, in some measure, those that are heard when a hollow shell is applied to the ear. The instrument should always have, in addition to the funnel-shaped portion, space enough for an inch or two of tube which is perfectly cylindrical, in order that, by the concentration of vibrations, this source of inconvenience may be obviated. The length of the original instrument of Laennec ren- dered it inconvenient of application in many cases; and it was by no means easy to place the end of the instrument entirely flat on the chest, whilst the other was in apposition with the ear. Hence, the writer has, for years, used an instrument, which, like that of Dr. Billing, (Principles of Medicine, Amer. edit. p. 15. Philad. 1842,) is merely Laennec's abridged. It is about four inches long. At the meeting of the British Association at Manchester, in 1842, Dr. Williams presented a communication on the construction and applica- tion of instruments used in auscultation. (Lond. Med. Gazette, Dec. 16, 1842 : or Braithwaite's Retrospect, vol. ii. Lond. 1843.) In this he states, that finding the considerable share which the solid walls of stethoscopes have in communi- cating sounds, and from experiment, that their efficacy depends chiefly on the formation of the pectoral end, by which they receive the vibrations, he had devised a form of instrument which quali- fies them better, he thinks, for this purpose than any now in use. This consists in a bugle or trumpet end, the edges of which being made very thin, and applied flat on the walls of the chest, are most readily affected by their vibrations. An instrument thus constructed of a light rigid wood, | such as sycamore, and tried with a test sound, , will be found, according to Dr. Williams, superior for most purposes to the stethoscope hitherto used.] I For further information on the construction of [ the stethoscope, assisted by diagrams, see the writer's " Rational Exposition of Physical Signs," j &c. second edition, 1833, pp. 52 and 184. [Amer. I edit. Philad. 1830.] After trying many artificers, we have at last succeeded in finding one who makes stethoscopes with nicety ; and to those who want a good instrument, we can, therefore, recommend Grumbridge, turner, 42, Poland-street, Oxford-street Our limits do not permit us to describe other forms of stethoscopes that are to be met with. In all those which we have seen, acoustic rules are sacrificed to portability or ele- gance. That of M. Piorry, which is commonly used, is faulty in having the conducting power of the wood impeded by screws and a thick cap of ivory ; besides which, the excavated end is gene- rally very ill fitted. Although, when unscrewed, more portable than the other instrument, the trou- ble of screwing and unscrewing the several parts is enough to counterbalance this advantage. Our friend Dr. Stroud uses a caoutchouc tube, with an ivory funnel attached, like the flexible hearing trumpet. The flexibility of this instrument is certainly an advantage, but it is obtained at a great sacrifice of intensity and distinctness of the sounds, in consequence of the imperfect and ir- j regular reflecting power of the interior of the | tube. This flexible stethoscope separates the sound from the impulse of the heart more com- I pletely than any other. [The author has frequently used the flexible stethoscope, but he greatly prefers the ordinary j instrument where the sounds require acuteness of i hearing. Dr. Williams has lately affirmed, that when tried by a test sound he has found it much inferior in conducting power for all the more deli- [ cate sounds of the breath and heart. Louder STETHOSCOPE —STIMULANTS. 239 sounds, he adds, such as those of bronchial or nance of the voice under the clavicles, beneath the cavernous breath, and voice sounds, it exaggerates scapula? and in the axilla?, and the morbid reso- by the addition of a conchal echo, which renders nance which an induration of the tissue of the it very difficult to distinguish them from each lung produces in parts immediately adjoining other. This objection has not, however, impressed these regions. The stethoscope, with the stopper, the writer.] I not unfrequently discovers a sound to be merely a Although, for general purposes, the common ste- natural resonance, which, to the open instrument, thoscope fulfils sufficiently well its triple office, it or to the naked ear, has the character of morbid might be well for the attainment of greater accu- ; bronchophony ; and the variations in the form of racy in physical diagnosis, if auscultators in hos-! the instrument furnish a means of distinction be- pitals would use separate instruments for the three ( tween the degrees of pectoriloquy more accurate classes of signs. 1. A solid cylinder of wood for! than can be obtained by the ear alone. (See the auscultation of the heart. 2. A metallic tube, ] Auscultation.) The capability of the stetho- half an inch in diameter, furnished with a wooden ' scope to separate the sound from the impulse of or ivory ferule at the pectoral, and an ear-piece at the heart, and the facility with which it can be the other end, for the investigation of the respira- ■ applied to the infra-clavicular and axillary regions, tion and vocal resonance of small spots. 3. A and to the examination of the sounds in the caro- metallic tube, like the last, but with its pectoral tid arteries and abdominal aorta, which are not end expanded into a tapering cone, for the same within convenient reach of the unassisted ear, are purposes as the stethoscope without the stopper.' further and important advantages of mediate aus- After a little practice, we have little doubt that cultation. In concltsion, we would express our these instruments would be more powerful aids conviction that although, with a view to expedi- than the common stethoscope, but we do not pre- ' tion and convenience, immediate auscultation may tend to recommend them for general adoption.' be occasionally substituted, no one who has once [See, farther, on the construction and application '. thoroughly trained his ear to the use of the stetho- of instruments, Dr. Williams in op. cit.] j scope will ever so lightly esteem its aid as again Before we conclude this article, we would say a to abandon it. P1 T R W t t i few words on the advantages of mediate ausculta- WILLIAMS. tion, and on the necessity of the stethoscope to j STIMULANTS, (from stimulare, to prick, to those who wish to avail themselves fully of physi-' goad,) Excitants, are medicines which augment cal diagnosis in general practice. After what has the functions peculiar to the different organs of been said by Laennec and others on this point, we the body, by a primary impulse on the sensibility should have hardly deemed it necessary to mention and irritability of the part to which they are ap- it here, were it not that several writers, otherwise plied, extended to the whole system of the nerves. advocates of auscultation, have spoken slightingly Every medicine, indeed, which communicates mo- of the stethoscope. Could the naked ear be in all bility, or increased action, to any organ, may, in cases applied to the chest of a patient, the utility strict language, be regarded as a stimulant; con- of the stethoscope might be more reasonably ques-' sequently, expectorants, emetics, cathartics, diu- tioned. But it cannot be denied that immediate retics, emmenagogues, diaphoretics, and epispas- auscultation is in many circumstances impractica-: tics, are all stimulants ; but their influence is chiefly ble,—in some cases being indelicate, in others dis- exerted on particular organs, whilst stimulants, gusting, and in infectious disorders unsafe,—while exclusively so called, are substances which excite these objections are not applicable to the use of j the entire system. the stethoscope. Further, if it be said, restrict the j All substances that operate as stimulants pro- use of the cylinder to these cases, we reply, that' duce some effects in common. When adminis- unless we have more practice with it than can be ' tered in small doses, their influence is scarcely per- obtained in these only, the stethoscope would be' ceptible; they cause no obvious change in the comparatively useless in our hands ; for its indi- j condition of the organ into whichsthey are receiv- cations, although decidedly more accurate than J ed ; but, nevertheless, their impression on the those of the unaided ear, unquestionably require nerves of the part is communicated to the brain more practice to obtain them. j and spinal cord, the nervous energy is exalted, and But there are other circumstances which give their excitant property becomes evident in the in- to mediate auscultation a claim to preference. The creased action of the pulse. When administered unaided ear, although capable of perceiving very in larger doses, they first impart a sensation of delicately the sounds produced under the surface' warmth or acrimony to the organs of taste ; this to which it is applied, cannot isolate any particu-' is extended to the stomach ; and the particles of lar spot; and the sounds transmitted by the parts the substance being carried into the blood, the im- adjoining the ear, the temporal zygoma, the mas- pression on the nervous system is not only greatly toid protuberances, &c, as well as the adventitious augmented, but, every organized tissue sharing the noises liable to be produced by the friction of the j impression, all the functions are exalted, and the hair of the head and face, are frequently mixed ' whole system becomes prcternaturally excited. In with and confuse the signs from the spot under still larger doses, their effects assume the charac- examination. On the other hand, with the stetho- j teristics of disease. Besides producing such im- scope, we can isolate any particular point; and, pressions on the vital energies, almost all stimu- by tracing the sounds to their real position in the lants possess some sensible properties in common. organs within, we can accurately determine their] These impart, as already stated, a warm and acrid value as signs. This faculty is, in some cases, of great importance. It is only by its means that we can discern the limits between a natural reso- impression to the organs of taste; awaken the sensation of smelling in the olfactory organ; arid, when applied to the surface, augment the sensi- 240 STIMULANTS. bility and the temperature of the part, and cause a greater flow of blood into its vessels than is con- sonant with their natural condition. The quali- ties producing these effects are regarded by several writers on Materia Medica as constituting the essential properties of every stimulant; but they are those chiefly found in stimulants obtained from the organic kingdom of nature, and belonging to that class of vegetable bodies termed aromatics, in which it is probable that the exciting agent is volatile oil. It must nevertheless be admitted, that there are even vegetable stimulants in which no volatile oil can be detected; but these furnish a principle analogous in its effects to volatile oil There are stimulants which have neither taste nor odour ; as, for instance, caloric and electricity, as well as those of a mental description, such as the exciting passions ; but, whatever may be the na- ture of the stimulant, the impulse communicated to the system differs rather in degree than in kind. In one respect, however, inorganic are particularly distinguished from organic stimulants ; they have no principle in common to which their excitant influence can be referred. Four changes in the condition of the body are obvious, on the administration of stimulants: — 1. a greater than usual susceptibility of impression in the nerves; 2. an increase of action in the moving fibres; 3. an acceleration of the beat, and an augmentation of the force of the pulse ; 4. an elevated degree of the temperature of the body. These effects are displayed chiefly on the cuticular organ, and in the organs of digestion, circulation, respiration, and secretion, as well as on the cerebro- spinal centres; and if we examine any of the organic tissues during the operation of stimulants, we find that they are redder, hotter, and more sensi- tive than in the ordinary state of the habit. These appearances do not always depend either on the nature of the stimulant, or on the extent of the dose, but very frequently on the state of the body of the patient. Something, also, is due to the manner in which the stimulant is administered, whether simple or uncombined, or in a state of combination. Stimulants differ greatly in the rapidity with which their effects are produced, some acting almost instantaneously, others requiring time to display their influence ; and this difference does not depend on the nature of the part to which they are applied. In general, the degree of power is in the ratio of the rapidity of their action ; and the permanency of the impression is more or less connected with the same circumstance. The operation, also, of all stimulants is followed by symptoms of collapse; and this result, in an espe- cial manner, distinguishes them from tonics, and at the same time renders it extremely difficult to separate them from narcotics, which at first increase action, but soon afterwards exhaust both sensibility and irritability. To illustrate this effect of stimu- lants, it is requisite to have a clear conception of the nature of excitement and collapse,- terms that are evidently relative to some standard or point which, in the healthy system, can be considered as neither. With respect to excitement, "if," says Dr. Cullen, " we take the lowest, every higher degree than that must be called a degree of excitement; and if we take the highest degree, and consider the lower degrees which may take place while life still subsists, every lower may be called a degree of collapse." (Materia Medica.) In the opinion of the author of this article, excitement implies every condition of the nervous system in which the energy of the brain is greater than that which, in the waking state of a healthy man, is exactly adequate for the performance of the ordi- nary functions of the system; collapse, that condition in which the cerebral energy is so much diminish- ed as to suspend the exercise of the functions of sensation and volition,—a state of defective activity of the brain, similar to that which causes sleep, only in an augmented degree. The function of the brain cannot be carried on without a sufficient supply of blood, which is essential for its support and continuance: a greater increase of the momen- tum than usual produces excitement; a diminish- ed afflux, within certain limits, or an exhaustion of energy from previous over-excitement, is produc- tive of collapse. In some instances there is much difficulty in distinguishing these states. Let us now examine the effects of excitement on the different organs on which this class of medicines chiefly displays its influence. 1. On the digestive organs stimulants exert a primary action: a sensation of heat is experienced which is immediately referred to the stomach. The liver, the pancreas, the brain, and the spinal cord sympathetically share this local excitement: but the chief effect is felt in the stomach, the mucous membrane of which, could it be seen, would be found redder than natural, and more sensitive ; whilst the capacity of the organ is di- minished, owing to the contraction of its muscu- lar coat. If the stomach be empty, a sensation of hunger is experienced ; if the excitant be min- gled with the food, the process of chymification is hastened; and this also is the case, if food be taken soon after a stimulant has been swallowed. This excitement, commenced in the stomach, is extended through the whole alimentary canal. The effect of a stimulant on the prima? via? is always in the ratio of the dose; small doses merely augment the energy of the digestive faculty; large doses, on the contrary, impair this, awaken a sensation of heat, thirst, and uneasiness in the gas- tric region, and suspend or render inefficient the action of the stomach; causing nausea and some- I times vomiting. But although these effects are the result of a very large dose even of a salutary excitant, yet the impulse which it communicates to the rest of the system is not always commen- surate to the impression thus made upon the sto- mach ; and many substances that display scarcely any obvious influence on that viscus, operate powerfully on the general habit. But if they j quickly pass the pylorus without acting on the stomach, then their influence on the general sys- i tern is less than when their impression is pre- | viously made on that organ. We must search for the cause of this in the function of the intes- tinal canal, and the nature of the stimulants which i thus operate. The natural effect of the action of i a stimulant on the intestinal canal is to increase its peristaltic and vernicular motion; thence the stimulant is carried forward, and it continues its impulse in its progress; yet this is too transitory STIMULANTS. 241 to be very influential. With regard to the nature of the stimulants which thus operate, the active principle is often so sheathed in other matters, that the digestive process is not able to evolve it until it pass out of the stomach. Some stimu- lants, also, of an organic nature exert little influ- ence on the general habit until they are taken into the circulation; they may, therefore, be said to communicate their impulse directly to the heart and arteries, independent of any primary impres- sion on the stomach. The primary influence of stimulants on the digestive organs is, also, greatly modified by the condition of the stomach. If this be relaxed and thin, excitants appear to exert little action upon it; but small as the impression may be, the effect is salutary, the appetite is improved, and chymifi- cation proceeds with more regularity. If the capacity of the organ be considerable, and its pa- rietes thick, stimulants produce a powerful impres- sion on it: hunger is more urgent, the appetite is rendered voracious, and chymification accelerated. When the stomach is in an irritable state, every im- pression produced by an excitant is increased ; the patient suffers from anxiety, hot eructations, tight- ness across the epigastric region, and a general uneasiness, which is referred to the viscus. If ulceration or open cancer exist there, all these symptoms, accompanied by acute pain and a burning sensation at the epigastrium, are experi- enced in an augmented degree. If no organic lesions are present in the organ, but the gastric nerves are in an asthenic condition, owing to soft- ening or some similar affection of the brain or the spinal cord, then the impression of the most active stimulants is scarcely felt in the stomach ; but should the nervous centres be suffering from irri- tation, in that case the stomach shares in their morbid susceptibility, and even the slightest exci- tant produces a serious effect on it Something, also, depends on the state of the neighbouring organs, the morbid condition of which is more or less extended to the stomach, and consequently modifies the operation of stimulants received into it. On the other hand, the neighbouring organs, being more or less affected by contiguity when any excitant is taken into the stomach, have their secerning functions increased; but, at the same time, in making this statement, we must admit that this effect is not confined to the action of ex- citants on the stomach; for in whatever manner or on whatever part the impulse is first impressed, it is rapidly communicated to the neighbouring organs, and progressively to the rest of the system. 2. The influence of stimulants on the circu- lating and respiratory organ is a secondary effect of their impression on the stomach; thus when a stimulant is swallowed, it renders the pulse both quicker and stronger than before; and this excitement is extended even to the capillaries. Red blood is propelled into vessels not accustomed to receive it, and the skin appears, as it were, suf- fused with a blush ; its temperature is elevated, and either sweating is induced, or the action of the kidneys or that of the uterus is augmented ; or, if the dose of the stimulant be considerable, the brain feels its impulse, and restlessness, watch- fulness, and cephalalgia supervene. These effects are undoubtedly owing, in a considerable degree, Vol. IV. —31 v to the absorption of the excitant, or rather of its active principle, and to the impulse which it directly communicates to the coats of the vessels: they are necessarily proportionate to the dose and the nature of the excitant; but other circum- stances, in some degree, also modify them. Thus on persons of a sanguine temperament stimulants act with more energy, as far as concerns the cir- culating system, than on those of an opposite frame of body, in whom their influence upon the heart and arteries is often scarcely perceptible. Indeed, there is no doubt that the circulating or- gans are more or less susceptible in different indi- viduals, and, consequently, the variety of effects produced by the same stimulant substances, ad- ministered in the same doses and in the same manner, to different persons, are readily explained. One set of excitants, namely, the mental, display their influence in a striking manner on the circu- lation ; thus blushing, palpitation of the heart, and that sensation of a glow of warmth over- spreading the chest which often attends highly agreeable and pleasurable feelings, are merely the effects of the stimulant influence of these mental affections on the circulation. As in the case of the digestive organs, morbid conditions of the vascular system necessarily modify the action of stimulants on this part of the body. Thus, in hypertrophy of the heart, every impulse of an excitant, however slight, increases the movements of that organ ; both the momentum and the frequency of the pulse are augmented, the surface is reddened, and hemorrhages not unfre- quently follow. When the hypertrophy is chiefly confined to the left ventricle, the administration of excitants is often accompanied with singing in the ears, weight of the head, epistaxis, and other symptoms of congestion of the vessels of the en- cephalon ; and thence apoplexy is not an unfre- quent attendant of free living in persons labouring- under this affection of the heart. On the con- trary, if the right ventricle be the part affected,. the influence of stimulants is chiefly displayed on- the pulmonary circulation. In febrile states of the' habit, in which the cir- culation is rapid, and the animal temperature greatly elevated, stimulants precipitate still more this increased action, and exasperate every symp- tom which constitutes the disease. 3. That stimulants affect the respiratory system is evident ; indeed, the natural conse- quence of an accelerated action of the heart and arteries is an increase in the movements of the thorax. The result of a greater number of inspi- rations and expirations, occurring in a given time, is a more rapid change than ordinary in the blood circulated through the pulmonary vessels; it is exposed more frequently to the action of the air, becomes more arterialized, and displays a more vivid redness when drawn from the arm than is customary. If stimulants be administered during febrile states, this condition of the pulmonary sys- tem is augmented ; and the air expired from the lungs seems almost burning hot. If the mucous membrane of the bronchial tubes and cells be inflamed, stimulants oppress the breathing, and excite a dry cough ; and if the inflammation ex- tend either to the pulmonary tissue or affect the pleura, the consequences of their administration 242 STIMULANTS. are almost immediate ; the cough becomes hard, | excites violent pain, and the expectoration ceases. | This influence of stimulants on the pulmonary organ points out the advantages to be derived from their employment in those states of the chest in which the bronchial tubes are choked with mu- cus, and the debilitated state of the frame renders it impossible to clear them by the effort of cough- ing: in truth, expectoration is merely the effect. of the influence of an excitant on the lungs in a state of disease. 4. With respect to the influence of stimulants on tlic secerning system, we have already stated that an excitant taken into the stomach in- creases the action of the capillaries, and rouses the activity of both the secreting and the exhalant organs. This, however, never occurs until the excitant is carried into the circulation, and is im- mediately applied to the glands. It is difficult to trace the causes of the apparent selection which occurs: one set of excitants, for instance, aug- menting the secretion of the kidneys, another that of the salivary glands; a third the elaboration of bile in the liver, and a fourth the cutaneous exha- lation ; but every day's experience demonstrates the fact. The skin, in particular, is highly sus- ceptible of the impression of stimulants taken into the blood ; the capillaries act with redoubled vi- gour ; and diaphoresis quickly follows. It is only, however, within a certain limit of excitement, one considerably short of inflammatory action, that these effects follow; when the stimulant is too powerful, secretion is impeded; thence we find that some volatile oils, when taken in a large dose, if they do not immediately operate as purgatives, cause most distressing effects on the urinary or- gans. As it is also unquestionable that to a cer- tain extent the natural conformation of an organ modifies the action of stimulants upon it, so if the skin be thick, firm, and well nourished, a sudorific effect is readily obtained ; whereas this is slowly induced, and the secretion itself is imperfect, when it is thin, soft, and pallid. The condition of organs also, when altered by disease, modifies greatly the action of this class of medicines; and this is par- ticularly true with respect to the skin and the kid- neys. In febrile affections attended with cutane- ous eruptions, exciting medicines, instead of pro- ducing diaphoresis, augment the tension and the heat of the surface ; and, in the same state of the habit, the kidneys become morbidly irritable, and their secreting function is suspended; if stimu- lants be now administered, the irritation is aug- mented, and the organs are occasionally attacked with inflammation. On the contrary, when the kidneys are in a state of atony or paralysis from affections of the brain or spinal cord, and their secreting powers languish, then stimulants tend to re-establish the function of the organs, and the flow of the urine is more or less abundant, accord- ing to the supply of fluid received into the sto- mach. 5. In reference to the Nervous System, it is well known that no exciting substance, in a suffi- cient dose, can be taken into the stomach without primarily exciting the nerves of the viscus, after which the impulses thus received are rapidly trans- mitted to the rest of the frame, developing vital energy in the various organic centres to which the nerves relate. It is true that we cannot explain this power of transmitting impressions inherent in the nerves; and we must acknowledge that an acquaintance, however intimate, with the structure of the nervous tissue affords us no information. On the brain itself the influence of stimulants is obviously manifested by the perceptions becom- ing more vivid, the imagination more prolific with ideas, and those of a more brilliant and exalted character than usual. Indeed it cannot be denied that the employment of stimulating substances, within a moderate limit, is often followed by tho happiest inspirations, and the most delightful sen- sations ; but it is, also, well known that this ex- citation of the mental faculties, when stimulants a.e taken in the evening, is productive of agitated and sleepless nights ; thence the medicines belong- ing to this class were denominated exhilarants by the ancients; and, even in the present day, pow- ders, electuaries, and aromatic spirits composed of stimulating ingredients, are administered to dissi- pate melancholy and renovate the spirits. An- other proof of the influence of excitants on the cerebral functions, is the awakening of memory : many events and circumstances effaced from recol- lection ; verses, anecdotes, and facts long forgotten, again present themselves to the mind when under the operation of excitants. Even circumstances which occurred in a state of high excitation, and which were completely forgotten in the interval, are again remembered on the recurrence of the same state. A curious illustration of this fact is recorded by Mr. Combe. A porter, who when drunk left a parcel at a wrong door, on becoming sober could not recollect at what house he had left it; but the next time he got drunk, he at once called to mind the house, and went and recovered the parcel. In the state of inebriety, however, the influence of stimulants on the brain is more gene- rally manifested by vertigo, temporary delirium, and a change of perception, than by a restoration of memory. Whether the cerebellum be affected by excitants in the same manner as the brain, is uncertain; but there is no doubt that many stimulants affect, in a special manner, the medulla spinalis : the susceptibility of the sensitive nerves of the skin is increased, the respiration is quickened, and the muscular system displays an unusual aptitude for action. It is necessary here to remark that, al- though this power of augmenting the general sen- sibility of the body is common to all excitants, yet it is possessed in a higher degree by some than by others. Upon the whole, however, we may con- clude that the influence of stimulants is more or less evidenced on every part of the nervous sys- tem, by the greater susceptibility than usual to impressions on every part of the body, and by a higher degree of intellectual energy, displayed not only in the acuteness of perception, but in the facility of comparing, separating, and arranging our ideas. These phenomena, it must be admit- ted, are not always sequences of the administra- I tion of the same stimulants, neither in intensity, nor at different epochs, in the same individuals,— results which can only be referred to altered con- ditions of the organs receiving and transmitting the impressions ; and thence we are authorized in asserting the influence of the condition of the STIMULANTS. 243 nervous system in modifying the action of stimu- lants,—a fact of great practical importance. It is difficult to trace the alterations in the nervous tissue which produce these modifications; and we even hesitate in according with the opinion that a less natural susceptibility of impression is to be attributed to a defective development of the vol- ume of the nervous centres ; neither can we admit that an unusual bulk of brain and enlargement of the nervous fibrils are likely to produce a higher degree of excitement on the administration of stimulants. It must, however, be admitted that the changes on the nervous system produced by disease modify, in the most striking manner, the action of stimulants. In an irritable state of the brain, manifested by general morbid susceptibility, tremours, and agita- tions, with irregular muscular contractions, deli- rium, and maniacal hallucinations, or great mental exaltation, the administration of stimulants either exasperates these symptoms, or, producing san- guinous congestions, causes a new train of symp- toms equally unfavourable. If one portion only of the cerebral pulp or of the meninges be affected, the perturbation is confined to one or a few only of the senses; or if convulsions occur, they are limited to some particular muscles. Stimulants in such cases often induce epilepsy, or, if the patient be already subject to its attacks, augment the violence of the paroxysms ; and the same occurs when the spinal cord or its theca is the subject of irritation. If the excess of stimulus be always hurtful, in a moderate degree it is salutary; and, conse- quently, we are in the daily habit of employing excitants mixed with our food, and rely on their salutary influence, under certain circumstances, as remedial agents. With regard to the state of the body in which they are useful as remedies, we may advance the following as a general principle, —namely, that it is that state in which powerful and sudden impressions on the system are re- quired ; in which the functions of the brain and the nervous energy are diminished, and in which the impulse of the blood on the brain, necessary for its healthful action, is defective—in truth, one of direct debility of the brain. That this condi- tion of the brain depends on a deficient impetus of blood to that organ, may be inferred from the fact that a state closely resembling it is induced by pressure on the carotids; but, when this im- petus is excessive, so as to produce convulsions, these are subdued by whatever diminishes the action of the heart — for instance, bloodletting. They have also been stopped by compression on one or both carotids. The renewal of impulse, when it is absent or defective, is to be obtained by increasing the general momentum of the blood ; an effect most rapidly induced by the application of stimulants either to the nerves of the stomach, or those of the Schneiderian membrane, or of other parts in which their influence can be di- rectly impressed. Some objections may be raised against the explanation of the mode in which the increased momentum is produced, by those who contend that the brain exerts very little power over the action of the heart and arteries ; but when we reflect upon the influence which passions exert over the heart during perfect health—when we consider the magnitude of the cardiac nerves, and the sympathy that exists between the heart and other organs in relation to its momentum, we shall not hesitate to admit that excitants, operating on the blood-vessels, produce their effects chiefly through the medium of the nervous system. With respect to the nature of the substances operating as stimulants, it is necessary to remark that their distinction from tonics is not solely in degree, but also in the character of their effects. Thus stimulants augment the mobility of the sys- tem, tonics the strength of the muscles; stimu- lants exhaust the excitability, tonics, within a certain limit, maintain it; the action of stimulants is immediate, powerful, and transitory, that of tonics slow, almost imperceptible, progressive, and permanent. The necessity, therefore, for separa- ting these two classes of medicines must be obvious. Stimulants may be arranged under three distinct heads : organic products, inorganic substances, and mental affections. 1. The most important of the organic products employed as stimulants is undoubtedly volatile oil, whether in its uncombined state, or as separated from the plants containing it, or as it exists in combination with other principles in the roots, wood, barks, flowers, fruits, and seeds of many vegetables. The uncombined volatile oils are chiefly obtained from plants belonging to the natural orders Umbellifera?, Myrtacea?, Aurantiacea?, Ru- tacea?, and Labiata?. Those procured from the umbelliferous plants, namely, the oils of caraway, anise, dill, fennel, and carrot, are secreted in the seeds of the plants, and deposited in small cells or vittx in these organs. The melaleuca cajuputi, one of the Myrtacea?, which yields the cajuputi oil, contains it in the leaves ; whilst in those well- known members of the natural order Aurantiacea?, the citrus aurantium and citrus medica, the un- combined oil which they yield is found in the cells of the rind of their fruits. It is the product of the flowers of lavandula spicu, and rosmarinus officinalis,- and of the whole plant of ruta graveo- j lens, and the following Labiata?, namely, mentha I piperita, mentha viridis, mentha pulegium, and origanum vulgare. From all of these plants it is procured by distillation with water, the oil and the watery vapour passing over together and after- wards separating, and the oil either collecting on the surface or settling at the bottom, according as its density is less than or exceeds that of the water. This is not the place to enter into the considera- tion of the chemical properties of these oils ; it is only necessary to remark that, although they are all insoluble in water, yet they are readily rendered soluble by combining them with sugar, or as an oleosaccharum, and they may thus be prescribed in conjunction with aqueous fluids. All these uncombined volatile oils operate at first as direct stimulants on the tissue with which they are in contact, whether introduced into the sto-. mach or applied to the surface of the body ; but their influence is soon extended over the body, both by nervous sympathy and by absorption into the circulation, and they can be generally detected in one or more of the secretions. When the dose of the oil is moderate, and its acrimony sheathed 244 STIMULANTS. with mucilage or other demulcents before being swallowed, the stimulus proves salutary; the di- gestive function is promoted, the action of the heart and arteries is moderately augmented, and the secreting faculty both of the skin and the kid- neys favoured. Although they are all more or less general excitants, yet the volatile oils are indi- vidually determined to particular parts of the sys- tem, and display their influence specially upon distinct organs : thus, whilst the oil of anise ope- rates as a sudorific, that of dill produces an anti- spasmodic effect. But in whatever manner they operate, the volatile oils are too violent in their action to be administered in the simple form, or uncombined with some material which can ob- tund or sheath their acrimony. The best form for internal administration is that of an oleo-sac- charum dissolved in any aqueous infusion or decoction. Externally, volatile oils operate as counter-irritants, and relieve deep-seated inflam- mation ; whilst in cases, such as tooth-ach, in which they can be directly applied to the part, they exhaust the nervous excitability and thus allay pain. Many vegetable stimulants owe their efficacy to volatile oil, although it cannot be readily separated from their other components. Thus we find it in the roots of the Asistolochia serpentaria, in com- bination with a bitter principle, gum and resin ; in the rhizomes of the Acorus calamus, ginger and turmeric, Curcuma tonga with fecula ; in the wood of sassafras, and the barks of Drymis Win- teri and cinnamon, with tannin and gallic acid; and in that of Canella alba with fecula; in saffron, the stigmata of Crocus sativus, with a peculiar colouring matter which chemists have named poly- chroitc; in the clove, allspice, laurel-berries, the cardamom and the nutmeg, chiefly with fecula, tannin, and gum ; and in the cubeb, the fruit of Piper cubeba, with resin, gum, and extractive. In all these the volatile oil is the efficient principle. It is separated by the digestive function of the sto- mach when these medicines are given in substance, and is afterwards taken into the circulation : thence its primary influence is exerted on the coats of the stomach and intestinal canal to which it is applied, its secondary on the capillary system, and the cerebral and rachidien centres. When the action is intended to be confined to the diges- tive organs, either uncombined volatile, oil, as an oleo-saccharum, or those substances containing it in combination with tannin and the bitter princi- ple,—namely, the roots and barks above enume- rated,—should be selected. When the stomach is suffering under that chronic debility which is characterized by sickness and occasional vomiting, and in all cases of deficient action of that organ, particularly when it is accompanied with cardial- gia and flatulence, these aromatic stimulants are indicated. It is, however, important to discrimi- nate that pain which is the result of spasm, and that arising from inflammatory action, in dyspeptic affections ; and even when the disease is grafted upon a hypochondriacal condition of the habit, the uncombined volatile oils should not be employed. In affections, also, of the intestinal canal, when no inflammation is suspected, as, for example, flatu- lent colic and cholera and atonic gout attacking the stomach, the warmest of the uncombined vola- tile oils may be prescribed, even during the utmost violence of the pain. In Asiatic cholera these oils have been strongly recommended, but the patho- logy of the disease is still too obscure to enable us to decide on the propriety of their employment, although in general atony of the bowels, produc- ing either obstinate constipation or passive diar- rhoea, the addition of aromatics, more especially the uncombined oils, in conjunction with purga- tives in the one case and astringents in the other, by rousing the nervous energy, is productive of the best effects. In the administration, however, of these agents in gastric and intestinal disease, it is of importance to ascertain the exact condition of the abdominal viscera, and most particularly that of the whole mucous membrane of the ali- mentary canal. We should be satisfied that no ulcerations, nor scirrhous or cancerous tendency exist in any portion of the canal; and if vomiting or gripings be present, that these are not sympto- matic of cerebral congestion or irritations of the encephalon or of the spinal cord; and at the same time the state of the liver, the pancreas, and the spleen must be carefully investigated. Much caution is also requisite, in prescribing any of the aromatics, when the tongue displays that red and glazed state which denotes subacute inflammation of the mucous membrane of the stomach,—a not unfrequent cause of dyspepsia. In looking at the peculiar determination to dis- tinct organs produced by some of the combined oils, we are enabled to select the substances con- taining them for the relief of particular symptoms, when the general state of the habit does not con- tra-indicate the employment of stimulants. Thus, in those dyspeptic affections in which the circula- tion is languid with a dry harsh skin; or in cases of remittent and malignant fever, when the powers of life sink and the skin is hot and dry; or in pustular eruptive fevers, when the eruption sud- denly recedes ; or in protracted intermittents, espe- cially when these are combined with cough; the serpentaria root is better calculated to fulfil the intentions of the physician than any other of this class of stimulants. If the surface be kept warm, it rarely fails to excite the action of the cutaneous capillaries; and while it promotes diaphoresis, it supports and supplies energy to the general system. In such cases the best form of administering the medicine is tincture, as proof spirit takes up both its volatile oil and bitter extractive. On the same principle the volatile oil of cubebs is determined to the kidneys, and probably produces its beneficial influence in gonorrhoea both by stimulating the kidneys and augmenting its secretion, and act- ing directly on the urethra during the excretion of the urine; thus overcoming the disease by setting up a new action in the affected part. When this action on the urinary organs does not take place, cubebs excite great irritation and fever, and paralysis is sometimes the result. In a case which fell under the care of the writer of this article, in which the extent of the dose was 31, so much febrile irritation was excited that the life of the patient was in danger. All of the aromatic stimulants are admirable additions to tonics when judiciously prescribed, and some of the most important of the class owe their excellence to a natural combination of tbi» STIMULANTS, 245 description ; as, for example, Winter's bark and Calamus aromaticus, the latter of which is one of the best additions to cinchona bark and sulphate of quina in intermittents. Several of the aromatics, nevertheless, cannot be combined with cinchona or the salts of quinia, as, for instance, cinnamon, cloves, and pimento, on account of the precipitates which they throw down, — a disadvantage from which the uncombined oils are free. As external stimulants, all the uncombined vola- tile oils may be employed, the extent of their rube- facient effect being easily regulated by the quantity of bland oil used for diluting them. Such are the stimulant properties of volatile oil, both in its uncombined and combined state; the list of substances yielding it, contained in the British pharmacopoeias, might be greatly abridged, and yet ample means afforded for fulfilling every indication for which vegetable aromatics can be required in the treatment of diseases. Many vegetables owe their stimulant influence to acrid fixed oil, which exists in the plants in a state not in all cases quite evident, although in some it seems to be deposited in distinct cells. This acrid principle is apparently mixed with fixed oil if the parts of the plants containing it be sub- mitted to the operation of expression, but it is perhaps in every instance separate from it during its existence in the plant: it is usually more or less volatile. All the peppers, mustard, and pelli- tory, derive their stimulant property from an acrid principle of this description. In black pepper it is combined with fecula, uric and malic acids, and piperina ; and its stimulant powers, whether inter- nally administered or externally employed as a suppurative, are solely due to this acrid principle. When separated, this oil is too pungent to be tasted with impunity; it reddens and inflames the skin, and thence we can readily trace the cause of the long-continued insupportable burning sensa- tion which it excites when taken into the stomach. It rapidly increases vascular action, and powerfully excites the sexual organs. The effect of pepper as an antiperiodic has been attributed solely to the piperina; but the writer of this article accords with Magendie in thinking, that something is due to this stimulant principle, as alone it has cured intermittents. It has not generally been employed as a therapeutical agent; but pepper in substance is given in the form of powder, in doses of six, eight, or ten grains. The same remarks apply to mustard and pelli- j tory root; both of which, however, are employed almost exclusively as local stimulants. The chief j advantage of the mustard cataplasm is in the promptness of its action, and the facility of regu- lating it. The use of pellitory is confined almost exclusively to cases of paralysis of the tongue and the internal organs of deglutition, arising from circumstances affecting partially the nerves of these organs. A small portion, more or less bruised according to the power of mastication enjoyed by j the patient, is chewed as constantly as the sensi- ' bility of the mouth will admit, and the saliva ejected. There can be no doubt that camphor is pro- ! perly placed in this class of remedies; but much difference of opinion exists regarding the mode in which its stimulant influence is exerted. Its first effect, in a full dose, is undoubtedly derived from j its stimulant power; this might, indeed, be assumed | from its reddening and causing heat and increased action in the part when it is applied to the skin ; and it is rendered evident, also, by the warmth which is felt in the throat and at the epigastrium in swallowing it. Its influence on the gastric nerves is propagated to the brain, the spinal cord, and the whole ganglionic system; and, during this time, the heat of the surface is diminished, rigors sometimes occur, and vertigo with perverted vision supervenes. Were our observations to proceed no further, camphor might be regarded as a simple narcotic, not affecting the heart and ar- teries ; but a secondary effect—one, undoubtedly* of increased action—soon displays itself: the pulse becomes strong, frequent, and vibrating ; the tem- perature of the body is elevated ; the eyes glisten, and cephalagia occurs. From these effects we may conclude that camphor operates, at first, solely on the nervous system; and that it is not until it is taken into the circulation, that it stimulates the vascular organs. Its influence as a stimulant is much less permanent than that of aromatics, as it passes rapidly out of the habit by the cutaneous exhalants, producing its excitant effects in transitu. The action of camphor is also greatly modified by the dose of the medicine. In moderate doses, namely, from five to twelve grains, it softens and fills the pulse, and promotes diaphoresis, mitigates pain, dissolves spasm, and seems to rouse the ner- vous energy without quickening the pulse; thence, in combination with antimonials it may be admin- istered even in diseases of excitement: but when its stimulant property is required, the dose should not be less than a scruple; and it may be com- bined with aromatics, opium, or tonics, as the in- dications direct. In such combinations, its influ- ence in checking the progress of gangrene, and in supporting the powers of the habit, in confluent small-pox, measles, and other eruptivevfevers, when they assume a typhoid character and the eruptions recede, has been amply demonstrated. Professor Halle informs us that it acts as an antiperiodic when it is administered in combination with nitrate of potassa, in the intervals of intermittent fever. As an external local stimulant or rubefacient, cam- phor is in very general use when dissolved in oil or soap liniment; nevertheless, when dissolved in proof spirit and applied to a hot and inflamed sur- face, instead of stimulating it causes an agreeable sensation of coolness,—a circumstance depending on the great volatility of the camphor ; whereas, when dissolved in fixed oil, its volatility is re- strained, and its stimulant effect secured. Another method of employing camphor as an external stimulant is as a fumigation. The patient is covered with a blanket pinned close round the neck, and from half an ounce to an ounce of cam- phor is thrown on a hot iron plate placed within the blanket. The effect is copious perspiration. Owing to the insolubility of camphor in water, aqueous fluids are unfit vehicles for its exhibition, unless means are adopted to keep it suspended in them. The best method of effecting this is by dissolving the camphor in fixed oil, then forming this solution into an emulsion by triturating it with gum and water, or the almond emulsion. It has also been formed into a soap by means of 246 STIMULANTS. liquor potassa?, or triturated with soap, and thus strychnia is now, therefore, generally regarded as rendered miscible with water; or it may be dis- | a most valuable stimulant in paralytic affections, solved in milk in the proportion of £ss of the ! especially those of the lower extremities. With camphor to f.^iv of milk and f.gviiss of distilled : respect to the mode of prescribing it, on account water, as recommended by Dr. Cassils, of Kendal. ' of its great insolubility in water and the variation (Edinburgh Med. and Surg. Journal, vol. viii. p, 124.) One of the most powerful of the vegetable sti- mulants is strychnia, an alkaloid,* the active principle of Strychnos nux vomica, the seeds of which contain in it combination with igasuric acid, as an igasuriate. Its first obvious effect when taken into the stomach in a moderate dose, namely, one-tenth of a grain, is an augmented energy of the digestive function, without much change on the pulse; the vigour of the cutaneous function is also increased, and perspiration flows freely. By degrees, however, as it accumulates in the system, the respiration becomes oppressed, and the respiratory muscles suffer a clonic con- traction. This extends to the rest of the system, and violent twitchings and tetanic contractions supervene. In addition to these symptoms, the surface of the body becomes morbidly sensitive to the slightest impressions, even the motion of the air, as in hydrophobia; whilst a sensation of heat, prickings, formications, and other uncomfortable feelings, are experienced in the limbs. These symptoms increase at one moment and subside in the next, keeping pace, as it were, with the changes which supervene in the power of the irri- tations impressed on the medullary matter of the spinal cord. From these symptoms, as well as the fact ascertained by experiment, that strychnia produces no effect on the system when the spinal cord has been previously destroyed, it is evident that it acts directly on the motor tract of the spinal marrow;-(- and when the dose is sufficient to de- stroy the animal, death soon follows the clonic spasm of the respiratory muscles, and the deficient decarbonization of the blood in the lungs. The employment of the extract of nux vomica, and of the powder of the seeds, was formerly common in pyrosis, and its influence in changing morbid into healthy action in the digestive organs was well ascertained; but the introduction of the administration of strychnia in paraplegia is due to Dr. Fouquier, of the Hospital de la Pitie, in Paris; and the expectations of its powers raised by the result of his practice have been fully verified: * Strychnia, according to the analysis of Liebig, con- sists of £arbon,....................76.43 or 30J equiv. 183 Hydrogen,.................. 6.70" 16 " 16 Nitrogen................... 5.01 " i •< 14 Oxygen,...................1106" 3 " 24 100.00 237 It is procured by precipitating a concentrated decoction of the seeds of nux vomica, or St. Ignatius bean, with acetate of lead; decomposing the acetate thus formed with magnesia, and treating the precipitate, well washed and dried, with strong alcohol. By repeated solution and crystallization it is procured in the form of minute white, elongated, tetrahedral prisms, terminated by a pyramid, permanent in the air, and inodorous, but so intensely bitter as to impart a sensible bitterness to 506.400 parts of water. t Fodere found, that on exposing the spinal cord in the loins of an animal to which strychnia had been admi- nistered, he could arrest the tetanic convulsions by making pressure on the anterior segment of the spinal cord. of activity according to the greater or less asces- cency of the 6tomach during its employment, the author of this article has proposed to administer it always in the form of an acetate, which is readily produced by dissolving one grain of the alkaloid in a fluidrachm of distilled vinegar. Six minims of this solution, containing one-tenth of a grain of strychnia, is the dose of the medicine to be given at first. It must be gradually increased until the tetanic twitchings appear, which gene- rally occur before the dose amounts to thirty minims, equivalent to half a grain of strychnia. When the powder of nux vomica is given, the dose may be gradually increased from five grains, until fifty be taken in the course of a day; or if the extract be preferred, two grains may be first prescribed to be taken at night and in the morn- ing, and one grain added every day or every se- cond day, until the specific effects of the remedy display themselves with sufficient intensity to lead to a salutary result. If strychnia be employed in cases where there is much irritability of stomach, instead of being swallowed, it may be sprinkled on a denuded surface in double the dose requisite when internally administered. Besides the use of strychnia or its acetate, or the extract of nux vomica, in paralysis, it has been found useful in several other diseases. M. Frisch, a German physician, affirms that he has cured ague in robust persons, when sulphate of quinia failed, by adding to this salt the powder of nux vomica in doses of four or five grains; and Dr. Bardsley has found strychnia equally serviceable in amenorrhoea and chronic diarrhoea. (Hospital Facts and Observations, &c, by James Lomax I Bardsley, M. D. p. 57.) When overdosed, the fatal effect which has followed seems to proceed chiefly from the poison exhausting the irritability of the heart The first symptom characterizing j an overdose, or the result of its poisoning influ- ence, is tremour; this is followed by stupor, which is quickly succeeded by tetanus, stiffness of the muscles of the neck, trismus, severe pain under j the ensiform cartilage, opisthotonos, laborious re- spiration, and fatal asphyxia. M. Donne has pro- posed iodine as an antidote in such cases; and the results of his experiments on dogs afford I strong reasons for trying it on man.$ [See Te- | TiNUS.] ! The stimulant influence of alcohol in all its modifications and combinations has been known almost from time immemorial. When alcohol, diluted and uncombined, is applied to the living system, it acts upon the nervous energy, augment- ing the tone of the part, diminishing the capacity 1 As the advantage, however, arises from a chemical change effected on the strychnia by the iodine, it cannot prove useful if the poison be absorbed ; but it is nmrc probable that it operates solely through the intestinal nerves. Post-mortem examinations display the venous system of vessels gorged with blood, whilst the arterial is nearly empty, and the arteries contracted to nearly one-half their usual diameter. Scarcely any traces of inflammatory action have been detected even in the sto- mach. STIMULANTS. 247 of the blood-vessels, and adding to their power of carrying forward the blood which they contain. But this effect is modified both by the strength of the alcohol and the susceptibility of the part to which it is applied : if the sensibility be consider- able, and the alcohol strong, the state of augment- ed tone, and the contraction which renders the surface pale, are of short continuance; the vital energy is rapidly exhausted, and inflammation is the consequence. The stimulant property of al- cohol thus becomes obvious to our senses. When taken into the stomach in large quantity and pure, its primary influence is experienced on the organ itself; its mucous membrane is inflamed and its vitality destroyed: this shock is communicated through the nerves to the brain; and the person often dies before there is time for absorption to have taken place. In animals killed by injecting alcohol into the stomach, Mr. Brpdie found on dis- section every appearance that indicates strong in- flammatory action, and blood extravasated between the tunics; but, except a gorged state of the ves- sels, no appearances of any injury to the brain were observed; thence dissection strengthens the opinion that the impression is wholly on the nerves. When the alcohol is somewhat diluted, it acts with less energy, and merely causes ebriety. The first impression, in this case, is one of augmented energy; the mental function acts with unwonted power; fancy is awakened, and creates, from un- interrupted associations, new and often brilliant combinations; and at this moment, imagination luxuriating unrestrained, the poet pours forth his most harmonious and sublimest strains. By de- grees, however, this blissful sensation vanishes; all control of the will as well as reason is sus- pended ; and, instead of agreeable conceptions, ideas crowd into the mind in the most incongru- ous order; vertigo supervenes, and delirium pre- cedes a state of exhaustion, which at length termi- nates in collapse and sleep resembling that of apo- plexy, and not unfrequently proves the prelude to death. In general, however, nature adopts this method of restoring exhausted excitability; but, after the repose, the shock given to the nervous system is rendered obvious in the tremulous hand, the unsteady limb, the rigors, the nauseated sto- mach, the irascible temper, and the completely overpowered state of the system which the indi- vidual experiences on awaking. That all these \ symptoms depend more on the impression made on the nerves of the mouth, the gullet, and the stomach, and its transmission to the brain by ner- vous sympathy, than by absorption, is evident from the influence of a small portion of wine or of alcohol in causing intoxication, if it be allowed to pass slowly over the sensitive extremes of the nerves of the tongue and fauces in its progress to the stomach ; and, also, by the sudden sobriety ' which often follows the act of vomiting. The repetition of such impressions, however, affects seriously the powers of life ; cancer of the pylo- rus, abscess of the liver, delirium tremens, palsy, dropsy, epilepsy, mania, and a long train of evils, attack and soon subdue the strongest constitution. It is true that some habitual drunkards have lived to a good old age ; but this is an exception to a general rule— | " Perhaps some doctor, of tremendous paunch, Awful and deep, a black abyss of drink, Outlives them all; and from his buried flock Retiring, full of rumination sad, Laments the weakness of this latter time." Thomson's Seasons—Autumn. But notwithstanding these frightful results of the dietetical abuse of alcohol, it is, when tempe- rately indulged and discriminately prescribed as a medicine, a most salutary stimulant. As a medicinal excitant, alcohol in some respects resembles a narcotic in its operation ; its use is more or less followed by sedative effects; but its stimulant influence is too great to allow it to be employed as a narcotic. In its diluted state it is serviceable in those fevers, and those periods of fever, which indicate much depression. Great attention is necessary in determining the degree of dilution which is always requisite: as a gene- ral rule, one part of ardent spirits to five of water, and the mixture acidulated with lemon- juice and sweetened, is a mixture of a proper strength, and forms an excellent substitute for wine. In this degree of strength, it may even be prescribed in some diseases of excitement, if no vital organ be affected, and the powers of life are sinking. In dyspeptic states of the stomach, although often recommended, alcohol is often pernicious. The symptoms of dyspepsia sometimes depend on a state of subacute inflammation instead of de- bility of the organ ; thence only one opinion can be formed respecting the propriety of prescribing stimulants. If alcohol, simply diluted with water, produce these effects, we may also look for them from its combination in wine, beer, and cider. In regarding the therapeutical influence of wine, we must consider both the chemical proper- ties of the kind of wine to be prescribed, and the condition of the habit of the patient. With re- spect to the former, sweet wines, such as moun- tain, constantia, tent, lisbon, &c. although they do not intoxicate so quickly as some other wines, yet, owing to their imperfect fermentation, promote acidity, and therefore they should not be prescribed in any case when the stomach is in a low state of vitality. The brisk and sparkling wines, the pro- duce of Champagne and Burgundy, intoxicate sooner than dry or still wines, owing to the car- bonic acid which they contain ; but their effect is more transitory, and the subsequent exhaustion less than that caused by other wines ; thence they are salutary stimulants in those diseases which are termed nervous, when taken in moderation ; and no opinion is worse founded than that which re- gards them as injurious to gouty habits. The light wines of the Rhine and the Moselle are less likely than any of the others to influence injuri- ously the nervous system : they are less inebriating and possess diuretic properties, and although acid- ulous, yet they do not disorder the stomach so readily as the stronger wines, both because the acid which they contain is the tartaric, the least fermentable of the vegetable acids, and also be- cause their alcohol is intimately combined with the other principles of the wine. The strong wines, as port, sherry, madeira, and the aromatic spirit- uous wines of Burgundy, are the least wholesome, owing chiefly to the uncombined brandy which is 248 STIMULANTS. mixed with them for the purpose of securing their exportation, and their powerful intoxicating pro- perties. All of them, also, contain volatile oil, which displays narcotic properties in the nervous system, and induces a tendency to apoplexy. With respect to the second object of considera- tion,—the state of the habit in diseases which re- quire the stimulus of wine,—we may venture to affirm that wine, under proper management, is well adapted for the advanced stages of continued fevers, and every disease in which the powers of the constitution fail. Its exciting powers are of primary importance, and it is grateful to the palates of most patients; but various circum- stances are requisite to be attended to in its ad- ministration. 1. It is more necessary and safe if during health the patient has been accustomed to take wine, than if his habits have been abstemious. 2. It is indicated when, in the advanced stage of fever, the pulse is frequent, small, and compres- sible ; if there is low muttering delirium, and subsultus tendinum. 3. It is also indicated when there is a strong instinctive desire for it; on the contrary, its use should not be urged when there is no such desire. 4. Its effects should be watched: if it do not disorder the stomach, or augment the heat of the skin, but fill the pulse and lessen its frequency, mitigate delirium, and remove restlessness, it is not only proper but absolutely requisite. 5. In contagious fevers, with a languid pulse and oppressed spirits, wine may be administered in an early stage. It should be given in small quantities, frequently repeated, as long as it seems to answer the intention of its exhibition; nor should it be rapidly withdrawn, but gradually diminished as the febrile symptoms abate, and the system displays more susceptibility of its impres- sion. 6. Claret and Rhine wines are more proper than the stronger wines in the earlier, but not in the later or sinking stages of fever. The lighter wines generally tend to open the bowels, the stronger to check diarrhoea ; but sometimes the opposite is the case. 7. With respect to the form of administering wine, it is generally most grateful to the sick when warmed, sweetened, and slightly acidulated ; but to many patients it is most grateful when diluted with cold water. Wine proves hurtful in neuralgic and rheuma- tic affections, and, like every remedial agent, is beneficial or injurious, according to the degree of skill, discrimination, and judgment which directs its administration. These remarks are applicable to ether and its preparations, which differ from wine in their ope- ration chiefly by the rapidity with which their effects are propagated over the system. It is pro- bable that ether is absorbed in its state of vapour, and applied directly to the nervous centres. When taken into the stomach in moderate doses, twenty : or thirty minims in a glass of water, it stimulates ; the gastric nerves, and has a powerful influence in checking vomiting. In malignant fevers it aids in allaying subsultus tendinum and hiccough ; and when prescribed in larger doses, on the ap- proach of the intermittent paroxysm, it often suc- ceeds in preventing its accession. In treating ot clectri< it j- as a stimulant, it would be out of place here to enter into any investigation of the causes of its phenomena ; its influence as a therapeutical agent in the removal of disease is our object. In whatever form it be employed, whether as voltaic or common electricity, when it is applied to the animal system in a moderate de- gree it increases excitement; in a large quantity, it destroys life. It operates equally on the sen- sibility and the irritability of the system, is quickly propagated, and excites the action of the most distant parts. It differs from other powerful sti- mulants in not being followed by those secondary effects which are the result of the excitant influ- ence of almost every other stimulant. It is indi- cated only in diseases of debility, and it requires to be continued,for many weeks in order to secure beneficial effects from its use. Much, also, de- pends on the mode of applying it. In all cases the isolation of the patient and the accumulation of the electrical fluid on his body should be first tried ; then the aura used ; after which sparks may be taken ; and, lastly, when the system has ac- commodated itself to the stimulus, shocks may be given. The necessity of proceeding in this cau- tious manner is obvious : in delicate and nervous habits a strong shock may not only induce syn- cope, pain, and vomiting of blood, but it may fur- ther so exhaust the strength as to accelerate and even cause death. (Percival's Essays, vol. i. p. 393.) Electricity has been found a useful stimulant in glandular affections. In recent cases it operates | by exciting the capillary action and reducing the swelling; in the more advanced, by promoting suppuration. On the same principle much con- fidence is placed on it in amenorrhoea ; it produces i a current of blood to the uterus, and stimulates the secreting powers of that organ. It is espe- cially indicated when atony of the uterus accom- panies a pale leucophlegmatic condition of the habit. The shocks should be passed directly through the part. When, on the other hand, there is plethora, with rigidity of fibre and a high sanguine complexion, electricity is hazardous in amenorrhoea, unless preceded by bleeding, purg- ing, and other antiphlogistic measures. In every case, before determining on the employment of electricity on the female habit, it should be ascer- tained that pregnancy is not present, as either miscarriage or premature labour, according to cir- cumstances, and the death of the fcetus, may fol- low its use. In passing shocks through the ute- rus under any state of the organ, much caution is requisite in regulating its force : if the shocks are too powerful, danger may result; if too weak, no benefit will accrue from their use. The beneficial influence of electricity has often been observed in paralysis in all its forms, if it be not complicated with determinations to the head. Thence it is more useful in old than in recent cases, in partial than in general paralysis, and in paraplegia arising from the poison of carbonate of lead, than hemiplegia following apoplexy. In the most favourable cases for its employment it must still be cautiously applied, and the remark of Dr. Pcrcival should always be kept in recollection, STIMULANTS. 249 »that few cases which resist the power of small and repeated shocks, yield to great and terrifying ones." Rubefacients aid considerably the bene- ficial power of electricity. In asphyxia, gentle shocks may be passed through the region of the heart. In deafness from atony of the auditory nerve, sparks should be taken from the internal part of the meatus by means of a metallic con- ductor passed through a glass tube: the effect is swelling of the part, with an increase of cerumi- nous matter, which is followed by an improve- ment in the faculty of the organ. In amaurosis from mere defective sensibility of the optic nerve, much benefit may result from taking sparks from the eye, directed through the back part of the head, following the course of the optic nerve; but if the cause be a tumour pressing on the nerve, either at its origin or in its course, no benefit will follow the use of electricity. In some cases galvanism may be substituted for common electricity, but in general electricity has succeeded where galvanism has failed. See Electricity and Galvanism. Wc have already treated of the stimulant influ- ence of caloric. See Bathing. Iodine is a powerful stimulant, whether it be employed in its simple or uncombined stage, or as it exists in many preparations. Its great uti- lity depends on its entering the circulation and ! exciting the capillary system. Its primary influ- ence, however, is exerted upon the stomach, a fact which has been fully ascertained by the appear- ance observed on that organ in persons who have been poisoned by it: indeed, the powerful man- ner in which it attacks the skin might have enabled us to prognosticate a similar effect when it is introduced into the stomach. Like some other medicines, it accumulates in the system; and, therefore, the continued employment of it, even in small doses, has occasionally proved hurt- ful. Its absorption is demonstrated by the facility with which it is detected in the blood, the urine, the perspiration, and other secretions ; thence its stimulant influence is extended to every part of the frame; the absorbents are urged to unusual activity, and not only diseased but healthy parts are carried off by its means ; the mamma? in wo- men and the testicles in men waste: in truth, no gland is exempt from the influence of iodine. There is a remarkable discrepancy, however, in its action, which was first observed by M. Lugol,— namely, that women labouring under scrofula, in- stead of becoming emaciated, gain flesh. In over- doses it operates as a poison, causing heat and a sensation of weight at the epigastrium, pain at the lower part of the sternum increased on pressure, cardialgia, burning heat of the skin, excessive thirst, and frequent purging of dark bilious mat- ter ; the pulse is weak and tremulous; great rest- lessness and palpitations supervene; with frequent syncope and extreme exhaustion. The principal diseases for which iodine has been advantageously administered are broncho- cele, scrofula, amenorrhoea, chlorosis, dropsy, and every form of disease arising from or connected with diminished capillary action. The activity of the medicine is modified by its combination with other substances; as in the hydriodate of potassa, the iodurets of mercury and of lead, and ioduret and hydriodate of iron. The first is the Vol. IV. — 32 least active of these preparations, and is chiefly employed as a vehicle for augmenting the solu- bility of iodine in aqueous fluids : the iodurets of mercury and of lead are more powerful stimulants than the iodine alone, and require to be cautiously administered in doses at first not exceeding the sixth of a grain ; on the other hand, the combina- tion with iron, which was introduced to the notice of the profession by the writer of this article, di- minishes the irritative action of the iodine, whilst the iron being rendered soluble, and in a state to be readily converted into the protoxide, is carried into the habit with the iodine, and aids its deob- struent influence by giving tone and support to the system.* It is admirably adapted for chlorotic affections, and cases of glandular obstructions, connected with diminished power and a leucc- phlegmatic state of the habit. On account of its deliquescent property it cannot be administered in substance; and when dissolved it is converted into a hydriodate, in which form it may be adminis- tered in doses of from two to six grains three times a day. The influence of both its compo- nents is rapidly visible on the habit, by the im- proved colour of the skin, the increase of appetite, exhilarated spirits, and invigorated strength of the patient; and so quickly does it get into the sys- tem, that in twenty-four hours after the first dose has been taken, both the iron and the iodine can be detected in the secretions. It is incompatible in prescriptions with alkalies and their carbonates ; the metallic salts; all vegetable infusions and de- coctions containing tannin and gallic acid ; the preparations of opium, henbane, and conium; the alkaloids and their salts, and chlorine. It has one advantage over all the other preparations of iodine, —it does not produce emaciation, or that wasting of glandular bodies, which renders the closest watchfulness requisite in their administration.— [See Eutuopiiic] The stimulant influence of all the preparations of mercury has been long known and acknow- ledged. In whatever manner they are introduced into the body, whether they be taken into the sto- mach or applied by friction to the skin, they excite powerfully, and set up a febrile condition of the system, evidenced both by the state of the pulse and the nerves, and by an augmented energy in the whole secerning organs. This action, like that of every other energetic stimulant, when car- ried beyond a certain point, or when long conti- nued, debilitates, and, consequently, emaciation is a constant attendant of a mercurial course. In producing their effects, mercurial preparations, *The ioduret of iron is prepared by placing one part of soft tempered iron-wire in a hollow porcelain vessel with a considerable quantity of distilled water, and add- ing five parts, by weight, of pure iodine, and then sub- jecting the mixture to heat, constantly stirring until the solution is accomplished and the liquid is nearly clear. The solution is then to he filtered and immediately eva- porated to dryness in a flask, which must be broken as soon as the ioduret has crystallized, and the preparation directly put into a well-stopped phial. It is a proto- ioduret, containing one equivalent of each of its com- ponents. When well ma4e, and well preserved from the air, it dissolves entirely, and affords a pale greenish- yellow solution ; but when not well preserved from the air, a portion of the iron is converted into the peroxide of the metal, and a sosqui-ioduret is formed, so that when it is rubbed up with water the peroxide remains insoluble. [For one of the best modes of preparing it; see Pharmacopccia of the United States, Philad. 1842.] 250 STIMULANTS. whether oxides, chlorides, cyanides, or iodides, are j decomposed, and the mercury, in a metallic form,; is either thrown out of the body by the skin and lungs, or, under certain circumstances, is depo- sited in the glands and the bones. The first of these facts is demonstrated by the amalgam formed between the exhaled mercury and gold and silver coins worn in the pocket of a person under a course of mercury : the second has been confirmed by the discovery of metallic mercury in various parts of the body, in post-mortem examinations. Amongst other well-authenticated proofs of the latter, there is a pelvis of a young woman who died of syphilis, preserved in the Lubben cabinet of midwifery, which is infiltrated with metallic mercury. The stimulant influence of mercurials is much modified by the manner and the doses in which they are administered, and to a certain extent by the nature of the preparation employed. In large doses, given at distant intervals, mercurials operate as local stimulants, first on the liver and pancreas, by exciting the orifices of their excretory ducts, through which the impression is conveyed to these glands; and, secondly, on the exhalants of the alimentary canal, thereby unloading the vascular system and giving a new impulse to the circulat- ing powers. In this case no primary excitement is communicated to the capillary system. When smaller doses, repeated at short intervals, are ad- ministered, the mercurial is absorbed, and being directly applied to the capillaries, the whole glandu- lar system is excited; and the salivary glands being more susceptible of impressions than those of the rest of the body, salivation is the conse- quence. When this high degree of irritation is carried to excess or long-continued, it is apt to be followed by a state of exhaustion which sometimes proceeds rapidly to a fatal termination; or when that condition of the nervous system which has been denominated hysterical, exists, particularly if the patient be exposed to sudden alternations of heat and cold, the ordinary febrile symptoms resulting from mercurial action are attended by dry cough and tightness across the pra?cordia; and an eruption closely resembling eczema ap- pears. At first a redness is diffused over consi- derable portions of the surface; this is followed by crowded minute vesications, accompanied by a stinging sensation, and this continues after the vesications; dry and extensive exfoliations of large flakes of the skin occur; the eyes and pal- pebra? are completely denuded of their hairs; the head swells ; the whole body exhales a fetid odour; and a degree of exhaustion, which, tends to the fatal termination, generally supervenes. (See ar- ticle Eczema.) This affection was first noticed, as a result of the action of mercury, by Mr. Alley of Dublin, (Essay on a peculiar eruptive disease, arising from the exhibitions of mercury, by George Alley, Dub. 1804,) and afterwards ably investi- gated by Dr. Moriarty, (Description of Mercurial Lepra, by D. Moriarty, Dub. 1804,) Dr. Spens, j (Cases, &c. by Thomas Spens, M.D. Edin. Med. and Surg. Journ. vol. i. p. 7,) and others. All temperaments, it is stated by those who have writ- ten on the disease, are liable to this species of j eczema, but the experience of the author of this article is at variance with that opinion ; and he j believes that it is peculiar to that state of habit which is termed hysterical, occurring in a san- guine temperament. In no circumstances, not even in the treatment of syphilis, is the introduction of mercurials into the habit required to be carried so far as to risk the appearance of these effects. Salivation is not essential, and can be regarded as a mere proof that the system is fully under the influence of the mercurial action ; to throw in more is merely raising a higher degree of irritation, which is not only unnecessary but hurtful. Too profuse sali- vation has induced epilepsy, and occasionally led to that fatal erethismu3 which sometimes occurs when mercurials appear to act as poisons on the system, in which the use of the stimulant must be discontinued, and the patients exposed freely to a cool atmosphere, whilst the strength is sustain- ed by a liberal allowance of mild but nutritive diet. On this account, mercurials should be introduced into the system gradually, and the mildest forms of the preparations first employed. The efficacy of the remedy undoubtedly depends on its exciting power, but this should be maintain- ed only in a moderate degree ; and it is of impor- tance that the excitement should not be dis- turbed by that of any other stimulus, dietetical or medicinal; thence the necessity of dieting patients during a mercurial course. If wine or other stimulants be allowed, the peculiar action set up by the mercury may be so modified as to prevent it from overcoming that induced by the virus of syphilis; a rule which is applicable, perhaps, in regulating the employment of all other stimulants. It is proper to remark here, that the degree of the febrile action induced by mercurials does not always depend on either the extent of the dose or the nature of the preparation ; two grains of calomel will cause salivation in some persons, whilst in others no effects can be produced by the largest doses, long continued, until fumigations are resorted to ; and even these have been resisted. A knowledge of the circumstances on which these anomalies depend is important : they may be arranged under those which refer to the body,— temperament, idiosyncrasy, and sex; and those extraneous to it, — climate, and the nature of the preparations employed. 1. With respect to temperament, the sanguine and choleric are more susceptible of the mercurial action than other individuals : if the remedy be given for the cure of syphilis, great caution is necessary not to bring the habit suddenly under the full influence of the medicine. 2. Some idiosyncrasies are occasionally met with which prevent the free use of mercurials ; and as this may occur in reference to some preparations and not to others, it is proper, when syphilis is the disease, that a person who seems to suffer in this manner should try other preparations before his system is pronounced incapable of bearing mercury, and he is thereby deprived of the only chance of being cured. 3. With regard to sex, women are more easily brought under the mercurial influence than men ; and as it promotes the uterine secretion, the use of mercurials should be suspended during the continuance of the catamenia. In pregnancy, also, their employment requires the utmost caution. STIMULANTS. 251 They do not, however, materially interfere with lactation; and therefore, when infants are affected with congenital syphilis, the mercurial influence is readily communicated to the system of the child by the milk" of the mother. 4. As climate renders the human habit highly susceptible of the impression of all medicinal agents, a smaller quantity of mercury and a shorter period for its application will suffice to cure syphilis in a warm than a cold climate; and, for the same reason, this stimulant is more benefi- cial when employed in summer than in winter. Sydenham sent his syphilitic patients to the south of France. 5. In reviewing the comparative merit of the various preparations of mercury, it would be out of place here to enter into pharmaceutical details. Among the protoxides the blue pill, when pro- perly prepared, is the mildest of those which cer- tainly mercurialize the habit It seldom incom- modes either the stomach or the bowels, unless much acid be present, in which case it is apt to gripe and purge. From the mildness of its opera- tion, it is admirably adapted for the naturally delicate and those debilitated by previous disease. But in some persons, however, it proves too active, and requires the addition of opium, or the adminis- tration of a few grains of rhubarb, in the morning, to communicate tone and prevent griping. It gradually displays its influence by affecting the gums, when given in doses of five or six grains night and morning. The hydrargyrum cum creta, in doses of a scruple to half a drachm, is sometimes substituted for the blue pill when much acid is present on the stomach, but its action is slow and uncertain. The grey oxides, although precipitated from active salts, yet are mild preparations. They in- commode the stomach and bowels less than the blue pill, and, being more oxidized, they act with more certainty; but they are not much employed, except for fumigations. The peroxides, constituting the red precipitate per se and the precipitate with nitric acid, operate with too much acrimony to be used internally, in- ducing griping, diarrhoea, and tenesmus. They are, consequently, used only as topical excitants. The chlorides, calomel and corrosive sublimate, are also most active stimulants. The protochlo- ride, calomel, in doses of four or five grains, fre- quently operates topically, stimulating the orifices of the gall-ducts, and, by thus throwing much bile into the intestinal canal, causing purging. In smaller doses, it brings the habit under the mercu- rial influence more rapidly than the blue pill, and it is even more manageable. Its stimulant influ- ence on the capillaries greatly aids the action of other remedies; as, for instance, the diaphoretic powers of antimonials, and the diuretic of squill and foxglove ; it aids, also, the force of the milder purgatives, whilst it moderates the acrimony of the more drastic. The best form of administering it is that of pill combined with opium. The perchloride, corrosive sublimate, is the most active of all the mercurial salts, but it fre- quently gripes, even when administered in very small doses, and is supposed to have the power of oausing cough, hemoptysis, and phthisis. It is, nevertheless, one of those preparations on which experience has taught us to rely in cases of syphi- litic eruptions, especially those which assume the characters of psoriasis or of lepra; and from the rapidity with which it brings the habit under the mercurial influence, it proves, as Mr. Pearson has remarked, often beneficial at the commencement of a course of mercury. The dose of the per- chloride should not exceed, at first, one-tenth of a grain ; but, if it be guarded by opium, it may be gradually increased to half a grain, twice a day. A good vehicle for administering it is nitric acid, in which the salt dissolves without undergoing any chemical change; and in this form it may be given in conjunction with decoction of sarsaparilla or of elm-bark, in cases of syphilitic eruptions. In such case that attention to diet, which has been already noticed, is most essential, little benefit following the use of the perchloride if the patient is permit- ted to indulge in his usual diet, and to use, even moderately, either wine or spirits, or any ferment- ed liquor; he should be restricted to milk and farinaceous matters. These remarks are applicable to the remaining mercurial preparations, the iodides and cyanides, which are gradually coming into general use ; the iodides in particular, as they are equal in stimu- lant power to the most active of the old prepara- tions, and possess, besides, other advantages. From the influence of the iodine which they contain, they are likely to supersede the perchloride as an internal remedy. [See Ectkophic] The only other material stimulants which require to be noticed are ammonia and its carbonates. In the state in which the former is medicinally employed, it excites powerfully the living solid, inflaming and causing vesication or suppuration, according to the nature of the surface or tissue to which it is applied. When very largely diluted, and taken into the stomach, its primary stimulant impression is made on the nerves of that organ, and the impulse is rapidly propagated over the system ; but its effects are transitory; thence it is, like ether, regarded as a diffusible stimulus. It is indicated in those diseases and stages of the habit in which there is an evident deficiency of nervous power, and where it is important to rouse the ner- vous energy without affecting, in an equal ratio, the sanguiferous system. In prescribing it, the only object to be kept in view is not to administer it in doses sufficient to exhaust the excitability. The carbonates operate in a similar manner, but with less energy. The dose of the liquor ammo- nia? is from ten minims to half a drachm ; that of the subcarbonate from five to fifteen grains ; both should be involved in some bland mucilaginous emulsion. The ammonia possesses one advantage over the carbonates—it may be prescribed in con- junction with muriate of lime and the salts of ba- ryta, which are precipitated by the carbonates.* Some consideration is due to mental stimu- lants, which are too much overlooked by the physician. The effects of all the exciting pas- sions closely resemble those that follow the im- pression of a powerful material stimulant; the action of the heart and arteries is suddenly aug- mented ; the animal temperature is elevated; per- * Nothing is more likely to prove injurious than apply- ing a bottle of liquor ammonia; to the nostrils of persons who are in a state of syncope. The life of a medical man was nearly sacrificed to a rash act of this kind. 252 STIMULANTS. 6piration flows freely, demonstrating the direct in- fluence on the capillaries; the face glows, the eyes 6parkle, and the respiration becomes quicker and fuller. The mental functions of the brain are not less excited than those of the body: the imagina- tion takes a more excursive range; the pleasura- ble scenes of former life are again presented to the memory ; the future teems with gay and delight- ful anticipations; every task seems easy, every labour light; whilst the most difficult and mo- mentous schemes appear already accomplished, and crowned with the most brilliant success. But, besides these effects, the excitement of some pas- sions, especially joy, quickens the corporeal sensi- bility ; every object makes a stronger impression on the organs of sense; the eye sees more dis- tinctly, the ear is more acutely alive to sounds, the taste and the touch are delicately sensitive, and every bodily movement is more prompt and ener- getic. It is unnecessary here to enter into any metaphysical conjectures respecting this influence of the intellectual essence, connected with our existence, on the material part of our frame ; the effects of its excitant power are sufficient to en- able us to trace its importance as a therapeutical agent. The condition of the habit in which the excit- ing passions, particularly joy, may be employed as a remedy, is that which is characterized by lan- guor and debility, in such diseases as melancholia, hypochondriasis, dyspepsia, and chlorosis; and many cases might be detailed to display their be- neficial influence on those afflicted with these dis- eases. (Lory de Melancholia, torn. i. p. 57.—Trel- lianus, lib. ix. p. 17.) The application, however, of such agents requires the utmost judgment and discrimination : a sudden impulse of joy has made so* powerful an impression on the nervous and irritable frame of delicate persons, as to produce epilepsy, and even death. The influence of men- tal excitants in such cases, like the stroke of a flash of lightning, whilst it illuminates, destroys its victim. (Haller's Physiology, vol. v. p. 501.) The knowledge of this stimulant influence of mind on body is also important in pointing out, to the student and the inexperienced practitioner, the necessity of guarding those weakened by dis- ease from indulging in impetuosity of feeling, whether during the progress of the malady, or in convalescence. The fatal consequence of such a state of excited feeling was once witnessed by the writer of this article. A gentleman in the ad- vanced stage of phthisis was visited by an old friend, whom he had not seen for many years; the conversation turned upon an event in which the poor invalid felt deeply interested; in relating it he became greatly excited, rose from his seat, and displayed an unusual impetuosity of manner; but he had scarcely concluded the narrative ere he sank into his chair and instantly expired. It is easy to conceive that in such a state of excite- ment the effects would be felt chiefly upon the thoracic viscera; for, even in a state of health, impetuosity causes an unusual glow of warmth in the pra?cordia, the pulse beats quickly, and a pe- culiar sensation is experienced, which is referred, and not without reason, to the heart. Such is the nature of those stimulants which are so manageable as to be fitted for therapeutical purposes; their importance as remedies is un« doubted ; but the very nature of the substances belonging to this class renders them more liable to be abused than those in any of the other classes; we shall conclude this article, therefore, with a few remarks upon the cautions requisite to be kept in view during their administration. I It is scarcely necessary to caution against the ! general employment of stimulants in febrile affec- ! tions marked by a quick and full pulse, with much heat of body : in truth, it is only in the latter stage of fevers, when the diminished action of the heart is manifested by a fluttering pulse and a I cold clamminess on the skin, that stimulants are advisable: they rouse again, not only the nervous ' energy, but also that action of the capillary system without which the powers of life cannot be sus- , tained. Great discrimination, also, is requisite in I determining the exact period when they are de- | manded, even in this stage of fever; and there is, perhaps, less risk in permitting the prostration of strength to proceed for a short time, than to ha- zard their administration on the first indications of the approach of collapse : even when the cir- : cumstances which demand the employment of | wine in typhus are fully developed, much caution is requisite. When the debility seems to yield to the free administration of wine, the observing phy- sician will often find sufficient reasons for suspect- ing that the temporary vigour that it apparently bestows is succeeded by a greater degree of debi- lity, and, consequently, that the utmost danger may result from persevering in the use of stimu- lants. When petechia? appear, or when there is protracted diarrhoea followed by sudden collapse, wine and other stimulants are not only admissible, but are remedies upon which we must rely for the safety of the patient; and this is also true when the tongue is coated with a brown fur, the teeth and gums are covered with sordes, the skin is hot and dry, and when subsultus tendinum and low delirium are present, with a rapid, small, compress- ible pulse. Stimulants have been found beneficial in those affections of the chest which are accompanied with spasm, as, for example, the latter stage of hooping-cough. In bronchitis and similar affec- tions, although, during the continuance of the in- flammatory action, when the cough is dry and the expectoration difficult, stimulants would be pro- ductive of the greatest mischief, yet in the ad- vanced stages, particularly in peripneumony, their administration is demanded, not only to aid ex- pectoration, but to excite the capillaries so as to relieve the engorged state of the pulmonary tis- sues. On the same principles, also, camphor and sulphuric ether prove successful in relieving the urgent symptoms in some varieties of dyspnoea, whilst they are as injurious in others. It is in those cases in which effusions into the air-tubes take place, consisting of either a redundancy of the natural secretion, or frothy mucus the result of previous inflammation, that we may most confi- dently anticipate advantage from the administra- tion of stimulants. In softening of the muscular tissue of the heart, they prove serviceable in re- newing the vigour of the ventricular action, and rendering the contractions more steady and regu- lar. Stimulants, however, are not only contra- STIMULANTS. 253 indicated, but are directly injurious, wherever there is reason for suspecting hypertrophy of one or both ventricles of the heart. When the hyper- trophy is confined to the left ventricle, their ad- ministration is followed by vertigo, dimness of sight, singing in the ears, weight in the head, and epistaxis; or, if this do not occur, by congestion of the encephalon and apoplexy. In hysteria, epilepsy, chorea, catalepsy, tetanus, neuralgia, and, under some circumstances, in hy- pochondriacal and maniacal affections, stimulants are clearly indicated. In these cases, however, the state of the brain and the spinal marrow must be clearly ascertained ; morbid dissections having demonstrated that many affections which are fre- quently regarded as altogether nervous, are con- nected with and dependent upon abscess, ulcera- tions, tumours, or depositions of blood in the substance of the brain, or collections of fluid in the ventricles ; sometimes on a similar affection of the spinal cord or its tunics. Wherever these are suspected, there can be only one opinion respecting the impropriety of the administration of stimulants. In many instances of paralysis, especially in that of the lower extremities, constituting para- plegia, experience has fully demonstrated the utility of strychnia and other stimulants; but, at the same time, circumstances may exist which contraindicate their employment, and nothing is more necessary than a sound judgment and a cautious diagnosis in such cases. The employment of external stimulants is less hazardous ; but the result of their employment, not excepting electricity, has been disappointment. From the state of the nervous centres closely resembling that which produces paralysis, the skin often loses its natural qualities, becomes pale or discoloured, soft and scaly, or covered with crusts. In this condition stimulants prove serviceable, by throwing the blood upon the surface and exciting generally the cutaneous capillaries. It is essential, however, to distinguish between this state and that in which inflammatory pustules and tubercles appear upon the skin, the disposition to which is undoubtedly increased by exciting medicines. In many painful affections, in which it is neces- sary to exhaust the sensibility of nerves, the topical application of stimulants has been found benefi- cial; as, for example, toothach from caries, whitlow, and paronychia ; the various species of erythema, and in some of those of herpes. In malignant sore throat, capsicum and some other stimulants form the bases of the most useful gargles. Many stimulants are employed as condiments ; some of them are our daily beverage; and the general predilection of all nations for diffusible stimulants, particularly wine and ardent spirits, is sufficient to demonstrate the caution requisite in their employment as remedial agents. It is of the utmost importance, also, that the student should clearly understand the distinction between stimulants and tonics, or those medicines which simply increase action and those which are capable of producing a permanent augmentation of power. It is true that the excitement which stimulants afford to the nervous system, in a debilitated state of the body, gives a temporary impulse to the power of the digestive organs and consequent in- crease of strength to every part of the frame; but this effect is merely temporary: and the continued employment of the stimulant, instead of main- taining this condition of the habit, is followed by I the directly opposite state, that of exhaustion; indubitably proving that action is not strength. The combination, however, of stimulants and tonics aids greatly the power of the latter ; the former calling forth, as it were, the tone which the latter renders permanent. A. T. Thomson. STOMACH, ORGANIC DISEASES OF.— The term organic disease, as it is used in this article, comprehends alone the morbid affections I which involve profound alterations of structure in the stomach, as distinct from those pathological ' states in which structural changes are impercepti- ble, or are only slight and transitory. The im- portant affections which fall under the latter de- scription are treated of in this work in the several articles, Gastritis, Indigestion, &c. In this acceptation the term organic disease has been employed for a long period, and is generally received at the present day. Its strict limitation, however, is not without ambiguity, on account of the great advancement which pathological anatomy has made in modern times, and in particular be- cause the doctrines of some influential writers have asserted for it a position in medicine which it is not likely to retain. When we consider the comparatively short period within which it has become a branch of science, and the copious fruit it has yielded, it seems indeed only difficult to imagine the bounds of its application. Previous to the time when Bichat's researches gave a new- direction to physiological study, the lesions of structure were not at all investigated. Descriptions of morbid appearances were occasionally recorded, but they refer almost exclusively to the surface of organs, and notice merely their alteration in volume, form, and colour. But the analysis of the tissues soon made it apparent that a rich mine of pathological discovery remained unworked in their morbid anatomy, and the attention of most of those who pursued medicine with scientific views was soon directed to this subject. To their labours is to be ascribed the unprecedented pro- gress which medicine has made within the last half century, and the partial remodelling which has taken place in its principles and practice. The effects of disease have been investigated not only in the interior of organs, but in every variety of tissue which contributes to their forma- tion ; morbid products have been discovered and classified, and the minutest alterations have been observed, insomuch that it would seem that the researches of anatomy have approached the verge of what is cognizable by the senses, in tracing the organic changes caused by diseased action. But notwithstanding this, the fundamental dogma of the school of Bichat and Reil (viz. that vital actions are ultimately referable to the organization of matter) is warmly maintained, and applied to pathology by some who are desirous of basing the latter altogether upon anatomy. They assert that every morbid action is primarily caused by an organic change, and they consequently admit no definite distinction between diseases which exhibit lesions of structure, and those in which none can 254 STOMACH, (ORGANIC DISEASES OF THE) be discovered, every disease having thus in their doctrine, the nature of an organic disease. (Ros- tan, Cours de Medecine Clinique, torn. ii. p. 6, et passim.) This appears to us to be an abuse of pathological anatomy. We shall not, however, discuss this matter further here, as our object in alluding to it is mainly to fix the value of the term, which, as we have said, has been somewhat embarrassed by being mixed up with those theo- retical subtilties. But these have not attached any uncertainty to its meaning (particularly when applied to the stomach) in practical medicine, in which it unequivocally signifies the diseases of that organ which are obviously connected with structural lesions. Organic diseases of the stomach may, for the sake of description, be conveniently divided into the diseases in which the parietes, or the separate tunics which enter into their composition, become altered in structure, and those in which the entire viscus suffers a pathological change. To the first class belong cancer or scirrhus of the stomach, ulceration, hypertrophy, and atrophy of the tunics, and softening. The second comprises the altera- tions in volume of the whole organ ; viz., its en- largement and contraction. This division is as precise as the present state of the subject will admit of, and seems to be founded on natural dis- tinctions. The lesions comprised in it possess different degrees of importance, and we now pro- ceed to notice them separately, in the order in which they are enumerated. We shall treat of them in as practical a manner as possible, and shall observe brevity on many of the subjects, to avoid the repetition of matters which are amply dis- cussed in this work, in articles specially devoted to them, viz. Atrophy, HiPEnTKorHT,ScmRHCs, Softening, Ulceration, &c. I. Cancer or Scirrhus of the Stomach.— This formidable malady has for its essential cha- racter the growth of a morbid product, usually called scirrhus, upon some part of the parieties of the stomach, which, being once developed, ad- vances until this viscus becomes disorganized, and in its course produces a slow succession of distress- ing symptoms, and eventually a fatal termination. Its history had been traced with considerable accu- racy long before anatomy had given any light to pathology, and it seems to have been among the first internal organic diseases which attracted notice. Some have asserted, not unreasonably, that it was described by Hippocrates under the name of /itXaiva ; and although this, from want of anatomical evidence, cannot be proved with cer- tainty, it will appear, on reference to the brief but graphic description which he has left us of the disease represented by this term, (De Morbis, lib. ii. sect. v. Chardel,) that it corresponds closely with that of cancer of the stomach. Galen also must have had this disease before him, when he observed that the growth of certain tumours in the stomach sometimes obstructed or even interrupted the passage of food, inasmuch as organic ob- structions of this viscus are almost invariably of a cancerous nature. And, as before necroscopic inspection had revealed its nature, its formidable symptoms had given it a place in medical writings, so at the earliest period at which this was prac- tised, we find an account of it. Antonio Bene- vieni, who is cited by Lobstein as the first author that was specially occupied with pathological anatomy, makes particular mention of scirrhus of the stomach. (De abditis nonnullis ac mirandis morborum et sanationum causis. Florent. 1507.) Afterwards Hildanus, Morgagni, Lieutaud, and Haller, noticed its external anatomical characters with reference chiefly to its obstruction of the ali- mentary canal. At the commencement of the last century the subject of scirrhus and cancer was much discussed in the schools. Then only the identity of this morbid structure as invading the stomach, with that which produces the long known cancer of external parts, became fully re- cognised, and from this period it formed an ordi- nary topic in every collection of medical observa- tions. Some interesting facts are recorded in these, but the history and pathology of the disease were advanced but little by them, as the theory of medicine was still fettered by narrow speculations, and the only method which was employed to in- vestigate cancer was to reduce it to the dogmas of the humoral pathology. At the beginning of the present century this had given place, and amongst the first benefits which accrued to medicine from the enlightened spirit of observation which suc- ceeded, is to be reckoned the ascertaining of the physical properties of the anormal tissues, inclu- sive of scirrhus and cancer. This, the result of the researches of Bayle and Laennec, was the chief step in our knowledge of the pathology of cancer of the stomach, as it at present stands. It is also to be acknowledged that in this as well as all other diseases of this organ, the science is greatly indebted to the labours of Broussais. His writings and the agitation of his doctrines chal- lenged for the stomach an importance in pathology which has directed to it the attention of the dis- tinguished men whose labours constitute the richest materials of modern medicine. History. — Cancer of the stomach is a disease very insidious in its commencement, and chronic in its course. Few cases come to a termination in a period shorter than six months from the time at which the organ first exhibits signs of being affected, but for the most part it entails upon the patient a protracted train of suffering not unfre- quently of several years' duration. On comparing the numbers of males and females affected by it, the former greatly predominates. The stomach of the latter comparatively enjoys an immunity from cancer, which observation has been confirmed by the rare occurrence of the disease at the great hospital Salpetriere at Paris, which is tenanted by old females. This difference as to the sexes seems to depend on the greater exposure of men to some of its causes, such as the habitual use of ardent spirits, and still more to the greater frequency in them of deep moral emotions of a gloomy charac- ter, which are observed to exert a peculiarly inju- rious influence upon the digestive organs. In the female these are less prevalent; besides, in this sex the genital system suffers those physical effects of moral emotion which in man bear upon the diges- tive system ; and, in agreement with this, it is found that cancers of the mamma and the uterus fully compensate for the lesser number of cancers of the stomach in the female than the male sex. It is a disease of mature age, and seldom manifests STOMACH, (ORGANIC DISEASES OF THE) 255 itself before thirty or after seventy. We believe there is no authenticated case on record in which it occurred before puberty, which observation, it may be remarked, is an additional indication of the influence which moral causes exert in its pro- duction. Some authors affirm that the tempera- ments have a different predisposing influence with respect to it, and that the lymphatic and sanguine are more liable to its invasion than the bilious and nervous. If this be on the whole founded in fact, the preponderance is not very great. As far as our own observation extends, individuals of dark hair and eyes possess a greater immunity neither from this disease nor from pulmonary tubercles (with respect to which the same difference in the temperaments has been asserted), than those whose complexion is of an opposite character. In detailing the symptoms of cancer of the stomach, it is convenient to consider its progress as having separate periods or stages. Chardel (Monographic des Degenerations Skirrheuses de l'Estomac, Paris, 1808) conceived this plan, and in his description marked three periods. Succeed- ing authors have observed it likewise, but as we think, with greater insight into the pathology of the disease, they have recognised but two. The latter division will be followed in this account of the symptoms which we shall give very succinctly, as we shall notice some of them separately in ad- verting to the diagnosis afterwards. First period. — There is but little perceptible difference between the earliest features of this dis- ease and those of common nervous dyspepsia. As in the latter, flatus, acid eructations, and weight at the epigastric region are commonly its first symp- toms, accompanied, however, by a greater degree of general languor than that which attends on any form of dyspepsia. No uncommon attention may be paid to these, until considerable pain begins to be felt in the region of the stomach, es- pecially after meals, and pressure in the epigas- trium detects soreness. On some occasions it has commenced by a sensation quite the reverse of pain, which consisted of an indescribable tickling of an agreeable nature, occurring when the stomach is empty. But sooner or later pain at length ar- rives ; at first it is confined to its own seat, and disturbs the patient only at intervals, but in a little time it becomes very oppressive, and shoots from the stomach into the hack and loins down the thighs. The animal spirits sink more or less, and often the individual is known to express his con- sciousness that he is the victim of some profound disease. Nausea sets in, and the food is rejected, mixed with quantities of ropy mucus, by which the pain and oppression are relieved, so that in the beginning the patient rather desires vomiting, and sometimes uses artificial means to provoke it. When tho process of digestion is past, much miti- gation of all the symptoms ensues, during which a comparative calm and even cheerfulness prevails in the mind of the patient. He learns to pay the greatest attention to his diet, from the peculiar dis- tress experienced after eating any substance which causes flatulency. On this account he avoids fecu- lent vegetables, highly seasoned puddings and other dishes, and prefers small quantities of solid meat. Yet the appetite is sometimes but little impaired, but it cannot be indulged to satisfaction from the aggravation of the symptoms which full meals induce. Feverish excitement rarely occurs at this period, neither is any remarkable thirst present, but occasionally spirituous drinks are taken with avidity for the purpose of helping the torpid digestion, and by this means mitigating the pains, which are more severe when this process is slowly and laboriously performed. A sensation of dryness and of constriction in the throat (more permanent than what is called globus hystericus) is not uncommonly an additional source of distress and alarm. The bowels are habitually costive, and the use of laxatives becomes indispensable. These are followed by temporary relief, for the same reason as the vomiting, viz., by the evacua- tion of the fiecal and gaseous accumulations which oppress the stomach by their distention. While the disturbance of the digestive organs is mani- fested in this manner, the tongue varies little from its natural appearance ; it rarely presents any sa- burral coating or redness, as in inflammatory affections of the digestive tube. Occasionally it is chopped, and lies flat and flabby in the mouth, and sometimes an excessive development, has been observed in the fungiform papilla? which are situ- ated at its base. So far the absence of some of these symptoms may cause variety in this account of the disease. But an observation of still more practical import- ance is presented in the fact, that in this first period the whole suite of phenomena has been known, under the influence of some cause, evident or undiscovered, rapidly to vanish, and continue suspended for a term of several weeks or months. This inconstancy may appear incompatible with the nature of an organic disease, and thus lead the patient, and even the physician, to form prognos- tics more favourable than are destined to be real- ized. The occurrence of this respite is the more usual event, but whether it takes place, or that the symptoms proceed without remission, a time ar- rives, the term of which it is impossible to assign, at which the malady takes firm possession; and its phenomena, although they may be still ambigu- ous as diagnostics, are no longer inconstant in ! their progress. They all at this period take on an increased activity, and henceforth the patient is never left entirely without suffering. The unfa- i vourable change is now and then connected with some imprudence of the patient, but for the most part it supervenes without any evident exciting | cause. Its phenomena constitute the second | stage. Second period.—Before the confirmation of the symptoms which marks the commencement of this stage, the nutrition is seldom remarkably affected; but now a visible wasting sets in, and as the malady advances, increases to a frightful degree of emacia- tion. The pain and weight in the epigastrium in a certain degree become constant; they are aggra- vated, however, at a particular period after meals, and spontaneous pains of a lancinating character are added. It occasionally happens that the appe- tite still remains, yet the wretched patient fears to satisfy it, and even prefers to sutler hunger rather than the pain produced by the entrance of food, or by the rejection of it, which he knows will ensue; for the vomiting no longer affords relief as at the beginning, but now much increases the distress. 256 STOMACH, (ORGANIC DISEASES OF THE) At length a tumour appears in the epigastric re- gion, which may be detected by accurate touch a considerable period before its external progress produces a visible elevation of the abdominal parietes. Pressure on the tumour does not aggra- vate the pain immediately, but often it causes great distress to the patient to recline upon the side which is most remote from it. This is evi- dently owing to the stretching of the irritated vis- cera by the weight of the tumour, as may be inferred from observing that the patient usually lies upon that side on which the latter least depends. To the foregoing causes of distress are added sleepless nights. Suffering now becomes habitual, and leaves its impress strongly marked upon the countenance by a peculiar contraction of the fea- tures—(the French call this painful expression " face grippee")—which is often rendered more ghastly by a dun discoloration of the skin. No- thing is more harassing than the vomiting, which is almost inevitably brought on by the smallest quantity of food. It has been observed that a re- markable anomaly sometimes occurs in the action of the stomach: amongst different articles intro- duced into it at the same time, it retains some and rejects others, exhibiting thus a kind of election as to the vomited matters. A stronger instance still of this is related, in that the food of the preceding day was vomited, whilst that latest swallowed was retained and digested. But besides the food, va- rious other matters are thrown up from the stomach. Of these the most common are fluids, containing a dark substance like coffee-grounds, uncoagulated blood, a thick porraceous matter, or finally, a dark green serum. The breath exhales a foul odour, which is dis- gusting to the patient himself. Towards the latter periods, aphthte appear in the pharynx. Dropsical effusions occur in the peritoneum and general cel- lular tissue, which may conceal the extreme ma- rasmus which would be otherwise visible. The constipated state of the bowels gives place to a diarrhoea, which hastens the close. When this symptom is present, a weak febrile action occurs; but independent of it, the disease runs its course without any exaltation of the pulse, loading of the tongue, or feverish heat. At the last, so much debility seizes upon all the functions, that the pains and vomiting cease, and death arrives with- out any struggle. In some cases it is preceded by delirium. Pathology and Causes.—As the essential ele- ment of this disease lies in the organic lesions to which it gives rise, a description of these is the first consideration in its pathology. Their situa- tion and extent are various. At one time the stomach is found lying in its natural position, un- altered in its size and external appearance; while in others these relations undergo the most important changes: its volume may be uncommonly en- larged, or it may be shrivelled up into a small compass. Instances are on record in which the parietes of the entire viscus were engaged in the cancerous development, but these are exceedingly rare. For the most part its seat is circumscribed, and it occupies in preference,—1st, the pylorus; 2d, the cardia; 3d, the body of the stomach. I. When it is situated at the pyloric extremity of the stomach, this part is changed in a greater or less degree. On inspecting it from without in- wards, the peritoneal coat is generally seen in its normal state of smoothness and transparency, and through it appears a dull white mass, forming a tumour of considerable magnitude. It extends from the pyloric orifice, where it is thickest, for some distance towards the body of the stomach, but it is seldom found to encroach upon the duo- denum. The cellular tunics are so confounded in the foreign tissue which forms the tumour, that they cannot be distinguished in the midst of it; they form the original nidus of it, and are incorpo- rated in its growth. The muscular tunic is also embedded in the mass, but is generally transformed into mere fibrous bands, or so atrophied as to be difficult of recognition. Cases, however, are re- corded in which this coat has not only been spared, but found hypertrophied to a considerable degree. (Laennec, Louis, Prus.) The appear- ance of the mucous membrane varies according to many contingent circumstances ; but the state of that part of it which bounds the cancerous tumour internally depends much upon the extent to which the latter is developed. If it has produced no lesion of continuity by its internal growth, the mucous membrane is generally united firmly to it as far as it extends, and in the most central part of the area occupied by the tumour a depression is often found, which has been compared to the round mark left by the blow of a hammer on a piece of lead. In many instances, however, the mucous membrane is found to have yielded by ulceration before the advance of the cancerous mass, which then presents itself at the internal surface of the stomach, with the appearances pe- culiar to itself. The intimate structure of the cancerous deposit possesses considerable variety in this as in other situations of the body. Its incision by the scalpel most usually shows it to consist of a firm homo- geneous substance of a white colour, resembling the section of a potato, from which this variety was called by Recamier solanoid. In other in- stances fibres in a concentric arrangement are observed to pass through the mass, which the same pathologist, under these circumstances, would propose to call napiform, from its resemblance to the fibrous texture of a cut turnip. Not unfre- quently the denser cartilaginous variety which has been more especially known under the name of scirrhous, is found to constitute the mass wholly or in part. Again, it is found in a softer condition, formed by a pulpy substance, having a lobular disposition, and traversed copiously by dark veins, by the rupture of some of which the softest portions of the mass are occasionally found infil- trated with blood. This is the description of cancerous formation to which Laennec gave the well-known name of encephaloid or cerebriform matter. In other cases a viscous jelly has been ob- served to form some part of the tumour, and this has been found situated in cells, occurring for the most part in the cartilaginous variety; whence it has been considered by some pathologists to be the latter in a state of diffluent softening. All these varieties occur in cancerous masses; and it is to be remarked that they may be combined in the same pyloric tumour, forming separate portions of it, or it may be mingled together so as to lose their distinct STOMACH, (ORGANIC DISEASES OF THE) 257 character. They are all referable to some of the varieties of carcinoma, which Dr. Carswell has classed under the two species, which he has de- nominated cephaloma and scirrhoma in the Article Scirruus. We refer to this for the anatomical and physiological history of these heterologous tissues. 2. The cardia is the situation in which, next in frequency to the pylorus, the disease occurs. The structural changes differ from those of the pylorus only with respect to their conformation and their relation to the neighbouring viscera. The can- cerous mass is seldom voluminous in this situation, but the disorganization extends generally for some space along the lesser curvature and into the oeso- phagus. Instead of the loose tumour which the pyloric extremity presents when it is the seat of the disease, rarely any morbid appearance is to be seen until by opening the stomach it can be in- spected from within. It is then perceived that a greater or less narrowing has taken place in the cardiac orifice by the deposit of the foreign sub- stance. The latter is disposed in various ways; at one time it forms an annular circumscribed stricture, occupying precisely the orifice; at an- other it projects internally, having burst through the mucous membrane, and presents a cauliflower fungus. Such a vegetation has been known to hang loosely from the edge of the orifice into the stomach, like a valve, so as to prevent the rejection of its contents by the act of vomiting. 3. The body of the stomach is, in comparison with the other situations, rarely the primitive seat of cancer. It is, however, by no means uncommon for the affections of the cardiac and pyloric orifices to spread for some space, and involve the adjoin- ing portions of the organ ; especially the lesser curvature, which is sometimes found disorganized through its whole extent. In this case the gastro- hepatic epiploon with the lymphatic glands and the vessels contained in it often partake in the disease ; as, in like manner, if the greater curva- ture be much engaged, the greater omentum may be found in a state of scirrhous degeneration. Independently, however, of disease of either the cardia or pylorus, the cancerous structures in the various conditions above recounted are occasion- ally observed in the body of the stomach. It is here more especially that a variety which is pro- perly called primitive cancerous ulcer (to distin- guish it from those ulcerations which occur in previously existing cancerous deposits) is found. This form of disease commences and runs its course without any antecedent deposit of cancer- ous structure which can be discerned ; yet, as it spreads, its edges are distinguished by a scirrhous hardness, and upon its surface grow fungus vege- tations which partake of this character. There is, moreover, another form which is in a measure peculiar to the body of the stomach, being rarely met with at the pylorus or cardia. We allude to a hard circumscribed condition of the parietes, caused by what is called atrophic cancerous de- generation. The area which this occupies ap- pears contracted, and the mucous membrane in- volved is condensed and puckered into hard ridges or star-like streaks. The scirrhous substance does not undergo softening as the other varieties; the alteration which time induces is rather to contract Vol. IV. —33 w* it, and give to its texture a more gritty hardness. It seems to be a laminar deposit of the cartilagi- nous structure, properly called scirrhus, and it is said to be accompanied with lancinating pains of a more intense description than any other variety of morbid product The lesions thus detailed are those which are immediately connected with the pathology of can- cer of the stomach : we have now to advert to some variations of these which are of minor inte- rest in this regard, but yet are worthy of attention as connected with some striking phenomena which occasionally complicate the disease towards its termination. The usual course which the cancerous mass takes in its progressive development, as above re- marked, is towards the interior of the stomach. Exceptions to this rule sometimes occur, in which a contrary direction is chosen, and then this mor- bid product exhibits its well-known characteristic of propagating itself from one surface to another, which is unconnected with it, either by continuity of tissue or analogy of organization. From this it results that other organs are involved in the morbid appearances by a process which is suffi- ciently evident from an examination of the lesion. In its outward progress adhesions are contracted '■ between the peritoneal coat of the stomach and that of the adjacent organ, and the cancerous matter is deposited in the latter, while its proper tissue is absorbed, apparently by its advancing pressure. This is most frequently observed in ! the liver, the middle lobe of which is often found I firmly united to the pyloric end of the stomach by ' a cancerous mass, which had originally spread from the latter. A similar propagation of it takes place to the other neighbouring organs, the spleen, pancreas, colon, &c. Many of the morbid phenomena depend upon | the degree in which softening has proceeded in the cancerous formation. This process is for the | most part slow in its arrival, and partial. In- stances, however, are known in which it pervaded the entire thickness of the mass, and induced | rapidly fatal peritonitis by its perforation. (See Perforation.) But this is rendered a rare oc- 1 currence by the adhesive union, which is usually established between the stomach and adjacent vis- cera before perforation can ensue. The same pro- • vision, however, which prevents this accident, gives occasion for the softening cancerous mass to pursue its course into the adherent organ : in this* way the liver has been found deeply corroded, and forming a cavity continuous with the stomach, the parietes of which were in this place destroyed, and their edges adherent to the liver. In an instance which is on record, a cancerous mass above the cardia propagated itself into the right lung, ami excavated it into a profound cavern, in which food was found lodged. Still more striking conse- quences are exhibited in some rare cases in which the softening cancer proceeds to a perforation, while the stomach is united by adhesion to the anterior wall of the abdomen, or to some of the intestines. In the former instance an external fistula is formed, and the food having free egress escapes in the abdomen. In the latter, the con- tents of the stomach and of the intestine pass re- ciprocally into each other by tha perforation: on 258 STOMACH, (ORGANIC DISEASES OF THE) the one hand, frecal vomiting occurs as a conse- quence ; and vice versa, the aliment passes from the 6tomach through the opening, directly into the intestine, and is voided without having undergone the action of its natural passage. These are the organic lesions directly connected with this disease which post-mortem examination discovers. Besides these, it is to be remarked that other organs are found simultaneously with the stomach to be the original seat of cancerous depo- sits, of which the most frequent are the liver and pancreas. Finally, we must not omit to observe that the morbid appearances of several other dis- eases, which are known occasionally to complicate its course and termination, are revealed by dissec- tion. Amongst these may be enumerated inflam- mation of the lower portion of the small intestines, peritonitis, bronchitis, tubercular disease of the lungs, and of other organs. In pursuing the pathology of the disease, it will be useful to subjoin to this account of the anato- mical lesions some remarks with reference to the influence of these in the production of the symp- toms as above detailed, and to notice here some variations in the latter, which are more or less ex- plicable by the former. The connection between some of the phenomena and the organic lesions is direct and obvious, in others obscure. In advert- ing to some instances in which it may be recog- nised, we shall consider in what manner the sto- mach is affected by the morbid product as to its functional and physical relations, and then notice that constitutional depravation which it gives rise to, called cancerous cachexy. a. Doubtless the organic lesion produces a pre- judicial effect upon the functions of digestion and general nutrition, and must in this manner con- tribute materially to the cachectic emaciation. This would be anticipated, on considering the malignant character of the disease, and the pri- mary position which the stomach holds in the digestive apparatus : and it seems proved by the fact that the emaciation is a more prominent fea- ture of cancer when seated in the stomach or in- testines, than in any other organ of the body. Some cases, however, are occasionally met with, which show that its influences in this respect are not so great, or at least so general, as would be suggested by these considerations; for such must be the inference drawn from cases on record, in which little diminution of the appetite and no emaciation took place, while the stomach was profoundly disorganized by cancerous deposit. In these instances the disease was situated at the pylorus and the lesser curvature, leaving the larger end of the stomach untouched. (See Chardel, p. 39; and Abercrombie, Diseases of the Stomach and Intestinal Canal, p. 61.) This is an interest- ing remark, inasmuch as the latter is the part of the stomach in which the functions of chymifica- tion and absorption are mainly performed ; and it permits the conclusion, that unless cancer either invades these parts, or becomes a focus of irrita- tion for the entire organ, these functions remain comparatively uninjured, b. In its physical rela- tions the chief pathological considerations are the mechanical obstacles which the cancerous pro- ducts afford to the passage of the aliment. These exist when the disease is situated at either of the orifices, and they become the source of some of the phenomena which are most pathognomonic of the malady. When they occur at the cardia, the food being hindered in its entrance into the stomach, is rejected shortly after deglutition. But if the pylorus be the seat of the obstruction, the alimentary mass is retained in the stomach for a period of two or three hours during the process of chymification; at the end of this, in its pro- gress towards the intestine, it meets the pyloric obstruction, and then vomiting is set up. The amount of obstruction which is presented varies from the smallest contraction of the dimensions of the orifice to a total occlusion. It appears self- evident as a general rule, that the constancy of vomiting is in proportion to the obstruction ; but exceptions to this occur of such a nature as make it manifest that the mechanical obstacle is but a part of the conditions on which this symptom depends. The most obstinate vomiting has been observed in cases where a pyloric tumour was so situated as to produce little or no contraction of this orifice: and, on the other hand, its calibre has been found greatly diminished in instances in which vomiting rarely happened during the course of the disease. These different facts demonstrate that other conditions conspire with the mechanical obstruction, and modify its effect in producing vomiting; the most obvious of which is a state of congestive irritation in the organ. Cardiac obstruction gives rise rather to a regurgitation of the food than the proper act of vomiting; but notwithstanding this, it is the cause of deeper dis- tress than that of the pylorus, as, on account of the food not reaching the stomach, the pangs of hunger may be added to the other sufferings of the disease, and the slow progress of the latter may be anticipated by a deplorable death from inani- tion, c. Its propagation to other organs, and the pathological complications which their affections furnish, constitute another class of phenomena entering into this malady. To this may be re- ferred the jaundice, which is not an uncommon occurrence, particularly in the advanced periods of the disease : it owes its origin for the most part to direct disease of the liver, but it may be also produced by the pressure of a cancerous tumour of the stomach upon the bile-duct. The anasarcous infiltrations have been simply referred to the debility of the last periods of the disease, which undoubtedly contributes in many cases to their production ; but they have been observed in others where the strength was as yet little broken, and the vigour of the circulation undiminished. On this account we must look to other sources in order to give a sufficient explanation of them; and these are presented to us in the obstructions of the venous circulation, which are caused alike by morbid states of the liver, and by the direct pressure of a pyloric tumour upon the trunks of the vena? porta? and cava?. These vessels them- selves may also be the seat of cancerous deposits, as in the remarkable case detailed by Reynaud, in which obliteration of the right branch of the vena porta and the inferior vena cava was produced by a foreign substance (apparently encephaloid) de- posited within their cavity. (Journal Hebdoma- daire, 31 Oct. 1829.) d. Cancerous cachexy is the term which designates the special alteration STOMACH, (ORGANIC DISEASES OF THE) 259 of the whole system sooner or later consequent' upon the disease in whatsoever part of the body I it is situated. It comprises all the effects of the morbific influence which it exerts on the general constitution, distinct from its local ravages, or the sympathetic derangement which these give rise to in other organs. When fully developed, it is characterized by a peculiar livid colour of the skin and the mucous membranes, emaciation, friability of the solids, and diminution of density in the liquids, but more particularly of the blood. To the change which it produces in this fluid is to be ascribed the facility with which hemorrhage occurs in advanced cancerous deposits, and the liquid uncoagulable character of that which is occasion- ally vomited during the latter stage of cancer of the stomach. It is to be observed that the full manifestation of the constitutional cachexy is less frequently met with in cancer of the stomach than elsewhere; because, as it would seem, the lesions of this organ are more injurious to the vital eco- nomy, and so anticipate the time in which the general system becomes fully subjected to the malignant influence of the cancerous disease. Finally, we would remark that this constitutional condition receives additional interest, if we may contemplate it as having any connection with the facts mentioned by Dr. Carswell relative to the presence of carcinomatous substance in the blood. (See Sciriihtjs.) The essential nature and the origin of cancer of the stomach are points to which all other mat- ters in pathology are secondary. As the elementary morbid product of which it consists is identical in this and in other organs, the question of its origin here involves that of cancer in general. Many doctrines have been from time to time promul- gated on this mysterious subject, but have succes- sively fallen into merited neglect, being founded on crude and insufficient observation. In the pre- sent day it is studied in a manner which promises more fruit; but it must be confessed that modem researches, while they have exposed false views, have done little more: the origin of cancer still lies covered by the veil which keeps from our pe- netration the secret operations of nutrition and special secretion. The reader is referred to the article SciRnnus for an account of the subject, which is carried as far as the actual state of know- ledge permits. We only desire to express here our full accordance with the author in renouncing two modern theories on the subject; one of which assumes it to be a degeneration of a pre-existing tissue, and the other (chiefly supported by Andral), which maintains, that in its essence it differs no- thing from hypertrophy and induration of the submucous cellular tissue. It is a generally admitted fact, irrespective of any theory concerning its essential nature and ori- gin, that the deposit of cancer in the parietes of the stomach is preceded by an irritation in this organ. Much diversity of opinion exists concern- ing the nature of this irritation, and it is well known to be the doctrine of Broussais that it is of an inflammatory nature; he has in fact main- tained that cancer is a direct product of inflam- mation. It is a question of very difficult solution to decide in what manner this irritation differs from inflammation; but that it does so is not doubted by any pathologists who confine the latter term to its ordinary signification. Without offer- ing any opinion on this subject, we merely notice it in this place for the purpose of adverting to a practical point connected with it, which is deserv- ing of notice; namely, whether the irritation which precedes it (whatever be its kind or degree) originates in the mucous membrane, or has its primary seat in the subjacent cellular tissue, where the foreign substance is found deposited. To de- termine this directly, the stomach should be in- spected in its first stage, while it yet retains the earliest appearances of the disease. But oppor- tunities of post-mortem examination are rarely presented until a long continuance of the disease has produced great alteration, so that immediate proof is wanting of the relative condition of the tunics at its commencement. The mucous mem- brane has, however, been found in its physiologi- cal state at a time when the subjacent texture was filled with the cancerous product. Recamier has observed the latter developed to several lines, or even an inch in thickness, while both the mucous and peritoneal coats were in a healthy state and glided without any adhesion over the engorge- ment. (Recherches sur le Traitement du Cancer, t. ii. p. 44. Paris, 1829.) This proves, according to him, that the latter was not of an inflammatory nature in these cases; and he infers, a fortiori, that as the tunics were not in a pathological state at an advanced period of the subjacent deposit, they had not been so at an earlier. M. Andral has exa- mined this question with his usual sagacity, and has fully shown that such negative facts are not to be received in evidence. In adducing his argu- ments we should state, that although we have not adopted the opinion with which this eminent pathologist has connected them, (namely, that scirrhus and cancer is a mode of induration of the cellular tissue,) yet, as we recognise the fact that such a conditjon is frequently a nidus for its de- posit, and moreover agree with him that it is pre- ceded by irritation, they are equally applicable to the notion we entertajn as to its origin. He first illustrates the fact, that in irritations of the intes- tinal, bronchial, urethral, and conjunctival mucous membranes, and of the skin, the subjacent cellu- lar tissue is frequently involved. He then passes in review some instances in which these mucous surfaces became free of the inflammation, while the subjacent tissue still remained the seat of or- ganic changes which had occurred during its sub- sistence. Of this' a familiar example presents itself to us in stricture of the urethra ; this is a circumscribed hypertrophy of the submucous cel- lular tissue, which for the most part supervenes at a period when the inflammation of the lining membrane of this canal is receding. Finally, M. Andral deduces arguments of a still closer analo- gical application from observation of certain con- ditions of the gastric mucous membrane itself: he has been able to follow the different degrees by which it returns to a healthy aspect after inflam- mation, and he has observed in many instances that the submucous tissue still remained morbidly affected. His observations and reasoning appear to us satisfactory as to the general principle: while, therefore, we draw a broad line of distinc- tion between scirrhus and hypcrtrophied cellular 260 STOMACH, (ORGANIC DISEASES OF THE) tissue, which he identifies, we are enabled to enter fully into his conclusion, viz. that cancer may arise in the submucous cellular tissue of the sto- mach, subsequent to irritation originally seated in the mucous membrane. We add, that Chardel arrived at a similar conclusion from the study of the anatomical lesions, (Op. cit. avant propos. p. 11); and his opinion is so much the more entitled to regard, as it was expressed before it became a subject of doctrinal emulation in the schools. We shall, lastly, advert to that branch of the etiology of the disease which includes its occasional causes. The concurrence of all observers places as the foremost amongst these, the operation of depressing moral emotions; and it may be indeed stated, that the influence of the mind upon the animal economy is not so prominently displayed by any other chronic malady. Corroding cares, caused by reverses of worldly circumstances and disappointment, concealed grief, and protracted terror, are the conditions of mind which are more particularly connected with its origin: so com- monly does it partake of their influence, that few cases occur in which some of them could not be discovered, were it always possible to fathom the moral history of its subjects. With reference to this, it is worthy of remark that during and sub- sequent to the French revolution the disease was common in France, and it seems probable that many of the numerous cases, which Chardel's monograph contains, were caused by " the reign of terror." This was the malady of Napoleon : when he arrived at St. Helena he was in the posses- sion of perfect health, and it was two years after- wards that the first indications appeared of this disease, which slowly consumed his life in a period of three years and a half. We allude to his case as an example of these conditions acting probably at a maximum ; yet we have seen the same causes produce similar effects in individuals who occu- pied the other end of the scale of moral power. The mode of action of this class of causes it is very difficult to explain, and according to the pre- sent strict method of investigating medical doc- trines, it seems rather to be drawing more than is warranted by the actual data, to offer any decisive opinion with respect to it. It cannot, however, be reasonably doubted that their direct action is on the nervous system, and we feel much inclined to assent to the opinion which Lobstein has ven- tured to put forth concerning their remote effect. He affirms that moral emotions give rise, first to a defective innervation; secondarily, to a perverted nutrition, in which consists the elementary change which produces organic products of an anomalous nature. (Anat. Pathol, tome i. p. 557.) There are various phenomena connected with the healthy action of the economy, the cessation of which may become occasional causes. Some of those are of a physiological nature, as the menses; others are pathological, but are so habitual or periodic that they become, as it were, grafted on the constitution; to these belong hemorrhoids, sweats in different parts, as the feet and axillae, headachs, periodic gout, &c. The suppression of these has been known to originate cancer in the stomach as well as in other parts of the body, and with these may be classed the existence of a syphilitic taint in the system, under the influence j of which, if not this, a disease in almost all re- spects similar has been known to arise. It has also been clearly traced, in some instances, spring- ing up as a consequence of hereditary predispo- sition. Other causes are to be enumerated of a more definite and local character ; amongst which is to be first mentioned the long-continued use of ardent spirits. It is incontrovertibly established by a collection of many facts that this disease is fre- quently brought on in those who become addicted to the inordinate use of spirituous liquors; it is not, however, so clear that the entire effect of these is owing to their local action as a stimulant to the stomach, which some are ready to maintain. Several considerations with respect to individuals of this class seem to oppose this, and we are dis- posed to think that this cause acts, in part at least, upon the nutritive function in a manner analogous to the first set of causes, either by a prejudicial effect upon the nervous system or di- rectly upon the blood. But whether its action be general, or merely local, or that it partake of both, it is certain that this effect of habitual drinking is much promoted by the depressing passions. These act in the relation of a predisposing cause to de- termine this effect from the former ; and unhappily amongst the poor, the influence of both is too frequently found in concert, from the prevalence of ignorance, and of the desperate delusion which tempts the wretch blindly to have recourse for solace to the ruinous habit of drinking. Continued pressure on the epigastrium, or me- chanical injury of this part by any means, are also to be reckoned amongst the causes of this disease. Chardel relates two cases, which exem- plify the effect of such causes: the one of a hatter, whose particular province obliged him to press the abdomen against a board ; a cancerous tumour formed in this man's stomach, which ulti- mately broke through the abdominal parietes by the formation of a gangrenous slough at the epi- gastrium: the other case was that of a coachman, in whom the disease occurred consequent upon the kick of a horse received at the lower part of the chest. (Op. citat.) Haller has recorded one of similar import in the instance of a young man, who in a drinking revel received a kick in the belly from his drunken companion, and afterwards became affected with a lingering and ultimately fatal illness, which was proved on dissection to be caused by an extensive cancerous disorganization of the stomach and omentum. (Opuscula Patho- log. Lausan. 1755, p. 49.) These cases are illus- trative of the effect of mechanical injuries of the epigastrium in giving rise to cancer of the stomach, a result, besides, which ample evidence has estab- lished. While, therefore, it is fully acknowledged as an occasional cause, the explanation of its action is not so easy as may at first appear, inas- much as, for several reasons, it seems evident that its influence is not to be directly referred to its immediate irritation of the parietes of the stomach. First, because, as Chardel observes, the cancerous product resulting is not found to occupy the part of the stomach which receives the direct mechanical impression, namely, the anterior wall which lies against the epigastrium, but manifests the same election as to situation (the pyloric or cardiac ex- eTOMACH, (ORGANIC DISEASES OF THE) 261 tremities) as when it arises from other causes. Moreover we remark that mechanical irritants acting, though with considerable force and perma- nency, merely on the walls of the stomach, do not produce cancer. Thus we find, in a case noted by Baillie, in which five halfpence were lodged in the stomach for some time, and had formed a pouch by their pressure, " the coats of the stomach were thinner at that part, but were not inflamed or ulcerated," (Morbid Anatomy, 1793, p. 92); and in another recorded in the Medical Commentaries, two pistol-bullets were lodged in the organ, previously the seat of cancer, for two months, apparently without any effect. (Vol. iv. p. 154.) A third, more curious than either, is the singular case narrated by Tonnelier, and witnessed by Laennec, of a girl, who, with the purpose of poisoning herself, swallowed an ounce of arsenic, but unexpectedly recovered. Again, a year afterwards she took poison, and this time died. On post-mortem examination, beside the effects of the recent poison, a cyst was dis- covered of the size of a goose-egg, which had been obviously just detached from the parietes of the stomach near the pylorus: on being opened, it was found to contain an ounce of arsenic. (Auscult Mediate, vol. ii. p. 634.) These cases afford examples of the action of powerful mecha- nical and chemical irritants immediately upon the stomach ; yet by none of them was displayed any disposition to the formation of cancer. The ques- tion then recurs undecided—in what manner do pressure and contusion in the epigastric region act, in occasioning cancer of the stomach 1 Chardel thinks that their injurious operation can only be accounted for by their mechanical disturbance of the process of digestion. It is an inquiry of much interest; and while we abstain from expressing a decided opinion, we beg to suggest it as an im- portant consideration, how far it is to be referred to a lesion of innervation, caused by a mechanical shock on the solar plexus. If such an explana- tion should be accepted, it would place epigastric contusions and moral emotions in the same class of causes, and permit us to express their mode of action similarly.* The abuse of certain therapeutic agents must not be omitted amongst the occasional causes of this disease. Those medicines are to be reckoned as such, which while they are exhibited for the sake of their specific effect, depress the animal system, and at the same time act locally on the organ. Preparations of mercury and arsenic are * The above was written before we met with M. Re- camier's opinion on this subject, and we are gratified at finding that it is expressly similar to that which we have proposed. He brings forward several arguments of a positive as well as negative import, against the notion of cancer being developed in the stomach by the mere irritation of the viscus from local violence, and proving that the operation of the latter is to be referred to " ner- vous commotion." He cites two facts which stem decisive. One person received a blow in the pit of the stomach, which was followed by violent pain and anxiety in this region, yet the individual stated that he had been scarcely touched by the blow. Another was only frightened by a gesture imitating a blow, which however was productive of the same anxiety and " malaise." In both individuals an organic affection of the stomach was consecutively de- veloped. " Such examples at the same time manifest this," adds this experienced and judicious author, " that general commotions of the system exhibit their local power in proportion to the local predominance of nervous susceptibility."—Op. citat. tome ii. p. 45. especially alluded to; and it must be confessed that the effects of the former in inducing that con- dition of the system which is favourable to the development of anomalous products, have not been hitherto sufficiently regarded ; they begin, however, to excite general attention. The fear of this dis- ease forms also one of the chief reasons for vigi- lance in using arsenical medicines in minute doses. Their exhibition should be strictly watch- ed, that the constitution be not kept too long under the influence of this mineral; which, as would appear from the case cited by Laennec, has not the power of originating the disease by its local effects, unless the economy be previously deteriorated by its general influence. Finally, with respect to inflammation, (without reverting to the question as to whether it may be an occa- sional cause of cancer of the stomach,) it is of the utmost importance to be aware that it frequently accompanies its commencement, complicates its course, and hastens its termination. Diagnosis.—Accuracy of diagnosis is the foun- dation of good practice in all diseases, but if it be required in the practitioner on one occasion more than another, it is when engaged about the dis- eases which are deemed incurable, because upon it so much depends. On the one hand, the mistak- ing of a disease beyond the resources of medicine for one in which these might be applied with success, subjects the patient to illusory hopes, and treatment that might have been spared, or that may even hasten the unlooked-for termination. On the other, the pronouncing a disease to be incurable, which in reality may not be so, is a still more grievous error; for this cuts off from the patient resources which had been available, were they not interdicted by ignorance of the nature of the disease ; not to speak of the loss of reputation which accrues to the practitioner, if the course of nature or the application of another's skill discover his error, by restoring to health the patient whom he had doomed to the grave. These remarks are worth attention in connection with the disease before us, to which they are obviously applicable with reference to its incurable nature; but they are so equally with respect to its diagnosis, concerning which we should greatly miscalculate, were we to estimate its facility by merely regarding the profound organic changes and the prominent features of its history, as we have endeavoured to trace them. No general description could comprehend all the diversity which its symptoms may present; more particu- larly, however, we wish to direct attention to this fact, that its most striking phenomena may be simulated in the course of some diseases which have a totally different origin and issue. For the purpose of elucidating its diagnosis, we shall now compare it with the affections which present similar phenomena: this can be effected most conveniently by noticing these affections in con- nection with the symptoms of cancer of the stomach which constitute the resemblance between them. This method also affords us the opportuni- ty of noticing some diversities of these symptoms, which were reserved for consideration in this place, as they are chiefly important with reference to the diagnosis. a, Vomiting—It may be in general stated, that 262 STOMACH, (ORGANIC DISEASES OF THE) when vomiting occurs immediately after deglutition, the disease is situated at the cardia, and that when a period of two or three hours elapses, its seat is at the pyloric extremity. No relation which can be with certainty relied on, appears to exist be- tween the intensity of this symptom and the extent of the cancerous deposit which causes the obstruction; for besides the latter, the state of general irritability of the organ influences it in a degree little inferior; and this is often observed to be greater at the first period of the disease than later, when much disorganization exists. Much diversity is to be remarked in the different stages of the disease with respect to the character of the vomited matters. In the beginning they con- sist of large quantities of ropy mucus, and of this mingled with the aliment in different stages of digestion. Afterwards they become mixed with secretions of dark-coloured fluid, in which a sedi- ment forms like the grounds of coffee. These, with a muddy liquid of the colour of chocolate, and occasionally blood, are the fluids thrown up from the stomach, which are regarded as charac- teristic of the confirmed and later periods of the disease. Nevertheless, it is to be remembered that this symptom may occur under every variety as a phenomenon of other diseases ; so that neither its constancy or periodic recurrence, nor even the quality of the matters vomited, can with certainty assign it to cancer of the stomach. Added to this, other semblances of the disease may coexist with it, which tend to heighten probability to its high- est pitch, and yet it may be unconnected with it. This is strikingly illustrated by two cases related by Louyer Villermay. One, a man aged forty, whilst a prey to profound grief, became affected with nausea, weight and shooting pain in the epigastrium; to these were added, while his strength declined daily, vomitings after every meal. After a month's treatment this man recovered. The other case was a youth aged twenty-one, who had many of the preceding symptoms, and in addition to these, the vomiting continued for nine months, and the matter rejected was of a blackish colour. The application of blisters and other remedies completely restored his health. Chronic gastritis, affections of the liver and gall- ducts, are some of the other various sources whence it arises. Certain forms of hysterical disease exist, also, in which a constant vomiting often prevails as the principal symptom for months; in one instance of this kind within our observation, it continued unappeasable night and day upwards of two years. An infinite variety of cases are also on record of nervous or spasmodic vomiting which for obstinacy might be compared with that caused by the most profound organic lesion. A, most remarkable in- stance of this is related by Morgagni in the case of a lady of Padua, who was affected with this symptom from her birth. It came on two hours after dinner daily, and during pregnancy at the age of thirty-four it became much aggravated ; and thence it continued unremitted until her death, which happened twenty-four years after- wards. No organic disease was found in the stomach, but it was small and contracted near the pylorus, so as to appear divided into two parts. Vomiting, with a long succession of symptoms which were mistaken for the effects of organic disease, were caused, in a singular case recorded in the Memoires de l'Academie Royale de Chirur- gie, (Tom. i. p. 702,) by hernia of the stomach between the recti muscles. The patient, a young surgeon, underwent the most severe sufferings, chiefly from the unconquerable obstinacy of the vomiting, and found no relief from a great diversity of treatment, until at length, hearing a description of this rare affection from Garengeo, he thought that he recognised the source of his own disease, whereupon he applied a proper truss, and from that hour was cured. Finally, with regard to bloody vomiting, and especially the fluids resembling chocolate, if these coincide with other prominent features of the disease, it cannot but be considered a symp- tom of ominous import. Yet in proportion as it merits this character in its true connection, caution should be exercised not to assign it a false value in cases where it is not really indicative of this disease. The other conditions under which blood may be vomited are its metastasis from hemor- rhoids, retention of the menses, or any suppressed discharges. Falls and contusions not unfrequently give rise to ha?matemesis which continues long after all their other effects have subsided. It may be caused by hemorrhage from the posterior nares, which has been found to pour its blood into the stomach, and to be rejected from thence at intervals of a mela?nic appearance.* b. Tumour.—On referring to the anatomical relations of the two orifices, it is scarcely neces- sary to remark, that when a tumour, externally perceptible, is developed by the disease, the pylorus is its probable seat. We say probable, because, although a rare case, a cancerous growth situated in the body of the stomach may attain to such a form and size as to be felt through the parietes of the abdomen ; and it is conceivable that even a cardiac tumour might be detected by the touch, under the ensiform cartilage, in an individual with a short breast-bone. The characters belonging to a pyloric tumour are more or less distinctive. It is felt, for the most part, rather on the right of the median line, lying obliquely from right to left, with its most prominent part two inches below the lowest rib. It is movable by the hand, so as to allow of being pushed considerably out of the position it occupies ; and it possesses, more- over, a spontaneous motion, which affords a diag- nostic mark with respect to it of peculiar value; under the influence of this, it may be placed one day in a different situation from that of the pre- ceding, and it sometimes even retires so deep, as to be no longer distinguishable by the touch, which circumstance has been known to create some embarrassment. The presence of the tumour is the least equivo- cal sign of the disease ; but yet the diagnosis can by no means be reposed upon it with an unreserved confidence ; for, in the first place, extensive can- cerous disorganization has been found at the pylo- rus as well as in other situations of the stomach, after death, which had previously escaped the most accurate investigation. Its thickness may be * See this origin indicated, case by Manchart Misc. Acad. Nat. Cur. dec. iii. and iv. (Arckiv. Generates, Oct, 1833;) also by Dr. Graves, Dub. Med. Journal, vol. i- p-287. STOMACH, (ORGANIC DISEASES OF THE) 263 too small, or take an internal development, or its situation may be entirely confined to the posterior part of the pylorus. Any of these conditions may prevent it from being recognised; moreover, other abdominal tumours frequently present themselves, from which it requires not a little discrimination to distinguish it. It is unnecessary here to do more than indicate that these may be constituted by any of the following, namely, tumours situated in the liver, the pancreas, the omentum, the me- sentery, the colon, the abdominal parietes, and by aneurisms of the aorta. Two cases are before us which illustrate this double source of fallibility here referred to, that is, with regard to the presence and the nature of the tumour. The one was fering with an aneurismal tumour. The utility of this admonition is testified by a case published by Mr. Porter, of a man, who, amongst other dis- tressing symptoms, had nearly complete inability of passing any food into the stomach, and fre- quent vomiting ; for these a probang was intro- duced, without meeting any decided obstacle, but without relief. Death suddenly occurred six days afterwards, and post-mortem examination disclosed a large aneurism of the aorta, which had burst into the oesophagus. (Dub. Med. Journal, vol. iv. p. 206.) c. Emaciation, pain, <$c.—Cachectic emaciation is common to this with many other chronic dis- eases ; it is, however, to be noted, that as far as that of a man who died of pulmonary inflamma- | this symptom depends upon cancerous develop- tion of five weeks' standing. He was under the observation of Dr. Graves for seventeen days pre- ceding his death, and during that time no pheno- menon was remarked, capable of exciting the sus- picion of organic disease of the stomach. This organ, on dissection, externally presented the ap- pearance of an hourglass contraction, but on open- ing into its cavity, a morbid growth of a medul- lary structure, equal in size to a large mushroom, was found projecting internally from the greater curvature, about midway between the two orifices. (Dublin Medical Journal, vol. ii. p. 175.) The other case, occurring under the same physician, in the Meath Hospital, was one in which a fistulous opening permitted the food to pass out from the stomach through the abdominal parietes; and no doubt was entertained but that this remarkable phenomenon depended upon the softening or ul- ceration of a cancerous mass, its ordinary source. On dissection, however, it was shown to be caused by the bursting of an encysted abscess of the pe- ritoneum at once into the stomach and externally through the walls of the abdomen. Cancerous growths of the cardiac orifice become also frequently objects of exploration ; and as ob- structions in this situation are in the majority of instances caused by tumours of this nature, their diagnosis is of fearful interest, both on account of their ominous character, and of the dysphagia re- sulting from them, which occasionally proceeds to such a degree as to occasion death from inanition. As the various abdominal tumours complicate the diagnosis of disease of the pylorus, in like manner cardiac cancer may be simulated by morbid pro- ducts within the thorax of a very different origin. Innumerable instances are on record in which en- ment it is unaccompanied by febrile action. This observation serves to distinguish it more especially from that which attends upon tubercular phthisis, as hectic fever is more or less prevalent from the time that emaciation sets in in the latter disease. But notwithstanding this, in individual cases of cancer of the stomach which are complicated by a catarrhal affection, so much resemblance may exist in many of their features to phthisis as to embar- rass the diagnosis at the first examination; at the present day, however, in which the resources of auscultation and percussion are becoming fully recognised, this difficulty cannot exist long. The pain belonging to this disease is peculiar, and a difference has been even remarked with respect to it as occurring at the two orifices. When the cancer is seated at the cardia, the pain is described as a tensive circumscribed sensation about the pit of the stomach, striking through to the back, and exciting a feeling of incipient suffo- cation, which is aggravated on taking food, and relieved by vomiting. (Pemberton, Practical Trea- tise on various Diseases of the Abdominal Viscera, fourth edit. 1820, p. 128.) The pyloric affection gives rise to pain less confined to one spot, but rather producing a dragging sensation (as the pa- tient sometimes expresses it) over the upper part of the abdomen. But, besides these local pecu- liarities, the lancinating pains which are common to cancer in all situations must not be omitted, nor yet a characteristic circumstance which is still more properly diagnostic of this terrible disease, namely, that the pain does not immediately respond to pressure upon the morbid product, as does the pain of inflammation, but allows a sensible after- period to elapse, when it occurs, as it were, by a largements of the bronchial, oesophageal, and the j spontaneous reaction. It is here, however, im other lymphatic glands of the mediastinum have caused dysphagia, and ultimately, as its conse quence, death. (De Glandulis Thoracis Lympha- ticis atque Thymo, Specimen Pathologicum. F W. Becker. Berol. 1826, p. 56.) The same re- sults may be derived from abscess situated behind portant to observe, that on collating the history of several cases of simple ulceration of the stomach, with reference to this symptom, no difference suf- ficiently distinctive could be established between it and that of cancer. The dark colouring of the skin is one of the the oesophagus, and from aneurism of the thoracic most characteristic signs of the cancerous cachexy, aorta. In these doubtful cases the principal me thod in use for exploring the state of the cardia is the introduction of the probang, but when this is called for, it is commonly as much for the purpose of endeavouring to overcome the obstruction as to establish its diagnosis. Under such circumstances, however, this means of examination requires to be employed with great caution, and this more es- pecially with reference to the possibility of inter- yet it is so often absent in this disease that it can- not be depended on as a symptom of negative import. Terminations.—When it once becomes estab- lished that the stomach is the seat of cancer, the only question which the prognosis admits regards the duration of the malady, for no other hope grounded on experience can be entertained but that it must inevitably terminate, sooner or later, 264 STOMACH, (ORGANIC DISEASES OF THE) in death. We are aware that some, in contem- plating the cicatrices of ulcers of the stomach, which have been found in a few rare cases, have been led to express a less rigorous conclusion ; we cannot find, however, that this is countenanced by the healing in any instance of ulceration of the stomach which could be demonstrated to be con- nected with a cancerous deposit We have referred to the intermission which occasionally takes place in the early periods of the disease, and to the progressive manner in which its course proceeds, when these being passed away, its symptoms are all established ; but with respect to the disease in general, it is not possible to as- sign any period of time as the term of its duration. This is obvious, when we reflect upon the diver- sities in the power of resistance to morbid action which the various constitutions exhibit, and the other contingent affections which modify this ma- lady. To the slow exhaustion of the vital powers produced by the disease itself, the weakening effect of the constant vomiting is added, and not unfre- quently the deficiency of actual nutrition. The fatal period is at one time brought on suddenly by the softening and breaking up of the cancerous mass, and the consequent hemorrhage ; at another, it is hastened by the occurrence of perforation and communication with the peritoneum, which is, however, rare, from the protective causes before explained. Moreover, the affections above indi- cated, as complicating its latter stages, the diar- rhoea, inflammations of the peritoneum, lungs, and j the liver, are all influential in its termination. | Finally, observation confirms that the disease of I the pylorus lasts a considerably longer time than that of the cardia. Treatment.—It is obvious that since this dis- j ease, when decidedly formed, is one which does not yield to the resources of medicine, the most practical considerations which it presents to the mind of the physician arc those attempted to be illustrated in the foregoing part of this notice of it, which conduct to correct notions of its nature and its diagnosis. These, in the first place, sug- gest the responsible part which he performs to- wards the patient in pronouncing positively upon its existence ; and, secondly, when it is recognised beyond doubt, they should dissuade from the em- ployment of untried experiment in its treatment, which must necessarily fail, and not only disap- point hope, but tend to hasten the unavoidable pe- riod. This remark would much misrepresent our meaning, were it conceived that it contains any pretext for omitting the assiduous application of means: the first part of it is intended especially to convey a warning against a too hasty conclu- sion in any given instance that wo have to do with an incurable disease ; while the second is directed against an abuse of therapeutic agents, which mi^ht bring them into unmerited neglect were not the period in which they are unavailing plainly pointed out. In the confirmed disease, medicine, with its present resources, can only be applied with a palliative view. In the early period, however, while there is yet ground for hope that the malady has not become irreversibly fixed, or when some doubt exists in the diagnosis between it and other oiganic affections, the treatment should be directed with perseverance to combat it 'radically. But the line of demarcation must be I very obvious before we give up the latter, hope- lessly to resign the treatment to the former; and on this subject there may exist some danger of reposing too much reliance upon the minutiae of diagnosis. The following remark of a modern writer expresses appropriately our meaning, coup- i led also with a statement which may not be alto- gether unwarranted. " Our predecessors, Who were less acquainted than we with the fatal pro- ■ gress of organic lesions, succeeded perhaps oflener than we do in palliating the symptoms and pro- longing the life of the patients, by applying them- selves incessantly to oppose the most obvious symptoms. Their attention was not entirely pre- occupied, like that of the anatomist-physicians of the present day, with the incurability of the local lesion which is the source of the disease." (Gibert, Revue Medicale, Juin, 1833, p. 375. The first care which should engage the physi- cian in entering upon its treatment, is to investi- gate its occasional cause, and, if this be possible, to have it set aside. Moral causes are at once the most frequent and the most difficult to remove; but until this be, in some part at least, accomplish- ed, little success need be expected from any reme- dial measure; while, on the other hand, a decided improvement has been often observed to follow upon a change of circumstances which has alle- viated mental depression. If the malady be ob- served to spring up simultaneously with the cessa- tion of the menses, or of any other discharge or pathological condition which had become habitual, in case it be not possible to restore these, it would be a most advisable step to effect a substitute for them by the employment of some derivative plan, as issues, blisters, or local bleedings. Pains should be taken to examine into the probability of a sy- philitic taint having got entrance by any means into the system : it is a fact of a most interesting nature, that some cases presenting the characters of an advanced stage of this disease have been known to yield to a mercurial treatment, which had been undertaken as a last resource, on disco- vering that the patient had been either mediately or personally exposed to venereal contamination. Hereditary predisposition should also be inquired into,* and idiosyncrasies dependent upon temper- ament, or other conditions; and if any source of this nature be detected, appropriate attempts to obviate its influence by a total change of circum- stances should form a consideration in the treat- ment of primary importance. The main principle to be observed is the ab- straction of every condition which tends to cause or maintain a state of irritation in the stomach. It will be readily seen that, in pursuit of this, the regulation of the diet is to be chiefly relied on, and this, in fact, demands, from the earliest suspi- cion of the disease, the attention of the practi- tioner even more decidedly than medical agents. At this period he should impress the patient's mind with the necessity of submitting himself to a peculiar regimen, from which the latter ought not to suffer himself to be tempted on any occa- sion to depart. The object of this is to regulate * See Recamier, op. cit. tome ii. p. 48, for some remark- able instances of the influence of this, and the attempts proper to counteract it. STOMACH, (ORGANIC DISEASES OF THE) 265 in such a manner both the quantity and quality of the food, as that every thing of an exciting na- ture should be steadily renounced. It seems cer- tain that this disease owes its chief progress to the physiological congestions which occur during di- gestion, in accordance with the law, that the func- tional action of an organ becomes a source of irri- tation to it when in a morbid state; all the symp- toms are aggravated during the continuance of this process. This is the explanation of Chardel's remark — "La digestion finie, ordinairement le calme renait." Our aim should be to preserve a state of as great quiescence in the organ as is pos- sible, consistently with affording sufficient nutri- ment to the system. With this view the patient should deny himself the use of solid meat; and, in cases where excessive irritability of the stomach prevails, animal food should be altogether dis- pensed with. However, as the object is to spare the organ, not to reduce the system, this is not in all cases advisable ; and in individuals of a lym- phatic constitution, in whom the more animalised materials of the blood are deficient, it is contra- indicated. Nutritious broths, made without spice or vegetables, answer well for such ; they should be taken rather in small proportions, oftener re- peated, than much at one time. All the varieties of boiled vegetables should be inflexibly refused. Where animal food in other forms is judged in- expedient, jelly may still be used, arid this will be advantageously interchanged with the bland gela- tinous substances, arrow-root, sago, tapioca, &c, which, being at once nutritious and unexciting, are valuable adjuncts to the patient's diet-list. With respect to the choice of these, experience must decide, as that which is adapted to the sto- mach of one does not agree with a second, and too frequently it will be impossible to find in any of them articles which fulfil our end. Few cases occur in which milk does not serve, and, when it agrees, it should constitute a large portion of the aliment. If, as sometimes happens, it sours upon the stomach, this may be obviated by the addition of lime-water, in the proportion of one-third. (Diet, de Sc. Med. t. iii. p. 631.) Asses' milk has been endured on the stomach in cases where all other substances have been vomited. The pa- tient must be inhibited the use of wine and spi- rits ; it is sometimes, however, deemed necessary to allow some stimulant potion of this nature on account of painful digestion; and in such a case light table-beer should be preferred to alcoholic liquors, which, whatever impression they make for the time, invariably promote the progress of the malady. The meals should be taken at a fixed hour; irregularity in this matter increases irrita- bility in the stomach ; nor is it unworthy of being noted, that slowness in mastication has the effect of making substances, otherwise difficult, pass through the digestive process with much less irri- tation. We would remark, finally, that the bene- ficial effect of a rigorous regimen, in this first doubtful period, will mainly depend upon the con- stancy with which it is persevered in. We have seen a decided improvement which had followed upon its adoption speedily lost, because the pa- tient permitted himself to indulge in a slight re- laxation upon some incidental occasion. On the other hand, the example of the eminent anatomist Vol. IV___34 x Beclard affords much encouragement (if not in cancer, yet in simple ulceration) to a steady perse- verance. Having become affected with an organic disease of the stomach, manifested by unequivocal symptoms, he determined on treating it by a rigor- ous diet, little short of abstinence, from which he did not suffer himself to swerve until, after a con- siderable period, the symptoms disappeared. He recovered perfectly, and afterwards his death took place from an acute disease of the brain, conse- quent upon erysipelas; post-mortem examination displayed the cicatrix of a large ulceration in the stomach. The use of local bleeding by leeches is found beneficial when there exists evidence of more than ordinary gastric irritation, and for the relief of excessive weight and pain in the epigastric region. It may be sometimes preferable to apply them be- side the spinal column, about the first lumbar ver- tebra, in which situation acute shooting pains often occur. General depletion can never be requisite in this disease, and care should be taken in the use of leeches that they be not applied in number sufficient to give rise to a very prejudicial debility. Small blisters on the epigastrium re- peated at intervals, or kept open by an irritant ointment, may be in some cases attended with benefit, in others setons applied in this situation, or at the back, merit the trial more. Not unfre- quently, however, the weakness and irritation con- sequent upon the derivative means will be found to interdict their use. The state of the bowels will demand the continued attention of the phy- sician : they are seldom free from constipation, and the accumulation and distension of flatus, together with the weight of the alvine contents consequent upon this condition, give rise to con- siderable distress. Aperient medicines can seldom be endured by the stomach, and drastic purgatives of every kind, especially such as contain mercu- rial preparations, should never be exhibited. The daily use of emollient injections, on the whole, fulfils this indication better than the habitual use of any laxatives ; but as those lose their efficacy in time, it will be expedient at occasional intervals to assist them by a purgative or turpentine in- jection. In certain cases, however, gentle laxa- tives, composed of senna, manna, rhubarb and magnesia, or castor oil, do not disagree with the stomach, and then their use may be conveniently alternated with the enemata. Emetics are to be deprecated as injurious in any stage of the dis- ease. The antispasmodics, as castor oil, ether, valerian, ammonia, assafcetida, &c, which afford relief to the flatulence and pain in nervous dys- pepsia, should never be exhibited for the same purpose here ; their use, it is to be remembered, is invariably followed by irritation, which by no means compensates for their temporary effects of this kind ; and besides the object is better fulfilled by the seasonable application of narcotics. The administration of narcotics should not be left over to that latter period, when they are indeed indispensable, but when their alleviation of the worst symptoms is in proportion to their oppression of the sensibility of the brain. It will be very advantageous to procure their sedative action for the stomach from the first suspicion of organic disease, and they may be properly used at 266 STOMACH, (ORGANIC DISEASES OF THE) the same time as the rigorous regimen and deriva- tive treatment. Recamier's plan of exhibiting the extract of cicuta, while the patient observes a severe diet (Callisen's cura famis), seems to be more appropriate in this disease than in the scirrhous engorgements, where he employed this combined treatment with decided advantage. (Op. cit. tome i. p. 476.) (See Scirrhus.) Opium, the extracts of cicuta, hyoscyamus, aconite, bella- donna, and stramonium, have been each lauded at different times ; a variety of circumstances may incline the physician to the choice of one of them rather than another, but it seems that the general suffrage of modern practice remains only with the three first. The salts of morphia are preferred by several before any other narcotic, as producing the sedative effect with the least local and general excitation. The acetate may be given in the dose of a quarter, third, or half a grain. The solution of the muriate, in the proportion of five grains to an ounce of distilled water, is considered to be equal in strength to the common tincture of opium. In some instances where a tendency to acescence in the stomach exists, alkalies and ab- sorbents may be advantageously given in combi- nation with narcotics ; for this end we have used the following formula : R Extracti conii maculati --------hyoscyami nigri aa. gr. i. Oxydi bismuthi, gr. ii. M. ft. pilula quo- tidie bis terve sumenda. The sedative effects of the prussic acid in gastrodynia may also commend its trial: it is con- veniently conjoined with a light tonic infusion as a vehicle, as that of chamomile, calomba, rhubarb, or cascarilla. Finally, we would repeat our former observa- tion, that the treatment here detailed is applicable to the cases where, the symptoms plainly indica- ting an organic disease, we are compelled to ap- prehend the coming on of cancer, rather than to those in which its presence is too obvious to be mistaken. Where the constitution is sinking under this disease fully developed, the medical art can do nothing more than attempt the palliation of its appalling symptoms, and it affords for this object scarcely any resource but a free use of anodynes. An opium plaster, or one composed of extracts of belladonna and cicuta, with a little camphor, applied to the epigastrium, may procure temporary relief. If diarrhoea supervene, it should be opposed by astringent opiate injections. In the case of impending inanition from the rejection of all kinds of food by the stomach, some support may be derived from the use of nutritive in- jections, and the application to the abdomen of large poultices of bread and milk. The anodynes fail at length in procuring rest, and towards the close the disease triumphs wholly without control. II. Ulceration.—In noticing this and the re- maining organic diseases, we shall not pursue the systematic method which we observed in cancer of the stomach. These affections are of great interest and have been much studied of late, but to the present time they have been handled by writers rather in the form of essay than of regu- lar treatise; and this appears to us to be still the best adapted to the measure of our knowledge of them. Besides, much information with reference to them is contained elsewhere in this work, as their consideration belongs in many respects as much to other articles as to this. Ulcerations of the stomach are less diversified in their anatomical characters than those situated in other parts of the alimentary canal; all the va- rieties which it is of any pathological interest to remark, may be comprised under three heads, as follows: 1. The form which is more especially called the simple ulcer. This is a solution of continuity which extends more in breadth than in depth, being seldom found to engage any of the tunics beneath the mucous membrane. Its shape and extent are various, but it is more usually found to affect a roundish form than any other. The edges are formed by the mucous membrane smoothly eroded, and are not elevated above the rest of its surface; the base or ground is uneven, and often studded with minute vascular eminences, or small patches of the mucous coat which had been iso- lated in the midst of the ulceration. Over the parts of the stomach which are not engaged in the lat- ter, more or less vascularity prevails, and accord- ing as this is the case, the ulcer presents different shades of colour. This is a form which is either acute or subacute, and it corresponds to the ulcer- ations which occur in the lower third of the ileum, and in the colon, but does not embrace the patches of agminated glands, which are so conspicuous in it, when it occupies those situations. It may be present in any part of the organ; more commonly, however, it is found on the greater curvature and the cul-de-sac. The slight erosions which are oc- casionally found on the surface of the mucous coat in fevers and other acute diseases are reck- oned by some pathologists to be a variety of it, while others with equal reason consider those as not produced by true ulceration, but rather as con- nected with the diseased condition which gives rise to the softening of the tunics. We have placed this variety first because it presents the simplest form of ulceration, not with reference to its frequency : it is, in fact, comparatively seldom met with, inasmuch as, however frequent in the intestines, ulceration is not a common consequence of acute inflammatory action in the stomach. 2. Ulcers of a small extent, with a defined cir- cular area, and edges somewhat raised above the level of the rest of the internal surface. The base may be formed by the cellular tissue, or it may have eroded through this and the muscular layer, so as to lie upon the peritoneal covering. Its size varies from that of a split pea to a shilling, and it more frequently occurs singly than in num- ber, although occasionally a succession of them seems to take place, in which case they may be presented in different degrees of development, some showing a tendency to form cicatrices. This form of ulceration is for the most part primarily seated in the glands of Brunner, which occur singly in different parts of the stomach, but chiefly along its curvatures and towards the duodenal end. It arises at one time on their surface by their direct irritation and ulcerative absorption, while at others it seems to succeed upon their in- ternal swelling from obstruction to their follicular orifices. 3. Circumscribed ulceration of a decidedly STOMACH, (ORGANIC DISEASES OF THE) 267 chronic character, with much thickening over its base and edges. It varies in extent from the size of a shilling to that of a crown-piece or larger ; it may occur in any part of the stomach, and in- volve the different tunics to a greater or less de- gree ; yet for the most part, as it proceeds, in depth, its ground becomes overlaid with a thick- ened cellular substance which also occasions the elevation of its circumference. Its origin does not differ obviously from the last form, but its course is more chronic, and although generally solitary, it is more extensive in its disorganization. Some pathologists are not disposed to admit the separation of this from ulcers of a cancerous na- ture, regarding the thickened and indurated cel- lular tissue as a mode of scirrhous formation. It appears, however, manifest to us, that an ulcera- tion with these chronic features is not unfrequently met with, which is entirely devoid of the cancer- ous character; and with regard to the thickened condition of the tunics which it originates, it seems that it is strictly analogous to the callous edges and base which are found upon certain old ulcers of the leg. We see the latter every day removed by stimulants, escharotics, or pressure; and cica- trizations have been found to ensue upon the for- mer. This at once affords a strong argument, and is an important practical reason for not general- izing them under the same head as the intractable scirrhus. Yet it is to be observed that by this distinction we do not deny that this form of ulcer- ation of the stomach may degenerate into a can- cerous disease by the deposit of foreign tissue, as happens in like manner occasionally to some ulcers of the skin. For the purpose of distinction, then, it would be advantageous to designate all the forms which are free from any foreign com- plication by the term simple ulceration, although this is in a peculiar manner applied to that first described, because it is generally confined to the mucous membrane. The inflammatory origin of ulceration of the stomach appears to be undeniably established. Accurate investigation has evinced that the ulce- rative solution of continuity is preceded on all occasions by more or less hypertrophy and hard- ening of the mucous membrane in which it arises. In those ulcers which are consequent upon an acute inflammation, this is less obvious than in chronic cases; and on the other hand also, in some of the most chronic forms occasionally little alteration is found in the parts surrounding the ulcer. Yet these appearances are so commonly found, that it gives room for the inference that ulceration is a change which has a secondary re- lation to foregoing inflammatory alterations in the stomach. The mucous coat, or the glands con- nected with it, are invariably the primary seat of the ulceration, which is a distinguishing circum- stance between the simple ulceration and those forms depending upon the development of foreign structures. In the latter, which have their seat generally in the cellular tissue subjacent, the ul- ceration is for the most part propagated from this to the other tunics ; but although these may suf- fer in simple ulceration, their destruction is secon- dary to that of the mucous membrane, in which it always commences. It is obvious likewise, that as it commences by inflammatory action, its ex- tension, whether in breadth or depth, is to be as- cribed to the occurrence of the same condition, which is from time to time kindled in the part. The inflammation which attends ulceration is of an extremely low character; on some occa- sions it is not indicated either by its symptoms during life or by the appearances after death, and the high free inflammation of acute gastritis never terminates in ulceration. It is true that it occurs in certain forms of fever, which, with reference to the general system, is an acute disease. This, however, does not form an exception to the re- mark, as it has been proved by the investigations of Krimer and Schrceder van der Kolk, and is sufficiently evident from daily experience, that in fevers of this kind in which the general nervous influence is weakened, the inflammations which arise are of a very imperfect character. (Die Darmgeschwiire dargestellt von Dr. J. Fr. H. Albers, Leipzig, 1839, s. 68.) It is also a re- mark of great interest, that if the nervous influ- ence of the part becomes prejudicially affected during the subsistence of this low and chronic form of inflammatory action, the ulceration may lose its simple nature, and assume a cancerous character. The symptoms attending upon the early stages of ulceration are rarely of a more alarming nature than those which are characteristic of functional derangement of the stomach. Flatulence, acidity, anorexy, oppression of the stomach after eating, and pain, are the ordinary indications which it presents in the commencement, and these are common to it and the dyspepsia which takes its origin from a different source. It is when the pain becomes the prominent symptom that a more serious affection is indicated, its character also being different from that of gastrodynia. In its degree and duration it varies considerably, but it is usually of a dull oppressive description, yet oc- casionally sharp and rather approaching to sore- ness. In many cases it is complained of only after eating, and continuing with much severity while digestion is going on, subsides when that process is completed. A frequent expression of such patients, says Dr. Abercrombie, is," I should be quite well if I could do without eating."- (Op. cit. p. 17.) It affects others more permanently, but in all it is aggravated on taking food, on which account the patient acquires a dread of his necessary meals, sometimes rendered the more distressing by the circumstance that the appetite remains nearly unimpaired. Occasional nausea is apt to occur from the commencement, but vomiting is not usual until the decided establish- ment of the disease. Great uncertainty, however, prevails with regard to this symptom; in some it occurs from the beginning, but without constancy, and may yield to a regulation of the diet; in others it is more permanent, and entirely uncon- trollable ; while cases are not wanting in which the disease ran its course to the last period with little or none at all. A similar diversity exists in the substances rejected by vomiting; these consist at one time of ropy mucus or various secretions, at others of a brownish fluid; and on some occa- sions blood in considerable quantity is thrown up. Dr. Abercrombie illustrates the variety which oc- curs in this and the other symptoms by several u> 263 STOMACH, (ORGANIC DISEASES OF THE) teresting cases, which serve to exhibit the insidious nature of the disease, and the impossibility of find- ing limits which would exactly define the features of its history. But their general outline is suffi- ciently distinct, and permits us to perceive the similarity which it bears to the phenomena of cancer of the stomach. The important practical question contained in the latter remark has re- ceived the attention of M. Andral; and his con- sideration of it leads him to the conclusion, that neither simple ulceration nor the other lesions re- sulting from chronic gastritis are to be distin- guished from cancer of the stomach, except where abdominal tumour, the least ambiguous sign of the latter, is present. (Clinique Medicale, t iv. p. 432.) | It is, however, needless to state that the issue of simple ulceration of the stomach is not to be regarded in so hopeless a light as that of those which are connected with foreign degeneration; but although this is so, it must be added that a favourable termination is rather to be counted an exception. Four modes of termination have been observed, in the consideration of which we are led to some interesting points of its pathological history. 1. Like other chronic diseases, it may terminate by the gradual exhaustion of the powers of life. In such instances it gives rise to a protracted train of suffering, and is generally complicated at an earlier or later period by other affections, as dropsy of the abdomen, or anasarca, disease of the liver, intestines, pancreas, or spleen. 2. It may prove fatal by a hemorrhage proceed- ing from the ulcer. The ha?matemesis resulting is sometimes at first inconsiderable, yet by its un- controllable continuance or frequent recurrence it wears out the patient; in other instances it comes on suddenly and extinguishes life rapidly by an overwhelming effusion. This termination has been observed to occur most frequently in the large chronic ulcers with much thickening. It is ascribed either to erosion of vessels by the ulcera- tive process, or to exhalation of blood from the surface without any lesion of continuity in these. The latter has been very seldom directly observed in simple ulceration, and analogy seems to teach us that the pouring out of blood from the superfi- cial capillaries is the more usual mode of its oc- currence.* 3. It may produce perforation of the stomach, and give rise to peritonitis, which proves rapidly fatal. (See Perforation', Peritonitis.) Some modifications have been noted with respect to the manner in which this occurs. At one time the disease proceeds to the gradual erosion of all the tunics in succession, and the forming of a direct opening between the stomach and the peritoneal cavity. This is infinitely more rare in the sto- mach than in the small intestines, in which situa- tion the observations of modern pathologists have shown it to be by no means an unfrequent acci- dent, especially at the close of certain forms of * We were much confirmed in this opinion by once observing the sudden effusion of blood which took place from the whole surface of a large ulcer at the nape of the neck, (which had been artificially produced by an escharotic application,) on the use of a douche over the head and back. The form and aspect of the ulcer wis like the third.variety above described. enteric fever. For the most part when the sto- mach is thus directly perforated, the ulcer is of a small extent, and belonging to the second variety we have above described. Several observations are recorded by ancient and modern authors which rendered the opinion more or less prevalent that such perforations were produced by the eroding action of intestinal worms. In some instances lumbrici have been found lying near the perfora- tion in the stomach ; in others, as in the case re- lated by Dr. Crampton, (Irish Med. Trans, vol. i. p. 29, New Series,) they had apparently passed through the opening into the peritoneal cavity. Gaultier de Claubry has described an appearance in which this origin was more strongly suggested than by their situation in either of the other locali- ties. He has seen the stomach and intestines per- forated in several places by lumbrici, which were so impacted in the openings as to require force for the purpose of withdrawing them. (Guersent, Diet, de Med. art. Vers.) At the present day, however, this opinion seems entirely discarded, and the presence of worms at or near the perfora- tion is regarded as a mere coincidence. In some instances the ulceration has not penetrated the entire parietes of the viscus, but resting upon the serous or muscular tunic, perforation suddenly occurs by the rupture of its deepest part during efforts of vomiting, coughing, or other forcible exertions of the muscles of the abdomen. A modification of this happens where the ulcer, hav- ing eroded the stomach and united it by its edges to a neighbouring organ, this union is torn by a similar shock. Cruikshank relates a remarkable example of this in the case of a lady in whom an illness, fatal in two or three days, ensued upon a fit of vomiting, which, as it was afterwards found, had separated the adhesions of a large ulcer from the left lobe of the liver. (Anatomy of the Ab- sorbing Vessels of the Human Body. London, 1786. p. 113.) 4. Finally, simple ulceration may terminate by cicatrization. The occurrence of this condition has been a matter much debated by pathologists. Some assert that cicatrized ulcers are seldom if ever met with in any part of the digestive canal, (Louis, Albers, Lesser); others affirm that their anatomical researches have demonstrated that their occurrence is not exceedingly rare. (Cruveilhier, Scouttetten, Prost, Trousseau.) Albers supposes that these opposite statements concerning a matter of observation are explicable by the fact, that dif- ferent conditions of the digestive tube were con- templated by the observers on either side, (Op. cit p. 120); that the attention of one party was par- ticularly directed to the ulcers connected with foreign degeneration; while that of the others was engaged about the simple forms of ulceration. In whatsoever manner this may be reconciled, too many cases amply authenticated are on record, to leave any doubt that ulceration of the stomach may heal by undergoing cicatrization. The im- portance of this conclusion in its pathology is manifest: a practical distinction arises out of it between the simple ulceration and that connected with foreign structure; and it affords a ground for hope in undertaking the treatment of these affec- tions, which its absence should entirely take away. The cicatrix which was found in the stomach of STOMACH, (ORGANIC DISEASES OF THE) 269 Beclard has been already referred to; it was situ- ated at the lesser curvature, near the cardia, and was about an inch in diameter ; its surface was depressed, and traversed by a few cellular bands, one of which passing through its centre divided it into two lacuna?, whose base rested upon the peri- toneal tunic. This example of cicatrization is cited by authors as a proof of the efficacy of a resolute adherence to a severe regimen in its treat- ment. Recamier has>recorded a case which equally deserves attention on another account. A woman, twenty-six years of age, presented symptoms of a profound organic disease of the stomach, viz. pain, vomiting some hours after meals, and progressive emaciation. From inquiry into her husband's health, this physician was led to suspect the pos- sibility of the disease being connected with a syphilitic taint, and accordingly recommended a mercurial treatment by frictions, and a milk diet; under this she gradually improved, and in four months entirely recovered her health. Six years afterwards she was attacked by pulmonary phthisis, and died. Examination of the body displayed, besides tubercular cavities in the lungs, a cicatrix in the stomach, of the size of a crown piece, rest- ing upon the pancreas, to which it adhered ; and the stomach immediately around it was formed into folds, like those of the mesentery. We recite this case, not only on account of the extensive cicatrization of which it affords an example, but more especially for the sake of the instructive les- son which it contains in the consideration of the occasional cause of the disease and of the success of the appropriate treatment. It evidently shows, says Recamier in his comment upon it, that even in an extreme instance of such a disease, we may have a hope of obtaining a cure, provided a cause be recognised which can be advantageously com- bated, such as the syphilitic taint. (Op. supra cit. t ii. p. 55.) This important remark is illustrated with equal force by the history of a case related by Andral, in which a train of the most profound symptoms, in every respect characterizing this disease, had brought a lady, after four months' illness, to the verge of the grave; when at this point the detection of an ulcer in the throat, pos- sessing a venereal aspect, together with the ac- count of former suspicious circumstances, sug- gested to the physician (M. Andral's father) the possibility of the disease of the stomach having a syphilitic origin ; whereupon, as every mode of treatment had entirely failed to arrest the progress of the disease, he acted upon this, as a last re- source, and exhibited mercury gradually, both in- ternally and by inunction. Some amendment was perceptible even from the commencement of this treatment; and ultimately, from its continu- ance, the patient, who had been to all appearance in the last stage of this disease, was perfectly restored to health. (Clinique Medicale, t. iv. p. 470.) ' ,The ordinary treatment of simple ulceration of the stomach consists in regulation of regimen, local depletion, and counter-irritation, together with the conservation of as great a state of calm with respect to the function of the stomach and the general system, as possible. It is unnecessary to enter into the detail of the means by which these ends are to be procured, as this would be x* but a repetition of those which are described under cancer of the stomach. The treatment exposed in that place is, in fact, given more with the aim of combating the disease here described than can- cer ; and any success which it promises is almost entirely grounded upon the similarity of the phe- nomena presented by the two affections, which in many cases permits us to encourage a hope that we have to deal with the least formidable. III. Hypertrophy and AtropUy of the Tunics.—An organic change, consisting in a mere increase or diminution of nutrition, is occa- sionally met with in the stomach, which may in- volve its tunics either separately or entirely. Its most frequent seat is the mucous membrane, but it has also been observed to occur in the subjacent textures; with the exception of the peritoneal co- vering, which is not affected with any structural alteration, properly limilable to the gastric portion of this serous membrane. 1. Hypertrophy invades the mucous membrane of the stomach either partially or generally, and may induce various modifications of form and co- lour. For the most part this membrane preserves its smooth and uniform aspect, but receives an in- crease in its density, as well as in thickness, so as to admit of being raised upon the scalpel in flakes from the subjacent tissues. Occasionally it is found developed in round eminences of various sizes, from that of a split pea to a large filbert, which appearance has been called mamillated (Fr. mamellonnee). The colour of the hypertrophied part is at one time that which is proper to the rest of the membrane; but this is not common, as it usually presents different shades of brown, slate- colour, or even black; and in some rare instances it is disposed in circumscribed patches of a milk- white colour, similar in appearance to those ly mphy exudations which are occasionally found incorpo- rated in serous membranes; but on examination by incision, according to M. Andral, they prove to be nothing but the mucous membrane in a state of hypertrophy, and altered in colour. To this condition are to be referred the poly- pous growths and vegetations of different sizes and shapes which are met with from time to time in examinations of the stomach. Considerable variety exists in the instances of excrescences of this nature, which are recorded by authors; at one time they are attached by a pedicle, and repre- sent pyriform polypi; at others they resemble mushrooms, or present a foliated appearance like the book portion of the ruminating stomach; but whatsoever diversity of conformation such produc- tions exhibit, they are constituted by the mucous membrane in a state of hypertrophy, and differ from its ordinary form chiefly by taking a project- ing development in isolated points. Their internal texture occasionally is contrasted with the remain- der of the villous coat by a different degree of firmness or of softness, and also by a greater de- velopment of the blood-vessels, which are some- times varicose, and so abundant as to give them the appearance of erectile tissue. In respect to the difference of texture in these productions, ob- servers have denominated them vegetations, ex- crescences, polypi, fungus, &c. We cannot, how- ever, follow M. Andral in comprehending under the same class any tumours which partake of a 270 STOMACH, (ORGANIC DISEASES OF THE) scirrhous nature, as those seem to us to depart entirely in their pathological characters from the others here detailed, which are, according to him, simple developments of the hypertrophied mucous membrane. (Precis d'Anatomie Pathol, t. ii. p. 49.) The muscular tunic also undergoes the change of hypertrophy, which may be confined to a por- tion of its fibres, or extend over the whole. But little notice has been taken of the occurrence of partial hypertrophy, although it is probable that it is more common than the silence of pathologists would account for. This remark appears to be warranted by the fact that the fibres of this tunic, altered in thickness and colour, are not unfre- quently distributed through a scirrhous degenera- tion of the cellular membrane, but have generally been mistaken hitherto for fibrous productions of the substance in which they were found imbedded. (Clinique Medicale, t. iv. p. 411.) General hy- pertrophy has been observed to pervade the mus- cular tunic of the stomach by M. Louis, who has furnished an accurate description of it, as well as of the lesion with which it was connected in the cases in which it occcurred. It gave to the pa- rietes of the viscus a double thickness and consi- derable increase of density, both of which condi- tions varied in the different parts of the stomach, but were greatest towards the pyloric extremity, in which the muscular fibres become interlaced in a cancerous degeneration. In the midst of this, however, they preserved their state of hypertro- phy, but assumed a bluish, semi-transparent ap- pearance. This condition of the muscular tunic has been almost invariably found to occur in cancerous dis- ease of the organ, and for the most part in cases where a contraction of the pyloric orifice existed. On this account M. Louis suggests that it may depend in the relation of effect upon the latter in the same manner as hypertrophy of the muscular parietes of the heart is caused by a contraction of the orifices of this organ. But he affirms this rather from analogical reasoning than on direct evidence, as a sufficient number of cases have not yet been collated with reference to it, to prove that it stands always in connection with a con- tracted state of the pylorus. The same observa- tion applies to the conjecture of M. Prus, that it owes its origin to the constant vomiting attending upon organic disease, which, by increasing the muscular efforts of the stomach, causes this tunic to assume an excessive development. It appears, however, very probable that both conditions more or less contribute to produce this effect. The cellular tissue which separates the tunics from each other is also not unfrequently the seat of hypertrophy. It then becomes condensed and deprived of its areolar structure, and may give so much firmness to the parietes of the stomach as to prevent them collapsing upon each other, as hap- pens in the natural state of the organ. For the most part it occurs in the tissue subjacent to the mucous membrane, but it may involve that also which separates the peritoneal from the muscular coat, and penetrate between the fibres of the latter. We have before adverted to the opinion of some pathologists, which has attached in modern works considerable importance to the hypertrophied con- dition of the cellular tissue; namely, that scirrhous and cancerous products are constituted by it, in a certain stage of development. It is certain that some varieties of these foreign structures bear much resemblance to it, and it even appears to us a tenable opinion that there is a gradation con- ! necting them together, of which the tissue called j Iardaceous is an example. When perfectly de- veloped, however, there does exist a distinction between the external characters of those products- and setting this aside, the difference in their his- tory, their respective effects on the general econo- my, and subjection to therapeutic means, afford weighty grounds for considering them as different organic textures. These counterbalance in our judgment any arguments for their identity derived from their original deposit or molecular analysis; the latter considerations scarcely afford to the science any basis for the division of morbid tis- sues, which can be placed in competition with such palpable marks of pathological distinction as are supplied by the former. It is certainly often a matter of observation that the foreign deposits are found in the midst of the hypertrophied cel- lular tissue, nor is it possible to define the grada- tion by which the change takes place; but we would only remark that the same may be pre- dicted of the conversion of cartilage into bone, Finally, we rather recognise that the hypertrophy of the cellular membrane of the stomach is fre- quently a nidus for the deposition of cancerous tissues, than agree with those who regard them as identical, and we publish this here only with the confidence derived from its being the opinion of some eminent British pathologists. 2. Atrophy of the gastric parietes is a change which is not unfrequently brought under observa- tion by necroscopic examination. It may be local or general, and involve the tunics separately, or embrace them altogether. At one time the villi of the stomach have disappeared under its in- fluence, partially or entirely ; at another, the sub- stance of the mucous membrane is so diminished as to be scarcely capable of being discerned sepa- rately from the subjacent tunics. These in their turn suffer the same diminution of nutrition; and lastly, it is found in different degrees to invade the whole parietes, which are occasionally reduced to such a thinness as to be transparent, and to seem to be constituted almost wholly by the peritoneal tunic. When the atrophy is local, it is ordinarily seated in the fundus of the stomach, and this situation manifests more obviously its effects, being naturally the thinnest portion of the organ. Every form of these organic lesions is referable to some variety of chronic irritation in the sto- mach. The hypertrophy of the mucous mem- brane appears to be the only one of them which is contemplated by pathologists in the light of a primitive disease; this is a direct result of chronic ! gastritis. We have stated before that the hyper- trophy of the subjacent cellular membrane is a | secondary result of the latter, and that of the muscular tunic is found generally to attend upon i cancerous disease. The atrophy of the stomach acknowledges an organ still more indirect, as proved by the researches of M. Louis, with respect , to its occurrence in the mucous membrane; in the STOMACH, (ORGANIC DISEASES OF THE) 271 great majority of instances it occurs as a second- ary lesion in the course of chronic diseases of other organs, such as phthisis and disease of the liver and of the brain. These organic changes will have to be referred to again in considering the dilatation of the stomach. IV. Softening of the Stomach.—This le- sion constitutes the post-mortem appearances of a disease, which is in a great degree peculiar to infants, but which occurs also in adults, and is found in them generally to accompany the last of the stomach; or to others, which deprive the organ of its power of propelling the alimentary mass. In both orders of causes retention of the latter is the invariable accompaniment of the dila- tation, in like manner as the urine is retained and becomes a secondary cause of distension, as well from obstruction in the urethra as from any con- dition which diminishes the expulsive power of the bladder. As far as has been already observed, the following pathological conditions of the sto- mach may be recounted as standing in the rela- slages of some profound affections of other organs. | '">" °f cause to tn's affection Although it has proved to be not a very rare oc- ! L Contraction of the pyloric orifice. This is currence, it escaped being fully identified until a I by far the most frequent source of dilatation of the recent period ; but upon the recognition of its fatal j stomach, and is ordinarily produced, as we have seen, by cancerous disease. Its mode of action is obvious: the alimentary matters not finding a free outlet by the pylorus, accumulate in the sto- mach, and distend it to a greater or less degree, which is determined chiefly by the extent of the character, and its importance as a pathological phenomenon, it received attentive investigation. It has been described by Jaeger, Cruveilhier, Guersent, Gairdner, and others, and experiments have been instituted by Camerer and Carswell which have furnished satisfactory evidence with i obstruction, and in part by the quantity of the regard to its true nature. It would be superfluous I accumulation which may be rejected by vomiting. to present its description in this place, as it has Wnen depending upon this cause, the parietes of already been amply treated of in other articles. 'the. viscus may be found in a state of simple dila- Under Dentition and Gastritis is to be found | taUon, or along with this they may have suffered an account of its history and symptoms; and for thinning and softening to such a degree as to give that of its pathology, which seems to be now ; occasion to rupture; or, on the contrary, hyper- fully established by the experimental researches troPhy of all the tunics, especially the muscular, of its author, we refer to Softening of Organs. mav coincide with its increased capacity ; which Nothing remains for us but to indicate it here lesions» il may be remarked, preserve an analogy amongst the organic lesions of the stomach. between this alteration of the stomach and dis- V. Enlargement of the Stomach, and eaS6S °f the heart connected with valvular obstruc- Contraction.—1. Enlargement of the stomach is an organic change, which involves in its causes and many of its phenomena considerations of great interest. On account of it being almost always a secondary lesion, and one which is not of common occurrence, it has seldom been for- mally noticed in medical works; extraordinary cases of it have, however, been recorded by Mau- chart, Riverius, Lieutaud, Bonet, Valsalva, Mor- gagni, and others among the moderns ; but it de- serves more special attention than it has received in any systematic work, if it were only because it forms one of the several causes of abdominal tu- mours, which are known to be a frequent source of diagnostic embarrassment in the practice of medicine. Amongst the descriptions of it which have been given by recent authors, none have oc- curred to us which contain so much information as that by M. Duplay, and we desire to acknow- ledge the obligations which we lie under here to his well-digested memoir.* When the functional and mechanical relations belonging to the stomach are considered apart, its morbid dilatation has a strict analogy with that of the other hollow viscera which are endued with muscular parietes, as the heart and the bladder. The organic lesions with which it is connected are at one time obvious, and at another are not demonstrable to the senses; but like the corre- sponding affection of the latter organs, they are referable to two distinct classes; namely, to lesions producing mechanical obstruction to the contents * De l'ampliation morbidede I'estomac consideree sur- tout sous le rapport de ses causes et de son diagnostic; par A. Duplay, chef de Clinique interne 4 I'liopital de la Pilie. Archives Giinerales de Medecine, Octobre ld33, et Deceinbre, ineine aunec. tion. It is, however, to be observed that dilatation does not occur in every instance of pyloric con- traction, nor even invariably where total oblitera- tion of the orifice is found. Moreover, it happens in cases in which this orifice has continued per- fectly patent, or still wider than in the natural state ; all which circumstances conspire to prove that other conditions co-operate with the mecha- nical obstruction to produce the dilatation, even when they appear most obviously in connection. M. Andral has made it apparent from researches on the action of the pyloric end of the stomach, in propelling the chyme from this viscus into the duodenum, that the integrity of its muscular action is necessary for the performance of this movement. But it will be observed that it always happens in cancerous disease of the pylorus, that the muscu- lar tunic, to a greater or less distance from the orifice, is surrounded by the scirrhous induration, which must impede its contraction, and thus de- prive the stomach of its action. This sufficiently explains the cases of dilatation with patency of the pyloric valve, for in all the instances of organic disease in which these conditions coincided, the muscular fibres in its neighbourhood have been observed to suffer either by surrounding induration or by their direct lesion. Another circumstance which frequently co-operates in cancerous disease to impede the muscular action, is the occurrence of adhesions between the stomach and the neigh- bouring organs, which, in the same manner as the former conditions, contributes to effect the dilata- tion of the organ by causing the retention of the alimentary mass. 2. Organic alterations in the muscular tunic. j With reference to their effect in originating dila- 272 STOMACH, (ORGANIC DISEASES OF THE) tation of the stomach, these may be partial or general. Observation has established that the de- struction of the muscular fibres which are situated near the pylorus is an occasional cause of this morbid condition, and not less certainly that it originates under an atrophied state of the whole of this tunic. On account of the special office which the pyloric end performs, of propelling the gastric contents into the duodenum, the partial injury of the muscular tunic, when seated here, is as effectual in causing retention'and the conse- quent dilatation, as the general atrophy of this tunic, but it is easily conceived that the action of both is similar. 3. Paralysis of the stomach. — The dilatation has been occasionally observed to occur where none of the foregoing causes existed, the stomach being entirely free from any organic disease. This organ in fact may be affected with a paralytic loss of its contractility in the same manner as the bladder; and as the urine, under such a condition of this viscus, accumulates without the power of being voided, so the stomach, in like circumstances, yields, as a flaccid bag, and becomes dilated gradu- ally by the accumulation of the food. This source is worthy of particular attention, as it affords a hope with reference to the employment of therapeutic means, which the affection connected with organic lesions leaves scarcely any room for entertaining. 4. Finally, it may be produced by tumours of various kind, polypi, fibrous growths, or hydatids, situated either internally and involving obstruction of the orifices, or by their weight giving rise to a relaxation of the viscus, which may occur when they have an external attachment, or are even situated in the omentum. History and diagnosis—With this enumeration of its causes prefixed, the phenomena of enlarge- ment of the stomach present themselves with free- dom to the mind, and we are prepared to meet the diversity which they offer, the result of the various morbid states connected with this lesion : in pro- ceeding to detail its symptoms, we shall first notice the manner in which it progresses. When the contents of the stomach become ac- cumulated, either, as we have seen, from the ob- struction of its orifice or loss of its contractile power, distension takes place. In the commence- ment this may not be immoderate, and only tem- porary, as it can be relieved by vomiting; which action, however, if the viscus be already somewhat weakened, is only partial, permitting much of the ingesta to remain still lying in its cavity. This, by its continual weight, diminishes the power of resistance, and by a reacting influence the ali- mentary matters are allowed to augment, so that at length the most depending part of the stomach begins considerably to yield under the downward pressure. As the dilatation advances, the oblique position of the viscus disappears, and the two ori- fices take the same level, and approach each other, so closely in some extreme cases as to be found in actual contact. The vomiting becomes more infre. quent as the capacity is increased, and in the same proportion it becomes more difficult to unload the stomach completely, so that all the circumstances contribute to the accumulation. The dilatation augments in this manner to an enormous measure; in some cases it invades the entire abdominal ca- vity and pelvis, stretching downwards to the pubis, and covering the intestines which lie compressed behind it; in others, its pressure extends upwards and produces great distress by interference with the thoracic organs, and sometimes even danger- ous effects by obstructing their functions. With respect to the appearances which are found post-mortem, as far as they depend simply upon the enlargement of the stomach, they cor- respond of course with this description of its pro- gress; but it is easily conceived that almost the entire pathological interest of those is absorbed in the investigation of the primary lesion with which they are connected. Concerning the latter we add nothing here ; it may be mentioned, however, that besides the displacement of the various viscera which is occasionally found to have been effected by the dilated stomach, not unfrequently every trace of the epiploon disappears; the gradually expanding organ having glided between its sepa- rate folds, those overlay it, and become united to its parietes. The symptoms belonging to the diseases of the stomach, which originates the dilatation, form an important part of its general features; but we shall consider them here only so far as they are characteristic of the lesion itself. Amongst the causes above enumerated, those which involve or- ganic disease, such as cancer of the pylorus, afford signs which have been more or less adverted to; but it is necessary to notice the conditions which have been observed in connection with the atonic relaxation or paralysis of the stomach. This morbid state has been found most frequently to occur in those who have contracted extreme habits of gluttony, and more especially in those extraor- dinary instances of perverted appetite in which the individuals have been accustomed to swallow foreign substances. In a man at Brest whose stomach was found to contain a quantity of frag- ments of glass, pieces of wood, iron, and tin, with an entire knife and handle, this organ was found enormously dilated. In the case of a lunatic which latterly occurred in Dublin, the enlargement was connected with his swallowing buttons, half-pence, pins, &c. which were found after death in consi- derable number, and even during life betrayed themselves by a jingling sound on the succussion , of the abdomen.* M. Perey has collected the histories of several cases of individuals addicted to gluttonous excess in eating and drinking, in whom enormous dilatation occurred; and it has happened in others in which the gluttony was not carried to j the immoderate excess which distinguished the latter, as in an interesting observation related by M. Pezerat, where an evident paralytic relaxation | of the stomach ensued in an individual who was unable to refrain from the indulgence of a habit contracted from his infancy, namely, taking co- pious drinks of weak wine and water. (Journal compl. des Diet, des Sciences Med. t. xxxv. p. 162.) It has been known also to occur in females liable to recurrent attacks of hysteria, in whom j the meteorismus of the stomach prevails, which is a common accompaniment of the nervous dys- pepsia attending upon this disease. Other in- * The particulars of this case, which arc, as we learn, interesting in many respect3, we hope to see shortly pub- lished by Mr. Adams, in whose practice it occurred. STOMACH, (ORGANIC DISEASES OF THE) 273 stances are not wanting where no connection could be traced between it and any of those excit- ing causes; in such the stomach seems to undergo a true paralytic relaxation, which was regarded by Lieutaud, who described it, as similar to that which is observed in the bladder in advanced age: the same condition is noticed by Chaussier, and compared by him to the relaxation of the scrotum, which occurs in certain individuals. Pain, oppression in the epigastric region, and general tension of the abdomen, repeated, uncon- trollable eructations of sour air, and profound di- gestive derangement, are symptoms which are to a greater or les* degree invariably present in this morbid condition. They cannot, however, be re- lied on as speoial characteristics; nor is any single sign entitled to be esteemed as such, as none taken alone is sufficient to establish the diagnosis. Yet for this object much assistance is furnished by the examination of a particular symptom, the vomit- ing, and more especially by the exploration of the abdomen. The vomiting consists at one time of the mucus of the stomach in great quantity, and at others of the alimentary matters which had been swallowed, more usually of a mixture of both, or, if cancerous disease exists, of its peculiar secretions. Its action is remarkable, being rather a regurgitation of the gastric contents than the forcible muscular expul- sion which characterizes ordinary vomiting. In the beginning of the affection it occurs more fre- quently than when the dilatation has already made some progress, and at the more advanced period it is apt to observe distant periodic intervals of two, three, or four days in its return, and then brings a much-desired relief, by unloading the or- gan partially or entirely of its enormous accumu- lation. To procure this artificially, the patient sometimes has recourse to tickling the fauces, or the use of emetics; in other cases he rinds the relief, still more effectual, which the operation of drastic purgatives produces. Unhappily, instances occur in which the vomiting ceases totally, the stomach seems insensible to any stimulant, the consequence of which is, that the feeling of oppres- sion is not to be relieved by any means, and the accumulation continually increases. The exploration of the abdomen, the most pal- pable sign, in every respect furnishes the most valuable data towards recognising this morbid state. On this subject we quote from the memoir of M. Duplay, in which the information derivable from this source is lucidly set forth. The patient should be subjected to a double examination ; the first to be conducted some time previous to the coming on of the vomiting, the second after the vomiting. " Before vomiting, the examination of an indi- vidual with enlargement of the stomach, whatever be the nature and cause of it, presents to the touch a tumour more or less indistinctly circumscribed, which extends from the left hypochondrium to the right iliac fossa. This tumour extends also to the hypogastrium, and ascends towards the right side; in some instances, its outline along this track is easily distinguished. When the patient is placed in a vertical position, the epigastrium projects less than the lower part of the abdomen; on the con- trary, when he lies in a horizontal position, this Vol. IV___35 region participates in the general tumefaction of the belly, which in every part gives the sensation of an obscure fluctuation and absence of elasticity (empaternent). " On practising percussion, the abdomen gives a clear sound in the epigastric region, which be- comes more dull as we descend towards the hypo- gastrium ; a difference which naturally depends upon the respective gravitation of the fluids and the air contained in the viscus. This considera- tion also evidently suggests that the difference is much influenced by position; the dulness in the inferior part of the abdomen augments in the ver- tical position and becomes diffused, and appears to ascend towards the epigastrium in proportion as the patient changes to the horizontal. " On tapping for fluctuation (ballotlement), by the hands being placed on either side of the ab- domen, a particular sound is perceived, similar to that which is produced by striking on a bladder half filled with air and liquid. " Succussion has not yet been employed in its diagnosis, or at least its application has not been described in any of the cases which the author has consulted. Smart shocks upon the trunk, with the ear applied to the epigastrium, would, how- ever, produce the sound of fluctuation more dis- tinctly than the ballotlement, especially in indivi- duals who have still preserved their fulness of flesh. This is evident from the fact that some individuals have the power of producing a gurgling sound by alternately contracting and relaxing the diaphragm and the abdominal parietes. " The ingestion of liquids or of aliments may also contribute towards establishing the diagnosis of this morbid condition. In some cases, the pa- tient will be able himself to perceive the sub- stances which he receives into his stomach de- scending to the lowest part of the abdomen. "After vomiting, all the signs above stated dis- appear in part, or become less evident. The pro- I jection which the distended stomach forms is less | easily to be traced through the abdominal walls, even when these are emaciated. The dulness on percussion disappears more or less completely ; the lateral pressure and the succussion no longer produce the fluctuation, nor the gurgling, or only in an obscure degree. Again, the signs are repro- duced upon the re-introduction of food or liquid into the stomach." (Archives Generates de Me- decine, Decembre, 1833, p. 549.) It is scarcely necessary to add that those means of exploration furnish their data, both positive and negative, in proportion to the extent to which the dilatation of the stomach has proceeded. If it be supposed that this lesion is of such a palpable nature that it would not be difficult to recognise it, this is not accordant with the histories of it which the annals of medicine contain; in the great majority of these, it has never been discovered until after death. But, besides this fact, cases are recorded in which it had been mistaken for other abdominal tumours, such as ascites, encysted dropsy, or pregnancy. A case, extraordinary for the enormous quantity of fluid which was con- tained in the stomach, amounting to ninety pounds, is related in the works of Riverius, in which the disease of the female was first supposed to be pregnancy; when the period passed which dis- 274 STOMACH, (ORGANIC DISEASES OF THE) closed this error it was taken for ascites, and after death a puncture was made in the abdomen to give exit to the fluid which was thought to exist ,n this cavity, the distension being so great as to exceed the size of the coffin: and finally the same case has been recited in several authors as an ex- ample of the disease which they named "dropsy of the stomach." A fact of similar import is re- lated by Bonet, namely, that a woman, the volume of whose abdomen had caused her to be regarded as pregnant, died, and being opened, it was dis- covered that the swelling was produced by the stomach enormously enlarged. In these cases the puncture of the abdomen was not made until after death; but in an instance related by Chaussier, (Essai sur les fonctions du grand epiploon ; Mem. de l'Acad, Dijon 1784,) and in another by Vacca, (Arch. Gen., Dec. 1823, p. 528,) this error was ! committed during life, and death was the speedy ■ consequence. All those cases, but particularly those last mentioned, are worthy of consideration 'with regard to the diagnosis of this disease ; it is not likely that at the present day any practitioner j who is in possession of the resources of diagnosis ; would be so far deceived as to proceed to such an operation ; but still much ambiguity may be found in certain cases, and it may be said that in none should we be so confident as to dispense with the diligent application of all the means which can be ' devised. For the purpose of distinguishing it from ascites, the following will serve as valuable marks of dif- ference. The form of the abdomen varies in the two affections; in ascites no approach to a definite contour is visible, as occurs where the tumefaction of the belly is referable to enlargement of the sto- mach. The progressive growth of the tumour in both diseases proceeds in contrary directions ; in the stomach the fundus supporting the liquid and solid contents, gravitates from the epigastrium downwards; while in the dropsy of the peritoneum 'the gradually increasing fluid ascends from the hypogastric region into the superior parts of the abdomen, and corresponding to this opposite pro- gress the dulness of sound on percussion also moves. Together with these the comparative -slates of the tumour before and subsequent to the emptying of the stomach afford a characteristic which is quite peculiar to enlargement of this organ, and distinguishes it with much certainty from ascites, pregnancy, or tumours in any other of the viscera of the abdomen. Many of the same differential signs are applica- ble to prevent it being confounded with preg- nancy. The latter condition, however, possesses in auscultation and its other means of exploration ' signs of such positive value, that an attentive in- vestigation can at the present day scarcely fail to j ■ decide correctly between them. Treatment. — It will appear manifest from the consideration of the a?tiology of morbid en- largement of the stomach that the resources of medicine are of little avail for its counteraction. The connection in which it stands in the majority of instances with the most profound organic le- sions leaves room for it only to be regarded as a distressing complication of a disease in itself hope- less'. We have already seen the fatal character of cancerous disease of the stomach, and how im- potent the medical art remains against ulceration, atrophy, or hypertrophy of this organ. In the variety of it which depends upon atonic relaxa- tion, more room is left for the trial of curative means; but they can rarely afford any prospect of success in an affection which is the accompa- niment either of old age or of some serious lesion of the nervous system. Where the dilatation ex- ists in individuals addicted to gluttony, at first view it would seem more amenable to treatment, as it has rarely in such to contend with primary structural lesions, or with loss of the organic ner- vous power. But are the perversions of our spiritual nature less untractable than the diseases of the body 1 Some relief may be obtained from the evacua- tion of the intestinal tube by means of gentle lax- atives. Strong purgatives are not recommenda- ble, as the irritation and weakness consequent upon their action tend to aggravate the evil. In the paralytic dilatation an attempt should be made to excite the action of the stomach by the use of light tonic bitters, such as the sulphate of quinine, gentian, calomba, or others of this class; a fair indication seems also to be afforded for the exhi- bition of strychnine. In a case in which M. Rayer employed it, the tetanic twitches seemed to be produced in the region of the stomach which have been sometimes observed to precede its suc- cessful operation in other parts affected with para- lytic disease ; but these were not attended by any sensible amelioration. The application of moxa to the epigastric region has been tried with the same object; it might be applied with as much suitableness to the dorsal region of the spinal column. It seems probable that in some cases the oppressive distension might be mitigated by the use of a bandage surrounding the stomach in such a manner as to give support to the depend- ing viscera. Finally, the regulation of the diet demands close attention ; it should consist of the materials which agree most with the stomach, and this at one time is answered by animal food, while at another this is improper. It is obvious that in the case of voracious eaters the overcoming of the vicious habit is the only hope of success ; but the accomplishment of this is extremely difficult. It should be attempted by the limitation of their meals to a restricted quantity, and making them consist of that which is of the most nutritive qua- lity, in the smallest compass. The internal use of ice may be employed for the purpose of allaying the hypersthenic state of the stomach, at once the effect and the reacting cause of the craving appe- tite of such individuals. On their part this treat- ment will meet probably with resistance, but it should be enforced, if possible, by persuasion, it not, by this combined with firm restrictive mea- sures ; and it will be happy for the victims of such a tendency who shall be placed in circumstances of life which admit of the employment of coercion. 2. Contraction of the stomach.—This lesion has been already adverted to as a consequence of cancerous disease of this organ, which is by far the most usual pathological state with which it is found connected. It is frequently met, however, quite independent of this; in almost every collec- tion of anatomical observations promiscuous cases of it are related, and to many of those much inte* [STOMATITIS.] 275 rest attaches; yet there is wanting (as far as we j are aware) a digest of the materials which illus- j trate the subject. When it receives an enlarged investigation of this nature, including facts which contain the light of modern research, little doubt remains but that this lesion will be found to pos- sess much practical importance ; at present we are obliged to be content merely to mention it with j reference to the circumstances in connection with which it has been observed. \ The diminution of volume is sometimes to be ! ascribed to direct pressure upon the organ, by collections of fluid in the abdomen or by enlarge- ment of the different viscera of this cavity adjoin- ing the stomach, as the spleen, the liver, and the pancreas. The same cause operates also acting from without; it has been proved to originate under the influence of tight lacing of the stays in females, and also in individuals whose daily em- ployments necessitated them to lean the abdomen upon the edge of a table, as in the case of hatters and writing clerks. It has been also observed to arise from the violent action of purgative medicines and emetics, I which in such cases are to be placed in the rank of poisons, as it is one of the most common appearances which are found in those who have died from poisoning, especially from having taken the metallic poisons or the strong acids. Hysteria seems to be another cause of this lesion, as it has been also occasionally found in individuals who had been subject to this disease. Portal affirms, that in several persons who died from the abuse of magnetism, which had caused a disease mani- festing languor, marasmus, and vomiting, the sto- mach and intestines were exceedingly contracted. (Cours d'Anatomie Medicale, t. v. p. 179.) Ac- cording to the same author, venereal excesses are also to be reckoned amongst the causes of it, which have been proved by post-mortem inspection; and in individuals who have died after prolonged ab- stinence or chronic diseases during which little food could be taken, the stomach is often seen to have its capacity so much diminished as to present its cavity nearly obliterated. Much diversity exists with respect to the forms which the contracted stomach under different cir- cumstances may assume ; in some cases longitu- dinally disposed, it appears like the remainder of the intestinal tube, in others it takes a globular shape, while in others it is found divided into two or more cavities; a condition which depends upon the irregular and spasmodic contraction of the muscular fibres, and seems to have originated a mistaken idea amongst some of the old authors, who describe the occurrence of two or three sto- machs as a variety which the human subject occasionally presents. j HorjQHTON# [STOMATITIS, Inflammation of the Mouth. The mucous membrane of the mouth is liable to various forms of inflammation, which may be simple or erythematous, accompanied by a pseudo- membranous or diphtheritic exudation, or by an eruption; or the follicles of the mouth may be- come ulcerated, or the stomatitis may end in gan- grene. All these pathological conditions deserve a separate inquiry. 1. Simple Stomatitis. Diagnosls_The mucous membrane is unu- sually red, hot, and dry, and extremely sensible to the contact of foreign bodies, even of the tongue. The redness is commonly in patches, and the affection rarely gives rise to general symptoms. It usually passes off in a few days by resolution, but occasionally terminates in ulceration or gan- grene. The latter is not, however, to be antici- pated ; but induration of the submucous tissue is at times left by it. Ptyalism is not an unfrequent concomitant. Causes.—The most frequent cause is the in- gestion of hot or acrid substances ; injuries done to the mouth by bruises, or the operations of the dentist, or by the accumulation of tartar around the teeth. During the age of the first dentition, stomatitis may arise from this source, when it may be accompanied by signs of general pyrexia. Oc- casionally, too, erythematous stomatitis would seem to be induced by disorder of the tube lower down. Treatment.—This form of stomatitis gene- rally yields readily. If induced by acrid or hot substances, it passes off spontaneously in a short time. Milk diet and mucilaginous gargles, as of flaxseed tea, or infusion of slippery elm, or a lotion of the white of egg mixed with water, are all that can be demanded. If the stomatitis be dependent upon gastric derangement, it disappears as soon as the derangement ceases. Small doses of magnesia, combined or not with charcoal, may generally be prescribed in such cases with marked benefit. 2. Diphtheritic Stomatitis. This is the stomatitis with altered secretion of some, and ought to include both the thrush or muguet of the French writers, and the pseudo- membranous stomatitis, stomatite couenneuse ou diphthcrite buccale. Both are varieties of the same kind of inflammation of the mucous mem- brane, but it may be convenient to examine them separately. a. Pultaceous Stomatitis. (See Aphthae of Children.) b. Pseudomembranous Stomatitis, Diphtherite Buccale.—This can be regarded as only a severe va- riety of the last, affecting the same parts; the exuda- tion being detached in large flakes, having the or- dinary appearance of false membranes. These are soon renewed, but in favourable cases, the in- flammation, that gave rise to them, gradually dis- appears ; in other cases, signs of gangrene super- vene ; this termination, however, and indeed the variety of the disease itself, is rare, except in large foundling establishments, where the mortality from it is at times frightful: of 193 cases, observed by M. Valleix, (CUnique des Maladies des Enfants, Paris, 1838,) 153 terminated fatally. In such cases a disagreeable sense of heat is experienced by the little sufferer, with pain augmented by the contact of foreign bodies ; the breath is fetid, and the submaxillary glands enlarge and become pain- ful. Later on, the lips and gums are tumid and bloody ; a sanious saliva flows copiously from the open mouth ; the breath becomes more and more fetid ; and the face flushed and swollen. The fever is more or less intense, with headache, rest- lessness and want of sleep. / 276 SUCCESSION OF INHERIT AN CE — LEGITI M AC Y. Treatment.—Where an impure air is con- nected with the origin of the disease, it is, of course, important that the patient should be re- moved from its influence. In the early period, the mucilaginous collutories, recommended in the last variety, may be used, with gentle laxatives of magnesia or castor oil. Afterwards, a mixture of muriatic acid and honey may be employed to touch the pseudo-membranous patches : this may be done by means of lint rolled around, or of sponge attached to, a small stick. Collutories of chlorine water, chlorinated lime, creasote, and vinegar and alcohol, have likewise been recom- mended. The application of muriatic acid, as well as of the other collutories, must be made once or twice, or oftener, in the twenty-four hours, as the case may require. Alum, nitrate of silver, and sulphate of zinc, have all been used as collutories, but they are not possessed of any advantages over the articles already mentioned. 3. Follicular Stomatitis, (See Aphtha of Adults.) STOMATITIS OF NURSES, (See Aphtha.) STOMATITIS, GANGRENOUS, (See Moh- TIFICATION, AND THROAT, DISEASES OF THE.) Robley Dunglison.] [STROPHULUS, Tooth Rash, Gum or Gown, Milk Spots, has by some been described as a va- riety of Lichen,—Lichen Strophulus. It is very common in infants, and is characterized by an eruption of greater or less extent, or papula? either more white or more red than the rest of the skin ; which are seated generally on the face, and are accompanied by more or less itching (A. Cazenave, Diet, de Med. xxviii. 659, Paris, 1844). It pre- sents great diversity in its appearance, and all the forms are seen at times on the same child. When the papula? are red, inflamed and prominent, scattered here and there, and intermixed with erythematous patches, it is the strophulus inter- tinetus of dermatologists, Red gum or Red gown. In some cases they are smaller or of different sizes, crowding in clusters, and in more extensive crops—strophulus confertus or rank Red gum ; and in others, the eruption appears in little circu- lar clusters, somewhat solitary, and generally on each arm or cheek; more commonly, however, flying from part to part — strophulus volatilis. Sometimes the papula? are minute, hard, and of a whitish colour, surrounded occasionally by a red- dish halo—strophulus albidus or white gum,— or the pimples are large, glabrous, shining, of a lighter hue than the skin, and without a halo or blush—strophulus candidus. In the majority of cases, strophulus seems to be connected with the process of the first dentition. It generally requires and receives but little atten- tion. It is commonly sufficient to administer an occasional dose of rhubarb and magnesia. The cause is generally transient; and as it yields, the disease yields likewise. Robley Dunglison.] SUCCESSION OF INHERITANCE.— LEGITIMACY.—It would be more than super- fluous to dwell, even for a moment, on the im- mense importance of the interests which are in- volved in the determination of the question of legitimacy. It is sufficient only to remember that the honour and purity of virtue, and the succes- sion to rank, titles, and property, not unfrequently depend solely for their invalidation or establish- ment on the settlement of this question; while the fact to be established is unfortunately one which does not always admit of being tested by any fixed criterion either in law or physiology, but on every new occasion of doubt or difficulty depends for its elucidation on the contradictory evidence of witnesses, and the opinion that may, in the particular instance discussed, be formed by judges or committees, of the connection between facts stated and admitted, and their relations with other circumstances, in general not admitting of any certain or satisfactory method of proof. Our ancestors of the olden time were satisfied with a very simple rule on the subject of legiti- macy : — the husband of the woman was the father of her children, unless he happened to be impotent or " beyond the four seas" during a pe- riod exceeding that of gestation; so that, in fact, the wife might with impunity, so far as the law was concerned, have twenty children by as many paramours, and the law would father them all on the husband. Absolute proof of paternity being nearly impossible, recourse was had to presump- tions, and of these the most natural, reasonable, and satisfactory is that founded on marriage; and hence the rule of the civil law, pater est quern nuptix demonstrant, was very early adopted, and could not be impeached, except in the two cases already mentioned—impotence of the hus- band, or his absence from the realm. No rule of law was ever more strictly adhered to than this for a period of nearly five centuries, the judges with singular pertinacity resisting every effort that was made to infringe it. The old English law, as laid down by Bracton, and copied from him in Fleetwood, differed con- siderably from this, and recognised three valid objections to legitimacy,—impotence, non-access, and all conclusive presumptions deduced from physical and moral causes; and so far did they carry the latter, that a refusal by the husband to recognise the child was held sufficient, so that it was in the power of any unnatural father to dis- inherit his offspring, and avoid the trouble and expense of rearing it. In all Bracton's cases this arbitrary recognition appears to have been a sine- qua-non, but the rejection of a once acknowledged child was at no time evidence. These statements are confirmed by Britton; but no sooner had the common law struggled into re- spectability and thrown off the bondage of canon- ists and civilians, than a sjstem entirely different grew up ; and from the time of Edward III. until that of Lord Hale, one simple and inviolable rule prevailed, viz. that every child born in wedlock was legitimate, unless the husband was impotent or beyond the four seas (extra quatuor maria) at the epoch of conception.* * For cases on the dictum of Hale, see Pendrill v. Pen- drill, Strange, 925; Rex v. Reading, Case, Temp. Lord Hardwicke, 82; Rex v. Luffe, 8 East, 208. See, also, Rex v. Rook, Jay. Rep. 61, and Rex v. Inhab. of Bedell, Andr. 8. SUCCESSION OF INHE RIT ANCE — LE GITIM AC Y. 277 That great judge resolved to purify the law from its manifest absurdity, and was the first to admit evidence of the non-access on the part of the husband without the foolish condition of ultra- marine absence. This occurred in the case of Dickens v. Collins, of which unfortunately no re- port exists; but this was the whole amount of in- novation. It was, however, regarded as of the greatest consequence, and immediately followed by the judges; and in a very important case in the beginning of the eighteenth century it was laid down by Lord Chief Justice Raymond, that the old doctrine was not to be held, but that the jury were at liberty to consider the point of ac- cess. This was the case Pendrill v. Pendrill:— the husband, after cohabiting with his wife for some months, went to Staffordshire, the wife re- maining in London. At the end of three years the wife had a son, who rested his claim upon the presumption of law in favour of legitimacy, he being born in wedlock and his father within the four seas. Strong evidence was admitted that the husband had never left his house in Stafford- shire ; and so upon the ground of non-access the jury found the son a bastard. (2 Strange, 924 ; see, also, Paris and Fonblanque, vol. i. p. 216.) Neither Lord Hale nor his successors ever thought of admitting evidence that did not de- monstrate the absolute impossibility of access, as where the husband was in a different country, or entirely disabled by disease during the period of conception. Thus in Lomax v. Holmden and another, 2 Strange, 490, which was a trial in ejectment, where the question was whether the lessor of the plaintiff was son and heir of Caleb Lomax, deceased, the defendants gave in evidence the inability of the ancestor from a bad habit of body; but their proofs going only to improbability and not impossibility, there was a verdict against them. The disavowal of the offspring by the husband was of no avail, nor was the wife allowed to prove his non-access, although she might the access of another man. As late as 1807, Lord Ellenborough said, " If we may resort to all impediments arising from natural causes, we may adopt other causes equally conclusive to show the absolute physical impossi- bility of the husband being the father, I will not say the improbability of his being such; for upon the ground of improbability, however strong, I will not venture to proceed." How strictly such a rule was acted upon by one of our most acute judges, the following case, de- cided in 1792 by Sir William Wynne, will show. It was a cause in the Prerogative Court of Can- terbury, for the administration of the effects of John Newport, Esq. The intestate was the only son of Ann the wife of Ralph Smyth, and was born when his mother had left her husband for someyears to live with Lord Bradford as his mis- tress. He was educated by that nobleman as his son, inherited from him a splendid fortune, and assumed his family name by act of parliament. The separation between Mr. and Mrs. Smyth was of an amicable nature; he appeared rather to promote her intercourse with Lord Bradford, and allowed her a small annuity. For the payment of this they had occasionally brief interviews, but there was no proof of any such having taken place for some time previous to the birth of her child. Mr. Newport, on his return from abroad, be- came insane, (the disease was hereditary in Lord Bradford's family,) and he was placed under the care of some members of it. Suits in chancery were instituted respecting his property, and Mr. Smyth as his mother's husband was made party to them; but although the latter gentleman would have de- rived great pecuniary advantages from claiming the lunatic as his son, he studiously avoided all declarations to that effect; and both acted himself, and allowed the court to act, as if no doubt could be entertained of Mr. Newport's illegitimacy. The lunatic survived his mother and her hus- band, and died possessed of property which had accumulated to an immense amount, which pro- perty was claimed by the grand-nephew of the deceased, Mr. Smyth; whereupon Sir William Wynne decided that the legitimacy of Mr. New- port was established, and consequently in favour of the claimant. His reasons were, that the circum- stance of the husband and wife both residing in London for some time previous to the birth of the child was proved in evidence. It was also proved that they occasionally met; that she visited him at his lodgings in Holborn to receive her annuity, and on those occcasions remained alone with him in his room, which was a bed-room, for half an hour at a time. It seemed probable that he occa- sionally dined with her at a house of Lord Brad- ford's, at Hammersmith. Thus possibility of ac- cess was established, and the learned judge de- livered his opinion as to the legal question in these words: — "The law of England on this subject, as now settled, I take to be this: that if such proof can be given, of whatever kind, as shall satisfy legally the mind of the court that the hus- band had no access to the wife at the time when the child must have been begotten, the child is a bastard, though born of a married woman in the lifetime of her husband; but if the husband and wife were so circumstanced that access must be presumed between them (as if they lived in the same town or place, and cannot be proved by persons who have watched them never to have come together); or if by direct evidence it can be proved that they had access to each other, in such a case I take it the son is legitimate, notwith- standing any circumstantial evidence that may be given to the contrary." Such appears to have been the law on this sub- ject until the year 1813, when it was first dis- turbed and altered by a judgment of the House of Lords in the Banbury peerage case, in which, although constant access was admitted and impo- tence not proved, the offspring was declared ille- gitimate from circumstantial evidence. On this occasion Lord Ellenborough proposed that " it was desirable to have the opinion of the judges, whether any circumstances could rebut the pre- sumption of access," and « whether there existed in this case any such circumstances." Accord- ingly, several important queries were submitted to them ; and amongst the most material of their answers were the following:—« That the presump- tion of legitimacy arising from the birth of a child during wedlock, the husband and wife not being proved to be impotent, and having opportunities 278 SUCCESSION OF INHERIT ANCE —LEGITIMACY. of access to each other during the period in which a child could be begotten and born in the course of nature, may be rebutted by circumstances indi- cating a contrary presumption. " That in every case where a child is born in lawful wedlock, the husband not being separated from the wife by a sentence of divorce, sexual in- tercourse is presumed to have taken place between the husband and wife, until that presumption is encountered by such evidence as proves, to the satisfaction of those who are to decide the question, that such sexual intercourse did not take place at any time, when by such intercourse the husband could, according to the laws of nature, be the father of such child. « That the presumption of the legitimacy of a child born in lawful wedlock, the husband not being separated from his wife by a sentence of divorce, can only be legally resisted by evidence of such facts or circumstances as are sufficient to prove to the satisfaction of those who are to decide the question, that no sexual intercourse did take place between the husband and wife at any time, when by such intercourse the husband could by the laws of nature be the father of such child."* Lords Ellenborough, Eldon, and Redesdale con- curred in their opinions on this case; and their arguments may be thus briefly stated. " This is a question of presumption : the presumption of legitimacy arising from the fact of marriage may be rebutted by circumstances inducing a contrary presumption. Impotence is such a circumstance ; so, also, is any other cause or combination of cir- cumstances, proving that the husband could not be the father of the child. It is agreed that nei- ther impotence nor want of access is proved in the present instance ; there is, therefore, no phy- sical impossibility of Lord Banbury's being the father. But in the absence of such evidence the question may be decided on the ground of a moral impossibility, which the conduct of the parties in this case establishes." Lord Erskine made great exertions on the op- posite side and in favour of the legitimacy, but he was unsuccessful; and on the 18th of June, 1813, the house resolved that the petitioner had no claim to the title, dignity, and honour of Earl of Ban- bury. (See Lords' Journals, vol. xlix. 178.) It appears, then, that the law formerly stood thus :— Presumption of legitimacy may be rebutted by physical evidence proving the contrary ; and that, since the Banbury peerage case, it stands thus:— Presumption of legitimacy may be rebutted by * In the celebrated case of Morris v. Davis, Mr. Justice Gaselee. who presided at the third trial of that cause in 1823, in summing up his charge to the jury, made the following observations on the subject of access and in- tercourse:— "The Banbury peerage is now the law. There is proof that the husband was in the wife's neigh- bourhood, and this is prima facie evidence of intercourse : but it is competent in the defendants to rebut the pre- sumption thus raised, by anything that amounts to satis- factory evidence that no intercourse took place. The question then will be, first, whether you are satisfied there was that access between the husband and wife, that sexual intercourse might take place : secondly, whe- ther the evidence satisfies you that no such intercourse did take place ? If it might take place, the law presumes it did, unless the contrary is proved. Many witnesses proved opportunities. If you are satisfied there were opportunities, the law says the child is the child of the husband." physical evidence proving, or by moral evidence rendering probable, the contrary. Accordingly, Mr. Phillips lays it down as a doc- trine to be extracted from this case, " that the jury may not only take into consideration proofs tend- ing to show the physical impossibility of the child in wedlock being legitimate; but they may decide the question of paternity by attending to the relative situation of the parties, their habits of life, the evidence of conduct, and of declara- tions connected with conduct, and to every induc- tion which reason suggests for determining upon the probabilities of the case." (Treatise on the Law of Evidence, vol. ii. p. 288. Edit. 1829.) Blackstone lays down the law on some of the most material points connected with this subject, thus: (Commentaries, vol. i. p. 454 et seq. Edit. 1832.)—"A bastard, by our English laws, is one that is not only begotten but born out of lawful matrimony. The civil and canon laws do not allow a child to remain a bastard, if the parents afterwards intermarry; and herein they differ most materially from our law; which, though not so strict as to require that the child shall be begotten, yet makes it an indispensable condition, to make it legitimate, that it shall be born after lawful wedlock. "As bastards may be born before the coverture or marriage-state is begun, or after it is determined, so also children born during wedlock may, in some circumstances, be bastards. As, if the husband be out of the kingdom of England, or, as the law somewhat loosely phrases it, extra quatuor maria, for above nine months, so that no access to his wife can be presumed, her issue during that pe- riod shall be bastards. But generally, during the coverture, access of the husband shall be presumed, unless the contrary can be shown, which is such a negative as can only be proved by showing him to be elsewhere; for the general rule is prxsumi- tur pro legitimatione. In a divorce a mensa et thoro, if the wife breeds children they are bas- tards ; for the law will presume the husband and wife conformable to the sentence of separation, unless access can be proved ; but in a voluntary separation by agreement, the law will suppose access unless the negative be shown. So, also, if there is an apparent impossibility of procreation on the part of the husband, as if he be only eight years old, or the like,-|- then the issue of the wife shall be bastards. Likewise, in case of divorce in the spiritual court a vinculo matrimonii, all the issue born during the coverture are bastards, because such divorce is always upon some cause that rendered the marriage unlawful and null from the beginning. " From what has been said it appears that all children born before matrimony are bastards by our law ; and so it is of all children born so long after the death of the husband, that by the usual t It would be very difficult to assign the opposite limit of advanced age which would preclude the possibility of procreation. "There is," says Lord Erskine, "no sta- tute of limitations on the powers and faculties of man. Instances of robust longevity might be cited still more extraordinary than that of Lord Banbury. Sir Stephen Fox married at the age of seventy-seven, and had four children. The first child was born when the father was seventy-eight: the second and third were twins in the following year; and the fourth was born when the fa- ther was eighty-one. The Earl of Ilchester and Lord Holland can vouch for the accuracy of this statement, and I believe their genealogy has stood hitherto unques- tioned."— Speech on the Banbury Case. SUCCESSION OF INHERIT ANCE — LEGITIM AC Y . 279 course of gestation they could not be begotten by him. But this being a matter of some uncertainty, the law is not exact as to a few days." (Comm. vol. i. p. 456.) In the foregoing statements of the law con- nected with this subject, there is frequent reference to " the usual period of gestation," " the course of nature," " the laws of nature," &c. a conformity to which, in the birth of any individual whose legitimacy may happen to be questioned, consti* tutes one of the requisites essentially necessary to satisfy the law; " but this being," to use the words of Blackstone, " a matter of some uncer- tainty, the law is not exact as to a few days." Unfortunately the law is not exact as to any time, however unusual, and affixes no limit; and when- ever a question of legitimacy is brought before the judges involving the determination of the usual period of gestation in women, and the variations to which it may be liable, the matter is made on every new occasion of the kind a subject of discus- sion, to be decided by the evidence of witnesses examined at the time : and the facts proposed to be investigated in reference to such questions generally are:—1. the natural period of gestation in women; 2. premature births; 3. the possibility of protracted gestation; each of which we shall now proceed to consider. 1. Natural period of gestation in women.— With regard to this point it must be confessed that our knowledge is by no means so precise as might be at first sight expected in a matter apparently capable of being made the subject of daily obser- vation ; but the fact is, that we are very rarely able to ascertain with anything like certainty the exact time of conception, and consequently having in general only one end of the chain, we can have no certain mode of counting the number of links of which it consists. Still, however, it appears to us that we are in possession of facts sufficient to warrant our belief that the natural period of gesta- tion is ten lunar months, or forty weeks, amount- ing to 280 days, which is also the period acknow- ledged in law. (See Coke upon Littleton, 123, b.) A good deal of the confusion on this point seems to have arisen from considering forty weeks and nine calendar months as one and the same quantity of time, whereas, in fact, they differ by from five to eight days. Nine calendar months make 275 days, or, if February be included, only 272 or 273 days, that is, thirty-nine weeks only instead of forty. Yet we constantly find in books on law and on medical jurisprudence, the expres- sion, " nine months or forty weeks."* Another source of confusion has evidently had its origin in the indiscriminate use of lunar and solar months as the basis of computation in certain writings of authority. This appears to have occurred in the Roman laws on this very subject. Hippocrates, in his book " De Septimestri et Octomestri partu," calculates by lunar months, while in several others of his works solar months are uniformly those referred to, and the Roman laws were founded on his authority. In like manner we find in the book of Esdras, (2 Esdras, iv. 40), « nine months" * Vide Coke upon Litt., loc. cit., and Paris and Fon- blanque, vol. i. p. 241. Smith's Principles of Forensic Medicine, p. 491. Dewees' Compendium of Midwifery, p. 164. Mr. Burns more accurately says, " nine calendar months and a week." Principles of Midwifery, p. 168. spoken of as the fixed time of gestation ; and in the Wisdom of Solomon, (Chap. vii. 2.), "ten months" is the period assigned for the perfection of the child in the womb; a discrepancy which could only have arisen from the writers using dif- ferent divisions of time. An opportunity was lately afforded us of observ- ing the natural term of gestation under circum- stances in which the day of conception was known with certainty. A lady who had been for some time under our care in consequence of irritable uterus, went to the sea-side at Wexford in the month of June, 1831, leaving her husband in Dublin, a temporary separation being considered essential to the recovery of her health. They did not meet until the 10th of November, on which day he went down to see her ; and being engaged in a public office, he returned to town next day. The result of this visit was conception : before the end of the month she began to experience some of the symptoms of pregnancy; and when she came to town on the 22d of February she was large with child, and had quickened on the 29th of the month preceding. Her last menstruation had occurred on the 18th of October. She went on well through her pregnancy ; and the writer was called on to attend her in labour on the 17th of August, when she gave birth to a healthy child after a labour of a few hours' duration. Here the gestation exceeded nine calendar months by just one week, making exactly 280 days from the time of conception. It may be observed that this was the earliest instance of quickening which has pre- sented itself to the writer,' occurring as it did before the completion of the twelfth week. 2. Premature births. — The premature birth of children not unfrequently gives rise to discus- sions of a very delicate and important nature, involving on the one hand the legitimacy of the child, and on the other the honour and fair fame of the mother, and consequently the happiness of families, when suspicions are entertained that the development of the fcetus does not correspond to the period which ought to have been that of gesta- tion, dating from the time of marriage, or the return of the husband, and so forth. It is, there- fore, essentially necessary that all who are likely to be consulted on such matters should possess themselves with as accurate a knowledge as possi- ble of the progressive development of the embryo, and the marks or characters which belong to each successive period of intra-uterine existence, even in the earlier months. The full details of this subject do not properly belong to the discussion of the question of legitimacy, the investigation of which can only become of interest or importance when the foetus has acquired such a degree of maturity as is likely to render it viable or capable of sustaining its functions independently of the mother. There will then be two distinct points of view under which we must consider this part of the subject. We must inquire, first, what is the earliest period of gestation at which the condi- tion of viability-j- may be expected to exist; and,. \ Viability is thus defined by Capuron :—" La viability pour un enfant qui vient au monde n'est autre chose que la possibility de vivre cornpletement et aussi long tenisi que le cominun des homines; c'est a dire de deveiiir un adulte. un hnmme fait, un veritable inembre societe."— Medecine Legale, p. 152. 280 SUCCESSION OF IN HE RIT A NCE —L EGITIMACY. secondly, can we admit that a child may in six or seven months acquire that degree of maturity which we observe to belong to those which have continued in the womb the whole natural period of gestation ? With regard to the first of these questions, we think experience warrants us in adopting as correct the opinion of Wm. Hunter, given in answer to an intenogatory put to him on this subject:—« A child may be born alive at any time after three months; but we see none born with powers of living to manhood, or of being reared before seven calendar months, or near that time.* At six months it cannot be."-{- We do not take into consideration, or attach any value to such rare and wonderful histories as those of Fortunio Liceti, the Italian physician, who was said to have been born at four months and a half, and to have attained the age of manhood ; nor to that of Cardi- nal Richelieu, in whose case the parliament of Paris decreed that the infant at five months pos- sessed that capability of living to the ordinary period of human existence which the law of France required for establishing its title to inheritance. In the consideration of the second point, we have to contend with a very formidable difficulty, intrinsic to and inseparable from the subject, — namely, the great variety constantly observed in the size, weight, strength, and appearance of chil- dren at the full time. Some of these, for instance, do not exceed seven pounds in weight, while oc- casionally we meet with instances where they are of double that weight. This should at least make us extremely delicate in forming, and cautious in pronouncing our opinion, particularly when the period of gestation may have advanced to within a month of its expected termination, in which case it might be impossible for us, with all our care and all our knowledge, to draw the distinction between a child of eight months and one of nine. But in such case as occurs from time to time, where a woman six or seven months after mar- riage, or the return of her husband, produces a healthy well-formed child of the full size and de- velopment, we need hardly hesitate about its ille- gitimacy ; at least we never saw an instance where a child, avowedly of six or seven months' growth, presented an appearance even remotely resembling that of a full-grown and matured fcetus. Even though the size alone may not enable us to dis- tinguish the one from the other satisfactorily, there are several characters of imperfect develop- ment which mark the really premature fcetus whatever may be its size; while, on the other hand, there are others which accompany the fully matured child, although deficient in bulk. Of the latter kind are the colour and firmness of the skin; the perfect condition of the hair and nails; the full development of the lower extremi- ties; the solidity of the bones of the cranium, and their close approximation along the sutures. If * The earliest instance we have met with were the fol- lowing:— A foetus which at the utmost could only have completed the fifth month, and which lived for a few minutes; and another of five months and a half, which lived for four hours. f'Ante septimum monsem foetus non potest super- esse."—Haller, Elem. Phys. vol. viii. p. 423. The French civil code, however, regards as legitimate and viable all children born after 180 days, or six months.—Capuron, Cours d'Accouchement, p. 69. along with these we find that the child is vigorous and active, crying strongly soon after birth, and taking the nipple readily or even eagerly, and sucking it effectually; that its length measures from 19 to 21 inches,} and that the middle point of that length falls at the umbilicus; we have an assemblage of characters which ought to leave but little doubt of maturity having been attain- ed. The situation of this middle point was first proposed as a test of the age of the fcetus by Chaussicr, and hi? observations have been since confirmed by several others.§ From the trial we have made of this test, we are disposed to attach considerable value to it. [Yet it is far from being decisive; as has been shown elsewhere.] (See the article Infanticide, [in vol. ii. p. 679.]) It should be recollected, also, that there are cer- tain women to whom it is peculiar always to have the time of delivery anticipated by two or three weeks, so that they never go beyond the end of the thirty-seventh or thirty-eighth week for several pregnancies in succession.|) La Motte (Liv. i. chap. 28,) mentions two women who always brought forth at the end of seven months; and the same thing happened to the daughters of one of them. Van Swieten (Comment, vol. xiv. p. 6, 7,) takes notice of a similar circumstance; as does also Fodere. (Med. Leg. vol. ii. p. 28.) A mem- ber of the writer's family never passed the end of eight months in three successive pregnancies; but such cases cannot be looked on as instances of gestation completed, but of premature labour from some infirmity of the system, or indisposition in the uterus to enlarge beyond a certain size ; nor is it contended or asserted by these writers that the children had acquired their full growth : in the instances occurring under our own observation they certainly had not. [In 1835, an investigation took place before one of the Presbyteries of Scotland, in regard to certain 'reports which had been circulated to the prejudice of a minister of the district. The mar- riage of this gentleman took place on the 3d of March, and his wife gave birth to a female child on the 24th of August, that is 174 days after the marriage, and the child continued to live until the 20th of March 1836. When born it was very weak, and did not weigh more than three pounds. The birth of a living child, together with its sur- viving for so long a period, led to the report, that there must have been intercourse between the par- ties before marriage. The case went through several appeals, and was not fully settled until May 1839, when the libel was found not proven, and the defendant was absolved from censure. Many medical witnesses in Scotland, and others from France, Italy, and Germany gave evidence, \ Rcederer concludes from his examinations, that the average length of a male at the full time is twenty inches and a third: while that of a female is nineteen inches and seventeen-eighteenths. § Capuron, p. 172. Hutchinson, pp. 6-14. Fodere, vol. in p. 149. Burns, pp. 114, 118. Metzger, by Ballard, 168. Beck, p. 112 et seq. || While writing these observations we met with an instance of this. The writer was engaged to attend a lady in her fifth confinement, who told him a month beforehand that from particular circumstances she knew her time would be up about the 23d of the mouth, but that she expected her labour to occur about the 9th, as she had on the two firmer occasions anticipated by two weeks ; she became in labour on the night of the lOtb, and was delivered on the lllh. SUCCESSION OF INHER the majority of them being in favour of this hav- ing been a legitimate and premature birth. (Lond. Med. Gaz. xvii. 92. Med. Chir. Rev. xxxi. 424. A. S. Taylor, Manual of Medical Jurisprudence, p 610, Lond. 1844; and Guy, Principles of Fo- rensic Medicine, p. 173, Lond. 1843.)] 3. Protracted gestation. — The possibility or otherwise of an extension of the ordinary period of gestation has been for a very long time, and still continues, a question of very warm debate; some maintaining that the time is fixed and admits of no variation; while others, who agree as to there being a certain period most frequently ob- served, believe that it is not exempt from variety, and may be prolonged. In this view of the sub- ject we entirely coincide; but at the same time we are ready to confess that many of the argu- ments brought forward in support of it have been vague and nugatory in the extreme, and several of the cases adduced totally unworthy of belief. We cannot imagine why gestation should be the only process connected with reproduction for which a total exemption from any variation in its period should be claimed. The periods of men- struation are in general very regular; but who is there who does not know, that as there are on the one hand women in whom the return of that dis- charge is anticipated by several days, so there are also many in whom the return is postponed an equal length of time without the slightest appre- ciable derangement of their health! (For a case in which the regular menstrual period was five weeks, see Burn's Principles of Midwifery, Edit. 7, p. 168.) Again, menstruation and the power of reproduction in the female very generally, in- deed almost universally, cease in these countries about the forty-fifth year; yet occasionally instan- ces are met with in which both are prolonged ten or fifteen years beyond that time of life; and a similar variety is observable in the period of the first establishment of that function in the system.* If we turn our attention to brutes, the conditions of whose gestation so closely coincide with those of the human female, and are less exposed to have it disturbed, we cannot for a moment doubt the fact that there is a great inequality in the term of gestation in different individuals of the same species. The experiments and observations of Tessier, which were continued through a period of forty years, contain facts and information more than sufficient, as appears to us, to satisfy any one on this point with regard to the lower animals. (Magazin Encyclopedique, quatrieme annee, t. vi. p. 7; or Becks Medical Jurisprudence, p. 194. Edit. 1829. See, also, Capuron, Cours d'Ac- couchement, p. 71. Edit. 1833.) [Similar results were obtained by Lord Spencer from observations made on 764 cows. (Journal of the English Agricultural Society, part ii. 1839. See also on this subject the writer's Human Phy- siology, 5th edit. ii. 426, Philad. 1844.)] There is a very curious fact mentioned by the * It is a law of nature very constantly observed, that dentition should commence a few hours after birth, and that some of the teeth of children should show themselves within the first year at farthest, and instances where the cutting of the first teeth is deferred to the end of a year are unusual; yet in the case of one of the writer's chil- dren, the first tooth did not appear until the child had reached the twenty-first month of her age, she being at the time and previously in perfect health. Vol. IV__36 " x* ITANCE —LEGITIMACY. 281 o late Sir Everard Home, which, if strictly correct, would go a great length in strengthening the ar- gument from analogy. He says that " where the female of one species of animals breeds from the male of another, the utero-gestation of whose spe- cies is different in its period, there appears to be no approximation in the time in which the hybrid j is brought forth ; but the longest term of the two is the time of such utcro-gestation. Thus the j mare covered by the ass goes eleven months, her usual period; and the ass covered by the horse goes eleven months, although ten is her usual pe- riod."—Philos. Trans. 1822. The circumstances of incubation are by no means without some weight, when we observe that of a clutch of eggs laid by the same hen and co- vered alike during the hatching time, some will produce the chick twenty-four, thirty-six, or even forty-eight hours later than the rest,—an excess in the period amounting to one-tenth of the whole, and as great as that which facts appear to show may be reasonably contended for as affecting the period of human gestation. But if we relinquish the less certain support of analogy, and resort to facts alone, as observed by ourselves, or others worthy of belief, we are quite satisfied that we are in possession of more than enough to prove the point; and let it not be for- gotten that the combined testimony of all who have maintained the unvarying fixedness of the natural term, merely because they had known no instance to the contrary, (and they could have no other grounds for their belief,) is, after all, only negative evidence, and must fall before a single well-established instance in which that term was exceeded. The weight of authority is altogether on the side of those who believe in the occasional pro- traction of gestation, in favour of which we find the following have recorded their opinions:—An- toine Petit (Recueil des pieces relatives a la Question des Naissances tardives, 1766), Lebas (in a Memoir in answer to Louis), Haller (Ele- menta Physiologise, vol. viii., pp. 421-425), Roussel (Systeme de la Femme, p. 174 et seq.), Zacchias (Questiones Medico-Legales, lib. i. tit. 2, quajst. 1), Buffon-Levret (Art des Accouchemens), W. Hunter (Hargrave's Notes on Coke upon Lit- tleton), Fodere (Medecine Legale, vol. ii. chap. 8, sect. 4), Gardien (Traite des Accouchemens, torn. i. p. 162), Velpeau (Traite de l'Art des Accouche- mens, torn. i. p. 388), Capuron (Medecine relative a la Grossesse, pp. 217-224; and, also, Cours d'Accouchement, p. 62, edit. 1833), Desormeaux (Dictionnaire de Medecine, t. x. pp. 374 and 462), Richerand (Physiology, p. 499, edit. 1824), De- wees (Compendium of Midwifery, p. 166), Ha- milton (Letter to Dr. Granville, Lond. Med. Ga- zette, Dec. 12, 1829, p. 344), Burns (Principles of Midwifery, p. 168, edit. 7), Denman,f with a host of others, of less though by no means incon- siderable authority. Many of these have, in con- firmation of their opinions, related the cases on t We think ourselves justified in adding the name of Denman on the strength of the following passage in his Introduction to Midwifery, p. 254, Edit. 5. " At the ex- piration of forty weeks the process of labour commenc- eth, unless it be hastened or retarded by some particular circumstance." 282 SUCCESSION OF INHERIT ANC E — LE GITIM AC Y. which their conviction was grounded, and which, of course, had fully satisfied their minds ; and we cannot believe it possible that all of these writers could have been mistaken in a mere matter of fact or observation, and that none of the cases which they have put on record were really instances of gestation prolonged beyond forty weeks. At the same time, we must add that the cases which ap- pear to us to carry with them the fullest demonstra- tion of their truth, are those in which the ordinary term was not exceeded by more than three or four weeks. Some of those which appear the most satisfactory, we shall now notice as briefly as possible. Dr. Blundell, in his evidence before the House of Lords on the Gardner peerage case, declared that he knew positively one case in which con- ception must have taken place on the 9th of No- vember, and delivery did not occur till the 23d of August following, making an interval of 287 days, or one week beyond the usual time. On the same occasion, Dr. Merriman deposed that he had known cases to be extended to 285 days; in two or three instances, to 296 ; in one, to 303 ; and in one to 309 days. (See, also, Med. Chir. Trans. vol. xiii.) Wm. Hunter, in answer to a query on this sub- ject (vide Hargrave's Notes on Coke upon Lit- tleton), said, " The usual period is nine calendar months; but there is very commonly a difference of one, two, or three weeks. I have known a wo- man bear a living child in a perfectly natural way, fourteen days later than nine calendar months, and believe two women to have been delivered of a child alive, in a natural way, above ten calendar months from the hour of conception." The late celebrated Professor Desormeaux says, " Observations well attested prove that the term may be prolonged beyond the usual period ;" and he adduces the following case, occurring within his own observation, in a patient whom he at- tended:—"A lady, the mother of three children, became deranged after a severe fever. Her physi- cian thought that pregnancy might have a benefi- cial effect on her mental disease, and permitted her husband to visit her, but with this restriction, that there should be an interval of three months between each visit, in order that, if conception took place, the risk of abortion from further intercourse might be avoided. The physician and attendants made an exact note of the time when the hus- band's visit took place. As soon as symptoms of pregnancy began to appear, the visits were discon- tinued. The lady was closely watched all the time by her female attendants. She was delivered at the end of nine calendar months and a fort- night, and Desormeaux attended her." Concern- ing this case, Raige-Delorme, who is rather scep- tical about retarded gestation, declares that it is a fact possessing " the elements of a perfect demon- stration," in favour of a protraction so far." (Diet. de Medecine, vol. x. p. 462.) Dr. Dewees, the professor of midwifery at Phi- ladelphia, relates " that the husband of a lady, who was obliged to absent himself for many months in consequence of the embarrassment of his affairs, returned, however, one night, clandes- tinely ; and his visit was only known to his wife, her mother, and Dr. D. The consequence of this visit was the impregnation of his wife; and she was delivered of a healthy child in nine months and thirteen days after this nocturnal visit."* Dr. Hamilton, the present distinguished pro- fessor of midwifery in Edinburgh, says, » But the result of my experience has been different; in one case, many years ago, the lady exceeded the tenth revolution (of the menstrual period) by twelve days; another lady exceeded it by sixteen days, and another by twenty-four days. This latter pa- tient menstruated on the 1st of August, and was not delivered till the 28th of June. Another lady, the mother of a large family, exceeded her period by above a fortnight on the 4th of March, when her husband went to England, where he resided for some months; but she was not delivered till the 6th of December." (See Extracts from his Lectures, in a letter from him in Lond. Med. Ga- zette, Dec. 13, 1829.) Mr. Burns says, " On the other hand it is equally certain that some causes which we cannot explain or discover, have the power of retarding the process, the woman carrying the child longer than nine months; and the child when born being not larger than the average size. How long it is possible for labour to be delayed beyond the usual time cannot be easily ascertained." " The longest term I have met with is ten calendar months and ten days, dated from the last menstruation. In the case of one lady who went this length, her regular menstrual period was five weeks, and in her other pregnancies she was confined exactly two days before the expiration of ten calendar months after menstruation." (Principles of Midwifery, p. 168. Edit. 7.) In the case of Anderton against Whitaker, tried at Lancaster a few years since, intercourse between the parties was sworn to have occurred on the 8th of January, and never at any other time, and labour did not take place until the 18th of October, being the 284th day from the time of conception. A case which occurred in the writer's practice, closely coinciding with those described by Mr. Burns, appears to be also an instance of gestation prolonged to a like degree. The circumstances were these :—A lady who had suffered from puer- peral mania after her previous confinement in 1830, from which however she perfectly recovered, conceived again in the month of July, 1831, and miscarried in October, being then in the third month of pregnancy. She menstruated regularly in November and December, and for the last time in the first week of January, 1832. The writer did not see her again till the 24th of March, at which time she considered herself as in the third month of pregnancy ; and as she was suffering pains, was fearful lest abortion was about to happen at the same period as before. It did not, however, occur, and she went on safely. At this date the symptoms of pregnancy were well marked; the areolae were very distinct on the breasts, and the increased size of the abdomen was obvious to the eye, and corresponded to the supposed period of pregnancy. Quickening occurred on the 10th of *An interesting fact connected with this case was, that at the time of conception the lady was within a week of her menstrual period, which was not interrupt- ed ; but the interruption of the next period gave rise to suspicion in her mind, which was realized by the birth of the child. TANCE— LEGITIMACY. 283 SUCCESSION OF INHER May, and all parties looked forward to the occur- rence of labour about the middle of October, which, however, did not happen until the 14th of November. Now in this case, if we suppose conception to have taken place very soon after the last menstrual discharge, as it most frequently does, we have an interval of exactly forty-four weeks, or 308 days, a period of time exceeding the usual one by four weeks, or twenty-eight days, one whole lunar month. And on the other hand, if we suppose conception to have taken place on the very last day of the interval between the two menstrual periods, we should still have an instance of gesta- tion occupying forty-one weeks and two or three days. And lastly, if we assume the middle period of the interval as the time of conception, we should have an interval of forty-two weeks and a half; and certainly, when we saw her in March, she had all the appearance of a woman in the third month of pregnancy. It is also to be recol- lected that quickening occurred on the 10th of May, just sixteen weeks after the probable period of conception, or eighteen weeks from the time of the last menstrual period, and nearly twenty-seven weeks before labour. We may add that this was the third instance of the same kind which has come under our own observation. We cannot close this part of the subject without directing the reader's attention to the cases related by Dulignac (in the Causes Celebres,) Fodere, (Medecine Legale, vol. ii. ch. 8, p. 195,) and Dr. Granville, (in his evidence before the House of Lords) ; which, occurring as they did in their own wives, and under circumstances where there could be no possible motive to deceive, and where every successive period of the gestation was carefully observed by persons so eminently qualified to form a correct opinion, are entitled to great attention. It appears to us that several of the foregoing cases ought to carry conviction to any unprejudiced mind ; and it is to be recollected, that if any one of them be true, it establishes the fact in defiance of all objections made by those who deny it be- cause they have not met with any case of it them- selves, or because they conceive it to be inconsistent with the usual or established order of nature.* " We ought to admit it," says Fodere, " not merely because it is possible, but because we have abundant proof that it has happened." [Cases of single intercourse, if well attested, would be sufficient to settle the question ; but it is difficult to obtain them in any considerable number. The following cases are recorded : (Guy's Prin- ciples of Forensic Medicine, p. 167, Lond. 1843.) Duration. A case by Dr, Nixon................273 or 276 days. Dr. Montgomery, before referred to . - 280 " Dr. Forster of New York,............283 " 285 " Seduction case (Lancaster assizes,)... 284 " De wees.............................286 " 288 " Desormeaux,.......................290 " Dr.Reid............................292 " 293 " The results of these cases are as follows: Average of the 7 cases...............284 or 285 days. Minimum...........................273 " 276 " Maximum..........................292" 2>J3 " Range.........................16,17,19" 20 " Excess above 280 days,...............12" 13 " Excess above 9 calendar months, 16 or 17 to 19 " 20 " • Ignorat natune potentiam qui illi non putat licere, aliquando, nisi quod srepius facit.—Seneca, Nat. Quest. lib. vii. cap. xxvii. On a trial for seduction in this country, the female swore to a single connection on the 16th of October, 1840. The child was born on the 10th of August, 1841, being forty-one weeks and four days, or 291 days. (Dr. T. R. Beck, Amer. Journal of the Med. Sciences, April 1842, p. 291.)] In the next place we find that the laws of different countries have been framed from a per- suasion on the part of the legislators that a pro- traction of the ordinary term of gestation might occur. Thus the law of France, the Code Napo- leon, provides that the legitimacy of a child born 300 days after the death or departure of the husband shall not be questioned ; and the child born after more than 300 days is not declared a bastard, but its legitimacy may be contested. The Prussian civil code declares that an infant born 302 days after the death of the husband shall be considered legitimate. The Scotch law is very precise:—"To fix bastardy on a child, the hus- band's absence must continue till within six months of the birth; and a child born after the tenth month is accounted a bastard." Our Eng- lish law fixes no precise limit,-}- but the decisions that have been made from time to time are in favour of the possibility of protracted gestation. The first satisfactory precedent of which we are aware is that M. 17 Jac. B. R. Alsop and Slacey. Andrews dies of the plague; his wife, who was a lewd woman, is delivered of a child forty weeks and ten days after the death of the husband ; yet the child was adjudged legitimate, and heir to Andrews; for partus potest protrahi ten days ex accidente. In the case of Forster and Cooke, (Brown's Chancery Cases, v. iii. 349,) a legatee filed a bill to have his legacy, and in order to define the per- son on whom he had claims, it was necessary to establish a will. But as it is requisite in chan- cery, for establishing a will, to have the heir-at- law before the court, it was a question to whom that title properly belonged, and so the period of gestation came to be considered. An issue was directed to try whether a child born forty-three weeks after the husband's death was legitimate; and it appears that the jury found this posthumous child to be the heir-at-law. With the exception of the last-mentioned case, the question of protracted gestation seems to have escaped legal inquiry for more than two hundred years before the contest for the Gardner peerage, which recently excited so much interest in Eng- land, and gave rise to a very lengthened investi- gation. The following were the facts of this remarka- ble case. In the year 1796, Captain Gardner (who afterwards became Lord Gardner) married Miss Adderley. They lived together as man and wife until the 30th of January, 1802, on which day Mrs. Gardner took leave of her husband on board-ship, and shortly afterwards he sailed to the West Indies; from whence*he returned to Eng- land on the 11th of July following. For some time before, and also during the whole time of Captain Gardner's absence, Mrs. Gardner carried f "And so it is of all children born so long after the death of the husband that by the usual course of gestation they could not be begotten by him; but this being a matter of some uncertainty, the law is not exact as to a few days."—Blackstont, 284 SUCCESSION OF INHERIT ANCE —LEGITIMACY. on an adulterous intercourse. Upon Captain Gardner's return to England he found his wife with child; and she, hoping to be delivered within the proper time, made no secret of her pregnancy. When, however, she ascertained that the child could not be brought forth in time to be supposed to be Captain Gardner's, she declared that she had a dropsy, and informed his family that such was the case; and not only Captain Gardner, but the whole of his family, considered her as labour- ing under that complaint. On the 8th of De- cember Mrs. Gardner was delivered in secret, in the presence of three persons only. The child was immediately removed to a lodging, and was afterwards christened by the name of the para- mour, who brought it up, and in all respects treated it as his son. The birth of this child was carefully and successfully concealed from Captain Gardner, who did not even discover his wife's adultery till the year 1803. He subsequently obtained a divorce, and married again. He suc- ceeded to the title in 1808, and died in 1815, leaving a son by his second marriage, who in the year 1824 presented his petition to the king pray- ing to be entered on the parliament-roll as a minor peer. This was opposed by the young man, Henry Fenton Jadis, alias Gardner, who claimed to be eldest son of Lord Gardner, being born 311 days, or ten calendar months and nine days after Captain Gardner's departure from the country. The petitions were referred to the committee of privileges, who called before them seventeen of the most eminent practitioners in midwifery in Lon- don and elsewhere, and examined them as to the possibility of such a protraction of the term of gestation as was here contended for. Five of these gentlemen maintained that the limits of ges- tation were fixed, and consequently denied the possibility of such a protraction. The other twelve supported the affirmative side of the question, and some of them adduced cases very strongly in favour of their views, particularly Drs. Granville, Con- quest, and Blundell. Without wishing to enter into any criticism of the medical evidence, we cannot help remarking that two or three of the gentlemen who asserted forty weeks to be the ultimatum, admitted that it might be exceeded by a few days; and we would ask, if the principle of extension be admitted, how or by whom can the limits be assigned ? The House of Lords decided in favour of the petitioner and against the counter-claimant, Henry Fenton Jadis, but not because of the time of his birth; for Lord Eldon, who was their Chancel- lor, in giving his judgment, says, »It is not by any means my intention to do more than express my conviction that the petitioner has made out his claim,—that there are a great many more ques- tions which arise in a case of this nature, almost the whole of which were considered in the Ban- bury peerage, but without entering into a detail of these questions, and without entering into a discussion as to the ultimum tempus pariendi, I am perfectly satisfied upon the whole evidence that the case has been made out." (Le Marchant's Report of the Proceedings, &c. p. 335.) It was the adultery of the mother, and the con- cealment of the birth from the husband, which justified the house in refusing the petition of the counter-claimant. If the only point in the case had been that he was not the son of Lord Gardner because it was impossible his mother could have gone forty-four weeks with him, the House of Lords could not have declared him illegitimate; and when Lord Eldon said he should give his opinion " without entering into the question of the ultimum tempus," it is perfectly clear he did so for the purpose of guarding against the decision being ever taken as a precedent that a gestation protracted four weeks beyond the usual time should be a ground for bastardizing a child. W. F. Montgomery. SUCCUSSION. (See Chest, Exploration or THE.) SUDORIFICS. (See Diaphoretics.) SUPPURATION. This term is employed to denote the process whereby a certain fluid, called pus, is formed or deposited on the surface or in the substance of any tissue. It seems to be strictly analogous to the words cuirvnas, eKwvnots, or otto- TTvtiotc, which Hippocrates appears to have applied indiscriminately to the deposition of pus, without any reference to the precise nature of the process by which it is produced. The propriety of re- garding this process only as a sequel of inflamma- tion will be considered in the course of this article; but it is obvious, that where there may exist a doubt upon this head, it is much more consonant with the most approved method of scientific defi- nitions to omit all mention of a questionable con- nection. We prefer to denote by suppuration that which it so clearly expressed by a term used by some French writers, pyogenie, which wo be- lieve originated with Brugmans. (Brugmans de Puogenia, sive Mediis quibus Natura utitur in creando Pure.—Groninga?, 1785. Diet des Sc. Medicales, Art. Pyogenie.) Having first treated of the properties of the fluid which characterizes the suppurative process, we shall, in the second place, proceed to the consider- ation of the precise nature of that process, and, lastly, to the various phenomena which accom- pany it. Pus is obtained in its greatest purity from the surfaces of external ulcers which are in a per- fectly healthy state, and show a disposition to heal, or from acute and healthy abscesses. As the qua- lities of this fluid are apt to vary considerably un- der the influence of even trivial causes, it is desi- rable to be particular in procuring that which is destined for examination, from a healthy source. Pus thus obtained, and absurdly denominated "laudable" is a homogeneous fluid, of the con- sistence of cream, of a white colour tinged with yellow, slightly tenacious, of a mild taste, and sometimes a mawkish smell, but at times also ino- dorous. It is important, in a practical point of view, to ascertain what are the fixed and constant charac- ters of pus. Most observers have stated that it consists of globules, which they consider its essen- tial part; these globules float in a fluid possessing some resemblance to the serum of the blood, but from which it especially differs in being coagulable by muriate of ammonia. Hunter, (on the Blood, Inflammation, &c.) Home, (on Ulcers,) and Pear- son, (Phil. Transact, an. 1810,) have considered SUPPURATION. 285 these globules as very similar to those of the blood; and (Jendrin, who regards pus as blood in a trans- formed condition, and whose microscopic observa- tions fully confirm those of MM. Prevost and Du- mas, thinks that the only difference between them is, that the globules of pus are somewhat larger and of an opaque yellow colour. (Histoire Anat. des Infl. torn, ii.) Mr. Lister and Dr. Hodgkin, however, have expressed a different opinion; and' they state, as the result of their observations, that the globules of pus are extremely irregular in size and figure, and " bear no resemblance to those of the blood." (Appendix to Hodgkin's Translation of Edwards on the Influence of physical Agents on Life, p. 441.) The following concise state- ment is from Kaltenbrunner, an exact and cautious observer. " In hominis pure meraco, quod ab aeris injuria* bene erat munitum, granula sequalia, sphe- rica, pellucida, nucleo penitus carentia, conspiciun- tur nee aliud quidpiam. Aeri vero exposita, gra- nula mox inter se conglutinantia et decomposita, floccos inrequales exhibent, qui sero quodam cincti Bunt." (Experimenta circa Statum sanguinis et vasorum in Inflammatione, § 86.) In fine, Ras- pail, the latest systematic writer on organic chem- istry, considers the existence of globules in pus entirely dependent on the presence of albumen in it, and observes that they so easily alter their shape that it is but lost time to devote any atten- tion to microscopic observations upon it, with the hope of ascertaining any determinate form in them. (Nouveau Systeme de Chimie Organique, p. 508.) The great importance which was formerly at- tached to the discovery of some criterion for dis- tinguishing between pus and mucus, led physicians to subject the former fluid very extensively to the action of chemical re-agents; nor does it appear that any very useful results have been obtained from their numerous trials. The well-known essay of Darwin, entitled " Experiments establish- ing a criterion between mucilaginous and purulent matter," was composed in consequence of this question having been appointed the subject for the medal offered by the .northward are tribes still more unlike the tropical African races. In the Isle of Madagascar the genuine Malecasses have black skins and crisped hair, though in their forms taller and more hand- some than the negroes. Passing over the ocean eastward to the Indian continent, we discover the natives of Malabar nearly black, and the Cingalese in Ceylon of a hue almost equally intense, though neither of these races is at all woolly; but in the Andaman Isles in the Bay of Bengal we again find negroes nearly similar to those of Africa. Pursuing thence the same direction through the intertropical space to the further continent, we find, under the names of Samang and Bila, black races with woolly hair in the hilly tracts behind Malacca and Penang. Likewise in the interior of all the great tropical islands of the Indian Archipelago, wherever woody and inaccessible tracts defend the oldest races from the intrusion of Malayan and other colonists, the Papuas, black and with long frizzled hair, are still the sole in- habitants. Beyond the Indian ocean lies the con- tinent of New Guinea, immediately under the equinoctial line Here again, together with other .productions of the equatorial clime, a black variety of the human race displays itself, woolly, like the negro tribes of Africa: they are the chief inhab- itants of the extensive region above-mentioned, as well as of the great adjacent islands of New Bri- tain and New Ireland. Still further to the east- ward the insular groups of Louisiade, Solomon's Isles, Santa Cruz, and the New Hebrides, are oc- cupied by tribes of a similar description. Here the woolly-haired people cease to be found : the natives of the more distant islands are of later origin or dispersed, as their still similar dialects .prove, at a comparatively recent period. Passing over to the shores of the new world, we find no trace of woolly-haired races ; but the people of California* and of Brazil, the hottest regions in America, are nearly as black as the Africans, and * La Perouse says, " the colour of these Indians (Cal- ifornians), which is the same as that of the negroes, and a variety of objects, presented the appearance of a plan- tation in St. Domingo." differ in a striking degree from the tribes inhabit- ing the north and south, as well as from the natives of the high plain of Anahuac. We have made this survey in order to establish a fact which has often been denied,—namely, that the production of those physical peculiarities which belong to the negro, and of which a black skin and woolly hair are the most conspicuous traits, is in some way connected with the local circumstances of a tropical climate. This fact affords a presumption that the temperament [?] or constitution of races thus distinguished is pe- culiarly fitted for the regions which they inhabit, and other observations seem to prove this to be the case in a greater degree than we can fully explain. Europeans and their descendants bear with ex- treme difficulty an abode in Africa as well as in most other countries between the tropics. The coast of Zanguebar has been visited by navigators from the earliest times, and trading colonies have been established there and on various parts of the African shores; yet between the tropics these colonies have never maintained themselves, and now among the Portuguese at Goa an exile to Mozambique is considered as almost equivalent to a capital punishment Even in the West Indies Europeans are supposed to be incapable of labour, and this opinion gave origin to the introduction of negroes. On the other hand negroes and black people in general seem to be under a cor- responding disability to thrive and multiply in Europe. In cold climates they are always un- healthy, and are particularly subject to scrofulous and tubercular diseases. It is not so easy to de- termine what are the peculiarities of structure on which these differences depend. " The skin of the negro," as Dr. Winterbottom observes, "is always cool and remarkable for its velvet-like softness." Linnaeus terms it, " cutis nolosericea." The head of the negro in his native region is covered with a thick dense mass of oily wool, which protects him from sustaining injury under the vertical solar rays. " The negroes," says Major Long, -'so far from suffering any inconve- nience, are found to labour with most alacrity and ease to themselves in the very hottest part of the day. The chilliness of the morning air in Ja- maica seems to cast a damp upon their spirits, and renders them for a time feeble and torpid: one sees them creeping slowly out of their huts, bun- dled up with a thick clothing, shivering, and uneasy ; but as the day advances, they grow more and more active and alert. The openness of their pores gives a free transpiration to bad hu- mours, and they would enjoy robust health under the hardest toils if they were less prone to debauch. They love warmth in the night, and never sleep without a fire in their huts." (Long's History of Jamaica.) Mr. Jefferson has given a similar account of the negroes of Virginia. He says, " they secrete less by the kidneys, and more by the glands of the skin, which gives them a very strong and disagreeable odour. This greater de- gree of transpiration renders them more tolerant of heat, and less of cold than the whites. They seem to require less sleep. A black, after hard labour through the day, will be induced by the slightest amusements to sit up till midnight, knowing that he must be out by the first dawn of TEMPERAMENT. 355 the morning. Their griefs are transient. Those numberless afflictions which render it doubtful whether heaven has given life to us in mercy or in wrath, arc less felt and sooner forgotten by them. In general their existence appears to par- ticipate more of sensation than of reflection." (Jefferson's Notes on Virginia, p. 233.) This philosophical and republican owner of slaves en- deavours to prove the negro to be of a species inferior to the white race. In the opinion that the negro is inferior in natural capacity, this writer is contradicted by the most intelligent and unprejudiced observers. The xanthous or fair variety of complexion, and the black and woolly-haired mark the strongest diversities of temperament to be found in the human species, with respect to the adaptation for particular local circumstances. The red-skinned races seem to hold an intermediate place between these two extremes. To this class belong most of the native American nations, for among the latter there are, as we have seen, contrary to the assertions of many, both blacks and whites. To the class of red races belong also many tribes in the interior of Africa, whose native regions are chiefly elevated countries near the tropic of Cancer. The most remarkable nations of this stock in Africa are the Foulahs, the Red Poules, of MoIIien and Golberry, who issued, about half a century ago, from their ancient abodes near the sources of the Rio-Grande, and spread themselves over the interior countries of Africa, where they have nearly conquered some of the most powerful of the negro states. To the same division of mankind, we must refer the Barabras on the Upper Nile, and some of the native tribes of Abys- sinia ; likewise the old Bedjas, according to Macrizi, the ancestors of the Ababde and the Bisharein, red tribes to the eastward of the Tacazze, as well as the old Egyptians. The physical constitution belonging to these tribes of men is in many respects different from the temperament of whites, as well as from that of blacks. They have less sensibility and irritability: the physical functions are not so actively performed : the pulse is slow. Dr. Rush states that out of eight Indians whose pulses he examined, the arteries had not in one more than sixty-four strokes in a minute. The secretions are scanty, but the muscular system is endowed with great strength and fortitude. These nations are patient of fatigue, and capable of enduring want of food and other privations. Females have the catamenia but sparingly, and they cease at an early period. AH writers inform us that their labours are remarkably quick and easy. This is the case among all the American tribes with whose physical history we have been made acquainted. JElian informs us that the ancient Egyptians were remarkable for the same peculiarity. The reader will find information with respect to the physical characters and constitution of the American nations in the work of Dr. Rush, already cited ; in the Physiological Memoir of M. Rollin, surgeon of the expedition of La Perouse; Keating's narrative of a journey to the source of St. Peter's River; the Report of Edwin James, botanist to the expedition from Pittsburgh to the Rocky Mountains; in Don Felix de Azara's work on Paraguay; and in those of Baron A. Von Humboldt on various parts of South America. Of Temperaments in relation to qualities of Mind.—We have surveyed the most remarka- ble varieties of constitution or temperament in several points of view, with regard especially to their origin and the external conditions under which they take their rise. But there is another subject connected with the doctrine of tempera- ments to which we have only adverted. This is the relation between the physical characteristics of particular constitutions and the qualities of mind supposed to be associated with them. Al- though we shall not venture to occupy so much space as might be requisite for entering at large into all the inquiries connected with this subject, we must not conclude an essay on temperaments without touching upon some of the most important questions involved in it. The relation of mental peculiarities to corporeal structure has been observed by medical authors of every age, and it has been stated and explained in different ways. Hippocrates said that " the soul is the same in all men, but that the body is different in different individuals. The soul," he adds, " is ever like to itself, and undergoes change neither in greater nor less by nature, nor by neces- sity : the body is subject to continual alterations." " The affections of the mind depend upon the body: there are many states of the latter which sharpen, and many which obtund it." (Hippocrates, lib. i. de dia?t£, § 21.) And Democritus, in a letter said to have been addressed by him to Hippocrates, asserted that " the intelligence of the mind depends greatly on the body, the diseases of which obscure the mental faculties, and draw the latter into con- sent." In the writings of Galen there is a treatise expressly composed to prove that the characters of men depend upon their temperaments. But it is in the works of modern writers that we find this doctrine most fully developed, and made a foundation for a division of human characters. According to Hoffmann, the choleric temperament by peculiarity of organization disposes men to precipitate and impetuous conduct, to anger, audacity, impatience, temerity, quarrels, sedition and the like. On the other hand the slow progress of blood through the vessels of the meninges, which is the result of its crassitude in melancholies, renders such persons timid, slow in business, anxious, suspicious, with difficulty of forming or uttering opinions. The sanguine by a happier temperament are rendered cheerful and free from care. A too abundant serosity causes the phleg- matic to be lazy, somnolent, and torpid. Certain temperaments qualify men for particular situations in life. Melancholic men, says Hoffmann, should be the king's ministers and counsellors; choleric persons should be appointed generals, foreign ambassadors, orators, conductors of all business requiring energy and despatch. Sanguine men are fit for courtiers, but individuals who have the misfortune to be of the phlegmatic temperament, being quite incompetent to any elevated condition, must be made common soldiers or labourers, and condemned to the lowest employments. (Hoff- mann, de temperamento fundamento morborum, I § 10.) The same writer applies the doctrine of 356 TEMPERAMENT. temperaments to nations, and explains by it their peculiarities. It is wonderful how ready a belief was given to notions so ill-founded, and to what an extent they were carried. The very learned Abbate Hervas finds a sufficient reason in the dif- ference of temperaments for the conquests which northern nations have so often made in southern countries.* The English, however, says this sensible but occasionally quaint writer, though belonging to the stock of colder climes, have become—" dal troppo bevere liquorigagliardi"— in temperament unlike the other inhabitants of the north. It is extremely improbable that an opinion should have held its ground for so many ages among men of observation, especially on a sub- ject requiring no abstruse research, without some foundation at least in fact. The doctrine of tem- peraments is true to a certain extent, and has ever been confirmed by an appeal to experience. In order to be convinced of this, let any person com- pare individuals who display the characters of the sanguine temperament in a high degree, with others who have strongly-marked signs of the melancholic. There is no doubt that among the first will be found many in proportion who have a lively and cheerful temper, great sensibility, ex- citable if not strong passions; and among the latter, persons who are, if not sullen and dejected, (for such qualities are morbid extremes,) yet calm and disposed to seriousness and reflection rather than to mirth and gaiety, at the same time tena- cious of impressions once excited in their minds, and capable of fixed and steady attention. These characteristic differences may be referred to greater or less degrees of sensibility, or to a more or less excitable condition of the nervous system, depend- ing, perhaps, in the first place, on the circulation of blood, the apparatus for which is, as we learn from the greater vigour with which the function is performed, more fully developed in the sanguine than in the melancholic. No facts are more fami- liar in physiology than the intimate connection between organic sensibility and a free circulation, or than the increase or diminution of feeling which results from warmth and increased vascular action, and from coldness and torpor and the re- tirement of blood from the surface of the body and the organs of sense. Stales of the mind are so connected with affections of the body, that it is impossible for any person who considers these and the many other analogous facts which present themselves, to doubt that with each temperament particular mental qualities must be associated, although it is manifest that many writers have indulged their fancy on this subject, and have gone into more full and minute details than expe- rience will establish. The somewhat vague speculations of which we have given a specimen, on the connection of men- * The work of Hervas, in nineteen quarto volumes, contains an epitome of human knowledge. It is entitled, " Idea del universo, che contiene la Storia della vita del uomo, dementi cosmogranei, viaggio, estatico al mondo planetario.e Storia della Terra." (Cesena, 1780.) Natural philosophy, physiology, anatomy, and other physical sciences, history, polities, statistics, are treated of in turn with a prodigious extent of information. The last volumes of the work consist of treatises on philology, and contain much original information on the history of languages not elsewhere to be found. tal qualities with varieties of temperament, have given way to theories of a more precise and defi. nite character. The observations of medical and physiological writers were strongly directed by the publication of Sommering's works on the brain and nerves, and by his treatise on the seat of the soul, to inquiries which have been pursued with much zeal, respecting the brain and the relations which mental phenomena bear to its functions and organization. The opinion that this organ is the immediate instrument of reason and perception has become generally prevalent, and all the phe- nomena of intellect have been supposed to depend entirely on conditions of the brain and nervous system. By later physiologists, to whose opinions we shall advert in the sequel, the moral and active powers have been referred to the same organiza- tion. Thus the whole mind is represented as depending, at least instrumentally, on movements in organized parts, and therefore deriving not only some of its predispositions, as the old doctrine of temperaments represents it to do, but all its par- ticular states and modifications from circumstances connected with the body. By this view of the relations between the mind and the brain, the in- fluence of temperament on constitutional pecu- liarity of organization is greatly extended, the theory of these varieties becomes still more im- portant than it formerly appeared, including as it does the whole modifications of which mind is susceptible, the conditions of structure on which these are dependent, and the external characters by which both are indicated in the form and out- ward appearance of the individual. We shall trace in a rapid sketch the history of these specu- lations. Sommering, in his celebrated treatise on the organ of the soul, takes it for granted that the object of his research is to be found within the cranium, and directs all his endeavours to discover the exact portion of the encephalon which may seem to present the highest claims to be the seat of animation. It is well known that he traced several of the nerves of sense to the parietes of the ventricles, and concluded at last that the se- rous fluid contained in those cavities is the inter- mediate vinculum between the soul and body, the instrument by which the former receives impres- sions from the appulses of gross material par- ticles. (Sdmmering uber das Organ der Seele. Konigsberg, 1796. Compare C. A. Rudolphi Comm. de ventriculis cerebri. Gryph. 1796.) Reil, so justly celebrated for the accuracy of his researches into the anatomy of the brain and nervous system, lays it down as undoubted thai the brain and nerves are exclusively the organ of the soul, the centre of every man's personal ex- istence—" den leib unseres ichs." P. F. Von Walther, in his "physiologie der menschen," maintains that the soul uses the brain as the organ of all its manifestations, is connected with it as is the »idea with the workmanship in the performance of an artist." " The cerebellum," he adds, " is the organ of animal instincts, among which the sexual is the principal. The lobes of the cerebrum which lie over the tentorium ap- proach to the same general character: they con- tain the organs of the affections." " The more tenderness and affection a man is endowed with, TEMPERAMENT. 357 the more developed are the posterior lobes of the greater brain." Magendie in his physiology maintains that the brain is the organ of the understanding; that the manifestations of the intellect must be looked upon as the results of the organization of the brain. In like manner he concludes that the pas- sions are connected with actions carried on in the brain and nervous system: " a great assemblage of facts and investigations prove that the brain is the organ of thought." The contents of Gall's voluminous works are summed up in his last publication " Sur les Fonc- tions du Cerveau." He there concludes that " the instincts, the inclinations, the sentiments, the in- tellectual faculties, the distinctive characters of humanity, owe their existence and their modifica- tion solely to the brain." « Sans cerveau, point de perception, point de sensation, point d'idee, point de jouissance, point de souffrance, point de mou" Rudolphi observes that the brain is the " seelen- organ," the " soul's organ," " sensorium commune, Ttf&nv aMijT^piuv." (Rudolphi, Grundriss der Phy- siologie, bd. 2. abth. 1. p. 29.) « The seat of the 60ul," he says, « cannot become an object of phi- losophical research; but this we know, that the soul acts only through the medium of the brain, as its organ, on our bodies, as on the higher ani- mals through the medium of the nervous system." Similar conclusions have been adopted by Neu- mann, Carus, and Hartmann, whose remarks have been cited to that purport by Jacobi. (Samm- lungen fur die Heilkunde der Gemuthskrankhei- ten ; zweiter band. Elberfeld.) The most distin- guished writers in this country and in France have agreed with those of Germany as to the ge- neral inference that the manifestations of intellect depend upon the instrumental operations of the brain for their existence in a sound state, and are liable to be affected by morbid changes in those operations; such affections constituting the so termed diseases of the mind. The principal dif- ference of opinion that now exists with reference to this subject turns upon the question whether we have proof that the organs of intellect and of physical phenomena in general are many in num- ber, according to the doctrine of Gall; or ought rather, in the defect of such evidence, still to regard the brain as performing its office with one energy and undivided action; the continuity of structure rendering this the most probable opinion, unless anything can be proved to the contrary. The celebrated system of Gall has eclipsed all other attempts to theorise on the functions of the brain, and the question which is now agitated with respect to that organ is whether its modus operandi has been discovered or not; it being taken for granted that there is no other speculation on this subject which can come into any competition with that of the renowned author of phrenology. So much has been said of late years with refer- ence to this dispute, that we would gladly have abstained, if the subject had not fallen inevitably in our way, from all allusion to a controversy in which it is difficult if not impossible to bring for- j ward anything new. The arguments which have been thought to bear upon it have been long since ! urged and repeated in various forms, until most ] persons are tired of the subject, and seem scarcely to expect any new evidence on the one side, and much less anything novel in the objections of those who oppose the statements and reasonings of the phrenologists. In fact nearly all that has been said of late by English writers on this side of the question was advanced many years since in the most forcible manner by the author of a critique in the Edinburgh Review. Similar objections are still frequently repeated, though most persons have become, or might have become, aware of their in- conclusiveness. It must, for example, be evident to those who reflect upon the subject, that the ar- guments against phrenology founded on the diffi- culty of applying measurements to particular por- tions of the brain, is no objection at all against the truth of the doctrine itself, or the principle on which it is founded. With equal justice might the obstacles arising from the imperfection of in- struments, or from states of the atmosphere which interfere with the observations of astronomers, be urged as invalidating the most noble of human sciences. Not less ill-judged have been the at- tempts of those who have argued against the speculations of the phrenologists on the ground j of their dangerous tendency, and the alleged fact that they lead to fatalism and destroy moral re- sponsibility. The pernicious results to be deduced from any new and specious doctrine are not rea- sons for shutting our eyes against the evidence on which it rests, but ought rather to render us more anxious to sift the matter to the bottom. If the thing be true, let this be known: "fiatjustitia; ruat caelum." The real merits of the case will ^ sooner or later be made apparent, and the sooner | the better. It is vain to tell the phrenologist that | his doctrine is at variance with the moral senti- ments of mankind. His appeal is not to senti- j ments, but to lines and measurements. If it be a fact that thieves and homicides labour under what ' may be termed a morbid growth of cerebral sub- ! stance above or behind their ears, the use of the halter and the gibbet should at once be laid aside for more scientific operations. Phrenology, how- ever, does not go further than does Philosophical Necessity, that favourite doctrine of some theolo- I gical professors, in destroying moral culpability, and proving that actions, by men termed crimes, are mere misfortunes, and the proper objects of pity and commiseration. There is, however, this difference between the two schemes which support 6uch an inference, that whereas philosophical necessity can never be proved or refuted, but can only be re-asserted without producing the assent of mankind, phrenology certainly admits of proof or disproof, and would obtain it if the measure- ments of a sufficient number of heads, and those belonging to persons of marked qualities of mind, could be accurately and indisputably known. Another immense privilege is, in the meantime, in the hands of the phrenologist. He has the whole terra incognita of the brain at his disposal, Whenever a new fact presents itself in the intel- lectual or moral constitution of man, whenever it is judged expedient to add one to the list of know- ing faculties or active principles, he finds space enough where to locate the new claimant, and furnish it with a domicile and suitable neighbour- hood. Nor can any one reasonably object to his 358 TEMPERAMENT. mode of sharing out his domain, or plead with effect that such or such a piece of medullary mat- ter is too small to be competent to a wish or a volition. But lest we should be thought decided partisans of cranioscopy, it behoves us to pay some regard to the arguments of those who, on more rational grounds than some of our country- men, have hesitated in admitting the conclusions of Dr. Gall. We shall advert to the opinions ex- pressed at different times on this subject by various writers on the continent, partly French, but chiefly in the country of the author. Among the latter this subject has not been given up, as it has been in a great measure among ourselves, southward of the Tweed at least, to dilettanti: it has been carefully examined by men of science, and if we could collect the general opinion of Germany, it might perhaps be regarded as conclusive of the ultimate fate of phrenology. To the well-known report presented to and adopted by the National Institute of France,* we shall only advert in order to express our wonder that no attempt has ever been made to counteract its effect by procuring some decision of equal weight and authority in opposition to it. It will be recollected that this report had reference solely to the anatomical researches of the phrenologists, and to the new facts discovered or asserted by them respecting the structure of the brain;—that the individuals deputed by the Institute dissected the brain repeatedly in conjunction with Gall and Spurzheim, who readily communicated their ob- servations and method of proceeding;—that the same persons afterwards examined by themselves the structures respecting which doubt existed in their minds, " endeavouring for a time to adopt the new manner of viewing the subject, and to give a clear and precise abstract of it," which was submitted to the phrenologists that they might be satisfied whether their ideas had been compre- hended. After such an investigation the unfa- vourable tenor of the report drawn up by such a committee on the validity of the anatomical facts asserted, could not fail to be a stumbling-block in the career of the new science. Attempts have been made from time to time by the advocates of phrenology to lessen this unfavourable influence by imputing unfaithfulness to the members of the committee. They were desirous, it has been said, of gaining favour with Napoleon by giving an unfair report on a discovery made by foreigners. But this suspicion cannot be entertained by any person who knows that the individuals de- puted to this task were Cuvier, Tenon, Portal, Sabatier, and Pinel: it is impossible that men so distinguished by high reputation as men of science and unblemished moral integrity, could commit so foul an act of treason against the majesty of truth. The anatomical discoveries of the phrenologists have never since the period of this report under- gone a similar investigation: they are upheld, in- deed, by declared partisans, but they have never been admitted by any number of competent judges like the committee above referred to, not self-constituted, but selected on the ground of * Report on a Memoir of Drs. Gall and Spurzheim, relative to the Analomy of the Brain, presented to and adopted by the Class of Mathematical and Physical Sci- ences of the National Institute. eminent qualifications for the task confided to them. The members of the French Institute already mentioned confined their objections to Gall's sys- tem, or rather their denial of his statements, to the principal facts which he asserted or discovered in the anatomy of the brain. Since the publica- tion of that report, the new doctrine has been con- sidered in all its bearings by some of the most distinguished anatomists and physiologists of Ger- many : Ackermann, Carus, Hartmann, Rudolphi, Nasse, and Jacobi, are thought by many to have refuted the most important of the positions on which it rests; and the arguments brought for- ward by these writers are allowed to be worthy of consideration even by those who do not hold them to be conclusive. It must be observed, before we can enter into the genera] reasonings on this subject which some of the authors above-mentioned have advanced, that the most important difference between Gall's theory and that of other physiologists, in respect to the functions of the brain, does not refer to tbe point of view in which the intellectual faculties are considered by him as lodged in particular organs rather than exercised by the whole cerebral structure. His views of animated nature are much more extensive: they comprehend not only the powers of sense and cognition heretofore referred to the brain, but regard as necessarily belonging to the function of cerebral structures all those which in the aggregate are termed psychical phe- nomena, including the whole properties of animal life, of feeling and instinct, of action, whether re- sulting from external impressions, or arising from internal impulses towards particular ends. This is a much wider view of the province of brain and of nervous structures in general, than former wri- ters have taken. Sensation, memory, imagination, have been referred perhaps by most to nerves and brain in man, and the properties resembling these faculties in the lower animals have been supposed to reside in corresponding structures. Muscular action has likewise been attributed to nervous energy, in the first instance at least, by one class of physiologists. But with Gall originated the attempt to discover in the brain the local seats of all those properties which constitute the principles of action, the whole psychical nature of all tribes of animated beings; to trace the social, domestic, personal characters of man within his cranium, and to find corresponding parts with which the phenomena of animal life peculiar to each lower tribe, all their wonderful instincts and specific habits, are equally connected. Gall has assumed as an universal fact, that every active and con- scious principle in man and in lower tribes of the creation originally resides in a given part of the bodily structure; that the manifestation of every psychical characteristic is the immediate result of a peculiar organization in some part of the brain or the medullary cord ; that the very existence of such properties is necessarily dependent on cor- responding cerebral organs. The main principle of the whole theory, to which we are continually in express terms or by implication referred, is the assumed fact that these properties and structures are everywhere coextensive with each other. Now if the proof of the dependence of such properties TEMPERAMENT. 359 upon corresponding cerebral structures is the uni- I versality of the connection or the coextensive ex- | istence of the structures and functions, we may expect that this relation will be shown to prevail through all departments of animated nature. Those who maintain this arrangement to be so funda- mentally interwoven with the very constitution of living beings, are bound to show that the observa- tion is limited to no particular department; but that, wherever certain psychical endowments are un- doubtedly displayed in animals of whatever tribe, corresponding organs really exist in the cerebral or nervous structure belonging to that tribe. Should it, on the other hand, appear that similar mani- festations of animal life, of instinct, appetency, feeling or tendency to action, exist in any two tribes for example, and that, in one, organs are discovered to which they may be thought referable, while corresponding organs are totally wanting in the other, the very foundation of the doctrine will be shaken; the universality of the law on which chiefly our admission of its claims is demanded, will be broken; the coextensive relation of pro- perties and structures can no longer be asserted ; and we shall require some distinct proof arising out of every particular example, before we can be expected to admit the asserted relation in single instances. It has been observed by Jacobi, that although we should allow for a moment that the Gallian doctrine is applicable to the higher classes of the animal kingdom; or rather, if we for a time ab- stract ourselves from the consideration whether it is so applicable; on directing our inquiry to the insect tribes, and to all the orders of animals which are below them in the scale of organized beings, we find that the fundamental principle of the system fails entirely in its application to these great departments of nature. " The attempt to display any correspondence or analogy between one or more of the knots or ganglia situated at the upper part of the oesophagus in insects, and the cerebral organs in mammifers and birds, can scarce- ly be spoken of as seriously undertaken or as wor- thy of regard; and when we find that Gall has tacitly assumed such a correspondence in the structure of these parts, without proposing to bring forward any proof of its existence by the usual and only method of anatomical demonstration, we are struck at once by the extreme inconsistency of this proceeding, and should feel astonished at the boldness displayed in thus erecting hypothesis upon hypothesis, if we were not accustomed to such deviations from correct reasoning in the wri- tings of the phrenologist." It is a fact that among insects, if we take collectively the different tribes, manifestations of all the psychical qualities ob- served in mammifers and birds, regarding here also as a whole the properties divided between particular departments, may be recognised in the most strict analogy. Attention, memory, the fa- culty of combining means to obtain ends, cunning, the desire of revenge, the care of offspring, and all other psychical qualities which have been traced in the former classes of animals, arc likewise to be discovered in the latter, as typical or character- istic phenomena, sometimes in one, sometimes in another combination, or in different groups, some- times more strongly, at others more feebly express- ed. Now if this be proved, and if we really find in those animal tribes which are considered as the lower orders, as for example in insects, the same phenomena of animal life, which in mammalia, in birds, fishes, and amphibia, are comprehended un- der the term psychical powers, whatever relation these last may in reality bear to those properties in human nature with which they are generally compared, it hence results that the conditions of organization on which such faculties depend in insects, and by analogy in tribes placed still lower in the scale, are different from those which are assumed in the higher classes of animals to be essentially connected with the development of similar phenomena. " Nor can it be maintained on any solid ground that phenomena so analogous depend on different causes, as metaphysicians formerly asserted when contemplating the psychical qualities of animals in general, and comparing them with the intel- lectual and moral attributes of the human species. We are not allowed to assume that the lower tribes are under the guidance of mere mechanical impulses while their activity displays effects paral- lel to the manifestations of animal life in the higher orders. For what essential difference can we point out in the principle of action, when we observe the young bee in its first flight from the maternal hive hasten straightways to the nearest meadow or sunny bank, and return home laden with wax and honey, and when the colt of the river-horse, foaled upon the land, after his mother has been killed rushes from the spot and betakes himself to the water which he has never seen; or when the young goat in the first hours of his life hides himself in the clefts of rocks, which nature already points out to him as his dwelling-place 1 Does psychical life display itself under a more limited or doubtful character in the flights of grass- hoppers and dragon-flies, than in the marches of lemmings, so closely bound by the impulse which directs the course of their wanderings that they even attempt to gnaw through rocks which lie in their way rather than go round them, and they follow each other troop by troop, to their certain destruction, into the deepest rivers or widest lakes? Does not the earth-worm secure himself against the pursuit of the mole, provided with a well- formed brain, by making his way along the sur- face of the soil, where the latter cannot further trace him, with as much cunning as the fox and the beaver display in acts which are typical or characteristic of their kinds? I will ask again what difference is there between the skill with which the ichneumon or the ant-eater procure for themselves the same food, between that of the diving-spider or the corpse beetle, and the acts displayed by so many birds and mammifers im- pelled to similar pursuits ] Are not like pheno- mena repeated in the economy of the ant and the bee, and in that of the beaver or of the Alpine marmot 1 And if we must refer to manifestations of a higher and freer sphere of agency, in what tribe of sucking animals does such a power dis- play itself more wonderfully than in the wars of conquest carried on by different races of termites, in which the subdued become vassals to the victo- 360 TEMPERAMENT. rious tribe, and serve their lords in laying up for them their stores, and watching and protecting their young] " In what relation to organic structure shall we consider these phenomena, as well as the mani- festations of analogous powers, which display themselves in tribes generally ranked in a still lower station in the scale of organized beings, and in which the existence of nerves has never been demonstrated ] Have we not also a right to ask how birds and reptiles nearly if not wholly destitute of many cerebral parts, the importance of which in mammalia can never be sufficiently extolled, yet collectively displaying not less than insects similar psychical phenomena to those of mammifers, come to be possessed of such faculties without the organs supposed to be necessarily connected with their manifestation V Without attempting to draw from these obser- vations a more extensive inference than the data entitles us fairly to deduce, we may be allowed to conclude that, if they do not disprove, at least they throw a strong shade of doubt on the as- sumed universal relation of psychical qualities, and corresponding organic structures. It cannot, indeed, be demonstrated that the instincts of the ant or of the bee are not organically dependent on some infinitesimal parts of the ganglia disco- vered in those animals, but there is no degree of probability in such a supposition, nor are we led to it by a single well-established fact or analogy. It may be thought by those who are accustomed to entertain the opinions of the phrenologists, or have imbibed what may perhaps be termed their prejudices, that every phenomenon of animal life must have its local commencement; that the ori- gination of instinct or internal impulse to action, whether in insects or in the higher animals, can- not be conceived but as taking place in some ap- propriate organ;—that if such organs are not to be found in the nervous system, of insects for example, they must be sought elsewhere. In this, we must observe that a physiological principle is assumed on mere conjecture, on no ground whatever of fact, since nothing is known as to the nature of instinctive impulses which entitles us to conclude that they have a local seat in particu- lar organs. A spontaneous tendency or aptitude to such acts as are needful or favourable to indi- vidual preservation, is well known to be an uni- versal property of organized beings. Even plants, although they cannot be said to have instincts, yet display movements typical of particular species or tribes, and though without consciousness, directed towards certain destined ends. Can such tenden- cies be thought with probability to reside in any particular part of an organized being ] Again, to what part of the conscious organized being or animal are we to refer the universal instincts, such as the desire of pleasure and the shrinking from pain ] Are they not properties of the whole being rather than of any particular texture]—and where is the proof of their excitement by the agency of any appropriate organ > The instincts are of two kinds; one more immediately connected with states of the body—namely, the animal appetites; the other having some outward object and direc- tion, as the instincts to build nests and to provide for young. As the former are connected with states of the body, their activity depends apon certain physical conditions which are temporary states of the natural and animal functions, and these may be more or less limited to certain struc- tures. Hunger and thirst, for instance, are felt under particular circumstances of the whole sys- tem, but more especially of the digestive organs: ! there is no proof of the additional intermediate agency of any cerebral or other corporeal organ endowed with the office of exciting a desire of j food or drink. The sexual appetite seems to obey similar laws as to circumstances of its ex- citement ; and no farther reason can here be as- signed than in the former case for conjecturing the existence of an intermediate organ of instinct. In this point of view the appetites or bodily in- stincts have a relation to particular structures, or rather to particular states. Less connected with any local organization appear to be the in- stincts properly so termed, and contradistinguished from the bodily appetites; as, for example, the instinct of self-preservation, or the impulse to shun the danger of individual destruction, the disposition to avoid pain, and seek pleasure or gratification. The attempt to localize all these universal principles of animated nature is a work of supererogation; the opinion that such laws of animal life are brought into operation by a par- ticular organism like the mechanical movements of a watch, is at present altogether a gratuitous assumption. We cannot venture to determine any thing on such a subject, but there is, unless we greatly mistake the matter, more of probability j in the supposition that the instincts or active ten- dencies proper to every tribe, typical of it, and varying with the diversities of organic structure, — that is, with the diversities of the whole or- ganization of bodies, — are principles of action impressed on the entire being, and not inherent essentially or mainly and initially seated in any particular organ. The brain, except as the seat of the common sensorium, is perhaps uncon- nected with the origination of these impulses; though in the conscious and voluntary actions which ensue, the brain, the nervous and muscular systems come into operation more or less as sub- servient instruments. If the advocates of phrenology should give up the universality of connection which they assume between psychical manifestations and particular organs, and allow that nothing of this kind can be proved, or even by analogy inferred, to have place in those which are termed the lower orders of animals, they may still maintain their position on a more confined scale,—namely, in respect to vertebrated animals. Here, however, these phy- siologists lose all the advantage to be derived from general analogy; they represent one department of nature as in opposition to another, even in re- spect to fundamental laws of its constitution. Negative reasoning is extremely difficult in such a case, yet Jacobi has suggested some considera- tions which in this point of view are not unim- portant. He has observed that within the limits of particular species, referring now to the higher animals, psychical phenomena vary with all the varieties of organization, and even with the tem- porary condition of bodies, and this under circum- stances which, in some cases at least, as we shall TEMPERAMENT. 361 show, preclude the possibility of assuming previ- ous or simultaneous variations in cerebral struc- tures. The animal qualities of the horse, for ex- ample, according to general experience, assume a variety of modifications, and these varieties in every instance correspond with peculiarities of structure: in connection with changes in the form of the skeleton, in the muscular system, in the texture of the skin, proportional differences mani- fest themselves in the vigour, spirit, courage, speed, and whole disposition of the animal. In dogs likewise the most striking varieties are found in the instincts of particular races, and every where in coincidence with the diversities of or- ganization, in the organs of sense, in the form of the body, and the capabilities of action thence arising. Domestication produces changes in the bodily structure of other tribes, and it gives rise at the same time to corresponding changes in the dispositions. The elephants of Ceylon are dis- tinguished from those of the neighbouring conti- nent as well by superior beauty in the colour and figure of their bodies, by greater strength and swiftness, and particularly by their remarkably tractable temper, their courage, patience, freedom from violence, and susceptibility of instruction. The buffalo, the goat, and many other animals which are more or less domesticated, exhibit great alterations both in the form of their limbs, and in their instincts and dispositions. It seems to have been ascertained by an extensive series of observ- ations, that wherever any changes have been in- duced in the psychical qualities of animals, wher- ever those dispositions which are typical of the race or species have deviated from their usual and natural character, a corresponding degradation, or at least a proportional change, may be found to have taken place in the structure of the body, in the form of the limbs and the bony fabric, in the organs of sense, the texture of skin, hair, or feathers, and in the whole organization. As these changes bear an uniform relation to each other, we have all the proof that can be expected of their intimate connection and mutual dependence. The numerous observations of Lavater, on the corre- spondence of external peculiarities of form with the qualities of mind, might serve as a ground- ' work for more comprehensive inquiries. Of La- vater's works, it is to be regretted that those parts only which refer to the face and skull have ex- cited general attention. The same attention di- rected to other parts of the corporeal structure points out a relation every where certain and de- monstrable between the form, measure of develop- ment, and natural aptitudes of particular parts as well as of the whole bodily fabric, and the psychi- cal qualities which are connected with, and are therefore indicated by, such organic variations. Now, unless it can be shown by the phrenolo- gists that all such corporeal modifications are de- pendent on previous changes in the cerebral struc- tures, (and the supposition is so improbable that we think it will scarcely be assumed,) we shall find in the correspondences above described a proof that psychical phenomena vary according to relations which are not dependent on the brain or nervous system. Changes in the habitual state of the disposition and feelings, and in the temporary condition of Vol. IV. — 46 2f the senses, and of the instincts and tendencies to action, induced by manifest causes affecting the physical or organic functions, lead us perhaps still more clearly to the same result. The states of the digestive organs influence the temper in a very sensible manner. Hunger or long fasting exas- perates the ferocity of beasts of prey : the effect of a full meal is well known to modify the dispo- sition in a reverse way : the inclinations are changed by the influence of wine and stimulants; cowards become valiant, and the timid and re- served loquacious. Nothing is better known than the influence which the sexual system exerts in the animal economy, on the psychical manifesta- tions. How decided an alteration in the disposi- tion is produced by emasculation ! Two animals can scarcely be found more different from each other than an ox and a bull. At the period of life when the sexual system becomes developed, a new character seems to be formed: the inclina- tions undergo a marked change, not only in re- spect to habitudes immediately associated with the functions of that system, but in others more re- motely or in no perceptible manner connected with it. When this natural development is im- peded or retarded by disease, morbid symptoms are consequent not only in the state of the body, but in that of the mind also. An artificial change induced in the human species by design, gives rise to effects not less striking in the whole character than the corresponding results above adverted to in the inferior tribes. Here, indeed, the phrenolo- gist brings in his doctrine as to the function of the cerebellum ; but without reverting to the gene- ral views of the animal economy which render it improbable that the instincts are called forth by any such system of organism as this doctrine im- plies, we may remark that the particular argu- ments on which it rests have been proved by Rudolphi to be inconclusive and even nugatory. The cerebellum, as this writer has observed, is found to lessen rapidly in its proportional develop- ment as we descend in the scale of animated beings, without any corresponding diminution, and perhaps even with increase in the propensity which Gall connects with it. How remarkably powerful is this instinct in birds, and yet how small is the cerebellum in these compared with its size in mammifers, and even in the latter when we consider the magnitude which the same organ attains in the human species. We observe those tribes of animals in which the cerebellum nearly or entirely ceases to be found, obey, nevertheless, the impulsion of instinct as blindly or devotedly as other kinds which have the organ remarkably developed. When we consider the great ampli- tude which the cerebellum attains in man in com- parison with its size in lower animals, we cannot fail to imagine some relation between this circum- stance and the transcendent superiority of the human intellect compared with the psychical powers of brutes. Other observations lead us to a similar conclusion. Cretins, in whom the cere- bellum is defective, display more or less of idiot- ism or defect of intellect, but no corresponding deficiency in the sexual instinct, which on the contrary often exists in such unhappy beings in the greatest intensity, and impels them to furious excesses. Again, injuries of the posterior part of 362 TEMPERAMENT. the head are observed to be followed by stupor and loss of memory, indicating the function of the cerebellum to be connected with the exercise of the mental faculties rather than of animal pro- pensity. The assertion made by Gall that the cerebellum undergoes a change in the rutting sea- son is entirely without proof, for the swelling of the neck which has been observed at that period has no connection with the state of the brain, and is a phenomenon of quite a different kind. On the whole, it would perhaps be scarcely too much to say that not only positive evidence is wanting to support the doctrine of Gall respecting the cere- bellum, but that, whatever evidence on the nega- tive side of the question the nature of the subject is likely to suggest, has actually been adduced. The only structures in animal bodies, the develop- ment of which is manifestly associated with the phenomena of instinct, so strangely referred to the cerebellum, are those immediately connected with the process of reproduction. With the temporary as well as the more permanent conditions of these particular structures, the animal instinct is con- nected as immediately as in the appetite for food with the state of the digestive organs. We have here one instance among many which indicate that nature has associated appetites and tenden- cies to action with conditions of structure, in such wise that the aggregate of these phenomena coin- cide with the whole attributes of organization, and that the modifications of the former keep pace with changes in the latter, and this on a system more comprehensive and less subject to exceptions than that suggested by the theory of the phrenologist. The preceding survey of psychical phenomena in various classes and tribes of animals furnishes many general facts which are perhaps scarcely reconcilable with the phrenological theory: they seem, in the first place, to show that the relations which in it are assumed as prevailing through all nature are at any rate subject to vast and nume- rous exceptions, and as the main proof of this doctrine is the alleged universality of such rela- tions, or the coextensive endowment of psychical phenomena with certain peculiarities of structure, the exceptions appear fatal to the system in its general bearing. In a more limited view, confined to the sphere of vertebrated animals, it has been shown that variations in these phenomena take place without any evidence of corresponding changes in the structure of cerebral organs, but in strict correspondence with changes in the general organization of the body, both in tribes and in individuals, and even with changes in the tempo- rary state of individuals. This last consideration may be thought to invalidate if it does not over- throw the more limited argument advanced in support of phrenology. Still the advocate of this doctrine will probably rest on his alleged experience of uniform coin- cidences in the human species between qualities of mind and the amplitude of cerebral parts, and within this sphere the phenomena would establish his inference if they were decidedly in its favour. If proportional amplitude in a given region of the brain were always coincident with a given quality of mind, the constant connection would prove a relation between the two phenomena. The phre- nologist need not go beyond the human species in order to establish his doctrines on the basis of ex- perience, but then this experience must be uniform and unquestionable. It is not enough to have a few chosen coincidences brought forward by zealous partisans who go about in search of such facts in favour of this doctrine, and pass by or really cannot perceive the evidence that ought to be placed in the opposite scale. The application of the main principle of the system ought to hold throughout. This, however, is not pretended by the phrenologists, who, aware of numerous and striking exceptions, elude their evidence by assert- ing that when a certain portion of the cranium and brain is greatly developed, while the faculty there lodged has never been remarkably distin- guished, it nevertheless existed by nature, though the innate talent, through the want of cultivation, has failed to be displayed: the predominant or- ganic power bestowed by nature was never dis- covered by the owner, though according to the fundamental principle of the doctrine, the natural preponderance of talent and propensity is alone sufficient to determine the habitudes of the indi- vidual and communicates of itself a strong impulse to particular pursuits. When, again, a strongly marked propensity or decided talent has been manifested without the corresponding amplitude of structure, it is in like manner pleaded that by sedulous exercise and cultivation a natural defi- ciency has been overcome. But should it even be admitted that some few exceptions to general ob- servations may thus be accounted for and allowed not to overthrow the whole system, this concession can no longer be claimed if the exceptions are numerous. If, for example, we should examine a hundred monomaniacs, in all of whom certain feelings and propensities have been developed even to morbid excess, and it should be discovered by a person competent to form a judgment on the subject, that no evidence displays itself in the cranioscopy of so many individuals tending to support the doctrine, we should hold that it ought in all fairness to be abandoned. Some hundreds and even thousands of such persons have passed a part of their lives under the inspection of M. Esquirol, who possesses most extensive resources for elucidating almost every subject connected with the history of mental diseases, and has ne-' glected no inquiry which could further the attain- ment of that object. The result of his observa- tion will be allowed to be of some weight on the decision of this question, in which the appeal is principally to facts of the precise description of those with which he Has been chiefly conversant. At his establishment at Ivry he has a large assem- blage of crania and casts from the heads of lunatics, collected by him during the long course of his attendance at the Salpetriere and at the Royal Hospital at Charenton, which is under his superintendence. While inspecting this collection, the writer of the present article was assured by M. Esquirol that the testimony of his experience is entirely adverse to the doctrine of the phreno- logists: it has convinced him that there is no foundation whatever in facts for the system of correspondences which they lay down between certain measurements of the heads and the exist- ence of particular mental endowments. This ob- servation by M. Esquirol was made in the presence TEMPERAMENT—[TETANICS.] 363 of M. Mitivie, physician ,to the Salpdtriere, and received his assent and confirmation. There are few if any individuals in Europe whose sphere of observation has been so extensive as that of M. Esquirol, but testimonies to the same result may be collected from unbiassed witnesses whose evi- dence taken collectively may have nearly equal weight. Among these there are men unscientific though capable of correct and unprejudiced ob- servation, as well as anatomists and physiologists. In the number of the latter is Rudolphi, who de- clares that he has examined many hundreds of brains without finding any thing that appeared to him favourable to the phrenological theory. (Grundriss der Physiologie, b. ii. abt. I. § 37.) In opposition to evidence apparently so strong and bearing against this doctrine in various ways, it might be thought difficult for the phrenologist to defend his ground; but he avails himself of the double method of elusion above described ;—his position, like the cave of Philoctetes, affords him an escape on either side, and in one direction or another he contrives to baffle all the address of his opponents. An inquiry may here present itself strictly in connection with the subject under consideration, and this is the last point of view in which we shall contemplate it: whether there are any con- ditions in the size, form, and structure of the brain, and in the measurement and external shape of the skull, which are connected with and tend to strength or weakness of understanding, or any other mental peculiarities of individuals : shall we go so far as to deny this connection so much insisted upon altogether, or how far it may be ad- mitted on sure and certain grounds] As the brain is the organ of the mind, in several at least of the intellectual processes, it can hardly be doubted that with a perfect structure of this organ, a relative state of the intellectual faculties will be associated. But by what external signs is per- fection or imperfection of structure denoted ? If we were at liberty, with an ingenious French writer,* to assume that in every instance the amplitude of particular organs indicates a relative energy in their functions, there would be no longer any room for hesitation on the subject; large heads would denote at once great intellect; but neither is this general principle established, nor will facts support its application. We might, indeed, assume that a very contracted volume of brain, indicating that some circumstances affecting the original growth and organization of the body have prevented that organ from attaining its usual and natural development, would be found con- nected with a proportional weakness or even a total failure in its function; and this opinion is confirmed by facts, a congenital idiotism being generally combined with a very small and con- tracted brain and head. It does not hence follow that a brain unusually large either in its general development or in particular parts, must indicate more than ordinary power of understanding. It would rather seem probable that the state of inte- rior organization from which the highest degree of energy in its appropriate action may be sup- * Physiologie des Temperamens ou Constitutions, nouvelle doctrine applicable a la Medecine Pratique, a' ■'Hygiene, dec. par M. Thomas. Paris, 1626. posed to result, would be found in a brain, the volume of which, both generally and in its parts, has the medium degree of development, or is neither greater nor less than the average dimen- sion. As far as our experience and observation reach, it bears out this presumption : the indi- viduals whom we have known possessed of the greatest intellectual powers have been those in the form and size of whose heads, compact and of moderate volume, nothing remarkable presented itself. We are inclined to suspect that deviations from this middle form and size partake more or less of the nature of imperfection and disease. Hydrocephalic or rachitic, or other morbid predis- positions, are perhaps the most frequent occasions of those unusual developments from which great and noble qualities are so frequently auspicated by the sanguine votaries of phrenology. [The whole of this subject belongs, however, rather to Physiology than to Practical Medicine.] J. C. Prichard. [TETANICS. — Between the therapeutical agents described under the head of Narcotics, (q. v.) and those that may be classed under this head, a well-marked difference exists ; for, whilst the former are anodyne and hypnotic in appropri- ate doses,—the latter leaving the encephalon un- touched,—may affect most prominently the nerves of voluntary motion, giving rise to tetanic convul- sions, especially in parts which are affected with paralysis; and only in excessive doses may induce the ordinary signs of acro-narcotic poisoning. It is in consequence of this effect upon the nerves that are distributed to the muscles, or to the portions of the nervous centres with which they are con- nected, that this class of agents has been termed, by recent writers, tetanies; a term which has been adopted by the writer, (General Therapeu- tics and Mat. Med. i. 384: Philad. 1843,) to avoid the confusion that might arise were he to attempt to suggest another, and perhaps one that would not be more expressive. Dr. Pereira (Elements of Mat. Med. and The- rap., Amer. edit. i. 177: Philad. 1843,) has called them convulsives, and has defined them, " agents which augment the irritability of the muscular fibre, and in large doses occasion convulsions;" but their action seems manifestly to be exerted upon the nerves, and through them on the mus- cular irritability. The fact, indeed, that they in- duce involuntary muscular contractions of the voluntary muscles, from slight twitchings to the rigidity of tetanus, according to the quantity given, is sufficient to demonstrate, that the phenomena resulting from their administration are purely nervous. Tetanies are chiefly given in paralysis, and especially in the local forms; none of them being well adapted for cases in which the cause of the paralysis is encephalic. The main agents belonging to this class are nux vomica, and its alkaloids strychnia and bru- cia, which are classed by D. A. T. Thomson, under Excitants, and have been considered there. (See Excitants.) Arnica and toxicodendron belong to the same class, but they are not much used. „ Robley Dunglison.] 364 TETANUS. TETANUS, from riraivu, root ravu, tendo, is the name given to a disease of which the essential character is a rigid contraction of certain muscles ; which contraction is sometimes called a tonic spasm, and is the opposite of that species which alternates with relaxation, and is termed clonic or convulsive. Although tetanus has been employed from the earliest times as a generic term, inclusive of several subdivisions, it will be seen presently that it is itself the peculiar designation of one of those varieties. Three principles of distinction may be noticed in the arrangements of the differ- ent specimens of the disorder, hitherto adopted. The most common is derived from observing the different parts of the body or sets of muscles affected in certain cases; whence the ancient names of emprosthotonos, opisthotonos, pleuros- thotonos, tetanus, and trismus. Another, and one of more importance in a practical point of view, is based upon the origin of the disorder, and re- gards it as idiopathic or symptomatic: a division known also to the ancients : not that they used these very terms, but that a marked distinction was drawn by them between cases which arose from common causes, and those which were the effects of wounds. The third principle of arrange- ment is derived from the degree and duration of the symptoms, and is most insisted upon in the present day. By virtue of this principle, tetanus is distinguished as acute and chronic. We think it would be convenient to add to these a subacute variety, to include those cases which are of mild character, but which do not continue long enough to be designated chronic* The grounds on which these several divisions are established will be spoken of in their proper places. Description.—We shall commence our ac- count of the symptoms of this disease, by a gene- ral survey of those phenomena which accompany its progress under all its forms, reserving the dis- tinctive characters of the latter for separate con- sideration. It will be seen, however, that the most general description must necessarily include trismus, which is a part of each of the other species. The accession of the disease is sometimes so abrupt as to give no warning of its approach ; but in general there are certdln precursory symptoms, which, however, can rarely be called premonitory, since they are common to many other disorders; such are uneasiness or restlessness, watchfulness, languor, depression, headach, dryness of skin, loss of appetite, and constipation. A more cha- racteristic affection than any of these, and which was first noticed, we believe, by Richerand, is an unusual and persevering extension of the limbs during sleep, the tendency in health being, as every one knows, to a state of semiflexion. The disease may be said to have commenced when the patient feels a stiffness about the back of the neck, sometimes extending to the occiput, and a dryness and soreness in the throat. These symp- toms, though common to many disorders, excite immediate alarm in the minds of surgeons, when the individual who experiences them is under treatment for local injuries. A violent pain under * Mr. Guthrie has the merit of having been the first to draw the attention of the profession to the mild species as contra-distinguished from the acute. the sternum is a very frequent concomitant. The next occurrence in the order of time is the closure of the jaws, which in some instances takes place with a sudden snapping contraction : in others it is preceded by a feeling of pain, stiffness, and weakness in the temporal and masseter muscles, and the parts approach by degrees, being at last so closely fixed that it is impossible to separate them. Even wedges and levers are of little avail, says Aretffius, (De Causis et Signis Acutorum Morborum, lib. i. cap. 6); and, as he further re- marks, if we succeed in separating the teeth we gain nothing by so doing, for on attempting to pour liquids into the mouth, the patient is found unable to swallow them, in consequence of the spasm which has by this time beset the muscles of the pharynx; or if he does accomplish deglu- tition, the effort is often so convulsive and agonis- ing, that he entertains the greatest dread of repeat- ing it, to such a degree, indeed, that, like the sufferer in hydrophobia, he is sometimes distressed at the very sight of water. The teeth are not always in complete contact, so that a viscid ill- conditioned saliva may exude through the inter- vening space. Thus far we are in possession of the principal symptoms of trismus,-|- or locked-jaw, which differs only from the other forms of the disease by the circumstance that in the latter the spasm occupies a greater number of muscles. This species is scarcely less formidable than the others with regard to its fatality, but it is probably attended with less pain than when the body is more extensively affected. As the disorder pro- ceeds, a violent stabbing pain, occurring in parox- ysms, is felt in the region of the diaphragm, and the trunk and extremities become variously dis- torted. The face is suffused with a dark red flush, and miserably disfigured by the perverted action of its muscles, which draw up the nose, wrinkle the forehead, and drag the angles of the mouth towards the cheek-bones in such a manner as to present one of the most frightful exhibitions of the risus Sardonicus. The spasms about the muscles of the thorax gradually increase to such a degree, that respiration is performed with the utmost difficulty and anguish; we know of no form of dyspnoea more distressing to the beholder. This occurrence, however, eventually plays a very important part in the extinction of the sufferings by death. Although the contraction of the mus- cles rarely ceases so completely as to form an intermission, t there are occasional remissions. These, as it regards the mouth and jaws, only aggravate the1 horrors of the case; for it often happens during a brief separation of the parts, that the tongue is convulsively protruded, and not retracted in time to escape the re-closure of the teeth,—an accident which is generally attended with profuse hemorrhage. Sometimes the teeth are shattered by the violence of the spasm. The eyes are for the most part rigidly fixed, and suf- fused with tears. To conclude this brief account of the muscular derangements, it may be remarked that the sphincters are variously affected; thus, t From rptfa, " to gnash or grind the teeth." Origi- nally this term implied a convulsive rather than a tonic spasm. t In two of Dr. Parry's cases there were marked inter- vals. TETANUS. 36S the urine is sometimes discharged with great and sudden impetus during the vehement contractions of the abdominal parietes, at other times it is re- tained. The anus is in general most obstinately closed, though cases have occurred in which the contents of the rectum have been expelled involun- tarily. The mind, in the midst of all these sufferings, is perfectly clear, and occasionally even cheerful. Mr. Abernethy used to state in his lectures, that he had often known patients express themselves as feeling better to the very last. We have never happened to notice this fact, but can testify to the absence of the excessive sensibility and terror, which are present in hydrophobic patients. There is neither headach nor vertigo, and the senses are unimpaired. It is almost needless to mention that articulation is very feeble and indistinct, and frequently attended with such distressing aggrava- tions of the spasms, that the sufferer, although fully possessed of his consciousness, remains si- lent. The circulation is only secondarily affected by the violence of the muscular contractions. Such is particularly the opinion of Sir James M'Grigor, (Med. Chir. Trans, vol. vi.) Dr. Hennen, (Mili- tary Surgery, p. 250,) and many other accurate observers. There is generally, however, a pro- gressive alteration of the pulse during the course of this as of almost all other maladies. At the beginning it is pretty hard and full, but towards the close it becomes more frequent and feeble, and often is irregular and intermittent. The heat of the skin also appears to depend on the violence of the paroxysms ; it has been found by Dr. Pre- vost of Geneva as high as 110° Fahrenheit. [It would appear, indeed, from experiments on the lower animals and pathological cases in man, that lesions of the upper part of the spinal marrow give occasion, at times, to an extraordinary de- velopment of heat. In the case of a man at St. George's Hospital, London, labouring under lesion of the cervical vertebrae, the temperature was marked by Sir Benjamin Brodie at 111°. (Lond. Med. Gaz., June, 1836.)] The perspiration is generally profuse over the whole body, but some- times is confined to the face and chest; it conti- nues during the whole course of the disease, and has a peculiar pungent odour. The urine pre- sents nothing remarkable as to quantity or quality; some describe it as always high-coloured, (Ro- choux, Diet, de Med. torn, xx.; Fournier-Persay. Diet, des Sc. Med. torn. Iv.) while others have observed it to be quite as often unchanged. Tor- por of the intestines, to a degree that resists the most powerful purgatives, is allowed by all who have witnessed the disease, to be a more invariable accompaniment than any other. Such dejections as arc obtained are excessively offensive and un- natural. At the end of twenty-four or thirty hours, (Lar- rey, Mem. de Chir. Militaire, t. i. p. 209,) in acute cases, the disease has so far advanced that the pa- tient is unable to swallow. In the progress of the attack we often notice an apparent emaciation, the forms of the muscles become distinctly visible through the skin, and their rigidity increases. Towards the close, a spumous fluid, mixed up of mucus, blood, and saliva, escapes from between 2l* the teeth, the face is more and more distorted, a cold clammy exudation bedews the skin, the spasms are aggravated by the slightest exertion, whether for change of position, or to take food or medicine, the remissions are fewer, the dyspnoea increases, the pulse becomes thready or impercep- tible, and death takes place on the second day, or may be delayed to the tenth. (Rochoux, op. cit.) The most common period is within the fourth.* Hippocrates states in one place, (Aphor. vi. sect. 5,) " that if the patient survives this day, he is pretty sure to recover," an observation confirmed by the moderns; but in another place he tells us that the third, fifth, seventh, or fourteenth, may be the fatal day. (De Morbis, lib. iii.) Professor Robison, of Edinburgh, relates the case of a negro, who happened to scratch his hand with a piece of broken plate, and died of tetanus in a quarter of an hour. [The average duration has been considered by M. Andral (Cours de Patkologie interne,) to be four or five days. Of 58 cases, that terminated successfully, 8, according to Mr. Curling, (.4 Trea- tise on Tetanus, Bell's Select Lib. edit. Philad. 1837,) recovered in a week; 3 in ten days; 4 in a fortnight; 4 in three weeks ; 15 in a month ; 4 in five weeks; 8 in six weeks; 3 in eight weeks; 3 in two months; and 2 in three months.] It is the general opinion that death takes place in the way of asphyxia. We have no doubt that the obstruction of the respiratory movements ac- ; celerates the termination, but are inclined to think j that the heart, enfeebled by the long-continued agony, and perhaps involved in the prevalent affection of the muscular parts (according to the [ opinions of Parry and Howship,) has at least an equal share in the production of the fatal result. There seems but little ground for Baron Larrey's notion, that the compression of the abdominal viscera, and the engorgement of the vessels of the brain, are importantly concerned in the catastro- phe. But in whatever manner death is brought I about, it is an event happy to the tortured patient, and gladly hailed by his friends. " Far less cala- ( mitous is it," says Aretseus, " than the previous sufferings, in the estimation of the bystander, even ! if he be the victim's own son or father !" The most common variety of this disease is opisthotonos. All writers concur in this statement with the exception of Larrey, who seems to have more frequently met with emprosthotonos. The distinctive character of the former, as the name imports, is that the neck or the whole body is bent backwards. The posterior muscles of the neck ' are so rigidly contracted, that the head is dragged down upon the nucha and the larynx thrown for- wards. In some cases there is no other incurva- tion, but more commonly the spastic action ex- tends to the muscles of the spine, the effect of which is to draw the trunk into the form of an arch, the weight of the body being supported by the occiput, or rather by the vertex, and the sa- crum. The inferior extremities are extended, and sometimes the muscles between the posterior parts of the pelvis and the thighs are so violently affected * Fournier-Pescay (whose treatise on Tetanus received the prize of the Parisian Society of Medecine) states that he had only five cases of general tetanus that ter. minated so late as the seventh day. 366 TETANUS. as to throw the pelvis upwards, and thus to pro- duce a much wider arch. This action of the ab- ductors is greatly assisted by the biceps semiten- dinosus and other flexors of the leg, which, by reason of the vigorous antagonism of the exten- sors, have their fixed points on the tibia, and their moveable ones on the pelvis.* So great is the stretch on the abdominal parietes, that they feel as hard as a board, and, according to Aretseus, are sonorous when percussed. The latter observation we have not verified by our own experience, but think it highly probable, inasmuch as the constric- tion of the sphincter ani must prevent the escape of air from the intestinal canal, notwithstanding its compression by the contracted parietes, and, consequently, the latter must afford a clearer sound when struck. The arms, in this form of the dis- ease, are usually in a state of extension and drawn backwards, but occasionally they are bent, and lie upon the breast. (See one of Larrey's cases, op. cit. i. 242.) The fingers not unfrequently escape any spasmic affection. During the remissions that occur in opisthotonos, we observe that the muscles on the anterior part of the body are not unaffected, but they are not incapable of resisting their anta- gonists. The suddenness with which the re- curvation takes place has been sometimes so great as to project the unhappy patient from his bed. In a case related by Fournier-Pescay the spasms occasioned a dislocation of the second cervical ver- tebra. Emprosthotonos is a variety which has never occurred under our own observation; nor are we singular in this respect. Dr. Hennen, notwith- standing his many opportunities of observing the disease, never witnessed this form of it. The most striking descriptions of it that we have met with are those of Baron Larrey among the moderns, and of Aretseus among the ancients. The mus- cles on the anterior part of the body are said to be so contracted as to bend the head upon the breast, to curve the spine anteriorly, and to draw the thighs towards the belly. In very severe cases the head is brought into contact with the knees, so that the body presents the shape of a ball rather than of a bow, according to the remark of Aretseus. The condition of the legs is differently reported by these two observers; Larrey, in his general sketch of the symptoms, does not mention the extremities, but in one of his cases he states that " les jambes etaient roides, et fortement flechies sur les cuisses." (Op. cit. p. 266.) Aretseus declares in one place that the legs are extended, and in another, that they are drawn forwards with such violence, that the knee-joint appears as if driven into the ham.-j- The arms are generally flexed, and the hands clasped together. Pleurostkotonos is still more rare than the va- riety just described. It consists in a lateral incur- vation of the neck and body. It is generally met with in the chronic form, but we once observed it in an acute case that but for this complication would have been simple trismus. The last variety to be mentioned is that to ♦The contraction of the femoral muscles was, in a case related by Desportes, So violent as to fracture the thighbones. See his " Histoire des Maladies de St. Do- mingo," ii. 171. t 'Hi Soxeeiv h lyvtirjv Kara y6vv ri apdpov U&odai. Op cit. lib. i. c. 6. which, in strict verbal correctness, the word teta- nus should be confined. It is tetanus proper, consisting as it does in complete extension of the whole body. The frame is so rigidly set, that it is impossible to move one part without changing the position of the whole. Many writers treat of this variety as evidencing a balance between the* flex- ors and extensors. This appears to be a correct observation so far as the head and the spine are concerned, because these parts are capable of mo- tion in two directions. But when applied to the extremities the remark is incorrect, since the ex- tension of these parts must be the result of the predominance of the extensors over the flexors. If there were a balance between the two sets, the position of the limbs must be intermediate to ex- tension and the extremest degree of flexion ; a po- sition frequent enough in sleep and recumbence, when neither set is in action. Now, extension of the spine is a condition intermediate to that which the column would assume, if either of the sets of muscles on the anterior or posterior surface had the predominance; for, properly speaking, both kinds are muscles of flexion, though the posterior are said to be extensors, inasmuch as they keep the trunk erect by counteracting the tendency of gravitation to incline it forwards; consequently, a rigid extension of the trunk may be correctly said to result from the equilibrium of the anterior and posterior forces, erroneously called flexors and ex- ! tensors ; but the same explanation is inapplicable to the limbs, because in them extension is pro- duced by the extreme of one of the antagonist - forces. From this remark we exclude the feet and hands, which are in the same predicament as the head and the spine, that is to say, are not subject, as is commonly described, to flexion and exten- sion, but to flexion in two directions. I Before proceeding to the next subject of consi- ' deration, we may observe that the inferior animals I are liable to all the above varieties. Dr. Mason Good speaks of parrots as being frequently affected with trismus. Horses are very commonly treated by veterinary surgeons for opisthotonos and teta- nus. Dr. Parry appends to his treatise some cases related by Mr. Sewell, of Bath. In the Revue Medicale for May, 1834, there are some cases with the post-mortem appearances, reported by M. Gelee, Professor of Veterinary Surgery at Toulouse. Lambs are also subject to the disease, " I have often seen lambs," says Dr. Parry," whose ears, for the purpose of marking them, have been bored with a red-hot iron too near the root, so rigid all over with tetanus, alternating with convulsions, that their bodies would project in a right line with their hind legs when one held them out horizon- tally by the hind feet." (Cases of Tetanus and Rabies Contagiosa, p. 12.) Causes. — Of the events which immediately precede that morbid 6tate of the system which presents the phenomena above detailed, none are more common than mechanical injuries, and the application of cold, with or without humidity. With regard to the former, there is an entire con- currence of opinion among practitioners, that their efficiency as causes bears very little relation with their nature or degree. Every description of wound, no matter how inflicted, or in what part, or in what stage, may be the occasion of tetanic TETANUS. 367 symptoms, which form the species denominated traumatic. Morgagni tells of a young lady of Verona, who was attacked with the disease in consequence of a bite on the finger from a tame sparrow. (Epist. Anat. Med. liv. art. 45.) Dr. Reid knew a case in which tetanus supervened on j the mere stroke of a whip-lash under the eye, I though the skin was not broken. Larrey men- tions, that a small fish-bone sticking in the pha- rynx was the occasion in one instance, and in an- other a slight solution of continuity in the exter- nal ear from a musket-shot. Andral alludes to a ■ case that occurred at La Charite, in which the j application of a seton to the thorax was the cause of fatal tetanus. (Clinique Medicale, t. iv. p. 445.) An instance is mentioned by Mr. Morgan in which the stroke of a cane across the back of the neck, and another in which a blow on the hand from the same instrument, produced the disease; in both the termination was fatal. (Lecture on Te- tanus, delivered in Guy's Hospital, 1833.) A reviewer of Dr. Reid's work on tetanus in the Edinburgh Medical and Surgical Journal, (vol. xv.) states that the extraction of a tooth was once followed by this disease. According to Sir James M'Grigor, " it occurs in every description and in every stage of wounds, from the slightest to the most formidable, from the healthy and the slough- ing, from the incised and lacerated, from the most simple and most complicated." (Med. Ch. Trans. vi. p. 453.) Dr. Hennen observed, in like manner, that the wound, so far from presenting any unna- tural appearance, would often pursue its course unaltered by the tetanic seizure; in one case he mentions that the cicatrization was completed on the same day that life terminated. Larry, how- ever, lays considerable stress on the condition of the wound, which he says was generally either dry, or covered with a thin serous exudation. One case that occurred after amputation he attributed to too early cicatrization, and the consequent " reflux des matieres purulentes qui suintaient en- core de la plaie." (Op. cit.) Dr. Rush speaks of an absence of inflammation in wounds that cause tetanus. (Med. Inquiries, vol. i.) Fournier- Pescay in like manner describes them as pale, livid, and affording either an ichorous secretion or none at all. (Diet, des Sc. Med. t. Iv.) The in- stances already recited prove that the situations as well as the characters of the wounds are very va- rious. When the predisposition is very strong, and collateral circumstances are favourable, the locality of the wound is almost a matter of indif- ference. But it would certainly appear that some wounds are more frequently followed by tetanic symptoms than are others. Hennen oftener ob- served these occurrences after wounds of the elbow j and knee ; many practitioners connect them with the extremities rather than with the trunk; and not a few speak of a greater liability to such symp- j toms from injuries of the thumb and great toe. (Mr. Morgan's Lecture.) Mr. Samuel Cooper j states that the only surgical operations which he j has known to be succeeded by this disorder, are those of amputation and castration. (Surg. Diet. J art. Tetanus.) It was an ancient opinion, and is1 still by no means extinct, that injuries of tendons and ligaments, more frequently than of any other i tissues, lead to tetanus,—a notion which we think' may have arisen from the confusion which pre- vailed in the early periods of anatomy respecting nerves and fibrous membranes. Few, however, would now be disposed to assert the existence of a necessary connection between the disease and fibrous tissue. Were it necessary to disprove such a view, the facts adduced by Parry would have considerable weight in the refutation. This phy- sician knew a case in which a long thorn was driven entirely through the tendo Achillis, and remained five days, producing no soreness in the part, but a pain in the ham; on suppuration being establish- ed, the thorn was extracted, and the patient felt no further inconvenience. " In the various expe- riments made by Haller, in order to investigate the sensibility and irritability of these parts, no bad consequence whatever ensued." (Parry, op. cit. p. 14.) Blows on the neck have been noticed both by ancients (Hippocrates and Aretxus, loc. cit.) and moderns* as frequent causes of tetanus; and it is evident that such injuries act directly on the cerebro-spinal centre. For a more ample ac- count of the tendency of certain wounds to induce the disease under consideration, we must refer to writers on surgery. But we may remark, before quitting the subject, that although the presence of the disease is not fully announced till the ap- pearance of soreness and stiffness about the neck and throat, it is not uncommon for the muscles in the neighbourhood of a wound to be spasmodically affected before any others become involved ; some- times indeed the patient escapes without any other sign of spastic disturbance. Next, in frequency to wounds, as an exciting cause, is exposure to cold and damp. There are indeed but very few cases of true idiopathic teta- nus referable to any other marked exciting cause. Aretseus asserts the influence of a low temperature, and states that the disease is in consequence more common in winter than in any other season, and least frequent in summer, except as the effect of wounds or of a particular epidemic constitution. In tropical climates, exposure to the chilly night air and dew is well known to be highly dangerous. The negroes in the West Indies are frequently affected with this complaint. But it is by no means confined to warm climates. Dr. Gregory, of Edinburgh, used to mention in his lectures a striking instance of idiopathic tetanus that occurred in Edinburgh. An account is given by Bonetus (Sepulch. lib. i. sect. 13,) of a young soldier, who contracted the disease by sleeping in the open air a whole night in a fit of intoxication. Fournier- Pescay also reports the case of a soldier at Breda, who went into a cold bath, when greatly heated, and on coming out was seized with fatal tetanus; and also of a woman who died in a similar man- ner, after falling into a river when in a state of perspiration, and during the flow of the catamenia. He frequently observed, during the campaigns in Spain, that the soldiers, if they went to sleep upon the ground, after fatiguing marches under a burn- ing sun, were particularly liable to tetanus. The cold and moist breezes from the sea have often produced the disease in hot countries. Many of the French soldiers were seized with it when * Frank relates a case of "horrible tetanus" induced by a blow upon the spine. See Abercrombie on Dis. of the Brain and Spinal Cord, p. 395. 368 TETANUS. marching along the coast, on their way from Acre to Jaffa. A sudden change from the heated atmo- sphere of a ball-room to the external air, was sufficient to produce a very violent attack in a gentleman known to the author last cited. But although wounds, and cold, and humidity are capable of producing the disease independently of each other, their combined action is infinitely more formidable. Many instances on record prove that the first of these would not have been followed by tetanus but for the intervention of the others, and that individuals have been placed under the most unfavourable circumstances with regard to cold, and yet have escaped the disease till the oc- currence of an injury. Hennen lays less stress on the agency of cold than on that of air in mo- tion ; for all the cases which fell under his own observation had been exposed to a stream of air, either hot or cold. We think that the analogy of neuralgia strongly favours this view. The irritation of worms has been regarded by some authors as the cause of tetanic affections. Laurent, of Strasburg, (Memoire Clinique sur le Tetanos chez les blesses, 1797,) went so far as to assert that even in wounded subjects the real cause was the presence of worms in some part of the alimentary canal. Dr. O'Beirne (Dub. Hosp. Rep. vol. iii.) is disposed to award them a very consi- derable agency in this disease. There can be no doubt whatever that worms have been frequently discovered in the intestines of tetanic patients ; but we imagine that every attentive practitioner must have observed these animals too often and in too great a variety of morbid circumstances, to be very ready to invest them with any specific efficiency in so rare a malady as that which we are considering. It is highly probable that the same state of the system which favoured the gene- ration of worms, may have facilitated the operation of the proximate cause of tetanus. The following instance of alleged verminous action was commu- nicated by Chaussier to Fournier-Pescay. A young man, after labouring under severe pain in the bowels and constipation, was attacked with tetanus, which yielded however to the free use of purgatives, under the operation of which an enor- mous worm was expelled. This animal was con- sidered to have been the cause of the disease, not- withstanding the patient had received a sword- scratch on the ribs some days before. (Diet, des Sc. Med. t. Iv. p. 11.) Terror has been considered the immediate an- tecedent in some cases, and sympathy in others. This we have on the authority of Dr. Hennen, whose observations were far too accurate to be called in question. Dr. Willan mentions a case in which there had been no local injury or other accident, and in which the only circumstance that could be fixed upon as the cause of the attack, was mental anguish ; it should be added that the constitution of this individual had been previously weakened by other causes. (Reports on the Dis. of London, p. 289.) The Greek author, to whom we have so often referred, intimates that women are very subject to the disease after abortion. We are not aware of any modern observations in sup- port of this opinion. We remember, however, attending a young woman, who was seized with locked-jaw soon after delivery of a still-born and 'immature fcetus; but the affection readily gave j way to a turpentine injection, and we looked upon | it as a mere sympathetic accident. The sudden suppression of perspiration has been known to bring on an attack. Such was the case with a woman, who, while labouring under a gastric fever, exposed herself at an open casement to the north wind. (Fournier-Pescay.) Heurteloup (Precis sur le tetanos des adultes) relates a case in which the attack was apparently brought on by an accu- mulation of cherry-stones in the intestines. Other exciting causes may be found in the works of various authors; such are suppression of the lochia, alcoholic intoxication, acute diseases, as variola, typhus, and gastric inflammation. Of the last of these an example will be given in another place. Fournier-Pescay adduces some curious I cases communicated to him by M. Duval, in which the disease assumed the form of anomalous ague; ; in one of them it was remarked that both sides of the body were never affected in the same parox- ysm, but regularly alternated in successive fits. Various causes may be traced in the body itself prior to the occurrence of the immediate and effi- cient agent. The state of the system peculiar to certain ages has been commonly enumerated as } one of them; but we doubt whether any thing very definite upon this subject can be gathered from ! the cases on record, if we except the liability of young infants; in consideration of which nosolo- gists have established a variety known by the name of trismus nascentinm. Instances of this variety have been met with principally in tropical climates, and particularly in the West Indies. Dr. Cullen, however, speaks of its having been witnessed in the Highlands, (First lines, § 1281); and Fournier-Pescay and Dagille bear : testimony to its occasional occurrence in France. i It happens for the most part within the first two i weeks after birth, and is supposed to depend on irritation of the primse viae by meconium, worms, unnatural secretions, &c. or on a morbid condition of the umbilical fossa. According to one practi- tioner, (Dr. Cadwallader Evans, cited by Dr. Rush, Med. Inq. vol. i.), cases of the disease be- came very rare under the prophylactic use of. purgatives, while another (Dr. Colics, Dub. Hosp. Rep. vol. i.) states that attention to the umbilicus j produced almost certain immunity. [At the Havana, according to Don Ramon de la Sagra, (Historia Economica-politica y estadis- tica de la Ma de Cuba, Habana, 1833), it de- stroys a large proportion of infants during the first fortnight. It has been suspected, that want of cleanliness and ventilation have as much to do with this as the changes of temperature that occui there so suddenly and so frequently, and in sup- port of this view, M. Andral ( Cours de Pathologit Interne) remarks that at Wilna, in Russia, where the climate is so different, the same affection ii | found among the Jewish infants, who are remark able for the same want of cleanliness, and for' i being crowded together into a small space. It if [common, too, in the Western Isles of Scotland and is singularly frequent in the Vestmann islei on the southern coast of Iceland. On these deso late rocks, the population of which does not ex ceed 160 souls, it was found, that in a period of I 25 years, 186 infants perished of the disease unde.'."i TETANUS. 369 the age of 21; and of these, 161 died between the fourth and tenth days after birth ; 75 on the eighth day. The condition of life of these poor people is singularly destitute—fish, and the eggs of sea- fowl being their sole aliment; yet it is said not to be so different from that of the Icelanders of the main land as to explain the frequency of this fatal disorder amongst them ; and hence it has been suggested by Dr. H. Holland (Medical Notes and Refections, Bell's Select Library edit. p. 21, Philad. 1S39) that some constitutional and here- ditary causes are concerned. It is more than pro- bable, that the influence of locality is excited in the causation, but how the organism is modified by these causes we know not. It has been sup- posed by some (as by Colles, Basch, and Levy) that the trismus of the new-born is owing to in- flammation of the umbilical arteries.] With regard to sex, the ancients considered females to be more frequently affected with teta- nus than males, but less severely. We may take it for granted that in this remark they included certain irregular spasmodic affections incident to nervous and hysterical women. Males have been by far the most frequent victims in recent times ; but this fact is perhaps more naturally explained by their being oftener subjected to such exciting causes as cold, vicissitudes, injuries, &c. than by their peculiar constitution. The predisposing influence of warm climates and seasons has been matter of very general re- mark. One of the most striking illustrations of this influence is given by Dr. Rush. After men- tioning the frequency with which wounds were succeeded by tetanus if the weather had been pre- viously very warm, he relates, on the authority of some French surgeons, that at the siege of New York in 1781, some troops which had arrived just before from the West Indies, were the only per- sons that suffered from the disease in question, and that not a single case occurred among the soldiers who had passed the previous winter in Rhode Island. This acute physician attributed the effects of the warm atmosphere to its relaxing tendency, and points out its analogy in this re- spect with other predisposing causes, particularly laborious exertion. He also explains the particu- lar liability of wounds received in battle to tetanic consequences, by the fatigue which soldiers gene- rally undergo before engagements. Humid situations also produce a very decided predisposition to this disease. We are informed by Larrey that great numbers of the wounded soldiers in the hospitals at Cairo perished of teta- nus, which he attributed to the circumstance that those receptacles were erected upon ground subject to the periodical inundation of the Nile. Bad or insufficient nutriment, close and ill- rentilated habitations, inattention to cleanliness, neglect of the bowels, &c, have been considered «s predisposing causes; views which derive no little probability from the diminished frequency of ! 4e disease in our naval department in the West todies, since the improvements which have taken jce in their hygiene. The experience of Drs. ickson and M'Arthur (Med. Chir. Trans, vol. j rii.) was a very striking contrast to that of Dr. Lind The latter states that five out of six cases of amputation used to die of tetanus; while Dr. r Vol.. IV. —47 Dickson reports that during seven years he met with only six cases of the disease occurring after amputation ; and Dr. M'Arthur, v\ho had the care of the naval hospital in Barbadoes, had witnessed only two cases in that institution during a space of six years, notwithstanding there was no lack of wounds, either from war or from surgery. Dr. Dickson concludes a very interesting paper with j the following remarks :—"I trust I am, therefore, ! justified in inferring that to the improvements in the medical and surgical treatment of wounds, in cleanliness and ventilation, avoiding at the same time exposure to currents of cold air or sudden changes of temperature ; in fine, to superior com- forts, diet, and accommodation, but particularly to the greater attention paid to the state of the bow- els, may be attributed the great infrequency of tetanus of late in the West Indies, when compared with former wars." (Med. Chir. Trans, vii. p. 465.) Whether the comparative infrequency was en- tirely due to these causes, might perhaps admit of some question, as there is reason for believing that there are latent causes of tetanus, the remo- val of which might, consequently, have escaped observation ; such causes, for instance, as are con- cerned in the limitation of the disease to particular districts, towns, streets, and even hospitals, not- withstanding they may be apparently in the same circumstances as other situations. (See Hennen's Military Surgery, p. 252.) Prognosis.—This is mainly to be determined by the nature of the exciting causes, and by the type of the seizure. With respect to the former, it is sufficient to remark that the greater mortality of the traumatic species, so well known to the earliest observers in our art, (En rpwfxan o-jrao-fio; l-aiytvonivoc, davaoipov. Hipp. Aph. 2. sect. V.) is matter of equal experience in modern times. Dr. O'Beirne witnessed two hundred cases in the pe- ninsula, not one of which recovered. (Dub. Hosp. Rep. vol. iii.) That the idiopathic disease is a far milder and more tractable affection " is a fact well known," says an able writer in the Edinburgh Journal, (Vol. xv. p. 292,) "to every planter in the West Indies, who never considers his negroes as safe when the disease supervenes on a wound, but is frequently successful in alleviating the idio- pathic species." The type, of the disease as acute or chronic is a no less important guide as to the probable termination. Hennen confesses that he never saw a case of " acute symptomatic tetanus" recover. In the acute species Dr. Dickson found all curative measures followed by " unqualified disappointment." Mr. Morgan's testimony is still stronger; he says, " I have never yet seen or heard of an instance of recovery from acute teta- nus." (Op. cit.) Many other authorities might be quoted to the same purport. The chronic spe- cies has acquired the additional character of mild, but the period at which the disease becomes chro- nic has not been sufficiently specified. "The disease which comes on suddenly," says Cullen, (First Lines, s. 1266,) « and advances quickly to a violent degree, is always more dangerous than that which is slower in its progress." If the pa- tient survives the fourth day, there are good hopes of his recovery; not but that death may occur at a much later period. A patient of Prof. Cooper's lingered five weeks, and then died; but instances 370 TETANUS. of a fatal termination after the lapse of a single week are extremely rare. The complaint may continue for many months in a chronic form, and then gradually wear away. It will be seen that a great proportion of the remedies which have got the credit of utility in tetanus, have been indebted to their application to this form of it. A prog- nostic observation made by that distinguished physician, Dr. Parry, respecting the state of the pulse, has been often quoted. " If, in an adult, the pulse by the fourth or fifth day does not reach 100, or perhaps 110 beats in a minute, I believe the patient almost always recovers. If, on the other hand, the pulse on the first day is 120 or more in a minute, few instances will, I apprehend, be found in which he will not die." (Op. cit. p. 18.) To us it appears that this remark does not by any means deserve the degree of notice that has been taken of it; for in the first place the author bases it upon an opinion altogether hypothetical respecting the affection of the heart in this dis- ease ; secondly, those who have had the most frequent opportunities of observing the disease, ■consider the circulation, as we have already stated, to be only secondarily affected by the spas- tic commotions of the system ; and, lastly, if the observation be correct, it teaches us little or no- thing additional, for if the patient lives till the fourth or fifth day to have his pulse examined, be it slow or frequent, there are good reasons for a favourable prognosis. Perhaps any considerable frequency of the pulse at the very commencement, may be justly esteemed a sign of severity, and likewise any remarkable smallness or irregularity ; but in such a case there would be other symptoms far less equivocal. Baron Larrey formed an opi- nion that perspirations in certain parts were criti- • cal, those, namely, about the chest and abdomen, while those beginning on the head and extremities were symptomatic only. We are not acquainted with any other authority confirmatory of this ■ opinion. Diagnosis.—The features of this disease are so striking and peculiar, that they cannot be very readily confounded with those of any other. If the muscular affection be not sufficiently character- istic, there are, the peculiar pain at the lower part of the sternum, the state of the tongue, and the absence of delirium or coma. In consequence of the difficult deglutition produced by the spasms in the pharynx, and the occasional dread of fluids, taken in connection with the aggravation of the ■ disease by trivial excitement, a superficial observer might possibly imagine that he was witnessing a case of hydrophobia. The differences are very decided, but we shall not stop to detail them, as 'they have already been set forth in a very ample and lucid manner by Dr. Bardsley, in the article on Hydrophobia, in this work. It is necessary to be aware that hysteria, which imitates so many formidable diseases, does not allow tetanus to escape her mimicry. Sometimes the representa- tion is 60 faithful, that we have not the slightest doubt that many reputed examples of successful treatment of tetanus have been merely conquests over hysterical spasms. Dr. Whytt, in his work on Nervous Diseases, alludes to these occurrences; and there is a well-marked case of the kind in Mr. Tate's Treatise on Hysteria. But it is need- less to refer to authorities, since no practitioner of even ordinary experience can have failed to observe spasmodic affections in irritable females, closely bordering upon what we have just alluded to. There is sometimes a locked-jaw from mere local inflammatory causes, which might perhaps be mistaken for a tetanic trismus. We have frequently witnessed it in inflammatory swellings of the face and fauces, in the tumefaction attendant on mercurial ptyalism, and in rheumatic affections of the temporal and massetcr muscles. In one instance of the latter kind, which fell under our notice, the jaws had been fixed at an interval of barely one quarter of an inch for the space of three months. The history of such cases, and a variety of concomitant circumstances, will render their discrimination easy. The diagnosis of spontaneous from artificial tetanus, or that produced by certain poisonous substances, is somewhat more difficult. The effects of nux vomica, the upas tiente, and other plants belonging to the genus strychnos, and of their active principle strychnia, are precisely similar to tetanus, both as it regards the peculiar nature of the spasms, and the absence of any mental distur- bance. The discrimination, however, of such cases is highly important in many points of view, and must be sought in a careful examination of the previous history, of the progress of the case, and of a variety of collateral circumstances. In a temperate climate a sudden accession of tetanic symptoms of great severity, and running their course rapidly, in a person who has received no local injury, nor been exposed to cold and damp, would create a strong suspicion of poisoning. Supposing their character were somewhat milder, and their progress more tardy, the presence of certain signs of irritation in the alimentary canal would materially assist our diagnosis, since we know that the substances alluded to not only act on the nervous system, but are also decided irri- tants,—that, in short, they belong to the class of narcotico-acrids. Accession.—The period of accession differs in the idiopathic and traumatic species, being in the former considerably earlier. When arising from exposure to the cold and damp of the night, the disease usually makes its appearance on the follow- ing morning. After injuries its appearance is generally, though not always, later. This differ- ence is perhaps more apparent than real, for in the latter case, although we date from the infliction of the wound, which is the obvious cause, it would be more correct, were it possible, to reckon from that change, or from the commencement of that state of the wound which is really the cause of the distant irritation, and then in all probability 1 there would not be observed the same protracted interval between the occurrence of the cause and of the effect. But this refinement, we confess, is I of little practical importance, the great object being | to ascertain how soon an individual who has suffered an injury may be pronounced secure from an invasion of tetanus. The most common period for the first appearance of the symptoms is during the second week. Sir James M'Grigor states twenty-two days to be the longest period. (Med. Chir. Trans, vi. 453.) Sir B. Brodie (See a Clini- ETANUS. 371 cal Lecture in Med. Gaz. vol. ii. p. 344,) mention- ed on one occasion that the seventeenth day was the latest at which he had known invasion take place. Sir Gilbert Blane, in his work on Diseases of Seamen, gives a range of four weeks. Fournier- Pescay declares that he has known it occur at a period longer than a month, and, on the other hand, that in some very rare instances only a few hours have elapsed. We have already alluded to a case in which the disease not only took place, but was fatal in a quarter of an hour after the injury. [In 128 observed cases, according to Mr. Cur- ling, (op. cit.) the disease appeared from the 4th to the 14th day, in 81.] Morbid Anatomy. — Though little if any thing of value is to be gathered from the researches which have hitherto been prosecuted in this de- partment, it would be highly improper to pass them altogether without notice. In the dissection of a case related by Bonetus, there was found nothing preternatural in the organs of the thorax and abdomen, but the ventricles of the brain were filled " materia quadam viscida. ac glutinosa, colore luteo, vitello ovorum perquam simili sed fcetida admodum." He adds, " Hsec incumbens principio nervorum tarn sseva sympto- mata in subjectis partibus excitarat. Venae inter- currentes utramque cerebri meningem, adinodum turgidse erant bilioso sanguine." (Anat. Pract. lib. i. s. 13.) Morgagni relates the appearances in three cases of tetanus. In one there was some venous congestion in the thorax, neck, and head, with more vascularity than natural of the medul- lary matter of the brain. (Epist. Anat. Med. liv. art. 44.) In another there was a somewhat larger quantity of serum than usual in the ventricles of the brain; the cerebrum was firm in tissue, but the cerebellum rather soft. (Epist. liv. art. 49.) The third presented no morbid appearances, ex- cepting a very little serum in the left lateral ven- tricle. (Epist. x. art. 2.) In recent times particular attention has been directed to the appearance of the spinal cord. Dr. Reid, in his work on Tetanus, describes what he considered to be an inflammatory condition of the membranes, with or without the effusion of serum. Similar appearances had previously been men- tioned by Burserius, who observed them in the case of a man who died of the disease after ex- posure to cold in a state of intoxication. Fournier- Pescay, who, while serving in the army, never neglected an opportunity of dissecting the bodies of those who died of tetanus, states that fluid blood was often found effused between the dura and pia mater, that the vessels of the latter membrane were gorged with blood, and that the cerebral sub- stance was depressed. He makes no remark on the state of the spinal cord. (Diet des Sc. Med. torn. Iv. p. 6.) Rochoux cites Trnka and other authorities in testimony of similar facts. (Diet. de Med. torn. xx. p. 338.) The periodicals of the last twenty years furnish several cases in which morbid appearances were said to be found in the spinal cord or its envelopes.* But since anato- * See particularly the notice of a case examined by Dupuy treu, in Med. Clnr. Kev. July, 1HH ; also two cases by Professor Brora, of l'adua, in Loml. Med. and l'liys. Journ. September, 1818; and one by Mr. Brayne, iu Med. Repository, July, 1831. mists have learned to place less reliance upon mere redness and turgescence as indications of inflam- mation during life, the profession have become less and less satisfied as to the constant presence of morbid changes in the spines of tetanic patients. Of the cases communicated to Hennen, many presented the cord and its membranes in a per- fectly natural condition, and he had reason to sus- pect that the apparent lesions of these parts were often due to the rude use of the chisel and saw. The unskilful mode in which we have often known the operation of exposing the contents of the ver- tebral column performed, leads us to consider this author's conjecture a very probable one. Sir B. Brodie could never satisfy himself that these parts were diseased. (Loc. cit.) Dr. Elliotson consi- ders the appearances described to be rather inci- dental than essential, (Lecture reported in Med. Gaz. vol. xi. p. 469) ; and Mr. Morgan, after men- tioning that in some cases cerebral congestion and increased vascularity or morbid deposits in the spinal membranes have been discovered, declares that in other cases he has looked in vain for the same appearances. (Op. cit. p. 28.) The following passage in a lecture delivered by Professor Mayo, at King's College, has just caught our attention. " In the museum of St. Thomas's Hospital, I am informed by Mr. Green, there are two specimens of the spinal cord, the membranes of which are studded with little cartilaginous and earthy flakes, taken from patients who died of tetanus. These small deposits did not, it is to be presumed, pro- duce the tetanus, but they probably had made the spinal cord preternaturally irritable. (Med. Gaz. Jan. 17, 1835.) Baron Larrey states that he often found the pharynx and cesophagus in a state of constriction, and their mucous membranes inflamed, and covered with a viscid reddish-coloured secretion, (Op. cit. i. p. 248) ; appearances which it is more reason- able to attribute to the violent action in these parts, than to consider as concerned in the pathology. Some observers have thought that they recognised the effects of inflammation in the stomach and in- testines, but they do not specify any thing more than such alterations of colour as are often the result of cadaveric changes. We except from this remark a case related by Andral, (Clinique Medi- cale, t. iv. p. 444), in which dissection presented very unequivocal signs of gastritis; but this was evidently the exciting not the proximate cause of the attack. This distinguished pathologist con- jectures that the patient must have had a very strong predisposition to the disorder, and that any lesion would have produced the seizure. Dr. M'- Arthur found in his dissections a very peculiar ap- pearance in the contents of the alimentary canal, particularly in the stomach. In one case " the villous* coat of the stomach was covered with a peculiarly offensive smelling yellow matter," (Med. Chir. Trans, vol. vii. p. 469) ; the mucus in the cesophagus was of the same colour ; and in another case, " the yellow fluid effervesced on coming in contact with the external air." (Med. Chir. Trans. vol. vii. p. 475.) Fournier-Pescay also speaks of a yellowish or greenish coloured mucosity found in the stomachs of some of his patients. Worms we have already mentioned, have been frequently found in the intestines ; they are particularly taken 372 TETANUS. notice of by Morgagni, StoU, Larrey, and Dr. O'Beirne. Anomalous appearances have been observed in other parts of the body. A writer in the Edin- burgh Medical and Surgical Journal (vol. xv. p. 289,) quotes from Meyer a case in which there was discovered an ossification of the pleura, which must have irritated the phrenic nerve ; and one from Vater in which the par vagum was irritated by an ossified gland. The heart was found to be preternaturally contracted, so as to occasion con- siderable resistance to the knife, in a case related by Mr. Howship. (Lond. Med. and Phys. Journ. vol. xxiv.) Mr. Swan, in his treatise on tetanus, details some, dissections in which he discovered inflammation of the abdominal ganglions. It must not be omitted, that in many cases of the traumatic species, the nerve in the neighbourhood of the wound has been found inflamed and thick- ened, while in others nothing unnatural could be« detected. Theory.—Upon the above post-mortem appear- ances it may be remarked in general terms, that they are by no means constant; that they vary in degrees that hold no correspondence with the dif- ference of the cases; that many of them are acci- dental accompaniments ; and that with regard to others it is extremely doubtful whether they are actual morbid lesions or mere cadaveric alterations. Consequently, upon facts of this description it would be absurd to attempt to erect any theory of the disease. Unassisted by morbid anatomy, the speculator is reduced to the data afforded by phy- siology and by the symptoms; and he is not likely to be questioned if he pronounces that the malady belongs essentially to the nervous system, whatever other be secondarily affected. He is baffled, however, in his attempts to explain the rationale of the derangements in tetanus, and must confess with the candid and enlightened Abercrom- bie, that "its pathology is still involved in great obscurity." (Disease of the Brain and Spinal Cord, p. 396.) That the pathology of any of the neuroses should be obscure, when so little is known of the instrumentality of nervous matter, can excite no rational astonishment. But in some of the dis- eases belonging to this class, there are states of the organization which show clearly enough that the mechanism was impeded or in a preternatural condition, though the action of the mechanism and the manner of its obstruction are entirely withdrawn from our observation. Thus we often find extravasations of blood, the products of in- flammatary secretion, changes in the membranes, morbid states of the tissue, consisting in ramol- lissement, induration, adventitious growths, &c.; but these appearances are valuable to us, not be- cause they explain in what manner the function was impeded, or in other words what alterations took place in the arrangement of the ultimate nervous molecules, but because they are connected with certain conditions of the system less or more under the control of our art. Such lesions, how- ever, belong to a few only of the circumstances which are necessary to the proper performance of the nervous function; and in the nervous matter itself there may be myriads of other conditions, owning no connection with any that are subject to our cognizance, but the disturbance of any one of which may be amply sufficient to occasion a fatal derangement. The imperfect pathology of epilepsy, chorea, mania, hysteria, hypochondriasis, &c, affords but too many illustrations of the truth of these remarks; and a still more striking testi- mony is borne by the autopsies of hydrophobia, and, as we have seen, of the scarcely less formi- dable disease under consideration. In all these instances, presenting no constant alterations of capillaries, of texture, or secretion, we are forced to believe that the essential morbid change, what- ever it be, must exist in those parts or actions of the mechanism which lie beyond our perception. Many conjectures have been thrown out as to the division of the nervous system which is more particularly involved ; but the prevalent opinion (which originated with Galen) is, that the spinal cord is the principal seat of the disease; an opinion founded upon the idea that this organ is the primordial agent of voluntary motion. Fer- nelius is very confident upon this subject — " Hujus morbi causam et vitium in spina? initio contineri extra controversiam est." (Pathologia, liv. v. cap. iii.) The same opinion, we are told by Dr. Abercrombie, was entertained by Hoffmann, Ludwig, Lieutaud, Burserius, and Belfingerus. The absence of any derangement of sensibility or of intellect in tetanic patients has led most ob- servers to the conviction that the brain is not involved ; but others, and among them Fournier- Pescay, fancy that this organ cannot be said to be free from disorder, inasmuch as the spastic action extends to muscles which derive their nerves from within the cranium. This doubt, however, can- not weigh with those who believe that all the cerebral nerves, as they used to be called, are ca- pable of being traced into the medulla oblongata, or at least into its superior prolongations. On the other hand, it cannot, we think, be maintained that the disease is confined to the spinal cord. The early symptoms, namely, the stiffness about the throat, and the spasms of muscles supplied with nerves from the medulla oblongata, prove beyond all question that this part is first affected, and that in simple trismus there is no reason to think the cord at all implicated. Whether in more general tetanus the spasms are primarily excited by irritation of the cord, or some re- moter organ, cannot be fully determined till the physiology of these organs is better established. The possibility of the spasms being originated in the medulla spinalis may, we think, be fairly deduced, were other proofs wanting, from the ex- periments of toxicologists. Thus Professor Em- mert of Bern found that on inserting the extract of false Angustura bark into the hind leg of an animal, after its spinal cord had been severed at the loins, the hind-legs as well as the fore-legs were thrown into spasms; and also, that if the medulla oblongata be cut asunder, and respiration artificially preserved, universal spasms might be produced by the introduction of the same sub- stance. (Christison on Poisons, p. 761.) But the researches of Flourens and Magendie prove that the cerebellum is so importantly concerned in muscular motion, that it would be wrong to leave this organ out of consideration, when reasoning upon the seat of such a malady as tetanus; a TETANUS. 373 conviction rendered still more forcible by a case related by Orfila and Ollivier of poisoning by nux vomica, in which there was " found much serous effusion on the surface of the cerebellum, and softening of the whole cortical substance of the brain, but especially of the cerebellum." (Christi- son, p. 757, quoted from Arch. Gen. de Med. viii. 18.) One of the most laborious and ingenious inqui- rers into the functions of the nervous system, Dr. Bellingeri,* attempts not only to determine the seat of tetanus, but to describe the limits peculiar to its separate varieties. Thus, as he supposes the motions of extension to depend upon the cerebellum and the posterior strands of the spinal cord, while those of flexion originate in the ante- rior strands and in the cerebrum, the former parts must in accordance with this hypothesis be affected in opisthotonos, and the latter in emprosthotonos. The reception of this explanation will depend on the estimation in which the Italian professor's doc- trine of nervous antagonism is held ; but we have no space for a discussion of its merits. Treatment.—In this division of our subject we regret that we can do little more than recount a series of defeats, incurred by almost every the- rapeutical agent that has been employed against the terrible malady under consideration. Opium has been more extensively resorted to than almost any other remedy; and certainly some of its well-known qualities are calculated to excite considerable expectations of benefit from its administration in a disease of which spasm is the most formidable symptom. Some practitioners have fancied that their anticipations have been realized, and have published cases in corroboration of their good opinion of this medicine. But a careful scrutiny of these histories tends very little to alter the unfavourable estimate which our own experience has compelled us to form of its virtues in tetanus, for they nearly all appear to have been instances of the milder form of the disease. We have known half-ounce doses of the tincture ad- ministered at brief intervals in acute cases, and not the least impression made on the system. In some instances, when stupor has been produced after immense doses, there has been anything but a remission of the morbid action of the muscles ; and the observation of cerebral diseases constantly shows us that coma and spasms are by no means incompatible. There are several cases on record proving the enormous quantities that may be ad- ministered with impunity, though not with benefit. It is right to mention, however, that under the treatment of Dr. Gloster of St. John's, Antigua, a negro who had contracted the disease from expo- sure to cold at night, recovered after taking the drug for seventeen days, and the greater part of that time in doses of twenty grains every three hours. (Good's Study of Medicine, iv. p. 362.) Mr. Abernethy once found JJxxx of solid opium undissolved in the stomach. Systematic writers uphold the employment of the medicine, but it would appear for theoretical rather than for prac- tical reasons, while those who give the results of their own experience express the greatest dissatis- * A very good abstract of this author's doctrines is given in the Edin. Med. and Surg. Journ. for Oct. 1834 and Jan. 1835, 2g faction with the remedy. Among the latter we find the distinguished names of Rush, M'Grigor, and Fournier-Pescay. The strongest testimony in its favour that we have met with, is that of Baron Larrey, (Op. cit. p. 271); he was in the habit of exhibiting it with camphor and nitre in emulsion of almonds, in which combination he found it most easily swallowed. Dr. Latham was very partial to its use in combination with ipeca- cuanha. There are on record three cases by Pro- fessor Mursinna of Berlin, treated with opium, in doses of from fifty to one hundred drops of the tincture every hour. (Edin. Med. and Surg. Jour. vol. ii.) They all recovered; but it is scarcely necessary to add that they were all idiopathic and apparently mild. [Twenty grains of opium, according to Dr. J. H. Bennet, (Tweedie's Library of Medicine, 2d Amer. edit. p. 80, Philad. 1842,) have been given every three hours for several days.] Bleeding, one of the most powerful of our anti- spasmodic resources under certain circumstances, has been the subject of some diversity of opinion, 1 as to the propriety of its employment in tetanus. Few, however, are averse to it in the very begin- ning of the attack. The best guide in this as in many other diseases is the constitution of the individual; in some habits we have not the least ' doubt that it would aggravate the violence of the disease.-|- There is not the least evidence to prove that it has any directly curative effect on tetanus; | and if it exerts any beneficial influence, it is only as a preparative or auxiliary to other measures. Dr. Dickson advises its use as a preventive of the traumatic species, when the wound is inflamed and swollen, and the habit plethoric. (Med. Chir. Trans, vol. vii.) Mr. Earle found it a very useful palliative in a case which ultimately terminated in death. In one of the successful cases related by Hennen, venesection was one of the measures employed, but the case was confessed to be chro- nic. Larrey speaks favourably of the measure, and Sir James M'Grigor, though it appears in his catalogue of remedies that had generally failed, seems disposed to recommend it for want of a better resource. Perhaps, in the present state of our knowledge, the most that we can say for the measure is, that till we are better acquainted with the pathology of the disease, it would be scarcely justifiable to lose sight of a remedial agent, of which experience, independently of theory, shows us the utility in a very extensive range of dis- eases, and which is known in some complaints to exert a most powerful control over symptoms which constitute the severest part of the malady under consideration. It is almost superfluous to hint that great caution must be used in the appli- cation of the remedy, as the production of syncope might be immediately fatal. No better rule can be devised than that of Aretseus : « ha-ra^ dipaiphiv, thjiiTpws, prj fii^pi XeiiroOvpins Kai iwptd/ufioj." (De Curat. Acut. Morb. lib. i. cap. 6.) The warm-bath would for obvious reasons oc- cur to the mind of any practitioner who had had no previous experience of the disease, and there is f Dr. Cullen says, " Bleeding has been formerly applied in this disease ; butof late it has been found prejudicial, excepting in a few cases, where, in plethoric habits, a fever has supervened." 374 TETANUS. a certain amount of testimony in favour of its em- ployment; but the majority of observers have either relinquished it as useless, or condemned it as prejudicial. Among the latter was Dr. Hillary of Barbadoes. The cold-bath has had strong re- coinmenders, particularly Drs. Lind and Currie. The latter, in his Medical Reports, (Vol. i. p. 136,) gives the case of a young soldier, in which immersion in cold water, after being pushed to the greatest possible extent, was quite successful; but after reading this case, we are disposed rather to think of the singular good fortune that prevented the patient from dying in the middle of the expe- riment, than encouraged to adopt it in our own practice. Sir James M'Grigor pronounces the measure to be " worse than useless:" and Dr. Parry's testimony is scarcely less condemnatory. (Op. cit. p. 22.) We remember a case in which it greatly aggravated the violence of the spasms. Mr. Morgan relates an instance that occurred in St. Thomas's Hospital, in which a tetanic patient was plunged into a cold-bath at his own request— "All the symptoms disappeared in a moment, and he was almost immediately taken out of the bath —but he was taken out lifeless." (Op. cit.) Cold affusion has the warrant of very ancient authority. Hippocrates prescribes it in the idio- pathic species, but strictly limits it to cases of this kind. (Aph. 21, sect, v.) In other cases, he ad- vises warm fomentations and inunction. (De In- tern. Affect, sect, v.) Schenckius records two in- stances of successful treatment by cold affusion. (Observationes Medicse Rariores, lib. i. p. 127.) The most earnest of the modern recommenders of this measure are Drs. Wright and Currie. The former, in a paper which was published in the London Medical Observations, detailed its good effects in the West Indies. The latter adduces two cases in which it was used in conjunction with other remedies, and which recovered; but they were both of the chronic kind. Latterly there has been but little experience of its beneficial operation.* It has been tried upon animals af- fected with tetanus, and failed; there is a ludicrous account of its unsuccessful application in the case of a horse, in one of Mr. Abernethy's lectures, (Lancet, vol. v.); and Dr. Parry states that it was quite useless to some lambs which were suffer- ing from the disease. Dr. Elliotson relates an in- stance in which, after a pail or two of water had been dashed upon a tetanic patient, he fell down dead as if shot. In connection with this subject we shall introduce a curious case, narrated by Sir James M'Grigor, of a soldier who recovered, appa- rently in consequence of exposure to wet and cold. " The symptoms of the disease occurred from a slight wound of the finger, and are stated to have been unusually severe. As it was impos- sible to think of leaving the man in the wretched village where he was attacked by the disease, he was carried on a bullock-car after the battalion. During the first part of the day he was drenched with rain, the thermometer standing at 52° ; but after ascending one of the highest mountains in Gallicia, the snow was knee-deep, and the ther- mometer below 30°. The patient was exposed to this inclement weather from six o'clock in the * In the Revue Medicale, 1833, there is a case of con- siderable severity in which it appeared to do good. ' morning till ten at night, when he arrived half starved to death, but perfectly free from every symptom of tetanus." [Recently, the resinous extract of Cannabis In- dica, Indian Hemp or Gunjah has been recom- mended in the traumatic form of the disease by Dr. O'Shaughnessy. It was given, at first, in doses of two grains every third hour, and after- wards of three grains every second hour, until the usual intoxicating effects were induced ; when the spasms were in some cases mitigated, and in others wholly removed. (New Remedies, 4th edit. p. 135, Philad. 1843.) Dr. Marshall Hall, (Principles of the Theory and Practice of Medicine, p. 299, London, 1837,) after laying down what he regards as the first in- dication of treatment in traumatic tetanus, viz.,— to divide the injured nerves, observes, that the second is " to subdue the spasmodic affection by such remedies as the hydrocyanic acid." We are satisfied, that narcotics are more powerful agents. Andral, indeed, (Cours de Pathologic Interne,) says, that the hydrocyanic acid has never suc- ceeded ; but it is asserted, that it was prescribed with advantage in a case of traumatic tetanus in the dose of from two to twelve drops, after opium had been given in vain. (Trevezant, Froriep's Notizen, Bd. xiv. No. 15, s. 324.)] Among the measures directed immediately against the spasms, we may mention tobacco in the form of enema, strongly recommended by Dr. O'Beirne, in consequence of a case apparently cured by the use of this substance. (Dub. Hosp. Rep. vol. iii.) In the Peninsula, " when tried in the advanced stage, it seemed to have no effect:" (M'Grigor.) [Yet Dr. J. H. Bennett (Op. cit.) is disposed to regard it as the most efficient re- medy of the class.] Musk is extolled by Four- nier-Pescay, who boasts of having been the first practitioner who had treated with success an acute traumatic specimen of the disease. His dose was ten or fifteen grains; and he often gave two drachms in the course of the day. Ammonia is mentioned by the latter author as having been very effica- cious in the hands of M. Francois. Oil of tur- pentine has been lauded for its power of relaxing the spasms in certain cases of locked-jaw, but they appear to have belonged to the milder species. We have already mentioned an instance that fell under our own observation. [In a case of tetanus algidus, which fell under the writer's observation, the patient, who lived in the country, was taken, in the violence of the opis- thotonos, to a brook which ran by the house, and the cold affusion was liberally administered. Nar- cotics were likewise given, and under the combi- nation he got well.] Dr. Rush, believing the diathesis in which the disease occurs to be one of debility and relaxation, administered wine and bark with a liberal hand, and not without success. Others have confirmed his opinion of these remedies, at least in the chro- nic species. In a case of this description, which lasted forty-two days, Dr. Currie administered one hundred and ten bottles of port wine. (Med. Re- ports, i. 148.) Some authors advise ardent spirits in large quantities, and one of them goes so far as to advise us to produce intoxication, but this is no easy matter. It is scarcely less difficult in teta- TETANUS. 375 nus to intoxicate with alcohol, than to induce stupor by opium. [In one successful case, according to Dr. Brig- ham, Dr. Hosack administered three gallons of wine in the course of three days. He was led to regard the disease as one of debility; and was in- formed by General Moreau, that lock-jaw was of rare occurrence in an army, when it first took the field; but that it was produced by the slightest wounds when the soldiers had become fatigued and debilitated by long marches and frequent battles.] Mercury has been tried both externally and in- ternally, and generally failed; the same insensi- bility being manifested in the system to the pecu- liar operation of this medicine as of those just mentioned. The indication for its employment is by no means obvious, and we are inclined to be- lieve that the principle which first suggested the use of it, was that of exciting a commotion in the body, which in some way or other should render it a less convenient habitation for the disease ; a principle upon which, however much they may be ashamed to confess it, practitioners have been but too often compelled to act. Among those who speak most favourably of this medicine, is Dr. Rush, and apparently in consequence of his no- tion that it has a tendency to create a tonic dia- thesis. The following is Sir James M'Grigor's summary of experience respecting the remedies, which we have mentioned. " The remedies which have been chiefly trusted to for the cure of this formidable disease, are opium, mercury, wine, warm and cold bath, vene- section, ipecacuanha, and digitalis in large doses, enlargement of the original wound, and amputa- tion of the limb. These have been tried alone and in various combinations, and I am obliged to confess that the whole failed in almost every acute case of tetanus which occurred. The three first have been administered in unlimited doses without effect; the cold bath is worse than useless." Dr. Elliotson, encouraged by the success which he had met with in the treatment of chorea and other neurotic affections by the subcarbonate of iron, was induced to exhibit this substance in three cases of tetanus, two of which recovered. (Med. Chir. Trans, vol. xv.) The doses were from ^ij to gss every two hours, administered in treacle. He is said to have stated in a lecture delivered at the London University, that a gentleman in the West Indies had been very successful with the same remedy since the publication of the above cases. (Med. Gaz. vol. xi.) If there be one class of remedies on which we should be inclined to put more reliance than on another, it is that of purgatives, both on account of the obstinate costiveness which attends the dis- ease, and because we have in daily practice such convincing proofs of their strong repulsive influ- ence on diseases of the cerebro-spinal centre. Hamilton and Abernethy, the chief advocates of this treatment, founded their expectations of its efficacy less upon the principle of counter-irritation than on their views as to the frequent origination of the disease in depraved conditions of the abdo- minal secretions. M'Grigor and Hennen consider purgatives to be some of the most hopeful of our remedies. The quantities required in some cases to produce any effect are all but incredible. In a case related by Dr. Briggs, (Edin. Med. and Surg. Journ. vol. v. p. 149,) the following quantities were administered: "The quantity of medicine taken from first to last is certainly very large, amounting, as far as can be ascertained, for the first twenty-five days, to calomel gr. 320, scam- mony gr. 340, gamboge gr. 126, powder of jalap §v. and ^viiss, infusion of senna, with tincture, lb.x2, colocynth pill giss and gr. 45; of which the greatest part was taken within the first week, namely, calomel 280, scammony 260, gamboge 110, jalap ^iij, gr. x., infusion lb. v|. The quan- tity given in little more than forty-eight hours, from the morning of the seventeenth, is perhaps unprecedented in this country, amounting to, scam- mony gr. 210, gamboge 89, jalap £]. and ^iv., infusion lb. ijj, calomel gr. 80, and all this with- out causing either sickness or griping, but, on the contrary, with the most decided benefit." Mr. Morgan, utterly dissatisfied with all the at- tempts that have hitherto been made towards the cure of the disease in its acute form, proposes to introduce into the system a substance which has the property of producing on the nervous system a condition directly opposite to that which is de- veloped in tetanus, namely, paralysis. In support of the propriety of this plan, he adduces some ex- periments on animals, in which the artificial teta- nus induced by inserting into the wound a poison called " chatic," and obtained from Java, was re- moved or abated by the counteraction of ticunas, a North American poison. (Op. cit.) We are not aware whether this able surgeon has followed up his experiments by trials on the human system, but we quite coincide with him in the opinion that it is incumbent on us to look about for new reme- dies, since the old ones have all failed. Upon this ground we are disposed to suggest a trial of strychnia; not that we have become followers of Hahnemann, but that it is a simple and undenia- ble fact that disorders are occasionally removed by remedies which have the power of producing simi- lar affections. It is quite unnecessary to explain this fact by an arbitrary principle, that an artificial irritation excludes a spontaneous irritation of the same kind. A more rational ground for an ex- pectation of benefit from homaeopathic medicines may be found in the consideration, that such agents prove by their occasional production of symptoms like those of the disease to be treated, that they act on the part which is the seat of that disease, and consequently that there is a probability that in their operation on that part, (whether it be in a sufficient degree to produce a similar disease or not,) they may effect a beneficial change. Oil of turpentine, for instance, having been known to produce a discharge of bloody urine, might be rationally administered in a case of spontaneous haematuri3, not because it has a tendency to pro- duce this disorder, but because that tendency shows it to have a specific action on the vessels from which the hemorrhage takes place. As to the dangers incurred in the experiment which we pro- pose, wc think it sufficient to say with an old writer " Satius est aliquid nonnulla fiducia, vel cum periculo facere, quam adempta spe certo pe- rire; et potentibus extremisque prsesidiis pugnare, 376 TETANUS —THROAT. (DISEASES OF THE) quam nihil agere." (Jason, de Morbis Cerebri, ex Valesio, cap. 21.) The application of blisters, moxas, the actual cautery to the spine, and a hundred other remedies and plans of treatment have been proposed, with an account of which we have not thought it worth while to burthen our pages. Tetanus, like cholera and other intractable disorders, has a host of alleged remedies, the very multitude of which is a proof of their inefficiency. [It has been affirmed, indeed, by Dr. Hartshorne, of Philadelphia,(2?c/ecfr'c Repository, Philad. 1819, and Med. Recorder, vol. 2,) and others, that bene- fit has resulted from the application of potassa along the spine, so as to inflame the surface. Dr. Hartshornc's mode of application is to tie a piece of sponge to a fork, and after dipping it in a solu- tion of the caustic in water, in the proportion of a drachm to an ounce, to apply it rapidly along the spine twice or thrice, if the patient can bear it.] Of the local treatment of the traumatic species we have nothing more to say, than that very little benefit appears to have been derived from the va- rious methods to which surgeons have resorted. Amputation of the injured limb, counter-irritation in the wound, division of the neighbouring nerve,* pressure by the tourniquet, stimulating applica- tions, &c, &c, have been found useful by some, and altogether inefficacious, if not prejudicial, by others. For more particular information upon these points we must refer to works on surgery. J. A. Symonds. THROAT, DISEASES OF THE. — The throat in the ordinary acceptation of the term in- cludes all that region which extends from the pos- terior opening of the mouth to about mid-way down the neck. In this region there are a number of parts, the integrity of which is essential to the func- tions of deglutition, the voice, and of respiration. The pharynx communicates with the mouth through the isthmus faucium, which is bounded above by the velum pendulum palati and uvula, on each side by the folds called pillars of the palate, between which are the tonsils, and beneath by the root of the tongue and epiglottis. The velum or soft palate is a compound mem- branous septum, composed of mucous membrane, loose cellular tissue, submucous glands, and muscular and fibrous membrane: it seems to per- form a valvular office in preventing the ascent of food and other ingesta, in the process of degluti- tion, to the upper part of the pharynx, and thus hindering the ingesta from passing into the posterior nares. The tonsils consist of a number of deep mucous follicles or crypts surrounded by and deposited iii cellular tissue, arranged in somewhat of a circular form, and situate on each side of the isthmus faucium between the pillars of the palate. They are largely supplied with blood from the pharyn- geal, palatine, and labial arteries, some of the ramifications of which are of great size ; they lie in the immediate vicinity of the internal and external carotid arteries. * A case in which this operation was beneficial may he found in the Dublin Journ. of Med. and L'hein. Sci- ence, vol. v. p. 311, extracted from the Calcutta Med. and Phys. Trans. The pillars of the palate bound the tonsils in front and behind : they are folds of mucous mem- brane containing muscular fasciculi: the anterior extending from the velum to the tongue surrounds the palatoglossus muscle; the posterior commenc- ing at the same point is lost upon the lateral part of the pharynx, and involves the palatopharyn- geus. The epiglottis is connected to the root or base of the tongue by three folds of mucous membrane, which pass off from the anterior surface of the former to the dorsum of the latter; it is a triangu- lar lamina of cartilage with curvilinear base, covered by mucous membrane, and tied below by a ligament prolonged from its apex to the angle of the thyroid cartilage; behind it is connected to the artenoid cartilages by folds of mucous mem- brane, which pass off from its lateral margins, the aryteno-epiglottidean folds.) These folds form the lateral boundaries of a triangular opening that leads into the larynx ; it is the false glottis so called in contradistinction to the true glottis or rima glottidis, which is bounded laterally by the chordae vocales. Below and behind the false glottis the pharynx communicates with the cesophagus. When the posterior wall of the pharynx is slit up, the following parts are brought into view pro- ceeding from below upwards—the posterior pait of the larynx, the glottis, the epiglottis and a small portion of the root of the tongue, the isthmus faucium, the velum, the posterior nares. We shall arrange the diseases of the throat according to the parts in which they are particu- larly seated. I. INFLAMMATION OF THE TilROAT. To the various forms of inflammation of the throat several names have been given by nosolo- gists. Hippocrates described them under the term paristhmiu, from napa and laBpbs, the literal mean- ing of which is morbus faueium, or disease of the throat. The Greek writers after Hippocrates em- ployed the terms cynanche, synanche, parucy- nanche, (from kvo>v, a dog, and ay^u, to suffocate, or strangle,) from the circumstance of dogs being , supposed to be subject to it. Latin writers have adopted the term angina, (from the Greek word ayx^, to strangle or suffocate,) while English authors have invented the name squinsy, squi- ! nancy, and quinsy. Dr. Mason Good proposed , to vary the Greek term to paristhmitis, in accord- ance with the terminology of the various forms ! of inflammatory diseases. 1. Aplitha Anginosa. — A species of sore j throat to which this name has been given is some- times prevalent in the autumn, when the season I is cold and damp. It is generally accompanied by slight feverish indisposition, the throat feels rough and painful, and on examining the fauces, the tonsils, velum, and uvula, are of a dark red colour, which extends along the margin of the tongue, the body and root of which is coated with a white fur. In a day or two after, small white specks or aphtha? form on the throat and tongue, and disappear in a few days, though in some in- stances they leave small superficial ulcerations in places where they have coalesced. The duration of this affection is various: it is generally short, . but occasionally successive crops of aphthce appear THROAT, (DISEASES OF THE) 377 and protract it for a week or two. It has been sometimes observed in persons attending those labouring under the more malignant forms of fever, small-pox, or scarlatina. It requires very little treatment; mild aperients, bland diet, cooling drinks, and saline medicines being generally suffi- cient to remove it. The mouth and throat may be frequently washed with a gargle composed of mel boracis and almond emulsion. 2. PHaryngitis.—Simple inflammation of the mucous membrane of the throat is a common disease in moist variable weather, and frequently epidemic in the spring. It is in general a mild disease, and troublesome principally from its lia- bility to recur from very trivial causes, such as exposure to cold or sudden variation of tempera- ture. The inflammation may be seated in the mucous membrane which covers the isthmus fau- cium, velum, and tonsils, [isthmitis,] or exclu- sively in the pharynx. When it occurs in the former situation, the symptoms are dryness of the throat, with frequent and painful attempts to swallow. If the inflammation extended to the Schneiderian membrane, there is, in addition, a sensation of dryness of the nostrils with frequent sneezing, succeeded by slight increase of the nasal secretion, which generally relieves these uncom- fortable feelirigs. If the patient cannot breathe through the nose, but is obliged to keep the mouth open during sleep, the mucus which is secreted by the inflamed membrane becomes dry and ad- herent, so that on awaking there is some difficulty in dislodging it. When the inflammation extends to the glottis and larynx, in addition to the other symptoms there is frequent cough with hoarse- ness. On examining the throat, the membrane cover- ing the velum, uvula, and tonsils, appears redder than natural and slightly swollen, and the tonsils are often covered with grey mucus, and sometimes with thin white concretions. This form of pharyngitis generally terminates in a very few days by spontaneous resolution or by mild treatment, though in severe cases some- times by suppuration, an abscess forming either in the velum or in the uvula : when it forms in the uvula, it is known by the increased size, while abscess of the velum is easily distinguished by the difference in the size and shape of the two halves, the one being depressed and convex, the other raised and of a concave or semilunar form. Besides, the sensation of a tumour or of fluctua- tion on the introduction of the finger will often indicate the existence of matter. This affection sometimes assumes a chronic form, commonly termed relaxed sore throat, which is troublesome from its being easily induced, as well as from the uneasiness in swallowing and feeling of dryness in the throat with which it is accompanied. When the inflammation is seated in the pos- terior pharynx, either in the superior or inferior part, the symptoms are very similar to those just described. It is to be distinguished chiefly by examination of the throat, when the upper and posterior surface of the pharanx opposite the superior cervical vertebra; appears red and injected, and covered with adherent mucus. In some cases, however, the membrane, instead of being covered Vol. IV. —48 2a* with mucus, becomes more dry than natural, and continues so while the inflammation lasts. This form of pharyngeal inflammation generally termi- nates in resolution, rarely in suppuration, though we have seen one case in which an abscess formed in the inferior part of the pharynx quite out of | sight, and destroyed the patient by its pressure on [ the glottis. Guersent mentions two similar cases, ' but in both the abscess burst and the patient was immediately relieved. The treatment of the milder forms of pharyn- j gitis is in general easily accomplished, the reme- dies which are commonly resorted to in common catarrh being in slight cases sufficient to remove it. When the inflammation is more considerable, and the throat consequently very painful, it is necessary to apply leeches under the jaw or be- | hind the ears, and to apply afterwards a large warm fomentation or an emollient poultice, which answers the double purpose of promoting the bleeding and of resolving the inflammation of the throat. The inhalation of the vapour arising from warm water to which a portion of vinegar is added also conduces much to the same end, and is preferable to the employment of gargles. The bowels are at the same time to be freely opened, and if the skin be warm, the ordinary saline dia- phoretic medicines are to be administered. If 1 these measures fail to remove the inflammation, or when a chronic form supervenes, a blister may be ; applied to the external fauces. [In the dusky inflammation, which indicates great hypersemia of the capillary vessels of the mucous membrane, perhaps the most effective agent, at all periods of the disease, is scarification with a lancet, which may be superficial if the in- flammation be confined to the mucous membrane, —deeper if the parts beneath be involved. The writer has found the advantage of this course in his own case, and has seen it successful when practised on others.] When an abscess forms in the velum or uvula, or in the posterior pharynx, it in general bursts j spontaneously ; if it do not, and more especially j if it be seated in the submucous cellular tissue of the posterior pharynx, it should be opened by the throat lancet. In some cases the abscess is situ- [ ated so low in the pharynx that it cannot be seen, as in the instance which occurred to us : under | such circumstances the danger of fatal conse- quences from pressure on the glottis may render | an opening into the larynx or trachea expedient. For some excellent practical remarks on abscess in the neighbourhood of the larynx, we refer the reader to Mr. Porter's valuable work on the Pa- thology of the Larynx and Trachea. A more severe form of pharyngeal inflamma- tion is that which is accompanied by the forma- tion of a false membrane, (angina membrana- cea.) In this affection, though the mucous mem- brane is intensely inflamed, it is evident that the membraniform exudation forms an essential con- stituent of the disease, and is not altogether the result of the intensity or duration of the antece- dent inflammation, since it has been generally found to be less under the control of bloodletting, but more successfully arrested by local stimulants or escharotics. This peculiar disease has been minutely inves- 378 THROAT, (DIS] tigated by Bretonneau, a physician at Tours, and subsequently by Guersent, physician to the Chil- dren's Hospital at Paris. It raged epidemically in 1818 and for three succeeding years, in Tours, where it first made its appearance among some troops who had recently returned from the island of Bourbon : in the beginning it assumed the character of scorbutic affection of the gums, and was treated with antiscorbutic remedies, but with- out the least benefit. The application of the hy- drochloric acid, however, at once removed the dis- ease. About the same time the angina maligna appeared at Tours—an affection which very few practitioners had ever witnessed in that situation. At the beginning of the epidemic, which attacked both children and adults, the death of the former was generally ascribed to croup, from the sudden- ness of the seizure and its being attended with the usual symptoms of that disease; in adults the fetor of the breath and the livid appearance of the throat, gave a strong suspicion that the disease was angina maligna. Bretonneau, however, as- cribed the fetor of the breath and gangrenous aspect of the fauces to the putrid condition of the false membranes, and not to gangrene of the af- fected structures; and conceiving that the redness of the mucous membrane without swelling or thickening of its tissue, accompanied by a con- crete membranous exudation, to be so remarkable as to deserve the name and character of a specified inflammation, he designated this phlegmasia by the term diphtherite, from Stinion, which lie ascribes to them. Paris, Phurmucologia, and Chapman, op. cit.| tent fevers." This power, he found, belongs to ipecacuanha, tartar emetic, muriate of ammonia, gentian root, chamomile flowers, and Peruvian bark. Indeed, when we reflect on the diversity of character and the number of the medicinal agents that produce tonic effects, it is evident that tone is the result of certain impressions on the vital tissues which may be communicated by many substances, and therefore that the hypothe- sis which refers it to any single principle cannot be maintained. Action of Tonics.—If a moderate dose of any tonic substance be taken into the stomach, its in- fluence, even upon the organ into which it is in- troduced, is scarcely perceptible; but on repeating the dose at short intervals, its power in controlling the functions, not only of the stomach itself, but those of the other vital organs of the body, be- comes gradually obvious; the appetite is improved, the powers of assimilation are augmented, the se- cretions altered, and a fresh energy and vigour infused into every part of the system. We pro- ceed to examine in what manner these effects are produced, first on the digestive organs, and after- wards on each of those systems in which we can trace the influence of the agents employed. 1. On the digestive organs.—When a vegeta- ble tonic is taken into the stomach, it is first par- tially digested, and the active matter is thus sepa- rated from the inert. This active part then exerts its influence upon the mucous membrane of the stomach, and the bundles of muscular fibres be- neath it suffer contraction : the same circumstance occurs through the whole length of the intestinal canal; the coats of the intestines become firmer and more resisting, whilst their cavity is contracted. The primary action, therefore, is upon the stomach and alimentary canal; but a secondary follows it upon the rest of the system. It is scarcely possi- ble to refer the extension of the tonic power to anything but nervous energy; although some of the metallic tonics are absorbed and carried into the circulation, and the vegetable tonics never produce their effects until their active principles are separated by the digestive function, and time is given for their absorption ; but admitting that they are carried into the circulation, still the im- pression which produces their tonic effect must be made on the nervous centres, and it is thus ex- tended over the entire system. If the stomach is labouring under disease, the action of tonics produces effects which require to be noticed. When the stomach is suffering from relaxation of its coats, a salutary effect follows the administration of tonics; the appetite is awakened, and chymincation is favoured. When simple irri- tation exists, tonics increase the evil: this is mani- fested by a red, dry tongue, and thirst, pain and fulness of the epigastrium, anxiety, and a strong desire for acidulous and cold fluids. If ulceration of the stomach exist, and this at the cardiac por- tion, little effect is produced by a tonic; but if it exist at the pylorus, or in the great curvature of the organ, the impression of the tonic is made evi- dent by a sensation of hea* and pain which cannot be mistaken. Thus, in cancer of the organ, if ulceration have commenced, tonics cause great uneasiness, morbid secretions, vomitings, heat, TONICS. 393 and severe lancinating pains. A knowledge of : influence; and they are supposed to act upon it there facts is highly important in a practical point through the medium of the nerves. Every muscle 0f view. \ is amply furnished with blood-vessels and nerves, As appetite and digestion are promoted by the ' both of motion and of sensation; the latter, it is operation of tonics on the stomach itself, it may appear singular that their frequent and long-con- tinued use is generally followed by a loss of tone; but such is really the case. 2. Upon the Circulating and Respiratory Or true, do not appear, " in invisibilem pulpam deli- quescere," as Blumenbach expresses himself, and then unite intimately with the muscular tissue; nevertheless any excitant, before it can produce a change in the condition of a muscle, must neces- gans. —Tonics act upon the heart through its sarily act at the same instant on the nerves of the sympathy with the stomach, and also by the ab sorption of the active principles of the substances employed, so that they can be directly applied to the moving centre and to the coats of the blood- vessels, and thus increase their muscular energy part; and the discoveries of Bellingeri and Sir Charles Bell have satisfactorily demonstrated that no motion can occur in the body without the medium of at least one set of nerves. But the change effected upon muscles by tonics does not After the administration of a full dose of a tonic ! augment their contractile power; and, although it medicine, the pulse is fuller and firmer, but the strengthens them, yet it does not render them current of the blood is not accelerated. The tonic j more agile : tonics, therefore, in reference to this strengthens the organs without precipitating their action. This influence of tonics is extended to the capillary system. In a diseased condition of the heart, however, the influence of tonics is hurt- ful, and extends to other organs. When hyper- trophy, for example, of the left ventricle of the heart is present, their employment causes cepha- lalgia, vertigo, ringing in the ears, and epistaxis, or congestions in the brain; when the right ven- tricle is the seat of this disease, the use of tonics is often followed by cough, oppressed breathing, and spitting of blood. In a healthy state of the lungs, no appreciable effect on those organs follows the employment of tonics ; but when labouring.under disease, the in- fluence of tonic substances on them is conspicuous. In an irritable condition of the lungs they excite cough, a sensation of heat in the chest, and a feel- ing of anxiety. In an inflammatory state either of the substance or the membranes of the lungs, the intensity of the symptoms is increased, the cough is augmented, and the expectoration sup- pressed. If tubercles be present, both bitters and astringents augment the cough, increase the gene- ral restlessness, and hurry on the fatal issue of the disease. On the other hand, when the lungs have system, render a man stronger or more capable of active exertion, but not more active. It is scarcely necessary to remark that the in- fluence of tonics on the muscular system is much modified by disease. 5. On the Nervous System. — On the nervous system tonics operate in two ways:—1. by their direct and topical influence on the nerves of the stomach, which convey the impressions they re- ceive to the brain and spinal cord, and through them to every part of the body : 2. by their active principles being taken into the blood, and carried to the nervous centres. The impressions made in either of these cases do not display any obvious effects on the brain in a healthy condition of the body ; but in the opposite state their effects are very striking. Thus in an irritable condition of the encephalon, tonics produce symptoms approach- ing to those of maniacal excitement, and diffuse over the body an augmented susceptibility to ex- ternal impressions. If the medullary portion of the spinal cord is morbidly excitable, tonics are apt to induce spasmodic movements ; if the theca be inflamed, all the symptoms are augmented; heat, tension, and tenderness are experienced along the course of the spine ; and the diseased suffered from previous severe disease, but all ex- condition of the part is confirmed. citement is over, tonics lessen the force and fre- quency of the cough and promote expectoration. 3. Upon the Secerning System. — It is chiefly upon the renal and subcutaneous glands that tonics exert any influence ; but in adding strength The effects of tonics upon the general system are never rapidly displayed ; but after they have been taken for some time, their influence is obvi- ous by the increased force of the circulation, the greater energy of the digestive organs, the im- to those organs, they do not increase their secret- provement of the secretions, the abatement of ing powers : the action of the glands is maintained nervous susceptibility, and the augmented power in that state which they preserve in health. Tonics in particular which is communicated to the mus- produce no marked action on the urinary organs cular system. The effect of a tonic, when admi- in a state of health, but in disease they invigorate nistered under proper circumstances, and when it the kidneys and secure their ordinary operation. In an irritable state of these organs, tonics add to the mischief; but in a leucophlegmatic condition, tonics increase the urinary discharge ; they enter the circulation and augment the vitality of the kidneys. They also increase the energy of the cutaneous capillaries, and consequently are indi- cated in cases of great debility accompanied with profuse sweating. In some conditions of the skin, they suppress the perspiratory function, as in some fevers, in which their administration is rapidly fol- lowed by a dry burning skin. 4. On the Muscular System. — It is upon the muscular system that tonics chiefly display their Vol. IV. —50 operates favourably, is, in fact, to place the system in that state which characterizes health ; and from the mode by which it produces this effect, the de- scription of diseases in which tonics are indicated is sufficiently obvious : they are evidently those of depressed power. The chief utility of tonics as medicinal agents is in convalescence, when there is a state of great debility after attacks of acute diseases; but in this condition, the power of tonics is required to be aided by that of moderate excitants ; and a com- bination of bitters and aromatics is found to be more useful than simple tonics. The view which has been taken of the opera* 394 TONICS. tion of this class of medicines enables us to arrange the agents belonging to it into two distinct sub-classes, material and immaterial; and these again into four orders, namely,—1. material to- nics, which produce their effects by a direct or primary action on the stomach ; 2. material tonics, which operate through the medium of the blood ; 3. material tonics, which influence the body solely through the nerves; 4. immaterial tonics, which operate through the mind. 1. The organic products which belong to the first of the above orders are alkaloids, resinoids, bitter extractive, tannic and gallic acids, and vola- tile oil. a. The alkaloids are the active principles of the tonic barks ; the first which we shall notice is, a. Cinchonia, the active principle of pale cin- chona bark, cinchona lancifolia, and that also of Angustura bark, cusparia febrifuga. In the first of these barks it is combined with kinic, in the second with igasaurie acid. It can be readily separated from either; but on account of its inso- lubility in water, one part requiring two thousand five hundred parts of that fluid at 212° Fahr. for its solution, it is never prescribed except in com- bination with an acid, and the sulphuric has been found the best adapted for this purpose. It is un- necessary to describe, in this place, the method of procuring cinchonia in a pure state: it is a white transparent salt, in needleform crystals unalterable in the air, displaying an alkaline reaction, soluble in alcohol and volatile oils, but only slightly solu- ble in ether; inodorous, and bitter to the taste. It is a compound of carbon, hydrogen, oxygen, and nitrogen.* The kinic and the igasaurie acids, with which it is combined in these barks, have no influence on the animal economy, but they render the cinchonia soluble, and enable this tonic prin- ciple of the barks to be taken up both by water and alcohol. There is no reason why the kinate or the igasaurate should not be employed in their separate state; but the sulphate is more easily procured, and answers every indication that a tonic can be expected to fulfil. The sulphate of cinchona is formed by the direct combination of the alkaloid and sulphuric acid. It crystallizes in short, lamellar, truncated prisms, soluble in fifty-four parts of water at 65° Fahr. and six and a half parts of alcohol of sp. gr. 817. With an additional quantity of acid a bisulphate is prepared, which crystallizes in acicu- lar octohedral prisms, soluble in half their weight of cold water, and in an equal weight of alco- hol.f The pale bark, of which cinchonia is the active principle, although designated in the Pharmaco- poeias as the bark of cinchona lancifolia, is pro- bably obtained from several other species of cin- chona.}: That usually preferred in this country is the bark of Lima, which appears to consist *The proportions are 20 equiv. of carbon=122.4-f-12 hydrogen=12+l nitrogen=14,l5-r-l oxygen=-8, making the equivalent of the salt 156.55. t The sulphate consists of 156.5.5 parts or 1 equivalent of cinchonia-r-41) 1 or 1 of sulphuric aciil-f3f> or 4 of wa- ter, making the equivalent of the salt -242.55; the com- position of the bisulphate is 67.241 of cinchonia-j-17.241 of acid+15.518 of water,=lu0. \ Cinchona nitida, C. hirsuta, C. scrobiculata of Hum- boldt, and C. glandulifera of Ruiz and Pavon also yield uale baric. chiefly of the bark of the cinchona glandulifera of Ruiz and Pavon. [The finest specimen is the Crown or Loxa- bark, or Crownbark of Loxa of commerce, which is referred by the London College to Cinchona Lancifolia. It is the Cinchona Coronx of the Edinburgh Pharmacopoeia, and appears to be the bark of Cinchona Condaminea. Under the name Loxa Bark, however, in the United States, are included all the pale barks (Wood & Bache, Dis. pensatory of the United States.)] Although it is almost inodorous in substance, its infusion and decoction are agreeably aromatic, and moderately bitter and austere, but not disa- greeable, to the taste. All infusions and decoc- tions of astringent vegetables render its infusion, decoction, and tincture turbid, owing to the de- composition of the kinate of cinchona, and the combination of its alkaline base with tannin, (tan- nic acid,) which produces an insoluble, inert, tan- nate of cinchonia. On this account not only are such vegetable infusions and decoctions incompa- tible in prescriptions with the preparations of pale bark, but infusion of galls is employed as a test of the goodness of the bark; the quantity of cin- chonia being in the direct ratio of the abundance of the precipitate thrown down in the decoction by infusion of galls. In prescribing the fluid pre- parations of this species of cinchona bark, it should also be remembered that precipitates are produced in them by tartar-emetic, the sulphates of iron and of zinc, the acetates of lead, hydrio- date of iron, the carbonates of the alkalies, and the tinctures and salts of opium; but these pre- cipitates do not render the cinchonia inert as the infusion of galls does, and by many of them it is not precipitated. With muriate of baryta no ob- vious change takes place, although that salt and also the kinate of cinchonia are decomposed; but both the muriate and the kinate of cinchonia which result are soluble salts. When sulphuric acid is added to the infusion or decoction of pale cinchona, the kinate of cinchonia is changed into the sulphate, and the alkaloid in this state being more completely separated from the other compo- nents of the bark, it is advisable to acidulate with this acid the water to be employed for making these preparations. The simple tincture of bark is an alcoholic solution of the kinate, tannin, and colouring matter, and, consequently, it is a useful preparation in cases in which alcohol is admissi- ble : the compound tincture is more stimulant than the simple, on account of the aromatics which it contains ; but the ammoniated tincture is at least of doubtful efficacy, as far as concerns the cincho- nia, as much of this salt is precipitated by the volatile alkali. The best preparation of this bark is the resinous extract of the London College; it consists of the kinate in the same combination as in the simple tincture, without the alcohol, and in a more concentrated state. The Angustura or cusparia bark, besides cin- chonia in combination with igasaurie acid,§ as an igasaurate, contains an acrid volatile oleoresin, gum, extractive and muriate of ammonia, and traces of brucia: thence it is more excitant than §This acid is characterized chiefly by affording a pea- greeu precipitate with ammoniated sulphate of copper; it exerts no obvious influence on the animal system. TONICS. 395 pale bark, in whatever form it is prescribed.* Owing to the acid which it contains, and the ab- sence of tannic and gallic acids, the infusion does not precipitate tartar-emetic and gelatine; whilst with nitric acid a precipitate of a lemon yellow colour is slowly produced, but it is affected by all the other substances that precipitate the prepara- tion of pale cinchona bark. The dose of the cusparia bark in the form of powder is from gr. x. to Jss. Quinia, another alkaloid, the active principle of the yellow cinchona bark [Calisagabark], the cinchona cordifolia of the Pharmacopoeias [of London*; but the precise species that yields it is unascertained,] differs from cinchonia in not being cry6talhzable when uncombined with an acid, and very soluble in ether. In other respects it resembles cinchonia in its chemical properties,]- and, like it, combines with two distinct proportions of sulphuric acid, forming a sulphate and a bisulphate.f The former salt is procured in pure white silky needleform crystals, which effloresce in the air, and require seventy-four parts of water at 60° Fahr., and thirty parts of boilingwater for their solution. The bisulphate crystallizes in qua- drangular compressed prisms, generally truncated, soluble in eleven parts of water at 60°, and in nearly the same proportion in diluted spirit, but scarcely soluble in strong alcohol. On account of its greater solubility, the bisulphate is prefera- ule in composition to the neutral sulphate, which is generally imperfectly converted into it by acidu- lating the mixture containing it with diluted | sulphuric acid. These sulphates are precipitated from their aqueous solutions by the infusions of all astringent vegetables and lime-water: with acetate of lead, an insoluble sulphate of lead is thrown down, and an acetate of quinia remains in solution, which is a less irritating preparation than the sulphate, and may, consequently, often supersede it with advantage. No change is pro- duced on either of the sulphates by the salts, a practical advantage of considerable importance. The yellow cinchona bark is more bitter, but less austere to the taste than the pale bark; be- sides an acidulous kinate of quinia, it contains a small proportion of kinate of cinchonia, kinate of lime, a fatty matter, tannin, a red insoluble colour- ing matter which precipitates in the decoction as * It is of importance to distinguish the true from what is denominated false cusparia bark, which is supposed to be the bark of some species of strychnos, arid exerts a poisonous influence on the stomach. It is distinguished j by its solidity and weight being greater than that of the true cusparia ; by the epidermis being covered with dis- tinct, rust-coloured, warty elevations; by impressing a disgusting durable bitter on the palate instead of the I aromatic bitter and slight acrimony of true cusparia ; { and particularly by the infusion in water acidulated with muriatic acid precipitating Prussian blue when I tested with ferrocyanate of potassa, whilst none is formed in the acidulated infusion of the true bark ; and, finally, by nitric acid striking a deeper crimson colour than with the true bark, owing to the presence of ; brucia. This bark is often mixed with the true. I t The components of quinia are 20 equiv. of carbon= l 122.4-f 12 liydrogen=12-f-l nitrogen=14.15-f-2 oxygen— 16, making the equivalent of the salt 164.55. {The composition of these sulphates is— Neutral sulphate. Bisulphate. Quinia...................80.9................63.5 Sulphuric acid............10 0................19.1 Water.................... 9.1................17.4 100.0 100.0 it cools, a yellow colouring matter, and fecula. The same substances which affect the infusion and decoction of pale bark also cause precipitates in those of the yellow, and are consequently in- compatible in prescriptions with its preparations. In the red bark, the cinchona oblongifolia of the Pharmacopoeias [of London and Dublin ; but the botanical origin appears to be unknown,] both the kinates which we have described are contained in almost equal proportions. It is more acidulous than either the pale or the yellow bark, and it seems to contain more tannin, and probably some free gallic acid, as its secretion strikes a deep blue- black with persulphate of iron. Its astringency and stimulant properties exceed those of the two other officinal species of cinchona bark. These alkaloids, whether in a separate state or in combination in the barks which yield them, are powerful tonics and antiperiodics. When they are received into the stomach, they operate topi- cally upon its tissue, causing often a slight sensa- tion of weight and uneasiness in the organ, dry- ness in the mouth, and an evident excitement in every part of the system; effects which differ from those caused by stimulants only in degree and in their permanency. It is to this sustained influence that we must ascribe their power of changing diseased into healthy action ; and this does not seem to depend so much on the absorp- tion of the alkaloids as on the impression which they make on the digestive organs being commu- nicated by nervous sympathy to the rest of the system, and in part on the more perfect chymifi- cation which is the necessary result of the invi- gorated state of the stomach. In prescribing, therefore, either the cinchona or the cusparia bark, or the salts of their alkaloids, the topical effects which they produce point out the necessity of directing our attention to the state of the stomach and intestines before prescribing them, and of not administering them internally when these impor- tant organs are in a morbidly irritable condition. | They are not, however, contraindicated on this account when they are introduced into the system either, according to M. Pointe's method, by rub- bing them in fine powder upon the gums, until the whole is absorbed, cautioning the patient not to swallow the saliva; or, as Signor Broglia dal Perseco has proposed, by sprinkling them in fine powder upon blistered surfaces. The writer of this article has seen the first of these methods followed by the most beneficial results. With respect to the question at one time much agitated respecting the period of fever in which cinchona bark ought to be prescribed, there still exists much diversity of opinion; but, notwith- standing the authority of Dr. Clarke of Newcastle, and Dr. Heberden, few practitioners in the present day venture to prescribe it at every period of the disease, or until a decided intermittent character be obvious, under which circumstances these barks and their alkaloids seldom fail to prove service- able : indeed, this may be regarded as a general rule to guide their administration,—that whenever diseases assume an intermittent type, whatever may be their denomination, whether gout, rheu- matism, eruptive fevers, catarrhs, or even phthisis, bark and its preparations seldom fail to be useful, and rarely or never are productive of injury. 396 TONICS. Even in local affections this rule holds good. Sir B. Brodie was consulted by a gentleman who had a spasmodic stricture of the urethra, which recur- red in paroxysms every alternate night, and con- tinued until five or six o'clock in the morning. The disease was cured by administering large doses of sulphate of quinia, at short intervals. In neuralgic attacks, also, which assume an inter- mittent type, it is equally beneficial ; and in rheumatic inflammation of the sclerotic coat of the eye it may be almost regarded in the light of a specific. Circumstances nevertheless interfere to modify the influence of these barks and their preparations. When hepatic symptoms are pre- sent, they prove invariably hurtful; and, indeed, every state of the habit indicating inflammatory action should be subdued before they can be properly prescribed. Their efficacy is also modi- fied by local and topographical circumstances. In India, says Mr. Annesley, although the bark is the grand remedy in fevers during the cold season, it fails in the rainy season, during which calomel and antimony only prove useful. With respect to the doses in intermittent affections, some physi- cians of deserved reputation recommend large doses;—namely, ^iii. of the powder of bark, or gr. x. of the sulphate of cinchonia or quinia, either immediately before or after the paroxysm ; but we have found that more certain henefit has followed the administration of doses of gr. ii. re- peated every hour or every second hour during the interval than of large doses at long intervals. Besides the forms of administering the alka- loids which have been described, they have been administered per anum, and have cured agues, but in this form they are apt to cause violent colic. The resinoids differ from the tonic alkaloids in their chemical properties, and have not equal powers as tonic agents, although their influence is still considerable. The most energetic of this class is undoubtedly salicin, the active principle of the bark of the salix alba, and of some other barks in the same natural family of plants. It is procured in white acicular prismatic crystals, ex- tremely bitter, and soluble in a moderate degree in water and alcohol at 60° ; but not at all in ether or volatile oils. In its ultimate components it differs from cinchonia and quinia in containing no nitrogen.* It forms precipitates with infusions of astringent vegetables, acetate of lead, and tartar- emetic. The bark from which it is chiefly pro- cured, that of the white willow, was introduced to the notice of the profession as an antiperiodic by Dr. Stone; but, as it required to be administered in very large doses, it never became a popular re- medy. Salicin has set aside this objection : it operates in the same doses as the cinchonic alka- loids, and being much cheaper than them, it is likely to be soon very generally employed. Baths made with a decoction of willow bark are em- ployed, on the continent, in weakness of the lower extremities in infants. The tincture is the best preparation of the bark ; but the introduction of salicin has nearly superseded the use of the bark in any form. ♦The components of salicina are 2 equiv. of carbon =12.24+2 hydrogen=2+l oxygen=8, making the equi- valent of the salt 22.24. Piperina, another resinoid, has been still more lauded as an antiperiodic than salicina. It is ob- tained from black pepper, which has long been a popular remedy in intermittents, and was re- garded as an alkaloid by its discoverer,]- and others, until M. Pelletier demonstrated the fallacy of this opinion. It is a crystalline body; and when pure, its crystal is a flattish quadrilateral prism, with two parallel large and two small sides, terminated by an inclined plain, of a pale yellow colour and semitransparent; insoluble in cold water, and scarcely soluble in hot; soluble in alcohol and acetic acid. Piperina is seldom al< together free from a pungent, very acrid "fixed oil, with which it exists in combination in the pepper; thence its tonic powers are always combined with an excitant quality which necessarily modifies their influence, and must regulate its administra- tion. This oil gives a pungent taste to the piper- ina, which in its pure state is insipid. The less pure it is, the more its acrid qualities are felt in the stomach and the intestinal canal: it causes great heat in the epigastric region, purges with colic, and leaves an uneasy sensation in the lower bowels, which continues for many days. These symptoms are due to the topical impression of the acrid oil contained in the piperina on the gastric tissue, as they are not experienced when the resi- noid is quite pure ; and to this oil, also, may be attributed the tingling sensation and eruption of small pustules which sometimes accompany the treatment of intermittents by piperina. It is by no means yet ascertained how much of the in- fluence of the resinoid as an antiperiodic is due to this oil. As it exists in chamomile flowers, in which it has been discovered by the author of this article, it is also combined with a fixed acrid oil distinct from the volatile oil to which the aroma of the plant is due. Long pepper contains less of this oil, and although it also operates as an antiperiodic, its influence is less energetic. These remarks suggest the question—Is the antiperiodic influence that of tone ? In reply, it must be admitted that no simple tonic, wholly or nearly devoid of stimulant power, cures intermit- tents ; and it is well known that perturbing powers of an immaterial kind, powerful passions of the mind, violent exercise, and such like; and also strong diffusible excitants, such as alcohol, opium, and ether, applied to the system at the moment of the accession of the rigor, have not only the power of checking a paroxysm, but even of com- pletely breaking the catenation of morbid actions which constitute the disease, and consequently of removing it. It is true that a simple tonic ope- rating for a long time steadily on the system may gradually subdue ague, but the effect is slow and progressive : on the other hand, the sudden bene- ficial influence of the excitant is seldom perma- nent ; and thence we may conclude that although both tonics and excitants may be in strictness re- garded as antiperiodic, yet that it is the combina- tion of the two on which we must chiefly*rely; and, consequently, if pure piperina be a simple tonic, it is less to be depended upon as a remedy for ague than when it contains some portion of the t M. Oerstadt, of Copenhagen. It consists of 80.M parts of carbon+8.13 of nydrogen+10.92 of oxygen in 100 parts. TONICS. 397 acrid fixed oil with which nature has combined it' in the vegetable productions from which it is ob- tained. The dose of pure piperina is from four to six grains, but in its impure state it is seldom ne- cessary to increase it beyond three or four grains, and then its acrimony should be sheathed by com- bining it with some bland demulcent or simple bitter extract. In prescribing it, its insolubility in aqueous fluids must always be kept in view; and this is one disadvantage attending its use, as in the form of pill, its primary effect being exerted on one portion of the stomach, causes very uneasy sensations in the gastric region, which are not experienced from the salts of cinchonia, quinia, or salicina. [Cornus Florida was at one time stated to con- tain a peculiar principle, to which the name Cor- nine was given ; but if such exist, it is not used. Liriodendron, Hippocastanum, Phloridzina, Ce- trarina, and Narcotina, have also been used as antiperiodics. (See the writer's New Remedies, 4th edit. Philad. 1843.)] Gentian, chironia, centaurium, lesser centaury, chirayita, and calumba, perhaps owe their tonic influence to principles closely resembling the resi- noids, and consequently the above remarks are applicable to them. They can scarcely be regarded as antiperiodics, but their tonic influence is un- doubted; and as simple corroborants, in conva- lescence from acute diseases, their freedom from irritant properties renders them more generally applicable than the antiperiodic tonics. The ad- dition of an aromatic, when indicated, is always readily obtained by combining them with volatile oils in the form of oleo-saccharum, the doses of which can always be apportioned to the degree of stimulus required. Bitter extractive, which is probably a compound of various vegetable products, exerts also a tonic influence on the diseased frame. We find it va- riously combined with other principles in Iceland liverwort, quassia, and simaruba barks, which have all been successfully employed in diseases either characterized by defective tone or debility, the se- quel of acute affections which have exhausted the powers of the habit. When a simple bitter is indicated, quassia will seldom disappoint the expectations of the practi- tioner, and it has the advantage of undergoing no chemical change when its infusion is combined with the salts of iron. It is particularly indicated in cases of dyspepsia connected with much irri- tability of stomach, in which, at the same time that it is necessary to allay this, the tone of the organ must be improved. In such cases quassia is advantageously combined, either with pure alka- lies or with hydrocyanic acid. Thus combined, it fortifies the tissue, and supplies energy to the digestive organs without accelerating the pulse, or causing any increase of the animal temperature. Bitter extractive is the tonic principle in many vegetable bodies. It is generally found in combi- nation with gallic acid, tannin, and volatile oil, which, although when separated, or the principal components of the vegetable body, cannot be strictly regarded as tonics, yet when thus united with bitter extractive, greatly aid its tonic power. It is that solid, transparent residue which remains in combination with other principles, when a vege- 2i table infusion is slowly evaporated, and which is oxidized, and rendered insoluble in water, when the solution containing it is hmg boiled in contact I with the air,—an effect which explains why long ! decoction of some medicinal barks renders them ! inert; why extracts, slowly prepared even in a j water bath, are seldom active medicines, or are at least much inferior to those prepared in vacuo. It is contained chiefly in roots, barks, and leaves; is j inodorous, and varies in taste, according to the 1 nature of the other components with which it is combined in different plants, for it is never ob- tained in a state of perfect purity. : Bitter extractive is contained in combination with a resinoid, which has been termed calumbina, in the calumba root. The aqueous infusion of i this root strikes a beautiful blue with tincture of | iodine ;* is precipitated by infusion of galls, yel- low cinchona bark, acetate of lead, bichloride of mercury, and lime-water ; but not by muriate of baryta, sulphate of iron, nitrate of silver, nor tar- trate of antimony and potassa. The new crys- tallized principle, calumbina, is procured from calumba by digesting the powdered root in ether, filtering, and evaporating. It possesses in an emi- nent degree the bitter taste of the root. Dr. Duncan supposed that calumba root contains cinchonia, and certainly the action of re-agents on its aqueous decoction might seem to confirm his opinion ; but the examination of the root, by M. Planche and M. Guibourt, has not detected this principle in calumba. The central part should be separated before making an infusion or decoction of the root. As calumba possesses no astringency, and is little stimulant, it is perhaps the best tonic in phthisical cases. It has also a considerable power in allaying the irritability of stomach accompanying pregnancy and dyspepsia, | and, occasionally, dentition. Dr. Denman recom- mended it in the low stage of puerperal fever ; and, as a tonic, in combination with rhubarb and sulphate of potassa, it is extremely useful in the mesenteric affections of infancy and childhood. Calumba root is one of a few vegetable medicines ( which should be given in the form of tincture, the alcohol taking up the active principles only of the root. The dose of the tincture is from f.^i to f.giii, and even more if the patient have been accustomed to the use of ardent spirits. The root of avens, gei urbani radix, also owes its properties to bitter extractive. It has been little employed as a tonic in this country ; but on the continent it is much used in intermittents, and in convalescence from acute diseases. It is also regarded as a useful corroborant in chronic diarrhoea and in scurvy. Extractive is developed in Iceland liverwort, cetraria Islundica, by muriate of tin; gum by subacetate of lead ; and fecula by the tincture of iodine. The tonic powers of Iceland lichen cer- tainly depend on the bitter principle; and there- . fore, when it is employed as a tonic in the latter * This distinguishes it from a false, calumba lately in- troduced, which is further known by its white colour, lighter texture, and its taste, which is at first sweetish, and not half so bitter as that of the true calumba. Its infusion also reddens the tincture of litmus; caustic potassa disengages ammonia from it; salts of iron pre- cipitate its infusion black; and ether, digested on it, acquires a bright yellow colour; none of which effects are presented by true calumba. TONICS, stage of phthisis, the bitter should not be wholly removed. Even when it is to be employed as nutriment, there is too much anxiety to remove the bitter, a small portion of which is requisite for aiding the digestion of the fecula. But, as the bitter is very nauseous to many palates, a part of it may be removed by boiling the lichen twice, and adding to the first boiling a small quantity of any alkaline carbonate. The addition of five or six minims of diluted sulphuric acid, and f.^i of syrup of white poppies, to f.^iss of the decoction, affords an excellent tonic in phthisis, and in cases of great emaciation from acute disease. In cases of chlorosis and imperfect menstruation, the de- coction may be advantageously combined with sulphate or muriate of iron, as in neither case is any precipitate produced. Marsh trejbil, menyanthis trifoliatx folia, after losing 75 parts in 100 of its weight in drying, consists chiefly of bitter extractive, and a peculiar substance approaching to the character of animal matter. The infusion strikes a deep black with persulphate of iron, showing the presence of gallic acid ; throws down a copious precipitate with alum and muriate of tin ; and also precipi- tates infusion of yellow cinchona bark. The extractive is rendered insoluble by solution of chlorine. Menyanthes acts powerfully on the stomach, and in an irritable state of that organ produces a deleterious impression ; it is taken into the circu- lation and stimulates the capillaries : nevertheless it is an admirable tonic, and would be much prized if it were less common. In large doses the infu- sion excites vomiting, and, under certain condi- tions of the body, purges or acts as a diuretic, as the surface is more or less exposed. It checks intermittents, and is peculiarly useful in rheuma- tism when it takes on an intermittent character. It was formerly much prized as an emmenagogue. On account of its nauseating properties, it is use- ful to combine it with aromatics. Uva ursi was recommended by Dr. Bourne in phthisis pulmonalis; but the remedy has not sue- \ ceeded in the hands of other practitioners. He combined ten grains of the powder of the leaves of the plant with fifteen grains of cinchona bark ■ and half a grain of opium, and gave this mixture three times a day. The effect of this mixture was to lower the pulse without adding to its force : it palliated the symptoms, and, in some cases, ap- pears to have effected a cure. No adjunct to bitter extractive aids its tonic in- fluence so effectually as volatile oil, and this com- bination is found in cascarilla bark, calamus aro- maticus, and myrrh. The first, besides the oil and bitter extractive, contains resin and gallic acid, possesses antiperiodic powers, and has been sub- stituted for cinchona bark in the treatment of re- mittent and intermittent fevers; but its influence in these diseases has been greatly overrated. As an aromatic it aids the powers of the pale cin- chona bark, and those of the salts of cinchonia and quinia; but its infusion forms precipitates with infusion of the yellow cinchona bark, and is consequently incompatible with it. Neither can it be prescribed with sulphate of iron, the salts of lead, or lime-water. It is useful in all cases in which a combination of a tonic and aromatic is indicated, as in flatulent colic, the latter stages of dysentery, and old asthmatic affections; and is peculiarly suited to cases of gangrenous thrush in infants, and in that state of languor and ema- ciation, accompanied with tumid tense abdomen, which depends on obstruction of the mesenteric glands. It is contra-indicated, however, when there is the least tendency to inflammatory action, and it has been accused of producing a tendency to haemorrhoids. The virtues of the acorus cala- mus, or calamus aromaticus as it is usually termed, closely resemble those of cascarilla, and even ex- ceed them in antiperiodic powers. The writer of this article has frequently seen both cinchona bark and sulphate of quinia, after failing to cure ague succeed in rapidly removing the disease when conjoined with calamus aromaticus. The volatile oil, which is now procured in a separate state, may be used with advantage instead of the powder or infusion of the rhizome, in the form of an oleo- saccharum ; and we cannot avoid remarking here the propriety of employing the volatile oils, in this form, in combination with the alkaloids and tonic metallic salts instead of the substances which yield them, as the latter often contain matters which decompose the salts and render them inert. If sulphate of quinia is prescribed in combination with the pulvus aromaticus of the Pharmacopoeia, the salt is decomposed and an inert tannate of quinia formed; but no such effect follows the combination of this salt with the volatile oils of the various aromatics composing the powder. Myrrh, which is now known to be the product of the balsamodendron myrrha, is a compound of volatile oil, resin, and gum. It is a stimulant tonic, well adapted to cases in which the powers of the constitution have been worn down by chronic disease: as, for example, humid asthma and old obstinate catarrhs, as it stops the progress of that exhaustion which accompanies profuse expectoration: on this account, also, its watery solution, in combination with nitrate of potassa, camphor, foxglove, and opium, is often prescribed in phthisis ; but it is only in the entire state that it can, in any way, prove beneficial in that intract- able disease. It proves useful in chlorosis, and in defective action of the uterine system in pale leu- cophlegmatic girls, when combined with prepa- rations of iron, particularly the ioduret of that metal; and added to oxide of zinc, its utility in a peculiar cough which occasionally accompanies pregnancy, of which the tendency is to induce abortion, is well ascertained. The inorganic substances which operate as tonics are metallic oxides, arsenious acid, and some metallic salts. With regard to the first of these preparations, it may be remarked that, when oxygen is com- bined in one definite proportion with a metal, the oxide is soluble in the animal fluids, and either enters the circulation, and is there decomposed, or exerts a primary tonic influence on the stomach. It is those only of the latter description which we have now to notice. Lime in its solution in water as lime-water,has generally been regarded as a moderate tonic of this kind; but its influence on the nerves of the stomach is rather that of a sedative than a tonic, allaying the irritability of the organ, and thereby TONICS. 399 favouring the secretion of a more healthy gastric juice, and consequently a more perfect chymifica- tion. It is only on this account that it can prove beneficial in dyspepsia, as its antacid properties are too trifling to be beneficial as a chemical remedy. Under any circumstances it is of little value. Oxide of zinc, although it has not fully realized all that was anticipated by the distin- guished physician who introduced it into practice, is a tonic of much value. In the decline of dis- eases of a spasmodic character, it has been found extremely beneficial; as, for example, in hooping- cough, when the cough is kept up by custom acting on a weakened, irritable frame of body. The most useful form of prescribing it is in com- bination with the pure alkalies, in an excess of which it is soluble. In this form it is especially indicated in that weakened condition of the diges- tive organs which induces psoriasis and some other cutaneous eruptions; the alkali allays the irrita- bility of the stomach, whilst the oxide of zinc re- stores its tone. It is only the protoxide of iron that possesses active properties as a tonic ; and this forms one portion of the scales from the anvil. Its acron is slow, and, therefore, it is only adapted for those cases of general debility in which a per- manent rather than a rapid effect is required ; its efficacy is much increased by its meeting with acid in the stomach, so as to aid its solution and consequent absorption into the blood. The dose is from gr. v. to gss; and it is known to be in active operation by the black colour of the alvine discharges. Arsenious acid exerts a most powerful antipe- riodic influence in all affections of an intermittent character; but there are objections to its employ- ment in this form, which would have altogether thrown it into disuse, had Dr. Fowler not sug- gested the combination of it with potassa, so as to form an arsenite, in the liquor arsenicalis, the ar- senical solution of the pharmacopoeias. In this preparation there is scarcely a sufficient quantity of potassa to saturate the whole of the arsenious acid. Each fluiddrachm of the solution contains a grain of the arsenite, or half a grain of arsenious acid ; consequently, the dose of eight minims, that generally commenced with, contains nearly l-16th of a grain. In this dose, gradually increased, if necessary, to forty or fifty minims, the arsenical solution has been advantageously administered, as a tonic, for the cure of intermittents. With re- spect to its mode of acting, it seems to exert a primary stimulant influence on the stomach, as- sisting the digestive powers of that viscus; and, both by that effect and also by the extension of its tonic influence to the whole system, to remove the debility which favours the repetition of the intermittent paroxysm. The diaphoretic power may also aid its curative influence in intermit- tents ; as it is well known that many substances j which have no other power than that of increas- J ing perspiration, and consequently diffusing the blood equally over the system, cure agues. The arsenical solution has been given, with j benefit, in those cases of chronic rheumatism j which assume an intermittent type: it has also proved occasionally useful in symptomatic epi- lepsy, chorea, and other spasmodic affections, as well as the tic douloureux and cephalalgia. Its ! efficacy in lepra and some other cutaneous dis- eases, when given in conjunction with large doses of the pure alkalies with conium, is well established. In the treatment of cancer, arsenious acid has been both internally administered and externally applied ; but whilst the benefit to be expected from its administration is doubtful, its deleterious agency has been manifested in many cases, even where its use has been confined to the surface. When applied to an external wound, it sometimes causes almost immediate inflammation of the sto- mach, accompanied with violent vomiting and purging; and death is as likely to ensue in such cases as if it were internally administered. Sulphate of zinc as a tonic exerts a primary influence on the stomach, but a secondary, also, on the general system. It is supposed to operate with less excitement than the other metallic salts, and to be well adapted for cases of phthisis and the humid asthma of old men; in both of which disorders, besides supporting the general tone of the system, it is supposed to diminish both the quantity and the acrimony of the expectorated matter. The acetate of zinc operates nearly in the same manner, but is less frequently employed as an internal remedy. 1 Sulphate of copper is a powerful but hazardous tonic. It has been given in doses of a quarter to half a grain in spasmodic affections, twice or three times a day. In chronic diarrhoea, in similar doses, it has been found to check the purging, and increase tone. It was resorted to in the attack of Asiatic cholera which visited our island; but, al- : though it seemed to aid in lessening the discharge, the benefit was not such as would recommend its general employment. It seems to influence chiefly the nerves of the intestines, and thus, by increas- ing the tone of the bowel, to diminish the excre- tion of the exhalants. The dose of this sulphate, as a tonic, may be gradually increased to two grains, which ought not to be exceeded. The subacetate possesses the same properties in every ! respect, but it is even more apt to cause poisonous symptoms than the sulphate. The subnitrate of bismuth is free from this objection. It has been found to be particularly useful, in doses of from two to six grains in combination with one grain of opium, in pyrosis, affording almost im- , mediate relief to the pain and sense of constriction which constitute the paroxysm. Muriate of baryta also operates by a direct I action on the stomach; it was introduced as a I tonic in scrofulous affections, by Dr. Crawford, I but it has not been generally employed. In pre- I scribing it, it should be recollected that it is | decomposed by phosphates, sulphates, and all I astringent vegetable infusions, insoluble inert com- j pounds being the result of such combinations. j The tonics that operate through the medium of the blood are chiefly oxides, iodides, metallic salts, and the mineral acids. They all enter the circulation, and can be detected in the secretions. One of the best preparations of iron, as a tonic, is undoubtedly the ioduret or iodide, already men- tioned in the article Stimulants.* It possesses * As the properties of this ioduret are still little under- stood, and as the specimens of it in the shops of the druggists are in many instances not what they ought to 400 TONICS. the advantage of the iodine as an excitant and deobstruent modified by the tonic power of the protoxide of iron ; so that, whilst the former is affording activity to the capillary system, the iron is sustaining its tone, and improving its general vigour and energy. It has been found highly efficacious in all cases requiring the aid of a stimulating tonic, more especially in those con- nected with deficient uterine action, chlorosis, and glandular obstructions, and in every instance of debility that demands a stimulant impulse to be given to the capillary system. The ioduret, it is useful to know, is incom- patible with the mineral acids; the alkalies and their carbonates; the sulphates, both alkaline and metallic; the acetates of zinc and of lead ; arseni- ous acid and arsenite of potassa; nitrate of silver, and all the soluble salts of mercury; solution of chlorine ; gallic acid; tannin and aqueous infu- sions of astringent vegetables; the tinctures of kino, hyoscyamus, and galls; sulphates of morphia, quinia, and muriate of morphia. On account of its deliquescent property, it cannot be prescribed in the form of pill; and in solution it becomes a'hy- driodate. It is contraindicated in every condition approaching to that of positive excitement. Nitrate of silver, the first of the metallic salts belonging to this division of tonics, communicates general vigour to the body, by acting primarily on the stomach ; but it is also absorbed and taken into the circulation—a fact demonstrated by the leaden hue which it sometimes communicates to the skin of those who take it. Although it operates as a powerful escharotic when applied to the surface of the body, yet the vitality of the stomach is sufficient to resist its chemical influence : its dose may be carried to the extent of even five grains three times a day. The best mode of administer- ing it is in the form of pills, made up with crumb of bread. It is always advisable to preface its use be, we shall enter a little more into detail respecting its preparation than was done in our previous notice of it. It is prepared by heating together, in a flask, equal pro- portions of clean, soft iron wire and iodine, with twelve or fourteen times their combined weight of distilled water; boiling the mixture until it wholly lose the colour of the iodine, and then filtering. The filtered fluid, which ought to be of a very pale greenish straw colour, should then be evaporated to dryness in a flask, terminating the process the instant the smallest appear- ance of the purple vapour of the iodine is perceptible. The flask should then be broken, and the ioduret, whilst it is still warm, put into a well stoppered bottle, and secured from the action of the air. Well prepared ioduret of iron is of a dark iron-grey colour, breaking with a crystalline fracture, and dissolving completely in twice its weight of distilled water. When exposed to the air, it rapidly attracts moisture and is decomposed, the iron parting with the iodine, and attracting oxygen so as to be converted into the peroxide, which, on dis- solving the ioduret, falls down as an insoluble red or ochrous precipitate. This decomposition also occurs, when the filtered solution, whatever may he its degree of strength, is exposed to the air; but when a piece of clean soft iron wire is put into the solution, and per- mitted to remain in it for three or four days, and the fluid then filtered, it will keep limpid and undecomposed for any length of time. This solution is most convenient for medicinal use when it contains, in every fluid drachm, three grains of ihe ioduret; but it must be re- marked that in solution it is changed to a hydriodate of the protoxide of iron, returning, however, to the state of the ioduret on evaporating the solution to dryness. In the dry state it is a compound of 28 parts of iron, and 12R of iodine, or one equivalent of each. fThe last edi- tion of the Pharmacopoeia of the United Slates contains a formula for the preparation of the Ferri lodidum, and also of a Liquor Ferri Iodidi. See, also, the writer's JVetc Remedies, edit. cit. p. 2?0.] by emptying the stomach and bowels ; forvwhen much acid, either muriatic or acetic, exists in the alimentary canal, it is decomposed and rendered inert. No salt food, nor much ssalt, should be used by persons taking this nitrate, as these form an inert chloride of silver in the stomach. Nitrate of silver was early employed as a tonic in the treatment of disease; but, from want of due precaution in its administration and the harshness of its operation, it fell into disuse. It was intro- duced by Dr. Sims of London, who employed it in the treatment of epilepsy, and from his success it became much used. In looking at its value in this disease, truth obliges us to say that, except in protracting the return of the paroxysms in symp. tomatic epilepsy, little is to be expected from its employment. In chorea, however, its merits have not been too highly extolled. It has also been given with great advantage in angina pectoris. The administration of nitrate of silver is pro- ductive of one great inconvenience, which stands in the way of its general employment as an inter- nal medicine—it is apt, (as already hinted,) in some habits, to give an indelible leaden or satur- nine hue to the whole skin. With respect to the cause of this change of colour of the skin, if we admit that the nitrate is taken into the circulation undecomposed, and arrives in that state at the ca- pillaries of the skin, we must also admit that it may be decomposed there, converted into chloride of silver, and deposited in the rete mucosum. The chloride acquires a grey leaden colour whenever it remains in contact with animal matter; and, as it is insoluble, it is incapable of being reabsorbed, and a permanent stain is given to the skin. This effect, therefore, happens whenever a more than usual quantity of muriates is separated by the cuticular capillaries. No remedy for this incon- venient effect of nitrate of silver has yet been sug- gested. We imagine that, by ordering diluted nitric acid, at the time of administering this salt, its decomposition may be prevented ; for, although we keep in view the difference between the living system and the laboratory of the chemist, yet it is not improbable that the employment of nitric acid may frustrate the evil by preventing the decompo- sition of the nitrate. As a local tonic, the nitrate of silver has been lately successfully employed in chronic inflamma- tion of the eyes; and to this local influence may be in great part ascribed its utility in diseases of the mucous tissues affecting the secreting surfaces, and in ulcerations, as recommended by Mr. Hig- ginbottom. It is true that it acts in ulcerations by forming as it were an artificial cuticle of the part, which chemically unites with the nitrate; but we are inclined to believe that something i« also due to its tonic power. On the same princi- ple, it cures the inflammation of the cervix uteri dependent on increased irritability of the part. All the salts of iron belong to the class of tonics now under consideration : the subcarbonate has, however, attracted the greatest attention; but owing to the nature of the preparation, it is a most uncertain medicine. The carbonate of the phar- macopoeias is prepared by decomposing the proto- sulphate of iron in solution by subcarbonate of soda ; but oxygen is so rapidly attracted from the atmosphere by the precipitate in drying, that it TONICS. 401 passes into the state of peroxide, and consequently loses its carbonic acid ; and no means hitherto devised have been able to prevent this change from taking place. [Of late, the protocarbonate has been formed in a manner to he permanent; and pills, called, after their proposer, " Vallet's Pills" have been introduced into the last edition of the Pharmaco- poeia of the United States, (1842.) The addition of sugar to the protocarbonate checks the oxida- tion of the iron, but does not wholly prevent it. The Pilulx Ferri Carbonatis of the Pharmaco- poeia of the United States are formed of sulphate of iron, carbonate of soda, clarified honey, syrup and barley-water. A preparation has also been intro- duced into the Edinburgh Pharmacopoeia, under the name Ferri Carbonas Saccharatum, in which the precipitated protocarbonate, obtained by the decomposition of the sulphate of iron by carbonate of soda is triturated with sugar, and dried at a temperature not much exceeding 120°. Experi- ence does not seem to show, that the protocarbo- nate, as a chalybeate, possesses any virtues not equally possessed by the subcarbonate or sesqui- oxide.] To render this preparation [the subcarbonate] perfect, the sulphate of iron should be recently prepared, or in the state of a protosulphate, as the oxide afforded by the persulphate does not com- bine with carbonic acid. When it is carefully prepared, this subcarbonate, according to Mr. Phillips, should consist of —carbonate of iron 40, + peroxide of iron 60, in 100 parts. But it is generally so carelessly prepared, that it does not contain more than ten per cent, of carbonate of iron. When properly prepared, it is soluble in the juices of the stomach, and is readily taken into the circulation; and, as the carbonate is un- doubtedly the active principle, it becomes a mat- ter of great importance that the carbonate should really be the salt administered; and this can al- ways be ensured by making it at the moment it is to be taken. An aqueous solution of eight grains of protosulphate of iron, mixed with a solution of ten grains of subcarbonate of soda, and immedi- ately swallowed, will afford a dose of ten grains of protocarbonate of iron in its most active state ; whereas, a dose of the ordinary subcarbonate con- tains little more than a grain only of the salt. The dose of the subcarbonate is from ten grains to four drachms. [Of late, other preparations of iron have been introduced,—as the lactate, which has been pre- scribed in the same cases as the protocarbonate; but is not much used,—the citrate, which is an elegant preparation, and has been often prescribed by the writer, (New Remedies, 4th edit. p. 273, Philad. 1843) ; and iron, reduced to the metallic state by means of hydrogen, which has lately been strongly recommended by M. Raciborski, (De la Puberte, &c, Paris, 1844.) MM. Quevenne and Miquelard, who proposed the formula, assert, that it comprises the two grand desiderata as regards chalybeates,—great activity, with absolute insipi- dity. It would be strange, however, if experience were to show, that it possesses advantages over the preparations now in use.] All the preparations of iron, whether those formed by the hand of nature in chalybeate waters, Vol. IV. —51 2i* or those contrived by the artifice of man, exert a powerfully tonic effect. They increase the diges- tive powers of the stomach, stimulate the intes- tines, and, being dissolved in the gastric and in- testinal juices, are taken up by the absorbents, enter the blood, and stimulate the whole system. This is demonstrated by the pulse being rendered stronger and quicker, the heat of the body and thirst being augmented, the countenance rendered more florid, and the whole powers of the system being called into action. It has been denied that iron is absorbed into the blood; but a series of experiments, detailed in the second volume of the Bologna Commentaries, places the fact of its ab- sorption beyond a doubt With regard to the medicinal powers of the salts of iron, the natural chalybeates are of eminent service in all cases requiring tonics : their primary effect is displayed on the digestive organs, whence their influence is propagated, rousing the nutritive faculty in every part of the body : they augment the power of the secretory system ; and, by the moderate but permanent nature of the impression which they impart to the nerves, increase the tone and general vigour of all the functions. Some- thing is undoubtedly due, at the same time, to the circumstances connected with drinking mineral waters at their source. But tone follows the use of iron in all its forms, and therefore its prepara- tions are employed in every disease connected with relaxation or debility, particularly of a chronic kind: dyspepsia, hysteria, amenorrhoea, leucorrhcea, scrofula, and chronic catarrh, are a few of the catalogue of those which chalybeates are calculated to benefit. When salts of iron are indicated, the doses should be large; but the propriety of giving the large doses of the carbonate which have been lately recommended, is questionable. Even in tic douloureux, we have never found it necessary, if the preparation be good, to exceed a drachm for a dose; and, in chorea, we have seen every benefit derived from the regular repetition of smaller doses at short intervals. In a weakened state of the uterine organs, causing a defective secretion of the menstrual fluid, the salts of iron are productive of the best consequences ; but when amenorrhoea is accompanied with heat in the region of the uterus, pain of the loins, and plethora, they prove hurtful. In both cases, the effects are attributable solely to the tonic influence of these preparations. Reflecting on the chemical characters and medi- cinal powers of the carbonate, the sulphate, and the muriated tincture, it is evident that they are sufficient for every indication desired from the salts of iron ; and therefore all the other prepara- tions of this metal might be dispensed with and rejected from the pharmacopoeias. The long-continued use of preparations of iron seems to predispose to disease by causing an excess of tone; thence those who have thus employed them are liable to inflammation, active hemorrhage, and similar affections. All the mineral acids are powerful tonics, es- pecially in those cases of great debility in which petechia? display themselves. The sulphuric, di- luted and combined with wine, is the only remedy on which we can rely in the confluent small-pox, when the pustules are filled with a bloody sanies and the urine is coloured by broken-down particles 402 TONICS. of blood. Tn cases of immoderate perspiration, also, as, for instance, in the hectic of phthisis pul- monalis, it is the appropriate remedy ; and, in com- bination with aromatics, it removes many of the urgent symptoms of dyspepsia, and is altogether a tonic of the highest value when judiciously em- ployed. In administering it, however, even in the diluted state, some anomalous effects occur which should be retained in remembrance. Thus, when given to women who are suckling, it acts power- fully on the system of the infant, causing gripings, and frequently convulsions, although it has never been detected in the milk of the mother. A case, extracted from a German Journal, appeared in the Medical Gazette of May the 10th, 1828, in which a woman poisoned herself with concentrated sul- phuric acid. The last efforts of nature were ex- erted to give birth to a child, in whom, upon ex- amination, sulphuric acid was detected In the cavity of the pleura and the peritoneum, and also in the heart and bladder. Its presence was also ascertained in the liquor amnii. Sulphuric acid cannot be combined in prescriptions with muriate of lime, lime-water, barytic-water, or the solution of acetate of lead, or muriate of baryta ; insoluble compounds being produced by these combinations. The tonic effects of cold bathing have been already noticed (see Bathing); it therefore only remains to notice the immaterial tonics. When we contemplate the number and power of the moving organs of the body under the control of the will; the strength of the extensor and flexor muscles, and the facility with which, by their aid, locomotion is produced ; few arguments are required to convince us that a state of constant rest is unnatural, and that motion or exercise is essential for the maintenance of health. Exercise, therefore, may be regarded rather as a prophylactic tonic than one actually adapted for the removal of ■ disease. But besides the immediate influence which some tonics exert over morbid actions, the greater number of this class of medicines is employed to restore vigour to the habit debilitated by previous disease ; and, in this point of view, exercise has a claim to the appellation of a direct tonic. It aids in circulating the blood more equably over the system, promoting especially the action of the ca- pillaries and the function of the skin. Amongst the various kinds of exercise in gene- ral use, walking is the best which can be taken when the strength of the body admits of a mode- rate degree of fatigue with impunity. It throws into action not only the muscles of the lower limbs, but those of the arms and several of the largest and most important of the trunk ; particularly those which, fixed in the loins, serve as flexors to the thighs. It is probable that the motion of these contribute, in some respects, to aid the peristaltic movements of the intestines, and thus to favour that regularity of the excretory function of the abdominal viscera without which health cannot be preserved. When walking, in a convalescent, causes difficulty of breathing, palpitation, or pain in the region of the heart, it should be discontinued ; but when it is performed with ease, it should be continued nearly to the point of fatigue. Horse exercise requires greater powers of mus- cles than can be expected in early convalescence; but as it engages the upper part of the body, and occupies the arms and large muscles of the chest, which influence the motion of the lungs, it is most important as soon as it can be borne. In taking horse exercise also, something is due to the extent through which the person passes in the open air, and the absorption of the attention by the scenery; for experience has demonstrated that the mere exercise taken ih a riding-school, or within a limited space of ground, is not so salutary as riding in the open country. As a prophylactic of phthisis, in those predisposed to that disease, riding has been justly extolled; and even when the disease has displayed itself, if, as Sydenham remarks, it be "without fever or ulcer," riding may be regarded almost as a specific. We have often witnessed the beneficial effects of horse exercise in frames of body greatly weakened by asthma, and have seen individuals who were scarcely able to mount on horseback return from a ride vigorous and alert, and by the daily renewal of this exercise rapidly regain a degree of vigour and tone which could scarcely have been anticipa- ted. When horse exercise or walking cannot be resorted to, the next best is carriage exercise or sailing; but it must be recollected that scarcely any of the influence of these can be referred to the muscular system. Friction may be regarded as a species of exer- cise, and its effects can be explained on the same principles. To produce a tonic effect it ought to be brisk, and performed in such a manner as to produce a degree of redness and warmth on the surface. The ancients judiciously employed fric- tion after tepid bathing, and aided its influence by the administration of wine and water during the intervals of the rubbing. On this principle only can be explained the beneficial effects of the oriental custom of shampooing. In phthisis the pains of the thorax are often relieved by friction; and the influence of percussion, which may be considered a variety of friction, of chronic rheuma- tism, is well known. It may be rationally inquired whether any advantage is derived from aiding the friction by stimulating embrocations or oils ? If the friction be well performed, and for a sufficient time, nothing of this kind is necessary, except to prevent the skin from being fretted; in which case, dipping the hand in dry flour or hair-powder is as useful as the most celebrated embrocation. It is only when a narcotic impression is to be added to the influence of the friction that embrocations are really useful. How far friction may owe its salutary influence to electrical agency, is a subject well worthy of examination. Mental tonics belong to this class. The tonic effects of hope and confidence have already been spoken of, and it is unnecessary to give such il- lustrations as no practitioner can fail to meet with in his daily duties. Travelling is another mental tonic ; but it has a closer affinity with material tonics than either hope or confidence, and in no disease is the advan- tage of it more conspicuous than in hypochondriasis. In this disease there are languor and torpor of the whole body, timidity and depression of the mind, and a general disordered state of the functions of the stomach and intestines. Medicines have little influence in relieving these symptoms; but by a TONICS. 403 change of climate and of scene, the disease is miti- gated, and often cured. Something undoubtedly is due to the state of the atmosphere, the tempera- ture, and other physical properties which distin- guish one climate from another; but as much more advantage is procured by moving from place to place than by remaining stationary even in the most favourable climate, the salutary effect can only be ascribed to the mental excitement produced by the constant change of scene. In prescribing travel- ling as a tonic, it is surely unnecessary to say that countries ought to be recommended most fertile in those objects which are likely to rouse the curiosity and arrest the attention. " Caelum patrio pulchri- us, mores festiviores, et scaense nova; et amocnae, mentem grate occupant, et imaginationem suavissi- me detinent." (Gregory, De Morbis Coeli Muta- tione Medendis Diss. Inaug.) To sum up these remarks on this class of medi- cines, we should say that in deciding upon their employment three things require to be attended to: — 1. The choice of the tonic ; for although all tonics necessarily possess the same kind of powers, yet these differ in degree: some are more acrid and astringent than others; some owe their efficacy to the presence of certain alkaline or acid princi- ples; some to bitter extractive or to volatile oil modified by combination with other vegetable constituents; and some to the conjunctions of chemical agents, forming new and active com- pounds. We must, therefore, determine how far these principles are likely to fulfil the indication for which the tonic is to be prescribed, before selecting it. 2. The dose. It is important to regulate the dose of the tonic employed, in order to meet the demand which is required, or not to exceed the impression which can be sustained : if it be inadequate to the effect anticipated, the thera- peutical indication will remain unfulfilled, and disappointment naturally ensue ; if it be too great, instead of tone, excitement and collapse may be the result. 3. The mode of administering the medicine must be duly considered. If a powerful impression is intended to be made on the stomach, the medicine selected ought to be administered uncombined with other substances, and in such a dose as will produce an impression both powerful and durable: if, on the contrary, the object is to 'introduce the medicine into the system, it ought to be associated with such substances as will favour its absorption, and to be administered in small and frequently-repeated doses. With regard to the diseases particularly re- quiring the employment of tonics, we may remark that in none do they produce more salutary effects than in affections of the digestive organs. The efficacy of tonics in these diseases is well esta- blished : their action upon the gastric nerves is communicated to the encephalon and spinal mar- row, and the reaction of these upon the stomach awakens its powers and augments the activity of the digestive function. In selecting the tonics to be employed, those which contain bitter extractive —for example, quassia, gentian, or calumba—are to be preferred : the pure bitter which these sub- stances contain, devoid of astringency, acts in a milder manner than those which contain either gallic acid, tannin, or the alkaloids. The tonic influence which they exert on the digestive organ alters also that condition of the mucous membrane which favours the generation of intestinal worms; whilst, at the same time, some bitter substances operate as direct vermifuges or poisons to these parasites. Although it is scarcely necessary to state that tonics are injurious in all inflammatory states of the chest, yet, when the mucous secretion is exu- berant, as in chronic catarrh, tonics are decidedly indicated: in these cases the cetraria Islandica, the lesser centaury, and the cinchonas are to be preferred to the other bitters. In hydrothorax, and in all serous accumulations within the thorax, however, they are useless, even when these states are the sequel of asthma and similar affections, in which tonics exert an unbounded beneficial influ- ence. In conditions of the cerebro-spinal centres producing epilepsy or hysteria, symptomatic of morbid states of the circulating system — for ex- ample, hypertrophy of the heart, or of the diges- tive organs, in connection with hypochondriasis or melancholia — tonics are likely to produce a salutary change; but when these diseases depend on morbid conditions of the brain and spinal mar- row themselves, then no advantage can be antici- pated from the use of tonics. In some convulsive affections—as, for example, chorea — tonics may be regarded as the only remedies to be relied upon. In diabetes, as they improve the condition of the digestive organs and re-establish the assimilating power of the system, they are likely to alter that state of the urinary secretion which constitutes the disease; but at the same time it must be re- collected that if the symptoms can be traced to any organic affection of the lumbar portion of the spinal cord, it will be vain to anticipate advantage from the employment of this class of medicines. In cutaneous affections not symptomatic of pe- culiar febrile states, tonics prove useful; and this is especially the case when these eruptions are connected with depression of the general powers, manifested by a pallid or discoloured skin, a dis- ordered state of the stomach, emaciation of the body, and a sluggish condition of the bowels. In such a condition of the system the more active tonics, in particular arsenic and the metallic salts, are especially indicated. But it is in fevers that the efficacy of tonics is most conspicuous. In simple fever they are rarely required ; and in complicated cases the proper time to administer them is a matter which re- quires great judgment. As a general rule, their employment should be deferred whilst any ob- vious local disease exists in the bowels; although, even under such circumstances, when there is a necessity for supporting the system, they have been productive of the best results. In typhous fever the indiscriminate use of tonics has been productive of much mischief. The ap- pearance of languor and debility is no reason why they should be prescribed; as in these instances they have been found to increase all the symp- toms without improving the strength. Ample experience has demonstrated that, in general, it is only after the febrile symptoms have been wholly subdued, when the patient does not rally, and the convalescence is slow, that tonics are beneficial. Under certain circumstances they may be required even during the continuance of the disease. Thus, 404 TONICS —[TOOTHACHE.] when petechia! appear, whilst the pulse is soft and compressible, and if there be a tendency to gan- grene, not only tonics but stimulants are indi- cated : in such cases, much advantage is obtained from a combination of volatile oil, as an oleo-sac- charum, with sulphate of quinia and sulphuric acid ; or, if the vegetable infusions be preferred, we should select those of serpentaria, cascarilla, or cusparia. After what has been stated respecting the value of cinchona bark as an antiperiodic in intermit- tents, it might be supposed that little remains to be said regarding the employment of tonics in those fevers; but it is necessary to guard the stu- dent and the inexperienced practitioner from being misled by too general a view of this subject. If the intermissions be imperfect, and any local in- flammation exist, much caution is requisite in pre- scribing tonics ; and in every instance a complete state of apyrexia in the intervals should be se- cured before venturing upon their employment. It is essential, however, to discriminate between local inflammation of the viscera and those en- gorgements of the spleen and of other parts which exist in persons who have suffered from long-pro- tracted agues, and which are generally aggravated by any fresh attack of the disease: the presence of these need not interfere with the use of the bark or arsenic. It has been asserted that the latter of these tonics may be administered even during the existence of inflammatory symptoms ; but upon this point we must confess that we are sceptical. In some peculiar modifications of in- flammatory action — such, for example, as occur in chronic rheumatism—arsenic may be adminis- tered ; but the salts of quinia, the menyanthes, and other tonics, are equally safe and useful. In remittent fevers much caution should be observed in prescribing tonics. The remission should be transformed into an intermission before they can with propriety be employed ; indeed nothing is so likely to change a remittent into continued fever as their injudicious administration. [Yet in the malignant remittents of the United States, and in yellow fever, (q. v.) very marked advantage has been obtained from the use of sul- phate of quinia in very large doses. Too great a dread would seem to have been felt in regard to the admission of tonics before a decided remission takes place. Whilst excitants proper may be de- cidedly disadvantageous, marked benefit may re- sult from tonic agents like the sulphate of quinia.] In infantile remittents, notwithstanding the high authority of Dr. Clarke, of Newcastle, who, in his work on fever, recommends bark to be imme- diately resorted to after the operation of an emetic, we accord with those who delay the use of tonics until the advanced stage of the disease, when it proves obstinate : then the cascarilla, which in 6uch cases is generally preferred to the other barks, maintains the tone of the stomach and bowels, and enables us to proceed with the altera- tive and purgative plan of treatment. In the modification of fever which constitutes hectic, it must be confessed that little reliance is to be placed upon any class of medicines. Upon the whole, it is necessary that tonics should not be confounded with stimulants, and that we should always recollect that tone is not excitement, nor strength increased vascular ac« tlon" A. T. Thomson. TONSILLITIS.—(See Thboat, Diseases or THE.) [TOOTHACHE, Odontalgia. — This disease is characterized essentially by acute pain in the teeth or their involucres, and is dependent upon various pathological conditions, which may require a brief and distinct consideration. 1. Inflammation of the Alveolo-Dental Membrane ; Periodontitis. — The membrane that lines the socket of the tooth is, at times, at- tacked with inflammation, giving rise to much suf- fering. An uneasy feeling is experienced in the alveo- lus, or alveoli, of some part of the jaws when the teeth are pressed together; the teeth of the affected periosteum being evidently slightly forced outwards, so that they cannot be accurately brought in contact. This painful sensation, pul- sative and constant, may exist for a few days and then pass off; but, at other times, the inflamma- tion spreads outwards, so as to be perceptible on the gums; the teeth become loose ; and, at times, pus is secreted in the alveolus, which makes its way outwards, between the gum and the tooth. In other cases, the parietes of the alveolus become carious, and a fistulous ulcer is kept up. When the inflammation has recurred frequently, the tooth may become permanently loose, and act as a foreign body in the socket. Periodontitis may be induced by caries of the fang, which is not often, however, the first cause. Cold and hot fluids, taken into the mouth, and partial exposure to cold and moisture, have been looked upon as exciting causes ; but, as in every other form of inflammation, the precise etiology is by no means clear. The affection generally terminates by resolu- tion ; but, should the excitement be great, and the pain excessive, it may be necessary to apply leeches externally, to scarify the gums in the vicinity, and to give a full dose of opium, or of some of its preparations. If the tooth be loose, and no chance exist of its becoming fixed, and the maintenance or recurrence of the disease be owing to this circumstance, it will be advisable to extract it. Periodontitis, followed by secretion of morbid matter, is a very common cause of the loss of teeth. Occasionally, it appears to be connected with some constitutional vice, when it has to be met by constitutional remedies. Dr. Graves gives the case of a gentleman, who had been affected by rheumatic periostitis, which was relieved by the internal use of iodide of potassium. Subse- quently, he suffered greatly and repeatedly from periodontitis, which resisted every remedy until the iodide of potassium was used, which com- pletely removed it. 2. Inflammation of the Dental Mem- brane ; Endodontitis. — The membrane that lines the dental cavity may likewise be inflamed j but it is not easy to distinguish this from tooth- ache dependent upon erethism of the nerve. I' may be suspected, if no signs of caries be ob- served on examination; but it cannot be accu- [TOOTHACHE.] 405 rately diagnosticated. The same intermission in the pain—the same absence of inflammation of the gum—occurs in the early stages; but, after- wards, the pain may become more constant. If endodontitis is believed to exist, the same plan of treatment may be adopted as in perio- dontitis. 3. Cartes of the Teeth.—This is one of the most common diseases of the teeth, and occurs in some countries more than in others. The travel- ler, in certain parts of the south of France, and of the southern regions of this country, is struck with the ravages of dental caries, whilst in other districts the inhabitants are equally characterized by the excellence of their teeth. Pain experienced when hot or cold liquids are received into the mouth, or the supervention of the ordinary signs of toothache, attracts the atten- tion of the patient to the condition of the teeth, and careful examination exhibits that there is either a cavity opening externally in some part of the tooth or teeth affected, or that an internal pro- cess of decay has been established, which leaves but a shell of bone between the cavity of the tooth and the open air, so that the dental nerves are readily affected through it by external agents. The precise part at which the caries or gangrene takes place varies. It is usually considered to commence immediately beneath the enamel, in the osseous substance of the corona of the tooth. A small, dark spot is observed, which gradually spreads, until there is a free communication be- tween the external air and the dental cavity. In this mode the whole of the corona may be de- stroyed — the fangs alone remaining, and often continuing to excite periodontitis, as extraneous bodies, until they are removed by the punch of the dentist. At other times the gum closes over them, and they no longer excite irritation. The disease is seated in the system of nutrition of the tooth, and has been presumed by some to consist originally in inflammation. It is a common belief that dental gangrene is universally owing to the action of external agents upon the teeth. The facts, already mentioned, that dental caries is more common in some regions than in others—that it is an evil affecting families in many cases—and that the caries is observed, first of all, beneath the enamel—would, of them- selves, make us pause in admitting this belief. There is, moreover, a greater liability to the dis- ease in some teeth than in others. The last mo- lar tooth but one, and generally of the upper jaw, is most usually the first affected; and, after it, the corresponding tooth of the opposite side suf- fers, owing to their being situate anatomically alike; and, consequently, the immediate cause of caries, after having acted upon the one, will be more likely to affect the other. Often, too, the next tooth to the one that is carious becomes so likewise, and on the side nearest to the diseased portion of the first. This has been supposed to be owing to contagion, but there is no good rea- son for admitting it. Next to the corresponding tooth of the opposite jaw, the one in immediate proximity with the tooth primarily affected, must be most likely to be implicated, seeing that its anatomical elements—blood-vessels and nerves__ can vary but little from those of its neighbour. The upper incisors are often decayed, and, in unhealthy children, caries sometimes attacks al- most the whole of the teeth of the first dentition. It is impossible to depict the kind of dyscrasy which predisposes to the affection. Some have imagined that those of a tuberculous constitution are more subject to it; but we often see the teeth largely decayed in persons who are neither tuber- culous nor strumous. The prevalent belief is, that acids are very de- structive to the teeth, and, therefore, a common cause of caries. But destruction of the enamel does not necessarily give occasion to caries. We have seen many cases in which portions have been broken off the incisors, yet decay has not supervened unless the individual was predisposed to it; and the dentist is in the daily habit of filing away the enamel, under the conviction, derived from experience, that caries will not necessarily, or be likely to follow. In certain cases, too, the enamel, in the progress of life, scales off by what John Hunter called " the denuding process;" yet decay does not necessarily result. It would seem, consequently, to be improbable that any agent which acts chemically upon the enamel could in- duce caries, when the removal of the enamel by the file of the dentist, or by mechanical injury, does not occasion it. Besides, it is not easy to conceive how any acid substance, having a greater affinity for the lime of the tooth than the phos- phoric acid,—and there are not many such,— could remain in contact with the tooth in a state sufficiently concentrated to exert any chemical agency upon it. The presence of acid in the mouth always augments the secretion from the salivary glands, so that it becomes speedily di- luted. If such be the case with acids, how unlikely is it that the free use of sugar should be directly injurious to the teeth ! In sugar there is no acid, yet it has been imagined that a chemical action may be exerted upon the teeth by indulgence in it. This is probably a bugbear which has been created, in the first instance, with the view of de- terring children from the use of a substance of which they are fond, and the indulgence in which is objectionable for sumptuary and other reasons. It has, indeed, been observed, that the negroes in the West India Islands, who drink the juice of the cane very freely, have unusually good teeth, and we know that the nutrition of the frame im- proves under its use. There cannot be a doubt, therefore, that external agents of a chemical na- ture are not as much concerned in the production of dental gangrene as is generally admitted ; but we can easily comprehend that, in one who is predisposed to the affection, substances that disa- greeably impress the nerves of the fifth pair in the mouth—as hot or very cold liquids—may act as exciting causes, by modifying the nutrition of the teeth, and producing the condition in question. The readiest method of cure, when caries is discovered in a tooth, is to plug up the hole, where this is practicable, with a metallic or othei substance. But this is only admissible when the caries communicates externally, and when the cavity in the tooth is greater than the aperture. Where plugging is impracticable, relief may be obtained by destroying the affected nerves either 406 [TOOTHACHE.] by the actual cautery, or by caustics introduced into the cavity. The pain may be palliated by substances that deaden the sensibility of the dental nerves, as the different preparations of opium; essential oils, as of cloves; mustard, alcoholic liquors, &c. One or two drops of hydrocyanic acid, put into the hollow tooth, have assuaged the pain; but it need scarcely be said, that so potent a remedy should be employed with caution. Pyroligneous acid has been used, in the same cases, dropped on cot- ton ; and, of late years, its main energetic princi- ple, creasote, has been more extolled, perhaps, than any other remedy. When creasote is applied in the same manner as the agents above mentioned, or by means of a pencil imbued with it, it causes instantaneously acute pain and a considerable se- cretion of saliva. The patient is often relieved, but the pain generally recurs, and perhaps the advantage derived from its use is not greater than that from the stronger essential oils. Creasote may be reduced by the addition of an equal quan- tity of alcohol. It is the opinion, however, of Dr. Cormack and others, that although creasote affords respite from pain, it hastens the destruction of the teeth. Tincture of chloride of iron, and solution of persesquinitrate of iron, have also as- suaged the pain. Revellents, which act on other nervous ramifi- cations than those implicated, often afford relief even in dental caries, although they would seem to be more advantageous in the neuralgic form. Hence, the chewing of tobacco—to one unaccus- tomed to it—of pepper, pyrethrum, ginger, the bark of aralia spinosa, (angelica tree, or toothache tree, of the United States,) horseradish, calamus, mezereon, or any agent, in short, which belongs to the class of local sialagogues, may yield relief. A union of narcotics and sialagogues—extract of belladonna, extract of hyoscyamus, opium, pyre- thrum, and oil of cloves, in a pilular form—has been proposed, and highly extolled by Rust. Where the decay is extensive, and the pain cannot be controlled by any of these agents, the tooth will have to be extracted. 4. Nervous Toothache.— Under this term many writers describe neuralgia of the teeth, which may be mistaken for ordinary toothache from caries, but may generally be distinguished from it by the history of the case, as well as by the pain being more periodical, and shooting with the utmost violence along the branches of the fifth pair distributed to the affected jaw. For the treatment of this form of neuralgia, the general rules, laid down under the head of neu- ralgia, will be appropriate. The reliance of the practitioner has to be placed upon narcotics in large doses, administered internally, and applied locally—and upon revellents, as blisters behind the ears. In rheumatic odontalgia, which may be regarded as a variety of nervous odontalgia, the insertion of a little cotton, imbued with creasote, in the ear of the same side, has been found ser- viceable. A tincture of spilantkus oleraceus has been much recommended in France and Germany, as a secret remedy, irt toothache, and it is only of late that its composition has been known. Its virtues are probably dependent upon its acting like the sialagogues before mentioned; all of which, by the way, are indicated in nervous odon- talgia. The tincture of spilanthus is said to re- lieve toothache instantaneously, when applied to the gums and teeth. By others, it has been es- teemed very uncertain. (See the writer's Prac- tice of Medicine, 2d edit. i. 9G, Philad. 1844.) The various stimulating liniments, the milder counter-irritant lotion of Granville, (seeCocsTEH- irritation,) and sinapisms, have been used with advantage, applied over the cheek or behind the ears; and the more rapid the revulsion, the more effective it is in general. It is in such cases, too, that the efforts of the animal magnetizer and the Perkinist, and the employment of the mineral magnet, may be expected to prove beneficial. To this division of toothache belongs that of the pregnant female, which may, likewise, be re- lieved by the agents just indicated. It cannot often be necessary to extract the tooth, an opera- tion which should always be avoided, where prac- ticable, for fear the shock may induce abortion. 5. Exostosis of the Teeth.—Like the bony structures elsewhere, the teeth are liable to exos- tosis. The deposition usually occurs in the fangs, but scarcely admits of detection. Violent, deep- seated pain, not relieved by the ordinary methods, induces the patient to have the tooth extracted, when the affection is, for the first time, apparent 6. Tartar of the Teeth.—From the saliva, a calcareous matter is deposited, which concretes around the base of the corona? of the teeth, and, at times, where due attention is not paid, accu- mulates in considerable quantities, causing the gums to inflame, and to be absorbed, so that the support to the teeth afforded by them is lost. The main constituent of these concretions is phosphate of lime, which is cemented by means of animal matter. It has, indeed, been affirmed by M. Mandl —as the result of his microscopic observations— that they are formed of calcareous skeletons of infusoria, agglutinated by means of dried mucus. When first deposited, the tartar of the teeth— for so it is termed—is soft, of a yellowish colour, and easily removable ; but, as it hardens, the co- lour becomes of a dark brown or black, and is extremely unsightly. When it accumulates in any quantity, it is impossible to cleanse the mouth properly, so that the secretions are retained there, and, at the temperature of the mouth, 98°, readily undergo decomposition, so as to taint the breath. Attention to cleanliness, by the daily use of the tooth-brush, will prevent the formation of this concretion. The brush itself may be sufficient, but any of the ordinary dentifrices may be used along with it. There is no better "tooth pow- der" than a mixture of powdered charcoal and powdered orris-root, but there is no end to the dentifrices that have been recommended. Each dentist, — nay, each druggist,— has his own, which is, of course, extolled by him as the best; and none are, perhaps, positively injurious. It may be well, however, to bear in mind, that the reiterated friction of a hard brush, employed daily and for years, may have some effect, of itself, in injuring the teeth; and, therefore, that the brush should be used no longer at a time, and with no more force, than is necessary for the removal of the secretions. Where the tartar has already formed, and does not yield to simple friction of TOXICOLOGY. 407 the kind advised, dilute acids—which, as has been already observed, are objected to by the dentist, but without sufficient reason—may be employed. Weak sulphuric acid will usually remove the concretions without much difficulty; but, should it fail, the services of the dentist are demanded to scale the teeth; after which, the re-formation of the tartar may be prevented by the tooth-brush and dentifrices. Robley Dunglison.] TOXICOLOGY.—This term is derived from tS^ikov, venenum, (itself derived from rrffov, a botv or arrow, by metonymy a poison,) and Xiyoc. In its most extended sense it would include the dis- cussion of the natural history and chemical habit- udes of all substances capable, when applied to the hiving body, of exerting effects injurious to or destructive of life; of their physiological action and pathologic consequences; and of the appro- priate means for controlling their deleterious in- fluence, whether by the exhibition of antidotes or other medical treatment. There are few sub- stances of animal, vegetable, or mineral origin, which may not, under certain circumstances, prove inimical to life; so that toxicology, in its most enlarged acceptation, is a science of almost bound- less extent, and would require in order to its com- plete development, such an extensive acquaintance with many departments of natural knowledge as rarely falls to the lot of any individual. A trea- tise, however, upon such a plan would include a number of topics, in a practical point of view, entirely superfluous, and answering no other end than that of uselessly loading the memory and thus embarrassing the progress of the student. For all useful purposes it is sufficient for the toxi- cologist to concentrate his attention upon those natural and artificial products which are distin- guished by the extreme energy with which they act upon the animal economy. The range of his inquiries is thus materially narrowed, while the many advantages to society to be expected from them, such as the preservation of life and health, the protection of innocence, and the punishment of guilt, may be considered as equally well se- cured. Rven with this limitation the subject is still sufficiently extensive, and the present article is undertaken with a deep sense of the difficulty of presenting an outline of the science of toxi- cology which shall at the same time be instruc- tive, and of such dimensions as to accord with the general plan of the work of which it is to form a part. The classification of poisons is a problem of considerable difficulty, and one which has engaged the attention of successive toxicologists. The arrangement, it is obvious, of the subject matter of a science should be regulated by, and rendered subservient to, its principal objects. In animal and vegetable anatomy, for example, parts are with propriety grouped together which possess an analogous structure and which perform similar functions; in chemistry, bodies are arranged ac- cording to their composition and properties, the great end of the science being the determination of the constitution and the affections of matter. Upon similar grounds, in toxicology, the principal aim of which is the investigation of the modus operandi of poisons with a view to the counter- action of their deleterious effects, such an arrange- ment should, if possible, be adopted as would bring together substances which impress the sys- tem in the same way. An attempt at the arrange- ment of them on this plan has accordingly been made, (Paris's Pharmacologia, vol. i. p. 242,) but the practical advantages which might be expected to flow from it have not been realized, partly be- cause the manner of action of deleterious agents is but imperfectly known, and partly because the same substance frequently acts upon the animal body in different ways,—that is, has a remote as well as a local action. The arrangement of poisons at present gene- rally adopted originated with Fodere, and has been slightly modified by Orfila and Christison. It is based upon the effects which, when adminis- tered, they are observed to produce. Some cor- rode or inflame the parts to which they are ap- plied ; others produce delirium or coma; while others determine sometimes an irritating, some- times a narcotic effect. All are thus reduced to three classes, (Christison,) the first of which in- cludes the irritants, the second the narcotics, and the third the nareotico-acrids. This classification is adopted throughout the present article, not be- cause it fulfils all the conditions of a philosophical division, but as being the least imperfect of those which have been hitherto proposed. The following is a tabular view of the principal known poisons, founded on this arrangement. Those derived from each of the three great king- doms of nature are classed separately, and the gases are placed apart from the other poisonous substances, as, from the identity of their physical constitution, and in consequence of the action of all being principally exerted through the lungs, it will be convenient to discuss them in conjunc- tion. I.—Irritants. 1.—Mineral. Aqua chlorinii. Chlorides of lime and soda. Iodine and hydriodate of potash. Sulphur and alkaline hydrosulphurets. Phosphorus. Sulphuric, nitric, and muriatic acids. Oxalic acid. Potash, soda, and their carbonates. Nitrate of potash. Ammonia and its sesquicarbonate. Muriate of gold. Nitrate of silver. Mercury. Arsenic. Copper. Lead. Zinc. Antimony. Bismuth. Tin. Barytes. 2.— Vegetable. Euphorbia officinarum. Jatropha curcas. Momordica elaterium. Cucumis colocynthus. Bryonia alba. 408 TOXICOLOGY. Ranunculus acris, &c. Anemone pulsatilla. Caltha palustris. Delphinium staphysagria. Daphne mezereon. Juniperus sabino. Convolvulus jalapa. Narcissus pseudo-narcissus. Gratiola officinalis, Stalagmitis cambogioides, 3.—Animal. Cantharides. Poisonous fish. Poisonous serpents. Animal matter rendered poisonous by dis- ease. Animal matter rendered poisonous by putrefaction. II.—Narcotics. Prussic acid. . Opium. Hyoscyamus niger. Lactuca virosa et sativa. Solanum nigrum et dulcamara. III.—Narcotico-Acrids. Atropa belladonna. Datura stramonium. Nicotiana tabacum. Conium maculatum. Cicuta virosa. OGnanthe crocata. OEthusa cynapium. Aconitum napellus. Helleborus niger. Digitalis purpurea. Veratrum album. Colchicum autumnale. Strychnos nux vomica. Brucea antidysenterica. Cocculus indicus. Upas antiar. Camphor. Poisonous fungi. Ergot of rye. Alcohol. IV.—Poisonous Gases. The morbid consequences of every variety of poisons are obviously twofold; — local, or those produced in the part of the body to which it is applied; and remote, or those which are observed to ensue either in some distant organ, or through- out the system generally. The local action of a poison is either to corrode, to infiame, or to paralyse the part with which it comes into con- tact. Now these effects are, per se, very seldom the cause of death; and indeed, they never are so unless when the organ they affect is essential to life, and that its functions have been suspended or materially deranged. The influence, in fact, of poisons in destroying life must, in almost every instance, be traced to their remote effects. As a preliminary therefore to the individual examina- tion of the several substances included in the pre- ceding table, it will be necessary to inquire into the manner of transmission of their remote action, or through what channel, when locally applied, their influence becomes extended to dis- tant organs. The earliest views which have prevailed in reference to this point were that the remote effects of deleterious agents were due to the impressions which they make upon the sentient extremities of the nerves, which impressions are transmitted to the brain, and thence, by a reflex operation, to different parts of the body. In 1811, Mr. Brodie, in a paper published by him in the Philosophical Transactions, endeavoured to establish that while some poisons, as the essential oils of almonds and tobacco, the juice of aconite and woovara, inter- nally exhibited, act by nervous impression, the same substances, with several others, when applied to wounds, pass by venous absorption into the circulation, in the course of which they are car- ried to the brain, whose functions they suspend or destroy by actual contact. Lastly, the old theory of the general action of poisons being the result of a sympathy between the nerves with which they come in contact and the brain, has been recently revived by Dr. Addison and Mr. Morgan, who have adduced in its support several weighty argu- ments and some very ingenious experiments. That many substances of a noxious nature do, at least occasionally, pass into the blood, would seem established by satisfactory experiments. There are, however, numerous facts which negative the supposition of absorption being necessary to their poisonous action. Some, as strong prussic acid, kill with such rapidity that it is impossible to refer their action to absorption and cerebral contact; and, in the case of others which operate more slowly, analysis seldom enables us to detect the slightest trace of them in the blood; a fact, how- ever, which can scarcely be considered conclusive against absorption, in consequence of the com- parative defectiveness of our means for conducting such delicate investigations. A celebrated expe- riment of Magendie was advanced by himself, and is often quoted by others, in support of the views which we are combating here. This emi- nent physiologist having reduced a dog to a state of stupor by opium, amputated one of its thighs, and then re-established the circulation through the member by the intervention of quills attached by ligatures to the cut ends of the femoral artery and vein above and below. An incision was now made in the paw of the amputated leg, and a small quantity of ticunas* inserted in it: after the usual time the animal was found to labour under the influence of the poison. The symptoms, however, were arrested by pressure on the vein above the amputation, but again returned upon allowing the blood to move forward. Here it is said, the limb having no connection with the body, the hypothesis of nervous impression can- not apply, so that the action of the poison can only be referred to absorption and cerebral con- tact ; a conclusion supported by the effects of ob- structing by pressure the passage of the blood towards the heart. Such an inference, however, by no means necessarily follows. Messrs. Morgan and Addison judiciously remark that all the ex- periment proves is, that the ticunas had passed into the circulation,—a circumstance the possi- bility of which they are not disposed to contest. Having once ascended beyond the quill connect- ing the amputated ends of the vein, its influence * An American poison, the nature of which has not been well ascertained. TOXICOLOGY. 409 ipon the system may be due to the impression which it makes upon the nervous fibrils which are distributed upon its internal coat, an impres- sion which by sympathy is extended to the brain. The retardation of the symptoms also upon the application of pressure to the vein, admits of ex- planation by supposing that the function of the nerves supplying the vessel were thus interrupted owing to a temporary paralysis. The physiologists just quoted would really seem to have rendered it highly probable that the inner coats of the blood-vessels are extremely susceptible of morbific impressions, and that the influence of poisons, when thus applied, is developed without any cerebral contact. Ticunas, for example, in- troduced into the femoral artery of a dog, produced death in 108 seconds; and when inserted in the carotid artery, was not fatal until after the same lapse of time, although in this case it must have been almost immediately conveyed to the brain. But that this poison may prove rapidly fatal with- out entering the blood at all, and of course without being conveyed to the brain, they established by the following decisive and well-contrived experi- ment. Two large bull-dogs, each weighing about 40 lbs., were the animals selected. The carotid artery of each having been laid bare on one side, and separated from its connection with surrounding parts to the extent of three inches, temporary ligatures were applied above and below, and the arteries divided between them. Brass tubes were then attached to the extremities of the vessels, and the necks of the two animals being held and closely bound together, the divided vessels were so re-connected that the lower half of the carotid in the one animal became continuous with the upper half in the other. One of the dogs was then inocu- lated on the back with a concentrated preparation of strychnine, which had been found in previous experiments to produce death in such animals in about three minutes and a half. In three minutes and a half exactly, the inoculated animal exhibited the usual tetanic symptoms which result from the action of this poison, and died in about four min- utes after. The arteries being secured by liga- tures, the living was now separated from the dead animal; but neither during the progress of the experiment, nor at any subsequent period, did the survivor exhibit the slightest symptom of the action of the poison. It is impossible to account for these results upon the hypothesis of absorption. Had such taken place, both animals would obviously have suffered equally from the influence of the poison; while, on the other hand, the immunity experi- enced by one of them is in perfect accordance with the theory of nervous impressions and cerebral sympathy. It may also be observed that the doctrine here advocated is supported by analogy. When, as in tetanus, the general system becomes deranged by the infliction of a local injury of a mechanical kind, the effect can obviously only be attributed to a sympathy subsisting between the sensorium and the nerves of the wounded part. Are we not, therefore, it may be fairly asked, justified, when similar effects follow the application of a poison to any particular part of the body, to conclude that Vot. IV. —52 2 k the medium of its operation is the same, or that the constitution becomes generally affected by reason of the sensorium sympathizing with the nerves to whose sentient extremities the poison is applied ? From these and other considerations which it is unnecessary to adduce here, we are disposed to concur in the conclusion, that though poisons may occasionally enter into the circulation, their dele- terious effects are in almost every instance, if not all, to be ascribed to the impressions which they make upon the nerves with which they come in contact, which impressions are conveyed from them to the brain, and thence, by a reflex operation, to the different organs of the body. We wish, how- ever, particularly to guard ourselves against being understood to deny the absorption of poisons. Many such have been detected by chemical exam- ination in the blood, but almost invariably in cases where a considerable interval has elapsed between their administration and the death of the animal; and even in such instances the experiments of Addison and Morgan furnish the strongest grounds for believing that their deleterious influence was due, not to an immediate contact with the sub- stance of the brain, but to their application to and the consequent impressions made upon the network of nervous fibrils spread upon the serous membrane, which lines the entire vascular system. The presence, in the excretions, of nitre, rhu- barb, turpentine, and other substances, which have been introduced into the stomach, has been gene- rally considered as establishing the theory of ab- sorption ; for such substances, it is argued, must | have passed through the blood. This reasoning, however, is far from being conclusive. Wollaston | (Phil. Trans. 1811) exhibited the ferro-prussiate of potash to animals, and though he was always [ enabled to detect it in the urine, he never could find a trace of it in the blood. Indeed, the rapidity with which certain substances introduced into the prima? vise pass into the bladder, renders it very improbable that they should have reached their destination through the circuitous route of the circulation ; and Darwin, as is well known, was hence induced to attribute the phenomenon to what he denominated a retrograde action of the absorbent system. We are far from adopting this idea, but at the same time we are convinced of the facts which it was intended to account for, and perceive in them new objections to the theory of the absorption of poisons as generally taught and understood. Lastly, it may be observed that the action of the more energetic narcotics, which destroy life in a few seconds, must of necessity be explained by the direct influence which they exert over the nervous system, and, as it is unphilosophical to refer similar effects to dissimilar causes, strong probable grounds are laid for the universality of the principle for which Addison and Morgan con- tend. Should alleged exceptions be adduced, it will at all events be necessary that they be sus- tained by direct experimental evidence. There is another topic closely connected with the modus operandi of poisons, to which we shall now briefly advert. The derangement which fol- lows upon their external application or interna] exhibition is seldom the same all over the body. 410 TOXICOLOGY. A poison will specially affect some particular organ or organs, while others appear to be little if at all disturbed. Thus the power of tobacco and the upas antiar, as was long since noticed by Mr. Brodie, is principally exerted upon the heart. Opium, prussic acid, and a number of other nar- cotic drugs, act chiefly upon the brain, while the influence of the different vegetable which include strychnia and brucia is chiefly directed to the spi- nal cord. The action of some, indeed, is pretty equally distributed over the entire system. Yet, even in the case of these, we may recognise a ten- dency to assail some in preference to other struc- tures. The ravages, for example, of mercury and arsenic extend to every part of the body. The former, however, as is well known, acts most forcibly upon the glands, the latter upon the mu- cous tissues : nor are these two metals peculiar in this respect. Every substance possessing medi- cinal efficacy, and many such are poisonous in an over-dose, has been introduced into our pharma- copoeias, chiefly in consequence of possessing this very property. The terms anodyne, purgative, diuretic, diaphoretic, sialagogue, &c, &c, owe their origin to, and at the same time attest, the knowledge which we have acquired from experi- ence of the determination to particular organs of the virtues of medicinal agents. A question suggests itself here, which should not be passed over unnoticed. The fatal effects of poisons we have seen reason to ascribe to the sympathy of the brain with the nerves of the part to which they are applied. When the upas antiar, however, or infusion of tobacco, is used, the heart, as has been stated, appears the organ primarily affected, while the functions of the brain are un- disturbed up to the instant of death. In such case is it not, it will be asked, more probable that the mischief is not done through the medium of the brain, but is the result of a direct sympathy be- tween the heart and the structure subjected to the action of the poison '( Such would certainly seem to be the most natural inference. There is, nevertheless, an experiment of Brodie's which points to the opposite conclusion. Having decapitated a dog, and then injected nine ounces of an infusion of tobacco into its stomach, the phenomena which were observed to follow were different from those which occurred in his previous experiments upon living animals. Thus, instead of suspending, it quickened the motions of the heart; and the voluntary muscles, instead of ex- periencing the usual paralysis, were affected for some time with strong convulsions. Its effects, in fact, in the living animal are of a sedative, in the decapitated animal of an exciting kind. These results, if they can be relied upon, would certainly seem to justify the conclusion that the upas and infusion of tobacco do not constitute any exception to the general rule, that the remote action of poi- sons is exerted through the brain. Of the circumstances which influence the action of a poison, the nature of the structure to which it is applied is that most deserving of notice. Ex- periment demonstrates that deleterious substances act with an energy proportional to the absorbing power of the tissue with which they are placed in contact; and this fact has been quoted as an argu- ment in support of a theory, as to their manner of action, which we have already seen reason to reject. This argument loses all force, if we adopt, with Morgan and Addison, the opinion that the nervous fibrils distributed to the serous lining of the arterial and venous systems, are particularly susceptible of morbific impressions. Upon this hypothesis, we can understand why poisons should be more noxious when applied to serous than to mucous membranes, and to mucous membranes than when placed in apposition with the external surface of the body, and without being driven to the necessity of supposing that when they get into the circulation they are conveyed to the organ which they appear principally to affect. The habits of individuals, as well as certain peculiarities of constitution usually referred to the head of idiosyncrasy, will also frequently modify in an important manner the operation of sub- stances taken into the stomach. Thus there are many persons, as is well known to every physician, who cannot partake of certain kinds of food with- out experiencing, shortly afterward, nausea, vom- iting, and purging ; in a word, without the occur- rence of the ordinary consequences of poisoning by the irritants. There are also individuals affect- ed so violently by minute doses of powerful me- dicines, such as arsenic, mercury and opium, that the fact is explicable only upon a similar principle. We have, on the other hand, many instances of persons who from habit had acquired the power of swallowing with impunity enormous doses of the most powerful poisons. The writer has at present under his care a girl of twenty-three years of age, affected with obstinate hysteria, who has been for some years in the habit of consuming daily four ounces of tincture of opium; and a multitude of similar cases are upon record. Alcohol, even of the strength in which it exists in Irish whiskey, is a poison of such energy that §iii in- troduced into the stomach of a rabbit produced death in a few minutes ; and yet there are in this city (Dublin) hundreds of individuals, particularly amongst the porters on the quays, who could swallow a pint without suffering perceptibly from the draught. In reference to this subject, Dr. Christison lays down a distinction, of the correct- ness of which doubts may, we think, be enter- tained. The immunity conferred by habit extends, according to him, merely to vegetable poisons, those derived from the mineral kingdom being as active in their effects upon the system after being used for a length of time, as at the very commence- ment. This statement is, we conceive, unfounded, for without referring to the very questionable case of Monsieur Chabert, who appeared to swallow arsenic, corrosive sublimate, &c, in handfuls, be- fore affrighted spectators, we need scarcely observe that it is the invariable'rule with the physician, when exhibiting these minerals medicinally, to be- gin with a very small dose, which he gradually increases, until at length such a quantity is given at once, and with impunity, as would, if adminis- tered in the first instance, have undoubtedly been productive of dangerous consequences. After what has just been observed, it must be obvious that the effects produced by a poison will, caeteris paribus, depend upon the quantity of it which has been taken. But not only do the symptoms vary in degree, according to the amount TOXICOLOGY. 411 of the deleterious agent which has been adminis- tered, but a variation of the dose will, in certain cases, altogether change the manner of its action. The oxalic acid furnishes a good illustration of this position. In a large dose it corrodes the mu- cous membrane of the stomach and alimentary tract, producing all the effects of an escharotic poison, while in a smaller one it appears to be absorbed, and to have its injurious influence pro- pagated, in the manner already explained, to re- mote organs. Corrosive sublimate and arsenic, administered in small quantity, produce certain specific effects which render them valuable as therapeutic agents, and in such cases are probably absorbed: but when taken in larger quantity, their action is chiefly directed to the mucous sur- face of the alimentary tract, which they inflame, and even occasionally destroy. The state of aggregation of a poison has con- siderable influence upon the degree of action which it exerts. When dissolved in a menstruum, it is applied to the living organs by the greatest possi- ble extent of surface, and is also in the best pre- dicament for being absorbed. Consistently with this it is found that solubility augments the energy of deleterious agents; and that, on the other hand, when insoluble, they act with a vastly diminished force. The state of aggregation, it is said, also affects the manner of action of a poison, and camphor has been quoted as illustrating this state- ment ; for, in mass, it has been found to produce gastric inflammation, while, when dissolved, tetanus and coma are the results which have been observed to follow its administration. The activity of a poisonous agent may some- times be greatly reduced by causing it to enter into chemical combination with a substance of a different kind: thus the corrosive action of an acid is diminished, and sometimes destroyed, by uniting it with an alkali, and that of an alkali by combining it with an acid. But, as Dr. Christison observes, this is only true of those agents which exert an exclusively local action. Poisons, the injurious action of which is the result of absorp- tion and sympathy, are not disarmed of their virulence by causing them to enter into chemical combination, unless their solubility is thus dimin- ished. If oxalic acid, for example, be united to lime, the resulting compound will be found inert, because of its insolubility; but if united to pot- ash, the salt thus formed will be absorbed, and produce the same train of symptoms which would be the result of the administration of dilute oxalic acid. It may be also here observed, that the com- mon practice of introducing fluids in large quan- tity into the stomach is not invariably proper. If the poison act merely as a local irritant, this action will be suspended by dilution ; but should it be a substance capable of entering the blood, and thus affecting remote organs, dilution, instead of counteracting, will augment its virulence, for it will render it more easy of absorption. From the preceding considerations certain max- ims of general practical application may be de- duced. When a poison is externally applied or internally exhibited, the first indication is obviously to remove it from contact with the organs to which it is applied, which, in the case of external poi- soning, may be accomplished by means too obvious to require description ; in the case of internal poisoning, by the exhibition of emetics, and by the use, if necessary, of the stomach-pump. If, in the latter case, or when the poison has been swallowed, these means do not succeed, and in- deed often in conjunction with them, it will be necessary to have recourse to antidotes. Now these are of two kinds : the chemical and the physiological, or those which chemically combine with the deleterious agent, and so alter its proper- ties or diminish its solubility as to render it inert; and those which excite in the system an action counter to that of the poison, or, at all events, one which neutralizes or prevents its usual inju- rious consequences. Of the first description of antidotes we possess many of well-established efficacy. Thus, common salt is an undoubted antidote to nitrate of silver, and sulphate of soda to muriate of barytes. In antidotes, however, of the other kind, or those which enable the system generally to resist the action of a poison, we are much more deficient. A few, however, are enu- merated. Ammonia and chlorine are frequently applied, and sometimes with success, as counter- stimulants to the nares in cases of poisoning by prussic acid. The antimonial preparations, parti- cularly tartar-emetic, are supposed to counteract the specific influence of mercury; and the salts of mercury, the deleterious influence of prepara- tions of lead. That some of these substances possess the powers ascribed to them there can be no question. The number of such antidotes, however, as has been already stated, is small, and the protecting influence which they exert such as we shall frequently fail in calling into action. Our chief reliance must, therefore, be placed upon the removal of the poisonous substance with as much despatch as possible from the structures with which it is in apposition; or upon the ad- ministration of innoxious re-agents capable, by virtue of a chemical decomposition, of neutraliz- ing their deleterious properties. If a poison which has been taken into the stomach has once passed into the vascular system, there is obviously no mode of recalling it or determining its expulsion from the blood. When, however, the absorption is the consequence of its application to a wound, this object may, according to Dr. Barry, be accom- plished by the prompt application of the cupping- glass. The blood in the vicinity of the extremi- ties of the divided vessels is thus sucked out, and when this treatment is resorted to sufficiently soon, the further consequences of the poison are, he alleges, completely prevented. With the appli- cation of the cupping-glass, it has been proposed by Verniere to combine the ligature of the chief vein leading from the wound, and to draw off subsequently the blood of the suspected vessel by venesection. The ligature of the vein alone is a sufficient protection according to Bouillaud, who has also established the interesting fact, that if occasionally relaxed for a few instants at succes- sive intervals, so that the poison may be gradually introduced into the system, its influence is, as it were, so diluted, as not to be productive of the injurious consequences which would otherwise follow. Proofs of poisoning. — In investigating a case of alleged poisoning, the circumstances which 412 TOXICOLOGY. must regulate the judgment which we shall pro- nounce, are only the following:— 1. The symp- toms which occurred previous to death; 2. the morbid appearances visible after death ; 3. the results of researches instituted for the detection of some deleterious substance in food, drink, or me- dicine, portions of which had been swallowed by the deceased, in matters discharged by vomiting, or in the contents of the alimentary tract; 4. the presence or absence of moral grounds for suspect- ing suicide or murder. Upon the latter topic it is not our intention to touch at all, as it belongs rather to a treatise on juridical medicine than to one on toxicology, properly so called ; and indeed we may add, falls more within the province of the civil magistrate than of the medical practitioner. It is now universally admitted that symptoms alone can seldom, if at all, enable us with certainty to declare whether poison has been administered or not. Their adequacy as data for the solution of this important practical question can scarcely be maintained ; for many natural diseases, such as cholera, gastritis, ulceration, and perforation of the coats of the stomach, intus-susceptio, strangu- lated hernia, peritonitis, melasna, haematemesis, &c. are attended by a train of symptoms not to be distinguished from those which accompany poison- ing by the irritants, or even the nareotico-acrids; and it would be equally unsafe, from the absence of the usual concomitants of poisoning, to infer that nothing deleterious has been administered, inasmuch as there are many cases upon record, as we shall find in the sequel, where the most power- ful poisons had been swallowed, and produced death, without the previous occurrence of those functional disturbances which they in general de- termine. The observations just made upon the symptoms are equally true of the post-mortem appearances. When organic lesions of the intestinal tract are present, they do not prove, and, when absent, they do not disprove the administration of poison ; for, on the one hand, deleterious agents of the narco- tic class destroy life without the production of any visible morbid change ; and, on the other, there is scarcely a pathologic consequence of poisoning by the irritants or nareotico-acrids, which is not occasionally simulated by the effects of spontaneous disease. The most decisive proof of a poison having been administered consists in its detection in me- dicine, drink, or aliments partaken of by the affected individual, in matters rejected by vomit- ing, or in the contents of the intestinal tube. To arrive, however, at this species of proof, the per- son who conducts the investigation must be pos- sessed of a variety of knowledge. He should be acquainted with the various products of the ani- mal, the vegetable, and the mineral kingdom; or, in other words, he should be a zoologist, botanist, and mineralogist, particularly the two former; for occasions will sometimes arise in which the na- ture of a vegetable or animal poison can only be deduced from the observation of its external cha- racters. But the success of his research will chiefly depend on the extent and accuracy of his chemical knowledge. In the vast majority of cases the deleterious agent is present in a form totally different from that which it presents in na- ture, and frequently in quantity so minute, or is such a state of combination, as to elude the in. vestigation of those most expert in natural history, These difficulties, however, create but little enj. barrassment to the accomplished chemist; for, by the resources of his art, the poison, if present, ia made to pass into other states of combination in which properties are developed so striking as to be sufficiently obvious, when the substance which is the subject of experiment is present only in an infinitesimal quantity, and so characteristic that they distinguish it from every other form of matter. But though chemistry unquestionably affords a more complete elucidation of the question under discussion than the other sciences which have been mentioned, and even in by much the greater proportion of cases leaves us nothing to desire, it must be admitted that it is not all-sufficient, and that difficulties sometimes present themselves with which it is unable to contend. Poisons, in fact, have been swallowed and produced death, and expert chemists have nevertheless been unable to detect the least trace of them either in the prima; viae, or in the matters discharged by vomiting or stool. Such failures are obviously highly inter- esting in a practical point of view, and it will be proper now briefly to enumerate the causes to which they may be referred. 1. Deleterious substances, as we have already seen, are occasionally taken up by the lymphatic vessels or veins, and conveyed into the sanguifer- ous system. A poison may, therefore, have been taken, and nevertheless be incapable of detection, in consequence of having been removed by the process of absorption. 2. When the noxious substance is derived from the vegetable or animal kingdom, it, generally speaking, admits with comparative ease of decom- position, and there is even good reason to believe that its nature may be so altered under the influ- ence of the digestive process, as no longer to exhi- bit the powers and properties which characterize it in a state of integrity. Should this opinion be well founded, and that it is there can be little doubt, the failure of chemistry to discover a poi- son in the prima? viae cannot be received as a positive proof that such may not have been swal- lowed, and have produced the observed injurious consequences. 3. The delicacy of chemical processes is ex- treme, and by means of them we are enabled to detect deleterious agents when present in quanti- ties amazingly small. These processes, however, have their limit, and it is easy to conceive the subject of experiment to include a quantity of a poison so minute as to elude the ablest and most experienced experimenter. 4. The precipitation of poisons in the insoluble form by the matters they meet with in the sto- mach, and their occasional incorporation with the coats of that viscus, constitute another great source of embarrassment, and the only additional one to which we feel it necessary to advert. These difficulties, however, it should be recollected do not establish the inutility of chemical investi- gation ; they only show that it is not all-sufficient, and that, in order to its conducting to a satisfac- tory result, the necessary experiments should be TOXICOLOGY. 413 made by a person of accurate and extensive in- formation, and one profoundly versed in the prac- tical operations of the science. Some one of the causes just recounted, or seve- ral of them combined, will sometimes render the results of our experimental inquiries uncertain or ambiguous; and in such cases we are bound, as far at least as respects an inculpated individual, to act as if the allegation of poisoning was alto- gether unsupported by proof. The symptoms, indeed, and morbid appearances may lead to sus- picions, but these it is necessary to suppress, for, as has been already seen, they may be utterly un- founded. It would probably be going too far to assert that the phenomena which precede, and the ap- pearances which are presented after death, may not in particular cases, especially when combined with evidence of a moral kind, constitute a degree of proof which would enable the physician to pronounce that death was the result of poison. Cases of this description may arise, and indeed are admitted by the best toxicologists. They are, however, we believe, of very rare occurrence, and we feel satisfied that in every instance the safer and the wiser course for the medical practitioner to pursue, when consulted in reference to a case of alleged poisoning, will be to abstain from the declaration of any opinion tending to criminate an individual, unless he can rest such opinion upon the basis of experimental proof. But, it may be asked, does the detection of a poison in, let us suppose, the alimentary tract, demonstrate that the individual died of the consequences of its action ? This question suggests considerations of a very important description, and which do not appear to have sufficiently arrested the attention of writers upon toxicology. It may be contended that the quantity found is much too small to per- mit us to conclude that it was the cause of death, or it may be said that the individual died from some other cause, and that the poison discovered had been introduced subsequently to his decease with the view of criminating an innocent person. To the first of these objections little weight should be attached, for it is impossible to assign what is the least dose of one of the active poisons capable of producing, in any given instance, a fatal effect; and, moreover, the amount of the de- leterious agent detected is no measure whatever of what may have been administered, inasmuch as a good deal of it may have been lost in the dejections and matters discharged from the sto- mach ; or it may have been removed by absorp- tion ; or, finally, when of animal or vegetable origin, decomposed in the alimentary tract. In dealing with the other case hypothetically suggested above, it will be essential to pay special attention to the symptoms present during life, and the appearances presented on dissection. Should these be of such a description as to correspond with those which are known to be characteristic of the action of the poison whose presence has been demonstrated, the case is divested of all dif- ficulty, and the proof of poisoning is complete. But, on the contrary, should the usual symptoms and morbid appearances not have been observed, doubts may unquestionably be entertained as to the cause of death, and it will be particularly in- 2k* cumbent upon us to inquire whether there be any- thing in the history of the case calculated to jus- tify a suspicion of the perpetration of the diaboli- cal act above suggested, to explain the presence of the poison. In the absence of circumstances to sustain such supposition, there are at least highly probable grounds for concluding that the deleterious substance in question was the cause of the death of the individual; for, as we have already seen, cases of decided poisoning have oc- curred in which the characteristic symptoms and morbid appearances were entirely wanting. Having disposed of those preliminary observa- tions, we shall now proceed to the examination of the various individual poisons, beginning with the irritants, and premising a brief enumeration of the symptoms and morbid appearances which are the results of their action upon the animal body. I. — Irritant Poisons. Symptoms and morbid appearances produced by the irritant poisons.—When a poison of this class is internally administered, the consequences which it produces are either the immediate and complete destruction of the parts with which it comes into contact, (an effect determined by the more powerful escharotics alone,) or such a degree of irritation as leads to inflammation of some part of the intestinal tract, succeeded by its usual con- sequences— increased vascularity, effusion of coagulable lymph and occasionally of blood, ul- ceration, softening, and sometimes preternatural thickening of the villous coat, and, lastly, gan- grene or slough. These effects are observable in the mouth and fauces, in the cesophagus, stomach, small and great intestines ; but they do not inva- riably occur in all these places, nor in all with the same degree of intensity. Such being the patho- logic condition of the intestinal tube, the accom- panying symptoms may be easily conceived. The epigastrium becomes the seat of a burning pain, and shortly after vomiting ensues, by which the contents of the stomach are first rejected, and subsequently a viscid mucus streaked with and often containing coagula of blood. The epigas- trium is obviously swollen, tense, and tender, and the distress felt in this region is greatly augmented by pressure. The inflammation is sometimes con- fined to the stomach, but more usually it extends to the lower intestines, producing general abdomi- nal pain and tenderness upon pressure, purging accompanied by tenesmus, and bloody dejections. When the deleterious substance belongs to the class of escharotics and is either very soluble in water, or has been administered dissolved in some chemical menstruum, the mouth, tongue, and throat are the parts which first suffer from its action, and to which the earliest symptoms are referred. These are burning pain and a sense of constriction in the fauces, preventing or materially impeding the act of deglutition, and the entrance of air into the lungs. In addition to these local symptoms it may be also observed that the consti- tution will be always found to have undergone serious general disturbance. The pulse will be rapid and feeble; the countenance will be flushed, or exhibit a deadly paleness; there will be ex- cessive prostration, and the entire body will be covered with a cold and clammy sweat. 414 TOXICC From the preceding summary it is obvious that the effects of poisoning by the irritants resemble very closely those which result from many forms of natural disease; and, such being the case, it will be proper to follow the plan of most writers on toxicology by enumerating the diseases in question, and briefly touching upon the diagnostic means which are known to be of most practical value. The maladies which may be mistaken for the effects of poisoning are bilious cholera, gastritis, enteritis, peritonitis, perforation of the stomach and intestines, melaena and haematemesis, colic, iliac passion, and obstructed intestine, whether produced by entanglement, intus-susceptio, or the strangulation of hernia; to which some add com- plete or partial rupture of the stomach, death from over-distension, and from cold water drunk while the body is strongly heated. The malady first mentioned,—namely, the bil- ious cholera, is undoubtedly that which is most liable to be confounded with the effects of irritant and escharotic poisons. Distinctions, however, do exist, and these have been very clearly pointed out by Dr. Christison. 1. Cases of poisoning by the irritants occur in which the throat is entirely unaffected, but in the bilious cholera it is, after the vomiting has begun, invariably the seat of heat, of pain, and of a pe- culiar sense of acridity. In poisoning, when these symptoms are experienced, they frequently pre- cede the vomiting, but this is never the case in cholera; and indeed in this disease they are, with much probability, referable to the contact of the irritating matters rejected from the stomach with the mucous membrane of the cesophagus and fauces. 2. In poisoning, the vomiting is frequently sanguinolent; in cholera, never. 3. The irritant poisons are much more fre- quently destructive, and produce death in a much shorter time, than the bilious cholera. Arsenic, for example, has often destroyed life in a few hours, while there are but a very few authentic cases upon record of cholera having terminated fatally until after the third day. Acute gastritis of the idiopathic kind is, accord- ing to many practical authorities, a disease which is never met with. Thus Dr. Abercrombie states that he " had never seen a case which he could consider as being of that nature ;" and Dr. Christi- son, who quotes him to this effect, makes a similar statement on the part of himself and several of his medical friends, and even seems disposed to deny the existence of any such affection. This opinion, however, is by no means generally received, for there are many alleged cases upon record of inflam- mation of the stomach arising from natural causes, and the writer of this article, unless he is much deceived, has had recently the management of one such. It would, indeed, be very singular if the stomach alone, of all the viscera, was exempted from being the subject of acute inflammatory action spontaneously arising. The determination of the question one way or another would, as Dr. Christison observes, be practically interesting; for if it were admitted that acute idiopathic gastritis does not exist, the symptoms and morbid appear- ances would frequently of themselves and without ) L O G Y. any chemical investigation, be sufficient evidence of the administration of poison. While, however, the point remains undecided, the following crite- rion is deserving of attention. In poisoning by the irritants, the throat is frequently affected before there is any evidence of gastric disturbance; but in idiopathic gastritis the burning pain and con- striction of the fauces, if present at all, are never observed until after the occurrence of vomiting. Enteritis, or inflammation of the intestines, may be confounded with the effects of the irritant poisons. The primary seat, however, of the pain and tenderness in such an affection, the almost uniform constipation of the bowels, and the mor- bid appearances, are sufficient to characterize it, In peritonitis also, the pain and tenderness are first referred to the abdomen, and are not confined to any particular region of it. The bowels are usually constipated, and, lastly, there is vascularity of the peritoneal coat, and effusion of lymph and serum visible on dissection ; circumstances which leave no doubt respecting the nature of the dis- ease. These last, however, cannot, unfortunately, be rendered available to the purposes of diagnosis during life. Spontaneous perforation of the stomach, an event much more common than was once sup- posed, is often attended by symptoms very analo- gous to those of irritant poisoning. This perfora- tion may be the consequence of scirrhus in the stage of ulceration, in which case it is but the termination of a chronic disease. It is sometimes, however, the result of recent morbid action, and then occurs in the centre of a superficial ulcer of variable size. Lastly, the coats of the stomach become perforated, not by ulceration, but in virtue of a softening or gelatinization which occupies the villous and even muscular coat, and finally destroys them as well as the peritoneal covering over a cer- tain extent of surface. The opinions of patholo- gists do not appear to be made up respecting the nature of this latter disease, some, particularly those of the French school, referring it to a mor- bid action set on foot in the living body, while others, with John Hunter, ascribe it to the solvent action of the gastric juice exerted after death upon the parietes of the stomach. When scirrhus of the stomach terminates in perforation, the nature of the malady will be pretty well determined by the history of the pre- vious symptoms, and is completely unfolded by inspection after death. In the second form of perforation, or that which is the result of recent disease, the diagnosis pre- sents greater difficulty, and cannot be made to rest upon any peculiarities in the form or appearance of the ulcer, for such peculiarities are not to be recognised. When, indeed, the mischief is the result of an irritant, or, as is more usually the case, of a corrosive poison, the deleterious agent is said to be sometimes found, if of difficult solubil- ity, adhering to the circumference of the perfora- tion. But this is obviously a circumstance which will but rarely be found to obtain, and to which, therefore, as a characteristic mark, but little value can be attached. In the destruction of the coats of the stomach by gelatinization or solution, the viscus, so far from exhibiting any degree of increased vascular- TOXIC TOXICOLOGY. 415 ity, is unusually white, the amount of corrosion is generally extensive, and the parietes are thinned down towards the edge of the orifice; all which circumstances are the very opposite of those ob- served when the perforation is the consequence of an ulcer caused by some deleterious agent. In this latter case the villous coat of the stomach, particularly the part adjacent to the perforation, is preternaturally vascular, the opening is small in size, abrupt, and exhibits thickened edges; to which we may add, as has been already remarked, that adhering to its edges will occasionally be found some remnants of the poison swallowed ; and, lastly, that in the colour of the circumference of the perforation we shall have indications of the nature of the agent by which it was produced, this colour being dark in the case of oil of vitriol, orange in that of iodine, yellow in that of nitric acid, &c. It is scarcely necessary to observe that in this, as well as in every other instance, where the symptoms and morbid appearances are not sufficienly characteristic, chemical analysis will be found our most valuable resource. When by means of it poison is detected in a perforated sto- mach, all obscurity is removed from the case; whereas, in the opposite event, still stronger grounds than any previously existing are estab- lished for tracing the injury in question to natural disease. (See the articles Perforation, Soft- kning of Organs, Stomach, organic diseases of the.) Stricture of the cesophagus is a common con- sequence of the swallowing of corrosive poisons, but they are not known to have ever produced its perforation, though this has sometimes occurred as a consequence of natural disease. The parietes of the great and small intestines are also sometimes penetrated by ulcers, but such are seldom, if ever, the results of the action of escharotics, for these will scarcely be permitted by the pylorus to pass into the lower intestines in such a state of concentration as to be capable of effecting the chemical corrosion of their coats. The simple irritants indeed may give rise to such perforations, and, when they do, there is no other mode than chemical analysis of determining whether they are due to such a cause or to spon- taneous disease. Colic is distinguished from poisoning by the absence of vomiting and purging, by the seat and the nature of the pain. Hrematemesis and melaena are sufficiently cha- racterized by the nature of the fluids discharged. In iliac passion stercoraceous matter is dis- charged by vomiting, a thing which never occurs in cases of poisoning. In intus-susceptio the pain commences at some part in the abdomen, and there is obstinate con- stipation. In strangulated hernia the same phenomena are observed, and, in addition, there is an external tumour. As to death from drinking cold water while the body is warm, from simple distension or rupture of the stomach, enumerated by some writers, such cases will, generally speaking, be readily distin- guished from the consequences of the administra- tion of poison, by the history and accompanying symptoms, or, at all events, by the post-mortem examination. [See, on all this subject, Mr. Tay- lor's Report on Toxicology, in Brit, and For. Med. Rev. for Oct. 1844, p. 533.] 1. Mineral Irritants. Aqua Chlorinli.—Water at the temperature of 60° absorbs about two volumes of chlorine, affording a solution having the yellowish-green colour and pungent odour of the gas. By keep- ing, it gradually loses its colour and smell, and is finally converted by the decomposition of water into a dilute muriatic acid, oxygen at the same time escaping. There is a formula for the preparation of an " aqua chlorinii" in the Dublin Pharmacopoeia, and it is pretty generally used as a tonic and anti- septic medicine in doses of from half a drachm to a drachm diluted with water. In an over-dose it would, no doubt, act as a powerful irritant, and produce inflammation and its consequences in the stomach and intestinal tube. In experiments per- formed by Orfila, five ounces of strong chlorine water killed a dog in twenty-four hours, and two ounces diluted with a double weight of water de- stroyed another in four days, the morbid appear- ances in the former being general redness and blackness, and in the latter ulceration of the villous coat. Aqua chlorinii may be recognised by its smell, and by its faculty of dissolving gold and of dis- charging vegetable colours. In testing this latter power a diluted solution of sulphate of indigo, or paper tinged with litmus, is the best substance to employ. A solution of albumen or the white of an egg is as good an antidote to its effects as can be exhibited. It combines with the chlorine, and is coagulated by it as it would be by corrosive sublimate. Chlorides of Lime and Soda.—»The chlo- ride of lime, as manufactured, is a white powder evolving a feeble smell of chlorine. A solution of it, however, is at present sold by the druggist for medical purposes, and this is likewise the form in which the chloride of soda is to be met with. The effects of these chlorides in large doses upon the animal economy have not been experimentally studied, but there is no doubt that, like chlorine itself, they would operate as irritants, and produce inflammation of the stomach and bowels. They are readily distinguished by evolving chlorine upon the addition of acetic acid, and thus afford- ing solutions which exercise powerful bleaching properties. By a solution of green vitriol they are immediately brought to the state of muriates, a form in which they may be considered as com- paratively inert. This salt would, therefore, seem an advisable antidote. Iodine and Hydriodate of Potash [Iodide of Potassium].—Iodine is a simple substance of a steel grey colour and metallic lustre, usually oc- curring in tabular prismatic plates, friable, evolv- ing an odour analogous to that of chlorine, and converted by the application of heat into a violet vapour. Wrhen exhibited in an over-dose to the extent, for example, of ten or twenty grains, it operates as an irritant poison, producing a sense Of constriction in the fauces, nausea, epigastric pain augmented upon pressure, vomiting,and colic. These symptoms, however, do not invariably occur, and, indeed, there is reason to believe that its in- 416 TOXICOLOGY. jurious action upon the economy has been over- rated. When administered for a considerable time in medicinal doses, effects have sometimes been observed finally to ensue analogous to those just described, and in addition, diarrhoea, pain and ten- derness in the region of the liver, cramps, general emaciation, and, in particular, a wasting of the larger glands, as the mammae and the testicles. In other cases complete anorexia, tremours, pal- pitation, and repeated syncope have been noted amongst the effects of its long-continued use. The morbid appearances which presented themselves in a case of slow poisoning by iodine recorded by Link, were redness of the mucous membrane of the stomach and intestines at several points, ad- hesion of the intestines by their peritoneal cover- ing, together with effusion into the abdominal cavity, distension of the intestinal tube with gases, and enlargement, accompanied by a slight red- ness, of the liver. Effusion into the sac of the pleura was also observed by him. The hydriodate of potash is also an irritant poison, producing all the symptoms and morbid changes which result from the use of iodine. The latter, according to Orfila, given to the extent of two drachms, killed a dog in seven days. The former, in a similar dose, caused death in three days in an experiment performed by Devergie. Notwithstanding these experiments, however, there can be no doubt that the action of the hydriodate on the human subject is much less energetic than that of iodine. In the solid form iodine is easily recognised by the application of heat, which converts it into a violet vapour. In the fluid form its presence may be demonstrated in a similar manner, or by the addition of a cold aqueous solution of starch, which affords with it a beautiful blue precipitate. The hydriodate of potash affords with the proto-salts of mercury a yellowish green, with the per-salts of mercury a scarlet precipitate, and with the solu- ble salts of lead a yellow precipitate very similar to chromate of lead. The hydriodate of potash may also be tested for by developing the iodine by the addition of a drop of nitric acid or chlorine water, and subsequently adding the solution of starch. Should the chlorine water be employed, care should be taken not to add an excess of it, for this would prevent the formation of the blue precipitate. To detect iodine in a coloured fluid containing organic matters, the following process, the outline of which is given by Christison, should be pur- sued. Supersaturate with caustic potash, evaporate to dryness, and ignite the residuum, taking care to apply but a low red heat, otherwise the iodide of potassium would sublime. Alcohol digested upon the residuum will take up the iodide of potassium, which, after the removal of the alcohol, and the addition of water, may be tested for with nitric acid and solution of starch, as already described. The conversion of any free iodine into hydriodic acid by sulphuretted hydrogen, directed by Chris- tison in the commencement of the process before adding the potash, is unnecessary ; for any iodate formed by the action of the alkali on the iodine is converted by the heat applied into iodide of potas- sium. Iodine is readily detected in the urine of patients using it as a medicine. It exists in the form of a hydriodate. In a case of poisoning by a large dose of iodine, starch, or what amounts nearly to the same thing, wheaten flour, would probably be an advisable an- tidote to exhibit. Sulphur and the Alkaline Hydrosulphu* rets.—Sulphur in medicinal doses operates as a laxative, and in larger ones irritates and inflames the intestinal tract. Its action, however, is not sufficiently energetic to entitle it to a detailed notice among the irritant poisons. Hydrosulphur et of Ammonia.—This com- pound, a solution of which is prepared for medi- cinal purposes by passing sulphuretted hydrogen into water of ammonia, proves an irritant to the different parts with which it is brought in contact and, like arsenic, inflames the stomach, whether introduced into this viscus, or applied externally to a wound. When internally administered to dogs and rabbits, Arnold found it to produce pal- pitation, excessive debility, slow breathing, and tetanic spasms. Its poisonous action has hitherto been witnessed only in the lower animals. A good antidote to exhibit would be a solution of green vitriol or some other soluble chalybeate salt. The other alkaline hydrosulphurets possess similar poisonous powers. Phosphorus.—This remarkable substance has been prescribed by some physicians as a general tonic and corroborant, and, in particular, to stimu- late the genital organs. Experiments made on the lower animals by Orfila prove it to be a pow- erful poison, producing irritation and inflamma- tion of the different parts of the intestinal tract; and there are two cases upon record in which, in very small doses, it has proved fatal even to man. In the primae viae it is converted into phosphoric acid, and partly into phosphuretted hydrogen, as may be collected from the alliaceous odour of the matters discharged by vomiting. The symp- toms and morbid appearances are analogous to those produced by the mineral acids, and which will be presently described. Phosphorus in the pure state possesses proper- ties so peculiar as to prevent it from being con- founded with any other known substance. In the form of phosphoric acid it may be distinguished by its fixity at a low red heat, by precipitating albumen after it has been ignited, but not before, and by producing, when neutralized with an alkali, in the latter case a yellow, in the former a white precipitate with nitrate of silver, both of which are soluble in ammonia and nitric acid. [A case of poisoning by phosphorus has been described lately in the journals. (London Lan- cet, Dec. 1843.)] Sulphuric, Nitric, and Muriatic Acid.— These acids offer examples of purely corrosive poisons, or of such as give rise to no other effects upon the system than what are the results of the disorganization they produce, and of the conse- quent impressions made by them upon the ner- vous system. They may be conveniently dis- cussed in conjunction, inasmuch as the symptoms they excite are very similar, and, as has just been observed, their manner of action is the same. Tartra, who has studied this subject with great TOXICOLOGY. 417 attention, describes two distinct varieties of fatal poisoning by the mineral varieties. The symptoms of the severer form are excessive debility, feeble and irregular pulse, general cold- ness and clamminess of the body, particularly of the extremities, repeated vomiting, the matters discharged being highly acid, and containing shreds of a coagulated mucus, occasionally por- tions of the villous lining of the cesophagus and stomach; a sense of burning heat in the throat and stomach, epigastric pain augmented by pres- sure, constipation of bowels, scanty urine, and, very generally, distressing tenesmus. [The diffi- culty of respiration is, at times, so great as to ren- der tracheotomy necessary, especially in young subjects. (Lond. Med. Gaz. xii. 220.)] Death relieves the patient from his sufferings sometimes in a few hours, but more generally not for two or three days; and there are even cases upon re- cord which did not prove fatal until the fifteenth. In the second variety we have, at first, all the symptoms which have been just enumerated, but these after a short time subside, and are succeeded by others of scarcely a less formidable description. The belly becomes distended, the respiration quick and embarrassed, the limbs are affected with pains and also with spasms. Profuse salivation sets in, and this after a little time is accompanied by a peculiarly offensive smell. The skin is dry and hot, the tongue parched, the pulse quick and strong; in a word, there is general fever: the vo- miting also recurs at intervals, membranous flakes being discharged in quantity; digestion appears almost suspended, and the individual finally sinks into a state of extreme emaciation. Where the poisoning does not terminate fatally, the recovery, nevertheless, is not always perfect. The stomach, in certain cases, ever after continues irritable, is often affected with pain, and frequently rejects its contents, particularly if the food em- ployed be of a stimulating nature, or such as the individual has not been in the habit of using. The morbid appearances are easily given, being such as might be anticipated from the symptoms just detailed, and from the corrosive nature of the poisonous agents in question. In the more rapidly fatal cases there is no wast- ing, and the body exhibits its usual appearance. Spots or stains are observed on the lips, and occa- sionally upon the adjacent parts of the face, of a dark brown colour when due to the sulphuric, and of a yellowish tinge when to the nitric acid. The teeth are similarly discoloured. The mucous membrane lining the mouth presents a hardened and glazed appearance. It is white or brownish from oil of vitriol, and yellowish or orange from aquafortis. The appearance of the pharynx is sometimes the same with that of the mouth; sometimes it is red and highly vascular, and the inflammation will also occasionally be found to have extended to the glottis and top of the larynx. The cesophagus is sometimes entirely destitute of its inner coat, (the same may be said of the mouth and pharynx,) and lined with an adventitious membrane of a yellow colour, and which adheres firmly to the subjacent parts. The stomach is in a state of distension from gases, its pyloric orifice is contracted, and it contains a quantity of serai- fluid matter of a dark colour, apparently composed Vol. IV. —53 of blood, mucus, and decomposed animal struc- tures. The mucous membrane itself is either in a state of high inflammation and vascular injection, the blood in the vessels being of a dark colour ; or its rugae are removed, as it were, by a process of solu- tion at several points; or studded with ulcers dis- charging pus; or, lastly, in a condition resembling a charred or half-burned towel. The walls of the viscus are sometimes traversed by a circular per- foration of variable size, the edges of which are thin at the margin, of a dark or yellow colour and invested more externally with a highly vascular ring or corona. Cases have occurred in which the cesophagus exhibited no morbid appearance whatever, and the only lesion to be observed in the stomach was a single perforation. The jeju- num and lower intestines are often unaffected, an exemption which is probably due, as Christison has suggested, to the spasmodic closing of the pylorus. In cases of perforation, peritonitis and its consequences, namely, the effusion of serum and lymph, are, of course, observed, unless death should very rapidly supervene. The blood has been found in large coagula or clots in the heart and great vessels, and these are described as exhibiting a particularly dark appear- ance. In the more protracted variety the body is in a state of extreme marasmus, the stomach is con- tracted enormously in size, and the calibre of the intestine so much reduced as to permit with, diffi- culty the passage of a quill at particular parts. The pyloric orifice of the stomach is also in a state of stricture or inordinate contraction. [Cases are on record in which two ounces of sulphuric acid have been taken without fatal re- sults. The smallest fatal dose which Dr. Christi- son (Treatise on Poisons, 3d edit. Edinb. 1836) has recorded, is one drachm. It was taken by mistake by a stout young man, and killed him in seven days. Mr. A. Taylor (Manual of Medical Jurisprudence, p. 90, Lond. 1844) says the smallest quantity which he has been able to meet with as seeming to have proved fatal, was in the following case : Half a teaspoonful of concen- trated sulphuric acid was given to a child about a year old by mistake for castor oil. The usual symptoms came on, with great disturbance of the respiratory functions, and the child died in twenty- four hours. The quantity taken could not have exceeded forty drops. (Lond. Med. Gaz. xxix. 147.) The smallest quantity of nitric acid, which Mr. Taylor finds reported to have destroyed life, is about two drachms. The smallest fatal dose of muriatic acid was about an ounce. The patients died in fifteen hours.] Tests for Sulphuric Acid. — The oily consist- ence, soapy feel between the fingers, power of charring bits of paper, slips of wood, &c, and of evolving considerable heat when mixed with water, are so many familiar characters by which the con- centrated acid may be recognised. To apply to it chemical tests, it will be convenient to reduce its strength by the addition of 6even or eight times its weight of water. Upon adding to it, in this diluted state, muriate of barytes, it will afford a 418 TOXICOLOGY. white precipitate insoluble in water or any other menstruum but boiling-hot oil of vitriol. This precipitate also, if mixed with an equal bulk of lamp-black and heated (rolled up in platina foil) to redness over the spirit-lamp, will yield to water a solution which will give, with acetate of lead, a black, and with tartar emetic, an orange precipi- tate. To this process it may be objected that the barytic precipitate is due, not to free sulphuric acid, but to a soluble sulphate existing in the acid solution. To obviate this objection, the acid should be boiled upon carbonate of barytes until it is neutralized, and any excess of carbonate re- moved by the action of muriatic acid. The resi- dual powder, if any, should be now subjected to the tests above described, for the purpose of prov- ing it to be sulphate of barytes. In practising this method, it is indispensable to attend to the following precautions:— 1. To wash the mixed sulphate and carbonate of barytes diligently with distilled water, for the purpose of removing the soluble sulphates before adding an acid to dissolve the carbonate. 2. To remove, before the addition of the carbonate of barytes, any free muriatic, nitric, or acetic acid; for these would form, with the carbonate of ba- rytes, barytic salts, which would be decomposed by any soluble sulphate present, and afford a sul- phate of barytes even though there were no free sulphuric acid. To remove the acids which have been mentioned, it will be sufficient to evaporate the solution, at a temperature of about 300 de- grees, in a porcelain capsule, as long as acid va- pours continue to be evolved. The chemical evidence in support of poisoning by oil of vitriol, is supposed not to be complete unless the acid be detected in the free state. This, however, cannot always be accomplished, even in cases where it has been swallowed in the uncombined form. Should antidotes, such as the carbonates of lime and magnesia, have been exhi- bited, they will neutralize it, and there are even cases on record in which this has been achieved by the spontaneous development, in the stomach, of ammonia, the result of incipient putrefaction. For these reasons, and because the normal secre- tions and usual contents of the stomach contain soluble sulphates, the detection of the acid in a state of combination can by no means be con- sidered, per se, as a proof that sulphuric acid was swallowed. But when the amount of these sul- phates is unusually large, (and their amount may be easily ascertained by the addition of muriate of barytes, to the washings of the precipitate got \>y neutralizing the sulphuric acid with carbonate of barytes, as already explained,) strong grounds are undoubtedly laid for suspecting the adminis- tration of oil of vitriol, and these will, of course, be strengthened by the occurrence of any circum- stances in the history of the case which may ac- count for its neutralization. The existence of stains upon the clothes fre- quently affords important collateral evidence in cases of suspected poisoning by the mineral acids. From the stained parts also, by digestion with dis- tilled water, a sufficiency of free acid may often be extracted to subject to the operation of tests. A portion of it, however, is always in a state of combination, usually with ammonia. Tests for Nitric Acid.—Nitric acid, when pure, is a colourless fluid, but, as usually met with, it presents an orange tinge, owing to the presence of nitrous acid. When strong, it emits white va- pours in the air, stains the cuticle of a per- manent yellow, which is heightened by contact with ammonia, and dissolves silver, copper, zinc, iron, &c, with the copious evolution of orange vapours. In the pure state, or when merely diluted with water, it is identified by the following properties :— 1. When brought into contact with copper, a colourless gas (the nitric oxide) is given off, which, by contact with the oxygen of the air, becomes an orange vapour, and when passed into a solution of green vitriol, communicates to it a dark colour. 2. With an aqueous solution of urea it affords a precipitate composed of crystalline pearly scales. 3. It discharges the colour of sulphate of indigo, or rather changes it to an orange. 4. By the addition of muriatic acid it acquires the power of dissolving gold. 5. When touched by a crystal of morphia the latter acquires a deep red or orange colour. The first test is quite decisive, but it can scarcely be applied in a satisfactory manner where the quantity of acid is but small. In such a case the better mode of proceeding will be to saturate the acid with potash, and, having evaporated the solu- tion nearly to dryness, to add sulphuric acid and a couple of crystals of green vitriol. The sulphu- ric acid will liberate the nitric acid, and this, by contact with the protosulphate of iron, will be resolved into oxygen and nitric oxide, the latter of which produces a dark annulus about the crystals, in consequence of being absorbed by such portion of them as has been dissolved, while the former converts more of the solution into a persalt. The second method given above is open to the objection of urea affording with oxalic acid a similar precipitate. The characters of the oxalic, however, are so distinct from those of the nitric acid, that no difficulty can occur in distinguishing them from each other. The accuracy of the sulphate of indigo test, first proposed by Liebeig, has been called in question by Dr. O'Shaughnessy, who states that a similar discoloration is produced by several other agents besides the nitric acid. This would, undoubtedly, be effected by the chloric, iodic, and bromic acids, which resemble the nitric acid so closely in composition, also by sulphurous acid, protomuriate of tin, and, according to Dr. O'Shaughnessy, by permuriate of iron. We cannot, however, sub- scribe to the statement that pure sulphuric or muriatic acids are capable of discharging the blue colour of sulphate of indigo. Should muriatic acid include, as it frequently does, permuriate of iron, sulphurous acid gas, or a trace of chlorine, iodine, or bromium, it will no doubt act as a deco- lorizing agent; but, when entirely free from such impurities, we find it to exert no action whatever on the sulphate of indigo. Dilute sulphuric acid we consider as equally inert, but, in the concentra- ted state and at the temperature of ebullition, sulphurous acid is developed, to which any bleach- ing powers exerted are, we believe, to be ascribed. If these views be correct, the solution of indigo in sulphuric acid may with proper precautions be TOXICOLOGY. 419 employed as a valuable auxiliary test in searching for nitric acid. The fourth method of conducting the investiga- tion was first suggested by Dr. Marcet, and is founded on the fact that when nitric and muria- tic acids are mixed, chlorine is set free, an agent which possesses the power of dissolving gold. A similar power, and one due to the same element, is developed upon adding muriatic acid to the chloric, iodic, bromic, or chromic acids. From the rarity, however, of these acids, (they do not, in fact, exist as natural products,) the process cannot, on such account, be considered as practi- cally impugned. In practising the last of the methods noticed above, it is essential that the morphia be not perfectly pure, for in this state its colour is not affected by the nitric acid. The sulphuric and muriatic acids communicate, not a red, but a dark colour to crystals of morphia with which they are heated. When the quantity of acid is small, (which indeed will be always the case where it is sought for in stains made on the skin or clothes, after being extracted from these by repeated diges- tions with distilled water,) the solution should be saturated with potash, and the residuum obtained by evaporation to dryness introduced into a glass tube, and heated with a few drops of oil of vitriol so as to liberate the nitric acid. If the latter be present, it will communicate a deep orange colour to a crystal of morphia dropped into the tube. This method, which is susceptible of great delicacy, was first proposed by Dr. O'Shaughnessy. When the nitric acid is sought for in the intesti- nal tract, where it is necessarily mixed with animal fluids, it should, as before, be neutralized by potash and crystals of nitre, if possible, obtained by filtration and evaporation, from which the nitric acid is subsequently to be liberated by means of oil of vitriol. The animal matter will sometimes prevent in this process the crystallization of the nitre ; and if the filtered solution be merely evapo- rated to dryness, it will, in consequence of the presence of chloride of sodium, frequently evolve, upon being heated with the oil of vitriol, chlorine, and no nitric acid. The evolution of the chlorine, however, may, upon the principle of Marcet's method, be looked upon as proving the presence of a nitrate, so that further investigation becomes unnecessary. To apply, indeed, the test by mor- phia, it will be necessary to develop the nitric acid itself; and when this is deemed essential, we must resort to the following method laid down by Christison. Saturate the fluid with potash, filter, and then add acetate of silver as long as there is any precipitate. This will throw down the chlorine of the common salt in the form of chloride of silver, and will also determine the coagulation of the animal matters present and the clarification of the fluid. Upon now filtering a second time, evaporating to dryness, and acting with oil of vitriol upon the residuum introduced into a glass tube, nitric acid will be set free and may be tested by the introduction of a crystal of morphia into the tube. [In the Annual Report of Berzelius, cited by Dr. T. R. Beck, (Amer. Journ. of the Med. Sciences, Oct. 1843, p. 498, from the Pharmaceutical Transactions, March, 1843,) an easy method of determining the presence of nitric acid is given on the authority of M. Berthemot. About a drachm of concentrated sulphuric acid, free from nitric acid, is to be placed in a glass, and to this are added a few drops of the liquid suspected to con- tain nitric acid. These are mixed together with a glass rod, and then, with the moist extremity of the rod, a small piece of brucia is introduced into the mixture, and the whole stirred together. If nitric acid be present, a red colour will be imme- diately developed, which will afterwards pass to yellow. If there be no nitric acid, the brucia will not dissolve. By this means, the presence of -pri^th part of nitric acid may be detected in a liquid.] Tests for muriatic acid.—The action of this acid when concentrated is analogous to, but less intense than that of the sulphuric acid, and the same may be said of the symptoms and morbid changes it produces. In the pure state, or when merely combined with water, it is at once detected by the addition of nitrate, or, what is better, sulphate of silver, which affords with it a preci- pitate, the chloride of silver, possessing the follow- ing characters: — it is white, but blackens upon exposure to light, particularly the most refrangible rays ; it is insoluble in nitric acid, but dissolves readily in aqua ammonia? and the solutions of the alkaline hypo-sulphites; lastly, it fuses into a sectile horny mass at a temperature considerably below a red heat. Should the acid be sought for in the contents of the stomach, the formation of a precipitate on the addition of the soluble salts of silver will take place, even though no muriatic acid has been swallowed, in consequence of the presence in this viscus of the chlorides of potas- sium and sodium, and the muriate of ammonia. In such case it will be necessary to begin by dis- tilling off the free acid, which may be accomplished by means of a gas-bottle furnished with a tube bent twice at right angles, and dipping into a bottle of distilled water to within a short distance of the surface of the fluid. By this process the free muriatic acid is distilled over, and a solution obtained which may be treated in the manner already described when speaking of the pure acid. In investigations of this description, it should be recollected that pure muriatic acid exists in the stomach during digestion in association with the acetic, as has been amply proved by the experi- ments of Prout, Gmelin, and Lassaigne. The quantity, however, is so small, not exceeding in an experiment of Prout's, in which the gastric secretion was morbidly acid, a quarter of a grain in the ounce, that this natural source of the acid can scarcely create any serious embarrassment to the toxicologist. Treatment of poisoning by the mineral acids. —This must of course consist either in removing the acids from contact with the animal structure on which they are acting, or in depriving them, by the exhibition of proper antidotes, of their in- jurious powers. The latter is much more easy of execution than the former, and is therefore that usually attempted. Their escharotic action may be suspended by copious dilution, or by combin- ing them with bases so as to convert them into innoxious saline compounds. It should, however, be recollected that the strong acids, particularly 420 TOXICOLOGY. the nitric and sulphuric, are very rapid in their action on animal textures, and that we can, there- fore, never expect to accomplish, by the adminis- tration of either variety of antidote, any thing further than the suspension of the corrosive in- fluence which they have been exerting. A certain amount of mischief is always necessarily inflicted, the effects of which can only be combated by ge- neral medical treatment. Water being always at hand should be repeatedly and copiously exhibited. The poison thus diluted is no longer a corrosive, but, in consequence of the injury already done to the mucous membrane, it operates upon it as a powerful irritant. To annihilate this effect we must combine the acid with some base, and that most, likely to be at hand, and which at the same time answers the purpose well, is powdered chalk, limestone, or old mortar. If carbonate of mag- nesia be within reach, it is preferable; but the magnesia usta, which is frequently recommended by toxicologists, should on no account be em- ployed. The heat, in fact, which results from its union with an acid is such as would of itself pro- duce inflammation, or even disorganization of the stomach. In the absence of these bases a solution of soap may be advantageously exhibited ; but the alkaline carbonates, if administered at all, should be given with caution, inasmuch as they are them- selves poisonous substances. The after treatment must be antiphlogistic, and conducted upon gene- ral principles. [Sulphate of Indigo has been taken acci-! dentally, and has proved fatal. It is a solution | of indigo in sulphuric acid, and produces the same effect as the latter. It may be suspected when, along with the symptoms of poisoning by sulphuric acid, the lining membrane of the mouth has a blue colour. The vomited matters will, likewise, be tinged blue; and, in the case of a girl, who swal- lowed an ounce, and died eleven hours afterwards, it was remarked, that the urine which she passed was tinged blue. After death, the mucous mem- brane of the lower part of the intestinal canal presented patches of a blue colour. In another case, observed by Orfila, a child which died in seven hours and a half, the urine was also tinged blue. (Taylor, Manual of Medical Jurispru- dence, p. 97, Lond. 1844.)] Oxalic acid. [Binoxalate of potash, Salt of sorrel.]—There is no poison more interesting to the toxicologist than the oxalic acid. It has been very frequently taken in mistake for Epsom salt, to which it bears a close resemblance; ami from the certainty and rapidity with which it destroys life, and the facility with which it can be pio- cured, it is very likely to be, and actually has been, employed as an instrument of murder. [fn the return of the coroners of England for 1837-8, there were nineteen cases of poisoning by this substance, of which number fourteen were the result of suicide. (Taylor, Op. cit. p. 117.)] When injected in small quantity into a vein, it proves almost immediately fatal, and it is scarcely less energetic in its action when applied to a wound or introduced into the sac of the perito- neum or pleura. It is a powerful poison also when taken into the stomach. The structure through which it acts with most slowness is the subcutaneous cellular tissue. The entire subject of poisoning by oxalic acid has been investigated with much success by Drs. Christison and Coin- det, in a joint paper published by them in the nineteenth volume of the Edinburgh Medical and Surgical Journal. The symptoms consequent upon swallowing a solution of the acid vary with the strength of the solution and the quantity of it which has been administered. When the solution is strong, and a considerable quantity of it has been swallowed, a very severe pain is almost always immediately felt in the stomach, and sometimes in the fauces, which after a little time is followed by violent vomiting,* cold clammy skin, and feeble or even imperceptible pulse. A drowsy or torpid state next ensues, characterized by great languor and debility, during which death takes place without being preceded by any other remarkable pheno- mena. The symptoms, in fact, first observed are those which belong to a powerfully irritant or cor- rosive agent, while those subsequently developed are such as one would expect to result from the exhibition of a narcotic poison. The former class are those which have been most prominent in in- dividuals of the human species poisoned by the acid. When oxalic acid is diluted with about twenty times its weight of water, like the mineral acids it loses its irritant action, but, unlike them, is still poisonous in a high degree. According to the researches of Coindet and Christison, it attacks in this form the heart, the brain, and the spinal cord, producing, when swallowed in quantity, paralysis of the first-mentioned organ, and in smaller doses a fatal coma, which is usually preceded by tetanic spasms, particularly of the respiratory muscles, fixing the chest, and thus determining asphyxia or suffocation. These results have been arrived at by means of experiments on the lower animals, and, in all probability, correctly represent those effects which, under similar circumstances, would be witnessed in the human species. Opportuni- ties, however, of studying these seldom present themselves, for when the acid is taken accidentally, or designedly administered as a poison, the solu- tion is usually strong and swallowed in considera- ble quantity. From this enumeration of symptoms it is obvi- ous that oxalic acid exercises on the economy an influence independent of its irritating action, and which is principally directed to the nervous sys- tem. We shall not revive here a topic which has been already sufficiently discussed, by inquiring into the precise medium through which its action is exerted ; but it would be improper to omit men- tioning that chemical experiment has failed in de- monstrating its presence in the blood, even in a case where eight grains of it were injected into the femoral vein of a dog, although it is very easily detected in blood drawn from the arm, and into which it is introduced subsequent to venesec- tion. Dr. Christison concludes that when intro- duced into the vascular system it is decomposed in virtue of some unknown vital action; and it must be admitted that the fact just referred to, ♦Cases have been recorded in which vomiting did not occur; [and ons is related by Mr. Taylor, whtre ahniil two ounces of the poison had been swallowed in which there was no pain.] TOXICOLOGY. 421 combined with the facility with which it is re- solved into carbonic acid by any thing which will supply it with oxygen, gives countenance to this opinion. [It has been a question how much oxalic acid is necessary to occasion fatal results; but this cannot be positively assumed. Anomalous cases are occasionally witnessed in which considerable quantities have been taken, been rapidly rejected by vomiting, and the patient has recovered. When the dose is upwards of half an ounce, death has usually resulted; but Mr. Taylor (Op. cit. p. 118,) refers to the case of a man who recovered after having taken an ounce of the crystallized acid. The period at which death takes place varies. Of two cases, where about two ounces were taken, one man died in twenty minutes, the other in three-quarters of an hour. One case is recorded in which death resulted in ten minutes. On the other hand, fatal results have not occurred until thirteen hours and more.] The post-mortem appearances closely resemble those presented after poisoning by the mineral acids. Marks of inflammation are to be seen in the cesophagus, the stomach, and sometimes the small intestines, such as unusual vascularity of those parts, softening and extreme pulpiness of the villous coat, portions of which are sometimes quite destroyed, and the presence in the stomach of a dark fluid resembling coffee-grounds, and ob- viously including a considerable quantity of blood. Cases, however, have occurred in which these morbid changes were altogether wanting, but it is worthy of remark that in such death occur- red very soon after the administration of the poi- son. [Tests for oxalic acid.—Oxalic acid reddens litmus, and is volatilized by heat. Nitrate of sil- ver, added to a solution of it, yields a white pre- cipitate of oxalate of silver, which is soluble in nitric acid, and, when dried and heated on the point of a knife by the flame of a candle or spirit- lamp, becomes brown on the edge, detonates very feebly, and is completely dissipated. With lime- water, or a solution of chloride of calcium, it yields a white precipitate of oxalate of lime, inso- luble or nearly so in excess of oxalic acid, readily soluble in nitric acid, and slightly so in chloro- hydric acid. If the precipitate be collected, dried, and calcined, it yields quicklime. With sulphate of copper, oxalic acid yields a bluish-white pre- cipitate of oxalate of copper. To detect oxalic acid in oxalate of lime, boil the oxalate with a solution of carbonate of potassa for two hours, and filter. The liquid will contain oxalate and carbonate of potassa. Add acetate of lead, collect the precipitate of oxalate and car- bonate of lead, suspend it in water, through which sulpho-hydric acid is to be passed; filter, to get rid of the dark sulphuret of lead; boil the clear liquor, which is a solution of oxalic acid, and test, as above, for the free acid. If the oxalate of lime be mixed with organic matters, the filtered liquor must be feebly acidu- lated with nitric acid before adding the acetate of lead. The acidulated liquor must be filtered, ren- dered faintly alkaline by carbonate of potassa, again filtered, then mixed with acetate of lead, and the precipitate treated as above. (Pereira, 2jl Elements of Mat. Med, and Therap., Amer. edit. by Dr. Carson, i. 307. Philad. 1843.)] Treatment of poisoning by oxalic acid.—The indications are, to remove the poison by emetics or the stomach-pump, and to neutralize what may not have been removed by the exhibition of appro- priate antidotes. With respect to the removal of the poison, it should be borne in mind that its action is ex- tremely rapid, and that it will be inexpedient to exhibit drinks with the view of washing it out of the stomach, for these, by diluting the acid, will promote its absorption. In fact it will, generally speaking, be the hetter plan to lose no time in attempting its expulsion, but proceed at once to the exhibition of chalk, or the carbonate of mag- nesia, both of which have been proved by direct experiment adequate to the perfect counteraction of its injurious action. The alkaline carbonates will not answer, for Christison and Coindet have found the soluble oxalates nearly as destructive as the acid itself, and moreover, if administered in excess, these carbonates themselves operate as poisons. [Where the usual antidote is not at hand, Sir Geo. Lefevre (London Lancet, June, 1844,) has reconfmended the administration of old mortar, finely powdered, or even the plaster scraped from a wall.] Potash, Soda, Lime, &c. and their Carbo- nates.—The modus operandi of the alkalies and their carbonates [Pearlash, Soap-lees,] is the same, both acting, in small doses or diluted solution, as simple irritants, but in larger quantity or more concentrated form as escharotic poisons. Such being the case, the symptoms they produce may easily be conceived. Great irritation, or even burning pain, is felt in the mouth, cesophagus, and stomach, accompanied by difficulty of deglu- tition. These are succeeded by bloody vomiting, epigastric and abdominal pain and tenderness, cold sweats, excessive prostration of strength, bloody dejections, subsultus, &c. Such are the symp- toms which have been observed to follow upon the administration of three ounces of the carbonate of potash. When the quantity swallowed is smaller, the effects are less severe, and are by Christison compared to those which characterize an attack of acute gastritis : in this latter case the recovery is sometimes rapid and complete. This, however, does not always occur. A train of phe- nomena indicative of a chronic inflammation and serious derangement of the intestinal mucous membrane, such as incessant vomiting and purg- ing, pains in the entire abdominal region, occa- sionally set in, and the patient ultimately dies in a state of extreme emaciation, the inner coat of the alimentary canal having been disorganized to such an extent as to be incapable of subserving the purposes of digestion or assimilation. There is, it should be observed, an instance of poisoning by carbonate of potash upon record, in which the injury sustained was limited to the cesophagus, where stricture was produced, and the patient ulti- mately perished of starvation. This summary of symptoms has, in strictness, reference only to poi- soning by the carbonate of potash, for instances of its effects upon the human subject have alone been recorded. There can, however, be no doubt 422 TOXICOLOGY. that the carbonate of soda would operate in a similar manner, and experiments upon dogs, many of which were instituted on this subject by Orfila, justify us in concluding that the caustic fixed alka- lies differ from their carbonates, not in the kind but the degree of action which they exert upon animal textures. [The quantity of any of these poisons required to destroy life is not known.] Upon dissection, the alterations of texture which have been observed are softening, and occa- sionally destruction, of the membrane which lines the mouth, fauces, and cesophagus, together with high vascularity and partial removal of the villous tunic of the stomach. The parietes of this latter organ are also some- times the seat of perforations, and in these cases peritonitis and its consequences, the effusion of serum and lymph, and extensive adhesions, are invariably witnessed. The calibre of the oesopha- gus, too, is often greatly reduced in size, and, as has been already observed, the diminution is such, in some instances, as to amount to stricture. Treatment.—The first curative step consists in neutralizing the poison, whether it be alkali or alkaline carbonate, by causing the patient to swal- low a quantity of vinegar, or, what will answer well, dilute sulphuric or muriatic acid. Oil also has been recommended, but that can evidently not operate as an antidote in the case of the carbonates. After the neutralization of the alkali has been achieved, the subsequent treatment must be con- ducted upon general antiphlogistic principles. Fe- brile action must be restrained by venesection or the repeated application of leeches. Cool and mucilaginous drinks must be exhibited, and jelly, milk, and such other nutritious matters as are easily swallowed and digested, alone permitted. Lime possesses strong corrosive qualities, and may be considered as exercising on the system powers similar to those exerted by caustic potash. The symptoms, however, to which it gives rise are more exclusively those of an irritant poison. Two cases are on record, in which, internally ad- ministered, it has proved fatal to the human sub- ject. The alkalies and their carbonates have a pecu- liarly acrid taste. They change turmeric to a reddish brown, the infusion of blue cabbage to a green, and restore the colour of reddened litmus. The former may be distinguished from the latter by their greater degree of causticity, and by dis- solving in acids without effervescence. Potash affords, with an excess of tartaric acid, a white crystalline precipitate, but this does not occur with soda. As additional distinctions, it may be men- tioned, that potash is precipitated by bichloride of platinum as a yellow crystalline powder, by car- bazotic acid in crystalline scales, and by hydrofluo- silicio acid in a gelatinous form, re-agents which have no such effect upon the mineral alkali. The only direct mode of testing for the latter consists in heating the substance under examination on the end of a platina wire before the blowpipe, when, if soda be present, the cone of flame beyond the wire is tinged of a deep yellow. These tests are equally applicable to all the neutral salts of both bases. Nitrate of Potash.—This salt influences the system in a double manner. Its principal action is that of a local irritant, but it also occasionally produces secondary effects upon remote parts, dis- turbing in a remarkable manner the brain and nervous system. The symptoms which first pre- sent themselves, when from half an ounce to an ounce has been swallowed, are such as are pro- duced by other powerful irritants, namely, acute epigastric and abdominal pain, and violent vomiting and purging, the matter discharged being frequent- ly mixed with blood. These, however, are very generally followed by indications of cerebral irri- tation, such as great debility, tendency to faint, tremours, and convulsions. The morbid appearances are inflammation of the stomach and intestines, which, though princi- pally affecting the villous coat, is not confined to it, but extends also to the other tunics of the ali- mentary tube. Upon the subject of treatment it is sufficient to observe that the poison is to be removed from the stomach by emetics or the stomach-pump, and the patient is to be made to drink largely of mucilagi- nous fluids, which will dilute the salt, and thus, at the same time, render it innoxious and contri- bute to its more easy and perfect elimination. The subsequent treatment must be regulated by general principles. Nitre may be recognised by its crystalline form, which is a six-sided prism terminated by a dihedral summit, unalterable by exposure to the air. Thrown upon a red-hot coal, it enlivens its combustion, and when treated with sulphuric acid, nitric acid va- pour is evolved upon the application of heat. The nature of the base may be demonstrated by the application of the tests mentioned in the preceding article. [Bitartrate of Potassa, Cream of Tartar, Argol.—Cream of Tartar is not generally re- garded as a poison, yet it has proved fatal in at least one instance, which occurred in London, in 1837. A man, aged 37, took four or five tea- spoonfuls of cream of tartar. He was seized with violent vomiting and purging, with pain in the abdomen, thirst, feeble pulse; and the thighs and legs appeared to be paralyzed. The fluid vomited was of a dark green colour, and the evacuations were of the colour of coffee-grounds. Death took place in about 48 hours. On inspection, the mu- cous membrane of the stomach and duodenum was found highly inflamed, the cardiac portion of the former being of a deep red colour, with some spots of black extravasation. The stomach con- tained a thick brown fluid, coloured by bile. The whole of the intestinal canal was more or less in- flamed. (Taylor, op. cit. p. 130.) Sulphate of Potassa.—It is only of late that any question has arisen in regard to the poisonous character of this salt. A lady, about a week after delivery, took, by the prescription of a physician, about ten drachms of the sulphate of potassa, in divided doses, as a laxative. After the first dose, she was seized with severe pain in the stomach, nausea, vomiting, purging, and cramps in the ex- tremities. These symptoms became more and more aggravated, and she died in two hours. On inspection, the mucous membrane of the stomach and intestines was found pale, except the valvule conniventes, which were reddened. The stomach TOXICOLOGY. 423 contained a large quantity of reddish coloured I liquid, which, on analysis, was found to contain I only sulphate of potassa, and no trace of any known irritant poison. The experts ascribed death to the sulphate of potassa given in an unusually large dose, whereby it acted as an irritant poison on a person whose constitution was already much debilitated. (Annales d'Hygiene Publique, Avril, 1842.) Since then, a case has occurred in England, in which a question arose as to this salt having acted as an irritant poison. It was that of the Queen v. Hayes, and was tried at the Central Criminal Court, in October, 1843. The prisoner had given to the deceased, the night before her death, two ounces of sulphate of potassa, dissolved in water; and it was affirmed, that a fortnight previously to this, she had taken as much as a quarter of a pound of the salt. The woman supposed herself to be pregnant, but she was not, as was shown on dis- section ; and the prisoner was charged with having given her the salt with the intention of causing a miscarriage. She died with the symptoms of irri- tant poisoning complicated with lesion of the ner- vous centres. (Taylor, Report on Toxicology, Brit. 4- For. Med. Rev. Oct. 1844, p 556.) MM. Merat and De Lens (Diet. Univers. de Maliere Medicale, art. Potassium,) state that in 1821, an ounce of the salt, taken by mistake in a glass of tisane, instead of the salt of Seidlitz, caused a sense of burning and pain in the epigastrium, vomiting, &c.; and they refer to another case, in which half a drachm caused hypercatharsis and death in a patient affected with fever. Other similar cases have been recorded. (Taylor, loc cit.)] Ammonia and its Sesquicar Donate.—The volatile alkali, as is well known, possesses caustic powers when applied to animal structures, but the experiments of Orfila upon dogs establish that its action is not exclusively of this kind. When given in a poisonous dose, effects indicative of dis- turbance of the spinal system, such as tetanic spasms and convulsions, invariably supervened, and, unless when death very speedily took place, the stomach was found extensively inflamed. The subcarbonate of the shops (sesquicarbonate) acts precisely in a similar manner. The treatment, as far at least as antidotes are concerned, should consist of the copious adminis- tration of mucilaginous drinks containing a dilute acid. Solutions of ammonia and its carbonate have both a very pungent smell, strike an azure blue with a small quantity of a dilute solution of sul- phate of copper, and give yellow precipitates with muriate of platina. They may be distinguished from each other by the addition of an acid, which causes the carbonate alone to effervesce, or by a drop of a solution of muriate of lime, which is unaffected by the ammonia, but affords with its carbonate a white precipitate. We shall have to return to ammonia when we speak of the gaseous poisons. Gold.—The only preparation of goki which requires notice here is that usually known under the name of muriate. This salt was once employed by the physician in the treatment of syphilis and other affections, and an attempt has recently been made to revive its use. It is also occasionally I manufactured in quantity, or at least an acid solu- ' tion of it, in one process for purifying the standard gold. When this solution is concentrated and permitted to cool, it affords prisms of a ruby colour, which are deliquescent and very soluble in water, and, when added to a proper proportion of chloride of sodium, form a beautiful double salt, which crystallizes in prisms or tables, and is permanent in the air. Both these preparations, the simple and the double salt, are powerful escharotics, un- dergoing decomposition, almost immediately upon contact with the animal structures to which they are applied. The symptoms, therefore, which they produce are exclusively local, or such as result from the action of the simple irritants. Nitrate of silver added to these preparations will detect their muriatic acid, and protomuriate of tin their base, which it precipitates in the form of a purple powder, the purple of Cassius. As another distinguishing character of these prepara- tions, it may be mentioned that they stain the cuticle of a beautiful purple colour. Green vitriol, which throws down from their solutions the gold in the metallic state, is the best antidote to administer where any of it is supposed to remain undecomposed in the stomach. Nitrate of Silver.—This salt ranks with the local irritants, for though it is in all probability partially absorbed,* its injurious effects are, un- doubtedly, the results of the disorganization which, as a powerful caustic, it produces in the textures to which it is applied. When any animal tissue is touched by it, it produces an eschar, being at the same time itself decomposed, and to such an extent that some of the silver is reduced to the metallic state. Its corrosive action may, therefore, be safely referred to its oxygen and acid, both of which are set free. It is not necessary to detail the symptoms of poisoning by lunar caustic, as they do not differ materially from those which are the consequence of the introduction into the stomach of other escharotic substances. Nor, for the same reason, will it be necessary to say of the morbid appear- ances any thing further than that, when swallowed, it corrodes the mucous membrane of the oesopha- gus and stomach, and produces ulcers analogous to those caused by it when externally applied in surgical practice. In doses of from half a grain to three grains, it is often exhibited in the treat- ment of epilepsy and other spasmodic diseases. In the latter quantity there can be little doubt that it would give rise to very dangerous conse- quences, were it not that the salts and free muriatic acid of the stomach decompose the greater part of it, and bring it to an inert or much less active state of combination. Nitrate of silver may be known by crystallizing in colourless tabular prisms, which deflagrate like nitre when thrown upon a red coal, coating it with a perfectly white lamina of silver. They dissolve also readily in water, and the solution affords, with muriatic acid or any soluble muriate, a white curdy precipitate insoluble in water, the acids and fixed alkalies, soluble in ammonia or its * That it, or at least its base, is taken into the blood would appear proved by the leaden hue of those who have used it medicinally for some time ; it is worthy of remark that this change of colour is limited to the parts habitually exposed to the light, as the face and bands. 424 TOXICOLOGY. carbonates, and also in the alkaline hyposulphites. Lastly, when treated with the arsenical solution, or with a solution of arsenic first and subsequent- ly a drop of ammonia, a beautiful yellow precipi- tate (the arsenite of silver) subsides. We possess in common salt an antidote for nitrate of silver, simple, effectual, and easily ob- tained. If swallowed subsequently to the intro- duction of the nitrate into the stomach, the nitrate is converted into the chloride of silver, a prepara- tion which is perfectly innoxious. Mercury.—The only mercurial preparations which are interesting to the toxicologist are the bichloride, the peroxide, the subsulphate or turbith mineral, calomel, and the nitrates. Of these the first is that which is most entitled to his attention, both by reason of its activity, and because it is that most frequently employed for the purpose of destroying life. It is also that, the action of which on the animal system has been studied with most attention and success. Corrosive Sublimate.—[Corrosive chloride of mercury, bichloride of mercury], operates as a powerful poison, whether introduced into the stomach, applied to the cellular substance, or in- jected into the blood; and the morbid changes it produces, as well as the symptoms which it deter- mines, would appear in all three cases nearly the same. The stomach is sometimes corroded, and it and the rectum are often inflamed and ulcerated. In cases in which death quickly supervened, Bro- die found, in experiments on dogs, the heart to be paralysed ; and this organ always presents (ac- cording to Smith and Orfila) signs of inflamma- tion when the poison is introduced into the sub- cutaneous cellular tissue, and more particularly when injected into the current of the blood. Besides the vomiting, purging, gastric and ab- dominal pain, cold and clammy surface, feeble pulse, and general prostration, which are the symptoms that might naturally be expected to result from the lesions just described, another and a peculiar class, of a secondary and more chronic kind, usually manifest themselves, unless the case should prove very rapidly fatal. The assemblage of these latter is usually known under the name of salivation, and is understood to consist of a peculiar fetor emanating from all parts of the body, and which is usually preceded by a brassy taste in the mouth, of ulceration of the gums, sometimes extending to the tongue and tonsils; and, lastly, of profuse ptyalism, [which may com- mence in a few hours, where a large quantity of the poison has been taken. In the report of the coroners of England, for 1837-8, there were about fifteen cases of mercu- rial poisoning, in twelve of which corrosive sub- limate was the poison taken. (Taylor, op. cit. p. 161.)] The other mercurials enumerated above do not possess irritant and escharotic powers as energetic as those of corrosive sublimate, but produce pre- cisely the same train of secondary effects. When the poison of mercury is very gradually introduced into the system, as in persons who work in quicksilver mines, gilders, looking-glass makers, and those who manufacture barometers and thermometers, a special disease is established, usually known under the name of the shaking palsy, a designation suggested by the tremours and convulsive movements by which the malady ii distinguished. The mercurial poisons are amongst those which when externally applied by inunction make their way into the blood. This has been established by chemical experiment, and we may add that they have also been found under similar circum- stances in the urine. Mercury, there is good evj. dence for believing, has been passed through the urethra in the metallic state by persons labouring under salivation; and many cases are recorded upon respectable authority, in which it was found after death in the brain, periosteum, and bones of syphilitic patients. Facts such as these leave no room for doubling that the poisonous action of the mercurials is exerted, at least partly, through the medium of absorption. Corrosive sublimate is the only one of the mercurial preparations whose im- mediate action is that of a corrosive poison. The local action of the rest is irritant. All, however, produce the same train of secondary effects. Mer- cury in the metallic state is generally considered innoxious, and so it probably is when applied in mass. In a state of minute division, however, it is far from being inert. To finely divided quick- silver, for example, the unguentum hydrargyri and blue pill owe their efficacy; and there are upon record several instances of profuse and even fatal salivation determined by mercury in the vaporous form. In connection with this latter topic it is important to remark that mercury is not, as is the common opinion, fixed at all ordinary tempera- tures, but that, as shown by Mr. Faraday, it emits an appreciable vapour at all heats above 60° Fahrenheit. [It is difficult to say what is the precise quan- tity of corrosive sublimate required to destroy life. It would seem that the smallest dose which has proved fatal was three grains. The subject was a child, and it has been presumed that from three to five grains would kill an adult. Yet cases have occurred in which large quantities have not de- stroyed, in consequence of their having been rejected by vomiting. Death has usually taken place, in an acute case, in from one to five days; but it has been known to prove fatal in eleven hours; and in one case, recorded by Mr. Elling- worth, (Land. Med. Gaz. xxxi. 557,) the dura- tion of the case would not seem to have been more than two hours from the time the poison was taken, (Taylor, Op. cit. p. 168.)] Dr. Christison seems to think that poisoning by corrosive sublimate, or some soluble mercurial preparation, may be inferred from the symptoms alone. This, however, may be doubted, seeing that the most characteristic of them, those, for example, which constitute salivation, may, as he himself admits, be produced by certain prepara- tions of gold, copper, and antimony, by croton oil and digitalis, and occasionally also arise either spontaneously, or as the consequence of a cy- nanche. The symptoms combined with the mor- bid appearances will, undoubtedly, often lead to a probable conclusion; but certainty is scarcely at- tainable in such a research without the aid of chemical experiment. Corrosive sublimate is sufficiently characterized by the following properties. It occurs in crystal- TOXICOLOGY. 425 line cakes, or small irregular prisms of consider- able density, which are soluble in water, and, more copiously, in alcohol and ether. Heated in a glass tube it sublimes unaltered, and its solution in water affords a yellow precipitate with caustic potash or lime-water, and a scarlet one with the hydriodate of potash. The latter, however, must not be added in too large or too small a propor- tion, for the new compound formed (biniodide of mercury) is soluble both in corrosive sublimate and hydriodate of potash. The chlorine of the corrosive sublimate may be detected by adding to its solution a little nitrate of silver, which will throw down the well-known chloride of this metal, and its mercury may be directly separated in the metallic state by boiling it with an acid solution of protomuriate of tin, or subjecting it in the usual manner to the action of a galvanic couple. Gold and iron, which are easily had, form a very efficacious combination for this pur- pose, and are best used, as Paris first suggested, by touching with an iron key a sovereign, or other piece of gold, through a drop of the solution. The sovereign may be advantageously replaced by a slip of gold leaf or platina foil, from which the adhering mercury may be separated by heating it over the spirit-lamp in a small glass tube, when the quicksilver will rise and condense in globules in its upper and cooler portion. In many cases, however, the corrosive sublimate will have to be sought among the contents of the stomach or intestinal tube, and in such the diffi- culty of the search is greatly increased, and for a double reason. In the first place, the operation of the tests which have been enumerated is ob- structed and screened by the presence of a variety of organic and alimentary matters ; and in the second place, these substances, as well as the coats of the intestines, frequently decompose the poison, reducing it from the soluble to the insoluble state. Should any of it remain undecomposed, it is best obtained separately by agitating the entire of the materials to be experimented upon with one-fourth their volume of ether, as first recommended by Christison. This will remove the corrosive sub- limate, and afford it upon evaporation sufficiently pure for the application of the tests already de- scribed. Should the result of this process be of a negative kind, the residue insoluble in the ether should be digested for some time with protomu- riate of tin, and the precipitate, after being col- lected on a filter and drained, should be boiled with a considerable excess of caustic potash. This will dissolve both the animal matters present and the oxides of tin, and leave quicksilver (should any corrosive sublimate have been originally pre- sent,) in the form of a greyish powder, which by sublimation in a small glass tube may be con- verted into metallic globules. By this method very minute quantities of corrosive sublimate may be detected, even when rendered insoluble by the notion of the mucous lining of the stomach, or of its organic contents. An affirmative result, how- ever, in such an investigation, may obviously lead to an erroneous conclusion should calomel or any other insoluble mercurial have been administered medicinally previous to death, and without the knowledge of the experimenter. The search for corrosive sublimate, when ren- Vol. IV. —54 2l* dered insoluble by combination with organic mat- ters, may be conducted in many other ways. Thus if the whole of the suspected mixture be dissolved in nitro-muriatic acid, rendered neutral by evaporation to dryness and re-dissolved in water, the mercury, if any such be present, will be thrown down in the metallic state upon the application, in the manner already specified, of the protomuriate of tin; or, by introducing into the aqueous solution a galvanic couple composed of iron and gold, the mercury will amalgamate with the latter, and may be sublimed by heating the bit of gold in a narrow glass tube. [The relative delicacy of some of the tests is thus stated by M. Devergie (Medecine legale, 2de edit. vol. 2, Paris, 1840). Degree of Dilution. Ferrocyamuret of potassium stops at. . 1500 Lime-water, « .. 4000 Potassa or its carbonate, « .. 7000 Iodide of Potassium, « . . 8000 Ammonia, « . .36000 Sulpho-hydric acid or sulpho-hydrate of ammonia stops at............60000 Protochloride of tin or galvanic pile stops at...................80000] Treatment of poisoning by corrosive subli- mate.—The immediate action of corrosive subli- mate is, as we have seen, to irritate and even cor- rode the textures with which it is brought in con- tact; the remote, to produce the shaking palsy, or the train of morbid phenomena which are com- prehended under the term salivation. When ef- fects of the latter kind are established, they can only be gradually removed by withdrawing the individual from all contact with the poison under the effects of which he is labouring, and making him the object of judicious medical treatment con- ducted upon general principles. The escharotic and irritant action, however, of corrosive subli- mate may be, as is well known, at present obviated by the timely administration of appropriate anti- dotes ; amongst which the white of egg, first re- commended by Professor Orfila, holds the most prominent rank. By contact with this substance the corrosive sublimate is deprived of half its chlorine, and thus reduced to the state of calomel, which precipitates in admixture, or, according to some, in combination with altered albumen. That this precipitate is inert, Orfila has proved by direct experiments upon dogs; and he has also estab- lished that a fatal dose of corrosive sublimate may be swallowed by these animals with impunity, provided that white of egg or any other kind of fluid albumen, be introduced shortly before or after into the stomach. Cases are also upon record which establish that it possesses an equal efficacy in the case of the human subject. [In employing albumen as an antidote to corro- sive sublimate, it must be borne in mind, that it may be given in too great quantity, as the com- pound formed is soluble in an excess of albumen, and in the deleterious combination, which enters the blood, producing the remote influence of the poison. So long as the vomited matters contain a white opaque material admixed, the antidote should not be withheld; when the ejecta, on the contrary, becomes transparent, the farther em- ployment of the remedy is generally useless, and 426 TOXICOLOGY. may be injurious. Dublin Medical Journal, cited by Dr. T. R. Beck, in Journ. of the Med. Sciences, Oct. 1844, p. 533.] The changes produced in corrosive sublimate by the white of egg admit of being also effected by other organic substances, in particular by the gluten of wheat and the casein of milk. The efficacy, however, of these principles as antidotes is not so well made out as that of albumen, and they should therefore not be resorted to unless in the absence of the latter substance, the powers of which have been amply confirmed. The only other antidotes deserving of mention here are iron filings and meconic acid. The former was recommended by Dumas, and must obviously operate by bringing the mercury to the metallic state. The meconic acid, particularly when combined with an alkaline base, affords, with corrosive sublimate, an insoluble and inert permeconate of mercury. The meconates of the ordinary alkalies, however, can scarcely be ob- tained in sufficient quantity to be applied to such a purpose ; and from the smallness of the satura- ting power of meconic acid, it would be hazardous to administer the quantity of opium which would be adequate to the decomposition of a few grains of corrosive sublimate, inasmuch as the muriate of morphia, which would be cotemporaneously formed, is a narcotic medicine of very considerable energy.* [Dr. T. Buckler, of Baltimore, (Maryland Med. and Surg. Journ. Jan. 1840, p. 52,) has re- commended a galvanic antidote, consisting of a mixture of gold dust and iron filings diffused in water containing gum, and slightly acidulated. He found that corrosive sublimate in solution is wholly precipitated in the form of mercury, when gold dust and iron filings are added to it; yet Orfila (Annates d'Hygiene, Oct. 1842,) reports unfavourably of it as an antidote. He found, that when given in large quantity, it did not prevent animals from dying within the usual time from the effects of the poison. Recently, M. Mialhe, (Proceedings of the Royal Academy of Medicine, of Paris, for Aug. 16, 1842, cited in American Journ. of the Med. Sciences, for Jan. 1843,) has strongly recom- mended the hydrated protosulphuret of iron, which, whilst it is inert, produces with corrosive sublimate protochloride of iron, and bisulphuret of mercury. The protosulphuret may be made by adding hydrosulphuret of ammonia to a solution of pro- tosulphate of iron, and washing the black precipi- tate without exposure to air. Orfila (cited by Dr. T. R. Beck, in Amer. Journ. of the Med. Sciences, Oct. 1843, p. 500,) has made experi- ments with it on animals, and has found, that when it was exhibited speedily after the poison had been taken, it possessed even greater powers as an antidote than albumen. Farther experiments are, however, needed. (See Mr. Barry, in Phar- maceutical Transactions, No. 6, p. 306, or Braithe- waite's Retrospect, No. 5.)] Arsenic.—White arsenic, which is the oxide of a peculiar metal, is the most active, the cheap- * Hahnemann states that four grains of corrosive sub- limate will kill an adult within twenty-four hours ; but there is reason to think that a much smaller dose would, under certain circumstances, prove fatal. | est, the most easily obtained, and hence the most generally employed, of the mineral poisons. All | its combinations are, though in different degrees, | destructive of life, and its noxious influence jj exerted through almost every tissue of the animal body, but not through all with the same energy or j rapidity. According to Jaeger, it is most ener- I getic in its action when injected into a vein, in- troduced into a wound, or applied to the perito- neal sac; less so when brought into contact with the stomach; and least of all when passed into the rectum. It is a curious fact that in his expe- riments it proved quite inert when applied to the substance of the nerves. The symptoms also which it produces would appear little influenced by the manner of its application, or the nature of the texture with which it is primarily brought into contact. Systematic writers on toxicology distinguish three varieties of poisoning by arsenic; and, though satisfied that this division is far from being perfect, we shall provisionally adopt it, as, by so doing, the history of the symptoms can be more readily and clearly given. In the first class of cases the symptoms are those indicative of irritation and inflammation in the intestinal tract and other mucous passages, the nervous system being more or less depressed, but not in other respects materially deranged. The duration of such cases is from one to three days. In the second class there are no indications of ir- ritation from the commencement, but the patients sink within the space of Ave or six hours, as if under the influence of a powerful narcotic. In the third variety we have, in the first stage, the usual symptoms of irritation of the mucous pas- sages ; but these after some days intermit, and are succeeded by some form of imperfect paralysis or by epilepsy which terminates the sufferings of the patient usually about the sixth or seventh day. 1. The detail of the symptoms which belong to the first variety is as follows. In half an hour, sometimes sooner sometimes later, nausea and faintness are experienced, and are shortly suc- ceeded by a burning pain in the stomach and by obstinate vomiting, which, should it for a moment cease, is immediately excited by the swallowing of any kind of drink. The matters discharged after some time exhibit a yellowish-green or bil- ious colour, and after the lapse of twenty-four hours are frequently tinged with blood. After the vomiting has set in, a sensation of dryness, heat, and tightness is experienced in the throat, accom- panied by unextinguishable thirst. The voice also is hoarse, and the articulation of words is effected with considerable difficulty. Diarrhoea now usually sets in, (not always,) accompanied by considerable anal irritation, often with tenes- mus. The abdomen becomes tense and painful, and the irritation extending to the urinary system produces deep-seated pain in the region of the bladder, and swelling and even gangrene of the genital organs. The pulse is small, quick, and feeble, the heart flutters, the surface is cold and clammy, the extremities are livid, the countenance is collapsed and expressive of pain. The tongue and mouth are furred, the papilla? on the back of the former become unusually prominent, and aph- tha are seen on the uvula and fauces. Finally TOXICOLOGY. 427 towards the close of the scene, there are delirium and convulsions, which are quickly followed by death. As an appendix to this enumeration it may be proper to observe that in some rare cases the entire body has become swollen, particularly in the vicinity of the eyes, and covered by miliary or petechial eruptions, which appear and disappear at intervals. 2. In the second variety the signs of irritation are either entirely wanting or unusually mild, but death nevertheless occurs, and with great rapidity, accompanied by all the circumstances character- istic of narcotism. The particular affections most uniformly present are extreme faintness, some- times amounting to syncope, a state of coma or stupor, and slight convulsions. This kind of case is rather uncommon, and it has been observed to occur only where the poison was swallowed in unusually large quantity, in solid lumps, or, lastly, in a soluble form. 3. The symptoms which characterize the third variety are, in the first stage, those of irritation already described, but in the second, such as are alone referable to nervous disturbance. The most formidable of the latter are coma, imperfect para- lysis of the arms, epilepsy, tetanic convulsions re- sembling those of hysteria, and, lastly, mania, which, however, has been but once observed. In cases which belong to the second variety no morbid changes whatsoever are observed. In the first and third varieties the throat and cesophagus are injected with blood, though this does not in- variably occur. The villous coat of the stomach is red and dappled with livid spots, in consequence of the extravasation of blood into its texture. The same tunic is also frequently softened to such a degree as to admit of being readily scraped off with the nail, and not only it but the other tunics are studded with ulcers at several points. Nor are ulcers confined to the stomach alone; they occur also in the duodenum and inferior part of the intestinal tube, and are particularly abundant and constant in the rectum. Coagulable lymph is also infused upon the inner membrane of the stomach, and the interior of this organ is occupied by a dense and consistent mucus blended with clots of extravasaled blood. The trachea, pleura, and inner surface of the heart exhibit frequently a reddened aspect indicative of inflammation, and genuine peripneumony has also been observed. Under the head of symptoms we have already alluded to the lesions of the urinary and genital organs, and to the swollen and erupted state of the surface. The blood, according to Brodie and others, is of a dark colour and does not coagulate; but this statement, or rather its latter half, though generally true, is liable to exceptions. The preceding summary of symptoms and mor- bid changes has been collected from cases in which the poison was internally administered. The description is applicable, however, with little modification, through whatever channel it is in- troduced into the system. When arsenic is applied to a wound or serous surface, or injected into the blood, the mucous passages appear to suffer less, while the derangement and depression of the nervous system is more decided than when taken, as is the more common case, into the stomach. [In the case of Mina, tried in Pennsylvania for the murder of Mr. Chapman, it was stated by several medical witnesses, that when the stomach was opened a peculiar smell resembling that of pickled herring was perceived; and Dr. J. K. Mitchell states, that a stomach, which he placed in some Fowler's solution, for two or three months, acquired the same odour. (Beck's Med. Juris- prudence, ii. 410, Philad. 1838.) Dr. Griffith, (Taylor's Med. Jurisprudence, Amer. edit. p. 138, Philad. 1844,) states, that he tried a similar experiment/using a solution of arsenious acid, with the same result.] From what has been said of the effects of arsenic on the human subject, it will probably be considered obvious that it is one of the poisons which exercise a double action, one immediate upon the part to which it is applied, the other remote or directed to distant organs. Such is the opinion usually entertained. When, however, we recollect that arsenic possesses no escharotic powers, and that, upon application to a wound, it produces those very symptoms and morbid changes characteristic of mucous irritation which follow upon its introduction into the stomach, we can- not but entertain doubts as to the justice of the views which would refer any of its consequences to local action. But supposing, as indeed can scarcely be doubted, that its noxious influence upon any particular texture or organ is the result of a remote action, the question a'rises, through what channel is this influence conveyed ] Is it through the medium of the nervous sympathy 1 Or does the poison enter the current of the circu- lation, and reach through it the parts which are found to suffer from its ravages 1 Having already discussed, at the commencement of this article, the general question of which the present is but a part, we shall not return to it here, further than to observe that we are not acquainted with any experiments establishing unequivocally the pre- sence of arsenic in the blood of individuals who have died of the administration of such poison. Some, indeed, have been put forward, but they appear to us unsatisfactory. It has been already observed, more than once, that the symptoms and morbid appearances, though conjoined, will seldom afford satisfactory proof of poison having been administered or taken in any particular case, much less enable us to in- fer the precise nature of that employed. Arsenic is unquestionably no exception to this statement. As an auxiliary in such a research, the alleged antiseptic powers of the poison have been sum- moned into use, and when the body of the de- ceased resists for a longer time than usual the process of decay, it is by many considered as a strong corroboration of death having been pro- duced by arsenic. This substance undoubtedly exercises, as is well known to the collector of specimens in zoology, a preservative power in reference to the parts to which it is topically ap- plied, and there can be no doubt that the alimen- tary canal of individuals who have perished by swallowing arsenic continues for a considerable time without exhibiting any symptoms of decay. This preservative influence, however, though the contrary has been alleged, does probably not ex- tend further than the parts which have been im- pregnated with the poison. 423 TOXICOLOGY. The most unequivocal proof of poisoning by arsenic is, it is scarcely necessary to observe, to be derived from chemical investigation; and this brings us to the consideration of those properties which best characterize the poison, and the detail of the processes by means of which its insulation from the matters it may be mixed with is most readily and perfectly effected. White arsenic, as this poison is commonly de- nominated, is the oxide of a peculiar metal of a steel grey colour, friable, and having a specific gra- vity of about 8.3. By exposure to air and moisture it rapidly oxidizes, combining with about one-third of its weight of oxygen, and being thus converted into the common oxide. This change, however, is never perfect, the result being always a mixture of oxide and metal. When heated in a close vessel to 356°, it sublimes unaltered, emitting a strong alliaceous odour. But if heated with con- tact of air, it absorbs oxygen, and passes to the 6tate of white arsenic. The oxide of arsenic is a white powder, or oc- curs in lumps, usually opaque, sometimes trans- lucent, and having the specific gravity of 3.7. Heated to 380° it sublimes, without, however, the production of any alliaceous smell; and if the process be conducted slowly, it will concrete into octohedral crystals exhibiting an adamantine lus- tre. These crystals are at first transparent, but, upon exposure for some time to the air, finally become opaque : 1000 parts of boiling water dis- solve about 80 of the oxide, and after cooling to 60° retain 30. The same amount of water, how- ever, will take up at the temperature of 60 but about three parts. Guibourt has found a difference be- tween its solubility in the opaque and transparent states, the former being more soluble than the latter. [The observations of Dr. J. K. Mitchell and Mr. Durand show, that the power of the solvent is modified by the fineness of the powder, the time the fluid is in contact with the arsenic, and even the shape^of the vessel in which the solution is made. They found, that 1000 parts of temperate water will take up from 12 to 16 of the acid, whilst the same proportion of boiling water will dissolve 148, and retain on cooling from 25 to 40, accord- ing to the time the boiling fluid is in contact with the arsenic. The smallest fatal dose on record is stated to have been thirty grains of powdered white arsenic. The man died in six days. A much smaller quantity than this, however, would doubtless kill. The smallest fatal quantity of arsenic, in a state of solution, is stated to have been four grains and a half. The child who took it died in six hours. In a case that fell under Mr. Taylor's notice, (Manual of Med. Jurisprudence, p. 141, Lond. 1844,) he had reason to think a young lady was killed by eating a portion of cake which could not have contained more than four grains of arsenic, and probably less than three grains. A fifth of a grain of arsenic, given in divided doses, in three days, occa- sioned, in one ease, symptoms of inflammation of the stomach, and alarming hemorrhage of a serious character, which rendered a discontinuance of the medicine absolutely necessary. Mr. Taylor con- siders we are warranted in affirming, that a dose of three grains and upwards is likely to prove fatal to an adult; and a much smaller dose to a child. Persons, however, have recovered after haviof taken very large doses of the poison, which Im been rejected immediately by vomiting. Dr Christison (Op. cit. 321) refers to one where in ounce was taken, and the patient recovered under no other treatment than the exhibition of magne- sia and sulphate of zinc. Large doses generally prove fatal in from eighteen hours to three days. In some cases, the fatal event supervenes much earlier—in from three to six hours. Mr. Taylor has referred to many such, and to one or two where death occurred in less than two hours. (See Dr. T. R. Beck, in Amer, Journ. of the Medical Sciences, for Jan. 1841, p, 59.) In the cases of poisoning by arsenic re- corded by the coroner of the city and county of New Yofrk during the years 1841,1842, and 1843, (J. B. Beck, Transactions of the New York State Medical Society, vol. vi. Pt. I., p. 72, At bany, 1844,) the smallest quantity taken was one drachm; the largest two drachms. The shortest time intervening between the taking of the poison and the death was four hours;—the longest two days.] Oxide of arsenic is soluble in the fixed oils, and also, though sparingly, in alcohol. Its solubility is much diminished by the presence of organic substances, such as milk, tea, animal mucus, &c. It reddens, though faintly, vegetable colours, and forms with bases saline combinations, propertia which have acquired for it the title ofarsenioui acid. Arsenic may become the subject of experiment to the toxicological chemist in the solid form, in a state of aqueous solution, and, lastly, when mixed with the contents of the stomach or intes- tinal canal. Should a solid lump or powder of a white co- lour, suspected to be arsenic, be presented to him, the necessary chemical inquiry may be conducted in the following manner. Let a small particle, previously rendered perfectly dry, be heated gently over a spirit-lamp in a clean glass tube of small diameter sealed hermetically at one end. If it be arsenic it will sublime and be condensed, when the process is conducted slowly, into shining octohe- dral crystals in the cooler part of the tube. If these phenomena should be distinctly observed, there can be little use in pushing the inquiry fur- ther. To satisfy, however, every scruple, let a little of the suspected substance be mixed with twice its weight of black flux, and let the mixture be heated to redness over the spirit-lamp in a very narrow tube, similar to that used in the pre- vious experiment. All doubt as to its real nature will now be removed by the reduction of the oxide, and the formation in a cool part of the tube of » metallic crust, exhibiting externally the lustre and polish of burnished steel, and which, when re- moved and again heated in a tube open at both ends, the upper extremity of which is held near the nose, will strongly affect the olfactory nerves, as would be done by a bit of garlic. Dr. Turner has proposed a further test, which may be here resorted to as a corroboration of the evidence already obtained, and which consists in subliming, from one part to another of a tube closed at one end, a particle of the crust. By this treatment, when arsenical, it gradually becomes TOXICOLOGY. 429 oxidized, and is finally deposited on the sides of | the tube in the octohedral crystals already de- scribed. In practising the reduction of arsenious acid, the only points to be attended to are to employ a tube whose diameter shall not much exceed the eighth of an inch, to introduce the materials with- out soiling the tube, and to remove, with a wire surrounded with cotton wick, the moisture which sublimes at the commencement of the process; for, if left in the tube, it would interfere with the dis- tinct and regular formation of the metallic crust. The production, by the process above explained, of a shining ferule of metal; the volatility of this metal with the emission of an alliaceous odour; and the conversion, by Dr. Turner's method, of a particle of it into octohedral crystals, possessing an adamantine lustre; are properties which establish beyond all question that arsenic, or some combi- nation of it, has been the subject of experiment, and enable us to dispense altogether with the liquid tests so frequently resorted to in researches of this description. Should the arsenic be suspected to exist in so- lution, the initial steps of the process to be pursued will be somewhat different. Our first object must be to convert it into the sesqui-sulphuret, or orpi- ment, by passing sulphuretted hydrogen through the solution. Before, however, doing this, it will be necessary to be assured that the arsenious acid does not exist in the solution combined with any base, for in such form the experiment would not succeed. To accomplish this, the solution should be acidulated with a few drops of muriatic or acetic acid. The hepatic gas is then made to tra- verse the solution for some time, as a consequence of which, if arsenic has been present, an orange precipitate forms and gradually deposits. When the quantity of arsenic present is small, the solu- tion merely acquires an orange colour, but there is no deposition. The formation, however, of a pre- cipitate may, in such case, be invariably deter- mined by boiling, which seems to act by expelling the excess of gas with which the solution is charged, and which probably prevents the subsid- ence of the orpiment. The matter thus obtained should be washed by decantation, and collected on a small filter, from which it is to be transferred while still moist to a watch-glass. Here it is to be mixed with twice its weight of black flux, and the mixture when perfectly dried at 212° is to be introduced into a glass tube, and reduced with the heat of a spirit-lamp, as already minutely de- scribed. The subsequent manipulations to be re- sorted to, in the event of a metallic crust being ob- tained, it is unnecessary to repeat. In the great majority of cases, and these by much the most important, arsenic will have to be sought for in the stomach or intestines, where it is necessarily mingled with a variety of animal secretions and alimentary matters. The poison may often, by minute examination, be recognised among these in little lumps, or the form of powder, particularly if sought for at the bottom of a tall cylindric jar, in which they have been agitated, mixed with an equal bulk of water. Should such a search prove fruitless, the process by sulphuretted hydrogen must be resorted to; but it will, as is obvious, be in the first instance necessary to re- move the organic matters present in the solution. These would obstruct, if not prevent, the precipi- tation of the orpiment, and materially interfere with and obscure the subsequent reduction. The following is the outline of the method of clari- fication first recommended by Christison, and which we have frequently found to succeed per- fectly. Let the matters among which the poison is to be sought be boiled for half an hour with an equal bulk of water, and to the filtered solution, first slightly acidulated with nitric acid, let nitrate of silver be added as long as it affords a precipitate. The animal matters are thus thrown down in combination with oxide of silver, while any arsenic of silver formed is kept in solution by the free nitric acid. Filtration is again resorted to, and to the clear solution so obtained muriate of soda is next added, so as to remove, in the form of chlo- ride, any silver which it may include. After an- other filtration, potash is added to neutralize the free nitric and arsenious acids, and the solution being then acidulated with a few drops of acetic acid, it is in a state for treatment with sulphuretted hydrogen, in order to obtain orpiment, which, if procured, is to be reduced, as already fully ex- plained. The only explanatory observations which it is necessary to add are, that, prior to the use of the sulphuretted hydrogen, the nitric acid is di- rected to be neutralized, as otherwise it would de- compose the hepatic gas, precipitating its sulphur; and that the acetic acid is subsequently added, in order to liberate the arsenious acid, if present, from the alkali previously employed ; as, while in a state of combination, the sulphuretted hydrogen would not affect it. The acetic acid is also or- dered rather than the muriatic or sulphuric, as the latter would liberate nitric acid, the former chlo- rine, both of which are incompatible with sulphu- retted hydrogen. This process we have upon four different occa- sions practised with success in searching for arsenic in the human stomach ; and we cannot assent to the justice of the statements which would appear to have influenced its author in giving it up. Arsenite of silver is extremely soluble in nitric acid; and if, therefore, the details just given be faithfully followed, the arsenic cannot, as has been alleged, subside in combination with oxide of silver. As a substitute for the method the particulars of which have been just given, Dr. Christison, in the last edition of his work, directs the solution obtained by filtering the boiled contents of the sto- mach to be simply evaporated to dryness, and the residue to be treated with successive portions of boiling water, to dissolve out any arsenic which it may include. A solution is thus obtained not perfectly free, like that which is the result of the first process, from organic matters, but, neverthe- less, sufficiently so to allow the precipitation of any arsenic which it may contain, by the sulphu- retted hydrogen gas to be subsequently employed. The orpiment, however, procured by this process invariably contains organic matter, which in the reduction is decomposed, and renders it difficult to distinguish any metallic crust which may happen to be formed, particularly if its quantity should be small. 430 TOXICOLOGY. [If arsenious acid be subjected to the action of nascent hydrogen obtained by the action of diluted sulphuric acid on zinc, it is deoxidized; and the metallic arsenic, thereby obtained, combining with hydrogen, forms arsenuretted hydrogen gas. This is Marsh's test. It is considered to be one of great delicacy, and it has been asserted that me- tallic deposits may be procured when the arsenic forms only the 2,000,000th part of the liquid ex- amined. M. Signoret affirms that he has procured metallic deposits with only the 200,000,000th part of arsenic in the liquid: this being in the propor- tion of one grain of arsenic dissolved in about 400,000 ounces or 3000 gallons of water. (Tay- lor, Op. cit. p. 152.) The mode of employing this test is given in chemical works. (Graham, Op. cit. p. 438 ; see, also, Pereira, Op. cit. i. 538; and Mr. Ellis, in Taylor's Report on Toxicology, in Brit. <$• For. Med. Rev. for Oct. 1844.) The fallacies of this test arise from the presence of either antimony or imperfectly charred organic matter in the suspected liquid, or from the em- ployment of either zinc or sulphuric acid contami- nated with arsenic. (Pereira, Op. cit. i. 530; and Taylor, Op. cit. p. 154, and his report just cited, for the views of Fresenius, as contained in the London Lancet, June and July, 1844.) Of late, a simple method has been proposed by Reinsch for determining the presence of arsenic in liquids, which has been called, after its pro- poser, Reinsch's test. (See British and Foreign Medical Review, July, 1843, p. 275.) To the suspected solution a few drops of pure muriatic acid is added, and a slip of bright copper is placed in it. There is no change until the liquid is brought to the boiling point, when, if arsenic be present, even in small quantity, the copper ac- quires an iron-grey coating from the deposit of that metal. This is .apt to scale off, if the arsenic be in large quantity. The slip of copper is then removed, washed in water, dried, and gradually heated in a reduction tube, when arsenious acid will be sublimed in minute octohedral crystals. If these should not be apparent from one piece of copper, several may be introduced successively. The test succeeds perfectly with powdered arsenic, the arsenites, arsenic acid, the arseniates, and orpiment. It will even separate the arsenic from the arsenite of copper, and from common lead- shot. When the quantity of arsenic is small, the copper acquires a faint violet or blue coat, and the deposit is materially affected by the quantity of water present, or, in other words, the degree of dilution. This test failed to detect the 4000th part of a grain of arsenic in thirty drops of water, the dilution being equal to 120,000 times the weight of the arsenic. The deposit on copper commenced with a violet-coloured film, when the quantity of arsenious acid was equal to the 3000th part of a grain in thirty drops of water, or under a dilution of 90,000 times its weight. An objection to Reinsch's test is, that other metals are liable to be deposited on copper under similar circumstances. This is the case with an- timony, whether in the state of chloride, or of tartar-emetic ; and it is not always possible to dis- tinguish, by the appearance, the antimonial from the arsenical deposit. Tin and lead become tar- nished under the same circumstances, but there is J no decided metallic deposit. Bismuth produces i deposit closely resembling that of arsenic. The arsenical deposit may, however, be discriminated by the circumstance, that octohedral crystals of arsenious acid may be procured by slowly heating the slip of copper in a reduction-tube. If, while heat is applied to the copper in a long piece of tube drawn out at one end, a current of air be gently blown through it, a ring of white arsenious acid will be obtained : this may be filed off, boiled in water, and tested by the ammonio-nitrate of silver and sulphuretted hydrogen. Of all the methods of detecting arsenic, this is regarded as the most simple and easy of execu- tion ; and, according to Mr. Taylor, (Op. cit.p, 156,) it will probably, in a short time, supersede most of the other more complex processes of test- ing for arsenic. In a recent case of alleged poisoning, Dr. Chris- tison employed this test, and readily detected arsenic in the substance of the stomach in its con- tents, as well as in the substance of the liver. At one time, Orfila affirmed that he had discovered arsenic as a normal constituent of the body; and Dr. Chris- tison was examined in a court of justice on this point. His answer was, that" Arsenic is not a con- stituent part of the human body, and is not formed in it. It was once alleged that it was, but that was disproved. The individual (Orfila) who first pro- mulgated this theory, only argues now that small quantities are found in the bones; but in three several experiments before the Academy of Paris, he was unable to show it. Arsenic could only have come into the liver by absorption." Elabo- rate experiments .were made by MM. Danger and Flandin, which demonstrate that there must have been some fallacy attending the original experi- ments of Orfila; as in no instance in operating on the largest quantities of animal matter, and cm- ploying the most delicate tests, could they detect the smallest trace of arsenic as a natural consti- tuent of the human body. (Taylor's Report, loc. cit.)] There are many other arsenical preparations in common use capable of destroying life in small doses, and which are therefore interesting to the toxicologist. The presence, however, of metallic arsenic in them all may be detected with certainty without deviating from the methods which have been recommended for the oxide. Thus, those of them that are insoluble, namely, the German fly-powder—a mixture of metallic arsenic with the oxide — the native and artificial sulphurous, and the arsenite of copper or Scheele's green, may all be reduced in a glass tube with a little black flux. And the same process is applicable to the soluble arsenical preparations, such as the arsenite and arseniate of potash, when orpiment is formed from them, by first dissolving them in water acidu- lated with acetic acid, and passing through the solution sulphuretted hydrogen. In the case of the arsenite of potash, a salt which not long since held a place in the Dublin Pharmacopoeia, it will be better to decompose its solution by nitrate of silver, and subject the insoluble arseniate thus procured to the usual process of reduction; ioi the arsenic acid, in a disengaged state, is but slowly converted by sulphuretted hydrogen into a sulphuret. TOXICOLOGY. 431 [Arsenuretted hydrogen has occasioned death by being respired accidentally.] In the treatment of poisoning by arsenic, anti- dotes of a chemical nature, to neutralize its malig- nancy, are entirely out^ of the question. There are, indeed, several reagents, such as lime-water, sulphuretted hydrogen, and the ammoniaco-nitrates of silver and copper, which are capable of convert- ing arsenic into compounds insoluble in water; but many of these reagents are poisonous them- selves, and there are none of the compounds which they form that are not appreciably taken up by the secretions of the stomach and intestines. Neither are we acquainted with any substance which may be viewed as an antidote, acting through the medium of the constitution by excit- ing an action contrary to that of the poison. Such being the case, it is obvious that we must rely upon expelling the poison, with as much des- patch as possible, from the stomach by an emetic, or the application of the stomach-pump, and ob- viating by appropriate treatment the symptoms of inflammation, and those of nervous irritation and occasional depression, which may manifest them- selves in the progress of the case. The experi- enced physician will not require any suggestion as to the course which he should take on such an occasion, and the student we must refer to hos- pital practice, or to works which expressly treat of clinical medicine. [Since the above observations were written, much evidence has been brought forward in fa- vour of the antidotal effects of the hydrated oxide of iron, which must be given as speedily as possible; and, if practicable, the recent oxide should always be administered, especially where the amount of poison taken has been large. (W. Procter, Jun., American Journal of Pharmacy. April, 1842, p. 37.) In another work, (New Re- medies, 4th edit. p. 297, Philad. 1843,) the writer has adduced various cases of successful results from its exhibition. It is necessary to ad- minister it largely, especially as uncertainty must exist in regard to the quantity of poison taken. It has been recommended, that to an adult a table- spoonful, and to a child a dessert-spoonful, should be given every five or ten minutes, until relief from the urgent symptoms is obtained. (T. R. Beck, American Journal of the Medical Sci- ences, July, 1841, p. 90.) A commission of the Royal Academy of Medicine of Paris recommend, that four ounces of the dry hydrated oxide, the subcarbonate or sesquioxids of iron of the shops, should be suspended in twenty-four fluidounces of water, and a good glassful of the mixture be given every ten minutes. After four ounces have been consumed, fresh doses of the same mixture may be administered in like manner, and the pa- tient should not be considered out of danger, until he has taken at least half an ounce of the oxide for each grain of arsenious acid supposed to have remained in the stomach. (Revue Medicale, Mai et Juin, 1839.) The oxide forms with the arsenious acid a pro- to-arseniate of iron. (Graham's Elements of Chemistry, Amer. edit. p. 439, Philad. 1843.) It would seem, however, from some experiments by Mr. Taylor, (Medical Jurisprudence, p. 145,) that the oxide of iron does not possess the power of combining with powdered arsenious acid, the form in which arsenious acid is generally admin- istered as a poison; and where recoveries have taken place from its use, there must have been some other mode of operation. (Taylor's Report in Op. cit. p. 540.) It has been objected to the use of the oxide of iron, that it is liable to contain arsenic, and might thereby give rise to embarrassment in the analysis. The objection was urged in the case of Madame Lafarge; but Mr. Taylor states, that he has ex- amined several specimens of oxide of iron by Reinsch's test, but has not found any arsenic in them. Instead of the pure hydrated oxide, Van Specs, (Med. Jahrbuch. des k. k. ost. st. xix. 621, Wien, 1836 ; and Brit, and For. Med. Rev. July, 1837,) employed substances in which the peroxide is known to exist in considerable quantity, and which require no previous preparation, as rust of iron, and haematite (red iron); and, from his ex- periments, he was led to conclude, that although these substances do not prevent all the bad effects of arsenic on the system, they may, in the absence of the hydrated oxide, be employed as antidotes to that poison. The rust of iron has the advan- tage of being readily procurable. A case has been published (Batilliat, Journ. de Chimie Medicale, Janvier, 1840,) which led to the inference that the hydrated oxide, dried in the air, is as efficacious as that which is kept moist. It certainly would seem, that the dry hydrated oxide—Ferri-Subcarbonas of the Phar- macopoeia of the United States, (1842,)—possesses the power, to a considerable extent, of neutralizing arsenious acid (Dr. Beck, loc. cit.); and hence it ought to be used in the absence of the fresh moist preparation—the Ferri Oxidum hydratum. The latter, however, may be obtained in a condi- tion fit for use, in ten or fifteen minutes, by using a solution of the persulphate of iron, (W. Procter, Jun., op. cit.) The experiments of M. Guibert (Bullet. General de Therap., Dec. 1841,) would seem to show, that the subcarbonate of iron, as ordinarily prepared, is about three times less active in neutralizing arsenic, than the dry hydrate pre- pared with ammonia, and six times less active than the same hydrate in the moist state. Still, when the hydrated oxide is employed, the prac- titioner should use every means to evacuate the poison.] Cobalt. — The salts of cobalt are poisonous. Thirty grains of the chloride killed a rabbit within a day. When applied to the subcutaneous cellular tissue, they were found by M. C. G. Gmelin to act in the manner of irritant poisons. According to Merat and De Lens, (Diet. Universel de Mat. Med. &c. Art. Cobalt,) the fly-powder, known in French commerce under the names mine de co- ball, and poudre aux mouches, is native arsenic. Cases have been recently referred to in which it proved fatal. (Lewis Hurd, Boston Med. and Surg. Journ., Nov. 20, 1844, p. 316.)] Copper. — The only combinations of copper deserving of attention in a toxicological point of view are the sulphate, natural and artificial verdi- gris, and certain pigments, which, like verditrr, include the hydrated peroxide of the metal. These preparations are seldom or never employed 432 TOXICOLOGY. for the purpose of destroying life, but some of them, particularly the carbonate and acetate, oc- casionally make their way into food, pickles, and preserves, &c. cooked in copper or brass vessels. The circumstances under which such an impregna- tion is or is not possible are deserving of attention. When vinegar is boiled in a perfectly clean copper vessel, not a particle of the metal is dis- solved. If, however, cold vinegar be kept in such vessel for some time, the metal becomes oxidized by the absorption of atmospherical oxygen con- tained in the vinegar, and, of course, immediately after converted into the cupreous binacetate. These facts were first experimentally determined and explained by the celebrated Proust. Now, what is true of pure vinegar, may, one would be led to anticipate, be predicated of the various articles of food and drink which owe their acidity to free acetic acid. The conclusion thus deduced from analogy is found to be in perfect accordance with experiment. Acid preserves of every de- scription may be boiled with impunity in clean copper vessels; but if kept in them for any time at the common temperature of the atmosphere, a sufficient quantity of copper is taken up to render them strongly poisonous. The relation of copper to the animal fats and fixed oils is nearly the same. In the cold they corrode it with the as- sistance of the oxygen of the atmosphere; but, at a high heat, their action, though probably not null, is considerably less energetic. [Mr. Warington has lately shown, that copper vessels, saucepans, taps, and other articles, which have been covered with a surface of silver by the electrotype process, are liable to be acted on by weak acids, such as lemon-juice and vinegar, when these are permitted to remain in contact with them for a short time. It seems, that the metallic silver with which they are covered is porous, and that the acid liquor can penetrate the silver, and reach the surface of the copper. A kind of gal- vanic action is thus established, which augments the chemical action; so that such vessels, whilst appearing to give security, are really rendered more dangerous. The presence of copper in acid liquids kept in electrotyped vessels, was clearly demonstrated by the usual tests for that metal. (Taylor's Report on Toxicology, in Brit, and For. Med. Rev., Oct. 1844, p. 552.) The symptoms which characterize poisoning by verdigris are, headach, cutting pains of the intes- tines, followed by vomiting and purging, coppery taste in the mouth, and strong aversion to the taste of the metal, cramps in the legs, pains in the thighs, and jaundice, a symptom never produced by mercury or arsenic. In fatal cases, shortly be- fore death there are coma, paralysis, and violent tetanic convulsions. The pulse, almost from the commencement, is small, quick, and feeble ; and, in some few cases, a slight salivation has been observed. The morbid changes which have been noticed, are yellowness of the entire body, and inflamma- tion, and even ulceration and gangrene of the mucous lining of the stomach and intestines, at several points. This membrane, also, along the entire tract of the alimentary tube, usually exhibits a decided greenish colour, a circumstance which occurs in no other variety of poisoning. From what precedes, particularly tho summary given of the symptoms, it is obvious that some of the most remarkable of the effects of copper are witnessed in its action on the nervous system. It is not, however, as yet clearly ascertained whether they are the result of sympathy, or of the trans- mission through the blood to the brain and spinal cord of some portion of the poison. It is asserted by some that copper has been found in the blood and by others in the liver, of individuals labouring under its influence. These statements, however, require confirmation. If verified, they would seem to establish, at least in one case, the doctrine of absorption and transfer. There are none of the symptoms or morbid appearances produced by the preparations of cop- per sufficiently characteristic to enable us to infer from them alone that such preparations, or any of them, have been employed in any particular case of poisoning. The jaundiced colour, indeed, of the surface, and the greenish tinge of the mucous lining of the alimentary tract, furnish, though not convincing evidence, yet strong probable grounds for believing that copper, in some form, has been administered. The suspicions thus raised will require for their confirmation or rejection the co- operation of chemistry; and this brings us to a brief description of the experiments by which the presence of copper may be detected in any of its ordinary forms. Should the suspected substance be soluble in water, as is the case with the sulphate and binace- tate, let it be acted upon with a minimum of this solvent, and then tested, in distinct portions, with the following re-agents, namely, ammonia, a pol- ished iron wire, and a drop of ferro-prussiate of potash. If copper be present, the portion treated with ammonia will require, if the alkali be added in sufficient quantity, a beautiful sapphire blue colour ; that in which the wire is immersed will, after the application of heat, if necessary, deposit upon it a coating of metallic copper; and that treated with the ferro-prussiate of potash will give a bulky precipitate of a deep red colour. If insoluble in water, as is the case with the carbonate, and the acetate or artificial verdigris, and also with the pigment known under the name of verditer, which is a mixture of chalk, carbon- ate, and hydrate of the peroxide of copper, it is to be taken up with the smallest possible quantity of muriatic acid, and then tested with the substances used in the preceding case, when, should copper be present, the phenomena already specified will be manifested. The preceding experiments, as will be seen, are calculated only for demonstrating that copper is present in some form or other, but they afford no information respecting the nature of the acid with which it is combined. This latter point, how- ever, can be ascertained by resorting to the tests for the acids explained in a former part of this article. When copper is sought for in the contents of the stomach, or in mixtures including animal or vegetable matters, such as albumen, milk, tea, and coffee, the first step to be taken is to digest such mixture with an excess of acetic acid. Any cop- per swallowed in an insoluble form, or rendered TOXICOLOGY. 433 insoluble by the decomposing action* of the fluids just enumerated, will be thus taken up, and, upon filtration, a solution will be obtained, from which the copper will be thrown down by sulphuretted hydrogen. This precipitate, heated on a watch- glass, with a few drops of nitric acid, the excess of which is to be expelled by evaporation to dry- ness, will be converted into the persulphate, which, when treated with ammonia, polished iron, or the ferro-prussiate of potash, will comport itself as already described. Should the search thus conducted not lead to the detection of copper, before pronouncing that it is absent, the insoluble matters, separated by the filter from the acetic solution, should be ignited in an earthen crucible. By this treatment any of the metal which may have existed in such matters will be reduced; and when the incinerated resi- due is treated as before with nitric acid, and filtra- tion performed, a solution will be obtained to which the usual tests may be applied. In certain cases the preceding investigation may be much abridged. Thus persulphate of copper, which is sometimes used by the baker, particularly in Germany, for the purpose of promoting the fer- mentation of the dough and contributing to the whiteness of the bread, objects which it is said to accomplish when used in a proportion not exceed- ing one part in 2000, may be at once detected by the light carnation tint produced by dropping a dilute solution of the ferro-prussiate of potash on the soft part of the loaf. Unless, however, the tint be very decided and characteristic, the wash- ings of a considerable quantity of the bread with distilled water acidulated with acetic acid should be concentrated, and subjected, for the purpose of verification, to the different tests already more than once described. Different antidotes have been proposed for the cupreous poisons. Sulphuretted hydrogen and the alkaline hydrosulphurets have been particu- larly recommended; hut experience has shown that they cannot be relied upon, and indeed this might have been inferred from the fact of their being themselves preparations highly inimical to life. Duval recommended sugar, probably be- cause, when boiled with salts of copper, it effects their reduction, but this action is not exerted at ordinary temperatures; and Orfila, though first a convert to the opinion of Duval, has since found that the antidote suggested by him does not pos- sess any real efficacy. Orfila has himself since recommended the white of eggs, and his experi- ments on dogs would really appear to prove that it neutralizes the influence of the acetate. Lastly, two French physicians have tried iron filings, in consequence of the power possessed by this metal of reducing the salts of copper, and the results they obtained, in some experiments performed by them on animals, are such as to justify considera- ble confidence in the antidote which they recom- mend. To the preceding remarks it is scarcely neces- sary to add that no time should be lost, and none of the ordinary means omitted in expelling the * Albumen, milk, tea, coffee, afford upon the addition of the persulphate of copper, insoluble combinations of animal or vegetable matter with the peroxide of the metal. Vol. IV. —55 2m poison from the stomach, and that the inflamma- tory or other symptoms which may arise in the progress of the case should be treated on general principles. Lead.—[A case has been reported by Dr. Bryce (London Lancet, Dec. 31, 1842,) which would seem to show that lead, in the metallic state, may be poisonous. A man, aged 23, swallowed three ounces of No. 4 small shot in three days. On the third day, there was great anxiety with de- pression, sunken features, coldness of surface, ver- tigo and numbness in the arms and legs. He continued getting worse in spite of treatment; the bowels were obstinately torpid, and there was increased numbness in the arms, and dizziness. Cathartics were exhibited ; the alvine discharges. were examined; but only one pellet was found; so that if the shot were discharged it must have been in the three days before he was seen by Dr. Bryce. The man perfectly recovered in a fort- night. A case is related in the Annates d1 Hygiene, &c, for April, 1844, which shows that serious results may follow from the shot used in cleaning bottles being left in them, and afterwards becoming j acted upon chemically by wine or other liquid put into the bottles. (Taylor, Report on Toxicology in Brit, and For. Med. Rev. Oct. 1844, p. 54G.)] The preparations of lead most used in medicine and the arts are litharge, red lead, the carbonate, or white lead, the acetate or sugar of lead, and the subacetate, commonly known under the name of Goulard's extract. The two last alone are soluble in water, and hence are the most active in their effects upon the animal economy. The others are, in a greater or less degree, acted upon by the acid secretions of the stomach, and thus acquire the poisonous properties they are known to exert. Before proceeding to examine, according to our usual plan, the subject of poisoning by lead, it will be proper to premise some remarks upon the different means by which lead may be introduced into articles of food and drink. This is, from the extended use of the metal, a subject of much prac- tical interest, and one which has been studied with considerable attention. If lead be kept any length of time in contact with distilled water deprived of the atmospherical air which water under ordinary circumstances ! always includes, not the slightest corrosion is ob- J served to take place. If, however, the access of J air be permitted, its oxygen gradually combines with the metal, and the oxide thus formed attract- ing carbonic acid from the same source, is gra- dually converted into the white carbonate. The water in which this change has been effected may, I if drunk, prove poisonous in one or other of two j ways; first, should particies of carbonate of lead be suspended mechanically in it, ana °fcondly, i should it abound in free carbonic acid; for tniZ gas possesses the power of dissolving carbonate [ of lead. If pure water in which lead has been corroded be boiled and filtered, it is deprived of all traces of the metal, and may then be used with perfect safety. Should water contain a minute quantity of saline matter, as is the case with almost all natu- ral waters, though kept in contact for any length 434 TOXICOLOGY. of time with lead, the metal will scarcely undergo a perceptible corrosion, for a minute film of inso- luble salts is gradually deposited on it, which pro- tects the subjacent metal from further oxidation. In the case of ordinary water, the contained salts of which arc almost invariably sulphates and muriates, the protecting film is composed of sul- phate of lead, intermixed, however, with traces of chloride and carbonate. All salts are not equally efficacious in protecting lead from oxidation, the general rule being that those answer the purpose best whose acids afford with oxide of lead the salts most difficult of solution in water. Experi- ments, for example, conducted by Dr. Christison, demonstrate that complete protection is afforded by TTjrVijrii of muriate of soda, TS!0Tyth of sulphate of soda, T_£51ith of arsenic, and ^^^th of phosphate of soda. [See a second paper by Dr. Christison, in Transactions of the Royal Society of Edinburgh, vol. xv.; or Lond. Edinb. and Dublin Philos. Mag. Aug. 1842.] The difference of the corrosive powers, in re- ference to lead, of perfectly pure water and that which is slightly impregnated with the ordinary salts, is well illustrated by the greater amount of oxidation experienced by the lid of a leaden cis- tern than by its bottom and sides. The latter are 'in contact with common water, while the former is subjected to the action of its vapour, or of water in a perfectly pure or distilled state. From the facts just stated, and which have been fully established, it would seem to follow that when a leaden cistern undergoes a rapid corrosion, it must be traced to an unusually small amount of its saline constituents. But though present in suffi- cient quantity, their preservative influence is, as has been already observed, sometimes counteracted by the agency of a large quantity of carbonic acid. When lead exists dissolved in water, it is held in solution chiefly by this latter substance ; but when alkaline muriates alone occur in the water, and in quantity insufficient for the protection of the metal, a little chloride of lead is also generally taken up, and this cannot, like the supercarbonate, be re- moved by ebullition. Lead has been intentionally administered in large doses, in the form of acetate, for the purpose of destroying life; but it is more frequently gradu- ally introduced into the system in consequence of its occurring in small quantity in different arti- cles of food or drink. It occurs, as we have seen, in water, and also occasionally in milk, pickles, preserves, &c. The vegetable acids existing in these corrode, with the assistance of the oxygen of the atmosphere, the leaden vessels in which they may happen to be made or preserved, and thus invest them with poisonous properties. Acescent fluids also, such as eour milk, have been known to become impregnated with lead when kept for -some time in earthenware glazed by .means of litharge, a circumstance which has in a great measure led to its disuse by the potter. The acetic acid is that the action of which is most energetic. Next to it come the citric and the malic, and, lastly, the tartaric, which though it combines with lead previously oxidized, will scarcely take it up, as the tartrate is nearly inso- luble in an excess of its own acid. Acescent wines are sometimes treated with litharge, which neutralizes their free acid and confers upon them a sweetish taste; and this pernicious practice, which once prevailed in France to a frightful ex- tent, is, we believe, not as yet entirely laid aside. In the cider counties of England, also, at one time a similar impregnation frequently occurred, not, however, in consequence of lead intentionally introduced, but because of this metal being used in the construction of the press and other imple- ments employed in the cider-house. Lastly, in the case of miners, smelters, painters, glaziers, litharge and white lead manufacturers, &c. lead enters the system either accidentally during meals, or by pulmonary or cutaneous ab- sorption, and thus gives rise to the different symp- toms so characteristic of its action. The nature and order of these symptoms we shall now de- scribe. The symptoms vary according to the nature of the preparation employed, and the amount of it administered. The insoluble preparations of lead do not produce in the intestinal tract any symp- toms of irritation or inflammation, and the same may be said of the soluble salts when given in small doses. When, however, a soluble salt of lead, such as the acetate, is taken into the stomach in doses of from one to two drachms, morbid phe- nomena ensue, analogous to those produced by the ordinary irritant poisons. Pain after some time is felt in the throat, cesophagus, and stomach; nausea and vomiting ensue, and these are suc- ceeded by all the symptoms of common colic. Finally, when the case proves fatal, convulsions, together with a general sensation of numbness, are experienced a short time previous to death. But if some one of the insoluble preparations, or even a soluble one in a small dose, be admin- istered sufficiently often, the results are very dif- ferent. From the commencement there are either none or but very slight symptoms of irritation of the alimentary tract. A colic, however, of a very decided and distressing nature is after some time developed. This sometimes begins suddenly, more frequently it is preceded by gastric derangement, such as nausea and vomiting; cramps of the sto- mach next set in, and these gradually extend over the abdomen, and at length degenerate into a colic scarcely to be distinguished from the idiopathic disease of the same name. The belly is unusually tense and is greatly drawn in at the navel; the pain, which is subject to intermissions of greater duration than those which . belong to common colic, is relieved by pressure; the bowels are ge- nerally costive, though in some cases the opposite condition of a diarrhoea prevails; the urine is scanty ; the saliva is copiously secreted and of bluish colour; the limbs are the seat of aching pains; the skin exhibits a dull and cadaverous aspect, and is bathed in a cold and clammy sweat; the countenance is gloomy and desponding, and the pulse, though in some few cases accelerated, is, generally speaking, considerably retarded. This combination of symptoms, which constitutes the lead or painters' colic properly so called, if not cut short by apoplexy, an event which has been but once observed, usually ceases of itself within the space of seven or eight days. In such event, however, it is often followed by a general and ex- treme debility, and by a wasting and partial TOXICOLOGY. 435 paralysis of the muscles which supply the wrist, thumb, and fingers, particularly those which serve for the purposes of extension. These symptoms are frequently the only ones which are observed to follow from gradual poisoning by lead, those of colic being wanting. The painters' colic and its sequels are, it may be observed, produced by lead in all its ordinary forms, and whether these be internally exhibited or externally applied. In a case in which Goulard's solution was swal- lowed, and which proved fatal on the third day, the stomach, duodenum, upper part of jejunum, and ascending and transverse colon, were con- siderably inflamed, and the villous coat of the sto- mach was, in addition, found in a soft or pulpy state. In cases which have commenced with symptoms of colic alone, and which have proved fatal, the most minute examination has failed to detect any morbid change save a preternatural contraction of the intestinal tube, particularly that part of it which constitutes the large intestine. Even when death has been preceded by well-marked symptoms of cerebral derangement, such as paralysis, coma, and convulsions, the brain and spinal marrow have been found perfectly healthy. We should not omit to mention that in individuals long under the in- fluence of the partial paralysis produced by lead, the affected muscles are invariably wasted, flaccid, and of an exanguious pale appearance. See Cor.ic. The soluble forms of lead in large doses often irritate, as we have seen, and inflame the alimen- tary tract, and such effect, from the rapidity with which in certain cases it has been determined, is no doubt the result of a local action, or the imme- diate application of the poison to the parts affected. The consequonces, however, of its administration upon the large intestines and the nervous system must be referred to an agency exerted through the medium of nervous sympathy or absorption. That its effects are, at least partly, produced in the latter way, would appear pretty well established by the experiments of Wibnier, which detected lead in the liver, spinal cord, and lumbar muscles of a dog thrown into painters' colic by repeated small doses of sugar of lead; and it may be added that this conclusion, as far at least as respects the lumbar muscles, has been confirmed by the more recent researches of Christison. If entitled to look upon this point as established beyond controversy, we shall henceforward be able to ascend at least one step higher than before in our search after the cause of the paralysis which characterizes slow poisoning by lead. When an individual dies of a large dose of some soluble preparation of lead, there is nothing in the symptoms or morbid appearances sufficiently char- acteristic to distinguish the case from one of poi- soning by any other irritant. But in those cases which are by much the most numerous, where the poison gradually insinuates itself into the system, the symptoms of colic during life, combined with the contractu! state of parts of the intestinal canal, and the absence of all other lesions, will, generally speaking, enable us to decide respecting its real nature. It will seldom, however, occur that a certain conclusion can be drawn without the aid of chemical research, and this brings us to the de- scription of the experiments by which lead in its various ordinary forms may be detected. If our search be directed to an aqueous solution, it will be only necessary to add to separate por- tions of it a little sulphate of soda and hydriodate of potash. If lead be present, the former will afford a white precipitate, which is blackened by sulphuretted hydrogen; and the latter, one of a bright yellow colour, and soluble in a large quan- tity of hot water, from which, as the solution cools, it subsides in scales of a beautiful orange hue. Should the suspected substance be insoluble in water, let it be heated on charcoal with the blow- pipe, by which treatment, if it be a preparation of lead, a malleable metallic button of a blue colour will be obtained ; and the solution obtained by acting upon this with nitric acid will, when ren- dered neutral by evaporation or otherwise, afford, with sulphate of soda and hydriodate of potash, the precipitates already described. When a mixture containing organic substances, such as milk, albumen, or the contents of the stomach, is the subject of experiment, it is to be acidulated with acetic acid and then boiled for some time, in order that the vinegar may take up any oxide precipitated by the organic matters. Filtration is now to be practised, and sulphuretted hydrogen passed through the filtered solution as long as a black precipitate is formed. This, if sulphuret of lead, will afford with nitric acid a nitrate of the protoxide, which, when rendered neutral by evaporation, re-dissolved in water, and separated from any insoluble residue by filtration, will be affected as before by the sulphate of soda and hydriodate of potash. One or other of these methods is applicable to any of the preparations enumerated at the commencement of this sec- tion. When a soluble salt of lead, such as the acetate, is swallowed, next to the adoption of such means as may effect its expulsion from the stomach, the most judicious course will be to introduce after it such re-agents as will convert it into compounds insoluble in the gastric juices. This object may be accomplished by solutions of the sulphates of soda or magnesia, for experiment proves that the sulphate of lead which is formed in virtue of the decomposition which ensues, is entirely destitute of poisonous action. The phosphate of soda is equally efficacious, and the alkaline carbonates, though themselves injurious in large doses, may, when cautiously used, be exhibited with advan- tage, as the carbonate of lead is much less active than the acetate or any other soluble salt of the same base. [Dr. C. G. Mitscherlich has lately shown, that the acetate of lead is a poisonous salt; and that when mixed with acetic acid, it is more energetic than when given in the neutral state. (Brit. c\ For. Med. Rev., No. vii., p. 208.)] Dr. A. T. Thomson has given publicity to the very paradoxical opinion, that the carbonate is not only the most poisonous of the preparations of lead, but that it alone is possessed of any injurious properties. It would be interesting to learn the ground of such a position. In recounting the chemical antidotes, the sul- phate of zinc should not be forgotten. This will not only favour the ejection of the poison by ex- citing vomiting, but will also convert any portion 436 TOXICOLOGY. of it which exists dissolved in the contents of the stomach into the inert and insoluble sulphate. [Albumen precipitates the oxide of lead when added in large quantity, and Mitscherlich has found, that casein is a very effectual precipitate of the oxide. It would, consequently, be advisa- ble to administer, in cases of poisoning by the soluble salts of lead, milk or albumen in large quantity. The compounds, thus formed, if not inert, are far less active than the acetate.] The consequences of slow poisoning by lead, namely, colic and partial paralysis, are to be treated upon general medical principles. The former is most readily subdued by the exhibition of alternate doses of purgative and anodyne me- dicines, while the latter can only be benefited, and finally overcome, by means which restore the ge- neral health. It may, however, be observed that this latter line of treatment seems considerably assisted by the use of splints or other mechanical means, for sustaining in the extended position the wrists and fingers, which are the seat of the paralysis. These symptoms are very apt to recur or re- peatedly attack the same individual, whenever he is exposed sufficiently long to the influence of the poison. To prevent, in some cases, such a recur- rence, a total change of occupation is indispensa- ble, and in all instances of inevitable exposure to the poison, the strictest measures of cleanliness and precaution should be adopted, so as to prevent as much as possible its ingress, through any channel, into the system. Zinc.—The sulphate of zinc is the only pre- paration of this metal which claims notice here. From its extensive use as an emetic in the dif- ferent varieties of poisoning, if for no other reason, it deserves the attention of the toxicologist. When white vitriol is administered to the hu- man subject, vomiting is shortly excited, and this being an almost invariable effect, it has been con- cluded that in no dose can it prove dangerous, as after a little time it is necessarily expelled from the stomach. Cases, however, have occurred in which it has caused very violent irritation, and there are even two instances on record in which it produced death. The symptoms which are witnessed when a large, dose of sulphate of zinc has been adminis- tered, are violent vomiting, which, for the most part, ceases after the stomach has been completely emptied, the individual shortly recovering his na- tural state. In some cases, however, the vomiting is succeeded by a diarrhoea, tenderness in the epigastrium, and abdominal pains; symptoms which, though very rarely, have terminated fa- tally. In a fatal case recorded by Mertzdorf, the sto- mach and intestines, particularly the latter, were found contracted, and the inner membrane of both studded with several spots of effused blood. Their contents also were fluid, and of a greenish grey colour. In other respects the body was natural. The preceding details are confirmed by the symptoms and morbid appearances witnessed by Orfila in dogs made to swallow large doses of sulphate of zinc, the salt being detained in the stomach by ligature on the cesophagus. When introduced imo the stomach, sulphate of zinc operates obviously as an irritant poison, and even inflames the part to which it is applied. The nausea and vomiting, however, are also pro- duced when the salt is applied to other mucous surfaces, as, for example, the rectum; and it has hence been concluded that the greater portion of the phenomena it produces are the result of its operation upon remote organs. But the precise channel through which this action is conveyed has not been determined. It is scarcely necessary to say that the exhibi- tion of sulphate of zinc cannot be inferred from the symptoms or morbid appearances which it produces. In suspected cases, the aid of chemistry must be invoked, and indeed there is no metallic preparation the presence of which in a given solu- tion or mixture can be determined by more de- cisive experiments than white vitriol. If the suspected substance be a white pulveru- lent or prismatic powder, if it dissolve in water, and if the solution afford with hydro-sulphuret of ammonia a white precipitate, but none with sul- phuretted hydrogen if previously acidulated with sulphuric acid, it may be pronounced, with much probability, to be a salt of zinc. This conclusion is confirmed, if, upon the addition of a drop of water of ammonia to a separate portion of it, a white precipitate is obtained, which disappears, affording a colourless solution, when more of the alkali is added. Should it be sought for in the contents of the stomach, it is necessarily mixed with organic matters. In such case the whole should be agitated for some time in a warm place, in a bottle, with an excess of the water of am- monia, and the insoluble matters separated by filtration. The solution thus obtained will contain the oxide of zinc dissolved by the volatile alkali, from which it may be recovered, in the form of the white sulphuret, by a stream of sulphuretted hy- drogen. If this precipitate be digested with nitric acid, a mixed sulphate and nitrate of zinc are formed, which, when rendered neutral by evapora- tion to dryness, dissolved in water, and filtered, may be subjected to the tests already mentioned. The process for organic mixtures given by Christison is defective, for it assumes what is erroneous,—namely, that the oxide may be thrown down from sulphuric acid by sulphuretted hy- drogen. This only occurs, to a very limited extent, when the solution is neutral, but not at all in one acidulated by a mineral acid. The preceding process will merely prove the presence or absence of oxide of zinc from any solution or mixture submitted to examination. The search for sulphuric acid will require the ap- plication of other tests, which have, however, been detailed in their proper place. Upon the subject of treatment it is not necessary to make any remarks. From its peculiar action on the stomach, it will generally be qun-kly dis- charged, so that the only point which can require attention will be the allaying, by appropriate means, the irritation or inflammation which it may have excited. Antimony.—There are at least four prepara- tions of antimony employed as therapeutic agents by the physician and surgeon, namely, the pre- pared sulphuret, kermes mineral, tartar-einetK, TOXICOLOGY. 437 and the chloride or butter of antimony. The two first possess too little activity to become objects of interest to the toxicologist, and as to the last, though a powerful corrosive, we have, owing to its rarity, very few instances of poisoning by it. It will therefore be nearly sufficient for us to con- fine our attention to the tartar-emetic. A few incidental remarks at least will suffice in reference to the other preparations. When tartar emetic is swallowed by man, it very generally happens that, whatever may have been the amount of dose, it, like the sulphate of zinc, is rejected by vomiting; and after these effects are over, the individual is found to have sustained no injury whatsoever. This, however, does not invariably occur ; for sometimes when the dose is large, or when the medicine is retained for a considerable time, the vomiting which finally sets in becomes obstinate, the stomach is the seat of a burning pain ; and purging accompanied with violent colicky spasms, shortly follows. A sense of constriction in the throat is also experienced, and the limbs are seized with the most distressing cramps. In case of a fatal termination, a thing very seldom witnessed, death is preceded by deliri- um and convulsions. In two cases recorded in the French journals in which death was produced by tartar-emetic, inflammation of the villous coat of the stomach, duodenum, and small intestines, constituted the only lesion which was observed. Magendie, in experimenting upon dogs, found that the lungs were always highly congested and inflamed, but the dissections hitherto made do not enable us to extend this observation to the human subject. [Professor Hamilton of Edinburgh was in the habit of referring in his lectures to fatal cases re- sulting, in infants, from the administration of the tartrate of antimony and potassa. He was led to believe that the fatal lesions were induced when no fluid was contained in the stomach, and hence urged the necessity of care on this point. Atten- tion has been recently drawn to the subject of poisoning by this salt in the case of the young by Mr. Goodlad and Mr. Noble, when given even in small doses. Four cases have been recorded by Mr. Wilton in which prostration and collapse followed the administration of ordinary doses of the tartrate to young children. Two of these were fatal. (Mr. Taylor's Report on Toxicology, Brit, and For. Med. Rev. for Oct. 1844, p. 552.)] It is scarcely necessary to observe that tartar- emetic exercises a local action, whether introduced into the stomach or applied by inunction to the external surface of the body. In the former case, redness, thickness, and spots of extravasation are produced upon the mucous lining of the alimentary tube; in the latter, a pustular eruption, as is well known to the physician and surgeon. It may, however, be doubted whether the effects it produces on the stomach are not partly the result of a remote action directed to the nervous system, particularly when we recollect that nausea, vomiting, and marks of gastric inflammation are also produced when the poison is introduced into the urethra or rectum, applied to a wound, or injected into a vein. The medium through which this action is exerted has not been ascertained, but it is probably nervous sympathy. 2«* No assistance can be derived from either the symptoms or morbid appearances in deciding upon a suspected case of poisoning by tartar- emetic. This is too obvious to require enforce- ment. The solution of the question as to whether antimony has been administered or not must be drawn from chemistry alone. The substance suspected to be an antimonial preparation is either soluble in water, or it is not. If soluble, let the solution be treated with sulphuret- ted hydrogen, and if an orange precipitate is formed, it furnishes probable, though not convinc- ing evidence of the presence of the metal. Let the precipitate be collected on a filter, washed, dried, then dissolved in a minimum of concentra- ted muriatic acid, and, finally poured into water. Should a white precipitate be thus produced, all doubt as to the presence of antimony is removed. When the metal is sought for in organic mix- tures, the whole should be digested with tartaric acid for the purpose of dissolving any oxide of antimony which may have been precipitated. It is now filtered, and through the solution thus obtained the sulphuretted hydrogen is passed as before, the temperature of 212° being subsequently applied in order to determine the subsidence of the precipitate. In consequence of the organic matters present, this precipitate, though it be sulphuret of antimony, will seldom exhibit its characteristic orange colour; but if upon treatment, as already described, with muriatic acid and water, a white precipitate be obtained, which is changed to orange by contact with sulphuretted hydrogen, the proof of the presence of antimony is complete. The preceding processes suppose the antimonial preparation to be either soluble in water or tartaric acid, and are therefore applicable to tartar-emetic and butter of antimony.* Should the native or artificial sulphuret be the subject of examination, they will dissolve with the evolution of sulphuret- ted hydrogen in strong muriatic acid, and the solu- tion poured into water will deposit the pulvis Algarotti, or white powder already described. The processes for the reduction of the metal recom- mended by Orfila and Christison are altogether omitted, as they are rather difficult of execution unless by the experienced chemist, and when suc- cessfully performed, afford, in reality, less satis- factory evidence than those with the description of which we have contented ourselves. Treatment.—The poison should be expelled as speedily as possible, but this will, generally speak- ing, be accomplished without assistance when the tartar-emetic has been taken. To neutralize any of it which may remain, draughts containing infu- sion or tincture of yellow bark, or in the absence of these, tincture or infusion of galls, should be repeatedly given.f The bark in powder has also been advantageously administered. After a suffi- ciency of cinchona has been given, if the stomach still continue disturbed, opium may be exhibited. Should gastric inflammation be developed, it is to be treated upon general principles. * This preparation, if swallowed, immediately depositg, . upon contact with the fluids of the stomach, the pulvis Algarotti, which dissolves in tartaric acid. t The gallate and tannate of antimony are insoluble, and, as far as experiments go, would appear to be inert. It is by the formation of these that cinchona acts as an antidote to tartar-emetic. 438 TOXICOLOGY. Bismuth.__When a solution of bismuth in nitric acid is rendered as neutral as possible by evaporation, and then poured into water, a beau- fully white precipitate immediately falls down. This, which is a subnitrate, is a good deal used by some practitioners in the treatment of the dif- ferent forms of dyspepsia. But, when exhibited in an over-dose, it is an irritant poison, and has occasionally produced fatal effects. In a case quoted by Christison from a French journal, in which two drachms were swallowed mixed with a little bitartrate of potash, the symp- toms were, shortly after swallowing the poison, burning in the throat, brown vomiting, watery purging, cramps, coldness of the limbs, and inter- mitting pulse; then inflammation of the throat, difficult deglutition, dryness of the membrane of the nose, and a constant nauseous metallic taste. On the third day, hiccup, laborious breathing, and swelling of the hands and face; on the fourth day, swelling and tension of the belly ; on the fifth day, salivation; on the sixth day, delirium; on the seventh day, swelling of the tongue and enormous enlargement of the belly ; on the ninth, death. The urine also was suppressed until the eighth day. It was ascertained after death, that from the fauces to the rectum there were but few points free from disease. The tonsils, uvula, pharynx, epiglottis, and larynx were gangrenous, the gullet was livid, and the stomach very red, with nume- rous purple pimples, the whole intestinal canal red, and here and there gangrenous, especially at the rectum. The inner surface of the heart was red. The kidneys and brain were healthy. The subnitrate of bismuth may be distinguished from other white powders insoluble in water, by being taken up by nitric acid of a density not less than 1280., and by the solution thus obtained affording, when poured into water, a white preci- pitate, (the original subnitrate,) which is black- ened by sulphuretted hydrogen. If sought for in a mixture containing organic matters, the insolu- ble portion should be separated by filtration and charred in an earthen crucible at a red heat. In this way the subnitrate, if present, is reduced, and may be subsequently dissolved by digesting the residue with nitric acid of specific gravity 1280. The solution thus obtained is of course to be tested in the manner above explained. Under the head of treatment it is sufficient to say that the poison should be expelled as rapidly as possible, and any subsequent inflammation en- countered by the usual antiphlogistic means. There is no chemical antidote for this poison. Barytes.—There are but two barytic prepara- tions which deserve any notice here, the carbonate and the muriate, [chloride of barium,] for these are the only ones which are prepared in quantity for medicinal or other purposes. The former is a native product, and has, in the districts in which it abounds, been employed as a poison for rats; the latter is artificially prepared with a view to its exhibition in the treatment of strumous affections. But few opportunities have occurred of studying the symptoms it gives rise to in the human sub- ject. In a case recorded in Brande's Journal, vol. iv. p. 382, in which an ounce of the muriate was taken in mistake for Glauber's salt, a sensa- tion of burning was felt in the stomach immedi- ately after swallowing the poison ; vomiting, con- vulsions, and headach ensued, and death took place within an hour. There is a case in the Medical Commentaries referred to by Christison, of a gentleman, who shortly after having swal- lowed by accident about thirty drops of the same preparation, was attacked with profuse purging and vomiting, and in half an hour with a degree of muscular debility of the lower limbs, nearly amounting to paraplegia. In twenty-four hours, however, he recovered his natural state. The morbid changes produced by barytic prepa- rations in man have not as yet been described, In the lower animals, when swallowed they pro- duce, unless death ensue with great rapidity, in- flammation of the stomach and lower intestines; and Dr. Campbell observed that when dogs were poisoned by the application of the muriate to an external wound, the brain and its membranes were so injected with blood as to exhibit appear- ances analogous to those of congestive apoplexy, The barytic salts obviously exert a local action, for they irritate and inflame the parts to which they are applied. The most remarkable effects, however, which they produce, are the result of a remote action directed to the brain and spinal marrow, and producing paralysis and convulsions. This second variety of action is established not only by the symptoms which have been observed in man, but also more completely by the experi- ments of Brodie, Orfila, and Gmelin, upon the lower animals. We do not know through what channel the morbific influence of barytes is con- veyed to the nervous system. It is important, however, in reference to this point, to observe that the muriate and other soluble salts of barytes ope- rate as poisons, whether introduced into the sto- mach, applied to a wound, or injected into the blood. The carbonate of barytes, though insolu- ble in water, is a poison in the stomach, being dis- solved by the acid juices which it encounters there; and Dr. Campbell even found it to produce alarming effects when applied to a wound. Intro- duced into a vein, it would probably act merely in a mechanical manner: for, from the alkalinity of the blood, it could not undergo any solution. The muriate of barytes may be distinguished from all other poisons by affording, with nitrate of silver, the well-known chloride of that metal, and, with sulphate of soda, a white precipitate quite insoluble in water, acids, or alkalies, and not blackened by sulphuretted hydrogen. These lat- ter experiments, indeed, do not sufficiently distin- guish it from the muriate of lime and strontites, for the sulphate of these earths, particularly the latter, are very sparingly soluble, and are equally unaffected by sulphuretted hydrogen. To remove all doubt, let the suspected solution be treated with less sulphate of soda than is necessary for its perfect decomposition, and let the precipitate be collected on a filter and washed with distilled water. If the washing, upon the addition of a drop of muriate of barytes, afford no precipitate, the salt must have been a barytic one. If there be a precipitate, it is one including lime or stron- tites. Should the poison be sought for in the contents of the stomach, these should be boiled with water, filtered, and the solution thus ob- tained should be evaporated to dryness, and ignited TOXICOLOGY. 439 in a platina crucible to destroy organic matter. The residue is next to be digested with a small quantity of water, and to the solution thus ob- tained, when filtered, the tests already described may be applied. If, in the treatment of a case of poisoning by barytes, the proper antidotes be ad- ministered with sufficient promptness, the earth can only be found in the stomach in the form of sul- phate. To form from it the muriate, with the application of the proper tests, the following me- thod must be pursued. Let the contents of the stomach be thrown upon a filter, and let the mat- ters detained thereby, when dried, be mixed with one-sixth of their weight of lamp-black, and ex- posed in a platina crucible, or, should the mixture be very small, rolled up in a little platina foil, to a 6trong red heat for ten or fifteen minutes. The sulphate of barytes is thus converted into a sul- phuret of barium, which is changed by the action of muriatic acid into muriate of barytes, sulphu- retted hydrogen being at the same time given off. The mode of testing this muriate need not be re- peated. In case of poisoning by the muriate, a solution of sulphate of soda or magnesia should be intro- duced into the stomach. This also should be done without loss of time, for the poison sometimes acts with extraordinary rapidity. The barytes is thus immediately converted into the insoluble sulphate, which experiment proves to be altogether inert. Should the carbonate have been the preparation swallowed, the Soluble sulphates should be re- placed by copious draughts of dilute sulphuric acid. Tin.—Metallic tin in a finely granulated state is employed in medicine as a vermifuge. Its action is considered purely mechanical, and, though given in large doses, it has not given rise to any poison- ous symptoms. The peroxide of tin also, though not inert, possesses but little activity. If the ex- periments of Schubarth can be relied upon, in drachm doses it exerted no action whatever upon a dog. The proto- and per-muriates, however, which are prepared in quantity in consequence of their uses in dying, are active irritants, whether exhibited to man or the inferior animals. The only description of the symptoms produced by these preparations published is that given by Orfila, in the case of several persons who partook of food seasoned with muriate of tin, accidentally used by the cook instead of common salt. All had colic; some diarrhoea ; and all recovered in a few days. The morbid appearances are exclusively such as result from violent irritation. In dogs, the stomach, according to Orfila, always looks as if it had been partially tanned. The symptoms observed after the exhibition of the muriate to dogs, combined with the morbid changes it effects, justify the belief of its action being simply that of a local irritant. Tin, in the form of protomuriate, is easily detected by its afford- ing with the muriate of gold the purple powder of Cassius, with corrosive sublimate a white pre- cipitate, which presently assumes a leaden hue, and by communicating a red colour to a very dilute solution of the muriate of platinum. As a permuriate, it does not yield to any very characteristic precipitates with re-agents, so that it will be necessary to heat the suspected substance to redness with black flux in a Hessian crucible, by which means, if tin be present, a metallic but- ton will be obtained. This will dissolve with the evolution of hydrogen in muriatic acid, and the solution thus formed will comport itself as proto- muriate of tin. In cases of the ingestion of tin, the first thera- peutic step to take is to expel as much as possible of the poison from the stomach by emetics or the stomach-pump; the next to decompose whatever may remain by the introduction of fluid albumen. Should inflammatory symptoms be developed, the usual antiphlogistic measures must be resorted to. To the irritant poisons of organic origin the term acrid has been usually applied. Some are the products of the vegetable, and some of the ani- mal kingdom. [Chrome—The only salt of this metal which has been productive of poisoning is the Bichromate of Potassa. This salt is much used in the art of dyeing, and is extensively manufactured in Balti- more, where several cases of poisoning with the saturated solution have occurred. The following instance was communicated by Dr. Baer to Pro- fessor Ducatel, (Manual of Practical Toxicology, p. 144, Baltimore, 1833.) A labourer, aged 35 years, on attempting to draw off from a reservoir a solution of the bichromate of potassa, in the effort to exhaust the syphon by suction, received a small quantity of the solution in his mouth. His first impression was, that he had spitten it out; but only a few minutes elapsed when he was seized with great heat in the throat and stomach, and violent vomiting of blood and mucus. The vom- iting continued until shortly before his death, which took place about five hours after the accident. No medical treatment was attempted, Dr. B. having been called in too late. In the examination after death, the mucous coat of the stomach, duodenum, and about one-fifth of the jejunum was found de- stroyed in patches. The remaining parts could be readily removed by the handle of the scalpel. The lower part of the intestinal tube appeared to be healthy. The bichromate of potassa seems to be an irri- tant poison, affecting principally the nervous sys- tem. In animals it has, in small doses, produced vomiting, diarrhoea, paralysis, and death in a few- hours. It seems, also, to produce extensive sores on the hands of dyers; and even in parts where the vapour alone could come in contact, the vapour being charged, perhaps, with chromic acid. (Du- catel, Op. cit. p. 145.) A case of poisoning by this salt has lately been detailed by Mr. Wilson, of Leeds, (Lond. Med. Gaz. xxiii. 734). It is worthy of remark, that in this case there was neither vomiting nor purg- ing ; death appeared to be induced by the indirect effect on the nervous system ; an occurrence which, as remarked by Mr. Taylor, (Report on Toxicolo- gy>) is °y no means unusual, even with irritants far more powerful than the bichromate of potassa.] 2. Vegetable Irritants or Acrids. This genus, though including a considerable number of species, admits of being discussed with brevity, for the symptoms and morbid appearances produced by all are nearly the same. There is another reason, also, why it will not be necessary 440 TOXICOLOGY. to dwell minutely upon them; they are seldom resorted to for the purpose of destroying life. The vegetable acrids, when swallowed in large doses, very generally give rise to vomiting, by means of which the poison is discharged. Some- times, however, they are retained by the stomach, particularly when the quantity has been small; and in these cases diarrhoea usually sets in, attend- ed by abdominal pain, which is at first remittent, but becomes more constant in proportion to the development of inflammation in the intestinal tube. The belly now becomes tense and tender. The debility is great, and giddiness and tendency to delirium are sometimes, though rarely, ob- served. The morbid appearances produced by the ve- getable narcotio-acrids are inflammation and its essential concomitants, redness, together with, oc- casionally, ulceration, principally in the stomach, duodenum, and large intestines. These poisons are direct local irritants, and probably do not enter the blood. Such, at least, is the conclusion deduced by some from the fact of their action, when externally applied being in a great measure limited to the parts with which they are brought in contact. The symptoms and morbid appearances will not, it is obvious, enable us to determine whether a vegetable acrid has been used in any particular case, much less to assign the precise substance which has been employed. Nor will chemistry be of much assistance in such an investigation, for we are but very imperfectly acquainted with the proximate principles of vegetables, and but in a very few instances know of re-agents by which their presence may with certainty be detected. Our chief reliance must be placed upon our know- ledge of the physical and botanical characters of the various substances which may become the object of toxicological inquiry. With respect to treatment, we have nothing to advise but that the poison be removed from con- tact with the body with as much speed as possi- ble, and that intestinal inflammation, should it follow, be controlled by the usual means. There is no one of these poisons for which there exists a true chemical antidote. The following list includes the plants which yield the more important vegetable acrids : al- though given in a former part of this article, we repeat it here for the convenience of reference:— Euphorbia officinarum, &c. Jatropha curcas, &c. Ricinus communis. Momordica elaterium. Cucumis colocynthis. Bryonia alba vel dioica. Ranunculus acris, &c Anemone pulsatilla. Caltha palustris. Delphinium staphysagria. Daphne mezereon. Juniperus sabina. Convolvulus jalapa. Narcissus pseudo-narcissus. Gratiola officinalis. Stalagmitis cambogioides. The euphorbium mentioned in works upon the materia medica is the inspissated juice of the euphorbia officinarum, an African plant. A simi- lar substance, however, may be obtained from several other species of the same genus. In con- sequence of the violence with which it acts, it has been long since discarded from medical practice. Its active principle is of a resinous nature, or it is rather, according to the researches of Buchner and Herberger, a combination of two resins bear- ing to each other the relation of an acid and a base. The latter they conceive to be that which gives it its acridity. Euphorbium in a large dose, whether internally administered or externally ap- plied to a wound, is a powerful poison. Even when kept in contact with the sound skin, it has produced extensive inflammation and gangrene. The seeds of the jatropha curcas are powerfully acrid, and the same property is possessed by a fixed oil and a volatile acid produced from them by distillation. The juice of the root of the jatropha manihot possesses, as is well known, similar powers; though the root itself, when de- prived of the juice, constitutes, under the name of tapioca, a wholesome and nutritive food. Half a pint of the juice has caused death within an hour. The seeds of the ricinus communis, which upon pressure afford castor oil, operate when chewed as a drastic purge. A single seed is sufficient to produce such an effect. Neither the nature of the acrid principle, nor the precise part of the seed in which it resides, has been ascertained. When castor oil is unusually active, it is probably owing to its containing an undue proportion of this principle. The momordica elaterium, cucumis colocynthis, and bryonia alba, are all found in the same natu- ral order, the Cucurbitaces, and all possess acrid •properties in a very intense degree. The active principle of the first resides in a fecula deposited from the expressed juice of the fruit; that of the second in a pith found within the capsule; and that of the third in the root. The two first are frequently employed by the physician in conse- quence of their purgative virtues. The elaterium has been found by Dr. Morries to contain a crys- talline principle which is the source of its drastic energies, and this discovery has been confirmed by Mr. Hennell. A tenth of a grain of this prin- ciple produces in man a very considerable purga- tive effect. The acrid principle of the colocynth appears to be of a resinous nature, being soluble in alcohol and but sparingly in water. It has received the name of colocynthin, though the substance so called is probably not entirely freed of foreign matters. In point of activity, colocynth is scarcely inferior to elaterium. It has frequently produced fatal effects. The bryony, which is a British plant, possesses properties perfectly analogous to, and scarcely less active than the two others with which it has been associated. Its acrid virtues reside in a principle soluble in water, which was discovered not long since by Brandes and Firnhaber, and which they have named bryonine. There are upon record some cases in which decoctions of the bryony produced death with hypercatharsis and the other symptoms already detailed. The different species of ranunculi, particularly the acris and sceleratus, afford by expression or TOXICOLOGY. 441 decoction with water a highly poisonous fluid. The same is true of the caltha palustris and the anemone pulsatilla, plants which belong to the same natural order. The latter plant, dried and reduced to powder, has produced gangrene when externally applied as a counter-irritant. The seeds of the delphinium staphysagria, a plant which also belongs to the Ranunculaceoe, have been found by Lassaigne and Fenoulle to contain an alkali which is the principle that gives them their activity. Orfila found that six grains of this delphinia dissolved in vinegar killed a dog in forty minutes. A crystalline principle possessing neither acid nor alkaline properties has been found by Dublanc in the bark of the daphne mezereon, to which it owes its acrid properties. The bark, as well as the berries of this tree, have produced very vio- lent symptoms, and even death. The root of the daphne laureola or spurge laurel, a British species, is, according to Withering, powerfully acrid.. The leaves of the juniperus sabina and an essential oil which may be procured from them by distillation, possess highly acrid properties. Internally, they produce dreadful irritation of the stomach and bowels, and applied externally to a recent wound, very extensive diffuse inflammation is the consequence. They are reputed to possess the power of causing abortion, but they probably do not exert any specific influence on the uterus. Death has occasionally occurred in consequence of their internal exhibition for such purpose. Half an ounce of the aqueous extract of the narcissus pseudo-narcissus, or common daffodil, internally exhibited, killed a dog in less than twenty-four hours; and one drachm applied to a wound produced a similar result in a quarter of the time. The symptoms and morbid appearances were in both cases the same, or such as belong to the vegetable acrids generally. The root of the convolvulus jalapa possesses, as is universally known, acrid virtues, and is hence extensively employed as a cathartic medicine. Mr. Hume, of London, was supposed to have in- sulated its active principle, which he named jalap- ine. The substance, however, which he obtained has been since shown by Pelletier to be nothing but the ammoniaco-magnesian phosphate. More recently Buchner and Herberjer have stated it to be a resinous substance constituting about one- tenth of the weight of the root, and, like that of euphorbium, composed of two others with oppo- site electrical relations. Scammony or the inspissated juice of the root of the convolvulus scammonia, possesses analo- gous properties to jalap, but according to Orfila it is much less active. The gratiola officinalis, or hedge hyssop, proved a powerful poison in the hands of Orfila. Three drachms of its watery extract, retained by a liga- ture on the cesophagus in the stomach of a dog, killed it in twelve hours. The same quantity ap- plied to an incision in the thigh of a dog, killed it in twenty-five hours. Half a drachm of the extract, dissolved in water and injected into the jugular vein of another dog, destroyed it in two hours. Serious accidents have occurred to man from the incautious use of this plant. The gum resin, called gamboge, and which is Vol. IV. —56 obtained from incisions made in the leaves and young shoots of the stalagmitis cambogioides, is one of the most violent of the vegetable acrids employed to produce a purgative effect. Orfila found that a drachm and a half, retained mecha- nically in the stomach, killed a dog in ten hours, and in very small doses it produces in man dan- gerous hypercatharsis. Externally applied, it pro- duces extensive cellular inflammation. In the preceding summary we have entered into no details in reference either to the mode of pro- curing the different active acrid principles, or the physical, chemical, or botanical characters of the various plants in which they are found. These are points of the greatest importance, but to dis- cuss them in an adequate manner it would be ne- cessary to extend this article to an inconvenient length; the chemical constitution and properties of the leading poisonous vegetables are given with great detail and clearness in the Traite de Chimie of Berzelius, vol. vi.; and their botanical charac- ters and relations will be found unfolded in a very able and satisfactory manner in the English edi- tion of Richard's Botany, translated and edited by Dr. Clinton. 3. Animal Irritants or Acrids. The animal as well as the vegetable kingdom furnishes several substances, which, from the na- ture and violence of their action on living beings, deserve to be ranked among the acrid poisons. Those which are most entitled to attention are certain species of insects, fish, and reptiles, and organic matter in a state of ordinary or modified putrefaction. The symptoms which they produce are pretty nearly the same as result from the action of tho vegetable acrids, with this difference, that they more frequently and decidedly influence and dis- turb the nervous system. Their powers are, therefore, in all probability not expended upon the parts to which they are immediately applied, but directed also to distant organs, which they affect either through the medium of sympathy or the circulation. Cases of suspected poisoning by these sub- stances are to be investigated, and of actual poi- soning treated upon the general plan already briefly explained under the head of the vegetable acrids. Cantliarides.—This substance is an insect, the lytta vesicatoria, and is familiarly known to every one as an external application for the pur- pose of producing vesication. Its active principle, the cantharadin, was first obtained by Robiquet, and has since been more particularly examined by Gmelin. It occurs in small crystalline scales, like plates of mica, which melt when heated, and sub- lime unaltered, are insoluble in water or cold alco- hol, but soluble in the latter with the assistance of heat. Cantharides is sometimes though not often ex- hibited internally by the physician ; and in such cases, in consequence of its activity, the dose is necessarily extremely small. It has, however, in several instances been taken in considerable quan- tity for the purpose of procuring abortion, and with the view of stimulating the genital organs, and exciting sexual desire. In some few cases it 442 TOXICOLOGY. has been swallowed with the view of effecting self-destruction. [In regard to the quantity of cantharides re- quired to destroy life, any dose larger than the maximum quantity prescribed as a medicine, may prove injurious. The smallest quantity of pow- der known to have killed is recorded by Orfila, (Op. cit.) It was that of a young female, who took twenty-four grains in two doses. She died in four days ; but as abortion preceded death, the case was not a simple one. An ounce of the tincture has been known to destroy. (Taylor, Op. cit. p. 228.)] The symptoms which characterize a poisonous dose of cantharides are burning heat of the throat and stomach, difficult deglutition, abdominal pain, vomiting, the matters discharged being often bloody and containing membranous flakes, parch- ing thirst, strangury, bloody urine, priapism, and, in some rare cases, gangrene of the genital organs. The nervous symptoms observed are headach, convulsions, loss of memory, and delirium. The preceding effects have been produced by scruple doses of the powder. In a fatal case recorded not long since by Orfila, the cesophagus, stomach, and intestines, the omen- tum, and peritoneum, the kidneys, ureters, bladder, and urethra, were highly inflamed, and the tongue, mouth and fauces were excoriated. Cantharides will remain in the stomach for a considerable time without losing its characteristic appearance and properties. If found there, the cause of the poisoning is revealed; but it must be recognised by its external characters, for chemis- try can contribute little, if at all, to its identifica- tion, and the same may be said of the symptoms and morbid lesions. There is no antidote for this poison : oil, which was once so considered, is de- cidedly improper, for it confers solubility upon the cantharidin. The poison should be expelled from the stomach, and the inflammation it excites should be met by antiphlogistic measures. De- mulcent drinks and the warm bath are calculated to alleviate the dreadful irritation of the urino- genital system which is sometimes observed. Poisonous Fish.—Under this head we do not intend to allude at all to those kinds of fish* which, though they constitute wholesome food to the generality of mankind, nevertheless produce, when used by some individuals, sickness, vomit- ing, cutaneous eruptions, and other alarming symptoms. Such effects, when they are observed, are undoubtedly referable to some peculiarity of constitution, or idiosyncrasy, as it is usually called. Two other varieties of poisonous fish remain to be noticed,—those which are so constantly, and to all individuals, and those which though generally edible and innocent, acquire under circumstances not well understood, injurious properties, the ori- gin of which it is not very easy to assign. Those of the first variety are so rare on our coasts that it is not necessary to enter into any particulars respecting, them. Of the latter variety, or such as, though generally wholesome, become occasionally poisonous, the only ones which have attracted the attention of toxicologists are the * Oysters, crabs, trout, salmon, turbot, herring, halibut, mackerel, &c. mytilus edulis, or muscle, the oyster, and the common eel. Muscles, &c.—There is a variety of theories as to the origin of the poison of muscles. Some refer it to copper derived from the copper bottonu of ships ; others to their having been, when used, in a state of putrefaction ; others, to a disease to which they are subject; and others again merely to an idiosyncrasy in the individuals who become affected by them. Some of these conjectures, ex. gr. the two first, are easily disproved; and it is the opinion of those who have considered the subject most maturely that none of them afford a perfect solution of the question. Dr. Christison throws it out that those which are poisonous may have developed in them an animal principle of a peculiar nature to which their noxious properties are owing, and suggests the investigation of such a principle as a proper object of chemical re- search. The symptoms are such as characterize gastric and internal irritation of a high degree, to which are sometimes superadded distressing dyspnoea and nettle-rash, together with coma, convulsions, and paralysis previous to death. The symptoms usually begin in a couple of hours, and quickly reach their maximum degree of intensity. The duration of the attack, whether fatal or otherwise, is very variable, death sometimes occurring in a few hours, and sometimes not for three or four days. The morbid appearances which have been ob- served are inflammation of the stomach and bow- els ; but cases have occurred in which no organic lesion has been detected. Oysters and eels have sometimes acquired dele- terious properties, but the accounts which have been published do not enable us to comprehend either the nature of the change which they expe- rience or the cause of it. The action they have been observed to exert is that characteristic of a simply irritant poison. Poisonous Serpents.—The most poisonous reptiles with which we are acquainted are ihe cobra de capello and rattlesnake; but as these do not exist in the British isles, we shall enter into no details respecting them. In England, however, a reptile is indigenous, the viper, the bite of which is always productive of distressing symptoms, and has in some cases even destroyed life. The poison is secreted by a pair of glands situated near the eye on either side, and is deposited in a sac con- nected with the cavity of a hollow tooth. When the animal inflicts a bite, the poison is forced from the bag into the wound through a perforation in the crown of the tooth. In about twenty minutes after the infliction of the bite, the part becomes the seat of lancinating pains, which extend up the limb, and of swelling, which after a little time assumes a livid colour and is extremely hard. The pulse is feeble, rapid, and irregular; the patient appears in a fainting state ; bilious vomiting, sometimes accompanied by jaundice, 6ets in, and is followed by dyspnoea, cold sweats, imperfect vision, convulsions, and derangement of the intellect. Death sometimes, though rarely supervenes. It is a curious fact that the virus of vipers may be taken into the stomach with impunity. This TOXICOLOGY. 443 has been fully ascertained by experiments on birds, and even on the human subject. The morbid lesions are chiefly such as are visi- ble to the eye, namely, inflammation, swelling, and lividity of the wound and adjacent parts. It is not ascertained whether the poison of venomous reptiles acts by entering the blood, or is the result of nervous sympathy. In support of the former opinion, the fact is relied upon to which the attention of the profession was first particu- larly called by Dr. Barry, namely, that the influ- ence of the virus can be suspended, and even altogether subdued by the timely application of the cupping-glass to the Wound. Addison and Morgan, however, as we have already seen, find no difficulty in reconciling such facts with their views. An outline of the appropriate treatment is rea- dily sketched. Should a cupping-glass be at hand it should be immediately applied to the bite, and as much blood as possible drawn, with the view of washing away the poison from contact with the extremities of the nerves and the patent mouths of the divided blood-vessels. But, if this manipulation cannot be performed within a few minutes after the infliction of the bite, the part should be carefully cauterized either with the potassa fusa or strong nitric acid, with the view of decomposing the virus. When the effects of the poison are fully developed, the treatment must be conducted on general principles. The consequences of the sting of the wasp and bee might be here with propriety discussed, but they are seldom such as to entitle them to a sepa- rate consideration. Animal matter diseased or putrid. —Of animal substances rendered poisonous by disease we have instances in the several matters by means of which contagious and infectious diseases of a definite character are propagated, but the exami- nation of these belongs rather to the practice of medicine than to toxicology. We shall allude, and with brevity, to those only which are but occasionally developed, and which seem to act the part of irritant poisons. When cattle are over-driven, though their flesh does not produce any disagreeable effects when eaten, if externally applied in the raw state to a wound, however small, a diffuse cellular inflam- mation is the result, which sometimes has de- stroyed life. The purulent matter discharged from the nostrils of glandered horses presents us with an instance of a similar kind. When this matter is applied to the hand by inoculation, in- flammation of the part and an eruption of car- buncles is the consequence; and there are even well-authenticated cases of the disease having been taken by grooms without inoculation. A disease to which cattle are subject, and which has been particularly studied in Germany, where it is known under the name of milzbrand, develops in the flesh of the animals it attacks highly acrid properties. The intestinal canal of persons who use the flesh, and even of those who have been engaged in flaying the beast, becomes highly irritated and inflamed, and they are seized with all the symptoms of cholera. More fre- quently, however, malignant pustules are thrown out, or rather a carbuncular eruption analogous to that observed in the cattle themselves, which has often proved fatal in twenty-four hours. The most interesting example, however, of poi- soning to be traced to a virus resulting from mor- bid action is that with which we are so familiar as a consequence of wounds incurred in dissec- tion. The effects to be observed in such cases cannot be referred to animal matter in a state of spontaneous decomposition, for they are never found to occur unless at so early a period after death as to preclude the possibility of ordinary putrefaction having been established. Experience, also, would seem to prove that they are more fre- quently produced by the fluids effused in the chest and abdomen, as a consequence of inflammation, than by any other of the solid or fluid constituents or secretions of the body. The symptoms which usually set in are briefly as follow. In a few hours after the reception of the wound an acute pain is felt at the tip of the shoulder, and a swelling, at first colourless, is ob- served on the lateral part of the neck between the trapezius and sterno-mastoid muscles, which is acutely sensible upon pressure. At first the wound exhibits no unusual appearance; but some time after the occurrence of the symptoms just detailed, it is found covered with a small pustule containing a milky fluid. The pain and swelling at and above the shoulder now become worse, and extend to the axilla, from thence to the thorax, and down along the side; and a similar species of diffuse inflammation seizes upon the arm and forearm, following the course of the great absorbent ves- sels. This inflammation Mr. Collis conceives to be a species sui generis, quite different from phlegmonoid erysipelas. Toward the close of the attack, particularly when the termination is un- favourable, a few pustules similar to that upon the wound appear in other parts of the body, and the skin of the inflamed regions is studded with little solid elevations, which at first sight are taken for vesicles. The constitutional invasion is some- times, though not always, ushered in by distinct rigors und vomiting, and a low typhoid fever of the most malignant type is present from the very commencement. Several individuals eminent for their anatomical zeal and scientific acquirements, have fallen vic- tims to this formidable malady; amongst whom we know of none more distinguished or lamented than the late Mr. Shekleton, museum curator to the Royal College of Surgeons in Ireland. An instructive account of his case, with some others of a similar description, has been published by Mr. Collis in the third and fourth volume of the Dublin Hospital Reports. No lesions of internal organs have, as far as we are aware, been traced to this affection. After the reception of a cut in dissecting, the part should be rendered as clean as possible by soap-water, and a cupping-glass, or the mouth, which will probably answer better, should be applied until by suction a considerable quantity of blood is drawn, and the surface of the wound entirely freed from all foreign matters. These prophylactic measures will, generally speaking, be sufficient; but for greater security it will be ad- visable to apply the potassa fusa or aqua fortis to the wound, with the view of destroying any of 444 TOXICOLOGY. the poison which may not have been previously removed, or at least of modifying the inflamma- tion which may follow. When the hand and arm have become swollen, and the fever already de- scribed has set in with violence, the treatment which has been found most beneficial consists in the free administration of opium, port wine, and other stimulants, the inflammation being at the same time combated by the usual topical antiphlo- gistic applications. Mr. Collis, on general grounds, but without any experience of its efficacy, recom- mends calomel in repeated doses, so as to produce rapid salivation. Animal Matter in a State of Ordinary Decay.—The effects just examined are the result of inoculation with animal matter modified in a certain manner by circumstances not well under- stood, but not at all in a state of decomposition or decay. Animal substances, however, in the putrid state, possess, as has been proved by the experi- ments of Orfila, similar powers; that is, when introduced into a wound they excite diffuse inflam- mation, and, at the same time, fever of the typhoid type. In animal flesh brought to this state by keeping in close vessels, Lassaigne, by an elaborate analysis, found carbonate and cascate of ammonia, together with a fetid volatile oil, in which the noxious properties are conceived chiefly to reside. Certain changes which spontaneously take place in particular articles of food, and which are usually considered as instances of a modified putrefaction, occasionally develop in them properties of a highly injurious description. The substances subject to such changes are common bacon and varieties of sausages, and of cheese, which are extensively consumed in Germany. The nature of the active principle of the poisonous sausage has been the subject of numerous researches, and it would ap- pear now pretty well determined that it is a matter analogous in its chemical properties to the fat acids. The changes in question occur only to sausages which have been boiled before being salted and dried, and their noxious powers are not manifested unless putrefaction has set in, and cease if it should pass a particular limit. The symptoms caused by these substances do not set in usually until twenty-four or forty-eight hours after the meal. Pain in the stomach, vomiting, purging, and aridity of the fauces, mouth, and nose, are those first observed: the voice becomes hoarse, deglutition difficult, and the ball of the eye, the eye-lids, and the pupils become fixed. There are fits of swooning, the pulse is small, and the skin extremely cold. The secretions are suspended, but diarrhoea often continues throughout the attack. There is no fever, and the appetite, it is said, is unaffected. The func- tions of the cerebrum also continue undisturbed. When the case proves fatal, which it does, if at all, between the third and eighth day, death is usually preceded by dyspnoea and convulsions. Post-mortem examinations have disclosed ap- pearances indicative of inflammation throughout the entire intestinal canal from the fauces to the anus. The body, it is said, putrefies with unusual slowness. Destructive effects have also frequently been produced by cheese, particularly in Germany, with symptoms and morbid appearances almost , identical with those just described as resulting from the use of the poisonous sausage. The experiments also of several German chemists who have elaborately examined the subject, concur in attributing the poisonous properties of the cheese to an acid fat analogous to that of which mention I has just been made. Both poisons, however, must be further investigated before we can decide | upon their real nature. In France and Switzerland an acrid principle has sometimes been developed in milk, particularly that of the goat and sheep, which has produced severe cholera and even death. Its nature and the circumstances in which it originates are entire- ly unknown. Several cases have occurred on the continent in which bacon acted as a violent acrid poison. The symptoms and morbid appearances are pretty nearly the same as those produced by the poison- ous sausages and cheese. The poisonous principle also is conjectured to be of the same nature. II.—NAncoTic Poisons. The substances in the discussion of which we have been hitherto engaged irritate the parts of the body with which they are brought in contact, and even determine a greater or less degree of inflammation of them. We have now, however, to enter upon the consideration of a totally different description of poisons. The narcotics do not irritate or inflame, but, nevertheless, they produce death with as much, if not more certainty and despatch, while in the body we are frequently unable to recognise any appearances of a morbid character. All the poisons of this class hitherto noticed are derived exclusively from the vegetable kingdom, if we except prussic acid, which admits of being also extracted from certain artificial mine- ral salts. The narcotics usually enumerated by toxicological writers are prussic or hydrocyanic acid, opium, its alkaline principles morphia and narcotine and their salts, hyoscyamus, lactuca, and solanum. Before discussing in succession the various particulars connected with poisoning by each of these, we shall make some observations having a reference to the group generally. The symptoms produced by the narcotic poisoni are such as indicate a derangement of the nervous system. There is pain of head, vertigo, partial or complete blindness, stupor, sometimes amounting to insensibility, paralysis, or convulsive action of the muscles under the control of the will and previous to death, profound coma. When, in a post-mortem examination, we look for morbid lesions, the search is almost invariably unsuccessful. In some cases congestion of the veins of the head is observed, and also an effusion of serum into the ventricles and between the pia mater and arachnoid membrane, but these appear- ances are much more frequently wanting. It is scarcely necessary to repeat here that the general opinion entertained in reference to the manner of action of the narcotics is that they enter the circulation, and are, by means of it, conveyed to the brain or spinal marrow, upon which their powers are thus directly brought to act. Nor does the reader require to be reminded that a different theory has been proposed and very ably supported by Addison and Morgan, who refer their action to the sympathy which subsists be* TOXICOLOGY. 446 tween the centre of the nervous system and those expansions of it on which the morbific impres- sions are made. We have already stated our reasons for inclining to this latter doctrine, and shall now merely add, that whatever difference of opinion exists as to the medium through which the influence of the narcotics is propagated to the brain, all physiologists seem to admit that their operation is most powerful and rapid when they are made to pass into the blood. The symptoms and morbid appearances pro- duced by the pure narcotics are not sufficiently characteristic to enable the practitioner who ob- serves them to declare that they could not have been the results of natural disease. Such cases, in fact, may and have been confounded with apoplexy, epilepsy, inflammation and hypertrophy of the brain, affections of the spinal marrow, and what is denominated by Chevalier, asphyxia idio- pathica. Distinctions undoubtedly do exist be- tween the effects of these diseases and of narcotic poisoning, but we are seldom if ever enabled by them to establish a satisfactory diagnosis. In medical jurisprudence, therefore, they are, per se, of comparatively little importance; but as they often contribute to the elucidation of doubtful cases, it will be proper to notice them briefly here. 1. An attack of apoplexy is usually announced by certain premonitory symptoms well known to the practical physician, which are of course wanting in cases of narcotic poisoning. 2. Apo- plexy more frequently attacks the old and corpu- lent, whereas death by a narcotic poison cannot be said to occur oftener at one period or in one habit of body than another. 3. The apoplectic attack is sudden, whereas, on the other hand, the symptoms of the narcotics gradually augment in intensity. To this statement, however, prussic acid is an exception, for its effects upon the sys- tem are almost instantaneously developed, espe- cially when it is given in a sufficient dose. 4. Pa- tients in a narcotised state from the action of a poison may be roused, at least for a short time, to consciousness, and a perception of what is going on in their vicinity, but this can never be accom- plished by those in the apoplectic coma. 5. When narcotics destroy life, this is usually effected in a few hours, and is never delayed beyond the twelfth; but the apoplectic stroke is often not fatal for twenty-four hours, or even more. Apo- Dlexy, however, sometimes kills almost instantly, and the same may be said of some of the narco- tics, for example, prussic acid. The diagnostic distinctions afforded by the morbid appearances after death are not much more satisfactory. When the morbid changes are either simple congestion or serous effusion, they do not assist the diagnosis, as both may be produced by narcotic poisoning, or by simple or serous apo- plexy. If, however, a clot of blood be found in the brain or its ventricles, all doubts as to the cause of death may be considered as in a great measure removed, inasmuch as such an extravasa- tion has but very rarely been known to result from the action of the narcotics upon the animal eco- nomy. Epileptics seldom die during the paroxysm. This, however, may occur, and when it does death may be referred to the action of a narcotic drug. 2s It will be proper, therefore, to say a few words upon the means of distinguishing between such cases. 1. Warning symptoms usually precede an epileptic fit; but in poisoning there are of course no precursory signs. 2. The epileptic paroxysm commences abruptly ; the effects of the narcotics are, with few exceptions, gradual in their access. 3. The epileptic paroxysm, when fatal, is, gene- rally speaking, of considerably longer duration than the attack which results from the narcotics; and, as another ground of distinction, though one not susceptible of much practical application, it may be observed that the first epileptic invasion scarcely ever terminates in death. The morbid appearances met with on dissection will, in dubious cases, show that death is the re- sult of epilepsy rather than of narcotic poisoning. This conclusion may be drawn when tumours or abscesses are found in the brain, or fungous growths upon the dura mater, or when worms occur in quantity in the intestinal canal, peritoneal sac, or other parts. But should there be no morbid lesions, what inference are we then justified in making '! Can we conclude that death was the result of the ad- ministration of narcotics ? Such a deduction is not allowable, for experience proves that epileptic cases frequently occur, which, upon post-mortem examination, exhibit no changes of structure what- soever. Inflammation of the brain, or, as it is termed by the French, ramollissement, is attended with symp- toms imitating very closely those which result from the action of narcotics. The course, indeed, of cerebral inflammation is seldom so short; but death does in some cases follow with as much rapidity as in cases of poisoning. They are com- pletely distinguished by the post-mortem appear- ances belonging to ramollissement, which are abscess in the substance of the brain, or preterna- tural redness and softness of some limited portion of the cerebral mass. (See Softening of Or- gans.) The history of the affection next in order, namely, hypertrophy of the brain, is not suffi- ciently known to enable us to say whether it can or cannot be distinguished by its symptoms of poisoning by the class of substances under con- sideration at present. Some pathologists, in fact, do not recognise it as a distinct form of cerebral disease. Diseases of the spinal cord, such as inflamma- tion of itself and investing membranes, and ex- travasation of blood into its substance, are of very rare occurrence, and when met with, ma\ be ge- nerally distinguished from the effects of naicotics by their longer duration. Fiorn the bitter they are completely separated by the appearances pre- sented on dissection. As to the sudden death which sometimes is ob- served to take place without any organic disease of brain or heart, and which is classed by Cheva- lier as syncopal asphyxia, we have only to observe that it can be confounded with the effects of those narcotics only which, like prussic acid, act with great energy and rapidity on the system. From a review of what preofdes, it i> obvious that a sound diagnosis can seldom be derived, in the cases under consideration, from symptoms 446 TOXICOLOGY. alone ; so that here, as in the case of the irritant poisons, it will generally be essential to call in the aid of chemical analysis. In applying, however, to narcotic substances chemical investigation, dif- ficulties of a peculiar nature arise. Many of these substances are, as far as respects internal constitu- tion, but very imperfectly known, so that we are unable to apply to them re-agents by which their presence can be detected ; and almost all are ca- pable of undergoing such changes in the alimentary tract, as will render tests applicable to them in a state of integrity entirely useless. These state- ments are fortunately less true of the ordinary and the energetic narcotics than of those which are rarer, and whose action on the animal economy is less intense. Prussic Acid—[Hydrocyanic Acid.]—This acid exists in a variety of vegetable productions, from all which it may be obtained by distillation, in combination either with water or an essential oil. It may be thus procured from the bitter almond, and, indeed, from the kernels of most stone fruit, from the peach-blossom, from the leaves of the prunus lauro-cerasus, and the leaves and bark of the prunus podus, and from the flowers, bark, and root of the sorbus aucuparia or mountain- ash. For medical purposes it is usually obtained from the ferrocyanide of potassium, or the bicyanide of mercury, salts familiar to the chemist. How- ever obtained, it is, as has been already more than once observed, a poison of the most overwhelming description, destroying life almost instantaneously, and in doses inconceivably small. The symptoms which follow on the exhibition of prussic acid vary with the magnitude of the dose, and according as it proves fatal or not. When the quantity of the poison swallowed is insufficient to produce death, the usual effects experienced are pain and weight of head, particularly in the occi- pital region, rapid pulse, nausea, and sometimes salivation. Such symptoms have sometimes been observed in patients under the influence of the acid exhibited for some time in medicinal doses. When the quantity exhibited is large enough to produce death within a few seconds, the patient sinks without any morbid symptom whatsoever. In fatal cases, however, which run a somewhat longer course, death is invariably preceded by vio- lent tetanic, convulsions. A similar difference has also been observed in experiments on the inferior animals. [It has been an interesting question among me- dical jurists, whether a person, after having swal- lowed a strong dose of prussic acid, could retain the power of performing certain acts of volition, indicating the preservation of sense. One indi- vidual exclaimed, after taking it, " it's gone;" and, in answer to a question put to him, said «• I have taken it." He was about to speak again, but his articulation failed him, he became insensi- ble, and died immediately afterwards. In another case, in March, 1824, a commercial traveller was found dead in his bed at an inn. The evidence clearly showed that he died from the effects of prussic acid taken by himself; yet, after taking a large dose, he had evidently performed several acts of volition : after swallowing the acid from a phial, he had corked the phial, placed it on a chair at the back of the bed, turned over in bed, drawn up ! the bed-clothes, and composed himself in a posi- tion of rest, in which he was found. From the evidence at the inquest, it appeared that not less than three drachms of prussic acid had been taken, and probably even a larger quantity. In this case ' there manifestly had been no convulsions. It would seem, consequently, that an individual may speak, and even answer a question rationally, and execute other voluntary acts, after he has taken this poison, and immediately before falling into a state of insensibility. Whether this were practicable or not, was an interesting topic of in- quiry in the case of Belany, who was tried for | poisoning his wife by prussic acid, in the Central Criminal Court, England, in August, 1844.] In individuals poisoned by prussic acid, the ex. ternal appearance of the body is natural, with the exception of the eyes, which are extremely promi- nent, and present an unusually glistening appear- ance. The venous system is invariably congested, particularly that part of it which supplies the brain, and the blood it contains is generally un- coagulated. In two cases recorded by Metzdorf, the bile was of a deep blue colour. Some physiologists of eminence conceive prussic acid to be absorbed, and carried by means of cir- culation to the brain and spinal marrow; organs which, judging from the symptoms, would appear to be principally affected by it. Nor is this opinion destitute of striking facts, which may be adduced in its support. Experiment proves that the ra- pidity of its action is proportional to the absorbing faculty of the tissue to which it is applied, and that its influence may be suspended by interrupt- ing, with a ligature, the circulation in the poisoned part. Lastly, there ate cases upon record in which it has been detected by chemical analysis in the blood. These facts completely establish that hy- drocyanic acid does occasionally enter the vascular system; but it is impossible to admit that, in cases in which life is destroyed by it almost instantane- ously, its absorption could have taken place, or that its deadly action can be due to any thing but the impression which it makes on the sentient ex- tremities of the nerves. It is scarcely necessary to remind the reader here, that though its absorp- tion were admitted to be an invariable occurrence, the portion of the theory which maintains the actual contact of the poison with the central man is, by the views of Addison and Morgan, rendered superfluous and improbable. The symptoms produced by prussic acid will not, it is obvious, enable us to infer that it has been administered; and the same, as we have already seen, may be said of the appearances presented after death. Some, indeed, contend that poisoning by prussic acid is sufficiently characterized by the peculiar stare and glazed character of the eyes noticed above ; others by the odour of,the poison being emitted by the blood, particularly that which occupies the heart and large vessels; and others, again, by the body resisting in an unusual degree the setting in of putrefaction. All these circum- stances are occasionally observed, but they are so far from being constant that they do not occur even in the majority of cases. Our chief resource, therefore, in this, as in most other toxicological investigations, must be chemical experiment. Such processes, in fact, must be applied to the matters TOXICOLOGY. 447 in which the poison is supposed to exist, as will verify or refute suspicion. The odour of prussic acid, which is usually compared to that of the peach-blossom,* is so pe- culiar that it is by some considered as furnishing a sufficiently delicate test of its presence ; and in this way it is said to have been often detected in the blood of animals poisoned by it. Orfila con- siders it more delicate than any chemical re-agent with which we are acquainted. This, however, is a statement which can scarcely be maintained, particularly if, as Christison observes, there be in- dividuals who are altogether insensible of the pe- culiar impression which it usually makes upon the olfactory organs. There are two very sensible chemical tests for prussic acid, namely, sulphate of copper, and a mixture of a proto- and a per-salt of iron, the manner of application of which we shall now ex- plain. 1. Let the solution to be tested for prussic acid be rendered alkaline with caustic potash, and to it let there be then added a few drops of a solution of the persulphate of copper. If the poison be present, a dirty green precipitate is thus formed, which, upon the addition of a little dilute sul- phuric acid, is converted into one of a perfectly white colour. In the greenish precipitate we have peroxide of copper mixed with bicyanide of the same metal, the former of which alone is dissolved upon the addition of the acid. The sulphate of copper thus applied will, according to Lassaigne, detect one part of prussic acid in 20,000 of water. 2. To the suspected solution rendered alkaline, as in the preceding experiment, let there be added a few drops of a mixed solution of a proto- and a per-salt of iron. Should the poison be present in the fluid, a precipitate of a dirty brown colour will be formed, which, upon acidulation with sul- phuric or muriatic acid, will be converted into prussian blue. The precipitate first formed is a mixture of prussian blue and of the two oxides of iron precipitated by the excess of alkali em- ployed, the latter of which are re-dissolved upon the addition of the acid. Some have recommended for the performance of this experiment a proto- salt and others a per-salt of iron ; but those who know that prussian blue is composed of a cyanide united to a sesquicyanide, and who understand the theory of its production, will perceive the ne- cessity of the presence of iron in the double state of oxidation. The green vitriol of the shops alone will undoubtedly often answer, but it is be- cause it is not a pure proto-salt, but includes a little sulphate of the peroxide. In addition to the two preceding tests, the ni- trate of silver and proto-nitrate of mercury are sometimes mentioned by systematic writers. The former affords with the acid a white, the latter an ash-grey precipitate, both of which, when dried and exposed to the heat of a spirit lamp, evolve a gas (cyanogen) which burns with a beautiful pur- ple flame. Should the acid be sought for in organic mat- ters, such, for example, as the contents of the * Ur. A. T. Thomson stales that this is not the odour of pure prussic acid, hut that it belongs to an essential oil adhering to the acid when the latter is extracted from vegetables. (See article Sedatives.) stomach, these should be slightly acidulated with sulphuric acid, and the solution obtained by filtra- tion should be introduced into a retort, and sub- jected to distillation at a temperature of 212° until an eighth part of the fluid has passed over. This portion will contain the acid owing to its volatility, and to it the tests already enumerated and explained may be then applied. The sul- phuric acid is added for the purpose of saturating and fixing any ammonia which may have been developed by putrefaction. Some facts have been recently ascertained by Leuret and Lassaigne having a close relation to the topic just discussed, and which may, there- fore, with propriety be mentioned here. In ani- mals poisoned by prussic acid and kept unburied for three days, they found it impossible to detect the poison : when buried, however, within twenty- four hours after death, they were able to find it until the eighth day, but not after. The failures in both cases they attribute either to its evapora- tion or spontaneous decomposition. So rapid is the action of this poison, parlicu- I larly when the dose is large, that there is seldom time for unloading the stomach either by emetics or mechanical means. Nor do we know of any | agent which can in this case discharge the func- [ tions of a chemical antidote. The alkalies were indeed once reputed as such, but this opinion is ! now no longer entertained, as the hydrocyanates I of ammonia and potash have been proved by di- rect experiment to be highly poisonous. There are, however, substances which by their stimulant powers counteract the anodyne influence of the poison on the nervous system, and are hence by many described as antidotes to it. Animals asphyxiated by prussic acid may often be restored by the assiduous application of the water of ammonia, by means of a feather, to the nostrils. In this way a fox, to which about half an ounce of the acid of the Dublin pharmacopoeia had been administered in successive doses, and in which the motions of respiration and circulation had for better than a minute apparently ceased, was brought to life last winter in the museum of the Royal College of Surgeons in Dublin. The animal did not entirely revive until after a lapse of fifty minutes. The success of such experi- ments in the case of the inferior animals led Mr. John Murray, of London, to recommend ammonia generally as an antidote to the effects of prussic acid ; and there can be no doubt of its efficacy, in cases at least which, if left to themselves, would not prove very rapidly fatal. In applying it, the patient's head should be held over a vessel containing water of ammonia, in order that some of the gas which it evolves may during inspira- tion be drawn into the lungs. The aqua ammo- niac, also, of the pharmacopoeia should be diluted with about twelve waters, otherwise such a quan- tity of the alkali enters the chest as to give rise to serious inflammation of the bronchial passages. The aqua chlorinii diluted with four times its volume of water, and applied in precisely the same manner as the volatile alkali, has also been found a very valuable counter-stimulant in poison- ing by the hydrocyanic acid. Its virtues as an antidote to this poison were first noticed in Ger- many, but have been brought into chief notice by 448 TOXICOLOGY. M. Simeon of Paris. Orfila has compared it with ammonia, and obtained with it much more satis- factory results. In some of his experiments, though not applied until the convulsions had ceased, and life appeared altogether extinct, the animal was in ten minutes placed beyond danger. The cold affusion has also been recommended by Dr. Herbert, a physician of Gottingen ; and Orfila admits its utility, stating at the same time that he considers it inferior to the treatment both by ammonia and chlorine. It should be repeated every fifteen minutes until the animal has reco- vered. The poisonous properties of the bitter almond and its essential oil, of laurel and cherry water, and of certain liquors and sweetmeats, in the pre- paration of which the two first are employed, de- pending on the presence of prussic acid, it would be superfluous to make each the subject of a sepa- rate discussion. Dr. A. T. Thomson represents the essential oil, even when entirely freed from adhering acid, as a powerful poison, " operating primarily as an excitant," and in fatal cases pro- ducing " violent convulsions." This statement, however, is quite inconsistent with the experi- ments of Stange and Goppert, referred to by Dr. Christison, and the recent very interesting re- searches of Robiquet and Boutron-Charlard, who found it quite inert when re-distilled from caustic potash. [A case of poisoning by ratafia, which is com- posed of one part of essential oil of bitter almonds to seven parts of spirit, has been lately recorded. (London Lancet, June, 1841.) A little girl, 8 or 9 years old, the subject of the case, took a tea- spoonful; but under proper treatment recovered. The cyanuret of potassium has caused death in several instances, when taken by mistake or in improper doses. A gentleman was poisoned in France by a dose of twelve grains. In another case, fifteen grains proved fatal to a man, aged 30, in a quarter of an hour. (Taylor, Report on Toxicology, Op. cit. p. 562.) The production of Prussian blue by an admix- ture of the protoxide ami peroxide of iron, preci- pitated from the green sulphate by caustic potassa, has long been known as an excellent test for prussic acid. The application of these mixed oxides as an antidote in poisoning by this acid, has been lately proposed by Messrs. T. & A. Lunth, of Edinburgh, and when administered suf- ficiently early it may be successful, for, by mere contact, it speedily converts the poison into the insoluble inert compound, Prussian blue. In the experiments of Mr. Lunth, it was found that when the acid with the antidote was given to dogs, they lived, whilst the same dose of the acid without the antidote proved fatal. The method by which ihe Messrs. Luntli prepare the antidote is not stated ; but Mr. Tavl.r (Report on Toxicology) has found that it m..y be prepared by precipitating, in a closed vessel, a strong solution of Ihe common green sulphate of iron by caustic potassa, and washing tin- oxide repeatedly with water recently boiled, until the ulkaii and the surplus sulphate are removed. The cold affusion with excitants must be re- sorted to at the same time.] Opium. — This powerful drug is, as is well known, obtained from the papaver somniferum, by incising its capsules and inspissating the milky fluid which flows from them. It is to the toxico- logist the most interesting of the anodyne poisons; for from the energy with which it acts, and the slight degree of distress or pain which it produces it is very frequently employed by the suicide and the murderer. For such purposes it is also recommend- ed by the small amount of organic lesion which it causes, even when administered in a poisonous dose, The effects of opium on the animal economy vary somewhat according to the quantity exhi- bited. Thus, in the ordinary medicinal doses il acts first as a stimulant, exciting the mind and adding strength and tone to the muscular system; these effects, however, quickly subside, and are succeeded by a drowsy and lethargic state. When the dose is large, the stage of excitement appears entirely wanting; or, in other words, stupor ap- proaching to coma almost immediately sets in, In the lower animals, convulsions very generally occur, but in man these are seldom witnessed. The breathing is slow, sometimes stertorous; the pulse is usually about ninety, weak, and irregular, occasionally, however, slow, full, and strong, like the pulse of apoplexy. The muscles are quite relaxed, the face is pale and tranquil, sometimes tumid, suffused, and anxious, and the body is usually bathed in sweat. The pupil is almost always greatly contracted, but some rare casci have occurred in which it has been considerably dilated. The stomach, as might be anticipated, continues undisturbed ; but to this statement there are exceptions, for cases are recorded in which vomiting commenced almost immediately after the swallowing of the poison. The operation of solid opium is seldom de- ferred beyond half an hour, and the action of the fluid preparations generally commences sooner. When a case of poisoning by opium terminates favourably, the patient falls into a profound sleep, which lasts for from twenty-four to thirty-six hours, out of which he awakes merely affected by slight nausea, thirst, and vertigo. In fatal cases, death takes place within from seven to twelve hours. The amount of a poisonous dose it is impossible to assign with accuracy: it is de- pendent upon age, upon idiosyncrasy, and upon habit. The latter is the most influential modify- ing cause, some people having acquired by use the power of swallowing with impunity eight ounces of the tincture per diem. [In a case lately recorded by Dr. M. H. Hous- ton, of Wheeling, Va., (Amer. Journ. of the Med. Sciences, Oct. 1843, p. 372,) ten grains of mor- phia seemed to destroy in about ten minutes. In the cases of poisoning by opium recorded by the coroner of the city and county of New York, during the years 1841, 1842, and 1843, (J. B. Beck, Transactions of the New York State Medical Society, vol. vi. part 1, p. 72, Albany, 1844.) the smallest quantity was one drachm; the largest an ounce and a half. The shortest time between the taking of the poison and death, was 8 hours; the longest, 20 hours. The ave- rage time of six cases was 14 hours. Of the cases of poisoning by laudanum, the smallest quan- tity was one drop; the largest, 16 ounces. The TOXICOLOGY. 449 shortest period between taking the poison and! in from six to twelve hours; but the fatal event death, was 2 hours; the longest, 48 hours. Ave-1 has occurred in two hours and a half. rage of 23 cases, 12 hours.] It has been not unfrequently observed in cases ige in *o woes, x* uuurs.j it nas Deen not unirequenny ODservea in cases The morbid appearances to be detected after of poisoning by this drug, that the individual has death are not very characteristic or important.' recovered from the first symptoms, and has then The back and most depending parts of the body, had a relapse and died. In December, 1843, a are usually livid; the veins and sinuses of the head are in a state of marked congestion ; and serous effusions are found on the surface of the brain and within its ventricles. Extravasation of blood into the cerebral mass has also been re- corded, but as a pure consequence of the action of opium it is of extremely rare occurrence; and the same may be said of redness of the villous lining of the stomach, of which mention is made gentleman swallowed a quantity of laudanum. and was found labouring under the usual symp- toms of poisoning by opium. The greater part of the laudanum was removed from the stomach by the stomach-pump, and he so far recovered from his insensibility as to be able to enter into conversation with the surgeon; but a relapse took place, and he died in the following night. In young infants the action of opium is ex- by some writers. The lungs and heart are usu- j ceedingly uncertain. They ore liable to be nar- ally gorged with blood, which, generally speaking, \ cotized by very small doses. Great caution is, is fluid, thouffh it has a\an hm>n fr.im.1 ir. *V.r. ..»..»! /.nnea/mAn.lw nnA.J».i :_ -J—:_:~.__:__*u_ .1___._ is fluid, though it has also been found in the usual coagulated state. Welper also found, both in man and other animals poisoned by opium, the kidneys gorged with blood, and denies the commonly re- ceived opinion that this drug suspends their se- cerning action, having always observed in his ex- periments the bladder distended with urine. It is an old remark, and one the truth of which would appear pretty well established, that the bodies of animals destroyed by opium enter very rapidly into putrefaction consequently, needed in administering the drug to them. (J. B. Beck, New York Journal of Medi- cine and Lond. Med. Gaz. Mar. 1844, p. 767.)] The influence of opium, as may be readily in- ferred from the symptoms it produces, is exerted principally upon the brain or centre of the ner- vous system. But whether it be conveyed to this organ through the medium of the circulation, or acts upon it indirectly by the impression which it makes upon the sentient extremities of the nerves, is still a matter of dispute among physiologists. r----_------^ ^ lc, owll „ uiouci in uispuie uuiung piiysioiogisis. [Iii particular idiosyncrasies, and especially in ' Many facts would seem to warrant the conclusion infants, very small doses of opium may prove | that it enters the blood, though chemists have poisonous. In 1838, a man, aged 45, was killed J failed* in detecting it there. But even though by ten grains of solid opium. Four grains and a' its presence in this fluid were established, it would half, mixed with nine grains of camphor, killed a j not, as has been already more than once observed. man in nine hours, with all the symptoms of nar- j follow that nervous sympathy was not the channel cotic poisoning. In September, 1843, an instance through which its poisonous energy was propa- occurred in London, of a woman, aged 38, being gated. On this head we shall add nothing fur- killed by eight grains of the drug, given in two ther than that opium operates as a poison whether doses. The smallest fatal dose of the tincture to an introduced into the stomach or the rectum, ap- adult, which Mr. Taylor (Manual Med. Jurispru- j plied to a wound or injected into a vein, and that dence, ft. 23) has found recorded, is two drachms, the symptoms it excites in each case are almost Occasionally very large quantities have been taken I exactly the same. without fatal results ensuing, A young lady took | Before proceeding to the description of the ex- an ounce of laudanum in whisky, and recovered periments by which opium is to be sought for in in five days : there was no vomiting, and the cause [ toxicological investigations, it will be indispensa- of the symptoms was not even suspected until she ; ble to premise a brief statement of its chief proxi- had recovered from her stupor, and confessed that J mate constituents, and their most salient and she had taken the poison. Mr. Taylor refers to a case, communicated to him by one of his class, of a medical student, after a hearty supper, who, at nine o'clock of the evening, swallowed four ounces of tincture of opium, made by himself from opium procured at a respectable druggist's. He went to bed and slept until six o'clock the next morning, when he was awakened by a feeling of nausea characteristic properties. Besides extractive, resin, a fatty matter, a substance analogous to caout- chouc, ligneous fibre, and some salts of lime and magnesia, opium includes two peculiar proximate principles, morphia and narcotine; the former of which is in union with an acid, the meconic, also found in this drug alone. The morphia and nar- cotine are the principles which confer upon opium He then vomited freely; and, as he supposed, the I its activity; and there is good reason for believing whole of the contents of the stomach, smelling | that its anodyne virtues are due exclusively to strongly of opium, were ejected. He recovered the former, and its stimulant powers to the latter; perfectly, without feeling any other symptom than i for when the narcotine is removed by the action inability for muscular exertion. This, Mr. Taylor [ of sulphuric ether, the residue acts as a pure nar remarks, is the largest dose which he has ever " known taken without fatal consequences ; and it is certainly surprising, that symptoms of nar- cosis and even death were not produced by its retention for so many hours in the stomach. It is a common error to suppose, that narcotic pheno- mena must necessarily result a short time after the reception of the drug into the stomach. Most cases of poisoning by opium end fatally Vol. IV—67 2ir* cotic. Direct experiment proves meconic acid to be destitute of any poisonous action. These three principles may be separated in the following manner. Let an aqueous infusion of opium be treated with ammonia, and the morphia, narcotine, and *M. Barruel (Archives Generales, vii. 558) describes himself as successful in the search. His experiments, however, appear inconclusive. 450 TOXICOLOGY some resin will precipitate, while the meconic acid will remain dissolved in union with the volatile alkali. From the precipitate the narcotine is re- moved bv hot sulphuric ether, and the morphia by distilled vinegar, ammonia being again added to the solution in order to throw down the vege- table alkali, should it be required in an insulated state. To procure the meconic acid, acetas plumbi must be added to the solution from whence the other two principles were precipitated by the volatile alkali, and which now includes meconate of ammonia. A meconate of lead is thus formed, which being insoluble, subsides, and from this the acid can be procured by suspending the precipitate in water, passing through it sulphuretted hydro- gen, and filtering in order to separate the sulphuret of lead. The solution thus obtained yields crys- tals of the acid, and if again united to oxide of lead, and separated as before, they will be obtained purer and of a whiter colour. In instituting experiments for the detection of opium, our search may be directed towards the morphia or meconic acid. For both these prin- ciples there exists very delicate tests, the most certain of which, with the manner of applying them, it will be proper to mention before proceed- ing further. If to morphia a little strong nitric acid be added, it is dissolved with effervescence, and the solution assumes a deep orange colour. This process is not applicable to morphia in a perfectly pure state, for the development of the orange colour has been clearly traced to foreign vegetable matter of a resinous nature invariably present in the alkali as ordinarily prepared, but which, nevertheless, may be entirely removed. Others of the vegetable alkalies, for example strychnia and brucia, are similarly affected by nitric acid, and from a similar cause. If morphia in a pulverulent state be brought into contact with permuriate of iron, it is dis- solved, and the solution exhibits a beautiful blue colour, which, however, when dilute has a tinge of green. If morphia be rubbed up with a little of a cold solution of starch, and iodic acid be then added, the morphia deoxidizes the acid, and the iodine set free is immediately indicated by the formation of the blue iodide of starch. This relation of the morphia to iodic acid is quite characteristic, and furnishes a most sensible process for detecting its presence.* Meconic acid is characterized by striking with a dilute solution of permuriate of iron a beautiful red colour. A similar change is effected in the ferruginous salt by the sulpho-cyanic acid. The persulpho-cyanuret of iron, however, may be dis- tinguished from the permeconate by the colour of the former being destroyed, but that of the latter not, by the. muriate of gold. This method of dis- criminating between them acquires practical im- portance from the discovery of Ginelin and Tiede- mann of sulphocyanide of potassium in the saliva of man. * In a recent case of poisoning by acetate of morphia, in reference to which the writer was engaged profes- sionally by the coroner, the test by iodic acid was the only one which afforded unequivocal evidence of the poi- son in the contents of the stomach. Having premised thus much upon the che- mistry of opium, we have next to inquire how a case of suspected poisoning by it is to be in- vestigated by the toxicologist. The symptoms, whether alone or combined with a post-mortem examination, can lead to little more than suspicion. The odour of opium is strong and peculiar, and has been frequently re- cognised in the stomach and intestines when other methods of investigation afforded but un- satisfactory results. On the whole, however, the chief reliance must be placed on the application of the chemical tests for its active principles, which have been above enumerated. If a pure aqueous solution of meconate of mor- phia were the subject of experiment, the acid might be thrown down in the form of meconate of lead by the addition of a little acetas plumbi, and be separated from the oxide of lead by sul- phuretted hydrogen, as already described. The solution, also, from which the meconic acid has been precipitated, if deprived by sulphuretted hy- drogen of any unprecipitated oxide of lead, will deposit the morphia on the addition of a slight excess of the water of ammonia; and to the acid and the alkali when thus insulated the tests already described may be applied. This method will also answer for opium itself and its several medicinal preparations, these being converted into aqueous infusions, and, if acid, rendered nearly neutral before the addition of the acetate of lead. But when morphia or meconic acid is sought in complex mixtures, such as the ordinary contents of the stomach, other preliminary steps are indis- pensable, the object of which is to afford a final solution containing as little as possible of other matters than those which it is the purpose of our experiments to detect. These steps are as follows:—The mixture is to be infused for some time with distilled water acidulated with acetic acid, then thrown upon a filter, and the solution thus obtained is to be eva- porated to dryness at or under 212°. Upon this extract boiling alcohol, specific gravity 810, is to be digested, and the spirituous solution thus ob- tained is to be deprived by distillation or evapora- tion of its alcohol. This second extract is to be acted upon by water, and the resulting infusion, when filtered, is to be treated with acetate of lead, &c, with the view of insulating and subjecting to their appropriate re-agents the morphia and meconic acid sought for by the process. By pro- secuting this route, opium, though present in an organic mixture in very minute quantity, may often be detected. Instances, however, have oc- curred in which, though the poison was un- doubtedly swallowed, it could not be found in the intestinal tract; and these are usually considered as accounted for by supposing it to be either ab- sorbed or decomposed in virtue of the digestive powers of the stomach and inferior intestines. When called to treat an individual labouring under the influence of opium in a dangerous de- gree, the first object for the physician to accom- plish is the expulsion of the poison from the sto- mach. This may sometimes be effected by half- drachm doses of sulphate of zinc, given two or three times at intervals of fifteen minutes; or by a solution of tartar-emetic introduced into the etc- TOXICOLOGY. 451 mach or rectum, or injected into the veins. In the latter method the quantity employed should not exceed a single grain, in the former it may amount to ten. Should the case, however, be an urgent one, the better plan will be to resort at once to the stomach-pump; for when opium has been swallowed in a poisonous dose, the stomach is often so paralysed as to be either insensible to the action of emetics, or but very slowly influenced by them. The evacuation of the poison being achieved, the next point which should fix the attention of the medical attendant is the assiduous employment of means for obviating the state of drowsiness and torpor which is the invariable result of the action of opium after it has abided for some time in the stomach. Every variety of chemical and mecha- nical stimulant should in succession be employed; or what is found to answer better than any thing else, the patient should be kept constantly shaken and driven with speed over rough roads in an open two-wheeled vehicle, supported of course by an attendant on each side. This course should be diligently prosecuted until all tendency to lethargy is overcome, and, in some cases, in order to the attainment of this desirable result, the stimulation and agitation must be followed up for ten or twelve hours. When the poison is removed from the stomach, venesection to the extent of twelve or sixteen ounces has been found beneficial; but it should not be practised sooner, as by promoting the ab- sorption of the poison, it might prove more inju- rious than beneficial. When the lethargy has proceeded to such an extent that the motions of the chpst and diaphragm have ceased, it will be advisable to restore them by artificial means, re- sorting at the same time to every practicable plan of stimulation. As to antidotes for opium, there are none which deserve the name. The alkalies and the infusion and tincture of galls have been vaunted as such, the former separating the morphia from the acid which confers upon it solubility, and the latter throwing it down as a gaIlatL\ These re-agents, by reducing the solubility of the active principle of the drug, will diminish its action on the animal economy, but experiment proves that they do not divest it of its poisonous influence. The stimu- lating effects of opium, which, as we have seen, are with some probability attributed to the narco- tine, may, as Magendie has shown, be obviated by the exhibition of vinegar. It should, however, be recollected that this, by increasing the solubi- lity of the morphia, will contribute to the aug- mentation of the narcotism produced by the poison. Hyoscyamus.—Several species of this genus possess powerfully narcotic properties, and in their action are found closely to resemble opium. The hyoscyamus niger, however, is the only one on which we shall observe, for it is the most generally disseminated and the most active, and it alone holds a place among the articles of the materia medica. Its narcotic principle, which Brandeshas found to be an alkali analogous to morphia, is found in every part of the plant,—in the stem, leaves, berries, and more especially the root; but the extract and tincture employed in medicine are prepared exclusively from the leaves. It exercises poisonous powers whether injected into a vein or the subcutaneous cellular substance, applied to a wound, or introduced into the stomach. When hyoscyamus is swallowed in a poison- ous dose, the most remarkable effects it produces are giddiness and loss of speech, great dilatation of the pupil, delirium, frequently of the most vio- lent type, and subsequently, a lethargic or coma- tose state. It has seldom been known to give rise to any symptoms indicative of gastric irritation or inflammation. There is no record of morbid appearances caused by the hyoscyamus. From the symptoms, this plant is concluded to be a pure narcotic. The medium, however, through which its influence comes to be exerted on the nervous system has not been ascertained. It is generally conceived to undergo absorption. The treatment of an individual labouring under the poisonous influence of hyoscyamus is pre- cisely similar to that already described under the head of opium. The poison is to be speedily ex- pelled from the stomach, and the state of torpor counteracted by every allowable method of stimu- lation. Lactuca.—Two species of this plant, the virosa and sativa, are, from their effects on the animal economy, usually classed among the narcotic poi- sons. An extract of the leaves of the Iactuca virosa, introduced by Orfila, to the extent of three drachms, into the stomach of a dog, deprived it of life in two days, without giving rise to any re- markable symptoms. When applied to a wound it also proved fatal, death, however, being prece- ded by giddiness and stupor. Collin of Vienna states that he employed the extract with much success in the treatment of dropsy. The Iactuca sativa, or garden lettuce, after it has flowered, contains a milky juice possessed of considerable narcotic powers. When obtained by pressure, and dried by exposure to the air, it con- stitutes the lactucarium of the Edinburgh phar- macopoeia. It smells strongly of opium, and has similar stimulant and anodyne powers, but requires to be exhibited in a larger dose. There can be no doubt that, if swallowed in sufficient quantity, it would prove destructive of life ; but we are not aware that any record of such a case exists. Caventou and Boullay could not find any alkaloid in lactucarium to which its sedative powers could be referred. Solatium.—There are several species of this genus, but in a toxicological point of view it will be sufficient to allude briefly to the solanum nigrum and solanum dulcamara. Orfila states that an extract of the former possesses powers analogous to and equally energetic with lactuca- rium. The dulcamara has also anodyne virtues, but in a much lower degree than the solanum nigrum, or nightshade. Despasses, it may be ob- served, has discovered in both a peculiar alkaline principle endowed with narcotic powers. The berries of the solanum tuberosum, or potato, have been known to destroy pigs. III.--NAnCOTICO-ACRID PoiSONS. Under this head are grouped the poisons which both produce a local irritation and exert an influ- ence on the nervous system. The term is far from being happily chosen ; for, in the first place, 462 TOXIC symptoms of irritation are often absent, and, in the second, the effects directed to the brain and its prolongations are not always of an anodyne or sedative kind. Still further to show the imper- fection of toxicological nomenclature and classifi- cation, it may be observed, that many of the mi- neral poisons, placed among the irritants, determine derangements of the nervous system very similar to those produced by the substances upon the dis- cussion of which we are about to enter. The true nareotico-acrids are the products of vegetables chiefly found in the natural orders Solanece and I Umbellifers. The Ranunculaces also afford a few. It is not necessary to detail the symptoms and morbid appearances which characterize the narcotico-acrid poisons generally, as those pro- duced by both narcotics and acrids have been already minutely discussed. Individuals of the class also differ so essentially in these respects, that their effects could not be comprehended within a i single description. Solajteje.—Of the plants of this order possess- ing most activity, those most common and there- fore most interesting, are the atropa belladonna or deadly nightshade, the datura stramonium or thorn-apple, and the nicotiana tabacum or tobacco plant. These poisons may be conveniently dis- cussed together, not only from their close botanical relations, but because they all agree in exciting a greater or less degree of delirium as their most prominent symptom. Atropa Belladonna.—All parts of this plant, the stem, leaves, root, and berries, are poisonous in a high degree. Its activity has been traced by Brandes to a peculiar alkaloid, which he terms atropia, and which is distinguished from all others of vegetable origin by the smallness of its atomic weight, which, upon the hydrogen scale, would appear not to exceed 44. According to Orfila, half an ounce of the extract prepared from the leaves will destroy a dog in thirty-six hours, if introduced into the stomach ; a quarter of an ounce in twenty-four hours, if applied to a wound ; and a much smaller dose with still more rapidity if injected into a vein. When belladonna is used in medicinal doses, either in the form of external application or inter- nally exhibited, the chief effect to be observed is dilatation of the pupil. But when the quantity is considerable, more serious consequences are observed to ensue. The symptoms indicative of irritation are seldom well marked. Dryness of the throat with difficulty of deglutition is very J generally experienced, and aphtha? of the mouth and fauces, abdominal tension, and strangury, have been sometimes, though rarely witnessed. The narcotic symptoms are delirium, usually of a very extravagant description, dilatation and insensibility of the pupils to light, accompanied by partial blindness; and lastly, a lethargic or comatose state. This latter effect is not observed for a con- siderable time after the administration of the poi- son ; in one case it did not set in until after the lapse of twelve hours. Convulsions of an exten- sive or violent nature are scarcely ever witnessed, but occasionally muscular twitchings and subsultus tendinum have preceded death. In the few fatal cases which have been examined, dissection has disclosed no very peculiar morbid appearance. I LOGY. Datura Stramonium.—An alkali has alio been discovered in this plant by Brandes, which is the cause of its activity. It probably resides in every part, but is most abundant in the seeds.* It is unnecessary to enumerate the symptoms produced by stramonium, as they are almost identical with those which result from the use of belladonna. Post-mortem examinations have not discovered in the case of the thorn-apple any morbid lesions of consequence. Nicotiana Tabacum.—The poisonous virtues of the tobacco are due to the presence of an alka- line principle, which has been discovered and very attentively studied by Possett and Reimann. It is a colourless liquid, very soluble in water, alcohol, and ether, and forming with several of the acids crystallizable salts. One grain of it, according to Berzelius, will destroy a dog. The symptoms produced by tobacco when exhi- bited in a moderate dose, are, in the first instance, a slight degree of excitement, which is shortly followed by giddiness, syncope, nausea, and vom- iting, feeble pulse, a state of stupor or lethargy, insensible pupil, laborious breathing, and convul- sive twitches of the muscles generally. To these effects it gives rise no matter how it be administer- ed, whether introduced into the stomach or inject- ed into the rectum. Several fatal cases are on record which have resulted from its administration in the latter form. A single drachm infused in a pint of hot water, and given as an enema, has in one instance destroyed life. The only morbid changes of note resulting from the action of this poison, and to which publicity has been given, are, vascular injection of the omentum and of the mucous and peritoneal coat of the intestinal tubes, together with detached spots of extravasation on different parts of the latter tunic. The limbs also have been found extremely flexible, and the back exhibiting a livid hue. Notwithstanding the activity of tobacco as a poison, it is, as is well known, most extensively employed as an article of luxury. Some use the dry and powdered leaves to stimulate the Schnei- derian membrane, others inhale the vapours which result from its combustion, and there are some who even chew the leaves. It is difficult to admit that such practices can be indulged in for any length of time without injury to health; and, indeed, the pallid and emaciated visages, debilita- ted frames, and deranged digestion of the young men of the present day amply attest its noxious influence. The essential oil of tobacco, which is a combi- nation of a true volatile oil with nicotine, is probably in a great measure indebted to the latter principle for its activity as a poison. According to Brodie it operates on the system in a manner different from the leaves, for while the latter paralyse the heart, the former produces coma and convulsions. In cases of poisoning, and they are not uncom- mon, by the tobacco injection, strong stimulants, such as brandy and ammonia, should be exhibited internally, and an infusion of galls thrown into * Orfila found, in experiments on dogs, the extract ef the seeds analogous, and equally energetic in its actioo, to that obtained from the leaves of Ihe belladonna. TOXICOLOGY. 468 the rectum with the view of rendering the nicotine insoluble. (See art. Sedatives.) Umbellifeii.b.—Many plants of this order are narcotico-acrid in their effects upon the animal body. They agree with the Solanese in very generally causing delirium in an over-dose, but beside this they also give rise to coma and convul- sions. We shall limit our observations to the following plants, all of which are native, namely, the conium maculatum, cicuta virosa, cenanthe crocata, and cethusa cynapium. Conium Maculatum, or Common Hemlock. -—The active principle of this plant, by which Socrates is said to have perished, has been re- cently found by Brandes to be an alkaloid, pos- sessing properties somewhat similar to those of strychnia. The extract made from the leaves was found by Orfila a tolerably active poison in experi- ments performed by him on the lower animals. An ounce destroyed a dog in five minutes when introduced into the stomach; ninety grains killed another in an hour and a half when applied to a wound ; and a third perished in two minutes when a scruple was injected into its venous system. The symptoms produced in man by poisonous doses of conium are, giddiness, delirium, coma, and convulsions. When the dose is insufficient to produce death, very violent delirium is usually observed. The only facts disclosed by post-mortem exami- nation are, venous congestion in the head, and general fluidity of the blood throughout the body. Cicuta Virosa, or Water-hemlock.—This plant possesses more energy as a poison than the coni- um. It gives rise, also, to somewhat different symptoms. These are, gastric irritation, vomiting, giddiness, profound coma and insensibility, and finally, very violent tetanic convulsions. Upon examination after death, nothing particu- lar has been observed but venous congestion of the brain. (Enantha Crocata, or Hemlock Dropwort.— This plant, which is often confounded with the conium maculatum, is much more active as a poison than either it or the cicuta. The symptoms usually commence with burning heat in the throat and epigastrium, which is followed by a state of stupor, and subsequently, in every instance, by violent convulsions. In some fatal cases the latter were the only well-marked symptoms. Death is seldom protracted beyond the fourth hour. The morbid appearances have not been recorded. JEthusa Cynapium, or Fool's Parsley.— This plant, which is often mistaken for true parsley, produces nausea, vomiting, headach, giddiness, sopor, and a partial paralysis or numbness of the extremities. Pains of stomach, swelling of abdo- men, lividity of surface, and great dyspnoea have also been observed. It has sometimes proved fatal. [Several fatal cases from eating of the root and leaves of this powerful poison have been record- ed lately by Mr. Bossey, (Lond. Med. Gazette, May, 1844.) Death, in one case, occurred in five minutes.] Ranuwculaceje.—Some of the plants of this natural order have been already discussed under the head of the acrid poisons. There are, how- ever, two of them which combine with their acrid a narcotic action. These are the aconitum napellus and the helleborous niger. Aconitum Napellus, or Monk's-hood. — The poisonous principle of the aconite, which is con- ceived by Peschier to be an alkali, is found in every part of the plant, but probably exists in greatest quantity in the root. At least such would appear to follow from the experiments of Orfila on dogs. In a sufficient dose it destroys life with rapidity, whether taken into the stomach, applied to a wound, or introduced into the blood. Brodie first remarked that the leaves when chewed produced a partial paralysis, or numbness of the lips, accompanied by a tingling sensation; and the same result has been obtained by Christison on chewing a single seed. In fatal cases, burning heat in the throat, vomiting, purging, abdominal tension, delirium, and convulsions, have all been observed. In two cases dissected after death, the morbid appearances detected were slight inflammation and vascular injection of the mucous membrane of the cesophagus, stomach, small intestines, and rectum, and congestion of the blood-vessels of the head. Helleborus Niger, or Christmas Rose.— The active principle of this plant, which is said to be an acid oil, is found in most abundance in the root A decoction of the root has produced, in forty-five minutes, in the human subject, vomit- ing, delirium, and convulsions, and death before the termination of the second hour. The lungs, stomach, and intestines of persons poisoned by this plant exhibit decided symptoms of inflam- mation. Digitalis Purpurea.—The manner of action of this plant, as indicated by the symptoms, ren- ders it necessary to separate it from the other narcotico-acrid poisons. In the leaves, which are considered its most active part, a crystallizable alkali is said to have been discovered by M. Panguy to which he has applied the term digitalin. The effects of, this poison, like those of mer- cury, are liable to accumulate, and without any premonitory symptoms to become suddenly de- veloped, sometimes a considerable time after the medicine has ceased to be exhibited. In cases which terminate favourably vomiting first sets in ; giddiness, beating in the head, and depression of spirits are experienced; and with these very fre- quently diarrhoea, sweating, salivation, and a very feeble and retarded pulse. In fatal cases the at- tack is usually ushered in by violent pain over the eyes, together with confusion of intellect; and to these succeed, within twenty-four hours, profuse diarrhoea, delirium, convulsions, and gen- eral insensibility. The most constant and charac- teristic consequence of digitalis, and that which renders it principally valuable as a therapeutic agent, is its influence in weakening and retarding the action of the heart. The salivation, also, to which it gives rise, may be mentioned as a curious, and, with very few exceptions, a peculiar symptom. The stomach has been found inflamed in an individual destroyed by six ounces of a decoction of the leaves, and the membranes of the brain in- jected with blood. [A fatal case of poisoning by this plant has 454 TOXICOLOGY. been lately recorded by Mr. Wilson. (Lond. Med. Gazette, Aug. 1844.)] The Veratrum Album and Colchicum Au- tumnale may with propriety be discussed together, for they both owe their activity to the same prin- ciple, the veratria, an alkali detected in them by Pelletier and Caventou. The toxicological action of this alkali has been studied both by Magendie and Andral. The latter found it to excite, when swallowed in very small doses, violent vomiting and purging, and in larger quantities, or when injected into a vein, to cause death with tetanic convulsions. The symptoms produced in man by the white hellebore and meadow-saffron themselves are so similar to those which characterize the veratria, that it is unnecessary to detail them. They indi- cate very clearly an irritating action exerted lo- cally upon the intestinal tube, and a remote one directed to the nervous system. The seeds of the colchicum possess similar powers to the root, and a tincture of them is at present much used in the treatment of gout and rheumatism. Plants including Strychnia and Brucea.— Several species of the genus strychnia and the brucea antidysenterica produce analogous effects upon the animal body. In both distinct alkaline principles have been detected, to which the terms strychnia and brucia have been applied. These alkalies, and the plants in which they are found, cause violent tetanic spasms, which destroy life by suspending those motions of the chest and dia- phragm which are essential to respiration. From other poisons, however, which give rise to violent spasms, they differ in not impairing sensibility in the slightest degree. Strychnia.—This principle is one of the most energetic of poisons, acting in extremely small doses, and with equal certainty, no matter what be the manner of its application. A sixth of a grain dissolved in alcohol, and injected into the pleura, killed a dog in two minutes. It is least active when swallowed, and most so when intro- duced directly into the blood. [Cases of poisoning by nux vomica are not unfrequent. In 1837-8, there were three cases noted in the return by the coroners of England, and one case of poisoning by strychnia. (Taylor, Op. cit. p. 265.) In regard to the quantity required to destroy life, Dr. Christison thinks, that half a grain in- serted in a wound would destroy a man in a quarter of an hour. It is impossible to say what quantity administered internally would prove fatal; but it is probable that half a grain would generally be sufficient for the purpose.] In all cases the symptoms are the same. Those first experienced are starting, and stiffening of the extremities, which gradually increase, and finally terminate in a tetanic paroxysm. An interval of calm succeeds, during which the intellect and the senses are found in the normal state; but another paroxysm shortly follows, and destroys life appa- rently by producing a state of asphyxia or suffo- cation. In animals poisoned by strychnia the intestinal canal has been found partially inflamed. Strychnia, as usually prepared, is turned to an orange-red colour by the action of nitric acid, but this is not true of the alkali in the perfectly pure state. The change of colour is by some referred to the adhesion of resinous matter, from which it is with difficulty entirely freed ; by others to the presence of a little brucea, a principle with which it is usually associated. The only other property which can be referred to as serving to distinguish it from the other vegetable alkalies, is its extreme bitterness, a distinct sensation of this description being produced by one grain of it dissolved in 600,000 of water. Strychnos Nux Vomica.—The nut of this plant, though an article of the materia medica, is a deadly poison, and owes its activity to the pre- sence of strychnia in combination with igasuric acid. The symptoms it produces need not be de- tailed, as they are quite the same with those which result from strychnia alone. In addition, however, it often gives rise to vomiting. When death rapidly ensues, it is impossible to observe in the body any morbid changes of import- ance. But in slower cases, the head is found in a state of venous congestion, and the stomach and intestines are inflamed. The heart is usually empty and flaccid, and the cortical substance of the brain and cerebellum has been observed to present that softened structure which is an index of inflamma- tion. The body, also, has in some cases continued rigid from the period of death. The strychnos sancti Ignatii and tieute, the latter of which affords the upas or Javanese poison, both contain strychnia, and produce effects quite analogous to, but somewhat more violent than, those which result from the use of the nux vomica. They need not therefore be recounted. [The smallest dose recorded as having proved fatal, is three grains of the alcoholic extract. Two cases occurred in London, in 1839, in each of which fifty grains of the powder, considered to be equal to one-fourth of a grain of strychnia, de- stroyed. In one of the cases, death took place in an hour. Usually it occurs in from one to two hours. (Taylor, Op. cit. p. 266.)] To the treatment of poisoning by strychnia, and the vegetable preparations in which it occurs, it would not be necessary to advert, were it not that M. Donne, of Paris, has recently put forward chlorine, iodine, and bromine, as efficacious anti- dotes. These principles, he says, combine with the strychnia, and convert it into innoxious com- pounds. This conclusion he arrived at through experiments on animals; and we should also men- tion, on the same authority, having forgot to do so in the proper place, that the same agents exer- cise a similar effect upon veratria, the active prin- ciple of colchicum, and white hellebore. Brucea Antidysenterica.—The bark of this tree was by mistake imported into Europe from South America, instead of that of the Bonplandia trifoliata, the true angustura bark.* It includes an alkali denominated brucea, and which, though much less active, is analogous in its action to strychnia. The symptoms, therefore, and morbid appearances which it and the bark produce need not be enumerated. ♦This generally received opinion Berzelius considered as erroneous. According to him, the false angustura bark is obtained from the strychnos nux vomica.—Trail* de Chimie, torn. vi. p. 218. TOXICOLOGY. 455 The true and false bark may be distinguished from each other by introducing into infusions of them in muriatic acid a drop of ferro-prussiate of potash. This will give a greenish blue precipitate with the latter, but none with the former. VVoorara, Ticunas, and Curare, employed as poisons by the native Americans, are usually supposed to contain strychnia. The last, however, has been proved by Boussingault and Roulin to include a peculiar principle, called by them cura- rine; and their experiments have been confirmed by the subsequent researches of Pelletier and Pe- troz. [Of late, Mr. W. Ley has recommended the extract of cannabis Indica as an antidote. (Pro- vincial Med. Journ. August, 1842, and March, 1843.)] Immediately after strychnia and brucea, and the plants in which they occur, we may with propriety mention the seeds of the menispermum coc- culus, or cocculus indicus. The active principle of this plant, discovered by Boullay, and termed by him picrotoxia, is an alkali. Like strychnia, it kills with tetanic convulsions; but, in order to produce such an effect, it must be given in a larger dose. Ten grains of picrotoxia have destroyed a dog in less than half an hour, and in the second tetanic fit. Cocculus indicus is, it is said, a good deal em- ployed by brewers to communicate to their liquors a bitter taste and intoxicating quality. In large doses it is a powerful poison, producing, in addi- tion to tetanic paroxysms, sickness, vomiting, and other symptoms of intestinal irritation. Three drachms of the seeds introduced into the stomach have killed a dog, and a less quantity, when ap- plied to a wound, has produced a similar result. It is fatal in very small quantity when injected into a vein. The examination of the bodies of animals destroyed by cocculus indicus, induced Wcbfer to conclude that it acts, at least partly, by exhausting the irritability of the heart; for imme- diately after death this organ was always found motionless, and distended with blood. The effects of this poison on man have not been accurately noted. The upas antiar, another Javanese poison, distinct from the upas tiente, is supposed to include picrotoxia. It has particularly attracted the atten- tion of physiologists, from its power of destroying the irritability of the heart. [Cytisus Laburnum. — Some experiments that have been made recently by Dr. Christison, (Edinb. Med. and Surg: Journal, Oct. 1843,) show that laburnum bark is a most energetic poi- son,—as powerful even as nux vomica. There ap- pear to be no means of detecting the nature of the poison, (specially when administered in powder or infusion; or when, as in a case recently detailed by Dr. Christison, (Op. cit.) a decoction of the bark was given as food. (See, also, Taylor, Re- port on Toxicology, Brit, and For. Med. Rev. Oct. 1844, p. 562.) The active principle of the seeds of the Cytisus was separated from it many years ago by MM. Chevallicr and Lassaigne. To it they gave the name Cytisine. It is possessed of pow- erful emeto-cathartic properties. (Magendie's For- mulary, the writer's edition, Philad. 1825.)] Camphor. — A solution of this substance in oil or alcohol acts upon dogs in a great measure like cocculus indicus, producing paroxysms of general spasm. These are succeeded by coma, accompanied by laborious breathing, and in this state life is soon extinguished. In lumps camphor excites no convulsions, but merely irritates and inflames the stomach and intestinal canal. In the human subject two scruples of camphor have produced languor, succeeded by giddiness, insensibility, and convulsions. Delirium and som- nolency have also been witnessed, and the breath is usually loaded with the odour of the poison. The morbid changes produced by camphor in the human body have not been recorded. In dogs the heart is found destitute of contractility, and filled on the left side with arterial blood. The brain has been found vascular in a morbid degree, and softened; and the stomach, duodenum, ureters, urethra, and spermatic cords, inflamed. The odour of camphor, also, emanates from every part of the body. ' Poisonous Fungi.—We shall conclude the history of the vegetable nareotico-acrids, by a few observations on the principal cryptogamous pro- ductions possessed of deleterious properties. According to Dr. Greville, there are twenty-six edible species of fungi indigenous in Britain, namely, tuber cibarium, moschatum, and album ; amanita casarea, and muscaria; agaricus procerus, campestris, edulis, orcades, odorus, eburneus, ul- marius, ostriatus, riolaceus, deliciosus, piperatus, and acris; boletus edulis and scabcr; fistulina hepatica; hydnum repandum ; morchella esculen- ta; helvella mitra and leucophsea. Of these but three, in these countries, are served up as food at the tables of the luxurious ; the tuber cibarium, agaricus campestris, and morchella esculenta. Orfila, in his enumeration of poisonous fungi, includes four species of amanita, — the muscaria, alba, citrina, and virides; seven species of hypo- phyllum—the maculatum, albocitrinum, tricuspi- datum, sanguineum, crux meliteure, pudibundum, and mellitum ; and seven species of agaricus— the necator, acris, piperatus, pyrogalus, stypticus, annularis, and urens. To these Christison adds, on the authority of Sowerby and Brandes, the agaricus semiglobatus, and also the agaricus cam- panulatus, and expresses his opinion that the list is still incomplete. It may be observed that the formation of a perfect list is rendered additionally difficult by the circumstance of certain species being innocent in one climate and poisonous in another, and by the fact of their qualities being to a certain extent influenced by a dry or rainy season, and by the period of the year at which they are produced. The deletrious fungi have been the subject of numerous experiments, but chemists are not yet quite agreed as to the nature of their active prin- ciple. Very recently Le Tellier announced that in some he had detected one, in others two, poi- sonous constituents, one of which is volatile and acrid, the other fixed and possessed of narcotic powers. These conclusions, however, require verification. There are certain external signs or obvious characters by which wholesome may be often dis- tinguished from poisonous fungi. The latter, for example, usually exhibit a warty pileus or cap, 456 TOXICOLOGY. exhale a heavy and peculiar odour, and sometimes when chewed produce a styptic taste. Those of an orange colour are also very generally poison- ous, and the same may be said of such as possess a tough or corky texture. Those also which grow in shady places or on the trunks of trees should be suspected, and if when cut they shortly assume a blue colour, this circumstance may be considered as conclusive of their noxious proper- ties. These rules will often serve as useful guides, but they must not be implicitly relied upon, for all are subject to exceptions. The symptoms produced by the poisonous fungi are sometimes of purely an irritating kind. Very often also they appear to operate exclusively as narcotics; but in the greater number of cases both classes of effects are combined. The symptoms of irritation which have been witnessed are an unaccountable feeling of anxiety, urgent dyspnoea, scorching thirst, tormina of the bowels, abdominal tension, and profuse diarrhoea, the matters discharged being particularly offensive. Dimness of vision, giddiness, delirium, and coma, constitute the usual narcotic symptoms. Convul- sions are rare. It may be mentioned as a pecu- liarity of this class of poisons, that the symptoms are rather slow in beginning, but are of unusually long duration. They have not in some instances commenced for twelve, and in several they have lasted for better than forty-eight hours. The morbid appearances which have been no- ticed are lividity of the body, fluidity of the blood, distension of the abdomen, inflammation, and even gangrene of the stomach and intestines, and venous congestion of the lungs and brain. It is scarcely necessary to say that there exists no antidote to the poisonous fungi. Our reliance must be entirely placed upon the prompt expul- sion, by emetics or otherwise, of the noxious con- tents of the stomach ; and it is worthy of being noticed here that the fungi continue for an un- usually long time in this viscus, having in one instance been discharged by vomiting nearly three days after they had been eaten. Ergot or spurred Rye.—The seeds of the cerealia are sometimes rendered unwholesome by imperfect ripening, apparently owing to the pre- sence of a free acid in the grain, for the flour is, if not perfectly cured, at least greatly improved by the addition to it of a little carbonate of magnesia. In some instances, however, they, or rather the meal prepared from them, acquires very deleteri- ous properties from the presence of a remarkable production known to botanists under the name of secale cornutum or ergot of rye, from the plant in which it is principally developed. It has also been observed in wheat, oats, and barley, but more rarely, and in a state of less development. This ergot or spur of rye which replaces in the ear sometimes one, sometimes several grains, is a cylindric growth varying from three lines to an inch and a half in length, and of the thickness of a crow-quill. Internally it is of a greyish colour, but outside it is covered by a bluish-black husk, presenting two or three dotted streaks of a lighter shade. The amount of it present in rye is in- fluenced by the nature of the soil and the character of the season. When the ground is damp and stiff, and the season unusually moist, we have combined the circumstances which have been found most favourable to its production. The district of Cologne in France, and several parti of Germany, have in particular been infested by it, but it has scarcely ever been produced in these countries in sufficient quantity to render it an object of interest to the toxicologist. With respect to the nature of this substance different opinions have been entertained, some viewing it as a spontaneous morbid growth, others as a parasitic fungus, and others still as the work of a species of papilio which punctures the glumes of the unripe plant, and thus causes an exudation of milky juices, which by inspissation are finally converted into the spur. In support of this latter theory it has been alleged that a similar growth may be produced by punctures inflicted with a needle. The ergot has been subjected to analysis by several chemists. Vauquelin found in it neither starch nor sugar, but a considerable quantity of i principle of an animal nature, and very prone to putrefaction. According to Robert, it includes prussic acid, but this statement is not in accord- ance with the experiments of other chemists. When the ergot is exhibited to man in a dose of about two drachms, the symptoms usually pro- duced by it are vertigo, headach, suffusion of face, nausea, succeeded by vomiting and purging, spasms of the stomach and intestines, and an universal feeling of debility and fatigue. If gra- dually introduced into the system, as occurs to those who have used for a considerable time rye- meal impregnated with it, the effects are materially different and of a twofold description. Either a convulsive disorder is established, or the disease usually known under the name of dry gangrene. The former begins with dimness of sight, gid- diness, and insensibility, symptoms which are quickly succeeded by frightful convulsions of the entire body. In this severe form the disease proves rapidly fatal; but in milder cases the con- vulsions occur only in paroxysms, and in the intervals the chief indication of disease which presents itself is an extreme voracity of appetite. This voracity either terminates in death, preceded by coma and convulsions, or in recovery after the previous appearance of anasarca, diarrhoea, cuta- neous eruptions, or abscesses in different parts of the body. The latter affection, or gangrenous ergotism of the French, begins with a sense of weariness and debility. After the lapse of a con- siderable but variable period of time, sometimes one, sometimes several weeks, the extremities be- come cold, numb, and stiff', and are seized with excruciating pains. A pyrexial state next sets in, accompanied with epistaxis; and, finally, the fin- gers and arms, afterwards the toes and legs, shrivel up and drop off at the joints in succession. In this modification of ergotism the appetite is also from the commencement inordinate. Alcohol.—The origin of this remarkable fluid, together with its physical and chemical characters, are so well known that any allusion to them here would be quite superfluous. We shall therefore proceed at once to the consideration of its influ- ence upon the animal economy. Alcohol and alcoholic fluids generally, when swallowed by man in moderate quantity, invari- TOXICOLOGY. 457 ably produce a greater or less degree of excite- ment ; that is, they augment the temperature of the body, accelerate the movements of the heart and respiratory organs, give tone and strength to the muscles, energy and rapidity to the operations of the mind, and in general call up a train of pleasurable emotions. Nor is this state of tem- porary exaltation followed by any material subse- quent languor or depression. When, however, the limits of moderation are transgressed, and such a quantity of a spirituous fluid is used in successive doses as to produce the state usually designated by the term intoxication or drunkenness, the consequences are materially different. The excitement, indeed, just described, is in the first instance observed, but it soon puts on a more formidable character, being attended by suffusion of face and conjunctiva?, difficult articulation, gid- diness, incoherency of mind, and, very frequently, true delirium. An irrepressible drowsiness next succeeds, which terminates in deep and sometimes stertorous sleep, from which, in cases which ter- minate favourably, the individual awakes affected by debility, giddiness and headach, universal lan- guor, and very often nausea and vomiting. The result, however, is sometimes different. The som- nolency just described passes not into sleep, but a state of general insensibility, accompanied by feeble and moderately rapid pulse, stertorous breathing, and dilated and non-contractile pupil, a combination of symptoms from which recovery is seldom witnessed. The case just described is an instance of sim- ple poisoning by fermented liquors, and many such have been observed. It, however, more frequently occurs that life is destroyed either by the occur- rence, during the fit of intoxication, of apoplexy in an individual predisposed to the disease, or in consequence of his exposure to extreme cold, or his accidental suffocation during the lethargic or somnolent state. Should the spirituous liquor be drunk not in divided portions, but all at once and in large quantity, apoplectic coma with stertorous breathing sets in, almost immediately, and death follows usually within a few hours. In habitual drunkards a particular affection, at present known under the name of delirium tre- mens, is often witnessed, which may with pro- priety be noticed here. Delirium, characterized by constant incoherent talking, is its leading symptom, and is accompanied by tremours of the limbs, particularly the upper extremities. In fatal cases coma, as in the preceding instance, precedes and ushers in death. Looking to the preceding history of symptoms, alcohol, it would appear, should be classed with the purely narcotic poisons. Cases, however, have occurred, though very seldom, in which, after the cessation of its narcotic action, symptoms of gastro-intestinal irritation and inflammation have set in, which justify the position usually assigned to it in the arrangements of toxicologists. The morbid appearances which have been ob- served in the stomach in cases of poisoning by alcohol are unusual redness and vascularity of its mucous lining. Such appearances are, according to Orfila, invariably witnessed in the stomachs of the lower animals. In man, however, though Vox. IV. —58 2o sometimes found, they are very generally wanting. In the head, as might have been anticipated from the symptoms, the principal lesions are to be found. These are venous congestion, serous effu- sion into the ventricles and between the mem- branes, and extravasation of blood into the sub- stance of the brain, producing genuine sanguineous apoplexy. When delirium tremens proves fatal, serous effusion is found in the brain, and in some rare instances flakes of coagulable lymph are at- tached to the membranes. Andral also in a single case witnessed a very extensive softening of the mucous tunic of the stomach. Should death take place very quickly, as when a large draught of spirituous liquor is swallowed, post-mortem ex- amination will not display any morbid lesions of the brain or other organs. Alcohol is generally conceived to enter the cir- culation, and through it to exert its poisonous in- fluence on the nervous system ; and in support of this theory the fact is alleged of a spirituous smell being perceptible not only in the stomach of per- sons who die of intoxication, but also in the brain and other organs. When, however, death occurs, as it often has, within a few minutes, it is difficult to admit that absorption could have taken place, and we are compelled, with Addison and Morgan, to refer its noxious influence to nervous impres- sion and cerebral sympathy. The diagnosis of a case of poisoning by alcohol will, in most instances, not be difficult. The symptoms already detailed, combined with the alcoholic odour of the breath, will often clear up the nature of the case even during life; and when it terminates fatally, the contents of the stomach, if subjected to distillation in a retort, will furnish a product which by rectification from dry carbon- ate of potash, or fused chloride of calcium, will acquire all the physical and chemical characters of alcohol. This method of research will always lead to a positive result when the individual dies shortly after swallowing the fermented fluid. Should the fatal event, however, be delayed for a few hours, the alcohol is absorbed, and cannot of course be subsequently detected in the stomach. We may also add, that in cases of rapid poison- ing, if the chemical search for alcohol be not in- stituted within a reasonable time, it will not prove successful, as the poison escapes by evaporation or transudation. The treatment of a person labouring under dangerous drunkenness is very simple. The sto- mach must be emptied by an emetic, or should this fail or be too slow in its operation, by the application of the stomach-pump; and the som- nolency or coma, should it have set in, is to be obviated by the assiduous use of the various means of stimulation recommended under the head of opium. In delirium tremens, opium in large and repeated doses has proved a very efficacious reme- dy. It is, however, only suitable during the con- tinuance of the delirium and tremours. Should a somnolent or comatose state be established, its use should be strictly inhibited. From the morbid appearances which have been witnessed in cases of delirium tremens, such as the effusion of serum and coagulable lymph in the brain, there is good reason to conclude that the disease occasionally passes into, or is complicated with, phrenitis. 458 TOXICOLOGY. Should such a combination be in any instance suspected, the exhibition of opiate preparations should be preceded by depletion from the head and other antiphlogistic means of treatment. (See a paper by Dr. Lendrick, Dublin Journal, No. iv. p. 7.) IV.—Poisonous Gases. The atmosphere in which we live, and by means of which those changes are effected in the blood as it circulates through the lungs, known under the term aeration, consists, in the main, of a mix- ture of four volumes nitrogen and one oxygen, a minute quantity of carbonic acid being also pre- sent, and a variable proportion of aqueous moisture. Such is the nature of the gaseous medium which we respire, and it is the only aeriform fluid which admits of being inhaled for a length of time without the production of effects injurious to or destructive of life. No single known gas at least can supply its place, and the same may, in all probability, be said with truth of any artificial mixture differing in the nature, or even the pro- portion, of its essential constituents from the natural atmosphere. Every known gas, therefore, may, under this point of view, be considered as a poison. All, however, are not equally energetic, and the manner of action of all is not the same. The first circumstance deserving of attention which serves to distinguish some from others of the gaseous poisons is, that certain of them will, in the pure or unmixed state, pass into the lungs, while against others the glottis closes spasmodi- cally, unless they be diluted with a sufficient quantity of atmospherical air. This difference of property has suggested a division of them into the respirable and the irrespirable.- the former being oxygen, nitrous oxide, nitrogen, hydrogen, car- bonic oxide, and carburetted hydrogen ; the latter, ammonia, chlorine, muriatic acid gas, nitric oxide, nitrous acid vapour, sulphurous acid- gas, carbonic acid, cyanogen, and sulphuretted hydrogen.* Nysten (Recherches Chemico-physiologiques) has resolved the poisonous gases into the negative and positive, or into those which merely operate by excluding atmospherical air, which alone can effect the proper aeration of the blood, and those which exercise on the parts with which they come in contact, or on the system generally, a directly injurious action. It is probable, however, that if we except nitrogen, there does not exist a truly negative aerial poison ; and when we find Nysten arranging subcarburetted hydrogen, carbonic ox- ide, and nitrous oxide, among the negative gases, there can be no doubt that the method which he adopted for determining to which class each indi- vidual belonged led him to erroneous results. This eminent physiologist laid it down as a prin- ciple that a truly negative gaseous poison can, when injected into the blood, produce no injurious effects save what are the result of its mechanical action ; and, therefore, that when other and dis- tinct morbid phenomena are observed to follow, they establish a direct or positive deleterious in- fluence. It would be easy to show, from d priori considerations, that this criterion could not be re- lied upon. The conclusions, however, to which * This enumeration of poisonous gases is obviously imperfect. It, however, includes all those which merit the attention of the toxicologist. Nysten was guided by it arc so inconsistent with experience, that any further objection to its validity would appear altogether unnecessary. Of the positive gases, or those which are di- rectly noxious, all do not operate in the same way. Some irritate or even inflame the parts with which they come in contact, while the action of others is directed chiefly to the nervous system. Hence the common division of them into irritants and narcotics, which, being founded on their manner of action, is probably, in a practical point of view the best which can be employed by the toxicolo- gist. In the following table an attempt is made to combine the principles of classification which have been just explained. I. NEGATIVE. Nitrogen. II. POSITIVE. 1. Narcotic. Oxygen. Hydrogen. Nitrous oxide. Carbonic oxide. Subcarburetted hydrogen. Sulphuretted hydrogen' Cyanogen ? Carbonic acid. 2. Irritant. Ammonia. Chlorine. Muriatic acid gas. Nitric oxide. Nitrous acid gas. Sulphuretted acid gas. Nitrogen.—This is one of the respirable gases, that is, when perfectly pure it can be drawn into the lungs. Being, however, incapable of effecting the arterialization of the blood, its inhalation can- not be repeated more than three or four times in succession without the production of asphyxia. The venous blood, in fact, reaches unchanged the left side of the heart, and, passing from thence to the brain, suspends the influence exercised by thia organ in determining the contraction of the respi- ratory muscles, and thus causes death by suffoca- tion. As pure nitrogen is not a natural product, and as it is but sparingly produced in chemical processes, no instances have occurred of death resulting from its inhalation. Oxygen.—This is the constituent of the atmo- sphere which performs the most important func- tions in the process of respiration. It was, indeed, long supposed to be the only element of the ait we breathe essential to life, and the nitrogen was considered to act merely by diluting it, and thus reducing the energy with which Kacts upon the system. That this latter gas operates at least partly in this way there can be little doubt. The experiments, however, of Dr. Edwards would seem to establish that it also is sometimes absorbed, and, therefore, in all probability, discharges other and higher uses in the animal economy. In the earlier experiments performed upon the smaller animals immersed in a given volume of oxygen, it was observed that life was maintained a much longer time than it would be in an equal bulk of atmospherical air. This method of expe- rimenting does obviously not enable us to examine apart the effects of oxygen gas, for carbonic acid TOXICOLOGY. 459 is gradually evolved, and we witness merely the influence of the mixture upon the animal. To insulate the agency of the oxygen, so that it alone may be studied, it is necessary to cause this gas to be inspired from one reservoir and expired into another, a thing which can scarcely be accomplished unless in the case of the human being ; or, when the experiment is conducted by surrounding the animal with a given volume of the gas, to remove the carbonic acid by chemical means as fast as it is produced. Operating in the first-mentioned way, Allen and Pepys observed phenomena some- what different from those which belong to ordinary respiration. A glow of warmth was felt over the entire body, accompanied by a gentle diaphoresis, the pulse was decidedly accelerated, and the ani- mal temperature appeared to undergo a slight aug- mentation. The excitement thus produced rapidly subsided upon the termination of the experiment, leaving behind it no depression or other inconve- nience whatsoever. (Phil. Trans. 1808.) These experiments would seem to lead to the conclusion that pure oxygen when respired operates as a sti- mulant, but that its action is not sufficiently vio- lent to justify us in considering it as a poison. To such conclusion, however, it may be ob- jected, that the experiment in question was not carried sufficiently far to put us in possession of the true physiological action of the gas ; that if it had been respired for a longer time, the observed effects would have been different: and some re- searches conducted not long since by Mr. Brough- ton, (Quarterly Journal of Science, January, 1830, p. 1,) have, in point of fact, led him to the belief that oxygen when respired sufficiently long exer- cises a narcotic influence. The first effects no- ticed by this physiologist were increased activity of the pulmonary and aortic circulation. A degree of languor, which gradually passed into extreme debility was next observed, and to this succeeded general insensibility and loss of power over the voluntary motions. The heart, however, continued to beat, and the intestinal muscles to contract, long after the cessation of the movements of the diaphragm and purely voluntary muscles, and after sensibility had been completely extinguished. In rabbits, cats, and guinea-pigs, upon whom the experiments were chiefly performed, the symptoms just enumerated did not begin to manifest them- selves until after the lapse of an hour, and death took place between the sixth and twelfth hour. Post-mortem examination showed the blood of a bright scarlet colour in both arteries and veins, and unusually prone to coagulation. The views of Broughton are pretty generally adopted, by Christison among the rest; and in accordance with them we have classed oxygen among the narcotic gases. We confess, however, we are by no means satisfied of their soundness. In his method of experimenting, the carbonic acid produced by the animal was mixed with the oxygen, and it is at least possible that the sedative effects observed were due to the former gas. Hydrogen.—This gas in the pure or unmixed state may be respired with impunity a few times, the only remarkable consequence which follows being a peculiar modulation of the voice, which lasts until the greater part of the hydrogen is ex- pired. But should its inhalation be continued much longer, speedy death by asphyxia is the con- sequence, as, like nitrogen, it is unable to effect the aeration of the blood. If this event be pre- vented by mixing oxygen with the hydrogen, a decidedly narcotic effect is produced. Thus, Allen and Pepys found that guinea-pigs made to respire a mixture of four volumes of hydrogen and one oxygen, first became somnolent, and were finally thrown into a profound, sleep, from which, how- ever, they recovered perfectly upon being with- drawn from the mixture ; and De Wetterstedt of Stockholm found a similar mixture to produce the same effect upon a young female labouring under phthisis. (Berzelius, Traite de Chimie, vol. vi. p. 106.) In such experiments, it should be ob- served, some hydrogen disappears, which is of course absorbed "by the blood. Nitrous Oxide.—The singular effects of this gas when respired were first studied by Sir H. Davy, who detailed its influence on himself, and gave publicity to the accounts drawn up by seve- ral of his friends of the sensations which they experienced. (Researches, chemical and philo- sophical, chiefly concerning nitrous oxide and its respiration.) The first feeling of Davy upon respiring the gas was giddiness, which was suc- ceeded by an uncommon sense of fulness in the head, accompanied by loss of distinct sensation and voluntary power; but these, in less than half a minute, the respiration being continued, dimin- ished gradually, and were followed by a sensation analogous to gentle pressure on all the muscles, attended by a highly pleasurable thrilling, particu- larly in the chest and the extremities. The ob- jects around became dazzling, and the hearing acute. Towards the last inspirations the thrilling increased, the sense of muscular power became greater, and at last an irresistible propensity to action was indulged in. These effects ceased very soon after respiration, for in ten minutes he had recovered his natural state, and what is par- ticularly worthy of notice, the excitement he ex- perienced was not followed by the slightest languor or depression. By repeated trials he found that he could breathe nine quarts of the gas for three, and twelve quarts for more than four minutes, but that he could never respire it in any quantity so long as five minutes. The pleasurable sensations also were with him at their height about the mid- dle of the experiment. Several others have been affected in a similar manner from the respiration of the nitrous oxide, but the effects of the gas are not the same upon all individuals. Some, for example, have been thrown by it into a state of syncope, others into convulsions. The researches of Davy (Opus citat. p. 394) prove that in such experiments the gas is absorbed in quantity by the blood. When injected slowly into this fluid, Nysten found that it was condensed, and that the only effect result- ing from it was a slight staggering. Carbonic Oxide. — Some interesting experi- ments upon the respiration of this gas were made a few years ago in the laboratory of the Dublin Society by the assistants of Mr. Higgins, the pro- fessor of chemistry. Three inhalations produced in one gentleman vertigo, tremours, and a lethargic state bordering on insensibility, which was suc- ceeded by debility and headach of some hours' 460 TOXICOLOGY. duration. Another, who after a forced expiration inhaled the gas three or four times, was struck down suddenly and remained for half an hour apparently lifeless, and almost without pulse. After the failure of various other means of stimu- lation, he was at length revived by inflating his lungs with oxygen, but continued nevertheless, throughout the day, affected by convulsive move- ments of the body, stupor, severe headach, quick and irregular pulse, and subsequently with nausea, and slight febrile paroxysms of an intermittent nature. Nysten found that when gradually introduced into a vein, carbonic oxide produced a state analo- gous to that of intoxication. Subcarburetted Hydrogen.—This gas is copiously disengaged in collieries, and, when mixed with a proper proportion of common air, constitutes the explosive atmosphere usually known under the name of fire-damp. We are not aware of subcarburetted hydrogen having been inhaled in the pure state, but as the fire-damp does not in any perceptible degree embarrass the respiration of the workmen in coal-mines, we are entitled to conclude that the gas is innoxious when diluted with fourteen volumes of atmospherical air, for a mixture thus composed cannot be ignited. There are several other gaseous compounds of carbon and hydrogen, one of which, the olifiant gas, has been known for a great length of time, but their effects when singly respired have not been made a subject of experiment by the phy- siologist ; and the same may be said of the mixed compounds of the same elements which are found in the gases prepared from oil, coal, and resin. The experience indeed of gas-men proves that at- mospherical air is not rendered injurious to health by being highly charged with the artificial illumi- nating gases; but an accident which occurred some time ago in Paris, shows that if a certain limit be transgressed, poisonous effects will follow. In consequence of the leaking of the gas-pipe which supplied a warehouse, five individuals who slept in the building were attacked during the night with stupor, and one of them died with most of the symptoms of narcotic poisoning. The phenomena, however, witnessed in this case can scarcely be considered as due exclusively to the influence of the gas, for one of the lungs was found congested, and the bronchus distributed to it blocked up by a kidney-bean. (Christison, p. 704.) The gaseous mixture which is produced by passing the vapour of water over red-hot charcoal, and which consists of subcarburetted hydrogen, hydrogen, carbonic oxide, and carbonic acid,* was inhaled by Sir H. Davy, (Op. cit. p. 467), both in the pure form, and diluted with two-thirds its volume of atmospherical air. In the latter state, when breathed for about a minute, it produced slight giddiness and pain in the head, and a mo- mentary loss of voluntary power. The pulse also was rendered quicker and feebler; but all the effects went off in five minutes. The first inspi- ration of it in the undiluted form caused a sort of numbness and loss of feeling in the chest and about the pectoral muscles. After the second he * This gas was probably removed, as allusion is made to some method of purification which was employed. lost all power of perceiving external things, and had no distinct sensation except a terrible oppres- sion on the chest. This feeling disappeared during the third expiration, but he felt (to use an expression of his own) as if sinking into annihi- lation. The further inhalation of the gas was now suspended, and after the lapse of a minute his pulse was found threadlike, and beating with excessive quickness. He now moved instinctively to the open air, where, upon arriving, his head became giddy, his knees trembled, and he had but just sufficient voluntary power to throw himself upon the grass. Here the painful feeling of the chest increased with such violence as to threaten suffocation ; but upon respiring for about a minute a mixture of oxygen and nitrous oxide, he felt relieved, and in an hour the painful feelings had disappeared, leaving behind them only an exces- sive weakness and swimming of the head. In three quarters of an hour after this, having walked about slowly in the mean time, great giddiness again returned, accompanied by nausea, loss of memory, and deficient sensation. To these, in about an hour and a half, a violent pain in the forehead and between the eyes succeeded, and transient pains in the chest and extremities; but these affections gradually diminished, and at ten at night no disagreeable feeling remained. From the preceding detail, the conclusion of Davy would appear pretty well established, namely, that the gaseous mixture which he respired, "acts as a sedative, i. e. that it produces diminution of vital action and debility, without previously ex- citing." Carbonic Acid. — This gas being copiously disengaged during the combustion of ordinary fuel, the burning of lime, and as the result of the vinous fermentation, the respiration of animals and the growth of plants, it is more frequently the cause of accidental as well as intentional death than any other of the aerial poisons. The action of car- bonic acid was once conceived to be purely nega- tive, or to depend merely upon its inability to aerate the blood. But this opinion is amply re- futed by a variety of facts enumerated by Dr. Christison. 1. The state of asphyxia produced by the respiration of an atmosphere charged with carbonic acid, is removed with much greater diffi- culty than that which is the result of immersion in hydrogen or azote. 2. If the azote of atmo- spheric air be replaced by an equal volume of car- bonic acid, such atmosphere will prove rapidly poisonous. 3. If a tortoise be made to respire atmospheric air with one lung and carbonic acid with the other, it perishes in a few hours. This experiment was performed by Rolando, of Turin. 4. Effects analogous to those which result from the respiration of the gas are produced by its pro- longed contact with the skin or stomach. In the latter method of application, for example, it gives rise, as is well known, to intoxication; and Col- lard de Martigny has shown that when an animal is enveloped by an atmosphere of carbonic acid, the access of atmospherical air to the lungs being still permitted, so as to maintain ordinary respira- tion, death, if the experiment be continued suffi- ciently long, is the invariable consequence. Carbonic acid in the pure state cannot, as Sir H. Davy has shown, be inhaled; for the irritation it TOXICOLOGY. 461 produces in the fauces is such that the glottis I closes spasmodically, and thus prevents its en-1 trance into the lungs. The undiluted form, then, may be considered as a true negative poison, destroying life by simple suffocation. Of death produced in this way, many instances occur in distilleries and breweries, from the workmen in- cautiously entering, or falling accidentally, into the fermenting tuns. It also often accumulates in old wells, in mines, where it constitutes the choke-damp, and in caverns, like that of the Grotto del Cane, near Naples, occurring in volca- nic districts, in a state of such purity as suddenly to asphyxiate individuals who enter them. In such situations, however, it will more fre- quently occur that the carbonic acid is diluted with a greater or less quantity of atmospherical air. If the proportion of the former gas be not too great, the mixture will enter the lungs, and Davy found, in an experiment performed on him- self, that when it amounted to 30 per cent., such atmosphere could be respired for one minute, the only effects being a slight degree of giddiness and inclination to sleep. But should the respiration of such a mixture be persisted in for a longer time, consequences of a much more serious de- scription are observed. A sense of weight in the head, attended by giddiness, is the first symptom, and this is rapidly succeeded by a somnolent state, which finally terminates in coma, with ster- torous breathing. In convalescence from the as- phyxia produced by a mixture of air and carbonic acid, violent and irregular convulsions, general in- sensibility, and dumbness, have been observed. Confined atmospheres, such, for example, as those of small and close apartments, in which a number of individuals respire without any provi- sion for renewing the air, or in which the com- bustion of carbonaceous matters is conducted with- out a flue, acquire deleterious properties of an analogous but still more energetic description. Nor is this difficulty to be understood; for in such atmospheres carbonic acid is not only deve- loped, but an equivalent portion of their oxygen is withdrawn. The emanations, indeed, from burning charcoal are not always of the same de- scription. When the combustion is brisk, car- bonic acid is the only product; but Orfila has shown that, when languid, equal volumes of car- bonic acid and subcarburetted hydrogen are evolved (Toxicol. Gen. ii. 474) ; and experience proves such mixture, when respired, to be in an eminent degree injurious to the animal economy. The same eminent toxicologist, it may also be ob- served, has established, that when the coals are red-hot, considerably less atmospherical oxygen is consumed, than when the combustion is languid. The narcotism established in these cases continues for an unusual length of time, and, though deli- rium sometimes supervenes, it is not, as in other instances of narcotic poisoning, to be looked upon as the precursor of convalescence. It is often said that if an atmosphere including carbonic acid supports the combustion of a taper, it is respirable, and such is the test relied upon by those employed in the sinking of wells for pumps, at the bottoms of which it is liable to accumulate. Such an atmosphere will undoubtedly admit of being respired for a certain length of time, but 2o» will, nevertheless, often finally induce a state of the most dangerous asphyxia. It is even said that a female servant fell suddenly down upon entering a cellar in which the vinous fermentation was going on, although the candle which she carried with her continued to burn. (Archives G6n. de Medecine, xiv. 205.) The literal correctness of this statement may be doubted; but, even though it were shown to be erroneous, abundant facts still remain to prove the fallacy of the method in question as a test whether a given atmosphere contaminated with carbonic acid be or be not poi- sonous. Several instances of poisoning by the fumes of burning charcoal, and some of suffocation pro- duced by the crowding of people into confined and narrow rooms, are upon record. Scarcely a month elapses without an account of death produced by a charcoal chaffer placed incautiously in bed- chambers without a flue; and in the celebrated narrative of the suffocation of one hundred and twenty-three out of one hundred and forty-six Englishmen, incarcerated for a single night in a dungeon at Calcutta, we have a very striking illustration of the injurious properties acquired by air which has been repeatedly respired. In all such cases, the effects, as has been already stated, are pretty nearly the same with those which result from the respiration of simple mixtures of atmo- spheric air and carbonic acid. If there be any distinction, it is that a greater or less degree of delirium is more constantly present in the former than in the latter instances. In individuals destroyed by respiring air con- taminated by carbonic acid, the countenance is usually tranquil and composed, sometimes red, often particularly pale, but more usually of a livid colour. The eyes are prominent and exhibit a glistening appearance, and the tongue is black and protruded between the teeth. The lungs, heart and brain are in a state of venous congestion, and the ventricles of the latter organ include a consi- derable quantity of serum. According to some toxicologists the back is extremely livid, the blood fluid, and the muscles are in a great measure des- titute of irritability. In some instances effusion of blood on the surface of the brain has been ob- served, and it is also said that the stage of rigidity which usually succeeds to death has occasionally not been established. The treatment of poisoning by carbonic acid may be discussed under two distinct heads :—1st, when the asphyxia is complete; 2d, when the functions of the heart and lungs being performed, there still prevails a state of coma, or a greater or less degree of insensibility. To remove the asphyxia produced by carbonic acid the means which have been found most effi- cacious are, the cold affusion, bleeding from the arm or jugular vein; or should this method of depletion not succeed, cupping from the nape of the neck or other part in the vicinity of the head. In conjunction with these, the artificial inflation of the lungs with oxygen, if practicable, should be resorted to, and it will be frequently found ad- vantageous to employ the stimulating powers of a galvanic machine of about forty couples. (See article Gaivanism.) In this form of asphyxia also, as in other kinds, it will be proper to main- 4G2 TOXICOLOGY. tain the temperature of the body by external heat, and to apply to it assiduous and general friction with warm flannel. As soon as the movements of the heart and chest are restored, our attention must be directed to the prevention of a relapse, and to the removal of the state of insensibility or torpor which re- mains. With a view to the accomplishment of these objects, the local bleeding from the vicinity of the head should be repeated, unless contra-in- dicated by peculiarities in the case; ammonia or its carbonate should be applied at intervals to the Schneiderian membrane of the nose, and even introduced frequently in small doses into the stomach. By the steady prosecution of this plan of treatment, the stupor, though generally deep and lasting, will in most instances be finally re- moved. Sulphuretted Hydrogen. — The experi- ments of Dupuytren and Thenard demonstrate sulphuretted hydrogen to be in the highest degree inimical to the animal economy, for they found air impregnated with 1-150th of this gas to prove fatal in a short time to a horse, with l-800th in about the same time to a dog, and when contain- ing but its l-1500th immediately to destroy a small bird. Sulphuretted hydrogen is evolved in nature, though in no great quantity, and impreg- nating certain mineral springs, acquires for them the title of sulphurous. It is also invariably dis- engaged as the result of the putrefaction of or- ganic matters, particularly those of an animal nature. Old privies, for example, especially such as, like those of Paris, are unconnected with any sewer, and continue uncleaned out for a length of time, exhale it in considerable quantity; not, however, pure, but in a state of mixture and combination with ammonia. Sulphuretted hydro- gen is not alone poisonous when taken into the lungs. It is equally so when applied to other parts of the body. It also proves fatal whether forced into the cellular tissue, stomach, or rectum, or simply applied to the skin. Chaussier found that nine quarts introduced through the anus of a horse killed it in one minute, and that a rabbit to whose skin alone it was applied perished in ten minutes. We are not aware that any instances are re- corded of death produced by sulphuretted hydrogen alone. When evolved in virtue of putrefaction, this gas is accompanied by ammonia; and in all the alleged cases of poisoning by sulphuretted hy- drogen, the volatile alkali has also been a compo- nent part of the noxious atmosphere. The effects of such atmosphere were detailed about forty years ago with great particularity by M. Halle, in a work upon the nature of the exhalations from the Parisian privies. According to this authority, the symptoms vary with the degree of concentration of the exhaled vapours. When undiluted with atmospherical air, they determine a sudden and complete asphyxia, from which recovery is very rare, unless the affected individual be almost immediately withdrawn from the influence of the exhalations. When the noxious vapours are respired in a state of admixture with a large proportion of atmo- spheric air, their injurious effects are more slowly developed, and are of a twofold description. In some a somnolent state terminating in coma if produced, from which, however, they may be roused, though with difficulty; all recollection of what occurred in the interval being entirely effaced. In others a variety of symptoms, which differ in different individuals, first present themselves, such as pains, particularly of the stomach and arms delirium, dyspnoea, a state approaching to asphyxia with dilated and immovable pupils, and feeble and irregular pulse; and to these succeed violent tetanic spasms of both trunk and extremities, Finally, in fatal cases, a short time previous to death, the patient becomes remarkably tranquil and indeed almost insensible. In the milder cases or where the vapours have been much diluted, and the exposure of short duration, nausea, a certain degree of lethargy, with slight abdominal and tho- racic pains, constitute the only symptoms which have been observed. In individuals poisoned by exhalations including the hepatic gas, the blood in every part of the body is found fluid, and of a dark colour, the muscjes destitute of contractility, and the lungs in a state of sanguineous congestion. The smell, also, peculiar to sulphuretted hydrogen emanates from the body, and may, according to Chaussier, be detected in the different organs by introducing into them slips of polished silver, or a small quan- tity of recently precipitated carbonate of lead. The substance just mentioned, or, what will answer equally well, a slip of filtering-paper moist- ened with a solution of sugar of lead, constitute as delicate tests as can be desired for sulphuretted hydrogen. The former is blackened by the gas, while upon the latter a film of sulphuret of lead is formed, so thin as to exhibit a beautiful iridescent play of colours. Should it be deemed expedient to deprive an atmosphere of any sulphuretted hydrogen it may include, this may be very readily and completely done by introducing into it a little chlorine gas, which will seize upon one of its elements, the hy- drogen, while the other is deposited. The same object may also be accomplished by nitric acid in the vaporous state. With respect to treatment, it will be sufficient to refer to what has been already said; for the manner of action of sulphuretted hydrogen and carbonic acid being the same, their effects should, in all probability, be combated in a similar man- ner. Cyanogen.—There have been no opportunities of observing the effects of this gas upon the human subject, but the experiments of Coullon, and those of Hurrefield, referred to by Christison, prove it to be a powerfully narcotic poison ; the symptoms which characterize it being coma, and more rarely convulsions. Like prussic acid, it sometimes pro- duces a local and temporary paralysis of the parU of the body to which it is applied. Irritant Gases.—The manner of action of the irritant is in one respect the same with, in another essentially different from, that of the narcotic gases. Both, oxygen being excepted, are incapable of aerating the blood, and would for this reason, if for no other, ultimately destroy life In addition, however, to this, the narcotic gases exorcise upon the nervous syslem an injurious influence of a specified description, and the irritant ones excite TOXICOLOGY. 463 in the mucous membrane with which they come in contact a greater or less degree of irritation and inflammation. In the pure state, the irritant gases are all irrespirable. Ammonia.—The aqua ammonia? of the phar- macopoeia, at ordinary temperatures, is constantly exhaling ammoniacal gas, and is hence often ap- plied as an analeptic remedy to the nares in syn- cope, hysteria, epilepsy, asphyxia, &c. From this application of it several accidents have arisen; for, in virtue of its escharotic powers, when applied in too great quantity, it corrodes and of course inflames the mucous membrane lining the different bronchial passages. The symptoms which in such event present themselves are of course those of a very severe bronchitis, and the morbid appearances are extreme vascularity of the lining membrane, exudation of lymph upon its surface, and, at some points, excoriation and ulceration. To prevent consequences of this description, the aqua ammo- nia?, before being held to the nose, should be di- luted with about three volumes of water. Chlorine.—This gas is often developed in the laboratory of the chemist, and, in great quantity, in factories for the preparation of the bleaching salt of lime; and, though highly irritating to the larynx and lungs, admits of being inspired when sufficiently diluted with atmospheric air. In this state, however, it frequently, by its stimulating and corrosive qualities, produces an inflammation of the bronchial mucous membrane, which either terminates fatally, or lays the foundation of some formidable form of thoracic disease. The younger Pelletier fell a victim to phthisis thus produced; and a gentleman of this city (Dublin), Mr. Roe, is said to have died some years ago of a chronic bronchitis which originated in a similar cause. Paradoxical, however, as it may seem, the respi- ration of an atmosphere impregnated with a small quantity of chlorine has recently been recommend- ed as an efficient means of contending with tuber- cular phthisis. Experience, indeed, proves that air slightly impregnated with it is not injurious to health; for, as Christison remarks, the workmen employed in the manufacture of chloride of lime are not less healthy than those engaged in other laborious occupations. Dyspeptic affections con- nected with acidity of the stomach would appear to be the only injurious consequences which result from its habitual inhalation. Muriatic Acid Gas.—There can be no doubt that this gas will, when respired sufficiently long, and in a sufficient state of concentration, produce an acute bronchitis. Its effects, however, when bo applied have not been observed, or at least not recorded. In consequence of its corrosive powers, Guyton Morveau employed it several years ago as a disinfector; but in this respect there can be no doubt that it possesses an efficacy inferior to chlo- rine or the vapour of nitric acid. Nitric Oxide, and Nitrous Acid Vapour.— When the nitric oxide comes into contact with oxygen, and it cannot be respired without such an occurrence, it is converted into nitrous acid ; so that, in a practical point of view, and in reference to our present discussion, the consideration of the former merges in that of the latter. So irritating are the vapours of nitrous acid, that a very minute quantity of them will render the atmosphere in which they exist irrespirable, by determining the spasmodic closing of the glottis. This, for example, occurred to Sir H.Davy, who, intending to breathe nitric oxide, for some time previously respired pure nitrous oxide, for the purpose of excluding oxygen altogether from the lungs. His attempt, however, was unsuccessful; for the small quantity of oxygen in the mouth and fauces gave rise to the formation of a sufficient quantity of nitrous acid to cause a convulsive closing of the larynx, as already described, and to produce extensive inflammation of the tongue, mouth, and throat. In reading the account of this experiment, one cannot but feel astonished that it should ever have been instituted by so intelligent an individual. Had he accomplished his intention of respiring the gas, upon suspending the process, air would ' of course have been inhaled, and the nitrous acid thus formed in the lungs by the union of the nitric oxide with atmospherical oxygen, would to a certainty have produced destructive corrosion and inflammation. Notwithstanding the stimulating qualities of nitrous acid, if mixed with a sufficiently large quantity of air, it will pass into the lungs; and it is worthy of remark, that when in such instances injurious consequences follow, pneumonia, not bronchitis, is the disease usually established. Such at least, as Desranges relates, was the nature of the attack experienced by a chemical manufacturer who incautiously inhaled the vapours given off from a carboy of nitric acid accidentally broken : and by some hatters, whose cases are given by Reitz in a German journal, who slept in an apart- ment in which the manufacture of nitrate of mercury was proceeding, a preparation employed in the felting of furs, and which is obtained by the action of nitric acid on mercury. Sulphurous Acid. — This compound, which at common temperatures and pressures is a gas, is the sole product of the combustion of sulphur, and is thus occasionally prepared for the purpose of bleaching silk or woollen goods, of whitening grain during the process by which it is kiln-dried, and with a view of restraining the vinous fermen- tation. Certain varieties also of anthracitous coal which abound in iron pyrites, during their combus- tion frequently evolve this gas; and the same has also frequently occurred in collieries in which some of the beds have either spontaneously or by accident taken fire. Nor is iron pyrites the only sulphuret which leads to accidents of this descrip- tion. In quicksilver mines the native cinnabar often burns for a length of time, filling the galle- ries and shafts with sulphureous vapours, which greatly incommode the workmen, and sometimes make it necessary to suspend their operations until the combustion is extinguished, and the atmosphere within the mine renewed by appropri- ate means of ventilation. Sulphurous acid is a very suffocating gas, and must be largely diluted with atmospherical air before it will pass through the glottis. When applied even in this attenuated state to the mucous membrane which lines the air-passages, it excites in it an extreme degree of irritation, and would no doubt ultimately produce, provided its contact 464 TOXICOLOGY —TRANSFORMATIONS. were continued sufficiently long, a state of active inflammation. Consequences, indeed, of this description have not been observed, for in the great majority of cases, as when it proceeds from the combustion of pyritous coal, it is accompanied by a large pro- portion of carbonic acid, the narcotic influence of which screens and obscures the proper action of the sulphurous gas. An atmosphere, however, of this compound nature would appear to affect the system to a certain extent in a peculiar manner, and to be more injurious than one impregnated with carbonic acid alone. Such inference at least would seem to follow from the narrative given by Surgeon Braid of an accident which occurred at Leadhills in 1817, and which is alluded to by Dr. Christison. Smoke from one of the steam- engines having got into the working, four individu- als who endeavoured to force their way through the impure air were immediately asphyxiated, and several others, who in two hours after descended to the same part of the mine, were very quickly seized with dyspnoea, headach, palpitation, vomit- ing, debility, and pains of the lower extremities. When first seen by Mr. Braid, who visited them while below, the greater number were in a deliri- ous state, as was indicated by the frantic violence of some and the terror manifested by others. Three, in addition to the four who had first descended, perished, but in a few days the rest perfectly re- covered. Similar accidents have since occurred at Leadhills, and, according to Mr. Raid, in a colliery connected with a burning mine in the possession of the Devon Company. The morbid appearances are not given by Sur- geon Braid ; but they were probably essentially the same with those which belong to poisoning by carbonic acid alone. Should such be the case, there can be no doubt that the same line of cura- tive treatment ought in both cases to be pursued. [In concluding the subject of poisons, it may be interesting to specify those that are most frequently taken by the suicide or employed for homicidal purposes. Two statistical articles of this kind we possess—one formed from the returns made by the coroners of England of the number of inquisitions held in the years 1837 and 1838, where death was caused by poison (London Med. Gaz. Nov. 1839) ; and the other by Dr. John B. Beck, of New York, on the deaths from poisoning in the city and county of New York, during the years 1841, 1842 and 1843 ; obtained from the records of the Coroner. (Transactions of the New York State Medical Society, vol. vi. Part 1, p. 72, Albany, 1844.) The number of deaths by poison returned by the coroners of England, in the two years men- tioned above, were 541; of which 282 were males, and 259 females. The poisons taken may be arranged in the following numerical order : Laudanum.....................133 Opium........................ 42 Other preparations.............. 21 ----196 Arsenic..........................185 Sulphuric acid..................... 32 Prussic acid....................... 27 Oxalic acid........................ 19 Corrosive sublimate and mercury...... 15 Mixed or compound poisoning........ 14 Oil of bitter almonds................ 4 Poisonous mushrooms............... 4 Colchicum, nux vomica, (of each 3,) .. 6 Nitric acid, caustic alkali, tartar-emetic, acetate of morphia, strychnia, deadly nightshade, aconite, (of each 2,).... 14 Bichromate of potassa, nitrate of silver, Goulard's extract, sulphate of iron, chloride of tin, hellebore, castor oil seeds, savin, hemlock, cantharides, cayenne pepper, (of each 1,)....... 11 527 Unknown........................ 14 541 From the report of the coroner of the city and county of New York, there were 83 cases of death from poisoning in the years mentioned. Of these 46 were males; 37 females. Of these there were poisoned by Arsenic...........................13 Opium............................8 Laudanum.........................39 Paregoric.......................... 1 Solution of morphia.................3 Corrosive sublimate..................3 Colchicum......................... 1 Sulphuric acid......................2 Tinct. of sanguinaria................ 4 Tartar-emetic ..................... 1 Ardent spirits...................... 1 Gin.............................. 1 Alcohol and laudanum............... I Brandy and laudanum............... 1 Strychnia.......................... 1 Prussic acid........................ 1 Phosphorus........................ 1 Carbonate of Potassa................ 1 83 Of these, there were, suicides..........50 Poisoned by mistake or through igno- rance, &c........................28 Unknown..........................5] James Apjohn. Robley Dunglison. TRANSFORMATIONS.—This term denotes those adventitious or accidental tissues which, when developed in organs, usurp to a greater or less degree the place of the natural structure, so that it appears to be, if it have not actually been, transformed into the new substance. Hence mo- dern pathologists, Dupuytren, Cruveilhier, Andral, and others, regard these accidental tissues as transformations properly so called. We cannot, however, admit that all the accidental tissues de- scribed by them as transformations are strictly so. We have familiar instances of real transformation in the ossification of cartilage where that does not take place as an obvious effect of age, as in the ossification of the laryngeal cartilages from dv* TRANSFORMATIONS. 465 case in the mucous membrane; or of the costal cartilages in phthisis; or in the alteration which an exposed mucous membrane exhibits, and the close resemblance which it assumes to the cuta- neous tissue—analogous, as Beclard has remarked, to what we see in trees, when roots are changed to branches, and vice versa under altered circum- stances. In treating of the various transformations no- ticed by morbid anatomists, we shall follow the order of the natural and healthy development of these tissues, as the same order is frequently ob- served in their morbid changes. We shall there- fore commence with the cellular and terminate with the osseous tissues. 1. Cellular Transformations. — The pro- duction of these tissues is generally due to the effusion and organization of coagulated lymph, and is more particularly observed in the union of serous surfaces under disease, particularly between the surfaces of the pericardium, of the pleura?, and of the peritoneum, sometimes with the total ob- literation of their cavities. These adventitious formations are frequently accompanied by a very considerable number of small granulations, which are converted into a dense and thick cellular tissue, as seen on the pleura, peritoneum, &c. This change is not, strictly speaking, a transformation, since we find the serous membrane itself unchanged, the false membrane being deposited above or below its sur- face. The mucous membranes are much less fre- quently the seat of this change, but the accidental cellular tissue sometimes seen between the globe of the eye and the lid, the occasional obliteration of the nasal and the biliary ducts, of the Eusta- chian and the Fallopian tubes, and sometimes even of the vagina, are due to this organization of lymph. It may, indeed, be looked upon as the germ of, and as affording a matrix for, the other morbid structures, and observed equally with respect to natural growth or morbid formations; it has already been considered among the inflammatory products. 2. Vascular Transformations.—The next step after the deposition of lymph assuming a cel- lular structure, is the generation of blood-vessels by which the part becomes organized ; this gene- ration of vessels being one of the most curious and important points in pathology, and being the offspring of nearly all the morbid products, de- serves a more minute investigation. If we examine by the aid of the microscope a clot of effused lymph, we observe, after a certain period, a series of continuous vesicles forming a kind of canal, or a single canal itself without any vesicular appearance; this is found after a time to contain a fluid which gradually assumes the cha- racter of blood; the canal elongates at each ex- tremity, and vessels are formed laterally, so as to give it the same disposition which we find in the trunk of the vena ports? and its hepatic and abdo- minal ramifications. The vessels by their further development at length inosculate with those of the parent or surrounding tissues. Kaltenbrunner describes the latter vessels as being ruptured and projecting the globules of the blood through the Vol. IV___59 clot, and thus forming the canals of communica- tion as observed in a part under inflammation. The process we have now described, and which has been alluded to by Hunter, Home, and Biier, Laennac, Beclard, Lobstein, Carswell, and several others, is identical with the commencing organi- zation of the embryo. From some of these observations, and from the experiments of Vogel, Home, and Brand, there is reason to believe that the formation of these vesi- cles and tubes is due to the disengagement of carbonic acid gas found in small proportion in the human blood. During its coagulation there is an extrication of this gas, which may be observed to form a number of vesicles or small canals in the clot of blood, and, remaining after its desiccation, may be shown by careful and fine injection. The development of the radicle and plumula of plants has been ascribed to the same mode of formation. Erectile or Vascular Tissue. — This compre- hends those accidental developments of the vascu- lar system recognised under the name df na?vi materni, or the aneurism by anastomosis, or spongy aneurism : these may either be accidental or con- genital. The proper seat of this species of tumour is the skin or its cellular membrane: it is ex- tremely rare in any of the internal organs; its principal situation is on the lips or scalp, and young subjects are more liable to this kind of formation. It consists of a congeries of blood- vessels with a considerable dilatation of the veins, showing sometimes a distinct pulsation followed by a kind of vascular erection, particularly on the approach of the menstrual period, &c. It has some resemblance to the natural erectile tissues of the clitoris and nipple, or the substance of the placenta. When not congenital, it commonly begins with a small spot, which soon acquires a development that might not have been expected from so small a commencement. Its roots occa- sionally shoot into the muscular fibres beneath. It seems to be a disease strictly local, but capable of reproduction while any portion remains, there- fore requiring its total extirpation in order to effect its cure. The character above mentioned will distinguish this kind of tumour from the fungus hematodes of Hey, although unfortunately the structure of which we now treat is known under the latter name by most of the continental writers. The late researches of Recamier authorise us in be- lieving that many hemorrhoidal tumours are of this description, and not from varicose veins; that the transudation from these tumours depends upon their connection with the arterial vessels, and upon their increased action in that part, and not upon any mechanical obstructions in the system of the vena porta? or elsewhere preventing the re- turn of the venous blobd. 3. Membranous Transformations.—False membranes, the origin of which we have pre- viously described, are found accidentally developed in various parts of the body, forming bands of communication and union between the different viscera of the chest and abdomen, becoming at length an integral part of the body, and assuming its vital properties; they are subject, therefore, to the same transformations and diseases as the pa- rent tissue to which they belong. Irritation from 466 TRANSFORMATIONS. the pressure or friction of any foreign body may give rise to the formation of this tissue, as exem- plified in the formation of false articulations after dislocation or fracture; in the capsules formed around any foreign body lodged in the part (as a bullet, for instance), and circumscribing the coagula seen in the brain in apoplexy, which have been therefore designated apoplectic cells. The various serous, synovial, and other cysts, come under this head, although they are not owing to the same cause; the lining membrane of these cysts may undergo the same changes as we ob- serve in other serous membranes from disease: it may become granulated and converted into a false and imperfect mucous membrane, as observed in pulmonary vomica?, &c. The contents of these cysts are still more various than the structure of the lining membranes which produce them, and may contain either the simple constituents of the blood or various morbid products. They some- times contain fluid or coagulated serum, serum itinged with blood, pure blood (or other substances resembling it, but of a darker colour) or its fibrous coagulum, albuminous mucus, fatty or tubercular matter, or a kind of substance resembling concrete albumen, and even several species of other cysts. Two or more of these products may be found in different cells of the same cyst, some of which would appear to be secreted by the lining mem- brane in different stages of its progress, from one kind of secreting surface to another. The more simple contents of these cysts strictly resemble the constituents of the blood, and were probably the offspring of the cyst itself. The surrounding ■ cellular tissue evidently forms the cyst in many instances by its gradual change into a serous sur- face. From their various contents these cysts have been called serous, synovial, melicerous, atheromatous, and steatomatous, &c. The se- rous cysts, that are to be distinguished from true hydatids, are more frequently met with in the kidneys and ovaries than in any other parts. It would be out of place here to enter into the much agitated question of the cystic origin of the various other tumours to be mentioned hereafter. Where the cysts are found to contain pus, and open externally or take a direction to do so, it is found that a serous is gradually changed into a surface highly vascular, granulated, and imperfectly mucous. These accidental membranes resemble the mucous membranes of the ureter, biliary ducts, &c. in not being possessed of either the follicular glands or villi of ordinary mucous surfaces. The lining membrane of the tubercular cavities of the lungs and common fistula? are examples of this. 4. Cutaneous Transformations* — As the mucous surfaces become more exposed to the air, they gradually assume more and more the charac- ter of cutaneous surfaces, of which they are natu- rally a continuation, as observed in prolapsus uteri, &c, but generally without the vascular tissue in which the colouring matter resides. The cica- trices in the skin of the negro, as accidental cuta- neous tissues, are usually white. Fibrous Transformations___The accidental mucous membranes alluded to above, sometimes undergo a metamorphosis into fibrous tissue. These fibrous transformations arc frequently pro- duced at the expense of the cellular membrane, in the form of bands, irregular patches, or of granu- lations ; and tumours of various kinds, simple or lobulated, such as the pancreatic and mammary of Abernethy, often confounded with scirrhus, sometimes connected with organs in apparently a healthy state, and sometimes accompanied with inflammation or atrophy of these organs. The coats of arteries are more frequently the seat of this kind of change than the veins, and observed in the course of nature where these ves- sels are no longer necessary, (as in the umbilical and other vessels of the fcetus), and as the result of disease when vessels are the seat of aneurism or of wounds, and are thus rendered useless. The synovial membrane, the cartilages, and even the muscles may undergo this change, as connected with fractures or dislocations. A mus- cular or a tendinous wound is united by this tissue, and not by its own substance. 5. Cartilaginous Transformations—These are produced at the expense of any of the othei tissues that precede it in the natural order of growth, that is, the cellular or parenchymatous, the serous, fibrous, and fibro-cartilaginous. 1. Hence they are found in the different organs themselves, or under their serous membranes, or in the cellular tissue of organs connecting different textures, or under the inner coats of arteries. 2. They are found in situations where they might be least ex- pected, for instance, in the form of round cartilagi- nous bodies, floating in the interior of veins, par- ticularly of the pelvis, being readily felt or moved about in the vessels by the hand. Hence they have been called phlebolites. They are also found loose and detached in the cavities of joints, where they vary extremely both in number and in size, either with rough or smooth surfaces. 3. In these various situations they may be in the form of small points, broader patches, larger knots, as seen in the serous membranes of the chest and abdomen, and in the serous cysts above alluded to. 4. In the joints as well as in the veins it would seem they are formed in the cellular tissue under the lining membrane; and carrying that membrane be- fore them in their growth, they become attached at length by a mere peduncle, which at last gives way and leaves them floating in the interior. 5. In all these instances their structure is homoge- neous, and, as we find in natural cartilages, they are without a trace of vessels, except in the event of their becoming ossified. 6. Transformations into Osseous Tissue or Ossifications.—In these formations, like the preceding, the same law of successive development is observed, being as strictly followed as in the healthy formation of bone; so that the cellular membranes, fibrous and cartilaginous, may any of them become transmuted into an osseous mat- ter, but differing somewhat in its chemical com- position from healthy bone, in form, structure, and composition. 1. They occur either granular, tubercular, or stalactitic, membraniform, or lamellated. 2. They may be seated in the sub-serous cellular tissues of the natural cavities or of cysts, varying much in extent. 3. Sometimes they are isolated, more fre- quently in company with other morbid products, TRANSFORMATIONS. 467 as seen in the parenchyma of different organs, but these have more the character of earthy deposits than of bone. In structure they are found in radiated fibres, more nearly approaching the texture of natural flat bones. In composition they are very various, both with respect to their earthy or saline ingre- i dients, as well as the proportion of animal matter 1 they contain. It is commonly said all the tissues may become osseous, but, correctly speaking, the cellular mem- brane, fibrous and cartilaginous tissues are, per- haps, the only parts that are convertible into bone, and with respect to the sub-mucous cellular tissue this change is seldom if ever observed. It is well known that as age advances the phos- phate of lime predominates more and more in the system, and when this substance has consolidated the bones, it transports itself to other parts, ac- cording to their greater or less affinity or approach to the osseous structure. The first in the degree of affinity is the carti- laginous tissue; this is a necessary step to arrive at the osseous state, since cartilages become bone by the simple addition of the phosphate or carbon- ate of lime. In old age the cartilages of the ribs and the larynx, and trachea, and sometimes the primary bronchi, are the first to undergo this change; afterwards the symphysis of the pubes, the sutures of the cranium, and the articulation of other bones become ossified, and even the cartilages of many of the joints. A remarkable exception to this was discovered by Harvey, in dissecting the body of Thomas Parr, who died at the age of 142 years. 1. The ossification of the cartilages generally commences by coloured spots in their centres, and open spaces observed in them that are filled with a kind of medullary matter, and the ossification gradually extends to the whole of the cartilage. The fractures or other wounds of cartilages are reunited by means of a ligament or band formed by the thickened perichondrium becoming ossified. This consolidation is a much slower process than that of the formation of bone. 2. Of fibro-cartilage.—The most frequent in- stance of ossification of the fibro-cartilages is that of the cartilages of the ribs, which almost uni- formly undergo that change in advanced life; sometimes in phthisical subjects are ossified even at an early period; and, on the other hand, one or two rare instances are recorded, in which the cartilages were perfectly natural, even though the subjects had reached an unusually protracted pe- riod of life. 3. Of fibrous tissue.—The articular tendons and ligaments sometimes present points of ossification, whilst, on the contrary, the aponeuroses are per- haps never ossified, except the tendinous part of the diaphragm. The dura mater, pericardium, proper tunic of the spleen, the sclerotic of the eye, and the periosteum, are very subject to ossi- fication. The ossification of the fibrous tissues of the heart, and more particularly of the arteries, seems the natural consequence of advancing age as well as of disease. The greater liability of arteries to this change appears connected with their pos- sessing more of a fibrous texture than veins. It commences in the cellular or fibrous tissue of these parts : (see Diseases of the Heart and Arteries.) The valves of the heart very fre- quently participate in this change, and even those of the veins, but more rarely, passing from the fibrous to the cartilaginous and osseous states. 4. Of the muscular tissue of the heart, the left ventricle seems the most subject to ossification, and afterwards the right, and, lastly, the auricles. True ossification of the muscular tissue itself is very rare, nor are the cases on record, with one or two exceptions, fully worthy of credit. Rey- nauldin has described a very remarkable case, in which the ossification was of considerable ex-tent, the parietes of the left ventricle being converted into a petrified mass. (Vid. Andral, vol. i. p. 343, and Journal de Corvisart, Janv. 1816.) 5. Of the nervous system. — Osseous concre- tions have been occasionally met with in the cere- brum and cerebellum, and even in the nerves; the retina itself is said not to have escaped, or at least it is certain that other membranes of the eye have been ossified, particularly the hyaloid mem- brane. 6. Ossifications of the serous membranes have been seen in the pleura and peritoneum and the tunica vaginalis in old hydroceles. The ossification of the synovial membrane is frequently the result of specific inflammation, and generally produces a perfect ankylosis of the joint. With respect to the parenchyma of organs, there is reason to believe that the uterus, testicle, and the thyroid gland are the only seats of true ossi- fication ; in other instances it is the fibrous and not the parenchymatous tissues that become os- sified. It will probably not be considered out of place here to add a few words on the accidental develop- ment of the teeth. The teeth of this kind that we meet with are generally such as are the least removed from their natural state (those we call supernumerary), and are found either in the al- veolar processes, or in their immediate neighbour- hood. Among other cases reported by Lobstein is that of a man fifty years of age, in whom three teeth were found under the tongue, each in its proper cyst; another in whom a tooth in its cyst was found in the orbit of the eye; in a third in- stance a cyst was seen upon the diaphragm, which contained four perfect teeth, besides a quantity of fatty matter and hair. Ruysch describes a fatty tumour of the stomach which contained four molar teeth, and a tumour the size of a child's head, situated upon the lumbar vertebra?, which contained two incisors, two canine, and eight molar teeth: two other incisors were imbedded in a rudiment of the jaw-bone. Connected with parturition several cysts have been observed containing a fatty and Iardaceous matter with portions of bone as well as teeth; these have either preceded or followed the birth. But the ovaries are most frequently the seat of these singular productions; numerous cases in proof of this are on record. In all these instances the laws relative to the ordinary production of teeth have been followed, the capsules having been filled as usual with gelatinous fluid, the crown having preceded the 468 TRANSFUSION. formation of the fangs, as found during the dif- ferent periods of their progress from the capsules to the milk teeth. The other teeth followed the usual order of succession, and the first set have been occasionally followed by those of the second dentition, the molar teeth being as usual the most numerous. Lastly, all that had a form sufficiently definite to be recognised were found to corre- spond exactly with the natural ones of the human species. It might be of some interest to ascertain how far the circumstances connected with some of these osseous deposits correspond with what has been observed relative to the bone-earth or phos- phate deposits in the bladder. These are known (so well pointed out by Dr. Prout) to arise at a more advanced age from debilitating causes acting through the nervous system, and inducing an irritable and cachectic habit of body, with sallow skin, disordered stomach and bowels, pain and distress of mind, and are found to be as much increased by mercury and alkalies, as they are relieved by acids and tonics. Laennec has observed that in the worst cases of chronic pleuritis, attended with sero-sanguine- ous effusions into the chest, ossification of the pleura may be anticipated. We want further data on this subject. In reference to other more remote or immediate causes of these different transformations, it may be stated in a general way that they are not ne- cessarily connected with pre-existing irritation or inflammation, although these states not unfre- quently precede, accompany, or follow such changes of structure. In many instances they are clearly dependent upon pressure or the repeated friction that a part may be subjected to, or upon some further demand made upon the part, or some new function im- posed, for the accomplishment of which a new structure is required. p Duesbury. TRANSFUSION.—The operation of trans- fusing the blood of one animal into the veins of another gave rise, about the middle of the seven- teenth century, to one of the most celebrated con- troversies which has ever agitated the professors of medicine. Transfusion was then supposed to be a recent discovery, and the most extravagant notions concerning its value prevailed. The honour of its invention was contested by the French and English, though passages in the an- cient poets* not obscurely indicate that it was known at a very early period ; and Libavius (in defensione Syntagmatis Arcanorum Chymicorum contra Heningum Schneumannum, Actione 2, p. 8, an. 1615) thus plainly describes the method by which it was performed fifty years previously to the origin of the French and English controversy. " Adsit juvenis robustus, sanus, sanguine spiri- tuoso plenus: adstet exhaustus viribus, tenuis, macilentus, vix animam trahens. Magister artis habeat tubulos argenteos inter se congruentes, aperiat arteriam robusti, et tubulum inserat mu- niatque: mox et a?groti arteriam findat, et tubu- lum fcemineum infigat. Jam duos tubulos sibi - Quid nunc dubitatis inertes ? Stringite ait gladios: veteremque haurite cruorum: Ut repleam vacuas juvenili sanguine venas.—Ovid; mutuo applicet, et ex sano sanguis artcriafis, calens et spirituosus saliet in regrotum, unaque vita? fontem afferet, omnemque languorem pellet." Boyle, in his work on the Usefulness of Experi- mental Philosophy, relates the experiments per- formed by Dr. Christopher Wren, Savillian pro- fessor in the University of Oxford, who transfused medicated infusions into the veins of animals. Dr, Wren's method consisted in putting a ligature on a vein, and having made an opening between the ligature and the heart, in introducing a slender syringe or quill fastened to a bladder, containing the matter to be injected, and then propelling it into the current of the circulation. Dr. Lower afterwards connected the carotid artery of one animal with the jugular vein of another, by means of a tube; and whilst blood was thus transfused, he also permitted it to flow from time to time from a tube inserted in the upper portion of the jugular vein of the animal on which transfusion was prac- tised, that, as plethora was induced, it might be relieved. The operation was continued until the animal from which the arterial blood was taken died at the side of that into which it passed. This experiment Dr. Lower frequently exhibited in the universities, and the dog which had received the fresh charge of blood generally leaped from the table immediately after the operation, shook him- self, and ran away without ailment. Dr. Lower proposed, in a letter addressed to Mr. Boyle, that experiments should be made to ascertain the effects of changing the blood of the old and young, of the sick and healthy, of hot and cold-blooded, and of tame and wild animals. He expected that this exchange of blood would alter the nature of the animals in which it was made. " The most probable use of this experiment," he says, "may be conjectured to be that one animal may live with the blood of another; and, consequently, that those animals that want blood, or have cor- rupt blood, may be supplied from others with a sufficient quantity of such as is good, provided the transfusion be often repeated, by reason of the great expense that is made of the blood." The operation was introduced into Germany by Major, professor of medicine at Kiel; and in 1G66 it was first performed on man in France by Denys and Emmerez. In the succeeding year their example was followed by Lower and King; and in 1668 two Italian physicians, Riva and Manfredi, repeated the experiment. In Paris, transfusion of the blood of animals into the human subject occasioned the most vio- lent excitement. A fierce controversy was directed by Lamartiniere and Peranlt against Denys and Emmerez, which was scarcely extinguished by the decision of the authorities forbidding transfusion. Each party engaged in this dispute committed the most extravagant excesses. The protectors of transfusion laid claim to the discovery of an uni- versal remedy, which would restore health, youth, and vigour, assuage diseases of the mind, calm the most violent dispositions, and might even pro- long life beyond its natural term. Their oppo- nents contended, that not only were these preten- sions false, but that the operation was always dangerous and sometimes fatal. The whole con- troversy degenerated into a contest of the most virulent abuse, in which each party degraded TRANSFUSION. 469 itself in the attempt to overwhelm its rival with reproach, by denouncing it with every ignomi- nious epithet. The whole city was agitated by this contest; it became the topic of the day ; and as it occasioned eager debate in every circle of society, from the courtier to the student of science, some account of experiments which attracted so much notice may not be useless or uninteresting. Denys and Emmerez performed transfusion by connecting the artery of the emittent animal with the vein of the recipient, blood having been gene- rally extracted from the latter. Their first expe- riments were made on brutes. The blood of three calves was transfused into three dogs, with- out any evil consequences; and that of four wethers into a horse twenty-six years old. From these and other experiments on brutes, they pro- ceeded to a moderate transfusion of blood into the human subject Calves or sheep were, from some hypothetical notions concerning the qualities of their blood, preferred for these experiments, and the first trials were said to have been unattended with evil consequences. From the method em- ployed, however, the quantity of blood transfused in each trial could not be correctly ascertained ; and it is probable that the eager character of the inquirers led them to imagine that greater than the actual quantities of blood passed in each ex- periment. Some fatal cases soon occurred. M. Gaspar de Gurie de Montpoly relates one which is well calculated to expose the extraordinary ex- pectations indulged by the promoters of transfu- sion. Baron Bond, son to the first minister of state of the king of Sweden, being affected with a malady which terminated in mortification of the intestines, underwent the operation twice, was re- ported to have been strengthened by it the first time, but died soon after the second operation. Denys performed his first experiments on the human subject on the 15th of June, 1667, on a young man of fifteen or sixteen years of age, who had been much weakened by repeated bleedings. He had become very languid, torpid, and slightly dropsicaL Denys reports that the first operation restored him to perfect health. On the 23d of November, 1667, Dr. Lower and Dr. King made the first trial of the transfu- sion of the blood of animals into the human sub- ject, on a man named Arthur Coyn, at Arundel House, in the presence of many persons of con- sideration and intelligence. Having prepared the carotid artery in a young sheep, a silver pipe was inserted into it, and the blood was permitted to flow freely out into a vessel. In the space of a minute about twelve ounces of sheep's blood escaped, and this fact guided them in judging of the quantity afterwards transfused. A rough ap- proximation, at best, could by this means be at- tained, and even this was vitiated by the subse- quent employment of a smaller tube. The arterial pulse was observed to have been communicated to the vein in the arm of the man during two minutes, and then the experiment terminated. Due allow- ance being made for the diminished size of the pipe, nine or ten ounces of blood were supposed to have been transfused. The man professed to have received great benefit from the operation, and, it is said, no ill consequences ensued. 2 p The crisis of the controversy was brought about by an experiment performed by Denys on an in- sane man. The insanity of this unfortunate per- son was periodical, and was attributed to severe disappointment. He had, during the seven or eight preceding years, alternately recovered and relapsed, but the fit generally lasted eight or ten months. He had been bled in his feet, arms, and head eighteen times, and had bathed forty times. Numerous applications to his forehead had been tried, and potions administered, but the remedies seemed rather to exasperate than to re- lieve his malady. His last relapse had occurred four months before the operation was tried, at a place twelve leagues from Paris. He had been confined, but contrived to escape, and ran away to Paris, in a dark night, quite naked. He was said to have spent these four months without sleep, rending his clothes, running naked about the Marais du Temple, and endeavouring to burn every thing that he could lay his hands upon. M. de Montnor proposed to Denys and Emmerez to subject this man to a trial of transfusion. They encouraged the experiment, saying, that they " could indeed give good assurance for his life, and that the operation was incapable of caus- ing the death of any one, if discreetly managed;" but professing to doubt whether it would relieve his malady. They, however, encouraged the hope that some improvement might be expected from transfusing the blood of a calf, which might, they supposed, from its mildness and freshness, allay the heat and ebullition of the patient's blood. The operation was performed on the 19th of December, before many spectators distinguished by rank and professional eminence. M. Emmerez opened the crural artery of a calf, and made every other necessary preparation in their presence; and after having drawn from the patient about ten ounces of blood, only five or six ounces of the blood of the calf could be introduced, on account of the constrained position of the patient and the pressure of the spectators. The operation was, moreover, discontinued, because the man com- plained that he was about to swoon. Neverthe- less, he supped two hours afterwards, and passed the night in singing, whistling, and other of his usual extravagances. During the following days little change occurred in his symptoms, and the absence of improvement was attributed to the smallness of the quantity of blood transfused. Eager to perceive some advantage, they imagined that his violence had in some degree subsided, and determined to repeat the experiment once or twice. The second trial was made on the Wed- nesday following the first experiment, in the pre- sence of Hourdelot, Lallier, Dodar, de Bourges, and Vaillant, all very able physicians. As he was very thin and meagre, having been wander- ing through the streets in nakedness and hunger for some months, it was thought proper to abstract only two or three ounces of blood from him, and to transfuse a pound. The quantity was much more considerable than in the first experiment, and the effects, which were immediate and very sensible, are thus described : As the blood en- tered his veins, he felt an increase of heat along his arm and in both axillae. His pulse speedily rose, and a copious perspiration covered his face. 470 TRANSFUSION. Immediately afterwards the pulse became very irregular; he complained of pain in his loins, that he was sick, and that he should be suffocated unless released. The pipe was therefore removed from the vein, and during the closing of the wound he vomited freely food which he had taken about half an hour previously. He continued to vomit much, and was frequently purged during the early part of the night, but fell asleep about ten o'clock, and did not awake until the following morning at eight o'clock. Denys reports that he then " showed a surprising calmness and pre- sence of mind." He made a glassful of black urine, confessed himself to M. de Veau with much propriety, and continued drowsy and unwilling to be disturbed during the rest of the day. Next night he slept well. On the following morning he filled another urinal with water as black as that of the preceding day, and bled so freely from the nose that it was considered proper to take two or three small vessels of blood from him. Next day he again confessed himself, and was admitted, at his own request, to the sacrament of M. Bon- net, it being then a time of jubilee. After this day his urine was restored to its natural colour. His wife came to Paris, after having vainly sought him elsewhere. He received her with much joy, and told her all that had occurred to him. He treated her with kindness, and she rejoiced in his manifest improvement. Denys was not imme- diately satisfied with the symptoms of his patient, and from what he observed, thought that a third transfusion would be necessary for his cure; but as he gradually improved, the operation was de- ferred, and sanguine hopes were entertained that he would be gradually restored. He continued in this promising condition two months ; at the expiration of which period, having indulged in various excesses, he was attacked by a violent fever. Denys and Emmerez were im- portuned by his wife to try the operation again; and though they professed to have been perfectly satisfied with the result of the previous trial, were with great difficulty induced to repeat it, and only in consequence of the continued importunity of the wife, who had previously resorted to various remedies without effect. « When the operation was attempted the third time," says the sentence given at the Chastelet, " it was at the instant re- quest of his wife : those that were to perform the operation refusing to do it without the permission of the solicitor-general; some days after that, the operation was begun, but as scarcely any blood issued, either out of the foot or the arm of the pa- tient, a pipe was inserted, which made him cry out, though it appeared not that any blood of the calf passed into his veins; the operation was given over, and the patient died the next night." From other accounts it appears, that as soon as the trans- fusion was commenced, the patient was seized with shivering, and complained of great oppres- sion, crying out, « Arretez :—je me meurs—je 6uffoque." Lamartiniere accuses the transfusers of disregarding their patient's cries, and continu- ing the operation until he died in their hands. Denys, on the other hand, affirms that little or no blood entered the man's veins; accuses the wife of having administered poison to him; says that he demanded that the body should be examined; and the inspection being refused, that he applied to the magistrates to be heard in his own justifica- tion. Meanwhile, the enemies of the operation united, and are said to have offered money to the woman to give evidence against the transfusers, These contests terminated with the sentence of the Chastelet, which decided " that the operation had succeeded well the first two times, and had been undertaken the third, but at the earnest re- quest of the woman, who moreover had ill ob- served the orders of those that made the operation, and who was suspected to have caused the death of her husband," &c.—" And then, that for the future no transfusion should be made upon any human body, but by the approbation of the phy- sicians of the Parisian faculty." This sentence was fatal to the practice of trans- fusing the blood of animals into man. Probably the patient whose death occasioned this declara- tion against the operation, died from the admis- sion of air into his veins, but the experiment had in no case been followed by an auspicious result, though in some it had produced no evil conse- quences. It had been applied to no rational pur- pose, had not been supported by any well-devised experiments, had sometimes been pernicious, and once, at least, fatal. Transfusion was, therefore, proscribed, in France„by a decree of the court of the Chastelet, and elsewhere by public opinion. As the blood of animals had alone been used, every subsequent discovery has tended to support the justice of this decision. The extravagant no- tions entertained by the promoters of this opera- tion, that it could remove disease and prolong life, as they had elevated public expectation to the highest pitch by their promulgation, so, when they were dissipated, they rendered the prostration of its credit greater and more permanent; and no inquiry was made whether there remained not purposes of a more reasonable character to which, under such modifications as science should sug. gest, so powerful an agent might be applied. Dr. Harwood, professor of anatomy in the Uni- versity of Cambridge, attempted to revive the in- quiry concerning the utility of transfusion, by making it the subject of his thesis in 1785. He performed many experiments on animals, which he exhibited in his lectures on comparative ana- tomy in the schools of the University. One of his experiments is thus related in a note to Dr. Hutton's abridgement of the Philosophical Trans- actions. " A dog, of middling size, from whose jugular vein eight ounces of blood had been pre- viously evacuated, was supplied with an equal quantity from the carotid artery of a sheep. Dur- ing the operation, the dog showed evident marks of uneasiness, but was little affected in any other way, till about twenty-four hours after the opera- tion, when he had a shivering fit, succeeded by a considerable degree of heat, thirst, and the usual symptoms of fever, all of which disappeared in the course of the next day, and the dog remained afterwards in perfect health. This experiment being several times repeated, and the quantity of transfused blood being occasionally increased oi diminished, the feverish symptoms were observed to be more or less violent in proportion to the quantity of arterial blood introduced into the vein of the recipient animal. It now occurred to Dr. TRANSFUSION. 471 Harwood, that the uneasiness of the animal dur-1 ing the operation, and the febrile disease with I which he was attacked some hours afterwards, | might probably arise from the preternatural degree i of stimulus occasioned by the introduction of the highly oxygenated arterial blood into the right | side of the heart. The experiment was therefore repeated with this difference, that the blood was ' conducted through the tube from the jugular vein ■ of a sheep, instead of an artery. The animal was perfectly composed during the operation, and did not suffer the slightest inconvenience at any time afterwards." The conclusion to be drawn from these experiments is very different from that proposed by their author. It is very probable that little if any blood was transfused in the second experiment, as the force of the current in the jugu- lar vein is not great. The experiments therefore prove, that though small quantities of blood may be introduced from animals of a different species into the dog, yet, that the operation occasions a constitutional disturbance which has a direct re- lation to the quantity of blood transfused. Ac- cordingly, two pounds of blood having been taken from a large pointer, and three pounds of blood from the jugular vein of another dog introduced, the recipient animal was severely affected with vomiting and purging; afterwards was very drowsy and stupid ; then suffered much from fever, which terminated in a copious evacution of blood, by stool, by urine, and by vomiting. He took no nourishment for three days after the operation ex- cept water, and was more reduced than Dr. Har- wood ever saw an animal in that time. After- wards he gradually regained his health, and lived some years. But another dog, having been bled till he fell into convulsions, and was apparently expiring, on being replenished with blood drawn from the jugular vein of a sheep, began to respire half a minute after the supply was commenced ; and when he had received a quantity of sheep's blood equal to that which he had lost, he leaped from the table and walked home, without experi- encing any apparent inconvenience, either then or at a subsequent period. This experiment was performed before a very crowded meeting at the public schools in the botanic garden at the Uni- versity. It was frequently repeated afterwards, and a variety of animals were subjected to the same experiments with equal success. Dr. Har- wood concludes from these experiments, " that the blood of a herbivorous animal may be substi- tuted for that of a carnivorous animal, and vice versa, without danger or even inconvenience to the animal which receives it." Later experiments show that this conclusion must be regarded with extreme suspicion; but the experiments of Dr. Harwood are so well authenticated, and were, in general, so carefully conducted, that the question (notwithstanding the more recent investigations of Prevost and Dumas) is still open to investiga- tion. The great defect in most of the experiments yet related, is the want of precision in ascertaining the quantity of blood transfused. Concerning the majority, it cannot be confidently affirmed that any considerable quantity was received by the animals subjected to the operation. When the blood of a different species was injected, much temporary disturbance often occurred in the health of the recipient animal, but it generally recovered from a moderate transfusion. This constitutional disturbance must be attributed to a difference in the qualities of the blood of the animals bled, which blood circulating through the various tissues occasioned an unnatural excitement, that gradu- ally subsided as the elements of this foreign fluid were assimilated to the blood of the recipient animal. Little is known concerning the distinguishing qualities of the blood of different animals; and for what is known we are chiefly indebted to the investigations of Prevost and Dumas. (Annales de Chimie et de Physique, vol. xvii. p. 281.) The sources of variety yet discovered chiefly consist in a difference in the proportion of the serum and globules, and in the form of the globules, which are either elliptical or spherical. They are spher- ical in all mammiferous animals. Hewson (Phil. Trans., vol. xliii. p. 230, &c.) even says that they have not an equal diameter in the same animal, and that in some animals these molecules change their size according to the age of the animal. They are elliptical in birds, (Prevost and Dumas), and differ little in size in this class ; a difference which is also only observable in their greater diameter. They are also elliptical in all cold-blooded animals: arterial blood contains a greater quantity of glo- bules than venous, and they are found in a greater relative proportion in the blood of birds than in that of any other class. Then follow the mam- miferous animals, and of these the carnivorous appear to have more than the herbivorous. In general, the number of the globules has a certain relation to the comparative development of the animal heat. In the cold-blooded, fewer globules are found than in the other genera. The investigations of chemists have, however, failed to discover many causes of difference in the blood of animals, which are of a nature so subtle as to elude their researches. The sense of smell detects in the halitus of the blood; the eye dis- cerns in its colour and consistency; and observa- tion concerning the time in which changes occur in it when at rest, and concerning the nature of the changes themselves, expose a sensible differ- ence in its qualities, the source of which no ana- lysis has yet determined. An animal bled until complete syncope is pro- duced, every muscular motion extinct, and the action of the heart and respiration suspended even for some minutes, (as is proved by experiments which will be related,) may be revived by the transfusion of blood from an animal of the same species. But if the blood be transfused from an animal of another species, but whose globules are of the same form, though differing in size, the animal is only imperfectly restored, and can seldom be kept alive more than six days. (Prevost et Dumas, Annales de Chimie et de Physique, loc. cit.) In the animals on which this experiment was tried by Prevost and Dumas, the pulse be- came quicker, the respiration remaining undis- turbed ; but the heat of the body fell with remark- able rapidity when it was not artificially sustained. After the operation the dejections became mucous and bloody, and continued so till death. If blood containing spherical globules be in- 472 TRANSFUSION. jected into a bird, the animal dies as though it were poisoned, with violent symptoms of distress of the nervous system; an effect which occurs, whether the animal have been previously copiously bled or not. The transfusion of sheep's blood, in the experiments of Prevost and Dumas, restored cats and rabbits from excessive hemorrhage which would have occasioned immediate death, but only revived them for a few days. But in ducks a similar injection excited violent and rapid convul- sions, followed by death. [MM. Prevost and Dumas, Dieffenbach and Bischoff, all agree as to the deadly influence of the blood of the mammalia when injected into the veins of birds. See the writer's Human Physio- logy, 5th edit. ii. 167, Philad. 1844.] Physiology and practical medicine are deeply indebted to Dr. Blundell for his ingenious re- searches concerning transfusion. Having, in the course of his extensive obstetrical practice, wit- nessed many distressing deaths after hemorrhage when the flow of blood itself had been arrested, he conceived that by the transfusion of human blood the exhausted energies might be recruited. Before performing this operation on the human subject, he performed a series of experiments on animals, (Blundell's Physiological and Patholo- gical Researches,) which form a most valuable contribution to medical science. From these ex- periments it appears, that after respiration has ceased, and the abdominal muscles are relaxed, little time elapses ere an animal becomes irreco- verable by the process of transfusion. Dr. Blun- dell, however, succeeded in reviving by transfusion a dog which had ceased to respire during five minutes. He also nourished a dog three weeks by the mere transfusion of blood into the external jugular vein, having in this period injected nearly eighty-four ounces of blood from other animals of the same species. Dr. Blundell's experiments on the transfusion of blood from animals of different species are quite consistent with those of Prevost and Dumas. He concludes that the blood of one genus cannot be substituted, indifferently and in large quantities, for that of another. Dr. Haighton had transfused some ounces of the blood of a sheep into a dog, without producing dangerous symptoms; but se- veral dogs, which might have been revived after copious hemorrhage by the injection of blood from animals of their own species, died when conside- rable quantities of human blood were substituted for that lost by bleeding. Dr. Leacock had also previously published similar facts in his thesis in 1817. The experiments of the older transfusers, and those of Dr. Harwood, however, show that small quantities of the blood of animals of some species may be introduced into the circulation of animals of certain other species without occa- sioning death, though the operation is generally followed by unpleasant consequences. From Dr. Blundell's experiments, it also ap- peared that blood might be received into a cup and passed through a syringe without being thereby rendered unfit for the purposes of life, though it appeared to undergo some slight deteri- oration. Practical medicine is thus indebted to Dr. Blundell for reviving the only reasonable ap- plication of the operation of transfusion which has yet been proposed,—viz. to replenish the system in cases of severe and sudden hemorrhage, when the larger vessels have been drained of blood, and death is imminent. These cases most frequently occur in obstetrical practice, when from the partial separation of the placenta, or imperfect contrac- tion of the uterus, and other similar accidents, sudden and violent hemorrhage hurries the patient to the brink of the grave. When great quanti- ties of blood have thus been lost, though the hemorrhage has ceased, the pulse is generally quick and thready, the face becomes Hippocratic, the animal heat is greatly reduced, jactitation su- pervenes, and stimulants and food are frequently rejected ; the patient rallies for a moment, only to sink into deeper collapse, and often little chance of recovery remains. Though in some eitreme cases of this kind the patients have been known to struggle through, they remain long afterwards in a state of miserable weakness, suffering from diarrhoea, dyspepsia, and distressing nervous malt- dies, and the constitution not unfrequently receives a shock which is ultimately fatal. Generally they have no such respite; and, at this last crisis, when life seems about to ebb away, Dr. Blundell pro- poses to replenish the system by transfusing blood from a healthy man. For this purpose Dr. Blundell has invented an apparatus which he has denominated an impellor, consisting of a syringe and tubes, and another called a gravitator. Dr. Blundell has contrived to impel, by this instrument, blood rushing from an artery into the venous system of an animal for twenty or thirty minutes, during which period nearly all the blood in its body must have passed through the apparatus. Yet the animal did not ap- pear to suffer materially in consequence of the ope- ration. Care ought to be taken to prevent the en- trance of air or clots into the instrument or tubes, and the blood ought to remain as short a time as possible in the basin. Performed by a cautious and skilful surgeon, the operation is simple and not attended with great danger, and is certainly justifi- able in cases of extreme collapse from loss of blood- Since Dr. Blundell has revived this operation, it has not unfrequently been performed for the relief of persons sinking from excessive hemor- rhage. Among the earliest and most earnest of its supporters, Messrs. Waller and Doubleday are distinguished, and to their fearless support the degree of credit which the practice has attained is in a great degree to be attributed. Other sur- geons in this country and on the continent have since successfully performed it, and evidence has at least been given that the dangers attending it have been exaggerated. Doubtless it has been applied to some cases which might have recovered without such interference, but every operation in surgery is liable to the same imputation. The examples on record prove, at least, that in cases of extreme exhaustion from hemorrhage, which without such interference might have terminated fatally, the operation has produced a more rapid restoration than could have been attained by ordi- nary means, and that without the production of any materially unpleasant symptoms. Cases, which were apparently in the last stage of a fatal exhaustion, have been revived, when, in the opi- nion of practitioners of skill and experience, they TRANSFUSION. 473 could have been restored by no other agent. The distressing secondary consequences of extreme exhaustion from hemorrhage are said to have been avoided, and a more rapid restoration of health to have occurred, when the operation has been re- sorted to, than could otherwise have been ex- pected, even had the. patient eventually recovered. In the present state of our knowledge, however, transfusion ought never to be performed excepting when all other remedies have failed, and the dan ger has become extremely great. So many hidden dangers are discovered by experience, that pru- dence is one of the chief signs of wisdom, and rashness of ignorance and folly. An astute prac- titioner will be careful also not to expose a prac tice of such moment to unmerited reproach, by employing so powerful an agent in cases in which a favourable termination is, without its aid, still within the legitimate limits of hope. The shock communicated to the nervous system by a great loss of blood is so great, that even if transfusion be performed before sensibility is ex- tinguished and respiration has ceased, it is some- times incapable of restoring the patient. In such extreme collapse the mechanical supply of blood to the large vessels cannot restore the powers of the exhausted brain, and the patient inevitably sinks. If the last agony of life has commenced, there are no facts to prove that in man transfusion can restore its phenomena, though it appears pro- bable, from the testimony of those practitioners whose names are associated with the operation, that when such a state was certainly approaching, patients have been rescued even from its verge. The operation is reported to have been success- ful in cases of extreme exhaustion from hemor- rhage which threatened speedy death. It is, how ever, greatly to be regretted that the reports of some of these cases are not sufficiently minute, and do not always include a description of the whole plan of previous treatment, and of the pro gress of the symptoms. Without such informa tion, the number of those who regard the opera- tion with distrust will not rapidly diminish. Large bleedings, followed by the injection of water into the veins, were proposed by M. Ma- gendie as a remedy for hydrophobia, and this method has been tried both by himself and by M. Dieffenbach of Berlin, but without success. Saline injections in the collapse of cholera seem, even more notoriously than other experiments for the relief of that disease, to have fallen into disrepute, and no other reasonable plan of injection has been proposed. When the operation is decided upon, Dr. Blun- dell is of opinion that a moderate transfusion only is necessary to restore the equilibrium of the trembling balance, which vibrates with the patient's fate. What is the average quantity of blood re- quired for this purpose has not yet been deter- mined by experience ; but, in the absence of such a test, Dr. Blundell's opinion is of the utmost value. He thinks that half a pint or a pint of blood " may be considered a very ample supply," and feels persuaded that many females have sunk from uterine hemorrhage, who would not have died could they have retained the last ten or six- teen ounces of blood which they lost. The syringe and basin invented by Dr. Blun- Vot. IV. —60 2p* dell, and improved by various instrament-makers, (Weiss, Reid and Scott, Laundy) should be used in this operation, care being taken that it is per- fectly clean, air-tight, free from rancid oil, or any other impurity. One or two persons should be ready to supply blood from the arm, and, if pos- sible, individuals not likely to be much disturbed by the operation should be selected for this office. The arm of the patient should then be prepared. The vein into which it is proposed to transfuse the blood, should be laid bare by an incision with a scalpel. When this vessel is fully displayed, a probe should be passed beneath it at the lower portion of the incision. A small opening should then be made with a lancet in the vein imme- diately beyond the probe, of sufficient size to admit the beak of the syringe or the extremity of the tubule which is to be inserted in the opera- tion. The whole apparatus should be warmed to the temperature of the human body, and the various joints should be adjusted with the utmost care, so that the operator, having confidence that no air can be admitted into the apparatus, may proceed with caution, but with decision, when transfusion is commenced. These preliminary arrangements concluded, the arm of the person who is to supply the blood should be bound up, and a free incision having been made into the vein, the blood should be permitted to flow into the brass basin attached to the extremity of the syringe. As the blood accumulates in the basin, it should be absorbed by raising the handle of the syringe, and should then be propelled onwards through the tubule attached to it. When the air has all been expelled from the tubule, and blood unmingled with any bubbles of air issues from it, the beak should be inserted into the vein, and blood should be constantly drawn up from the basin and propelled into the vein, not more than one ounce and a half of blood ever being per- mitted to accumulate in the basin. This process should be steadily performed, with a calm and unembarrassed mind, the operator watching the expression of the countenance and the state of pulse. In the extreme feebleness to which the vital action of all the tissues is reduced in cases of severe hemorrhage, it is desirable that the supply of blood should be very gradual, lest the action of any vital organ should be impaired by a sudden congestion of its tissue. The heart is especially liable to this danger; and Dr. Blundell advises that, if unpleasant symptoms occur after two or three ounces of blood have been transfused, the operation should be suspended for a moment, and a certain interval permitted to elapse, during which the patient may recover. When these symptoms have passed away, the operation may be resumed. A few ounces of blood may be sufficient to save a patient from immediate death, and Dr. Blundell thinks that even four or five ounces may some- times accomplish this ; but if the secondary con- sequences of severe hemorrhage are to be avoided, and a more rapid restoration is desired, these happy results cannot be anticipated with propriety, unless a more copious supply be administered. The syringe to which a tubule and basin are adapted is much to be preferred to the syringe invented by Dr. Blundell, and also to the gravitator. The 474 TUBERCLE. use of these latter instruments will, we think, be entirely superseded by the excellent apparatus which may be procured at several of the instru- ment-makers' establishments. J. P. Kay. TUBERCLE.—The term tubercle is employed to designate a peculiar morbid product, which pa- thologists describe as occurring in various organs in the form of a small round body, said by some to consist at first of a firm grey, somewhat trans- parent substance, which afterwards becomes opaque and of a dull yellow colour, and may then be broken down between the fingers like a morsel of cheese. These characters are said to represent what is called the first period or crude state of tubercle. At a subsequent but indefinite period, the crude tubercle loses its primitive consistence, in virtue, it is believed, of certain inherent pro- perties, by means of which it is converted into a liquid mass of the consistence of cream. It is further stated that this process, which constitutes the period of softening, is perceived always to take place in the centre of the crude tubercle, and proceeds from thence to its circumference. Such is the description of tubercle given by Laennec, (Traite de I'Auscultation Mediate, Paris, 1826), but which is considered by several eminent pa- thologists to be inaccurate. Andral (Precis d'Anatomie Pathologique, Paris, 1829), in par- ticular describes tubercle at its origin as a pale yellow, opaque, small, round body, of various degrees of consistence, and in which no trace of organization can be detected. He denies that the grey semitransparent corpuscule described by Laennec and since by Louis, (Recherches sur la Phthisie, Paris, 1825), constitutes the primitive state of tubercle, or that the process of softening takes place invariably in the centre of this sub- stance. The latter change he ascribes to the ad- mixture of pus secreted by the tissues subjected to the stimulus of tubercle as a foreign body, and not to any change originating in the tubercle itself. Definition of Tubercle.—The following is, we conceive, a correct definition of tubercle, or rather of the tuberculous matter which constitutes the essential anatomical character of those dis- eases to which the term tubercular is now exclu- sively restricted. Tuberculous matter is a pale yellow, or yellowish grey, opaque, unorganized substance, the form, consistence, and composition of which vary with the nature of the part in which it is formed, and the period at which it is examined. To comprehend fully the manner in which the latter circumstances modify the physical characters of tuberculous matter, it will be neces- sary to make a few remarks on the seat of this morbid product in general; a circumstance in the history of tubercle, which, notwithstanding its importance and the frequent anatomical researches of which it has been the object, has not, we be- lieve, been satisfactorily determined. The prevailing opinion among pathologists is, that the seat of tuberculous matter is the cellular tissue of organs;—that it may, however, be formed on secreting surfaces, as in the mucous follicles of the intestines; perhaps in the air-cells and bronchi; the surface of the pleura and perito- neum ; and likewise in false membranes or other accidental and new products; and in the blood itself. Seat of Tuberculous Matter.— 1st. In the mucous system of organs.—Considered in a gene- ral point of view, and in relation to the different tissues, systems, and organs of the body, the mucous system is by far the most frequent seat of tuberculous matter. In whatever organ the formation of the tuberculous matter takes place the mucous system, if constituting a part of that organ, is, in general, either the exclusive seat of this morbid product, or is far more extensively affected with it, than any of the other systems or tissues of the same organ. Thus the mucous system of the respiratory, digestive, biliary, urina- ry, and generative organs, is much more frequently the seat of tuberculous matter than any other sys- tem or tissue which enters into the composition of these organs. It is, however, much more easy to detect the presence of the tuberculous matter in the mucous system of some of these organs than in that of others. Thus it is at once conspicuous in the Fallopian tubes and uterus in consequence of the extent of the mucous membrane which lines their internal surface, and where it may be so abundant as to fill or even distend the cavity of either. Its presence in the ureters and pelvis of the kidney, in the lymphatics and lacteals, is ascertained with the same degree of facility as in the former organs, But in those organs in which the organization of the mucous system is very minute, as the liver, prostate, lymphatic glands, intestinal follicles, and pulmonary vesicles, it is sometimes very difficult to demonstrate the presence of the tuberculous matter in this system. The seat of the tubercu- lous matter in the mucous system of these latter organs is always rendered more palpable and more easy of demonstration, the more slow the progress of the disease, and the more the tuberculous dia- thesis has been developed and free of complication, as under these circumstances the mucous canals or cells into which the tuberculous matter is de- posited, often acquire an increase of bulk which renders them capable of being submitted to accu- rate anatomical inspection.* On the contrary, the difficulty of determining the seat of the tu- berculous matter in the mucous system of the same organs increases with the more rapid pro- gress of the disease, and more especially with the degree of inflammation, as a complication with which it has been accompanied. For when the deposition of the tuberculous matter takes place under such circumstances, for example in the lungs, the minute bronchi and air-cells are ren- dered more or less obscure in consequence of this matter being effused not only into their respective cavities, but also into the cellular tissue which separates their walls the one from the other, Great congestion, the presence of coagulable lymph or pus, induration or softening of the pul- monary tissue, render it either extremely difficult, or impossible to determine satisfactorily the seat which we assign to the tuberculous matter in the lungs. The more minute but more solid texture * Dilatation of the air-cells in emphysema has enabled Dr. Alison to perceive distinctly the tuberculous matter contained in these cells. Edin. Medico-Chir. Trans, vol. i. p. 427. TUBERCLE. 475 of the lungs in children than in adults, and more! particularly than in old persons, renders it also much more difficult to ascertain the seat of the tuberculous matter in these organs in the former than in the latter. We would therefore recom-1 mend those who may be desirous of investigating j this point for themselves, to choose a portion of j lung free from those complications to which we have alluded, from an old person, containing only a small quantity of tuberculous matter, and to submit it to careful dissection by means of fine scissors, and a sharp-pointed scalpel, or lancet. A single bronchus should be selected, and laid bare to its terminal extremity before being opened. A common lens may be useful, but injection and maceration create obstacles rather than afford assistance. 2. On serous surfaces.—The deposition of tuber- culous matter on serous surfaces is often observed, as in the cellular tissue in general, and on the free surface of serous membranes in particular. In those organs into the composition of which the serous and mucous tissues enter, the tuberculous matter may be seen in both at the same time, as in the bronchi and air-cells, and in the interlobular cellular tissue ; but in such cases it will be found, as we have said, to predominate in the former. And in those organs, such as the brain, muscles, bone, &c, in which there is no mucous tissue, we find the tuberculous matter deposited in the cellular tissue which unites their fibres or lamella?. 3. In the blood. — It very rarely occurs that tuberculous matter can be detected in the blood contained within its proper vessels, but it is fre- quently met with in this fluid in the cells of the spleen. This organ is particularly favourable for ascertaining the presence of the tuberculous matter in the blood. Its spongy structure admits of the accumulation of the blood in such quantity, that the tuberculous matter can be seen forming in this fluid at some distance from the walls of the cells in which it is contained. Thus, we can perceive the blood coagulated in one cell, coagu- lated and deprived of its red colouring matter in another, and in a third converted into a mass of solid fibrine containing in its centre a small nodule of tuberculous matter. It also sometimes happens that the blood is effused in consequence of rupture of some of the cells of the spleen, and an oppor- tunity afforded of witnessing its successive or si- multaneous conversion into fibrine and tuberculous matter. Repeated, careful, and minute anatomical re- searches have led us to regard these, the mucous and serous surfaces and the blood, as the exclusive seats of the tuberculous matter. In no instance is this morbid product deposited in the molecular structure of organs. It always makes its appear- ances on free surfaces as a product of secretion. We must, however, again repeat, that although it may form on serous surfaces, its seat of election is the free surface of mucous membranes. There, as into the great emunctuary of the system, it ap- pears to be separated from the blood, and becomes visible to us under a variety of forms afterwards to be described. As a morbid constituent of the blood, we can take no cognizance of the existence of tuberculous matter, otherwise than through the medium of the secretions, or until this fluid has ceased to circulate. Then it is seen to separate from the other constituents, the serum, fibrine, and colouring matter of the blood, and is distin- guished from them by the peculiarity of its physi- cal characters. External Configuration or Form of Tu- berculous Matter. — The round form which this substance is said to present is a purely acci- dental circumstance, is common to many other morbid products, and expresses one only, and per- haps the least important, of the many forms which this matter assumes in the several organs in which it is found. Thus, from the homogeneous nature of the cerebral substance, and the equal resistance which at every point it opposes to the accumula- tion of the tuberculous matter, the form of the latter must be nearly round. Such, also, and for similar reasons, is its form in the cellular tissue. But in other organs the form of this 'morbid pro- duct is as various as that of the parts in which it is contained. It assumes the form of a shut or open globular sack if confined to the secreting sur- face, and of a solid globular tumour of various sizes, if it fills completely the cavity of the air- cells ; and, for similar reasons, it presents in the bronchi a tubular or cylindrical form, having a ramiform distribution, terminated by a cauliflower arrangement in the air-cells. In the mucous fol- licles its form is similar to that which it receives from the air-cells. In the biliary system it has a ramiform distribution, from its being contained in the ducts and their dilated bulbous extremities. In the cavity of the uterus and Fallopian tubes, the infundibula, pelvis, and ureters, it is moulded to the respective forms of each of these parts ; and such also, it is obvious, must be the case when it is contained in the seminiferous ducts and pros- tate gland, in the lacteals, lymphatics, and their glands. On the surface of serous membranes, whether natural or accidental, it may have either a globular or lamellated form, as the secretion in which it originates may have taken place in dis- tinct points, or from a continuous surface of greater or less extent. When the secretion of tuberculous matter takes place in such a manner as to become disseminated throughout a considerable extent of an organ, as when it is said to be infiltrated, it has then no definite form, unless it occupies, for ex- ample, the whole of the lobe of a lung, when it assumes that of the affected lobe. The granular arrangement of the tuberculous matter in the lungs is owing to the accumulation of this morbid pro- duct in a small number of contiguous air-cells; and the lobular character which it sometimes pre- sents in the same organ is produced by its being deposited in the air-cells of a number of lobules, the neighbouring lobules being healthy.* Consistence and Colour of Tuberculous Matter.—Tuberculous matter does not acquire its maximum of consistence until an indefinite period after its formation. It is frequently found in its primitive state in the bronchi, air-cells, biliary ducts, and their dilated extremities, in the cavity of the uterus and Fallopian tubes, &c, that is to •Coloured representations of all these varieties of form, as well as of the seat of tuberculous matter on the free surface of mucous and serous surfaces and in the blood, may be seen in the First Fasciculus of the Illustrations of the Elementary Forms of Disease, now publishing by the author of this article. 476 TUBERCLE. say, resembling a mixture of soft cheese and water, both in colour and consistence. But when much resistance is offered to its accumulation, as in the lymphatic glands, and even sometimes in the air- cells of a whole lobule, it may feel as firm as liver, or even pancreas. These extreme degrees of con- sistence of tuberculous matter depend not only on the resistance which the tissues of these and other parts oppose to its accumulation, but also on the removal of its watery part some time after it has been deposited. Hence it follows that tuberculous matter may, when first perceived, be either very soft or remarkably firm. In the first case it is pultaceous, and feels somewhat granular when rubbed between the fingers; in the second, fria- ble ; and in both it is of a pale yellow colour and opaque. The grey semitransparent substance already alluded to by no means necessarily precedes the formation of the pale yellow or opaque tubercu- lous matter. Thus it is never seen in the cavity of the uterus or Fallopian tubes; in the uterus, pelvis, or infundibula of the kidneys, &c.; nor do we recollect to have seen it in the cerebral sub- stance. We have never met with it in the bron- chi, unless in some of their minute or terminal branches. On the contrary, this semitransparent substance is frequently seen in the air-cells, and on the free surface of serous membranes, particu- larly the peritoneum; and in both it is certainly sometimes observed to precede the formation of opaque tuberculous matter; because, first, a num- ber of cells of the same lobule are seen filled with the former, whilst the remaining cells contain the latter substance; secondly, because on the perito- neum the grey semitransparent substance is gene- rally more abundant than the pale yellow opaque matter; and, thirdly, because a small nucleus of the latter is frequently enclosed in a considerable quantity of the former. The following is the ex- planation which we would offer of these excep- tions to the regular and ordinary formation of the tuberculeus matter. But it is necessary to remark that the formation and manifestation of this mat- ter as a morbid product cannot take place unless the fluid from which it is separated—the blood— has been previously modified. We have already noticed this important fact, and shown that the tuberculous matter is contained in the blood ; and hence it follows, that a healthy secreting surface may separate from this fluid not only the mate- rials of its own peculiar secretion, but also those of tuberculous matter. Such is, indeed, what takes place in the air-cells. The mucous secre- tion of their lining membrane accumulates where it is formed ; but it is not pure mucus ; it contains a quantity of tuberculous matter mixed up with it, which after a certain time is separated, and gene- rally appears in the form of a dull, yellow, opaque point, occupying the centre of the grey, semitrans- parent, and sometimes inspissated mucus. This process of separation of tuberculous matter from secreted fluids is strikingly exemplified in tuber- cular peritonitis. When we examine the perito- neum in this disease, the three following stages of the process are frequently extremely well marked: first, on one portion of this membrane there is seen a quantity of recently effused coagu- lable lymph; secondly, on another we find the same plastic semitransparent substance, partly organized, and including within it, or surrounding a globular mass of tuberculous matter; and, lastlr, on another part, the coagulable lymph is found converted into a vascular or pale cellular tissue, covered by an accidental serous membrane, be- neath which, and external to the peritoneal or original secreting surface, the tuberculous matter is seated, having the form of a round granular eminence, resembling in colour and consistence pale firm cheese. In this as well as in the preced- ing case, we cannot but perceive that the forma- tion of the tuberculous matter originates in a pro- cess similar to that of secretion ; that its separation from the blood may be accompanied with that of natural and also other morbid secretions; and hence the reason why its physical characters are sometimes obscured, particularly in the first stage of its formation. [The minute texture of tubercle has been exa- mined of late by numerous observers, and, amongst others, by Mr. Gulliver, (in Gerber1's Elements of the General and Minute Anatomy of Man and the Mammalia, &c, with Notes, by Mr. Gulliver, Lond. 1842,) who considers it to be composed of granular matter, corpuscles, and cells. The gra- nular matter is seldom or never absent, and is com- posed of infinitely minute particles, and of minute spherules remarkably variable in magnitude, and generally from the ^\6 to the ^^th of an inch in diameter. This is the most prevalent ingredi- ent in tubercle. It is almost always mixed with the other constituents, and frequently forms the entire mass of caseous tubercle. The corpuscles are generally more or less globular, or oval, but are often either very irregular in form, or shapeless. They generally vary from the ^j to the ^jthof an inch in diameter, and are thought by Mr. Gul- liver to be probably imperfect, degenerating, 01 blighted cells and nuclei. The most common size of the cells is from the ^j-ff t0 tne ttVs10 °^ an inch in diameter. They may be frequently re- cognised in greyish miliary tubercles ; but as the tu- bercles increase in size, the well-marked and com- plete cells disappear,—probably, according to Mr. Gulliver, degenerating into the corpuscles and granular matter. From all his histological ob- servations, Mr. Gulliver thinks it highly probable, that tubercle, like the most highly organized tis- sues, has its origin in cells, generally mixed, at a very early period, with granular matter. It seems, however, to differ essentially from the matter of plastic exudations, inasmuch as the cells of the latter not only grow into a higher organization, but increase also in number towards the centre; in other words, plastic matter has an inherent power of multiplying and evolving organic germi) but tubercle has no such power; for it would sp- pear, that its primitive cells can only retrograde and degenerate, since they are wholly destitute of the plastic force, or—to use the language of Dr. C. J. B. Williams, (Principles of Medicine, Amer. edit, by Dr. Clymer, p. 313, Philad. 1844)—are " aplastic," from the beginning. It must be ad- mitted, however, as elsewhere remarked, (Prac- tice of Medicine, 2d edit. i. 342, Philad. 1844,) that the histology of tubercle is by no means set- tled. (For some recent observations on the sub- ject, see Amer. Journ. of the Med. Sciences, Oct TUBERCLE. 477 1844, p. 461, cited indirectly from Gaz. Mid. de Paris.)] Composition of Tuberculous Matter.— The composition of this matter, when examined anatomically and chemically, presents considera- ble variety. We have already said that it is com- posed essentially of a cheesy-looking material, without any trace of organization. It has, in fact, no definite internal arrangement, and the changes of bulk, consistence, and colour which it under- goes, are entirely dependent on the influence of external agents. In some animals, but more par- ticularly in the cow, it is frequently found to pre- sent a concentric lamellated arrangement, which, however, does not belong to the tuberculous mat- ter. It is owing to the presence of albumen, and sometimes even of fibrine, which, as in the cases referred to, are secreted along with the tubercu- lous matter. These substances, intermixed with tuberculous matter, are found lining the bronchial tubes, or filling their entire cavity, and forming masses sometimes an inch in diameter. They often assume the form of globular membranous cysts when they are contained in dilated air-cells, and then have a striking resemblance to hydatids. Or, they present the form of detached tubes or globular membranes, rolled up and mixed with tuberculous matter, like layers of boiled albumen or dead hydatids, a circumstance which has been taken advantage of to support the theory of the hydatic origin of tubercles; a theory which, if not founded in error, must obviously he regarded as extremely limited in its application, since we have shown that tuberculous matter is, in general, formed ab origine on the secreting surface of hol- low organs, where it is often seen as distinctly as if it had bee"n thrown into them from a syringe. [The researches of recent histologists appear to show that—in the language of Gerber, (Op. cit.)— albuminous or organized tubercles can only be produced from exudations abounding in albumen and poor in fibrin ; and such exudations, it need scarcely be said, are more likely to occur from blood which possesses less of the plastic or fibrin- ous material. Hence the important practical indi- cation, in such cases, is to modify the condition of the circulating fluid by improving its plastic or vitalizing power.] The chemical composition of tuberculous mat- ter varies not only at the different periods at which it is examined, but also in different animals, and probably in different organs. In man it is chiefly composed of albumen with various proportions of gelatine and fibrine; and in the cow in particular, it contains a large proportion of the earthy salts, in which the phosphate of lime is said either to predominate or to exist in the same proportion, along with the carbonate of the same earth, as in bones. The following are the proportions of these ingredients found in six grammes (a gramme is nearly equal to 15£ English grains,) of firm tuber- culous matter by M. Hecht of Strasburgh. (Lob- Btein, Traite d'Anatomie Pathologique, t. i. p. 378.) Gramme. Decigrammes. Albumen....... 1 ........ 4 Gelatine........ I ........ 2 Fibrine........ 1 ........ 8 Water (or loss).. 1 ........ 6 One hundred parts of crude pulmonary tubercle were found by Thenard to contain (Andral, Pre- cis d'Anatomie Pathologique, t. i. p. 417)— Animal matter...............98,15 Muriate of soda ") Phosphate of lime C..........1,185 Carbonate of lime j and some traces of oxide of iron. The most important fact connected with the chemical composition of tuberculous matter is, that, either from the nature of its constituent parts, the mode in which they are combined, or the con- ditions in wh^ch they are placed, they are not susceptible of organization, and, consequently, give rise to a morbid compound, capable of under- going no change that is not induced in it by ex- ternal agents. Softening of Tuberculous Matter.—When the process of softening takes place in tuberculous matter, it is clear, from what we have just stated, that it cannot, as Laennec believed, be owing to any change originating in its morbid product. Besides, when speaking of the consistence of this matter, we showed that in many organs it is al- ways in a state of fluidity, and consequently does not require to undergo the change in question, supposed to be necessary to, or at least to facilitate, its expulsion. When the tuberculous matter has become firm, owing to the circumstances already explained, it may, and generally is, at some future period converted into a granular-looking pulp, or grumous fluid of various colours, from the admix- ture of serosity, pus, blood, Arc, which have been effused or secreted by the tissues subjected to its irritating influence. The pus and serosity pervade the substance of the tuberculous matter, loosen, and detach it. These changes are further pro- moted by atrophy, ulceration, or mortification of the surrounding or enclosed tissues, the blood- vessels of which have been compressed or obli- terated by the tuberculous matter. If these changes take place slowly, for example, in the lungs, the tuberculous matter is expectorated in the form of a grey, somewhat puriform-looking fluid; but if they are effected speedily, it is often detached and expelled in masses of various sizes, resembling fragments of cheese that have been left some time in water. The process of softening of tuberculous matter is said always to commence in the centre, not only of masses of this substance, but likewise of every individual portion of it which has assumed the round or tubercular form. This opinion is ex- tremely incorrect; and, indeed, the explanation which we have just given of this process, when it does take place, shows that such cannot be the case. However, there must be some real or ap- parent circumstance connected with this central softening, so minutely described by Laennec, which has not been understood by this ingenious author, nor even by those who disagree with him on this particular point. The facts which we have pointed out regarding the mode of formation, the scat and forms of the tuberculous matter, en- able us now to offer a satisfactory explanation of the appearances which led Laennec and others into error, respecting the commencement of soften- ing of this substance. We have already stated that when tuberculous matter is formed in the 478 TUBERCLE. lungs, it is generally contained in the air-cells and bronchi. If, therefore, this morbid product is con- fined to the surface of either, or has accumulated to such a degree as to leave only a limited central portion of their cavities unoccupied, it is obvious that when they are divided transversely, the fol- lowing appearances will be observed: — 1st, a bronchial tube will resemble a tubercle having a central depression or soft central point, in con- sequence of the centre of the bronchus not being, or never having been occupied by the tuberculous matter, and of its containing at the same time a small quantity of mucous or other secreted fluids; 2d, the air-cells will exhibit a number of similar appearances, or rings of tuberculous matter grouped together, and containing in their centres a quantity of the same kind of fluids. Wrhen the bronchi or air-cells are completely filled with tuberculous matter, no such appearances as those we have just described are observed; and hence the reason why tubercle, in such circumstances, has been said to be still in the state of crudity, or that state which is believed to precede the softening process. Softening begins most frequently at the circum- ference of firm tuberculous matter, or where its presence as a foreign body is most felt by the sur- rounding tissues. Hence the reason why soften- ing is also frequently seen making its appearance in several points of an agglomerated mass of this substance, which has included within it portions of the tissues in which it was formed. This is frequently observed in the lungs, and in cellular tissue in other parts; whereas in the brain, the substance of which has, from the commencement, been separated and pushed outwards by the tuber- culous matter, the softening process begins, and is always most marked on the circumference or sur- face of this morbid product. There is another circumstance which should have been noticed before, and which requires some explanation,—viz. that state of tuberculous mat- ter which is said to be encysted. Encysted tu- bercle has generally been described as existing in the lungs, but the result of numerous researches fully satisfies us that the term encysted, whether applied to pulmonary tubercle or to tubercle in any other organ, is almost always incorrect. In the lungs, encysted tubercle is a deception; the distended walls of the air-cells having, in all pro- bability, in almost every case been taken for cysts. In like manner the extremities of the biliary ducts, when dilated and filled with tuberculous matter, have been described as encysted tubercles; and we have already said that the dilated air-cells, par- ticularly in the cow, which may vary from the size of a pea to that of a cherry, have frequently been regarded as hydatids. We do, however, meet with encysted tuberculous matter, but not until it has undergone important changes which precede its ultimate removal from the organ in which it was formed. We shall explain these and other changes connected with them when treating of the progress and termination of tuber- culous matter. Locality of Tuberculous Matter.—When treating of the seat of tuberculous matter, we en- deavoured to show that this inorganizable sub- stance is separated from the blood after the man- ner of secretion, and is collected on the free sur- face or in the cavities of mucous and serous tis- sues : and farther stated, that in no instance, so far as our researches had extended, had we been able to detect its presence in the molecular struc- ture of any of the elementary tissues of the body, Hence, by the term locality of tuberculous mat- ter, we mean only to imply a certain relationship between the existence of this matter and particu- lar organs, including an enumeration of the organs in which it is found, the relative frequency of its occurrence in different organs and in portions of the same organ, its extent, and the number of organs which it affects. Organs of Respiration. — Of all the organs of the body, those of respiration occupy the first rank, both as regards the extent and the frequency of the tuberculous deposition. The quantity of the matter deposited in the lungs, when compared with their bulk, presents great variety. In some instances only a few minute granular masses of the tuberculous matter are observable, either col- lected together and limited to a circumscribed por- tion of the pulmonary tissue, or separated from one another and scattered throughout the whole of a lobe, of one or both lungs. In other in- stances this matter exists in the form of large con- tiguous masses, and occupies the whole of a lobe, more frequently the greater part of two or three lobes ; and, lastly, it has sometimes been met with in such quantity as to occupy nearly the whole of one lung and a great part of the other. The comparative frequency of the tuberculous deposi- tion in each lung and in their several lobes is a circumstance which, as well as the extent of the disease, is of great value in a diagnostic point of view. We shall, therefore, only observe, in re- gard to this circumstance, that the superior and posterior portion of the upper lobe of either lung, but more frequently of the left, is so generally the situation in which the formation of the tubercu- lous matter first takes place, that its existence elsewhere may be regarded as a secondary occur- rence. From the result of our own experience we should indeed say that there is no exception to this rule when the deposition of the tuberculous matter has not been preceded by local disease, such as circumscribed bronchitis, pneumonia, or pleurisy; for, under such circumstances, any por- tion of the lung may become the primary seat of the deposition. The presence of tuberculous matter in the larynx, in the trachea, and its larger divisions, is not often observed. We have met with it in a few instances in the follicles of these parts, and occasionally in the sacculi laryngis. Organs of digestion. — Of these organs the small intestines are by far the most frequently af- fected with the tuberculous deposition at every period of life. In the great majority of cases it is confined fo the inferior portion of the ileum, more frequently in the glands of Peyer than in those of Brunner. Succeeding to the ileum in the order of frequency is the caput coecum coll, in the situation of the glands of Brunner. The deposition of the tuberculous matter seldom takes place in the other portions of the colon, and still less so in the rectum. It is equally rare in the jejunum, and we have never met with it in the TUBERCLE. 479 duodenum, stomach, cesophagus, pharynx, or mouth. In few cases, even of the most extensive tuberculous diathesis, do we meet with tubercu- lous matter in the liver of the adult; whereas, in children it is by no means rare to find this organ affected, although it seldom contains more than a few small, round, isolated masses scattered through- out its substance. We have never seen this mat- ter in the pancreas of the human species, and only once in that of the monkey. Mons. Lom- bard, however, states that in one hundred cases of tuberculous disease in children which he ex- amined, he found tubercle five times in the pan- creas ; whereas in the same number of cases he did not meet with a single example of tubercle in the liver (Essai sur les Tubercules)—results very different from those to which we have been led by our own dissections. Organs of Circulation.—It is seldom that these organs present any trace of tuberculous matter. In the few cases in which it has been found in the heart, it was contained in the intermuscular cellular tissue ; and we are far from agreeing with Andral in opinion that the plaster-looking matter, or cretaceous substance so often found in the coats of the arteries, is a tuberculous deposit. The occurrence of this matter in the arteries almost exclusively in the aged, or at least seldom to any extent until between the ages of forty and fifty, its occurrence, too, indifferently in those who are, or who are not, affected with tuberculous dis- ease, and frequently in those in none of whose organs any trace of tuberculous matter is observed, are circumstances which, notwithstanding any similarity which may exist between the physical and chemical characters of the two substances, would fully warrant the pathologist in regarding them as essentially different in their nature. Regarding the spleen as an appendage to the vascular system, this organ may be said to be fre- quently affected with the tuberculous deposition in children, but it is seldom so in adults. In the former this organ is also much more extensively affected than in the latter; in some cases we have found it almost entirely filled with tuberculous matter in the form of large masses, but more fre- quently this matter is grouped into small round masses varying from the size of a pin's head to that of hemp-seed, contained in the cells of the organ, and separated from one another by the elastic fibrous tissue of which it is composed. Urinary Organs.—The tuberculous matter is found in the kidneys, infundibula, pelvis, and ureters. It may be so great in quantity as to oc- cupy the entire cavity of these latter parts, and thence pass into the urinary bladder. It is gene- rally small in quantity in the kidneys, and appears in the form of small round masses, scattered throughout their substance. Both kidneys are generally affected when the deposition has taken place in their substance, and only one of them when it is contained in the cavity of the infundi- bula pelvis, or ureter. The kidneys are much more frequently affected with tuberculous diseases in children than in adults. The organs of reproduction furnish us with occasional examples of tuberculous deposition, occurring in the testes, vasa deferentia, vesicula? seminalis, and prostate; in the uterus, Fallopian tubes, ovaries, and mamma?. It seldom occurs in these organs before the age of puberty ; is more often observed in the male than in the female, in the testes and prostate than in the ovaries and Fallopian tubes; more frequently in the testes than in the prostate, in the Fallopian tubes than in the ovaries or uterus, and less frequently in the vesicula? seminales and mamma? than in any of the former organs. The deposition of the tuber- culous matter seldom takes place in both testes at the same time. It generally commences in the epididymis of one of them, and extends from thence to the body of the organ, which in some cases it entirely occupies. The quantity of'the tuberculous matter is also not unfrequently very considerable in the uterus and Fallopian tubes; we have found the cavities of both filled with it, and the Fallopian tubes distended to the size of the finger or thumb. The brain, cerebellum, and spinal cord, are not unfrequently affected with tuberculous deposition. The brain is more frequently affected than the other portions of this system, and sometimes to a considerable extent. In some instances we have seen the tuberculous matter collected in the form of round masses, varying from the size of a pin's head or pea to that of a cherry or hen's-egg, situated in various parts of the brain, sometimes in several parts at the same time, as in the medul- lary substance, in the cortical substance of the con- volutions, and in that of the corpora striata or thalami of one or both hemispheres. It may oc- cupy, also, the medullary and cortical substance of the cerebellum and spinal cord. It may be contained in one or both lobes of the former, and sometimes forms a tumour as large as a hen's-egg. The tuberculous matter has been found to occupy, in the great majority of cases, the cervical portion of the latter. In a few instances only has it been found in the lumbar portion ; in one case we met with it in both portions, forming two tumours, one of which was as large as a pea, the other nearly twice as large, and situated in the central brown substance of the cord. Tuberculous depo- sition is oftener observed in the brain and cere- bellum in infants than in children, and in the latter than in adults. Having already noticed the formation of tuber- culous matter in the absorbent system, we have now chiefly to mention the frequency of its occur- rence in the several divisions of this system, viz. in the glands, lymphatics, and lacteals. The fol- lowing may be regarded as the relative frequency of the occurrence of tuberculous matter in these glands in the order in which they are named:— the bronchial glands, the mesenteric, the cervical, submaxillary, lumbar, axillary, and inguinal. The bronchial and mesenteric are far more frequently and more extensively affected than any of the other glands; the bronchial in both these respects much more so than the mesenteric in children, the mesenteric, perhaps, more frequently than the bronchial in adults. In some cases we find all these glands affected in the same individual, but the quantity of the tuberculous matter is generally greatest in the bronchial or mesenteric; and those of the former, situated at the bifurcation of the trachea, are always most extensively diseased, and frequently contain tuberculous matter when those 480 TUBERCLE. of the large bronchi and neck contain none. Although it is reasonable to conclude, judging from the frequency and extent of the disease in these two latter systems of glands, that they are also those first affected, there are certainly cases in which the tuberculous deposition not only com- mences, but is also most extensive in those glands situated on the external parts of the body, particu- larly in those of the neck. Hence great enlarge- ment of the glands in this situation in scrofulous subjects is not always to be considered as evidence of extensive disease of those of the bronchi or mesentery. The lymphatics and lacteals contain tuberculous matter much less frequently than their respective glands. Indeed, the former are not unfrequently found to contain no tuberculous matter when the latter are filled or even distended with it,—a cir- cumstance which shows that the tuberculous mat- ter is not necessarily absorbed and carried into the glands, but, on the contrary, is originally deposit- ed within them. The deposition of tuberculous matter in the osseous system is a much more rare occurrence than in any of the organs already named. The bodies of the vertebra? and spongy extremities of the long bones are the situations in which this matter is generally observed. The deposition takes place in the cellular structure of the bones in which it accumulates, and often terminates in the pro- duction of caries, circumscribed necrosis, and gene- rally in perforation. In such cases the bony sys- tem is that in which the deposition generally com- mences, and is also that which is chiefly affected. When the tuberculous affection begins in any of the organs already mentioned, and exists in them to a great extent, the bones are seldom affected: at least, in a number of cases of tubercular phthisis, tabes mesenterica, &c, in which we have exam- ined the bones, we have only in a few instances found them to contain tuberculous matter. We have never found tuberculous matter in cartilage, fibrous tissue, serous, synovial, or mu- cous membranes, tendon, or muscle. When tu- berculous matter has been found in the serous, synovial and mucous membranes, the morbid con- dition of these membranes which always accom- panies the presence of the tuberculous matter in them, has not been properly appreciated; for in such cases these membranes, particularly the mu- cous and synovial, are completely disorganized by inflammation, and converted into a reddish brown pulp. It is in this substance that the tuberculous matter is deposited, as may be ascertained by ex- amining the mucous membrane of the intestines, and the synovial membrane of the knee-joint, when in this state of disease. What are called false membranes, or accidental cellular and serous tissue, become affected with the tuberculous deposition in the same manner as the natural tissues of the same class. Considerable variety prevails with regard to the number of organs affected with the tuberculous deposition in the same individual. It is rare to find the tuberculous matter confined to one organ; it generally is present in two or three organs, as the lungs, intestines, and bronchial or mesenteric glands, and is occasionally met with in all the organs which we have before named, in the same individual. The two organs by far the most fre. quently affected in the same individual, are the lungs and small intestines, and after these the small intestines and mesenteric glands. Sometimes the lungs alone are affected ; sometimes the bron- chial glands; and occasionally the peritoneum. It is, perhaps, only in children that the tuberculous affection is confined to the bronchial glands, and in adults that it is limited to the lungs or perito- neum. We have always found tubercles in the lungs when any other organ of the body was af. fected with them in the adult, except in tubercular peritonitis. In this case the peritoneum may be studded with tubercles, and masses of them may also exist in the adhesions which unite together the intestines and other abdominal viscera, and yet not a single tubercle be found in the lungs. We have seen several examples of this kind, and also of extensive tuberculous disease of the bronchial glands in children with complete integrity of the pulmonary organs, and therefore we are disposed to modify somewhat the law laid down by Louis, viz. that tubercles are always found in the lungs when they exist in any other organ of the body, —(Recherches Anatomico-Pathologiques sur la Phthisie, Paris, 1825.)—It is, however, import- ant to observe that the exceptions to this law are not very numerous, and, besides, seem to us to ad- mit of satisfactory explanation; for in every case in which we have found the tuberculous affection confined to the peritoneum, it was obvious that this was the consequence of previous inflammation of that membrane. [MM. Rilliet and Barthez, (Traite Clinique et Pratique des Maladies des Enfanls, iii. 48, Paris, 1843,) give the following table of the comparative frequency of tuberculous deposition in different organs in 314 children : Lungs,...........................265 Bronchial ganglions,................249 Mesenteric ganglions,...............144 Small intestines,...................134 Pleura,...........................109 Spleen,...........................107 Peritoneum,....................... 86 Liver,............................ 71 Large intestine,.................... 60 Meninges of the brain,.............. 52 Kidneys,......................... 49 Brain,............................37 Stomach,.........................21 Pericardium, heart.................. 10] Inflammation of any organ may be followed by the deposition of tuberculous matter in that organ, in the manner in which we have already explained. We have frequent examples of the subcutaneous glands of the neck and submaxillary glands be- coming tuberculous after an acute attack of inflam- mation, although previously they were neither enlarged, indurated, nor otherwise diseased. It is also, in all probability, owing sometimes to a simi- lar cause that one testicle, one kidney, or one long only is affected, whilst the corresponding organ of the opposite side remains in a state of perfect in- tegrity. We remember the case of a female, which is highly illustrative of the present question. The patient was twenty-one years of age, and had pneumonia and bronchitis in consequence of sitting during the greater part of the day between an open TUBERCLE. 481 door and a fire for several weeks in cold weather. The left side was turned towards the door during the whole time, and to this side these two affections were exclusively confined. Nearly the whole of the left lung was found after death to be in the state of tuberculous infiltration, and the mucous membrane of the bronchi of the same lung more or less inflamed, as far up as the bifurcation of the trachea. Here the inflammation stopped abruptly. The right lung was healthy throughout, except at the summit of the upper lobe, where there were only a few crude tubercles, just sufficient to attest the existence of the diathesis rendered so peculiarly manifest in the left lung under the influence of a morbid stimulus. But there are other causes be- sides inflammation which determine the presence of tuberculous matter in particular portions of or- gans, and more frequently in one portion of an organ than in any other. It is, indeed, easy to conceive that a diminution as well as an increase in the function of an organ may favour the depo- sition of tuberculous matter. If, as we have en- deavoured to show, the tuberculous matter is separated from the blood and deposited on the free surface of mucous and serous tissues, may it not follow that the presence of this substance in one portion of an organ, and its absence in another, may depend in great measure on a greater or less degree of facility afforded for its escape! Con- sidered merely in this mechanical point of view, it is not improbable that we may find an explana- tion for the localization of the disease in certain portions of organs, and its absence in others. Thus, if we compare the functional activity, or, rather, the extent of mobility possessed by the inferior and superior lobes of the lungs, we at once per- ceive a most remarkable difference in favour of the former. The inferior lobe ascends and descends throughout a space equal to that which the dia- phragm is capable of contracting, and expands in all directions to the fullest extent of the dilated inferior walls of the thorax. The upper lobe, on the contrary, has hardly any motion of ascent and descent, and a very limited lateral expansion. Under these circumstances, what should be the effect produced on a substance such as tuberculous matter effused into the vesicular structure of these two lobes .' In the former we should naturally expect that there would be a continual tendency towards the expulsion of this matter, whilst in the latter there would be the same tendency to its ac- cumulation. The result of observation is greatly in favour of this explanation ; for, besides the ex- treme frequency of the tuberculous deposition in the upper lobe, and its rare occurrence in the infe- rior lobe of the lung, it derives additional support from the fact that the latter is often the seat of in- flammation, notwithstanding its immunity from tuberculous disease, whilst the former is obnoxious to this latter disease, although, comparatively speaking, seldom the seat of inflammation. May it not be owing to the facility with which the tu- berculous matter escapes, that we do not find it accumulated on the mucous surface of the larger bronchi, or of the trachea, or on that of the intes- tines ? We have no proof that it is not deposited on the free surface of the mucous membrane in these situations. The facts we possess would seem to prove the contrary, since we have shown that Vol. IV. —61 2 a its deposition in the mucous follicles and air-cells in the same organs is a frequent occurrence; and I in these, in all probability, it accumulates because of the same facility not being afforded to its escape as in the other portions of the mucous membrane alluded to. There are various other circumstances which appear to us either to determine the locality or favour the extension of the tuberculous deposition in the manner in which we have endeavoured to explain. A narrow conformation of the chest depending on natural causes, or the influence of those mechanical instruments employed by females to accomplish this change in the inferior half of the thorax, may partly account for the great fre- quency of the disease in both sexes in the former case, and its greater frequency in the female than in the male in the latter case. The influence exercised by all those arts, trades, and professions which limit the free and full expansion of the pulmonary organs, either in consequence of a constrained position of the body, but more particu- larly of the chest, or from the partial and inefficient action of the respiratory muscles, must operate in giving a tendency to the localization of the disease. It is an important fact that, notwithstanding the greater frequency of tuberculous affections in children than in adults, the lungs are much less frequently affected in the former than in the latter. We do not know that this difference can be fully | explained, but we are disposed to believe that it I may in some measure be owing to the much \ greater activity of the lungs in children than in | adults: — we mean that kind of activity of these organs in children which is the consequence of almost continued change of place and position of the body: running, leaping, tumbling, wrestling,, and the numerous little gesticulations in which the upper extremities and muscles of the chest,. shoulders, and neck, are called into play in every possible direction and to the utmost of their extent, demand of necessity the most active co-operation of the lungs; thereby rendering the accumulation of the tuberculous matter in the air-cells and bronchi much less likely to take place in children than in adults, placed as the latter are, both by habit and occupation, in opposite circumstances. Whatever kind of employment or mode of life necessitates or facilitates an active and ample dis- play of the respiratory function, is generally ad- mitted as a powerful means of preventing the oc- currence of tubercular phthisis. We are far from believing that such prophylactic means operate merely on the mechanical principle of the locali- zation of the tuberculous deposition in the lungs, inasmuch as when these organs are placed under the favourable conditions just mentioned, the circu- lation, nutrition, secretion, and innervation of the same organs must acquire a vigour and a harmony of action which will render them the least apt to receive or retain any morbid impression or change whatever. We have no doubt that the physical explanation of the localization of the tuberculous matter in the lungs applies also to the localization of this deposit in other organs, the structure and functions of which do not afford a ready exit to foreign sub- stances contained within them which are not in a state of fluidity. The follicular structure of the intes- 482 TUBERCLE. tines; the bronchial and mesenteric glands; the biliary system of the liver; the infundibula and pelvis of the kidneys ; the Fallopian tubes, and even the cavity of the uterus, present in a greater or less degree, those conditions of structure and function which, under a variety of circumstances, must prevent the free exit of the tuberculous matter when deposited within them. All these facts would go for nothing were we to admit the generally received opinion that the cellular tissue is the almost exclusive seat of the tuberculous deposition ; for if it were so, we should, in accor- dance with the principle which we are now endeavouring to establish, find this tissue much more generally affected with the disease than it is. If the tuberculous matter accumulates on the free surface of mucous canals, it should, a fortiori, do so in the cellular tissue, — a circumstance which rarely occurs except in those organs in which the mucous tissue is present. The much greater frequency of the tuberculous deposition in the spleen in children than in adults seems to admit of explanation on physical princi- ples. We have already given it as our opinion that the presence of the tuberculous matter in this organ at any period of life is the direct conse- quence of its separation from the blood, when this fluid is brought to a state of stagnation, and un- dergoes spontaneous decomposition. This is not a mere assertion, for we sometimes find the quan- tity of the tuberculous matter greater in this organ than in any other organ of the body in children; and in the monkey this is not only the case to a much greater extent, but the masses of this sub- stance contained in the spleen of this animal are even sometimes found softened and large excava- tions formed, whilst in other organs, as the lungs and bronchial glands, no such changes have taken place. From these facts, viz. the greater quantity of the tuberculous matter in the spleen than in other organs in the same animal, and the exist- ence of those changes which follow the presence of this matter in the former and not in the latter, we should conclude that the disease originated in the spleen in such cases, or that it was not the consequence of the absorption of the tuberculous matter from a remote part, and its subsequent deposition in this organ. The localization of the disease, therefore, may be determined by all those causes which give rise to an inordinate accumu- lation of blood in the spleen. The extremely active habits of children, the hurry and violence which they carry into many of their amusements, often produce such a degree of sanguineous en- gorgement of the spleen as to arrest them in the midst of their pursuits, from the severity of the pain which it excites. If under these circum- stances an inordinate accumulation of blood is thus so obviously produced in the spleen in chil- dren, it should be still greater and more frequent in its occurrence in the monkey, from the reckless and almost incessant gambolling in which this creature indulges, even within the narrow limits usually allotted to it during its captivity in this country. Finding this correspondence between the frequency and extent of the tuberculous de- position in the spleen and the state of the circu- lation, or rather the remora of the blood in this organ, we should not expect to find the same re- sults if the conditions to which we attribute the localization of the disease in the present case were absent. Let us, therefore, take a case of an oppo. site kind, in an animal obnoxious to tuberculous disease, as the cow, yet in which the spleen is hardly ever affected, whilst the lungs are often and extensively so. Confined in a dairy, and condemned to an almost absolute state of rest for years, the circulation in this animal is never in a condition to produce congestion of the spleen, and this organ escapes the disease, which in the lungs occurs in all its severity, because of the function of respiration being reduced to its minim- um, and thereby favouring, on the principle al- ready explained, the accumulation of the tuber- culous matter in these organs. We might cite numerous examples of tuberculous diseases suc- ceeding to local accumulations of blood produced mechanically, or originating in a state of debility, such as that which is induced by the sedative effects of cold ; but those already brought forward seem to us to afford sufficient evidence in favour of the position which we laid down at the com- mencement of these remarks,—viz. that there are other causes besides inflammation which deter- mine the presence of tuberculous matter in par- ticular organs, and more frequently in one portion of an' organ than in another. We are, however, desirous that it be clearly understood that the in- fluence of the causes which we have enumerated is confined merely to the localization of the dis- ease, and that a marked distinction should be made between the actual presence of a disease in a tangible form,and that general condition of the economy whence it originates and derives the pe- culiarity of its local characters: for we are as fully warranted in believing that a tendency to the deposition of tuberculous matter, or that the tuberculous diathesis may exist, without the depo- sition of this matter actually having taken place, as we are justified in admitting the existence of a calculous diathesis, without the accompanying formation of calculi in the urinary organs of those persons in whose urine the elements of these foreign bodies are daily observed. It is in this latter affection that the distinction between the localization of, and the tendency to, a disease, is so conspicuous and beneficial in its practical appli- cation ; and if the theory of tuberculous forma- tions which we have endeavoured to elucidate be founded in fact, it may not lie too much to hope, that by means of a more intimate knowledge of organic chemistry, we may yet be able to detect in the mucous secretions or in the blood those changes which indicate the existence of the tu- berculous diathesis, and thus perhaps be led to discover a remedy for the disease before it has effected its localization, and produced changes in themselves incurable. Physical characters of the Tissues in which the Tuberculous Matter is contain* ed.—The tissues in which tuberculous matter U contained may present unaltered all those physical characters which they possess in the physiological state; or they may present those which belong to various pathological states. It is an imports'*1 etiological fact, that the mucous and serous tissue in immediate contact with the tuberculous matter, and even when this matter is considerable in quan* TUBERCLE. 483 tity, may be found of their natural colour, con-! culty of breathing which they occasion by com- sistence, thickness, and of that degree of transpa- j pressing one or both divisions of the trachea, is rcncy which is natural to them. Such is the very great. Such cases puzzle the physician ex- state in which we have often found the mucous tremely; for a clear sound may be elicited by per- membrane of the bronchi and air-cells, when filled ! cussion from every part of the chest, and by with tuberculous matter, and also the lymphatics, means of the stethoscope the respiratory murmur lacteals, and absorbent glands when similarly may be distinctly heard, although feeble, through- affected. It is, however, more common, even at' out the whole of both lungs. Being unable to any early period of the deposition of the tubercu- discover the existence of any organic lesion of lous matter, or at least before it has acquired con- these organs, the nature of the disease and the siderable extent, to find the tissues in contact with cause of the chief symptom equally escape his it or in its neighbourhood, more or less and va- ; researches, and the patient is perhaps treated for riously affected. Dilatation is a frequent occur- asthma or angina pectoris. Judging, therefore, rcnce, and the obvious and necessary consequence from our own experience, and from the fact al- of the accumulation of the tuberculous matter in ready noticed, viz. the great frequency of tubercu- the air-cells and bronchi, follicles of the mucous lous disease of the bronchial glands in children, membrane, Fallopian tubes, absorbents, &c. and . and particularly at the origin of the bronchi, we is sometimes carried to a great extent, without should not hesitate to give it as our opinion, that being accompanied by any other very obvious if a patient, say of four, six, or ten years of age, change. In such cases there is often produced were affected with considerable difficulty of breath- obliteration of the cavities, ducts, or canals in ing without any lesion of the lungs or other ob- which the tuberculous matter is contained, and vious cause capable of giving rise to this modifica- consequently cessation of their respective func- tion of the function of respiration, such a patient tions. It is chiefly to this mechanical effect, the had tuberculous disease of the bronchial glands obliteration of the lacteals, that the emaciation with compression of the bronchi near the bifurca- which accompanies tabes mesenterica is owing, tion of the trachea. When we consider the fre- and also that which accompanies the first and quency and extent of tuberculous disease of the second stages of phthisis pulmonalis, together bronchial glands, it is surprising that the large with the difficulty of breathing in this disease, bronchi are not found more frequently compressed both of which symptoms are often in proportion than they are, and that cases should not have oc- to the extent of the tuberculous deposition in the curred even of their obliteration. The only case lungs. of the latter kind which we have seen (and so There are two forms of phthisis to be here ob- far as we know there is no similar case on record), served; in one of which the chief symptom is occurred in a monkey, which, from its singularity difficulty of breathing, on account of the tubercu- and the possibility of its occurrence in the human lous matter being deposited and collected through- species, deserves to be noticed in this place. A out a multitude of points of the whole of both group of bronchial glands in the form of a round lungs, in the form of small round masses, varying tumour about the size of a chesnut, very firm, and from the size of a pin's head to that of a hemp- entirely composed of tuberculous matter, surround- seed. The pulmonary tissue around these masses ed the left division of the trachea, the walls of soon becomes infiltrated with serosity, thereby in- which were so compressed as to prevent entirely creasing the obstacle to the admission of the air, the passage of the air through it. A section car- and consequently the difficulty of the breathing, ried through the middle of the diseased bronchial In this manner death may be produced by as- j glands exposed the left bronchus lodged in the phyxia in the course of a few weeks, before soft- centre of the tumour formed by these bodies, in ening of the tuberculous matter or ulceration of j the form of a narrow band, the opposite surfaces the pulmonary tissue has taken place. In the i of its mucous membrane being brought into im- i>ther form of phthisis a rapid deposition of the mediate contact. The corresponding lung was tuberculous matter follows an attack of bronchitis greatly diminished in bulk and void of air, such, or pneumonia, and is diffused in such quantity in fact, as it is found in the case of extensive throughout the whole of a lung as to convert it j effusion into the cavity of the pleura. But this into a solid substance resembling boiled liver. ; cavity presented no trace of effusion of any kind, This, we believe, never occurs except in a lung adhesion, or other morbid state. The left side of affected with tuberculous disease previous to the ; the chest was, however, contracted, as it is ob- attack; and if the respiration has not been em- served to be after the cure of chronic pleurisy. barrassed before, it now becomes greatly so, con- ' From the striking resemblance between the phy- linuts rapidly to increase, constitutes the most ' sical signs of a case of this kind, and those to distressing symptom of the disease, and hurries j which the cure of chronic pleurisy gives rise it on its fatal termination. ; would certainly be difficult even for the best prac- A diminution in the capacity of the bronchi is ' tical pathologist to distinguish the one from the also not unfrequently produced by the presence other. The details of this singular case will be of tuberculous matter situated external to these found in an interesting paper on the tuberculous tubes. We have met with several examples in affection of monkeys, (De I'Affection Tubercu- children, of compression of the large bronchi, | leuse des Singes, &c. Archives Generales de which was the obvious cause of the difficult Medecine), by our amiable friend Mons. Rey- breathing observed during life. The tuberculous naud, an able pathologist, to whose kindness we enlargement of the bronchial glands has appeared are indebted for the opportunity of examining to us the sole cause of this change in the capacity this case, and the most of those contained in 'his of the larg'e bronchi, and in some cases the diffi- memoir. 484 TUBERCLE. Thickening and induration of the tissues con-! taining tuberculous matter are changes which occur in consequence of pressure or the deposition of coagulable lymph. The former, when com- ] bined with dilatation, renders parts extremely con- spicuous which in the natural state are just per- , ceived by the naked eye, such as the air-cells, mi- nute bronchi, or mucous follicles, and by means , of which we are enabled to ascertain the precise seat of the tuberculous matter in these parts. But of all the changes which succeed to the presence j of the tuberculous matter, the most important are those which depend either on the degree of irrita- tion or mechanical pressure to which this sub- stance gives rise—such are inflammation, soften- ing, ulceration, mortification, congestion, hemor- rhage. Inflammation is the most frequent and dangerous result of the presence of the tubercu- lous matter, and is probably excited by the me- chanical effects of this substance on the contigu- ous tissues. The occurrence of this pathological state and the degree of its severity do not depend altogether on the quantity of the tuberculous de- posit, although it is generally observed to be most extensive in the vicinity of the largest masses, and certainly always commences in that portion of organs in immediate contact with these masses. This is best seen in the substance of the brain in contact with large tumours formed of tuberculous matter. The cerebral substance becomes red and vascular, softens, and is sometimes converted into a creamy-looking pulp. The inflammatory con- gestion excited by large masses of tuberculous matter in the lungs is a very frequent occurrence; but instead of being succeeded by softening, as in the brain, it is followed by induration or consoli- dation of the pulmonary tissue from the deposition of coagulable lymph into the cellular texture, generally producing that state called grey hepati- zation. Inflammation of the pleura pulmonalis and intestinal peritoneum is often observed as the direct effect of the presence of tuberculous matter situated beneath them, and the redness and vas- cularity is frequently found to be limited to that portion of these membranes directly opposite to the accidental deposit. We allude to these rather minute anatomical details in order to show the connection, as cause and effect, between the pre- sence of tuberculous matter and inflammation of the tissues in which it is found; for it has been asserted that the tuberculous matter does not give rise to inflammation from irritation as a foreign body,—an assertion which is not only contradicted by daily observation, but is at variance with the law, that all inorganizable substances foreign to the part in which they are contained, excite that pathological state which, from its nature, tends either to eliminate such substances, or to protect the injured part from their irritating effects by the formation of a tissue of the lowest grade of organi- zation. It is because we know that tuberculous matter gives rise to inflammation, that we are often able to predict the occurrence of this pathological state at a certain state of the progress of tubercu- lous affections of the brain, lungs, intestines, ab- sorbent glands, &c. to explain some of the most dangerous symptoms and complications of these affections, and not only to combat them on rational principles, but sometimes even to prevent their occurrence. It is also from a knowledge of this circumstance, together with that derived from the locality and comparative frequency of the tuber- culous deposition in different organs, that we at- tribute the occurrence of cephalitis, meningitis, or myelitis, &c. in a phthisical patient, to the pre- sence of this accidental product in the brain, its membranes, or spinal cord. In the present state of our knowledge there is, perhaps, no practical rule regarding the local treatment of tuberculous affections of equal importance with that which is founded on the pathological fact of inflammation being the frequent, if not the necessary conse- quence of the mere mechanical presence of the material by means of which we recognise the local existence of these affections. To protect the in- dividual and the affected organ from the influence of all those agents, internal and external, which tend to create an inordinate degree of excitement, or favour the development of active congestion or inflammation, is the rule to which we allude, and to which there can be no exception in the treat- ment of tuberculous diseases. The frequency of inflammation as the conse- quence of the presence of the tuberculous matter, is sufficiently attested by the increased vascularity, red softening, and ulceration of the mucous folli- cles and mucous membrane of the intestines and bronchi. The inflammation thus produced is not, however, always followed by the same result. In the brain it proves fatal by the general disturbance of the functions of this organ, and before any other change than softening of the cerebral substance has taken place. In the lungs and intestines it gives rise to extensive solutions of continuity termed tubercular excavations and ulcerations, which always occupy those situations in which the tuberculous matter is most frequently deposited in these organs. The direction in which these solutions of continuity are propagated, as their extension in breadth and depth in hollow, and towards the surface in solid, organs; the peculiar characters of these solutions of continuity; ihe nature of their contents, and the pathological con- ditions of the tissues which enter into the compo- sition of their walls, are subjects of great interest in the history of tuberculous affections, but do not require to be discussed in this place. The occurrence of mortification is sometimes the consequence of the inflammation excited by the presence of the tuberculous matter, but more frequently of the pressure which it occasions, the subsequent obliteration of blood-vessels, and the cessation of nutrition in a limited portion of an organ. For an explanation of the manner in which the death of tissues and portions of organs is produced by this cause, we beg leave to refer the reader to the article Mortification. Mechanical congestion and hemorrhage are pathological effects to which the tuberculous mat- ter generally gives rise to a greater or less extent. They are not, however, observed to occasion any sensible modification of function, except when they occur in the lungs. The congestion may be partial or general, according to the situation and the quantity of the tuberculous matter contained in these organs. Should this substance be situated towards the root of the lungs, the congestion may be general, from the trunks of the pulmonary vein* TUBERCLE. 485 being compressed and opposing a free passage to the return of the blood to the heart. When, on the contrary, the tuberculous matter occupies the substance of the lungs at a distance from the large veins, the congestion is seldom general, because the lungs are seldom generally affected with the tuberculous deposition, and consequently the venous circulation is not interrupted to any great extent. This is by far the most frequent form of congestion, and often occurs during the first stage of tubercular phthisis, aggravating the usual symp- toms of the disease, and occasioning hemorrhage from the mucous membrane of the air-cells and bronchi,—a circumstance, the occurrence of which is not unfrequently followed by considerable relief from the oppression and difficulty of the respira- tion occasioned by the congestive state of the lungs. It is to this mechanical state of congestion that we are disposed to ascribe the occurrence of hemoptysis, which so frequently announces the early existence of tubercular phthisis. We are aware that this variety of hemoptysis is believed to be the consequence of active congestion excited by the presence of the tuberculous matter; but we are the more disposed to reject the opinion that irritation is the cause of the hemoptysis, by reason of the state in which we find the blood- vessels in those parts of the lung containing crude tuberculous matter. In these situations the veins are more or less compressed, or several of them are even obliterated, either in consequence of the compression alone, or the formation of fibrinous coagula within these vessels. Such a state of the veins must be followed by greater or less conges- tion and hemorrhage in an organ such as the lungs, in which the vascular system predominates, and the blood is effused on the surface of the mucous membrane from the greater facility af- forded to its escape. Hemorrhage from the mu- cous membrane of the digestive canal seems to us to afford an apt illustration of that which takes place from the mucous membrane of the bronchi, for congestion of the chylopoietic viscera is a necessary consequence of obstructed circulation of the liver, either from disease of the heart or the presence of tumours in the liver itself; and even hemorrhage from the bowels may be the ultimate effect of these causes, although it more frequently follows the sudden obliteration of the trunk of the portal vein or its hepatic branches. It is, how- ever, right to observe that we have had only one opportunity of examining the lungs of a phthisical patient, who died of a concomitant affection, and who had several slight attacks of hemoptysis during the short time he lived in the hospital. The greater part of the upper half of both lungs contained a great number of masses of crude tuber- culous matter, occupying here and there a single lobule, or two, three, or more lobules, between which veins, some of them as large as a crow- quill, were compressed or obliterated. The pul- monary tissue was red, vascular, and cedematous, but not otherwise diseased ; and a great number of the bronchi were filled with fluid and coagulated blood even to their terminal extremities. There is a fatal form of hemorrhage which occurs in phthisis pulmonalis, and also in tuber- culous disease of the bronchial glands, and which takes place in consequence of a communication ' 2d* being formed between a large blood-vessel and a neighbouring bronchus or a tubercular excavation. We have seen a remarkable case of the former kind, in which a communication was formed between the left division of the trachea and that of the pulmonary artery, in consequence of a tu- berculous gland situated between them. The patient, a child, perished in the course of a few minutes. The lungs were healthy. Hemorrhage from excavations is by no means common, from the well-known fact of the vessels which traverse them being seldom pervious. Hemorrhage of this kind may be extremely deceptive, as the quantity of blood effused may be in a great part retained in one or more excavations, and be followed by ex- treme prostration and even death, although only a small quantity of blood has been ejected. Progress and Termination of Tubercu* lous Disease.—In the preceding pages we have endeavoured to describe the more remarkable and important changes which take place in the tissues which are the seat of the tuberculous matter, in those more remote from it, and in this morbid product itself. The length of time required for the production of these changes; the average duration of the disease in both sexes at different periods of life; under the influence of tempera- ment, occupation, locality or climate; of the vari- ous complications to which we have alluded, and of acute and chronic affections of various organs, are subjects which could not be treated with ad- vantage in a general article such as the present, and more especially as the results of researches on these subjects will have a more immediate practi- cal application, by being introduced into the spe- cial divisions of tuberculous disease. For these reasons, also, we would beg leave to refer the reader to other articles for information on the symptoms, diagnosis, prognosis, and treatment of tuberculous disease in its various stages and com- plications. We shall, therefore, confine ourselves to a statement of those facts, more especially those of an anatomical nature, which demonstrate the favourable termination or cure of tuberculous dis- ease, and the necessary dependence or origin of this affection in a morbid condition of the eco- nomy, hereditary or acquired. The cure of a disease is indicated—1st, by the cessation of those symptoms which are peculiar to it, or the restoration of those modifications of function to which its existence gives rise ; 2d, by the disappearance of the local cause of the disease, or by the presence of certain lesions which are known to follow as the consequence of such local cause, and of no other. Such indications of the cure of tuberculous disease have been observed, even in those organs, the lungs, in which this dis- ease was long considered, and still is by most medical men, to prove inevitably fatal. There are few physicians who will hesitate to give their assent to the fact, that scrofulous swellings are curable, even without ulceration or suppuration having taken place in them. Such cases, we are aware, are regarded by some as simple, chronic, inflammatory swellings of the lymphatic glands; but this opinion we by no means believe to be correct, for among the great number of cases which we have examined, we have never found these glands, when generally affected, exempt from the 486 TUBERCLE. presence of tuberculous matter; and even when the cutis is pale (if they are situated beneath this tissue), we have sometimes found them almost completely filled with this morbid product. When, therefore, enlarged glands in a scrofulous patient ultimately disappear, we may almost with cer- tainty conclude that we have witnessed the cure of a tuberculous disease. Tabes mesenterica, which consists in a similar diseased state of the mesenteric glands, has also been known to termin- ate favourably. We are not, however, aware that a single case of this kind has been published by any pathologist, and in which the mesenteric glands were found, at some remote period, to fur- nish anatomical evidence of the previous existence of the disease and of its cure. We ourselves have had only one opportunity of determining these two important points. The patient, who, when a child, was affected with tabes mesenterica, and also swellings of the cervical glands, some of which ulcerated, died, at the age of twenty-one, of metritis, the seventh day after delivery. Several of the mesenteric glands contained a dry cheesy matter, mixed with a chalky-looking substance; others were composed of a cretaceous substance; and a tumour, as large as a hen's-egg, included within the folds of the peritoneum, and which ap- peared to be the remains of a large agglomerated mass of glands, was filled with a substance resem- bling a mixture of putty and dried mortar, moist- ened with a small quantity of serosity. In the neck, and immediately beneath an old cicatrix in the skin, there were two glands which contained in several points of their substance (which was healthy) small masses of hard cretaceous matter. We have also been able to trace the several steps of the same curative process in the bronchial glands, in individuals who had recovered from scrofula and pulmonary phthisis, but who died some time after of other diseases. We have found these glands situated at the bifurcation of the tra- chea, where they are most frequently and most extensively affected with the tuberculous deposi- tion, as well as some way up the trachea, contain- ing a greater or less quantity of a substance re- sembling putty or dry mortar, the consistence of which was sometimes equal to that of sandstone or bone. This substance has generally a stellated form, or presents a number of sharp spicula? pro- jecting from a central mass, which sometimes ex- cite inflammation, ulceration, and hence perfora- tion of the walls of the trachea or bronchial tubes with which they come in contact. A direct com- munication is thus formed between the cavity of these tubes and the diseased glands, through which the cretaceous bodies pass; and they are rejected along with the expectorated fluids. We have seen several examples of cure of tuberculous disease of the bronchial glands, effected in this manner. The patients were generally advanced in years, and had frequently observed the creta- ceous matter in their sputa, portions of which we have examined and found to present all the physical characters of that which was afterwards detected in the bronchial glands. When these diseased glands have evacuated the whole of their contents, they are found atrophiated, and con- verted into a fibrous tissue, which fills up the ex- ternal orifice of the perforated air-tube. The ac- cidental opening now contracts, becomes obliter- ated, and leaves in its place a puckered depres- sion or cicatrix, seen on the internal surface of the air-tube. Similar appearances indicating the removal of the serous and albuminous parts of the tubercu- lous matter, and the condensation of its earthy salts, have frequently been observed in the lungs of persons whose history left no doubt as to their having, at some former period of their lives, been affected with tubercular phthisis. The important fact of the curability of this disease has, in our opinion, been satisfactorily established by Laennec. (Traite de I'Auscultation Mediate, &c. 2d edit. Tome premier, p. 580.) AH the physical signs of tubercular phthisis have been present, even those which indicate the existence of an excava- tion, yet the disease has terminated favourably, and its perfect cure has been demonstrated by the presence of a cicatrix in that portion of the lung in which the excavation had formerly existed. In the few remarks which we think it necessary to make on this important part of our subject, we shall confine ourselves to a short description of those changes which take place in the tuberculous matter, pulmonary tissue, and bronchi, which in- dicate that a cure of tubercular phthisis has taken place. The tuberculous matter, whether con- tained in a bronchial tube, the air-cells, or cellular tissue of the lungs, has assumed a dry, putty-look- ing, chalky, or cretaceous character. If these changes in the tuberculous matter are observed in an excavation, the surrounding pulmonary sub- stance is generally dark-coloured and firm; and if the excavation exists in the course of large bronchial tubes, those situated between the exca- vation and the surface of the lungs are obliterated, whilst those in the opposite direction terminate either in a shut extremity near the excavation, or are continuous with the lining membrane or acci- dental tissue which incloses the altered tubercu- lous matter. The existence of this accidental tissue is an important circumstance as regards the cicatrization of tubercular excavations. It is formed by the effusion of coagulable lymph on the internal surface of the excavation, or into the substance of the contiguous pulmonary tissue; it has, in the former situation, so long as a ready exit is afforded to its secretion, the character of simple mucous tissue ; but at a later period, and especially when the latter condition is wanting, it becomes gradually and successively converted into serous, fibrous, fibro-cartilaginous, and cartilagi- nous tissues. The cartilaginous and the osseous transformations of this accidental tissue, are, how- ever, rare, particularly the latter. It much more frequently presents and retains the fibrous charac- ter, and possesses the property of contracting so as to diminish the bulk of the excavation, and carry with it the pulmonary tissue with which it is connected. The diminution of bulk which ac- companies the removal of the tuberculous matter, and the contraction of the accidental tissue, give rise to a puckering of the lung, which is best seen where the pleura has been forced to follow the retrocession of the pulmonary tissue beneath it, and around what is called the cicatrix : for there sometimes remains only a small globular, oval, or even linear portion of fibrous or fibro-cartilaginous TUBERCLE. 487 tissue in a part of the lung, where, from the ex- tensive puckering of the lung around it, there must have formerly existed an excavation of con- siderable extent. When the tuberculous matter is contained within the bronchi, or a cavity formed by the dila- tation of the air-cells, it does not appear that any accidental tissue is formed during the cure. This matter appears to be gradually removed by expec- toration, if the bronchi remain pervious, or by ab- sorption, if they have become closed ; and then we have the same obliteration of the terminal branches already noticed, and the same puckering of the surrounding tissues. So complete is some- times the cicatrization of a tuberculous excavation, that the fibro-cartilaginous substance by which it is generally recognised has entirely disappeared, and there remains only a small nucleus of creta- ceous matter not larger than a pin's head. Even this, the remains of the tuberculous matter, may also have disappeared; so that, to a common ob- server, the pulmonary tissue appears to be in all respects healthy. But when more narrowly ex- amined, we perceive that there is a central point towards which the course of several blood-vessels and bronchi is directed. These blood-vessels and bronchi can be traced terminating in this point, either by dissecting them with care, injecting, or inflating them. There are many circumstances, into the details of which we cannot enter, which prove most satisfactorily that the obliteration of the blood-vessels and bronchi in such cases is the consequence of the entire removal of a quantity of tuberculous matter, and the cicatrization of the cavity in which it was contained. There are two circumstances of importance connected with the changes which take place in the tuberculous matter, in the blood-vessels and bronchi, during and after the cure of tubercular phthisis, which require to be mentioned, viz. the situation and extent of the lung in which these changes are observed to occur. We formerly stated that the upper and back part of the superior lobe of the lungs is by far the most frequent situation of tuberculous deposition in these organs. It is also in this situation that the changes we have described are generally found. Indeed, it may be said that it is in the upper lobes alone that they are observed, for we have met with them only in two or three cases in the upper part of the middle lobe of the right, and inferior lobe of the left lung; whereas we have seen them so often in the upper lobes, that, not having counted, we shall not venture to name the probable number of cases, lest we should be accused of exaggera- tion. It is a curious fact that we have seen them oftenerin/ewa/ea than in males, in the former of which the greater frequency of tubercular phthisis is also generally admitted. But a much greater difference in the frequency with which these changes occur, is observed relative to age. Thus we have met with them almost exclusively between fifty and seventy, having found them only in two or three cases at an earlier period, and never in children. The extent of the upper lobe of the lung, oc- cupied by cretaceous matter and cicatrices, varies considerably. Most frequently the presence of one or both is confined to a circumscribed portion of the summit or back part of the lobe. Some- times cretaceous matter, and cicatrices in various stages of their progress, occupy the upper half or two-thirds of this lobe, and the bronchial glands may, at the same time, present similar appear- ances. The upper lobe of one lung, or of both lungs, may present these appearances; or, being present in this lobe on one side, they may be ac- companied with tuberculous deposition and exca- vations on the other side. Lastly, cretaceous matter, cicatrices, or both, may be accompanied by the presence of tuberculous matter and excava- tions in the same or neighbouring lobe; thus in- dicating, when the other circumstances already mentioned are taken into account, the dependence of the former on the previous existence of the latter. There must be few practical pathologists who will not consider these anatomical facts as evidence that tubercular phthisis is a curable dis- ease. No objection has been brought forward calculated in the slightest degree to invalidate the conclusion to which we have been led by the re- peated observation of the changes we have de- scribed, viz. that these changes are positive indices of the removal of the material element of the dis- ease, and also of the cure of those lesions of struc- ture to which it gives rise, even at an advanced period of its progress. We feel all the import- ance that would deservedly be attached to an ac- curate statement of the conditions under which the cure of tubercular phthisis was effected, in the great number of cases in which we have found these anatomical proofs of this happy termination of the disease. On this point, however, our in- formation is too vague and incomplete to be of any practical utility ; but we cannot avoid repeat- ing the fact that pathological anatomy has, per- haps, never afforded more conclusive evidence in proof of the curability of a disease than it has in that of tubercular phthisis. [The author has met with several cases in which a cure was accomplished ; and the details of the case of an eminent practitioner of this city, Dr. Parrish, have been published, (A Memoir of the Life and Character of the late Joseph Parrish, M. D., by Dr. G. B. Wood, p. 32, Philad. 1840,) in whose lungs there were marked evidences of cicatrization. He had suffered in early life from manifest symptoms of tubercular phthisis, which had yielded to a regimen to be mentioned here- after. (See Tubercular Phthisis). M. Boudet has affirmed, before the Academic Royale des Sciences, of Paris, that in 197 cases, taken indiscriminately, he found 10 examples of caverns completely cicatrized, without any trace of recent tubercles; and 8 examples of complete or partial cure of caverns coinciding with recent tubercles; and he concludes, that recovery is pos- sible at any period of pulmonary consumption; and that nature generally works the cure. A recent writer, M. Fournet, (Recherches Cli- niques sur I'Auscultation, c\c, Paris, 1839,) whilst he admits that pulmonary phthisis is, in extremely rare cases, susceptible of cure in the stage of exca- vation, considers it to be by no means demonstrated that the cure depends upon complete cicatrization of the excavations; nor is the mode, he maintains, in which the cure is effected yet understood, al- though he thinks it more likely to be by conver- 488 TUBERCLE. sion of the excavations into fistula? than by their closure.] The cure of tuberculous disease in other organs has not been satisfactorily demonstrated. We have, however, as was before done by Jenner, and since by Dr. Baron, frequently produced tubercles in the liver of the rabbit, and afterwards ascer- tained that their complete removal was effected by absorption and excretion. When this is accom- plished by the latter process, which is most com- monly the case, no trace of the disease remains ; and when effected by absorption, we have found the surface of the liver marked by irregular fur- rows or depressions, apparently produced by atrophy of the organ around the seat of the tuberculous matter. The origin of tuberculous affections in a morbid condition of the economy is the last, and perhaps the most important part of our subject, but on which we propose to make only a few observations. In a former part of this article we endeavoured to show the necessity and importance of making a broad distinction between the localization or actual presence of a disease in an organ, and that general morbid condition of the economy in which it originates and derives the peculiarity of its local characters. The absolute necessity of this distinc- tion is obvious as regards all those diseases which consist essentially of two elements—a local or gen- eral modification of function, and the actual pre- sence of an organic lesion or product. The presence of tuberculous matter constitutes the material ele- ment of the disease now under consideration, and like every other morbid product of the same class, has its peculiar and distinctive characters. It is in consequence of the tuberculous matter present- ing these peculiar characters, that we consider it to be a disease sui generis,- and it is also in con- sequence of this niatter being formed in particular organs, as it were indifferently (at least as regards the rapidity and extent of its formation), under every variety of morbid agency to which these organs may have been subjected, that we cannot admit its formation to be the necessary consequence of any of those local causes to which it has been ascribed. Were we to examine these causes in detail, we should find that there is no necessary connection between any of them and the formation of the tuberculous matter. The most obvious of these causes, and that to which by far the greatest importance has been attached, is inflammation, or certain real or imaginary modifications of it. Now it is well known to every practical pathologist, whose mind is not biassed by preconceived theory, that inflammation, whatever may have been its degree, extent, or duration, whatever may have been the tissue or organ affected with it, is not necessarily followed by the formation of tubercu- Jous matter or any other product of a similar kind, inasmuch as in such cases we often meet with no trace of this particular product in the affected organ after death; and, on the contrary, the formation of tuberculous matter is found to take place in I organs, the functions of which were never observed to have been deranged, and in which, after death, none of those lesions could be detected which are known to follow the presence of inflammation. Under such circumstances, it would be absurd to •ascribe the origin of tuberculous matter to inflam- mation—an effect and its cause are always insepa- rable under conditions of a similar kind. Applying this law to the solution of the question before us, we arrive at a fact which of itself is sufficient to overthrow every argument which has been brought forward in support of the local origin of tubercu- lous disease, and which supersedes the necessity of those researches which have been made to prove or disprove such a theory, by determining the re- lative frequency and order of succession of local lesion and functional derangement, observed in the affected organ, viz. that the products of inflam- mation are always the same under conditions of a similar kind. These products are cougulabk lymph or pus,- and that inflammation has always a tendency towards the formation of one or both of these products, is proved by the infinitely more frequent occurrence of these than of any other morbid product, consequent on this physiological j change. We are therefore entitled to conclude that pus and coagulable lymph are the natural products of inflammation, and that, were the con- ditions under which this pathological state takes place always the same, its products would be so also. Hence it follows that when other products than these make their appearance in inflammation, the legitimate conclusion is, that some other mor- bid condition besides inflammation is present, and to which morbid condition alone must be owing the essential and distinctive characters of such products. In what this morbid condition consists we have no means of ascertaining. The etiology of lu- | berculous disease [tuber calosis] furnishes the strongest proofs, independently of those which we have brought forward, of the reality of its exist- ence, and the certainty of its origin under the in- fluence of circumstances which effect a general change, perhaps more especially in the function of nutrition in general, and which is made mani- fest to us by the presence of a particular morbid product, through the medium of secretion. The production of the tuberculous disease in the rabbit, by changing as it were the conditions of its exist- ence, that is to say, by forcing it to live on food not suited to its species, and by confining it in a cold, dark, damp, and narrow habitation, strongly illustrates the influence of those physical agents to which the origin of the disease in the human species is attributed by the generality of patho- logists, and also the general character of the change thereby induced. The production of the disease in the cow takes place under similar circumstances, with the exception of cold ; the treatment of this animal when confined within the walls of a dairy being, in point of fact, an experiment of the same kind, and followed by similar results, but to a far greater extent. Such, also, is the treatment of the monkey in this country, an experiment of a more decided kind, in which animal the extent and fa- tality of the disease is seldom equalled, even in its worst forms, in man. The conditions under which tuberculous disease prevails in the human species, are so similar to those to which we have just alluded, that their influence in its production must be admitted to operate on the same general principle. These remarks apply to the formation of tuberculous dis- ease under circumstances where there is no reason TUBERCULAR PHTHISIS. 489 to suppose that it has been favoured by any origi- I nal tendency or disposition. For more ample information on the acquired origin of this affection, and also on its hereditary origin, we again beg leave to refer the reader to the article Tubercular Phthisis. [See an interesting summary of the existing knowledge on Tubercle and Tubercular Phthisis, in the Retrospective Address delivered in 1843 to the Provincial Medical and Surgical Association by Dr. James Black, an extract from which is given in the American Journal of the Medical Sciences, April 1844, P. 446.] R. Carswell. TUBERCULAR PHTHISIS, or Consump- tion, Phthisis Tuberculosa,Phthisis Pulmo- nalis. The term phthisis (QQiais, from ol. IV. — 66 2t* 522 TUBERCULAR PHTHISIS. In two cases, where the lungs contained only two excavations, the adhesions existed only in the parts corresponding to them. These facts show, in the clearest and most satis- factory manner, the intimate relation of tubercles and adhesions as cause and effect. From the ad- hesions being often confined to the spot corre- sponding to the tuberculous excavations, and from the absence of all appreciable signs of inflamma- tion during their formation, it is probable that the lymph of which they are composed is frequently poured out from the vessels with little or no irri- tative action. If the ulcerative process goes on in the walls of the caverns till the intervening pul- monary tissue and pleura are destroyed, these ad- hesions form the proper walls of the caverns; and if the process advances, they also may be de- stroyed, and the matter point externally. These adhesions sometimes present the appearance of semi-cartilaginous crusts, covering the summit of the lungs, and are in other instances changed into true tuberculous matter; instances of which are recorded by Louis. Perforation of the pleura. — One of the most distressing accidents which occur during the pro- gress of phthisis, is the perforation of the pleura, and the consequent escape of air and purulent matter into its cavity. It is characterized by the suddenness of its occurrence and by the marked symptoms to which it gives rise; such as sudden pain in the side affected, accompanied with great oppression of breathing and extreme anxiety, which are speedily followed by symptoms of acute pleurisy. This accident coincides in character with the perforation of the intestine, the escape of feculent matter into the cavity of the perito- neum, and the violent inflammation of that mem- brane. Perforation of the pleura for the most part oc- curs in the advanced stage of the disease when the patient's strength is greatly reduced, and in gene- ral proves speedily fatal. It has caused death in twenty-four hours; but when the symptoms are less acute, the patient has lived for thirty days, and Dr. Stokes states a case where the patient survived five months. A sudden attack of pain, on one side of a phthisical patient, with much op- pression and anxiety, may be considered as indi- cating the accident. Louis, however, gives a case (xliv.) where oppression and anxiety indicated its occurrence without the presence of pain. The perforation of the pleura may take place under two circumstances:—a tuberculous cavity, which communicates with the pleura by means of the perforation, may or may not communicate with the trachea. In the former case we have generally an effusion of air and fluid into the cavity of the pleura, connected with which there is a peculiar symptom present, called metallic tinkling, or a clear fine sound resembling that produced by the falling of a pin on glass, and heard when the pa- tient speaks. When there is no communication between the tuberculous cavity and the pleura and bronchi, or when there is an effusion of air only or a very small quantity of liquid, it was Laennec's opinion that there could be no metallic tinkling. Dr. Williams, however, has shown this opinion to be erroneous, and that neither commu- nication with the bronchi nor liquid effusion is necessary to the production of the phenomenon:- he considers it to be nothing more than an echo or resonance which any sound or impulse props. gated to a cavity of a certain form may produce, (Rational Exposition of the Physical Signs of the Diseases of the Lungs and Pleura, by C. J. B, Williams, M.D., p. 139-46.) Of eight cases of perforation which occurred to Louis, seven were on the left side,—a circumstance which he attributes to tuberculous disease being more frequent on that side, and often more ad- vanced than on the right. Perforation of the pleura generally takes place over a tuberculous abscess or cavern of considerable extent; yet cases occasionally occur in which a small softened tubercle immediately under the pleura bursts and discharges its contents, and this may be one of a very few contained in the lungs. Andral mentions a case of this kind where the lungs contained only five or six tuber- cles. In such cases, from the small size of the cavity, little or no effusion of pus or other mate takes place, and, consequently, such perforation is not necessarily followed by pleuritis. The accumulation of air in large quantities in the pleura gives rise to the most distressing dys- pnoea, and death generally follows, after a short interval, from impeded respiration. We lately met with one remarkable example of this kind: tuberculous disease was far advanced in the right side, while the left was but little affected; the patient was suddenly attacked with severe dyspnoea after a fit of coughing: the left side was found tympanitic, the intercostal spaces were distended, and no respiratory murmur could be heard. An opening was made between the intercostal space of the fourth and fifth ribs, from which the air rushed out with great violence and with considera- ble relief to the patient Death, however, took place in twelve hours from the commencement of the attack. On opening the body, the right lung was found every where adherent and full of caverns and tubercles; the left was, for the most part, free, but in one part a dense though not extensive adhesion had been partly torn from its attachment, thereby causing a rupture of the pleura over a very small tuberculous cavity, through which ths air passed freely from the bronchi into the chest, and gave rise to all the distressing symptoms. The history of this case affords a good example of the mode in which the perforation is sometime! produced. This patient was seized, a few days before the accident, with acute pain in the left side of the chest, accelerated pulse, and other symptoms indicating an attack of pleuritis, which was combated by antiphlogistic treatment, and had entirely ceased two days before the accession of the dyspnoea. From the weak state of the patient the existence of effusion could not be ascertained during life, but after death it was found to have taken place to the extent of twelve or fifteen ounces ; this, by separating the pulmonary from the costal pleura to a considerable extent, had pro- duced a partial rupture of the cellular tissue which formed the adhesion, and which was elongated between the two pleurae to nearly an inch, and kept in a state of tension. In this state of the parts, the succession of the cough had torn through the pleura at the edge of the adhesion, and thus TUBERCULAR PHTHISIS. 523 produced the perforation. We are indebted to Dr. Carswell for this ingenious explanation of the mode in which effusion may break up adhesions, and occasionally give rise to perforation. In addition to the lesions we have described, which, in a greater or less degree, accompany the progress of the disease, there are others which frequently occur towards the termination of phthi- sis; but, as they also attend the latter stages of other chronic diseases, they cannot be considered as peculiar to it. Inflammation of the lungs and of the pleura and pericardium, are among the most common inter- current diseases which attend and complicate the last stage of phthisis, and not unfrequently cut off in a few days a patient who might otherwise have lived for weeks, or even months. II. Diseases of the Abdominal Viscera.— The mucous membrane of the alimentary canal rarely escapes disease during the progress of tuber- cular consumption. A distinguished pathologist observes, " softening of the mucous membrane of the stomach, hyperaemia of the different portions of the intestines, ulceration of the small intestine, accompanied in many instances by a development of tubercles, are all of such frequent occurrence in phthisis, that they may be fairly considered as constituent parts of the disease." (Andral, op. cit, vol. ii. p. 558.) These morbid states of the ali- mentary canal generally occur subsequently to the pulmonary disease, although they occasionally appear to precede it; at least, it has occurred to us to observe the usual symptoms of diseased bowels some considerable time before those indi- cating disease of the lungs. This also accords with the experience of Andral, who observes that "these lesions may either precede or follow the formation of tubercles in the lungs ; and in some cases the pulmonary and abdominal affections set in together." The stomach, the lower portion of the ileum, and the colon are the parts most fre- quently affected. Morbid conditions of the Stomach.—Inflamma- tion of the mucous membrane of this organ is not an infrequent occurrence during the progress of phthisis. It generally comes on at an advanced stage of the disease; but we have frequently found it present, in a slight degree, at its com- mencement The symptoms are loss of appetite, thirst, epigastric pain, and heat, with nausea, and sometimes vomiting. When the inflammation is situated in the anterior part of the stomach, the pain is generally much increased by pressure. Of one hundred and twenty-three phthisical patients observed by Louis, eight suffered from the present affection, and one only of this number was exempt from pain;—in the others, a sensation of heat and pain, much increased by pressure, was experienced in the epigastrium, and also a degree of resistance which was found to arise from enlargement of the liver. Ulceration of the stomach is accompanied by nearly the same symptoms. It becomes a matter of some moment, in a practical point of view, to distinguish the vomit- ing which occurs in the course of phthisis, (and which is commonly attributed to the cough,) from that which depends on a diseased state of the sto- mach. A little attention to the concomitant symptoms will generally enable us to make this distinction. When the vomiting is simply the consequence of the cough, we find no epigastric tenderness or pain; the appetite remains, and the digestion, in the intervals of coughing, goes on well ; in this case it frequently occurs at the commencement of the disease. When, on the other hand, it is the result of a morbid condition of the stomach, it is generally preceded for some length of time by loss of appetite and pain in the region of that organ—symptoms which continue and usually increase during the course of phthisis: the period, also, at which vomiting first occurs in this case is generally late in the disease. We occasionally meet with another morbid con- dition of the stomach in tuberculous subjects, the nature of which is not fully understood ; its chief symptoms are vomiting and pain. Louis con- siders it dependent upon softening and wasting of the mucous membrane; but the experiments of Dr. Carswell have clearly demonstrated that such softening of the coats of the stomach is a post-mortem change produced by the action of the gastric fluid : the red softening is essentially different in its nature, and is the result of inflam- mation. But, whatever be the pathology of the gastric affection at present under consideration, it is very distressing and difficult to remedy. Ac- cording to the observations of Louis, it occurs from two to six months before death ; but we have known it to exist for a much longer period, and even long before any symptom of pulmonary dis- ease presented itself. In one young lady we saw it exist for several years ; and it was only within a few months of death that the pulmonary disease became evident. The extent to which the latter was found after death, showed how long it had remained latent, masked by the deranged condition of the stomach. We have another case at present under our care : this patient has retained very little on the stomach for the last eighteen months; —a few table-spoonfuls of some fluid being gene- rally the extent of her nourishment for a whole day, and this is more frequently rejected than re- tained :—the emaciation, as may be imagined, is extreme. This patient is also a young female, twenty-five years of age, whose brother died lately of tuberculous consumption; she presents all the external characters of tuberculous cachexia, with a short dry cough, and will most probably die of phthisis at no very distant period, if the affection of the stomach do not prove fatal previ- ously. The pain in the epigastric region is not great in this case, even on pressure; but in some it is so severe, and so entirely absorbs the patient's feelings and attention, that without minute obser- vation on the part of the medical attendant, the pulmonary disease will escape notice. In general the stomach can digest very little during this state, and then only the lightest nourishment Occa- sionally the appetite returns for a time, but in other cases the mildest fluids are injected. This occurred in the patient last alluded to ; during a residence in the country for several months in the summer, the stomach retained and digested light food well; and she is, at this moment, able to re- tain more than she has for many months, although this only amounts to about a spoonful of fluid food two or three times a day. Enlargement of the Stomach.—An increase in 524 TUBERCULAR PHTHISIS. the size of the stomach has evidently an intimate connection with phthisis, as Louis found it in more than two-thirds of the cases which he ex- amined ; while in two hundred and thirty subjects who died of other diseases, only two examples of this enlargement presented themselves. It some- times goes on till the organ acquires double or treble its usual volume, and descends so far into the abdomen as to be on a level with the spine of the pubis. The other lesions observed in this organ do not appear to be necessarily connected with phthisis, though their occurrence in the course of other chronic disorders is far less frequent. They con- sist of a thickened, reddened, mammellated, or ulcerated state of its mucous membrane. The same lesions occur in the mucous mem- branes of the small and large intestines; but in these they appear to have a more intimate relation to phthisis, inasmuch as they depend on the de- velopment of tuberculous matter in the mucous follicles ; where it is deposited in its usual forms, and after a time excites inflammation and ulcera- tion of the surrounding tissues. Ulceration of the Intestines. — Ulcers of the intestines, when first formed, are always small, and, from the locality of the mucous follicles, occur most frequently in the lower portion of the ileum, and chiefly in that part opposite its attach- ment to the mesentery, where the glandulae agmi- natae are most numerous. In the large intestines the ulcerations occur irregularly. When the Ulcerative process is once established, it often ex- tends to the surrounding tissues; the neighbour- ing ulcers coalesce, and the mucous membrane is frequently undermined or destroyed to a great ex- tent. Louis found them spreading to the length of nine inches, and running quite round the colon. Perforation of the intestine occasionally takes place, although it is a very rare occurrence. The period at which tubercles are developed in the intestinal glands during the progress of phthi- sis, varies in different cases : in some they occur early in the disease, giving indications of their presence at the commencement of the pulmonary affection, and in a few rare cases, even at an ear- lier period ; but more generally they appear when the disease of the lungs is considerably advanced. In a small proportion of cases the intestines are not affected. The more early that ulceration of the intestines occurs, the more rapid in general is the progress of the disease, because it is usually accompanied with intractable diarrhoea, which speedily wastes both the flesh and strength of the patient Louis found tuberculous ulceration in the small intes- tines in five-sixths of the cases which he exam- ined, and noticed it almost as frequently in the large intestines, the mucous membrane of which often presented other diseased appearances, being red, thickened, or softened in one-half of the cases; so that, of the whole number of phthisical cases examined by this physician, the large intes- tines were found in a healthy state through their whole extent in three instances only. The mesenteric glands are very often found in a tuberculous condition in phthisical subjects, and more especially in children. Papavoine found them so in one-half of the cases of tuberculous diseases of children ; while in the cases of adults. examined by Louis, they were tuberculous in something less than one-fourth only. Disease of the Liver.—The liver, in phthisis, presents one remarkable alteration of structure which consists in an equable transformation of its substance into a fatty matter. This change ap- pears to take place simultaneously over the whole organ, and to be intimately connected with the development of tubercles in other organs; for of forty-nine cases of this degeneration observed by Louis, forty-seven were phthisical; and of two hundred and thirty subjects who died from other diseases, it occurred in nine only, seven of whom had a few tubercles in the lungs. When far ad- vanced, it soiled the scalpel and hands like com- mon fat:—when the change existed in a less de- gree, its presence was detected by the impregnation of paper with fat, on a portion of the organ being enclosed in it and exposed to heat. This degene- ration of the liver is marked by a pale fawn co- lour, diminished consistence, and increased bulk of the organ, which sometimes enlarges to double its usual size. The rapidity with which it takes place seems to depend almost entirely on that of the development of phthisis ; for it has been found when this has run through all its stages in fifty days. Its occurrence is modified neither by the patient's age nor strength of constitution; sex, however, has a decided influence, since of the forty-nine cases observed by Louis, only ten were males. The causes which conduce to this morbid change are very obscure: affections of the duode- num, which Broussais supposed to affect it, have been found by Louis to have no influence in its production. It is yet more remarkable that it is accompanied by no appreciable symptom except increase of bulk, and that the functions of the organ seem to go on undisturbed. The liver sel- dom presents other morbid alterations in phthisis: however, like all the other organs, it occasionally contains tubercles, particularly in children. A diseased state of the liver appears more frequent in some localities than in others. According to Desault, it is a very common occurrence at Bor- deaux ; so much so, indeed, that he scarcely met with a case of phthisis in which he did not find this organ enlarged during life. This is certainly not the case in this country ; for, although a con- gested state of the liver is a frequent attendant on phthisis, and often long precedes it, still we believe that it does not often proceed to such an extent as to form, during life, a perceptible tumour in the abdomen. Fistula in Ano.—This affection has been fre- quently found in consumptive patients, and has been supposed to be connected with the disease, Although we have often met with it, we have been unable to trace any connection between it and phthisis, further than its probable dependence on abdominal venous plethora, which so often precedes pulmonary consumption. Andral states that the result of his observations does not con- firm the opinion of a connection between the two diseases; [and M. Louis accords with him; yet Dr. Morton, (Illustrations of Pulmonary Con- sumption, p. 72, Philad. 1834,) states, that he has met with four cases, in three of which fistula su- pervened so directly on the pulmonary 6ymptomi TUBERCULAR PHTHISIS, 525 and so kept pace with them, that he could scarcely consider its presence as an accidental coinci- dence.] It occasionally happens that death occurs sud- denly in the course of phthisis. When this ter- mination takes place, it is almost always in the advanced state of the disease, and in persons greatly reduced. The cause is often unknown. The patient does not appear worse than he has been for some days, when, suddenly, while sitting up, he falls back and expires. Examination after death does not always enable us to explain this sudden cessation of life. Louis gives two cases, in one of which oedema of the glottis appeared to be the cause; and in the other, a rapid hepati- zation of a large portion of the lungs; but neither of these pathological lesions could account for the cases to which we allude. Among the causes of sudden death during the progress of phthisis, pulmonary hemorrhage may also be mentioned, as it is occasionally so profuse as to prove fatal in a few minutes. In such cases the blood flows from a considerable artery, the coats of which have been destroyed by ulceration in the progress of the tuberculous disease. We cannot conclude this section without ex- pressing our obligations to M. Louis, the able author of the Traite de la Phthisie. We are so much indebted to this zealous and indefatiga- ble physician for all our more precise knowledge of the pathological anatomy of phthisis, that we think it due to him to acknowledge the great as- sistance we have derived from his researches in the composition of this article; and we beg to refer our readers for more full information to his treatise, as they will not only find therein the best account of the morbid anatomy and symptoms of the disease, but will moreover learn to admire, and perhaps to imitate, the industry, the zeal, and the scrupulous veracity of this most accurate and philosophical observer. Sect. VIII. — The Statistical Histokt of Phthisis. The influence of age, sex, race, climate, &c, in disposing to tuberculous disease, and the more decided effects of various occupations and modes of living in the production of phthisis, form a very important part of our subject. It is, however, to be regretted that the materials which have hitherto been collected are still too scanty to enable us to enter so fully into this question as its merits demand. But we trust that a subject of so much interest and utility will be soon elucidated by the more extended co-operation of numerous medical observers. L—Of the prevalence of Tuberculous Dis- eases at the different periods of life. Tubercles have been found in various organs at every age, and examples are not wanting of their presence in the fcetus, in which they usually occur in the form of transparent granulations, although they have been also found in the state of suppuration. Chaussier discovered miliary tubercles in the lungs of a fcetus which died at birth, and an encysted abscess, or rather vomica, in the lungs of another. (Proces Verbale de la distribution des pris aux eleves sages-femmes de I'Hospice de la Maternite, an. 1812, p. 62.) Oehler found the mesenteric glands swollen, hard, and of I a fatty consistence, not only in the foetuses of scrofulous mothers, but of others who did not present any appearance of scrofula. (Desormeaux, Diet de Medecine, vol. xv. art. GZuf, p. 402.) Husson reported to the Paris Academy of Medi- cine the dissection of two infants, one eight days old, and the other still-born at the seventh month of pregnancy, both of whom had tubercles in a state of suppuration ; the former in the liver, the latter in the lungs. (Ibid. p. 402.) Billiard, who examined a great many infants at the Found- ling Hospital of Paris, found tuberculous granula- tions of the peritoneum in an infant who died four days after birth; and in two still-born children he met with evident tuberculous disease of the me- senteric glands. (Traite des Maladies des En- fans nouveaux-nes et a la mamelle, p. 648.) Although many other cases of the presence of tubercles in the foetal state might be cited, still the fact that Velpeau and Breschet never observed them in the course of their researches, (Thesis, p. 10,) and that M. Guizot did not find a single example of tuberculous disease in four hundred new-born children whom he examined, is sufficient to show that its occurrence in the fcetus is com- paratively rare. (Journal des Progres, loc. cit.) During the progress of infancy, tuberculous disease is frequently developed. Billiard found tuberculous granulations of the spleen and liver in five infants whom he examined at the Found- ling Hospital; in two of the cases there were also tubercles in the lungs: he also found tubercles in the lungs of four children in one year, all of whom appeared healthy at birth, but gradually fell into a state of marasmus, and died at the respective ages of one, two, three, and five months, without presenting any of the symptoms proper to the phthisis of adults. (Op. cit.) We have not sufficient data to estimate the comparative fre- quency of tuberculous disease during the first two years of life, yet we are well assured, from ob- servation, that the disease is not uncommon at this early age. We have met with several cases of infants dying of phthisis within the first year, in whom the lungs were not only extensively tuberculous, but contained large caverns with all the characters of those found in the lungs of adults. We have reason to believe that the disease in in- fants is frequently overlooked from the symptoms being less evident than in more advanced life, and from the want of the oral information afforded by the adult. The expectoration also is rarely seen in them, and the cough often assumes the charac- ter of pertussis; so that the disease is not unfre- quently mistaken for that or chronic catarrh. After the second year of life, the great pre- valence of tuberculous diseases has been remarked by many pathologists. M. Guersent, a physician of extensive experience attached to the Hopital des Enfans Malades in Paris, where none are ad- mitted below the first nor above the sixteenth year, is of opinion that tubercles existed in two- thirds or even five-sixths of the bodies which he examined. (Clinical Reports, Journ. Hebdom. t. vii. p. 588.) The researches of M. Lombard, (Andral, Anat. Path., Townsend and West's Translation, vol. i.) and more lately those of M. Papavoine, (Journal des Progress,) carried on in the same institution, have determined with great 526 TUBERCULAR PHTHISIS. precision the frequency of tubercular affections, and the differences in their prevalence at various periods. From the records of deaths under fifteen years of age in the practice of the New Town Dispensary during two years, Dr. Alison is of opinion that the mortality from scrofulous diseases in the children of the lower orders in Edinburgh might be estimated much higher than one-third of the whole deaths. (Trans. Med. Chir. Soc. Edinb.) The following table is calculated from six hun- dred and ninety-five examinations recorded by Papavoine and his colleagues. The bodies were examined with great care, and the tuberculous distinguished from the non-tuberculous for each year of age from the third to the fifteenth inclu- sive. It is, however, to be observed that in two- fifths of the cases the tuberculous disease was not the cause of death. It is probable that the num- bers here given express with considerable accuracy the relative proportion of the tuberculous to the non-tuberculous that die in the hospital, and per- haps among the poor of Paris generally; but since the children admitted are from the most indigent classes, and generally remain some time in the hospital, it may be supposed that the proportion of the tuberculous is exaggerated ; as, however, Papavoine's observations do not include the deaths in the scrofulous wards, any error which may arise from these circumstances is thereby obviated. To exhibit the influence of age on the production of tubercles, our table was constructed by ascertain- ing the annual mortality in ten thousand indivi- duals at each age, and setting down in opposite columns the proportions of the tuberculous and the non-tuberculous determined by Papavoine. Ten thousand children are supposed to be alive at the beginning of each year. The first column gives the age ; the second is calculated on the law of mortality in France, (Annuaire 1832, p. 83,) and shows the total number of deaths in the course of the year; the third shows the proportion of tuberculous, and the fourth the proportion of children not tuberculous, that die in the ten thousand. The fifth column gives the number of tuberculous in a hundred deaths. Table V. Total Tubercu- Tubercu- Age. deaths. lous. culous. hundred deaths. 1 2630 100? 2530? 0 2 1290 161? 1129? 12? 3 729 292 437 40 4 408 204 204 50 5 263 173 90 66 6 178 130 48 72 7 125 87 38 70 8 99 74 25 75 9 82 52 30 63 10 78 52 26 67 11 77 44 33 57 12 78 47 31 60 13 80 60 20 75 14 4 56 28 66 15 89 47 42 52 From an examination of this table, we are led to conclude that age has more influence in deter- mining tuberculous disease than all other appre. ciable causes taken together. The tendency to this process is five times more intense at one period of life than at another; it may, perhaps, be said that it is some hundreds of times more intense in the fourth year than at birth. The frequency of the disease is in no constant relation either to the mortality or the growth. Tubercles prevail moat through the third, fourth, fifth, and sixth years, when the annual growth does not exceed one-tenth of the child's weight, and the mortality declines to nearly one in a hundred. Papavoine has com- mitted an error in stating that tubercles are gene- rally most frequent in those periods of life when the mortality is least. If we refer to the table, the mortality is least (seventy-seven in the ten thou- sand) in the eleventh year, and forty-four in the ten thousand die tuberculous; the mortality ii much greater in the fourth year (four hundred and eight in the ten thousand), and so is the num- ber of tuberculous (two hundred and four). The error originates in supposing that the number of the tuberculous is as the relation of the tuberculous to the non-tuberculous among the deaths. M, Andral says, after M. Lombard, that " tubercles are most prevalent from four to five : they appear in much greater quantities, and in a greater num- ber of organs at once." (Op. cit vol. i. p. 528.) Now there is little doubt that the proportion of those who die tuberculous is at its maximum re- latively to those who die without tubercles, about this period ; but it is erroneous to suppose that i child aged five years is more liable to tubercles than a child aged three:—indeed the contrary is the fact; for only one hundred and seventy-three aged five, and two hundred and ninety-two aged three years, are tuberculous in ten thousand. M, Andral, depending on the accuracy of the calcu- lations, has been led into the error of concluding that at this age every irritation or congestion ii far more to be dreaded than in the preceding years, inasmuch as it may be followed by the production of tubercles. More than one-fourth (27) of those that die from birth to puberty are affected with tuberculous disease; yet this causes death in about one-sixth only of the cases. From the third year upwards, these proportions become two-thirds and one-third, The great prevalence of tuberculous diseases in early life, which the researches of these patholo- gists have demonstrated, is a subject highly de- serving the attentive consideration of the physi- cian. The mortality from these affections in infancy and childhood is much greater than is generally believed ; at least we can say for ourselves, that although we had long had occasion to remark the frequency of phthisis in childhood, we were not aware of the extensive prevalence of the disease at so early an age, until we examined the results obtained by the French pathologists; and we be- lieve that many of our readers will find themselves in the same position. The practical inferences to be deduced from the facts which have here been stated are sufficiently evident, and rpquire litus comment. They show the paramount importance of attending to the health of infants and children, particularly in scrofulous families. But we shall have occasion to return to the consideration of tbu subject in a future part of the article. TUBERCULAR PHTHISIS. 527 With the view of ascertaining the comparative prevalence of tuberculous disease at different pe- riods of life, we have examined all the statistical reports which appeared worthy of attention. The results of our researches concerning the relative prevalence of phthisis at different ages above pu- berty, as shown in the following tables, are so conclusive as to preclude the necessity of any comment. Table VI. gives the numbers as we found them in the various works which we have consulted. Table VII., constructed from the first, gives the absolute mortality from phthisis, the number of persons in the thousand who die at each age in the different places, and the average of the whole. The comparison of this general average with any of the separate observations will show the correctness of the results by the similarity which it bears to many of them. It will be seen that, with one exception, all these instances, al- though collected under different circumstances of time, place, &c, agree in showing the greatest number of deaths to occur between the age of twenty and thirty ; the next in proportion between thirty and forty ; the next between forty and fifty; the succeeding grade of mortality being sometimes placed between fifteen and twenty, at other times between fifty and sixty, or even above sixty. This remarkable agreement of all the places warrants the conclusion that, after the fifteenth year of age, fully one-half the deaths from phthisis occur be- tween the twentieth and fortieth years of age, and that the mortality from consumption is about its maximum at thirty, and from that time gradually diminishes. Table VI. Mortality from Phthisis- at different ages. Place of Observation. 15 to 20 20 to 25 9 28 73 9" 25 to 30 13 7b" 4 7 30 to 35 8 27 4(i 87 9 35 to 40 11 :i <=> = 1 6 18 42 182 15 15 11 10 4 9, 53 3 4 5 28|20 565 22 31 23 21 13 6 259 fi fi 45 39 23 2fi 34 33 23 24 15 12 15 21 15 7 8 Q 5 8 10 11 Ditto, Blacks,....... 1 1 4 5 1 1 7 3 1 0 9 3 3 3 3 Table VII. Shorving the proportion, at different ages above fifteen, of one thousand deaths from Phthisis. Place of Observation. 15 to 20 78 69 117 59 13M 97 92 99 99 20 to 30 2-5 212 416 305 245 290 325 225 30 to 40 245 256 271 275 218 219 275 225 40 to 50 1*2 190 134 178 200 200 l')2 206 50 to 60 157 274 45 106 145 97 100 147 Above 60 1 52 ? <) 17 81 4 a 54 97 42 78 6 R Average of the above,* 285,248 185 108 78 1. Reports of Vciv Town Dispensary, three years, Edin Journ 1821-25 S. Sussiuilch Gottliche Ordnung. * In comparing this average, it must be borne in mind that the first column embraces a period of five years only, while the others comprise ten years. 3. Dr. Clark's Report. 1806-10, Edin. Med. Journ, 4. American Journal of Med. Science, 1826-32. 5. Dr. Haygarth, Phil. Trans, vols. 64, 65. 6. Dr. Hevsham on Mortality, tec, of Carlisle. 7. Louis, Traite de la Phthisie. 8. Bayle, Traite de la Phthisie Pulmonaire. The researches of MM. Andral and Lombard have led them nearly to the same conclusions as those deduced from the preceding tables. The former considers that males after puberty are par- ticularly subject to tubercles between the ages of twenty-one and twenty-eight; while females seem to be more exposed to them before twenty. (Op. cit. vol. i. p. 529.) The latter believes that after the age of puberty females are most liable to tubercles between their eighteenth and twentieth year, and males between twenty and twenty-five. (Op. cit. p. 29.) The opinion of Hippocrates on this subject cor- responds still more closely with the results ob- tained from our tables. That accurate observer fixed the age at which phthisis most frequently occurs, between the eighteenth and thirty-fifth year. (Coac. Progn. 539.) II.—Of the influence of Sex in determining the prevalence of Phthisis* It has generally been believed that phthisis is more prevalent among females than among males ; but the Paris Reports have been the chief sources from which statistical information on this subject has been obtained. It will, however, be seen by the following table that Paris forms a remarkable exception in this respect to the other places for which we have been able to collect materials for our calculations. Table VIII. Place. Males Fe-males. ■ Males Ff' males. 1 555 55 382 1584 71 328 20i-8 3054 560 47 2219 3965 3(53 445 44 315 137(1 62 292 I860 3103 655 58 2970 557!) 567 10 to 8-7 10 to 8-6 10 to 8 2 10 to 8(i 10 to 8-7 10 to 88 2 3 4 5 fi 7 8 10 to 10-4 10 to 11-6 10 to 123 10 to 133 10 to 143 10 to 15 ti 9 10 11 Blacks, New York..... 1? 13 Berlin, boys and girls,.. 1. Julius JVachrichten fiber die Hamburgischen Kran- kenhu'user, 1829. 2. Hellis, Clin. Med. de 1'Hotel Dieu de Rouen, 1825. 3. Remi, Topog Med. di Napoli. 4. New York Med. and Phys. Register. 5 Chisholm on the Climate and Diseases of Tropical Countries. 6. Sussmilch Gottliche Ordnung. 7. Kon Swenska Vetanskaps Hand. 1801. Nicandar. 8. Ditto, quoted from Marshall's Statistics of the British Empire. 9. Neue Berliner Monat Schrift. 1809, p. 225. 10. New York Med. and Phys. Register. 11. Conseil de Saluhrite. 12. Chabrol Statistique de la Ville de Paris. 13. Neue Berliuer Monat Schrift, 180:1, p. 225. The two first columns in the preceding tahle give the facts as we found them ; the two last columns show the relative deaths, ten being taken for the number of males. The conclusions which might be drawn from this table are fialile to error, from our neither knowing the relative number of the sexes alive in each place, their relative deaths from other dis- eases, nor their relative admissions into the hos- 528 TUBERCULAR PHTHISIS. pitals referred to. The smallness of the numbers also allows any accidental circumstances to modify the result; so that any conclusion deduced from our materials can only be considered an approxi- mation to the truth. In noticing the observations more particularly, we shall refer to the numbers given to each place in the preceding article. Nos. 1 to 7.—The constant equal relation of the first seven numbers is certainly most remark- able, and appears to warrant the conclusion that ten males die phthisical for every eight or nine females, which is very nearly in the relation of the number of males born to that of females. It therefore goes far to prove that the sexes are equally subject to phthisis. Nos. 8 and 9, do not materially affect the preceding conclusion, as the preponderance of deaths among the females might probably be soon counterbalanced by more ex- tended observations. No. 10, referring to the blacks, is rendered of little value by the small number of cases to which it refers, and by our ignorance of the relation of the sexes in a black population. No. 13, is a very curious observation; it does not, however, apply to the general calcula- tion, for it refers to children only. If it be cor- rect, it would show that, in childhood, phthisis is much more frequent among females than among males. Nos. 11 and 12, referring to Paris, are in direct contradiction to the first seven observations, and differ widely from Nos. 8 and 9, but approach 13 rather closely. They would show that the disease is more prevalent among females than among males in Paris by about one-fifth ; and it is worthy of remark that other observations made in that city have led to the same conclusion. M. Lepelletier found that the number of phthisical females admitted into the hospitals of Paris were in relation to the males as five to three. From the data, however, which we already possess, it is evident that the law of comparative mortality from phthisis which results from the observations hith- erto made at Paris, is not applicable to the com- parative mortality from that disease in other places. We have no statistical reports in this country on a sufficiently extended scale, to enable us to in- stitute a comparison on this subject between Eng- land and other countries. [The great frequency of tuberculous disease in childhood is shown by the fact recorded by MM. Rilliet and Barthez, (Traite Clinique et Pratique des Maladies des Enfants, vol. iii. Paris, 1843), that it existed, in a more or less advanced state, in some part or other in 314 out of 525 children examined after death. In regard to the influence of sex and age, they found that it was more fre- quent from 6 to 10£ years than from 11 to 15: next from 2 to 5: and lastly from 1 to 2$. The female sex was on the whole more liable to it than the male; but this did not apply to all ages: from 1 to 2J more cases were met with in the male; from 3 to 5 there was a slight excess amongst females; and from 6 to 10 the two sexes seemed to be equally liable ; but from 11 to 15, or at the age of approaching puberty, females suffered much more than males.] III. — Of the influence of certain occupa- tions in inducing Phthisis. Although from an early period medical writers have noticed the influence of certain occupation! in producing pulmonary disease, it is only iii late years that their attention has been more particu- larly directed to this very important subject Those trades which expose the workmen to m atmosphere loaded with pulverulent bodies or charged with gaseous substances of an irritating quality, and sedentary occupations of all kind* are believed to exert a very deleterious action on the respiratory organs, and to cause pulmonary consumption; while, on the contrary, those which require constant exercise in the open air are ai generally considered to afford protection against this disease. Up to a very recent period, writers on this sub- ject contented themselves with giving the result! of their observation in a general manner; but at- tempts have of late been made to determine the relative effect of different occupations by numeri- cal tables. Of this kind are the observations of M. Benoiston de Chateauneuf, published in the Annales d'Hygiene, and the more recent research*! of M. Lombard, recorded in the same journal. In order, by this method, to ascertain with precision to what extent phthisis is produced by the cir- cumstances in which an individual is placed by particular pursuits, it would be necessary to ascer- tain the numerical relation which persons engaged in such pursuits bear to the whole population of the place, the relation of the deaths of such pet- sons to the whole deaths, and, thirdly, the number of deaths from phthisis among the total deaths of each trade Possessed of such data upon a suffi- ciently extensive scale, we might arrive at accu- rate conclusions respecting the influence of occu- pation in the production of this disease; and having established the aggregate effect of the cir- I cumstances connected with the exercise of any particular trade, we might be able, by a careful study of all such circumstances taken separately, to refer each of them to its proper place in the scale of causes, and determine the positive effect of each. Researches of this kind, if carefully conducted, could not fail to lead to valuable practical results, by showing what alteration of circumstance! might render any particular trade more salubrioui. The materials, however, for such calculations do not exist, although they are essentially necessary to enable us to speak with precision on a question of so much importance. The most complete in- formation which we at present possess on the subject is contained in the paper of M. Lombard already referred to; but unfortunately the calcula- tions adduced by him to show the prevalence of phthisis in the different trades at Geneva, although very valuable in enabling us to approximate to the truth, are defective, inasmuch as the number of persons engaged in each trade is not stated. In consequence of this defect it is impossible to ascer- tain the absolute frequency of phthisis, and we can only determine its prevalence in relation to the total mortality in each trade, which may of course vary from many causes; and the most un- healthy trades in other respects may appear the most healthy in regard to phthisis. Our othei sources of information are still more deficient in the essential elements of such calculations, bo thai TUBERCULAR PHTHISIS. 529 in the present state of the subject we are unable to determine by numbers the relative influence of trades, and must therefore endeavour to arrive at the most probable conclusions by reasoning upon such general observations as we possess. All the agencies enumerated by authors may be reduced to two classes, the first embracing those which act as local irritants to the lungs; the second, those which exert an injurious effect on the whole economy. These two classes are so distinct in their nature that the evidence of their influence, and the consideration of the man- ner in which they lead to pulmonary disease, might be separately investigated with great pro- priety, if they were not so frequently combined in the same case. The occupations which have been noticed by various authors as exerting a direct influence in irritating the respiratory organs and inducing pul- monary consumption, comprise a large proportion of our industrious mechanics; such as stone- masons, miners, coal-heavers, flax-dressers, brass and steel polishers, metal-grinders, needle-pointers, and many others who are exposed during their labours to inhale an atmosphere charged with irri- tating particles. We have Dr. Alison's authority that there is hardly an instance of a mason, regularly employed in hewing stones in Edinburgh, living free from phthisical symptoms to the age of fifty.* Mr. Thackrah remarks that masons are generally in- temperate ; they are exposed to the vicissitudes of the weather, to great bodily exertion, and to the inhalation of fine particles of sand, dust, and powdered stone: they are subject to chronic in- flammation of the bronchial membrane and to pains of the limbs, and generally die before the age of forty.-(- Miners, as we learn from the same author, particularly while cutting through sand- stone, are much exposed to inhale dust; but they bIso take large quantities of ardent spirits, and seldom attain the age of forty. Dr. Forbes also states that an immense proportion of the miners in Cornwall are destroyed by chronic bronchitis; one of the principal, though by no means the sole cause of which he considers to be the inhala- tion of dust.t Wepfer remarked the destruction of the miners in his time employed in cutting millstones from the mines of Waldschut on the Rhine, where all the men are said to have become consumptive. (Observ. de capitis affect.) The inhalation of silex in a minute state of division is shown to be equally pernicious by Benoiston de Chateauneuf and by M. Clozier. The latter, speaking of the workmen in the quar- ries of St. Roch, says, " Quelque forts et robustes que soient ces ouvriers, les uns plutot, les autres plus tard, mais ordinairement avant quarante ans, &ont attaques d'abord d'une toux seche," &c. and * See his excellent paper in the first volume of the Trans, of the Mod. Chir. Soc. Edinburgh. t On the Etrects of Arts, Trades, and Professions, &c. on Health and Longevity. By C. Turner Thackrah, E*<|. t Translations of Laennec, second edition, p. 137. For extensive statistical researches respecting the health of this class of men, see an admirable essay on the Me- dical Topography of the Land's End, by Dr. Forbes, in ihe second volume of the Trans, of the Provincial Med. and Surg. Association. Vol. IV. —67 2u few reach the age of forty. (Le Blanc, CEuvres Chirurgicales, vol. i. p. 585.) The effects of this trade are so constant that the disease is commonly known by the name of " La Maladie de St. Roch." The evidence of Chateauneuf is more conclusive on this point:—the entire population of the small commune of Meusnes has been for the last hun- dred years exclusively employed in the manufac- ture of gun-flints. During this period the mor- tality has increased to a frightful extent, and the mean duration of life diminished in proportion. The inhalation of metallic particles appears to be equally injurious to the respiratory organs, and perhaps as destructive of life. The pernicious f effects of needle-pointing were long since de- | scribed by Dr. Johnstone of Worcester (Memoirs of Med. Soc. Lond. vol. v.) ; and Thackrah notices the operation of dry-filing cast-iron as most inju- rious to the workmen. The mouth and nose are I blackened; the lining membrane of the nostrils, | where the annoyance is first felt, discharges co- piously ; the fauces become preternaturally dry, respiration difficult; habitual cough succeeds, ac- companied with derangement of the digestive j organs and morning vomitings; and the common | termination is bronchial disease, and no doubt often tubercular consumption : while on the other ■ hand, dealers in old iron, whose clothes are covered with a thick brown layer of metallic dust, suffer no inconvenience. Thackrah attributes the mor- j tality of the filers to the greater irritation of the j mucous membranes of the respiratory organs pro- , duced by the angular particles of steel. The filers are remarkably short-lived ; in the two principal machine manufactories at Leeds there were only ! two filers of the age of forty-eight. The men of j these establishments are not intemperate ; nor can j their shortness of life be attributed to anything but i their employment. But the history of the grinders of Sheffield, recorded by Dr. Knight, affords one of the most striking examples of the pernicious , influence of the inhalation of mechanical irritants with which we are acquainted ; and the delete- rious effect of such inhalation is further illustrated by the difference between the health of the dry [ and wet grinders. The number of grinders « alto- gether amounts to about two thousand five hun- dred ; of this number about one hundred and fifty, i namely eighty men and seventy boys, are fork- grinders : these grind dry, and die from twenty- eight to thirty-two years of age. The razor- grinders grind both wet and dry, and they die from forty to forty-five years of age. The table- knife grinders work on wet stones, and they live to betwixt forty and fifty years of age." (North of England Med. and Surg. Journal, vol. i. p. 86.) Dr. Knight is of opinion that the grit-dust is not only the most copious, but also the most injurious part of what is inhaled by the grinders. On com- paring the diseases of these men with that of the other mechanics in Sheffield, he found that of two hundred and fifty grinders, one hundred and fifty-four laboured under disease of the chest; while only fifty-six were similarly affected in the same number of workmen engaged in other trades. On examining the respective ages of grinders and other workmen, he obtained the following re- sults :— 530 Age. Above 30 35 40 45 50 55 60 286 529* Many more instances might be adduced to show the pernicious effects of mechanical irritants ap- plied to the mucous membrane of the respiratory organs in producing fatal disease of the lungs; but the account of the grinders and flint-cutters which has just been given, is so conclusive that it is unnecessary to enter more fully into this part of our subject. There are, however, other cir- cumstances in the history of these cases of chronic bronchial disease which deserve particular consi- deration, in addition to the question of pulmonary irritation which we have just discussed. In al- most every instance the sufferers are exposed to causes fully adequate to the production of the tu- berculous cachexia ; they pass much of their time in a confined deteriorated atmosphere, often in a sedentary posture unfavourable to the free action of the respiratory organs; many of them are ex- posed to the vicissitudes of the weather, and the majority are addicted to the use of ardent spirits. The influence of a confined and deteriorated atmosphere is shown in a remarkable manner in the fork-grinders confined to the town of Sheffield and those employed in the same occupation in the country. The former die, as we have stated, be- tween the ages of twenty-eight and thirty-two; the latter generally attain the age of forty. In both cases the exposure to mechanical irritation is the same, and the habits of the grinders in and out of Sheffield do not differ; but the rooms in which the country workmen carry on their occu- pation are much better ventilated. Persons employed in many other manufactories suffer in the same manner, but in a less degree. Feather-dressers and brush-makers, according to Chateauneuf, are confined to close apartments, and generally work in a sitting posture. In the former trade the deaths from pulmonary disease amounted to 11-47 in the hundred, and in the latter to 7-76. Thackrah observes that in such trades the digestive functions are even sooner dis- ordered than those of respiration. The process of flock-dressing appears to be most pernicious in this respect. "The subsequent sieving and ex- amining of flocks produces great dust, and deci- dedly injures both respiration and digestion. In proportion to the degree and continuance of this deleterious agent is the head affected, the appetite reduced, respiration impeded, cough, and finally bronchial or tubercular consumption produced:" (p. 66.) » Dressers of flax and persons in the dusty rooms of the mills," he continues, " are ge- nerally unhealthy. They are subject to indiges- tion, morning vomiting, chronic inflammation of * The disease which thus embitters the life of the grinder, and ultimately destroys him when he lias scarcely attained one-half the ordinary age of man, is generally denominated grinders' asthma, and often, from ita great fatality, grinders' rot. R PHTHISIS. the bronchial membrane, inflammation of the lungs, and pulmonary consumption." (Op. cit, p. 71.) In all these cases the effect of the causes acting on the general system is made evident hy the prominent place which disordered digestion, &c. hold among the symptoms enumerated, When disease is produced by bronchial irritation alone, these symptoms are not present, or occur only at a late period of the disease. With respect to the nature of the pulmonary disease induced by the inhalation of mechanical irritants, of which the hard impalpable kind, ac- cording to the researches of Lombard, have the greatest influence, our information is still very de- fective. It is surprising, indeed, how few accu- rate examinations have been made and recorded of individuals dying under the circumstances de- scribed. The symptoms are so similar to those of tubercular phthisis, and are no doubt so often connected with this, that we shall only be able to state how far the mechanical irritation of the bron- chial membrane contributes to the development of tuberculous disease, when we have a consider- able series of well-conducted post-mortem exami- nations of mechanics employed in the operations referred to, and of others who are engaged in simi- lar occupations without being at the same time exposed to the action of mechanical irritants on the organs of respiration. That there is sufficient disease to destroy life, and this with fearful rapid- ity and to an immense extent, is fully established; but we have no doubt that in many cases tuber- culous disease has no share in it. Our opinion on this point will, we apprehend, be confirmed by the following summary of all the morbid inspec- tions of the disease which we have been able to collect. In the cases of the stone-masons of Edinburgh, reported by Dr. Alison, he enumerates the follow- ing as the appearances generally observed : "por- tions of the lungs hardened and condensed, others in a soft pulpy state, nearly resembling the ordi- nary texture of the spleen, and others loaded with effused serum, with much adhesion of the pleura; and much effusion into the bronchi." (Op. cit. p. 372.) These are certainly not the appearances presented by tubercular disease of the lungs; and we quite agree with Dr. Alison that they were the consequence of inflammation. Dr. Hastings, in his excellent work on Bron- chitis, has recorded the examination of three lea- ther-dressers, (his eighth, tenth, and eleventh cases,) who died from pulmonary disease excited by the inhalation of dust. In the first of these cases, the lungs were more solid than natural; the mucous membrane of the bronchi much inflamed, thickened, and containing several extensive super- ficial ulcers ; the bronchi filled with purulent fluid mixed with blood ; no tubercles were found. In the next case, the mucous membrane of the tra- chea and bronchi was highly inflamed and ul- cerated ; the air-cells were filled with mucus mixed with pus; the lungs strongly adherent over the whole surface, their substance was much gorged with blood ; no tubercles. In these two cases, the heart was enlarged. In the third case, the bron- chial membrane was thickened and ulcerated i there were many tubercles in both lungs, 6ome of them in a state of suppuration. Grinders. ,. 124 . . 83 . . 40 . .. 24 , . 10 . ,. 4 . 1 . UBERCULA Other workmen. ___140 ... 118 , ... 92 . . .. 70 .... 56 ,... 34 .... 19 TUBERCULAR PHTHISIS. 531 Dr. Knight has recently favoured us with an account of two cases which have occurred to him since the publication of his valuable paper in the North of England Medical Journal.* Dr. Knight's first case was that of a fork-grinder, who died July 31st, 1831, at the age of thirty-eight, and had lost two brothers, also grinders, at the respective ages of twenty-four and twenty-eight years. The ex- amination disclosed the following appearances : extensive adhesion of the pleura?, especially on the right side; tubercles mostly in a crude state in both lungs; in the superior posterior part of the left lungs was a mass of the appearance and con- sistence of cartilage, and the size of a pigeon's egg; upper part of the right lung indurated ; nu- merous ulcers in the bronchial membrane, parti- cularly of this lung, over which the adhesion of the pleura was most extensive and firm. Several bronchial glands were enlarged and indurated; the larynx and trachea were free from disease; heart of natural size. The immediate cause of this man's death was acute inflammation of the perito- neum and pericardium, presenting the usual ap- pearances. The second case was a scissor-grinder, aged forty-seven, of a scrofulous habit, very tem- perate and industrious. He had for many years laboured under cough, at times dry, and at others accompanied with copious muco-purulent expec- toration. The following appearances were ob- served on examination forty-eight hours after death: adhesions to a considerable extent between the pleura?; upper part of both lungs emphysematous, particularly the right, which was gorged with blood to the extent of a large orange, but not in- durated, immediately below the emphysematous portion. In the same lung were a large cretace- ous mass inclosed in a cartilaginous cyst, and many tubercles in an indurated state. The left lung likewise contained many small hard tuber- cles, and at its posterior part a small collection of pus in a cartilaginous cyst. The bronchial glands were enlarged ; the bronchial membrane was red, softened, and covered with pus and blood. Heart adherent to pericardium ; many of the mesenteric glands enlarged and of cretaceous consistence; mucous membrane of the stomach extremely vas- cular and softened, and thickly covered with red blood. The patient had vomited a pint of fluid blood a few hours before death. Such, we apprehend, are the appearances which will be generally found in these cases, viz. vascu- lar congestion and ulceration of the bronchial membrane, congestion or induration of the pulmo- nary substance, and adhesion of the pleura. They will probably be found in all cases, and, in many, complicated with emphysema, tubercles, and en- larged heart. The mechanical irritation of the re- spiratory organs, the sedentary habits and con- strained position of the workman, the impure air in which he works, and his usual habits of life, are abundantly adequate to account for all these morbid changes; but we cannot admit that the mechanical irritation alone is sufficient to produce them. In two of Dr. Hastings's cases, wherein mechanical irritation of the bronchial membrane * We are gratified to learn that the objections to post- mortem examinations, which have hitherto been almost insurmountable, are beginning to abate; and we there- fore trust that we shall soon have this subject fully in- vestigated. had been maintained for years together, extensive disorganization was thereby produced, and death caused without the formation of a single tubercle. In regard to Dr. Knight's second case, it may be remarked that the grinder was originally of the tuberculous constitution, and that he had passed the ordinary term of a grinder's life; and notwith- standing the constant irritation kept up in the lungs by his occupation, nature had made consi- derable advances to effect a cure of the tubercu- lous disease. We have already observed, with respect to Dr. Alison's cases of the stone-masons at Edinburgh whose occupation is constantly car- ried on in the open air, that no tubercles were found in the lungs. But there can be no doubt that a very considerable proportion of the persons will be found to have real tuberculous disease ; as when a disposition to it exists, nothing is more likely to prove an exciting cause than the perpe- tual irritation produced by the inhalation of me- chanical particles. [(See, on this subject, Dr. G. Calvert Holland, Lond. and Edinb. Journ. of Med. Science, Oct. 1843, p. 886.)] We shall now notice some circumstances which affect the general health of labourers, and thereby induce tuberculous cachexia. Among these none operate more injuriously in disposing to this mor- bid state than the deficient bodily exercise and the want of pure air which are generally united with sedentary occupations. Shoemakers, tailors, weavers, and dress-makers, may be cited among those who suffer most from these causes. Their sedentary position, the crowded and ill-ventilated apartments in which their labour is generally car- ried on, and the peculiar posture which they ha- bitually assume, are eminently calculated to pre- vent the free exercise of the pulmonary organs, to diminish the powers of the system, to impair the nutritive function, and produce a corresponding depression of nervous energy. Their habits also are frequently careless and irregular; they adopt little precaution against the vicissitudes of tempe- rature, expose themselves to the influence of cold and damp, and too often to the evils arising from dram-drinking, and to those other causes which are most likely to produce congestions, fevers, and inflammations. If the female dress-makers and other females employed in similar occupations are exempted from some of these causes, the total privation of exercise, the late hours and long du- ration of their work are more than sufficient to in- jure, if not destroy, their health in a few years. Now in all these circumstances we find not only the conditions most favourable to the develop- ment of the general tuberculous diathesis, but those also which have a peculiar influence in pro- moting its manifestation in the lungs. The effect of sedentary habits in all classes and conditions of society is in our opinion most pernicious; and there is perhaps no cause, not even excepting hereditary predisposition, which exerts such a de- cided influence in the production of phthisis, as the privation of fresh air and free exercise. In- deed, the result of our inquiries leads to the con- viction that sedentary habits are among the most powerful causes of tuberculous disease, and that they operate in the higher classes as the principal cause of its greater frequency among females. In this rank of society we find the mortality from 532 TUBERCULAR PHTHISIS. phthisis below the average, almost all the active causes of the disease being removed. M. Egret (Annales d'Hygiene, vol. vi. p. 46,) found that only two males and five females died of phthisis, in seven hundred and thirty persons of this class, treated by him during a period of ten years ; and Lombard calculated that the disease is only half as prevalent among persons in easy circumstances as it is among the great bulk of the population. There are certain trades which are generally considered 'unfavourable to the occurrence of phthisis; among these, seamen, butchers, and tanners hold the first rank.* It has been ima- gined that there is something in these occupations which has a special effect in preventing the de- velopment of tubercles, arising, in the one case, from the impregnation of the atmosphere with saline particles,—in the other, from peculiar pro- perties in the atmosphere when impregnated with effluvia from dead animal matter or living vegeta- bles. We have no belief in the special effect of such agents, but refer the exemption of these classes chiefly to the free and regular exercise in the open air which they enjoy. The facts which we have adduced in this sec- tion, although they are, we admit, imperfect, may nevertheless lead to useful practical results. They not only open an interesting field of observation and inquiry, but suggest measures for improving the health and condition of society, which are simple and in many cases available. We can only expect to see a decided diminution of disease among the industrious artisans of this country, when their workshops and apartments are more spacious and better ventilated,—when their physi- cal powers are less exposed to the depressing in- fluence of variable temperature, when they take more exercise in the open air, pay more regard to cleanliness, and cease to seek excitement in the pernicious habit of spirit-drinking.' IV. Of the Influence of Climate in the pro- duction of Phthisisa Our information respecting the influence of climate in the production of tuberculous disease is still very imperfect, and its operation as a pre- disposing and exciting cause has not been suffi- ciently discriminated. A cold, damp, and variable climate, such as that of this country, not only gives the predispo- sition to the disease, but becomes its exciting cause, and determines in an especial manner its local manifestation in the lungs. Sir William Crichton states that "consumption is infinitely more frequent in Great Britain and Ireland, in comparison of their population, than in the north- ern parts of Russia; yet the climate of Russia is in general infinitely colder and ruder than ours. The scrofulous or strumous constitution is more common in the northern and middle governments of Russia than in England, and commits greater ravages and disfiguration than are ever witnessed * We beg to refer the reader who is desirous of more minute information, to the writings of Dr. Beddoes, who has collected a considerable body of evidence on the subject of this section ; to Mr. Thackrah's valuable work on the Effects of Trades; to Dr. Forbes's able Memoir in the Transactions of the Provincial Medical and Sur- gical Association; to the excellent articles of Benoiston de Chateauneuf and our friend Dr. Lombard of Geneva in the Annales d' Hygiene, and of Dr. Knight and Dr. Kay in the North of England Medical Journal. in this country. Great Britain no where exhibits such dreadful effects of scrofula as Russia does; but in that empire its attacks are mostly confined to the external set of glands, to the face, the eyes, and throat, and to the bones, especially those of the extremities; the lungs suffer rarely, except in public schools, and among those who adopt the European dress and fashions." (Pract. Obs. on Pulmonary Consumption, p. 50, &c.) There are however, circumstances which must be taken into account in estimating the influence of the respec- tive climates of Russia and England: the Rus- sians clothe themselves more warmly, and take greater precautions against the severity of the cli- mate than the English; on the other hand their poorer classes are worse fed, black sourish rye- bread and vegetables being their chief nourish- ment. The occupations also of the Russians are for the most part in the open air; whereas a large proportion of the labouring classes in England are employed in manufactories, in which they are shut up for the greater part of the day in a con- fined and deteriorated atmosphere. [See on this subject Sir George Lefevre, Thermal Comfort, Amer. edit. New York, 1844.] Great heat appears also to have a powerful effect in predisposing to tuberculous disease. The general constitution of the inhabitants of very hot countries, as the Malays and negroes, may be cited in confirmation of this opinion, as both these races are well known to be much more subject to tuberculous disease than Europeans when exposed to the same causes. We shall adduce further proof of this in the subjoined tables, containing a statistical account of the prevalence of phthisis in different countries.^ Table IX. Showing the general result of our researches on the effect of Climate in determining the rela- tive prevalence of Phthisis among the troops. Place. N. S. Wales and East Indies*. East Indies................ Cape of Good Hope......... Mediterranean.............. West Indies (Europeans)..... Canada ................... France.................... Great Britain.............. Blacks in West Indies....... Proportion of phthisis to the total deaths. one-thirty-fifth one-thirty-third one-seventh one-sixth one-fifth one-fourth one-third one-third one-third The isolated facts relating to the prevalence of phthisis in different nations, which we have col- lected from their statistical documents, are so dis- crepant and contradictory, that no positive conclu- sions can be drawn from them respecting the effect of climate in producing the tuberculous diathesis. On this point, therefore, our information remains very incomplete, although by reference to the pre- ceding table it is quite evident that the actual t We avail ourselves of this opportunity to eiprew our acknowledgments to Sir James M'Grecor and at William Burnett, to whose kindness we are indebted to' the facilities afforded us of examining the valuable col- lection of journals and reports from the medical office" of the army and navy. t The troops were employed in different parts of It* East Indies, in 1838,1839, and 1830. TUBERCULAR PHTHISIS. 533 ravages of the disease decrease in a direct ratio with the increased warmth and equability of cli- mate, and increase in the same ratio under opposite conditions ; and it is a well-known fact, that the inhabitants of warm climates, whether men or brutes, frequently fall a sacrifice to phthisis, when removed into colder countries. To determine the influence of climate satisfac- torily, we require an accurate table of the preva- lence not only of pulmonary phthisis, but also of all the forms in which the tuberculous diathesis manifests itself among the inhabitants of different countries ; for the influence of any climate in pro- ducing this diathesis cannot be estimated from tables illustrating the prevalence of one form of the disease among strangers to that climate, who of course brought with them that disposition to disease which their native country induced, and which we have no means of estimating. We may, therefore, seem to have arrived too hastily at the conclusion that this disease is favour- ed by excessive heat, and is more prevalent among the negroes and Malay race. We have, however, been led to it by the study of their physical pecu- liarities, by the general character and course of their diseases, and by the fact that when these people are removed to Europe, the diathesis mani- fests itself rapidly in its most characteristic form of crude tubercles, not in their lungs merely, but simultaneously in almost every organ of their body. The two following tables have been compiled from the Army Medical Records, for the purpose of determining the greater prevalence of phthisis and other diseases of the lungs among the blacks than among Europeans in the West Indies. The first gives the relative mortality from phthisis, &c. among the blacks and whites of the West Indian army, for eight years, 1822 to '29. by dividing the deaths from phthisis, X 1000, by the total deaths, we obtain the third. Table XI. Table X. Deaths from all diseases. Phthisis. Other pulmonary diseases. Cases. Deaths. Cases. Deaths. Whites, Blacks, 2275 555 318 221 177 158 3550 1488 100 105 By our calculations from the above table, we find that in every thousand deaths among the whites, one hundred and twenty, or little more than one-eighth, are from pulmonic diseases; while in every thousand deaths among the blacks, four hundred and seventy-two, or nearly one-half, are caused by pulmonic diseases. The following table has been constructed to show that phthisis is not only relatively but abso- lutely more prevalent among the natives than among Europeans in the East Indies. The table has been compiled from Mr. Marshall's Medical Topography of Ceylon. By adding together the items of his tables from 1815 to 1820 inclusive, reducing them to unity, and then dividing the total deaths per annum, X 1000, by the average strength, we obtained the first column, showing the absolute mortality in 1000 of each race during the equal period of one year. By dividing the deaths from phthisis per annum, X 1000, by the average an- nual mortality, we obtain the second column; and 2u* c o 3 W >> a s O a •3 e Total deaths in 1000} persons during one V. 142 56 49 45 Deaths from phthisis,"} in 1000 persons, du- v 6 2.0 7.0 2.6 Deaths from phthisis,") in 1000 deaths from C 4.3 58 146 59 In concluding this section, we beg to express our thanks to our ingenious friend, Mr. Fergus, for assisting us in collecting materials for various parts of this paper. We are indebted to him for the six last tables which this section contains :— founded as they are on researches which have re- quired great industry and labour, the task of col- lecting the materials and of making the necessary calculations has occupied more time than we could have devoted to it, and much more than persons unacquainted with such inquiries imagine. We also avail ourselves of this opportunity to express our thanks to Mr. Farr, for the compilation and arrangement of the first, second, and fifth tables in this article. [It would appear from the statistical report on the sickness, mortality, and invaliding among the British troops in the West Indies, by Major Tul- lock, that in Jamaica, with a high temperature, consumption is as frequent as in Great Britain; and M. Rufz states, that in Martinique this dis- ease is the most frequent of all chronic maladies. It has been shown, moreover, that consumption is much less frequent amongst sailors than amongst soldiers. The benefits of a sea voyage to the phthisical valetudinarian have been long known, and there can be no doubt, that in those who are predisposed to pulmonary disease, the re- vulsion thereby effected in the system may prove most salutary. According to the statistical reports laid before the House of Commons, it appears, that in the West Indies and North America, the mortality from consumption in the navy was at the rate of 1.9 per thousand, whilst among soldiers in the same region, the returns were as follows :— In the Windward and Leeward Island command, 12 per 1000 were annually attacked with con- sumption. In Barbadoes, 15.8 per 1000 die of it; in Jamaica, 7.5 per 1000; and in the more northern portions of the same command, the deaths from diseases of the lungs amongst the troops were, in Nova Scotia and New Brunswick 7.1 per 1000; and in Canada, 6.7 per 1000. In Bermuda, there were attacked annually by con- sumption, 8.8 per 1000. When a tuberculous individual passes from a warm and dry country to one that is cold and damp, the tubercles undergo development. It was observed, that the French regiments suffered more from phthisis in Holland than in Spain and Italy ; and it would appear, that almost all the animals 534 TUBERCULAR PHTHISIS. which are brought from the torrid regions to our menageries, die of tuberculosis of the lungs. See, on all this subject, the writer's Practice of Medi- cine, 2d edit. 362, Philad. 1844.] Sect. IX. — Of Tuberculous Diseases in Animals. The history of tuberculous disease in animals is a subject of much interest to the physician, inasmuch as it affords a collateral illustration of the disease in man. We believe that tuberculous disease may be in- duced in any class of animals by those circum- stances which produce it in the human subject, being equally influenced by climate, impure air, imperfect nutrition, deficient exercise, and other causes. Tubercles have been noticed in many orders of the mammalia, carnivorous and herbi- vorous, in birds, and perhaps in insects. Among the mammalia, they have been found in the lion, dromedary, horse, antelope, deer, cow, sheep, goat, domestic pig, monkey, guinea-pig, hare, rabbit, squirrel, and porpoise: among birds, in the psit- tacus erythaeus and some other macaws and par- rots, in the flamingo, house-sparrow, turkey, and domestic fowl. Mr. Owen, Assistant Curator of the Museum of the Royal College of Surgeons, informs us that he has discovered tuberculous dis- ease in the following animals which died in the Gardens of the Zoological Society,—felis caracal, Persian lynx,- paradoxurus typus, paradoxure gennet,- viverra Rasse, civet cat; herpestes mun- gos, Indian ichneumon,- nasua fusca, brown coati mondi; usus Thibetanus, Nepal bear of the Hi- malaya Mountains,- tapirus Americanus, Ameri- can tapir; alces Americanus, American elk; simia satyrus, ourang outang; Macacus cyno- molgus, Macaque monkey,- M. radiatus, bonneted monkey,- M. Rhesus, pig-taikd monkey; cerco- pithecus saboeus, green monkey,- papio maimon jun., Mandrill baboon,- lemur nigrifons, black- fronted lemur; lemur macauco, ruffed macauco. Our friend, Mr. Newport, a comparative anato- mist of great promise, whose name is already favourably known by his researches into the mi- nute anatomy of insects,* has favoured us with an account of what he believes to be tuberculous deposits in that tribe. In the larva of the spinx ligustri, or common privet moth, he met with a peculiar matter disseminated in small, irregular, aggravated masses, white, opaque, and of a cheesy consistence, over the whole internal surface of the insect, between layers of very delicate cellular tissue. These masses were most numerous among the muscles; on the exterior of the alimentary canal, particularly the stomach ; on the secretory silk glands, in the biliary ducts, and on the nerves. In the carabus catenulatus, or ground-beetle, and in the staphylinus olens, both carnivorous feeders, he noticed similar deposits of more uniform and much smaller size in the cellular and pulmonary tissues: he has also detected appearances similar to those observed in the sphinx ligustri, in the common cray-fish, the astacus fluviatilis of Leach. It is worthy of remark that the sphinx was fed upon stale leaves of the privet for some days pre- vious to examination, the unusual wetness of the season having prevented a fresh supply ; the de- * See his papers on the Sphinx Ligustri, in the Phil. Trans. 1833 and 1831. position of the same matter has also been pro- duced by purposely feeding the insect upon dete- riorated or stale food. Although the existence of tuberculous disease in insects requires to be established by more nu- merous observations than have as yet been made, still the view which we take of the pathology of tuberculous disease inclines us to believe that no class of animals is exempt from it; we therefore have little doubt that the application of the causes which lead to it in the human species will also induce it in any animal which is exposed to their influence.^ The morbid appearances presented on examina- tion of the animals we have enumerated also bear a close analogy to those observed in man: the lungs, spleen, mucous membrane of the intestines, the liver, mesenteric, bronchial, and lymphatic glands, are the organs most frequently affected, We are, however, better acquainted with the morbid anatomy of monkeys, because, of all ani- mals, that family is most subject to tuberculous disease; indeed, nearly all the monkeys in our menageries die tuberculous. Dr. Reynaud, of Paris, has devoted much research to this depart- ment of comparative pathology, and has published an excellent memoir on phthisis in the monkeys at the Jardin des Plantes. (Archives de Mede- cine, t. xxv.) In fourteen of these animals he found the lungs containing tubercles, and in many cases entirely converted into tuberculous matter. In three monkeys the disease was confined to the lungs exclusively; in the others various organs were at the same time affected. The larynx was ulcerated in two cases; the bronchial glands were always more or less tuberculous, and in one in- stance were, so much enlarged as to obliterate the left bronchus and prevent respiration in the cor- responding lung, which was much contracted. The spleen in six cases was much diseased, being enlarged and adherent to the peritoneum. The blood in the cells formed reddish clots, in the midst of which were tuberculous points. The tuberculous deposit was found in various stages of softening, and sometimes in caverns lined with a false membrane. In one case the tubercles were isolated and crude in the lungs, while in the spleen they were large and softened in the centre; show- ing that the spleen was the organ in which the tuberculous matter was first deposited. The disease occurs in animals, as in the human species, at all ages. MM. Andral and Dupuy have even observed it in the fcetus of the sheep and rabbit. Sect. X. — Of the Causes of Tuberculous Disease, and in particular of Phthisis. The causes of tuberculous disease, like those of most diseases, are referable to two distinct heads, the remote and the exciting, — or those which induce the constitutional predisposition, and those t All the milch cows in Paris become tuberculous after a certain period of confinement to the house. IVY have been informed that for some time after tho disease has commenced, the quantity of milk obtained from them is greater than before, and their flesh is more esteemed by the unsuspecting epicure than that of the healthy animal. A circumstance of the same kind is mentioned by Aristotle, who observed tubercles in the put, the ox, and ass ; he says, in regard to strumous pi;:*, that when the disease (grandines) exists in a slight decree, the flesh is sweeter (caro dulcior est). Historia Animalium, lir*. viii. cap. 31. TUBERCULAR PHTHISIS. 535 which determine the local deposition of tubercu- lous matter after such predisposition is established. The one class of causes operates by modifying the whole system, the other by determining in a sys- tem so modified, the particular morbid action of which tuberculous matter is the product. Until this distinction between the causes of the consti- tutional and local disease is fully understood and acted on in practice, we shall make little progress in the prevention or treatment of tuberculous disease. The share which these two classes of causes have in the production of tubercle varies in differ- ent cases. When the person is little exposed to the exciting causes, the constitutional predisposi- tion may be long present without any local affec- tion, while continued exposure to exciting causes may determine the local disease when the morbid state of the constitution exists in a slight degree. We have examples of the former among the weal- thy classes of society, where we see the tubercu- lous cachexia prevail for a considerable time with- out the actual development of tubercles, because the person is little exposed to the usual exciting causes, and even seduously avoids them; and we meet with instances of the latter amongst the poor, when engaged in occupations in the exercise of which the lungs are peculiarly exposed to irrita- tion, by which a diseased state of the bronchial membrane and ultimately tuberculous disease are produced. Of this number are the numerous classes of mechanics, who breathe, for many hours every day, an atmosphere charged with fine parti- cles of sand, metal, &c. But the most striking examples of consumption which have been addu- ced as the consequence of pulmonary irritation, occur in persons who are at the same time exposed to some of the most powerful causes of tubercular ca- chexia, such as sedentary occupations carried on in a confined and deteriorated atmosphere, and very often also to excessive indulgence in the use of ardent spirits; so that they are exposed to that Cause of the constitutional and local disease at the same time. I.—Of Hereditary Transmission considered as a Cause of Phthisis. That pulmonary consumption is an hereditary disease, — in other words, that the tuberculous constitution is transmitted from parent to child, is a fact not to be controverted; indeed we regard it as one of the best established points in the etiology of disease. But it may not be so generally ad- mitted that various other morbid states of the parent produce the predisposition to tuberculous disease in the offspring; a position, however, which we hold to be equally true, and still more important in its consequences. A parent labour- ing under tuberculous cachexia entails on his offspring a disposition to the same affection, pro- portioned to the degree of disease under which he labours. Examples of this fact are constantly present in the families of scrofulous parents, where we find the scrofulous constitution much more strongly marked in general in the younger than in the elder children. We even occasionally meet with families the first children of which are healthy, while the last are the subjects of tubercu- lous disease ; the health of the parents having undergone a change during the increase of their family. There may be exceptions to this rule, depending on circumstances beyond our cogni- zance, but we have little doubt that it is generally true. It has been made a subject of inquiry whether the child is more disposed to the diseases of the father or mother ; and we believe the majority of authors give it in favour of the father: Professor Nassi, however, of Bonn, in his excellent tssay on tuberculous diseases, expresses his opinion that the hereditary disposition is more frequently derived from the mother. The point is one which it is very difficult to decide. There can, we think, be no doubt that the child may inherit the consti- tution of either or both parents : on some occasions we see the constitution of the father, in others that of the mother, predominating in different children of the same family. It has also becn.re- marked, and we think the observation is founded in truth, that the more a child resembles in its external lineaments one or other parent, the more certainty will it inherit the diseases of that parent. But a state of tuberculous cachexia, as we have just remarked, is not the only morbid condition of the parent which entails the tuberculous predis- position on the children ; there are several diseases which have that effect, the most frequent and important of which are a disordered state of the digestive organs and its consequences. Gout, cutaneous diseases, the injurious influence of sy- philis or long courses of mercury on the constitu- tion, debility from disease, age, &c; in short, a deteriorated state of health in the parent from any cause, to such a degree as to produce a state of cachexia, may give rise to the scrofulous constitu- tion in the offspring. However various the causes of the cachectic state of the parent, its effect is constantly manifested in the disposition of the children to tuberculous disease. This is a most important fact in the history of consumption, and is highly deserving the attentive consideration of the profession. It may appear that we are disposed to generalize too much in ascribing tuberculous disease in the offspring to morbid conditions of the parent; nevertheless we have not formed our opinion upon superficial observation, nor without mature consideration; and we feel persuaded that the more carefully the subject is investigated, the more correct will our views be found. We have frequent opportunities of remarking a strong dis- position to this disease in the children of parents who enjoy what is usually termed good health, and in whose family no scrofulous taint can be traced; whereas, according to our own observa- tion, we never see the parents in an unhealthy state, whatever the nature of their disease may be, without finding, at the same time, that the children are strongly predisposed to tubercles. An opinion is entertained that one generation sometimes escapes tuberculous disease, although their parents and children suffer from it. This is to be explained by the improved state of health enjoyed by the generation exempted, and by the other circumstances which counteract or prevent the development of tubercles. Of all diseases, we consider dyspepsia the most fertile source of cachexia of every form, for this plain reason, that a healthy condition of the di- gestive organs and a proper performance of their functions are essential to the due preparation of the food, and consequently to the supply of healthy. 538 TUBERCULAR PHTHISIS. nourishment to the body. The adjusting powers of the system may do much to correct a disordered condition of the different functions concerned in the process of assimilation, by means of the in- creased activity of the healthy organs; but the system cannot continue long in a healthy state when any one important function connected with nutrition is materially deranged. Without, how- ever, entering into this most interesting subject, we consider it an established fact,—it is so at least to us,—that dyspepsia and any other disease which induces a cachectic state of the parent, shows it- self either in the tuberculous constitution of the children, or in their strong tendency to become the subjects of those disorders which generate such a constitution, such as that form of dyspepsia which has been denominated strumous by Dr. Todd, (see article Indigestion.) A cachectic state of the system may also origi- nate in a defective state of the various secretory and excretory functions, the effete matter not being fully carried off; and this cause very gene- rally accompanies dyspepsia, and accelerates its deteriorating influence on the health. There are doubtless other circumstances in the state of the parents which may give rise to the strumous dia- thesis in their offspring, which are not so evident as those which we have noticed : and yet there can be little question of their influence when we see children so often present the characters of the scrofulous diathesis at the earliest age, while their parents are in the enjoyment of good health, and free from all appearances of tuberculous disease. local or constitutional. Some remarkable exam- ples of this kind have come under our observation, where whole families have fallen victims to tuber- culous consumption, while both parents have not only enjoyed good health themselves to an ad- vanced age, but have been unable to trace any hereditary disposition to the disease in their fami- lies for generations back. An imperfect develop- ment or a feeble state of the organs of generation has been considered a cause of scrofula in the offspring ; anything which interferes with the act of conception or with the nourishment of the fcetus in utero, such as a disordered state of the mother's health, depressing passions, a sedentary or unhealthy mode of life, and whatever induces imperfect nutrition in the mother during preg- nancy, may lead to such a result; and this may even explain why in some instances one child is predisposed to disease, while the others of the same family are exempt. It is quite impossible to define the various circumstances in the health of the parent which may give rise to the scrofu- lous disposition in the child, much less to explain their operation: we rather allude to them as sub- jects deserving the investigation of the general pathologist and practical physician. That tuber- culous disease can generally be traced to an here- ditary origin, will not be disputed by any medical observer who has given his attention to" the sub- ject ; but there may be a difference of opinion as to the particular condition of the parent which ' induces the tuberculous constitution in the off- spring, and also as to the degree in which this constitution may exist in the child at birth. We have already stated our opinion respecting the for- mer, and we shall now give our views respecting the latter of these conditions. 1. We have seen that in a very small propor- tion of cases the child is tuberculous at birth, This, we believe, will rarely occur unless one or both parents are labouring under tuberculous dis- ease in a very advanced stage. 2. The next degree of hereditary disease is that in which ihe infant is afflicted with tuberculous cachexia from birth,—a state which requires very slight exciting causes to determine the deposition of tuberculous matter in some of its organs; which in such cases occurs early in life, the child often dying tuberculous within the period of in- fancy. This is a frequent occurrence in the chil- dren of consumptive parents. 3. Again, the child presents all the characters of the tuberculous or scrofulous constitution which have been already noticed, and without care will probably soon acquire tuberculous cachexia and die of tuberculous disease in early life. The greater number of scrofulous and consumptive cases which we meet with in childhood and youth are referable to this degree of hereditary disease. 4. In another class of cases, the child is mere- ly predisposed to those functional derangements which generate the tuberculous constitution. The cases of predisposition to consumption which come under this class are, according to our ob- servation, the offspring of parents who have laboured under dyspepsia, gout, cutaneous dis- eases, and other deranged states of health not of a tuberculous nature. They constitute the most numerous and the most remediable of all the classes; and yet, we take leave to add, they are the least generally understood. This view of the hereditary causes of tuber- culous disease we consider of great practical im- portance, as it is only by our acquaintance with the mode and degree in which the hereditary predisposition affects the constitution, and the circumstances on which its increase depends, that we shall be enabled to direct the management of the child so as to correct the constitutional predisposi- tion, and obviate those derangements which in- crease it. II-—Of the Causes which give rise to Tu- berculous Cachexia in individuals not hereditarily predisposed to Phthisis. The earlier in childhood the causes of tuber- culous cachexia are applied, the more speedily will this be induced. If, for example, an infant born in perfect health, and of the healthiest parents, be insufficiently or improperly fed, that is, be nursed by a woman whose milk is inade- quate in quantity or quality to afford due nourish- ment ; or if the child be fed on other food ill-suited to the state of the digestive organs, or be kept in close rooms in which free ventilation and clean- liness are neglected, a few months will often suffice to induce tuberculous cachexia. The countenance will become pale, the flesh soft, the limbs emaciated, the abdomen tumid, the evacua- tions fetid and unnatural. The external lymphatic glands, especially those of the neck, will enlarge and become tuberculous, and the child will speedily fall a victim to tuberculous disease; and this may happen in a family in which the brothers and sisters of this infant who have been properly suckled and reared with care and in pure air, attain a healthy maturity. We may thus see the change from perfect health to complete tuber- TUBERCULAR PHTHISIS. 537 culous cachexia effected in the infant in the course of a few short months. Now, if this occurs in a strong infant, born of healthy parents, and perfectly healthy at its birth, how much more certainly and rapidly will the same effects be produced in a feeble infant born of unhealthy parents, or, still more, of parents absolutely scro- fulous 1 Again, take a child of three or four years of age, in perfect health, having been born with- out any hereditary predisposition to disease, well- nursed, and properly nourished, — let it be fed upon coarse innutritious food, and confined in close apartments, where neither the heat nor light of the sun have free admission, and where the ventilation is imperfect, and we shall soon see the blooming healthy child changed into a pale, sickly, leucophlegmatic creature,—a fit subject for tuber- culous disease. This will occur during the whole period of youth, a longer time being required to effect the constitutional deterioration; but in all cases it will vary according to the number and force of the causes, and the power possessed by the individual to resist their operation. Up to the period of the full development of the system, till the body has ceased to increase in stature, till it has reached maturity and acquired the stability of the adult, tubercular cachexia may be readily induced. After maturity the powers of the system in resisting the causes of disease are greater than at an earlier period ; still we see the same results produced by similar causes, — the constitutional affection being the same, although it manifests itself more slowly and in a different manner, according to the age and peculiar con- stitution of the individual. As we increase in years, a more powerful or longer application of the causes is required to induce tuberculous cachexia, but we are not satisfied that this rule holds good after a certain period of advanced life. In old age, it has appeared to us that tuberculous cachexia is acquired more easily than about the middle period of life; but we admit that our facts are not sufficiently numerous, and have not been observed with enough of care to enable us to speak with confidence on this point. The principal causes which induce tuberculous disease may be arranged under the heads of im- proper diet; deficiency of pure air, exercise, cloth- ing, and cleanliness; excessive labour and affec- tions of the mind. Improper Diet. — Of the remote causes, the leading are those circumstances which interfere with the nutrition of the body ; among these the imperfect supply of food holds a conspicuous place. But we have rarely an opportunity of seeing the effects of this alone, because when the mean-! of procuring proper nourishment are want- ing, there are generally other causes of the disease in action at the same time; such as residence in ill-ventilated and dark apartments, exposure to cold from imperfect clothing, &c.; the whole of which are often combined, and hence more speedily effect the deterioration of the health. Food in excess, or of a kind too exciting for the digestive organs, may also induce tubercular cachexia, — a circumstance which is not suffi- ciently attended to, — we may say not generally understood, even by medical men : nevertheless we hold this to be a frequent cause of scrofula, Vol. IV. —68 and believe that it produces the same effects on the system as a deficient supply; the imperfect digestion and assimilation in the one case, and the inadequate nourishment in the other, being equally injurious: the form and general charac- ters which the disease assumes may differ, but the ultimate result will be the same in both cases. The adaptation of the food, both in quality and quantity, to the age of the individual, as well as to the powers of the digestive organs, is too little considered; and the evil consequences of this neglect are often evident in the children of the wealthy classes of society, who are frequently allowed an unrestricted use of the most exciting kinds of animal food. Impure Air.—Next to improper food, we rank an imperfect supply of pure air. It is in the lungs that the assimilation of the chyle is com- pleted ; and when either the respiration is imper- fectly performed, or a sufficient supply of air is wanting, perfect assimilation is prevented. In the confined abodes of the poorer inhabit- ants of large and populous cities, where neither pure air nor sufficient light can enter, in conse- quence of the obscure and overshaded sites of the buildings, the food cannot be assimilated even though the supply be unexceptionable. A sensi- ble writer on scrofulous diseases considers impure air as the only real cause of scrofula; other causes may assist, but this he considers essential to the production of the disease. " Personal ex- perience," says Baudelocque, " reading, reflection on a great number of facts, and the analysis of many observations, have impressed me with the deep conviction that there exists one principal cause of scrofulous disease, a cause which predo- minates over all others, and without which, per- haps, the disease would never, or at least very rarely develop itself. This cause consists in particular conditions of the atmosphere in which the individual resides. However ill-chosen or un- substantial his food may be—however much clean- liness may be neglected—whatever be the nature of his clothing and its adaptation to the tempera- ture—whatever the climate in which he lives, the exercise he takes, or the duration of his sleep and waking,—if the house in which he dwells be placed in a situation to which the fresh air and the sun's rays have free and direct access, and the house itself be sufficiently airy, light, and well- proportioned to the number of its inmates,—scro- fulous disease will never make its appearance. On the contrary, however well-chosen and nutri- tious the food, however minute the attention paid to cleanliness, with whatever care the clothing be adapted to the temperature, or the duration of ex- ercise, sleep, and waking be regulated, — if the houses are so placed that the sun's rays cannot reach them, or the fresh air cannot be renewed without difficulty,—if, in short, they are small, low, dark, and badly aired, scrofulous disease will inevitably supervene." (Memoire sur les Scro- fules, Revue Medicale, 1832, vol. i. p. 10.) Though we are fully satisfied of the powerful influence of impure air in the production of scro- fula, we cannot entirely coincide with M. Baude- locque. We believe that the other causes which we have mentioned are capable of inducing tuber- culous cachexia, while the patient is breathing a 538 TUBERCULAR PHTHISIS. very pure air. We find the disease not infre- quently affecting the inhabitants of elevated and dry countries, where the atmosphere is pure and the people are occupied in grazing sheep and cat- tle, and are hence so much in the open air during the day that the confined atmosphere of their ill- ventilated hovels can scarcely be considered the chief cause of the scrofulous diseases by which they are often afflicted, since we have other and more evident causes in the coarse and innutritious vegetable food which forms almost their only sus- tenance, and in their scanty clothing and exposure to the inclemency of the weather. But there can be no doubt that the habitual respiration of the air of ill-ventilated and gloomy alleys in large towns, as well as that of many manufactories, workhouses, and even schools, is a powerful means of augmenting the hereditary disposition to scrofula, and even of inducing such a disposi- tion de novo. Children reared in the workhouses of this country and in similar establishments abroad almost all become scrofulous, and this more, we believe, from the confined impure atmo- sphere in which they live and the want of active exercise, than from defective nourishment. Deficient Exercise.—Deficient exercise ranks next as a cause of tuberculous disease. If a due supply of proper nourishment and pure air is ne- cessary to nutrition, bodily exercise is equally ne- cessary to apply such nourishment to the growth and development of the body. The amount of exercise necessary to produce this effect and to maintain a healthy state of the system, will vary according to the age and nature of the constitu- tion ; but without such exercise there can be no sound health. Excessive Labour.—While a certain quantity of exercise is necessary to the maintenance of health, excessive labour, by debilitating the body, may be ranked as a cause of disease. It operates on the whole system, though, according to the mode in which the fatigue is produced, one set of organs may be more affected than another ; and when these are overworked and require an excess of nervous influence, others must suffer from a deficient supply. When the labour is carried on in confined apartments, its injurious effects are more decided. Improper Clothing.—Proper clothing is essen- tially necessary to the preservation of health. An imperfectly covered state of the body in the cold season, especially in persons engaged in sedentary occupations where exercise does not assist the cir- culation of the fluids, is most injurious, especially to young persons, in whom it is necessary to maintain a vigorous circulation through the ex- treme parts of the body in order to ensure its growth and development, to secure the due per- formance of the cutaneous secretions, and to pre- vent sanguineous congestion of the internal vis- cera. These objects cannot be effected without exercise and warm clothing. While on this subject, we must advert to the pernicious effects of the modern system of female dress. We consider the free expansion of the chest and unimpeded action of all the muscles connected with respiration, as highly conducive to health, and as one of the means of obviating pul- monary congestion. The employment of tight stays and other forms of dress which impede the full and free action of the respiratory organs, can- not be too strongly reprobated. This, however, has been so well explained in the excellent article on Physical Education, that it is unnecessary for us to say more than express our concurrence in the views therein promulgated on this impor- tant subject. [Yet it has been affirmed on the high authority of M. Louis, (On Phthisis, Sydenham edit. p. 440, Lond. 1844,) that " the alleged influence of clothing of different kinds, and especially of stays, on phthisis, is perhaps nothing more than matter of assertion wholly unsupported by proof."] Want of Cleanliness.—Cleanliness is also es- sential to health, and inattention to it is another common cause of disease; and although this may be less powerful than those causes which have just been mentioned, still it has its influence. Without attention to cleanliness, the functions of the skin cannot be properly performed, the effects of which in producing tuberculous cachexia we have elsewhere explained. Abuse of Spirituous Liquors. — Among the causes of tuberculous cachexia, a free indulgence in ardent spirits holds an important place. While it is one of the most powerful means of debasing the morals and of extinguishing the best feelings of human nature, this pernicious habit is no less effective in destroying the physical constitution. We believe that the abuse of spirituous liquors among the lower classes in this country is pro- ductive of tuberculous disease to an extent far beyond what is usually imagined. Indeed, it is only necessary to observe the blanched cadaverous aspect of the spirit-drinker, to be assured of the condition of his internal organs. The tale of his moral and physical degradation is indelibly written on his countenance. Nor does the evil rest here —he not only destroys his own health, but entails on his unfortunate offspring the sure disposition to tuberculous disease. [It has been doubted, however, whether intem- perance develops tubercles. Of 35 persons dying of various diseases, all of whom were decidedly intemperate, and most of them grossly so, in 26, according to Dr. J. B. S. Jackson, of Boston, (New England Quarterly Journal of Medicine and Surgery, July, 1842, p. 30,) no tubercles were found; in 5 there were tubercles in the lungs; in 1 in the bronchial glands; and only 2 died of phthisis. In several of the most striking, the organs were as free from tubercular disease as those of a new-born infant. These results led Dr. Jackson to suggest, whether intemperance may not have some effect as a prophylactic ?] Mental causes.—Too close application to study is a powerful cause of tuberculous diseases. It operates in several ways:—it necessarily implies sedentary habits, and hence exposes to all the evils which have their origin in want of exercise, such as imperfect digestion, constipated bowels, &c. In addition to these, the sensorium is so much exhausted by excessive exertion, that the nervous system generally is weakened, and the various organs of which the functions are essen- tial to health are deprived of their due proportioni of nervous influence. Mental depression holds a very conspicuous TUBERCULAR PHTHISIS 539 place among those circumstances which diminish | the powers of the system generally, and often proves one of the most effectual determining causes of phthisis. Disappointed hopes which have long been cherished, slighted affections, loss of friends, and reverse of fortune, exert a power- ful influence in inducing phthisis in persons pre- disposed to the disease. Various other causes of consumptive diseases have been noticed by authors. Hard water, that is, water holding an unusual quantity of calca- reous matter in solution, has been recorded among these causes, and the evidences of this are suffi- ciently strong to show that such water has an in- fluence in the production of scrofula. The effects of the water at Rheims, related in the Memoirs of the Royal Society of Medicine at Paris, has often been adduced as a striking example. (Mem. de Soc. Royale de Med. vol. ii. p. 280.) Heber- den (Commentaries, p. 362,) and Cullen (Materia Medica, vol. i. p. 406,) have both noticed the in- fluence of this cause ; and we may refer the reader to the various works of Dr. Lambe, who has gone into minute details on this subject. It may be difficult to explain how hard water produces such an effect; but the fact should be sufficient to guide us in our selection of a residence for children, more especially for those of a tuberculous consti- tution. Mercury, when used so as to affect the system, has been very generally considered capa- ble of inducing tuberculous disease. We are in- clined to believe this, and therefore consider that its use requires the greatest care in persons of a delicate or strumous constitution. Contagion.—There remains another imputed cause to be mentioned, viz., contagion. The con- tagious nature of phthisis has been believed by some authors of high authority, at the head of whom may be placed Morgagni, and altogether disbelieved by others. In the south of Europe the general opinion is in favour of contagion, in the north of Europe against it. The subject is one that scarcely admits of being confirmed or refuted. It would, therefore, be profitless to oc- cupy the pages of this work in adducing authori- ties or in detailing opinions on a subject, on which every medical man in this country has too fre- quent opportunities of making his own observa- tions and forming his own judgment. The view which we take of tuberculous cachexia, without which tuberculous disease of the lungs in our opinion cannot occur, leads us entirely to disbe- lieve that phthisis can be communicated by con- tagion. But we consider that the practice of sleeping in the same bed, or even in the same room with patients in the advanced stage of phthisis, is highly objectionable, because the rooms of the consumptive are rendered peculiarly inju- rious to health by the nature of the disease, and the confined atmosphere and high temperature in which they are too often kept. Reviewing what has been 6aid respecting the causes of tubercular cachexia, they may be stated generally to comprehend all those circumstances which debilitate, and increase the irritability of the system, impede the due digestion and assimi- lation of the food, diminish the various secretions and excretions, and induce internal sanguineous congestion. Defective assimilation,—from what- ever cause it proceeds, — whichever be the first link in the chain of morbid actions which derange this process or series of processes,—induces, ac- cording to our view, tuberculous cachexia ; and whether the primary error exist in the inadequate supply of food, or in the incapacity of the organs to extract from this the elements of nutrition, to assimilate and apply them to the reparation, growth, and various purposes of the animal eco- nomy, the ultimate result is the same. Seeing that the causes which produce tubercu- lous cachexia are so numerous, we should be ex- tremely cautious in estimating their power, and in at- tributing to any of them specific properties. When- ever their combined effect is such as to depress the vital energy, and lower the power of assimilation beyond a certain degree, the tubercular diathesis will be produced: whenever, on the contrary, the nutritive functions are vigorously carried on, this disposition will not manifest itself, however strong- ly it may be favoured by the separate action of any one of the causes in the degree in which it is usually applied. III. Causes determining Tuberculous Dis- ease of the Lungs, The chief causes that come under this head may be divided into two classes : those which act immediately on the lungs, and those which act partly on this organ and partly on the general system. 1. To the first class belong bronchitis, pneumonia, haemoptysis, pertussis, and some other pulmonary affections. Bronchitis.—Irritation and inflammation of the mucous membrane of the larynx, trachea, and bronchi, are considered a frequent cause of tuber- cles. Certain it is that no affection so commonly appears to precede tuberculous phthisis as bron- chial irritation. This circumstance may be ac- counted for in two ways. The pulmonary mu- cous membrane of tuberculous subjects is more susceptible of the impressions of the causes which produce congestion and irritation, such as vicissi- tudes in the temperature and humidity of the at- mosphere, or mechanical irritants conveyed into the air-passages during respiration,—and tubercles often prove a source of bronchial irritation some time before their presence is indicated by other symptoms. But we also readily admit that re- peated attacks of bronchial inflammation, or the long-continued application of mechanical irritants to the membrane of the bronchi, may prove the exciting cause of tubercles, when the constitutional predisposition exists. In some instances the irritation commences in the larynx, and from thence appears to extend to the trachea and bronchi; the patient in this case is subject to frequent attacks of laryngeal irrita- tion, which are usually excited by exposure to a cold humid atmosphere: there is a sensation of uneasiness in the larynx, and after a short time an increased secretion of mucus, with frequent hawking to remove it: generally, also, more or less hoarseness is present, and some cough. In other cases the person suffers from repeated at- tacks of inflammation of the internal fauces, and from thence the disease seems to extend to the larynx. After a series of attacks of laryngeal irri- tation have occurred, one, more obstinate than the others, does not subside, but continues, and is 540 TUBERCULAR PHTHISIS. soon accompanied by a cough; or should this symptom have existed previously, it is increased in severity; and the uneasy sensations, which were at first confined to the larynx, are now felt under the upper part of the sternum, and soon extend over the whole chest. The cough likewise becomes deeper, calling into action all the muscles of respiration. A patient may continue in this state for a considerable time, without fever or any other symptom, except the uneasiness of the chest and the cough ; the latter of which gradually be- comes more troublesome, and medicine is found to do little more than palliate it. Such a patient is commonly said to have an " affection of the trachea," although in truth the tracheal portion of the mucous membrane is that which is the least affected, and when affected pro- duces the least irritation: for extensive ulceration is frequently found in this part without giving any signs of its presence during life. In another class of cases (and these are the most numerous) the morbid state of the mucous membrane commences in, and is chiefly confined to the bronchi; the larynx and trachea appearing to be little affected. The patient is liable to pul- monary catarrh on the slightest exposure to cold ; during the whole winter and spring one attack succeeds another, so as scarcely to leave an inter- val of a few weeks free from cough. This state of bronchial disease often continues for many years in persons even of a tuberculous constitu- tion, without terminating in phthisis, and has been termed tubercular bronchitis. The subjects of these chronic bronchial affections, when they occur in early life, are generally persons of great delicacy of constitution. Their cases are extremely puzzling, and without the aid derived from the physical signs of pulmonary disease, the medical attendant will remain ignorant of the nature of the disease. With care such patients may be pre- served for many years; but after a shorter or longer period the catarrhal affection generally be- comes permanent, the respiration is more op- pressed, the pulse habitually frequent; and the emaciation, which had varied according to the severity or duration of the catarrhal attacks and the length of the intervals between them, now re- mains or progressively increases. The aspect of the patient is also much changed, and the symp- toms collectively leave little doubt that tubercu- lous disease is established in the lungs. These cases of long-protracted catarrh preceding the manifest existence of tuberculous disease, afford the strongest evidence of the influence of bron- chial irritation in exciting phthisis; and we have no doubt that when the least predisposition to tu- bercular disease prevails, long-continued disease of the bronchial membrane leads to the deposition of tuberculous matter in the extreme branches of the bronchi and the air-cells. But, as M. Andral observes, « what ought never to be lost sight of is this, that in order that inflam- mation of the mucous membranes of the air-pas- sages shall be followed by the production of pul- monary tubercles, it is necessary to admit a pre- disposition. This being admitted, we can easily conceive how in one individual very slight bron- chitis is sufficient to produce tubercles, whilst others do not become phthisical from the most severe and long-continued pulmonary catarrh." (Clinique Medicale, t. ii. p. 32.) [Light has been thrown upon this subject by more recent researches of M. Andral, (Hematolo- gic Pathologique, Paris, 1843, or American edit, Philad. 1844.) He found when tubercles were under the form of hard masses, without any sign of inflammation around them, that the blood con- stantly exhibited, on analysis, its normal quantity of fibrin; but in proportion as they experienced softening, a process of elimination, similar in cha- racter to the inflammatory, was established around them; the blood became charged with a larger and larger proportion of fibrin; so that, he properly infers, the formation, in excess, of this principle is not dependent upon the development of the ac- cidental product, but rather on the inflammation, which becomes associated with it at a certain pe- riod of its existence; an additional fact, he adds, to many others, that the process which creates different accidental products is not of the same nature as that which constitutes inflammation. In all the cases of incipient tuberculosis, the indivi- dual was, to a certain extent, anaemic, or the blood possessed a modification of composition like that which belongs to feeble constitutions, or those in which, owing to some cause, the vital forces have lost their energy. The quantity of globules was diminished. In proportion, too, as the tubercles progressed, the diminution of the globules became greater and greater; and when the lungs were filled with caverns, it attained its minimum; yel this diminution was never so great as in chlorosis. M. Andral ( Op. cit.) has only seen a single case in which the proportion of globules was below 80 in 1000. In every other, it oscillated between 80 and 100. (Louis, art. Phthisie, in Diet, de Med. 2de edit., p. 366, Paris, 1841.)] The bronchial affections which we have just noticed are those which are met with in all classes of life, and are for the most part the consequence of exposure to a cold and humid atmosphere, oi the alternation of this with hot rooms. Another fruitful source of bronchial irritation, originating in those occupations which expose the labourer to breathe an atmosphere loaded with particles of matter which mechanically irritate and excite per- manent disease of the bronchial membrane, has been noticed in a former part of this article. Pneumonia.—Inflammation of the pulmonary tissue next claims our attention, as being consider- ed a frequent, and, by some authors, the chief cause of phthisis. The question of inflammation as a cause of tuberculous disease has been already treated so fully in the preceding article, (Tuber- cle,) and we accord so perfectly with the opinions of the author, that it is quite unnecessary to enter on the subject here. Although we believe inflamma- tion incapable of producing tubercles in a healthy subject, we are of opinion that it may prove a de- termining cause in u tuberculous constitution; and on this account the most sedulous care should be taken to prevent its occurrence in such subjects, and to remove it when it has taken place. Pneu- monic inflammation is one of the worst evils that can befall a patient already labouring under tuber* culous disease of the lungs, as it never fails to in- crease the mischief, and frequently converts that which was latent, and might have long remained TUBERCULAR PHTHISIS. 541 bo, into active disease. It promotes the softening of the tubercles, and renders the pulmonary tissue at once incapable of the functions of respiration, and a fit nidus for the further deposition of tuber- culous matter. Indeed, we shall not err far, we believe, in stating, that in proportion to the extent of pneumonic inflammation, will be in general the rapidity of phthisis. It is chiefly in those persons who, without suffering from extreme debility, are little liable to inflammation, that we observe phthisis protracted to a great length; the tuberculous disease passing slowly and gradually through its various stages, and often arriving at a considerable extent without producing much febrile disturbance. Hxmoptysis.—Pathologists differ in their opin- ion respecting the influence of haemoptysis, as we have already had occasion to remark while on the subject of diagnosis. One class of authors regard the effusion of blood as the consequence merely of the presence of tubercles; while some others consider it a cause of the disease. M. Andral be- lieves the haemoptysis to be at once a proof and consequence of pulmonary congestion, which he considers necessary to the formation of tubercles; and having also on several occasions found, both in man and in the horse, tubercles deposited in the coagulum of blood which is the result of pul- monary apoplexy, he concludes that in this way the effusion of blood may become an exciting cause of the disease. There can be no doubt, we think, when wc attend to the history of the cases in which hae- moptysis occurs, that it is very generally a conse- quence of tubercles in the lungs, or at least occurs subsequently to their formation; although it may originate in simple pulmonary congestion. It is to be regretted that in the accounts of this and other diseases adduced as causes of phthisis, the patient's previous health and the diseases of his family are not stated. The cases of French authors, which in other respects are detailed with such praiseworthy care and minuteness, are often defective on this point. It is a kind of informa- tion which is not sufficiently appreciated, and we have had constantly to lament the want of it in our examination of works on the subject of this article. Pertussis.—Hooping-cough occurring in a pre- disposed subject may lead to the deposit of tuber- culous matter in the lungs, but we are not aware that it is a frequent cause. 2. We now proceed to consider the second class of causes, which embrace various diseases affecting the general system, and which have been considered capable of giving rise to phthisis. Fevers.—Fevers, both continued and intermit- tent, arc not infrequently followed by the disease so closely as to make them appear in the light of exciting causes. Portal gives a chapter on a form of phthisis induced by fevers, both continued and intermittent; yet the cases which he has adduced, chiefly from Lieutaud, are fever complicated with inflammation of the lungs and pleura, followed by tuberculous disease. But independently of such complications, it is often remarked that symptoms of phthi>is occur towards the conclusion of fever, or during the succeeding convalescence. When fever occurs in a person of a tuberculous constitution, it may prove the exciting cause of 2v tuberculous deposits in the lungs, from the irrita- tion to which these organs are exposed in all fevers; or if tubercles already exist in a latent state, (which we believe to be the most frequent case when fever is the exciting cause of phthisis,) it is very likely to call the tuberculous disease into activity. In this last case, the fever commonly goes through its usual course favourably : the febrile symptoms abate; the tongue becomes moist and clean ; the skin soft, the various secretions natural; but there is still a slight return of fever towards evening, and the pulse is frequent at all times: yet the pa- tient seems on the verge of convalescence, and the medical attendant expects to find the pulse slower at each visit, and generally predicts a speedy re- covery. But he is disappointed: the frequency of the pulse continues ; the evening accession of fever becomes more marked; there is a circum- scribed flush on the cheek different from the gen- eral flush of fever; the cough which attended the latter in a slight degree increases; perspirations occur towards morning; and the breathing is ob- served to be more rapid than during the severity of the fever. The real state of things now be- comes evident. The fever has ceased, but in place of terminating in convalescence, as in a healthy subject, it is immediately succeeded by, or rather lapses into, hectic fever. The patient, already greatly reduced, becomes an easy victim to tuber- culous disease of the lungs, and generally sinks rapidly under it: a few months, and in some cases a few weeks, suffice to complete his destruction. When the individual is merely predisposed to phthisis before the attack of fever, it is generally succeeded by a more perfect but lingering conva- lescence : the patient gains strength slowly : he is observed to cough occasionally ; his pulse remains quick, and after some time a degree of hectic fever supervenes. These symptoms gradually in- crease, and at length evening fever and morning perspirations occur more regularly, and are soon followed by a train of symptoms which need not here be noticed. The disease in this case also proves speedily fatal. There is a third class in which the fever ap- pears connected with consumption, although this does not succeed so closely upon it. Months may elapse before the presence of phthisis is indicated by the usual symptoms, although the fever may still have been the determining cause; inasmuch as the patient never regained his wonted health after it. In this case the fever acts as a remote rather than an exciting cause of phthisis, and might more properly have come under remote causes. The rapid progress of many cases of phthisis, apparently originating in fever, depends upon the existence of tuberculous disease in a latent state previously to the occurrence of the fever, during the convalescence from which symptoms of con- sumption were first observed. The irritation of the mucous membranes of the lungs and digestive organs which generally accompanies fevers, fa- vours the increase of tuberculous disease already existing; and the state of convalescence is perhaps of all conditions the most favourable to the pro- gress of pulmonary disease. In a subject ex- hausted and debilitated by an acute disorder, ex- 542 TUBERCULAR PHTHISIS. posure to cold, over-fatigue, &c, may easily deter- mine the production of phthisis. Another circumstance which often occurs to aggravate and complicate the cases now under consideration, is an attack of pleurisy, pneumonia, or bronchitis, which is a frequent occurrence from imprudent exposure after febrile diseases. There remains to be noticed a febrile affection peculiar to childhood, at least in its more acute form, which is fraught with the utmost danger, as it proves a frequent exciting cause of tubercu- lous disease; we allude to what is commonly de- nominated Infantile Remittent Fever. If ne- glected or improperly treated, it often induces fatal cerebral disease; but more frequently as- sumes a chronic form ; and being essentially seated in the digestive organs, speedily leads to a derangement of the digestive function and the various secretions connected with it, and moreover renders the child extremely liable to acute attacks of gastric and bronchial irritation, from slight errors in diet, exposure to cold, &c. This affection is considered by Hufeland as so intimately connected with tuberculous disease, that he regards it as a precursor of the scrofulous diathesis, or a sign of its presence, and proposes to name it scrofulous fever. According to his observation, it is most frequent within the two first years of life. (Traite de la Maladie Scrophuleuse, p. 92.) Eruptive fevers, particularly rubeola, scarla- tina, and variola, are attended with still greater danger to persons of a tuberculous constitution than continued fever. Rubeola.—Bronchial disease, often of a very severe character, forms an essential part of mea- sles ; so that we have bronchial irritation super- added to the fever. In early life measles are known to prove a frequent exciting cause of tu- berculous disease. Scarlatina.—Although attended with less bron- chial irritation, scarlatina is still a very dangerous disease to young persons disposed to or labouring under the tuberculous diathesis. During conva- lescence from scarlatina there is a peculiar dispo- sition to inflammation ; and pleurisy and pneumo- nia are easily induced by slight exposure to cold, fatigue, &c, for some time after the eruption has ceased; and the rapidity of phthisis after scarla- tina, which was noticed by Morton, is, we believe, chiefly owing to the inflammation of the pleura or lungs being superadded to the tuberculous disease previously existing. It is during the convales- cence from these diseases that the great danger is to be apprehended, and the most sedulous care should be taken during that period to guard against exposure to cold and other exciting causes of pul- monary inflammation. Variola.—Small-pox is generally accompanied with much bronchial irritation, and proves a very fatal disease in the strumous habit; but fortu- nately we have few opportunities of witnessing the evil consequences of this disease at present. The following remark of Heberden will show that the influence of the diseases which have just been noticed, in inducing phthisis, did not escape the observation of that sagacious physician : " Fieri potest ut morbilli graviores, vel peripneumonia, vel tussis convulsiva, vel alia adversa valetudo la- tentia tabis semina excitent, vel etiam gignant, tarn in ultiml senectute, quam in pueritia; cujus rei excmpla ubique obvia sunt." (Commentarii.) Several other diseases have been considered causes of phthisis, such as rheumatism, syphilis, psora, &c.; but the observations upon which this opinion rests do not appear to us to have been made with sufficient accuracy to merit notice in this place. Sect. XI. — Of the Pathology of Phthisis AND OF TCBF.HCCL017S DISEASES I2T OENEHAI, In a certain condition of the system which we have endeavoured to describe under the title of tuberculous cachexia, a peculiar matter is poured out by the blood-vessels and deposited in the vari- ous tissues and organs of the body. This matter, constituting one of the forms in which the morbid modification of the general system manifests itself, is subject to laws of formation and has physical characters proper to itself, by which it can gene- rally be recognised, however modified in form and appearance by the structure or functions of the part in which it is deposited. From remote antiquity to the present day, the disease of which this matter constitutes the dis- tinctive anatomical character, has received different names according to its development in particular organs and tissues. In the external glands and in bones, it is commonly called scrofula; in the lungs, phthisis; and in the glands of the mesen- tery, tabes mesenterica, &c. The identity of these affections was only suspected by the ancients from the similarity of the general symptoms, but has been demonstrated by the moderns on the clear evidence of morbid anatomy; an increased atten- tion to which science, and the study of the causes of the disease, have led pathologists to entertain more accurate opinions and more comprehensive views regarding it. From the rounded form which this matter as- sumes in certain situations, it received the very inappropriate name of tubercle,- a term which is still applied to it by modern pathologists, although it designates an appearance not constant to this, but occasionally assumed by other morbid products, and depending rather on the structure of the or- gans in which it is deposited than on the matter itself; as is clearly shown in Dr. Carswelfs"Il- lustrations." It occurs perhaps more frequently than any other morbid product; and a proof that it is dependent on a certain morbid condition of the animal economy is to be found in the circum- stance, that it is often deposited at the same time in various parts of the body,—on some occasions in almost every organ. Tubercle or tuberculous matter is now, we be- lieve, generally considered as a secretion or depo- sit depending upon a morbid state of the general system, from the liability to which no constitution, no temperament, age, sex, or race, as we have already seen, is entirely exempt, though the dispo- sition to it is strongest in that condition of the body called lymphatic in the age of infancy, in the female sex, and in the negro race. These and other circumstances of climate, occupation, &c, not only influence its absolute frequency, but have also a powerful effect in determining its de- velopment in particular organs or structures, in modifying the course of the disease, and in giving a various character even to the general diathesis TUBERCULAR PHTHISIS. 543 by which the disposition to its formation is cha- racterized. But in whatever point of view we may regard tuberculous cachexia, we shall find its phenomena explicable only by admitting that it depends on a general modification of the whole and every part of the animal economy; and that all notions which regard it as the morbid degeneration of any organ or tissue, or of any particular system, or the morbid modification of any single fluid, are necessarily erroneous, and founded on limited views of its nature and laws, and totally inade- quate to explain its phenomena. The deposition of the peculiar matter of tuber- cle in any of the tissues or organs of the body is only the result of previous changes in the general system, cognizable, as we have endeavoured to show (Sect. II.), by the physical condition of the patient and by a disordered state of various functions,—a condition of body quite distinct from mere debility, and therefore inexplicable on the idea of a difference of force or tone of the system; and which, though very generally accompanied with a feeble organization, is not inconsistent with too great development and inordinate action of particular parts, and even with considerable phy- sical power of the system. As tuberculous cachexia appears to be the con- sequence of an imperfect assimilation of the nu- tritive matter received into the economy, it is evident that its influence cannot be confined to any part, tissue, or organ, but pervades the whole system, and modifies the entire organism,—the structure of every part and the nature of every secretion. Thus the osseous system is more spongy ; the cellular tissue is singularly lax ; the muscular flaccid and imperfectly developed ; the vascular system is weak and irregular in its ac tions, and subject to local congestions from the slightest disturbing causes. The circulating fluids also partake of the general disorder; the blood is serous, and deficient in fibrine and colouring mat- ter. (Andral, Anat. Path. Trans, vol. i. p. 535.) The glandular and lymphatic systems are more peculiarly affected, as being more intimately con- cerned in the function of nutrition ; and hence this system has been by many considered as the seat of the disease. The 6kin is generally thin and soft, or thick, coarse, and dry, and subject to many diseases apparently arising from the morbid condition of its function of secretion, which is always in tuberculous subjects more or less de- ranged. The mucous system is peculiarly sus- ceptible of disease ; and great discharges of mat- ter, differing more or less from the healthy secre- tion, are poured forth from the surfaces of the mucous membranes on the application of the slightest causes of irritation or congestion. These we consider as examples and proofs of a defective state of organization,—the consequence of defec- tive power in the assimilative organs, or an imper- fect supply of nutritious matter, &c. This view of the pathology of tuberculous cachexia is that, we believe, generally adopted by the best patholo- gists of the present day. But Dr. Todd has gone further, and explained his opinion by attributing the formation of tubercles to the deposition of co- agulable lymph imperfectly organizable. From his experiments on the reproduction of the ampu- tated members of the lower animals, he is induced to consider coagulable lymph as the matrix of the various tissues of the body. (See our work "On the Influence of Climate, &c." pp. 311-314, note.) . , In the healthy state of the nutritive function each part separates the materials proper for its support, and converts them into its own particular tissue or structure; and the various secretory or- gans secrete their peculiar fluids in their due quantity and healthy qualities,—some to be ap- plied to the purposes of the animal economy, others to serve as vehicles for eliminating effete and useless matter from the system. Hence, im- perfect assimilation on the one hand, or defective secretion and elimination on the other, may ulti- mately give rise to a state of tuberculous cachexia. Such a condition being once established in the parent, it is easy to conceive what will be its in- fluence on the offspring. The extended view which we take of tubercu- lous cachexia, and of its influence on the secre- tions and on the products of diseased action, in- clines us to believe that tuberculous deposits are always at first in a fluid or semifluid state, and that the concrete form in which they are com- monly found arises simply from the absorption of the more fluid part, and is in many situations de- pendent even on their compression, as is shown by Dr. Carswell; and we have no difficulty in conceiving that the matter formed in certain cuta- neous eruptions, and that thrown off from the free surfaces of mucous membranes, would have as- sumed all the characters of crude tubercle, had it been confined in the parenchyma of organs, or the extreme bronchial ramifications, &c. When the tuberculous diathesis prevails to a great degree, large depositions of tuberculous matter may take place in many organs of the body about the same time; or irritation of any one organ may deter- mine the production of the disease in that alone, and death may be the result, before other parts of the system are affected. The foregoing observations, with some slight exceptions, are to be regarded rather as a detail of the more constant phenomena which accompany the progress and development of phthisis, than as an exposition of the real pathology of the disease. In the few remarks which we are now about to make, if we deviate from the sure path of demon- strable fact, we believe that we are still borne out by observation and by the results of practical ex- perience ; and we are willing to incur the imputa- tion of yielding a little to theory rather than ha- zard the chance of leaving unsaid that which, we are disposed to think, may be of practical value to some of our readers. It is reasonable to believe that the remote causes of phthisis, however variously they may appear to operate, do so by inducing some peculiar or de- terminate derangement of the system—some posi- tive pathological condition, which, being constant- ly present wherever tuberculous disease is found, may be regarded as necessary to its production. Although we hesitate not to say, that, in the ac- tual state of our physiological and pathological knowledge, we are unable to define with certainty all the conditions in which tuberculous disease has its origin; we think that it would not be diffi- 544 TUBERCULAR PHTHISIS. cult to point out some of the more important links of the chain which connects special functional disorder with the formation of tuberculous ca- chexia. On some future occasion we may take an opportunity to enter more fully upon the sub- ject ; our limits at present merely permit us to call the attention of the reader to that morbid con- dition which, in our minds, constitutes the most obvious and important in a practical point of view. A congestive state of the venous system of the abdomen is the condition to which we refer; it is one which was familiar to the pathologists and practitioners of the last century, and, although it has not been quite overlooked, it has been too much neglected by the moderns. Such of our readers as are familiar with the writings of the German physicians of the middle of the last cen- tury, particularly Stahl, (see his «Vena Portae, Porta Malorum,") Hoffmann, (Med. Rat. t. i. s. I. cap. viii.) and above all Kaempf, and his disciples, will be aware of the extensive influence and im- portance attached to this state of the abdominal circulation, at that time. Referring to those works where the facts upon which the doctrine rests are fully exposed, we shall restrict ourselves here to a few observations more particularly bearing upon the subject of this article, and which it is but jus-. tice to ourselves to say were established in our mind as the result of practical observation, before we were aware of the existence of the German doctrines of abdominal infarctus.* In children originally of a strumous habit, we observe a constant disposition to this congestive state of the abdominal circulation ; and unless we succeed in obviating it, they become tuberculous and die early in life. In youth we find the same state of congestion as a precursor of tuberculous cachexia ; but it is during the middle period of life, from thirty-five to fifty, that it is accompanied with more marked symptoms, such as dyspepsia with its various concomitants, which exist often for a very considerable time, and not unfrequently obscure the pulmonary affection till tuberculous disease has made considerable progress. This is the form of the affection which has beeen denomi- nated dyspeptic phthisis,- and if the term referred merely to the cause of the pulmonary disease, there would be little harm in retaining it,—but if used to designate a species of phthisis differing from the tubercular, we consider it decidedly ob- jectionable ; because, however prominent the dys- peptic symptoms may be, tubercular disease of the lungs is the cause of death. While we admit to the fullest extent the necessity of attention to the * John Kaempf, the original improver, if not author, of this doctrine of abdominal infarctus, and of its pecu- liar treatment by clysters, did not himself publish any work on the subject. The doctrine was first made known in the inaugural dissertation of his eldest son (also named John) De infarctus vasorum ventriculi, published at Basil in 1751. It was afterwards more fully developed in the dissertations of Koch, De infarctibus vasorum in infimo ventre. Argent, 1752; of Schmid, De concrementis uteri, Basil, 1753 : of Elvert, De infarctibus venarum ab- dominalium, Tubing. 1754: of Faberand Brotbeck, Ulte- rior expositio novm methodi Kaempftanm, Tubing. 1755 ; of G. L. Kaempf (the second son), De morbis ex atrophia, Basil, 1756; and, finally, in the treatise published in his native language by John, the eldest son, entitled Fur Aerzte und Kranke bestimmte Abhandlung, t\c, Dessau, 1784-8. The best of these dissertations, viz. those of J. Kaempf, Koc, Elvert, and Faber and Brotbeck, are re- printed in the third volume of Baldinger's Sylloge, Gott. state of the digestive organs, we must object to the pathological view which limits the attention of the practitioner to the dyspeptic affection, ne- glecting other and equally essential parts of the treatment. We do not know such a disease u dyspeptic phthisis as constituting a particular spe- cies ; but we are well acquainted with that form of tuberculous phthisis which is long preceded and accompanied in its progress by dyspepsia. In- deed, tubercular phthisis rarely occurs in the mid- dle period of life without this complication; hut it cannot be doubted that the deranged condition of the digestive organs is, in these cases, very often a mere consequence of a long pre-existing state of congestion of the venous system of the abdomen ; and which, if not corrected by more efficient measures than those generally applied to relieve the dyspeptic symptoms, may soon termi- nate in pulmonary consumption. The profession are highly indebted to Dr. Wilson Philip for call- ing their attention to the congestive state of ihe hepatic system, and pointing out some of the most effectual means of obviating it*; but we cannot admit that this dyspeptic phthisis differs in its nature from common tubercular phthisis. The effects of congestion and derangement of the abdominal viscera have long been remarked as causes of phthisis : they were regarded by Kaempf and his disciples as giving rise to most of the chronic diseases of the chest. Portal ob- serves, that it is certain that engorgement of the liver and other affections which derange the secre- tion and even excretion of the bile, may become a cause of pulmonary phthisis; and several other authors have remarked the connection of phthisis with abdominal disease, but in a manner so vague and undefined as to attract little attention. Abdominal plethora, when once established, gives rise to a series of deranged functions in the digestive organs, the lungs, skin, &c, which, by impeding digestion and assimilation, affect the whole animal economy. These are mani- fested in imperfect biliary secretion, constipated bowels, and irritated mucous surfaces, in conges- tion of the lungs, and a dry and harsh state of the skin. In consequence of the overloaded condition of the venous system, the heart, generally feeble in the tuberculous constitution, is oppressed, and the arterial circulation impeded and enfeebled. In this state of the system, very slight exciting causes induce disease, especially inflammation and he- morrhage ; hence arises the constant liability of strumous subjects to inflammatory diseases of a sub-acute and chronic character, and hence also we derive an explanation of the hemorrhages to which they are peculiarly liable even at a very early age. The same pathological state of the abdominal circulation forms the remote cause of the various congestive and chronic diseases so common in the strumous subject; such as glan- dular swellings, cutaneous eruptions, &c. &c. Sect. XII. — Prevention of Ti bercclocs Diseases. We have stated our views so fully respecting the nature and causes of tuberculous diseases, that it is unnecessary to enter into minute details on the subject of prevention : we shall, therefore, confine ourselves to some general remarks re- garding the principal circumstances which require TUBERCULAR PHTHISIS. 545 the attention of the physician who may be called upon to lay down rules respecting this most im- portant subject. The first question that suggests itself under the head of prevention regards Hereditary Transmis- sion, and involves the consideration of two distinct objects;—the first being to check the transmis- sion of the disease by the parent to the offspring ; the second, to prevent the disease in children born with the constitutional predisposition to it. I.—Prevention as regards Farentsi Wij have already endeavoured to show, in the section on the causes of phthisis, that it is not necessary that the parents should be the subjects of tuberculous disease in order to transmit the tuberculous constitution to their children :—the belief that scrofulous parents only have consump- tive children is an error that cannot be too soon corrected. We have also shown that a deranged state of health in the parent from many different causes, may render the offspring predisposed to the disease before us. Every member of the profession, by observing what is daily passing before him, may see nume- rous proofs of the truth of this statement: he will find that when the parents are unhealthy, the children are so likewise, and that the latter often show evident signs of the tuberculous constitution when the former have no symptoms of it. The children of parents who have suffered long from dyspeptic complaints, gout, cutaneous affections, or any other form of disease which has influenced the general system, are very frequently the sub- jects of tuberculous disease, or of such derange- ments as dispose to tuberculous cachexia. When both parents are affected, this result is brought about with more certainty. Marriage.—In order to prevent effectually the extension of tuberculous disease, it is essential that we should in the first place direct our atten- tion to the health of the parents:—were they con- vinced that the health of their children depended upon their own, a beneficial effect might be pro- duced among the more reflecting part of mankind, and especially among families of a strumous habit. If more consideration were bestowed on matrimo- nial alliances, and a more healthy and natural mode of living were adopted by persons in that rank of life which gives them the power of re- gulating their mode of living according to their own choice, the predisposition which is so often entailed on their offspring might be checked, and even extinguished in their family, in the course of a few generations. In the present state of so- ciety, the reverse of this very commonly happens; and from the total disregard of the precautions alluded to, the third generation often terminates the race. The children of dyspeptic persons generally become the subjects of dyspepsia in a greater degree and at an earlier period than their parents; and if they marry into families of a deli- cate constitution, their offspring become highly tuberculous and die of phthisis in early youth or even in childhood. We could at this moment adduce many examples of this melancholy fact; but it is consolatory to know that it is an evil which may be in some measure obviated or re- moved. This extinction of families may, we be- lieve, be prevented by judicious intermarriages with Vol. IV. —69 * 2T* healthy persons. Families already predisposed to tu- berculous disease should at least endeavour to avoid matrimonial alliance with others in the same con- dition ; but above all they should avoid the too common practice of intermarrying among their own immediate relations,—a practice which is at once a fertile source of scrofula, a sure mode of deterio- rating the intellectual and physical powers, and eventually the means of extinguishing the dege- nerated race. "There can be no question,"— says Dr. Mason Good," that intermarriages, among the collateral branches of the same family, tend more than any thing else to fix and multiply, and aggravate hereditary predisposition. And hence nothing can be wiser, on physical as well as on moral grounds, than the restraints which divine and human laws have concurred in laying on marriages between relations." (Study of Medi- cine, vol. v. p. 35.) It would also be well if all persons who contemplate marriage were aware of the necessity of attending to their state of health previously to and after the adoption of this change of life. The dyspeptic should have recourse to those means which are calculated to restore the functions of his digestive organs; the gouty sub- ject should renounce the well-known causes of his disorder; and those who are afflicted with or- ganic disease, more especially with consumption, should pause before they enter into a contract which can only entail disease and unhappiness on all concerned. The medical practitioner alone sees, or at least comprehends the extent of misery originating in marriages of this description; he will, therefore, appreciate the justness of these remarks, although he will acknowledge the difficulty of enforcing them on the practical consideration of the public. We are well aware that the mass of mankind are- far too reckless to attend to any precautionary measures on the subject, even though perfectly satisfied of their truth and necessity; still there is a small proportion on whom we are inclined to think these cautions may not be wholly thrown away. It must not be forgotten that this is not merely a question which has reference to private feelings and social happiness, but one of great public importance, involving at once the well- being of society, and the moral as well as the physical character of nations.* Pregnancy.—There are certain rules of man- agement and conduct which it is necessary for every mother to pursue during pregnancy. Far too little regard is paid by females to their health during this most important period of their lives, and they are in general little aware of the influ- ence of their own health upon that of their chil- dren. From the commencement of pregnancy, every female, especially if she is delicate or be- longs to a strumous family, should regard her health with more than common solicitude. She should take daily exercise in the open air suited to her strength, and when circumstances permit, we would recommend that she should pass the period of pregnancy in the country. It has often been imagined that females during * We beg to refer to the valuable little work of Mr. Belinaye, on the "Sources of Health and Disease in Communities," for some very judicious remarks on this subject. 546 TUBERCULAR PHTHISIS. the state of pregnancy require a fuller diet than that to which they have been previously accus- tomed. This is a great error as a general rule: increase of diet is not necessary or beneficial; on the contrary, it is often useful to reduce the usual quantity of food, especially in the advanced months, a period during which stimulants of all kinds are generally hurtful. There is an increased activity in the system of the pregnant female, which, so far from requiring any additional in- crease from art, more frequently renders it ne- cessary to diminish the stimulants in common use. Crowded assemblies of all kinds, public specta- cles and theatrical exhibitions, in short every thing calculated to excite strong feelings, to depress the mind, or excite the passions, ought to be sedu- lously avoided. There arc numerous other cir- cumstances regarding the cenduct of females during pregnancy which do not come within the province of this article; these it will be the duty of the medical attendant to point out and enforce. He should particularly impress upon the attention of the young mother, that the health of her infant depends upon her own, and that from the com- mencement of pregnancy she is to consider her- self responsible in a great degree for the health of . her offspring. II.—Prevention as regards Children. Although we are not acquainted with any di- rect remedies for the constitutional predisposition to tuberculous disease, there can, we think, be no doubt that we are possessed of the means of cor- recting it in many instances in an indirect man- ner. By placing the predisposed child in circum- stances the most favourable to health, as regards nourishment, air, exercise, &c.; by removing functional derangements as they occur, and by maintaining especially a healthy condition of the digestive organs, we may improve the constitution so as to overcome the hereditary predisposition. By the measures now referred to, we are persuaded that a large proportion of such children might be saved, although it is perhaps not beyond the truth j to say that five-sixths perish under the present j system of management. In proceeding to de- velop more fully the measures which we deem essential in the accomplishment of this object, we | are well aware that many of our recommendations ] will unfortunately be beyond the means and at- tainment of the public at large; but nevertheless we feel called upon to state them without regard to individual exceptions, as they are in our opinion the most effectual means of prevention when cir- cumstances admit their application. In order to render our observations more practi- cal, we shall apply them to the different periods of life: this will, no doubt, give rise to some repetitions; but these are unavoidable in treating of a disease, the causes and remedies of which vary so much at different ages. 1. Prevention of the disease in Infants.— During the growth and development of the body, all those measures which are known to contribute to the general health must be adopted, in order to prevent tuberculous disease in an infant born with the predisposition to it. The rules for governing the health of strumous infanta are nearly the same as for others; but they require to be more rigidly enforced and more strictly attended to, Unless the child of tuberculous parents be reared with the greatest attention to every circumstance which can contribute to health, he has but little chance of reaching maturity without becoming the subject of tuberculous disease. Nursing. — If the infant derives the strumous constitution from both parents, or from the mother only, he should be suckled by a young healthy nurse; but should the disposition to disease 1« derived entirely from the father, and the mother's health be unexceptionable, she should suckle her own child. It is always satisfactory when this can be accomplished, as it is, with few exceptions, the plan most agreeable to the mother; and if her mode of living be consistent with her duties as > nurse, it will be far better for the infant: but all these contingencies acquire consideration before we decide on the plan which it is desirable to adopt. We do not enter upon the moral con- sideration of the question, — we merely speak of it in a medical point of view ; and we are satis- fied that when the mother's health renders her unfit to nurse her child, or her habits or mode of living are such as to prevent her from adhering to those regulations by which every nurse, whether mother or not, should abide, it is much better for the health of the infant that he should derive his first nourishment from the breast of a stranger. The arguments advanced in favour of the opin- ion that every mother should nurse her own infant, appear very plausible, and would be perfectly just if every mother enjoyed that state of health which renders her fit for such a duty. In the present state of society, however, this is far from being the case, and we therefore consider it better for the delicate mother herself, and infinitely so for her child, that she should at once renounce a task for which her constitution renders her unfit, than struggle on for a few months in an attempt which may injure her own health and destroy her infant Half measures, so often recommended in such cases, are always unwise ; they generally end in the child being fed by hand in place of being suckled, — a plan which never fails to injure the health of a strumous infant. We would therefore lay it down as an invariable rule, that the child of a consumptive mother, or of one in whom the strumous constitution is strongly marked, more particularly if it be attended by decided scrofulous disease, should be suckled by another woman, and that the period of nursing should generally range from twelve to eighteen months, or even longer. We recommend the suckling to be continued for this length of time, partly with a view to enable the infant to pass over the dangerous process of teething with greater safety: indeed the strumous infant should not be weaned till the first set of teeth have appeared ; he should have no food in general but the nurse's milk till he is six months old at least, and for some time after this it should be of the lightest quality, and constitute a small proportion of his nutriment. It is almost unnecessary to add to these remarks, that the selection of a nurse for a tuberculous infant deserves especial attention. She should b* young, healthy, and free from all suspicion of a TUBERCULAR PHTHISIS. 547 strumous constitution, and her child should not be older than that which she is required to nurse. She should take daily exercise in the open air; her regimen should not differ much from that to which she has been accustomed, and any change which is made in it should be gradual. It is er- roneous to suppose that women when nursing require to be much more highly fed than at other times : a good nurse does not need this, and a bad one will not be much better for it. The quantity which many nurses eat and drink, and the indolent life which they too often lead, have the effect of deranging the digestive organs, and frequently induce a state of febrile excitement, or a premature return of the catamenia. Dress, Bathing, 4-c. — The dress of all infants should be carefully suited to the season. The whole surface, particularly the extremities, should be well protected during cold weather: the notion that infants may be hardened by exposing them to the air in a half-covered state is false in the case of all children, and leads to pernicious conse- quences in those of a delicate constitution. Much has been said and written in favour of cold bathing; and authors who have laid down rules on this subject have adduced in support of the practice the customs of savage nations, alto- gether overlooking the difference in the condition of infants in civilised life. The object of washing and bathing children is two-fold; the first and most important being that of cleanliness, especially in the tuberculous infant, in whom it is essential that the cutaneous functions should be maintained in a state of healthy activity. At first the infant should be washed with warm water ; and a bath every night, with the view of thoroughly cleaning the hody, will be beneficial; by degrees the water with which he is sponged in the morning may be made tepid, but the night bath should be continued of such a temperature as to prove grateful to his feelings. The second object in bathing being to brace and strengthen the infant, he may, as his age increases, be sponged with cold water, or even plunged into it, every morning during the summer with advantage. The judicious adoption of this plan, along with subsequent friction of the body with flannel, is, we believe, one of the most effec- tual means of strengthening children; but its effects must be carefully watched, as all children will not be equally benefited by cold bathing, and the health of some may even be injured by it. Air.—As we regard the respiration of a dete- riorated atmosphere one of the most powerful causes of tuberculous cachexia, so we consider the respiration of pure air an indispensable requi- site for strumous children; indeed, without this all our efforts to improve their health will fail. Too much attention, therefore, cannot be paid to the construction and ventilation of the child's apartments: the room in which he sleeps should be large and well-proportioned, the air should be frequently renewed, and his bed should not have more curtains than are necessary to guard against currents of air. The custom which prevails in this country of surrounding beds with thick cur- tains is most injurious to health; and it is to this habit, and to the heated atmosphere of their bed- rooms, that the languor and bloated appearance of many young persons, on first awaking in the morning, is in a great measure to be attributed. The bed-rooms should be large in all their dimen- sions, they should be in an elevated part of the house, and so situated as to admit a free supply both of air and light: those apartments to which the sun's rays and the refreshing breeze have free access, are always the most healthy and de- sirable. The proper time for carrying an infant into the open air must be determined by the season of the year and the state of the weather. A delicate infant born late in the autumn will not generally derive advantage from being carried into the open air, in this climate, till the succeeding spring; and if the rooms in which he is kept are large, often changed and well ventilated, he will not suffer from the confinement, while he will most probably escape catarrhal affections which are so often the consequences of the injudicious exposure of in- fants to a cold or humid atmosphere. Residence.—It is almost unnecessary to say, that when an infant can be suckled in a healthy situation in the country, it is, cxteris paribus, far preferable to the town; but the choice of situation requires so much judgment and is so little regard- ed, that we trust to be excused for offering a few remarks in this place on the rules by which it should be regulated. There is no circumstance connected with health, concerning which the public are, in our opinion, so ill-informed, as the requisites of a healthy resi- dence, both as regards the local position and the internal construction. In this island we have chiefly to guard against humidity, on which ac- count our houses should not be built near water, especially when stagnant, and, still less, near marshes. Large trees, which are both an ornament and an advantage at some distance from a house, be- come injurious when so near as to overshadow it, or prevent the air from circulating freely around it, and through its various apartments. The at- mosphere of a building overhung by trees, or sur- rounded by a thick shrubbery, is in a state of con- stant humidity, except in the driest weather; and the health of the inmates rarely fails to suffer. The natural moisture of the country, arising from the humid state of the soil and vegetation, is greatly increased by such an injudicious mode of planting; an artificial atmosphere is thus created which renders a situation of this kind much less healthy than the more open parts of large towns. It is not generally known how limited may be the range of a damp unhealthy atmosphere; a low situation surrounded by trees may be capable of inducing tuberculous disease in an infant, where- as a rising ground a hundred yards distant may afford a healthy site for his residence. The dry- ness of the air in towns, which is the consequence of good drainage and an artificial soil, is at once the safeguard of the inhabitants, and a compen- sation, in some measure, for the want of that unimpeded circulation and renewal of pure air which the country alone affords. 2. Prevention of the disease in Childhood.— During the period of childhood the same unremit- ting attention is necessary to the circumstances just mentioned under the head of infancy. The important process of teething being fairly passed, 548 TUBERCULAR PHTHISIS. the food of the child ought to be regulated chiefly by the state of the digestive organs. In propor- tion to the delicacy of the child, the diet will in general require to be mild; when he thrives upon farinaceous food, milk, and light broths, no strong- er or more substantial diet need be used during the first two years of life: when he looks healthy, and grows, and his bowels are regular (for this is one of the surest indications that the food is suited to the digestive organs), we have the best proofs that the diet agrees with him. When, on the other hand, the child appears heated or flushed towards evening, when he drinks greedily and more than is usual in children of the same age, and when his bowels do not act regularly, we may be assured that there is something wrong in the regimen employed. There is no greater error in the management of children than that of giving them animal diet very early in life. To feed an infant with animal food before it has teeth proper for masticating it, shows a total disregard to the plain indications of nature in withholding such teeth till the system requires their assistance in masticating solid food. Before that period, milk, farinaceous food, and broth afford that find of sustenance which is best suited to the digestive organs, and to the nourish- ment of the system. The method of grating and pounding meat as a substitute for chewing, may be well suited to the toothless octogenarian, whose stomach is capable of digesting it; but the sto- mach of the young child is not adapted to the digestion of such food, and will be disordered by it. When the child has the means of masticating, a little animal food may be allowed; but at first it should be of the lightest quality and given on alternate days only, and even then its effects should be watched; for all changes in the regi- men of children should be gradual. The frequent origin of scrofulous disease in de- fective nourishment has led to the opposite ex- treme ; and children who are disposed to tuber- culous disease are too often subjected to a system of over-feeding, which induces the disease it is in- tended to prevent. By persevering in the use of an over-stimulating diet, the digestive organs be- come irritated, and the various secretions imme- diately connected with digestion are diminished, especially the biliary secretion ; at least the sen- sible qualities of the bile enable us to observe it best. Constipation of the bowels soon follows, congestion of the hepatic and abdominal veins succeeds, and is followed by the train of conse- quences which have already been detailed. It would be well if the advocates of the system of high-feeding would bear in mind the salutary adage, corpora impura quo plus nutries, eo magis Ixdis. Exercise.—When the child has acquired suffi- cient strength to take active exercise, he can scarcely be too much in the open air; the more he is habituated to this, the more capable will he be of bearing the vicissitudes of the climate. If children are allowed to amuse themselves at plea- sure, they will generally take that kind and de- gree of exercise which is best calculated to pro- mote the growth and development of the body. When they are too feeble to take sufficient exer- cise on foot, riding on a donkey or pony forms the best substitute; this kind of exercise is at all timei of infinite service to delicate children ; it amuses the mind and exercises the muscles of the whole body, and yet in so gentle a manner as to induce little fatigue. Young girls should be allowed, and even encouraged, to take the same kind of exer- cise : it is chiefly the unrestrained freedom of ac- tive play that renders boys so much less subject to curvatures of the spine and other deformities than girls,—a large proportion of whom are more or less misshapen, in consequence of the unnatural restraint which is imposed upon them in their ex- ercise and dress. The clothing of young persons requires particu- lar attention, and must of course be regulated ac- cording to the season. The winter dress should be early resumed and laid aside late. It is in spring and autumn that the vicissitudes of our climate are greatest, and congestive and inflamma- tory affections most common; this is peculiarly the case in the spring, which is also the season when local strumous affections are most liable to occur in constitutions disposed to them. Flannel next the skin is, in our opinion, not only propel but generally necessary : it may be put off with advantage during the night, and cotton may be substituted during the summer, the flannel being resumed early in the autumn. Education. — The education of strumous chil- dren requires much judgment and consideration; no such child should be condemned to pass the greater part of the day in the close apartments of a crowded school until he has attained his ninth year at least. We consider that the hours of confinement in schools are much too long for the purposes of in- struction, and might be abridged with great ad- vantage to the health of the children; the young mind is easily wearied, and it is not sufficiently considered that the intellectual development ought for a time to give way to the physical improve- ment of delicate children. School-rooms should be large and lofty, so as to insure ventilation without the risk of exposure to currents of cold air, for the impure atmosphere which too com- monly prevails in schools is an unfailing source of injury to health. During the first years of education, children should be allowed a little re- laxation and play at intervals in the school hours. At no period of youth should education be pushed beyond its proper limits, or the mind be worked above its powers; the welfare of the pupil demands the observance of this rule on the part of the master as well as the parents, more espe- cially when the child belongs to that class of strumous children whose intellects are preternatu- rally acute. Unfortunately, however, these are generally the pupils selected by the master to do credit to his establishment; every means are taken to encourage the premature manifestation of mind, and to stimulate the child to renewed exertions; and thus health, and even life, are often sacrificed at a period of brilliant promise, when the hopes of friends are buoyed up by the fallacious expectation of a harvest, which a more rational system of edu' cation might have realized. In some cases, however, the mischief resulting from this cause does not make its appearance at this early age; we have met with many distresnnS TUBERCULA examples of young men, who, after years of close application at school, had entered upon their studies at tho university with the same unabated zeal, but were soon compelled by the sudden failure of their health to abandon their literary pursuits and the prospects which they had in view. The more we have seen of the prevailing system of management in schools, the more have we been persuaded that no subject more deserves the attention of parents than the education of strumous children; and, however laudable may be their desire to see the minds of their offspring highly cultivated, it should be checked by the knowledge that this object can only be attained by the sacrifice of health, and too often by the loss of life. " The time," says Dr. Beddoes, " is not perhaps far distant, when parents shall discover that the best method of cul- tivating the understanding, provides at the same time most effectually for robustness of constitu- tion ; and that the means of securing both parts of the comprehensive prayer of the satirist,—ut sit mens sana in corpore sano—are identical." The consequences which we have just noticed as arising from the erroneous system of education in the schools for boys, prevail in a greater de- gree, and are productive of more injury in female boarding-schools. If the plans pursued at many of these establishments were intended to injure the health of the pupils, they could not be better contrived to effect that purpose. The prevailing system of female education is indeed fraught with most pernicious consequences; — at a period of life when the development of the physical consti- tution demands the most judicious management, young girls are sent to schools in which no other object appears to claim consideration than the amount of mental improvement, or rather the variety of accomplishments with which they can be stored. At an early hour in the morning the pupil is set down at the piano or the drawing- table, where she remains in a constrained position, often in a cold room, till the whole frame, and more especially the lower extremities, become chilled: — the brief relaxation during the short space allowed for meals and the formal walk, are insufficient to restore the natural warmth of the system ; and it often happens that girls are allowed to retire to their room at bedtime with their feet so chilled as frequently to prevent sleep for hours. Those who are acquainted with the boarding- schools of this country will allow that this is no exaggerated picture of many of them. A deli- cate girl submitted to such a regimen cannot es- cape disease. While school-boys have the advantage of a play-ground, or enjoy their recreation at pleasure in the open fields, the unfortunate inmates of a female boarding-school are only permitted to walk along the footpaths in pairs in stiff" and monoto- nous formality, resembling, as Beddoes justly re- marks, a funeral procession, and wanting nothing to funeral melancholy but sables and the hearse. The consequence is, that the muscles of the upper extremities and those which are chiefly concerned in the support of the trunk arc rarely called into active play ; they do not acquire strength as the body increases in stature; they remain weak and unequal to the task of supporting the trunk in the erect posture. A curved state of the spine is PHTHISIS. 549 generally the consequence; and this, by altering the position and form of the thorax, renders the respiratory movements imperfect; the capacity of the chest is diminished, and the lungs are conse- quently more liable to congestion, and the diseases which are its consequences. While the natural form of the body is thus destroyed, the derangement of the general health is manifested by the paleness of the countenance, the dry and coarse appearance of the skin, costive bowels, and cold extremities. In short, all the requisites for the production of struma may be found in a large proportion of female boarding- schools, where the system we have described is pursued. There are many exceptions to this system of boarding-school education, and the number would no doubt be considerably increased if the conduct- ors of such schools were aware of half the misery they inflict on the young committed to their charge. In the establishments to which we allude, as being conducted on different principles, the cultivation of the mind and the acquirement of the various female accomplishments are not the only objects of pursuit; the health of the girls forms, as it ought, the first and paramount con- sideration. The time devoted to study by the present sys- tem should be greatly abridged, and that allowed for exercise augmented in proportion. The situ- ation and construction of the school should be free from all the objections which we have already pointed out, and the exercise should be such as to call into action every muscle of the body in suc- cession. The clothing during the winter must be warm, and every means should be adopted to guard against coldness of the extremities. The pupils should not be allowed to sit so long at one time as to induce this state, nor to go to bed with chilled feet. Were we to select any one circum- stance more injurious than another to the health of young girls, it would be cold extremities, the consequence of want of active exercise and the prevailing and most pernicious habit of wearing thin shoes while in the house. A warm bath should form a necessary appendage to every board- ing-school, and every girl should enjoy the benefit of it occasionally. A large, lofty, and well-ven- tilated room should be set apart for the express purpose of exercise, when the weather is such as to prevent it in the open air. We believe that a system of gymnastics is quite as necessary in the schools for girls as they are in those for boys; and, although they need not be carried so far as in the latter, they should be sufficiently varied to give free exercise to the trunk and arms, so as to ex- pand the chest and strengthen the back. If the girl has any tendency to curvature of the spine, those exercises which are employed to cure this deformity should constitute a part of the daily gymnastics. To the room devoted to these exer- cises, the younger girls should be allowed to ret ire | for a short time during the usual hours of school, and amuse themselves at pleasure. This latter recreation we consider of the utmost importance : it must nevertheless be understood that no exer- cise is to be considered a substitute for that which is enjoyed in the open air: and for this reason 1 every female boarding-school ought to have a play- 550 TUBERCULAR PHTHISIS. ground, where the pupils may choose their own amusements, and play without restraint. It is almost unnecessary for us to observe that all tight-dressing is utterly incompatible with the extent and variety of exercise which we recom- mend, and must therefore be discarded. The idea that young females require stays as a means of support is admitted by all medical men to be most erroneous, and only tends to perpetuate a practice which is productive of much evil and frequent deformity ; especially at that unfortunate era, when, as Dr. Beddoes remarks, " the girl is taken up to be manufactured into a lady." If girls were properly exercised in the open air, and strengthened by the various means which are within the reach of all, and which nature points out to us as best, stays would not be necessary before the body is fully matured, and would even then be scarcely wanted. The measures which we have suggested appear to us to be practicable, and could not fail to be productive of much good. We believe that if a judicious system of management were pursued in every boarding-school, the opprobrium which has so long attached to them would not only be re- moved, but they might be made the means of improving the general health of the pupils, and even of correcting the scrofulous constitution, and would thus become the source of much future happiness both to the children and their parents. When we take a comprehensive retrospect of the nature and causes of consumption, the claim of this subject to our best attention will be fully apparent; and in urging it on the consideration of the profession, we would remind them that the most important object of physical education in this country, as Beddoes justly remarks, unquestion- ably is to guard against all tendency to consump- tion ; and that it is only through their exertions that the desired improvements can be effected.* Before we conclude these remarks on the educa- tion of youth, we would advert to the great and paramount importance of the choice of a profes- sion. There may be some advantages, as our great moralist contends, in fixing a young person, from the first dawn of thought, in a determination to some state of life; but we consider that it is far more essential that the parent should pause in selecting a profession for his son before he has fully ascertained that his health and physical capacity arc sufficient to sustain the duties inse- parable from it. So little is this now considered, that the most unhappy results are very frequently produced by the ill-judged selection of professions without any regard to health. III.—Prevention of the Disease in Youth* The period of life which extends from youth to adult age, from about the eighteenth to the twenty- fifth year in males, and the sixteenth to the twenty- second in females, is one of great importance as regards persons predisposed to phthisis. If their health, has suffered by mismanagement in educa- * We would strongly recommend the careful perusal of Dr. Andrew Combe's excellent work on "The Princi- ples of Physiology applied to the Preservation of Health, and to the improvement of Physical and Mental Educa- tion." It is far superior to any work of the kind that we have met with; — it ought to be familiar to every schoolmaster and schoolmistress, and cantiot be too gene- rally read. tion, or from other causes, during early youth, the system very often .begins to show it about the period of puberty in a remarkable manner. The development of the body which should naturally take place at this epoch, and which in healthy persons is accompanied with an increase of strength and vigour in the system, is often delayed in such persons beyond the usual age, or imper- fectly accomplished. If, therefore, they remain weak and thin, or look unhealthy after the period of puberty, they are in great danger of falling into tuberculous cachexia; this more especially hap- pens in young persons who have been hard- worked at school, or kept much at sedentary occupations. Under these circumstances, the utmost care will be necessary to prevent tuberculous disease. A strict inquiry should be made into the state of every function, and more especially of those con- nected with nutrition. The condition of the digestive organs and skin requires especial atten- tion, because they are most commonly deranged: the tongue will very often be found furred; the alvine evacuations irregular; and the skin dry, harsh, and affected with eruptions, particularly with acne in its various forms:—in young females the catamenia will be found either to be imper- fectly established, or not to have appeared. Such are the common symptoms presented to us in these cases, but they admit of considerable variety in different constitutions and temperaments. The absolute necessity of attending to these early indications of tuberculous cachexia cannot be too strongly impressed by medical men upon the consideration of parents, in order to save the young persons to whom we allude. We have no doubt that a very large proportion of our youth who fall victims to phthisis from twenty to thirty years of age, might be saved by a timely adoption of the simple measures which we shall presently point out, and which are, in some degree, within the power and reach of all. In the constitutions to which we allude, the pulse is generally feeble; the veins are largely de- veloped ; and the change in the balance between the arterial and venous circulation, which in others occurs only after the middle period of life, takes place in such persons before they have reached maturity, and hence we derive an ex- planation of many of their diseases. The chief object in our preventive treatment ought to be the maintenance of a healthy condition of the chylo- poietic system, and an active state of the pul- monary and cutaneous functions ; for which pur- pose very simple and available remedies are found beneficial: combined with these, warm bathing, frequent friction of the surface, exercise in the open air, and above all on horseback, along with a residence in a healthy part of the country, will often in a few months produce the most beneficial effects. There is one kind of exercise which has not been sufficiently attended to in the prevention of pulmonary disease, but which deserves particular notice in this place ; we mean the exercise oftht respiratory organs themselves, and of all the muscles employed in the process of respiration ;— the great object of this is to expand the chest and ensure the full action of the lungs. TUBERCULAR PHTHISIS. 551 Dr. Autenreith, of Tubingen, according to Sir Alexander Crichton, first recommended the prac- tice of improving the narrow and contracted chest by deep and frequent inspirations. He advised his patients to place their hands upon some solid support, and to exercise themselves by taking repeated deep inspirations; but cautioned them against carrying this so far as to produce pain. (Crichton, op. cit. p. 137.) We are in the habit of recommending the full expansion of the chest in a manner somewhat different from that of Au- tenrieth; we desire the young person, while stand- ing, to throw his arras and shoulders back, and, while in this position, to inhale slowly as much air as he can, and repeat this exercise at short intervals several times in succession: when this can be done in the open air, it is most desirable, a double advantage being thus obtained from the practice. Some exercise of this kind should be adopted daily by all young persons, more espe- cially by those whose chests are narrow or de- formed, and should be slowly and gradually in- creased. Fencing, the use of dumb-bells, and similar modes of exercising the arms, will also be eminently useful in attaining the important end we have in view; but they should never be carried so far as to induce fatigue or uneasiness. If regu- larly employed by boys under this necessary re- striction, they would not merely expand the chest, but would tend to remove that disproportionate development of their upper and lower extremities which we so frequently observe in youth. By thus exercising the upper extremities and the mus- cles of the trunk, and inflating the lungs to their full extent, the chest and pulmonary organs will acquire their due proportions. We also consider exercises of this description particularly necessary to persons engaged in occupations which require a bent or stooping posture; and especially to those mechanics, as tailors and shoemakers, whose con- strained position seldom allows the upper parts of the lungs to be fully expanded. Reading aloud and public recitation will also, when prudently employed, be useful in strength- ening the pulmonary and digestive organs, and in giving tone and power to the voice. The clear and distinct enunciation which is acquired only by long practice, is seldom found associated with pulmonary disease, and we are therefore inclined to commend the practice of recitation and elocution at schools. It would, we believe, be difficult to cite the example of any great orator who died of pulmonary disease, while many might be adduced whose health was improved and their life prolonged by the beneficial effects of this exercise. Cicero was disposed to phthisis in early life; and Cuvier attributed his exemption from pulmonary disease, to which he was expected to fall a sacrifice, to the increase of strength which his lungs acquired in the discharge of his duties as a public lecturer. Many of the modes of exercising the pulmo- nary organs which we have just described will be equally useful to young females, although they will not require to be carried to so great an extent. We consider the ancient and well-known game of battledore and shuttlecock one of the very best exercises which can be adopted by them within doors. Although we so highly approve of every judi- cious means of exercise, we would strongly con- demn those which require excessive bodily exertion, such as climbing precipices, &c, and which have been sometimes recommended for the prevention of phthisis. These violent measures undoubtedly exercise the lungs, but they at the same time ex- cite the action of the heart, and render it liable to be oppressed by the blood being suddenly forced upon it by the inordinate muscular exertion. We consider all such violent exertion fraught with danger: indeed we have met with several cases of diseased heart in young persons, apparently originating in forcible and long-continued exertion, as in boat-rowing, &c. Of course, all these modes of exercise are quite incompatible with the existence of organic disease; it will therefore be incumbent on the medical at- tendant to ascertain the actual condition of the lungs before he recommends the adoption of any measures which would tend to aggravate the dis- ease of which those now proposed are merely preventives. There are also other rules relating to this im- portant period of life, which the medical attendant will not fail to keep in mind in laying down direc-. tions for his patient; but these are so obvious that it is unnecessary for us to enter on them here. [Some experiments on the influence of different agents in preventing the development of tubercles have been made by M. Coster, who has laid the details before the Academie Royale de Medecine, of Paris. He experimented upon dogs, rabbits, guinea-pigs, and fowls, which he subjected to the most injurious hygienic influences ; and, to com- bat these, administered iron, baryta, iodine, bro- mine, mercury, and tannin. The agent, which always succeeded with him in the prevention of tubercles, was a ferruginous bread, composed of half a drachm of the subcarbonate of iron to a pound of bread. A quarter of a pound of the bread was taken in the day. The writer is satisfied—and such he believes is the general feeling—that it is a great mistake to regard the tuberculous diathesis as sthenic and re- quiring depleting measures to prevent its develop- ment. It has been lately, indeed, affirmed by M. Paris (Bulletin General de Therapeutique, Sept. 1841,) that since the discovery of auscultation and percussion, the disease is in general more rapidly fatal. He attributes this to an early decided pro- gnosis, which causes the patient to be put at once upon a medicated diet, by which the blood becomes sooner impoverished; for he regards the very es- sence of phthisis to consist in a poverty of nutri- tious principles in the blood,—that its character is chronic, and that its more irregular and rapid pro- gress is owing to the employment of an antiphlo- gistic treatment, to a dietetic regimen, or to a milk and mucilaginous diet, producing a tone of the digestive organs, and also to the depression of the active moral sentiments. (Dr. James Black, cited in Amer. Journ. of the Med. Sciences, April, 1844, p. 448.)] Remedial Measures.—We have already seen that it is about the period of puberty that phthisis so often occurs and tuberculous cachexia is estab- lished ; this, therefore, will be the proper place to consider the utility of those remedies which have been adopted for the cure of this morbid state of, 552 TUBERCULAR PHTHISIS. the constitution and for the prevention of phthisis. The utility, however, of these remedies is not con- fined to this period of life; they may be employed at any age, almost from infancy, when the circum- stances of the patient indicate their use; and some of them, although ranked among preventives, are often applicable in the early stages of phthisis. 1. Alteratives.—We first notice this important class of remedies, both on account of their very general employment, and their beneficial effect on the health. The remedies which we shall notice under this head are Mercury, Taraxacum, Sarsaparilla, Anti- mony, Sulphur, Mineral Waters, Alkalies, Lime- water, and the Muriates of Lime and of Barytes. Mercury.—The influence of this medicine on the secreting functions of the liver renders it, when properly administered, a very valuable remedy in the tuberculous constitution: but if, on the other hand, it be carried beyond its alterative effect on the hepatic system, it seldom fails to prove inju- rious : it requires, therefore, to be administered with great caution to persons of a tuberculous con- stitution. We give the preference to its milder preparations, such as the hydrargyrum cum creta*: this, or the pilula hydrargyri, given in such doses and at such intervals as shall prevent its producing irritation of the mucous surfaces of the alimentary canal, and followed by the employment of some gentle laxative, will be very useful in all those cases in which an imperfect biliary secretion and a torpid state of the bowels are prominent symp- toms. It is usually, and we think very properly, prescribed in combination with some narcotic me- dicine, such as hyoscyamus or conium; and in our opinion it should always be followed by an aperient. Dr. Wilson Philip has recommended mercurial alteratives in small doses for the cure of hepatic congestion in a species of phthisis which he considers to originate in dyspepsia. We have already stated our opinion on this form of disease, but entertain no doubt of the existence of the he- patic congestion as a precursor of tuberculous dis- ease of the lungs. In such cases, a judicious employment of mercurial alteratives with aperi- ents, and a well-regulated diet, may relieve the abdominal plethora, and thus remove congestion of the lungs. Although we cannot adopt Dr. Philip's views respecting the mode in which he- patic disease is communicated to the lungs, we agree with him that minute alterative doses of mercury, if used with judgment and discretion, may often produce the most salutary effects in threatened or incipient phthisis.* Beyond this stage the practice can only be palliative; although it may afford relief, it cannot cure tuberculous disease of the lungs, and unless employed with much discretion, may be productive of mischief. Taraxacum.—We consider this a very valua- ble medicine in tuberculous constitutions, from its power of diminishing abdominal plethora, and its especial influence on the urinary and biliary se- cretions. Hufeland strongly recommends taraxa- cum every spring in the treatment of scrofula, and the translator of his work regards it as an effica- * For the effects and mode of employing minute doses of mercury, we refer to Dr. W. Philip's work " On Indi- gestion," and his more recent work " On the Influence of Minute Doses of Mercury," &,c, 1834. cious remedy in the mesenteric disease of infants, and in the congestions of the abdominal viscera which are the consequences of intermittent fevers; he also cites Zimmerman's opinion that it is the best remedy for the dispersion of pulmonary to. bercles.-j- Kaempf and his followers made exten- sive use of taraxacum in the form of enemata in almost all the chronic diseases of the abdomen, and with great success, if we may judge from the reputation which their method of treatment ac- quired. (Op. cit. See our sect, on Pathokeu p. 324.) 6y' After a few doses of mercurial alteratives, a course of taraxacum, steadily pursued for several weeks during the spring or summer, will often produce a very beneficial effect. The expressed juice is the form in which it is usually given on the continent, where it is considered infinitely superior to every other preparation of the plant, and we think that it deserves a preference when it can be procured. The extract, however, when well prepared, contains, we believe, the virtues of the plant, and is more readily taken than either the expressed juice or the decoction. We usually prescribe it in combination with some tincture of hops and aromatic water, and in this form we find no difficulty in getting children to take it for many weeks. The bowels require attention, and an oc- casional laxative will generally be beneficial in all cases during its use. Sarsaparilla. — Although the powers of this medicine have been very differently estimated, and the cases in which it is most beneficial are by no means well ascertained, it has been long used as an alterative. We have frequently found it of service after a course of mercurials or taraxacum, but we think its effects are less salutary when the internal secretions have not been previously im- proved. Its influence on the skin is most evident, and it is in a defective stale of the cutaneous functions that we prescribe it with the greatest expectation of benefit. In a dry harsh condition of the skin, with a disposition to eruptive affec- tions of the slighter kind, a course of sarsaparilla combined with warm bathing seldom fails to pro- duce benefit. We are of opinion that it should always be given after a course of mercurial altera- tives ; and being a mild medicine, it may, if ad- ministered in such doses as will not oppress the stomach, be prescribed to the most delicate pa- tients. The infusion of the root in distilled or lime-water is the preparation we usually prefer. Antimony has been much extolled for its alte- rative powers. The once-celebrated anti-hectic of Poterius consisted of oxide of antimony and tin. Hufeland has the highest opinion of anti- mony in correcting the strumous diathesis. (Op. cit. p. 166.) We have not often administered its preparations alone as alteratives, but very fre- quently in combination with other medicines of the same class, more particularly with mercury, and occasionally with sarsaparilla. When a dis- position to fever with a dry hot skin, or bronchial irritation, exists, we consider antimony a valuable addition to any mild alterative which may be suited to the case. Sulphur.—The great frequency of cutaneous t Traite de la Maladie Scrophuleuse. Traduit et ao- compagne des Notes par J. B. Bouswiuet, p. 275, et seq. TUBERCULAR PHTHISIS, 553 affections in strumous constitutions has led to the use of sulphur, and we regard it as a valuable re- medy in many cases. We have the authority of Bordeu for the powerful effects of the sulphureous waters of the Pyrenees in the cure of scrofula; and in some forms of strumous diseases we have a high opinion of them. In the cases to which we allude, the skin is coarse and dry, and the whole constitution is of a torpid character; but in the more delicate class of strumous patients with a thin skin, the use of sulphurous waters re- quires much caution. We consider the mineral waters of this class the best form of administering sulphur; bathing should generally be combined with their internal use; and when the water does not act ort the bowels, they should be kept open by laxatives. Bordeu combined mercurial frictions with the sulphurous waters of Barege; but this is unne- cessary when the patient has been properly pre- pared for the operation of the waters by a course of mercurial or vegetable alteratives, which, if not always necessary, will very generally be use- ful, and render the course of sulphurous waters more effectual. Mineral waters.—We consider mineral waters superior in efficacy to all other alterative medi- cines. The operation of these invaluable remedies may be so directed as to promote all the secretions and excretions, to influence the functions of almost every organ, and improve the condition of the cir- culating fluids. In strumous habits, affected with great abdominal plethora, a defective state of the biliary secretion and an unhealthy state of the skin, &c, no remedy with which we are acquainted is so well calculated to produce a full alterative effect on the whole system as a well-directed course of mineral waters, combined with warm bathing. They are not, however, suited to every person of the strumous constitution. In the class of cases we have just described, the advantage of them is at once apparent; but in young persons of an excitable temperament, their operation, even though they be of the mildest kind, will scarcely be borne with impunity. The waters of this class in which we have the greatest confidence, and from which we have observed the most marked benefit, are those of Ems, of Carlsbad, of Marienbad, and Eger. The purer chalybeate waters have also been esteemed valuable remedies in correcting the scro- fulous constitution. Morton considered them the most useful of all preventives of phthisis, and he states that he has seen some cases of evident con- sumption perfectly cured by the use of these waters, " et sine ull£ recidivatione redditos :" he also found them of great utility in chronic cases of phthisis accompanied with haemoptysis, when taken daily for a long time in small quantities. (Op. citat. lib. ii. cap. ii. et. ix. lib. iii. cap. v.) It would be encroaching on another department of this work to go further into detail on the sub- ject of these remedies; but we cannot conclude these few observations without expressing our belief, that when the powerful influence of mineral waters over the extensive class of diseases which have their origin in abdominal plethora and defi- cient excretion, together with the mode of exhi- ; Voi. IV. —70 2w biting them, is more generally understood, they will be more frequently employed and more fully appreciated.* Alkalies.—This class of medicines has often been employed as alteratives in the treatment of scrofulous diseases, and chiefly with the view of correcting the constitutional diathesis. The theory which gave rise to the employment of alkalies, namely, that acidity was the chief cause of scro- fula, is now exploded; still these remedies are held in considerable repute and are unquestionably useful. The fixed alkalies are mostly used in this country, the liquor potassa?, the carbonates of potass and of soda being the forms in which they are chiefly used. The mode in which they act is not well understood ; they evidently increase the urinary, and appear to have some influence in promoting the bilious secretion, and in rendering that of the mucous membranes more fluid. Their alterative action on the skin is also evinced by their abating cutaneous irritation; and the effects of the liquor potassa? in correcting the disposition to boils is very remarkable. But, whatever be their mode of operation, they are certainly benefi- cial in many tuberculous affections; they also form valuable adjuncts to purgative medicines. [Very recently alkalies have been highly ex- tolled by Dr. J. S. Campbell. He recommends the liquor potassa? in the dose of f.^ss. to f.^i. three or four times a day, in milk or water,—care being taken, that no medicine, which might con- vert it into a salt, is prescribed simultaneously, and that it is persevered in for a long time. Of late, naphtha has been brought forward by Dr. John Hastings, on faulty chemical considerations (Pulmonary consumption successfully treated by naphtha, Lond. 1843. See, also, D. Wilson, London Lancet, June 3, 1843, and Lond. Med. Gaz. Nov. 17, 1843; or Braithwaite's Retrospect, Pt. viii. p. 47, and Pt. ix. p. 33.) He prescribes it in doses of fifteen drops, three times a day, for an adult, mixed with a table-spoonful of water; after the second or third day, the dose is augmented by about one-fourth, regulating its increase or de- crease according to the increase or decrease of nausea, vomiting, or any other untoward symptom referable to its use. As the writer has expressed elsewhere, (Practice of Medicine, 2d edit. i. 373, Philad. 1844,) it will probably rank as a revellent with codliver oil. A hope can scarcely be in- dulged that it will be capable of accomplishing more.] Lime-water has been long held in estimation : Morton prescribed it in combination with the de- coction of sarsaparilla; Hufeland, also, speaks in high terms of its efficacy in glandular swellings, in mesenteric disease, and even in incipient tuber- cular phthisis. The muriates of lime and of baryta were likewise, at one time, in great repute in the treatment of scrofulous diseases, and are at present too much neglected. * We are unwilling to quit this subject without calling the attention of our readers to the artificial mineral waters prepared at Brighton, and which supply an accu- rate imitation of the most esteemed waters of the north of Europe. At this well-conducted establishment an opportunity is given of varying the water according to the state of the patient,—the advantages of which are obvious. 554 TUBERCULAR PHTHISIS. We would here remark, that during the use of all the alteratives we have noticed, the warm bath will be productive of considerable benefit. By promoting a free circulation in the cutaneous ves- sels, it favours the action of those medicines which act specifically on the surface, relieves internal congestion, and thereby indirectly aids also the operation of those alterative remedies which exert their influence on the abdominal secretions. 2. Purgatives. — These medicines are chiefly useful in obviating constipation, or in promoting the operation of alteratives ; but their employment in the tuberculous subject must be regulated by certain restrictions. In a torpid state of the bowels with little dis- position to irritation of the alimentary canal, ac- tive purgatives may be occasionally useful; but we beg to enter our protest against the indiscrimi- nate practice of active purging which still prevails too generally in the early stages of tuberculous disease. It is lamentable to observe the injurious effects of this practice in the debility which it produces, and in the irritation which it establishes in the mucous surfaces. Although we consider abdominal congestion as forming so important a part in the pathology of tuberculous diseases, we regard the frequent repe- tition of harsh purgatives as the worst possible means of remedying it: a single dose or two of cathartics often gives relief by the copious dis- charge which is excited from the liver ai<| mucous surfaces; but their frequent repetition never fails to do injury. Entertaining these views respecting the action of purgatives, we read with much plea- sure the strong opinion of Dr. Stokes of Dublin, a valuable contributor to this work, on the same subject. Speaking of the influence of gastro- enteric disease in accelerating the fatal termina- tion of phthisis, he says, "I feel satisfied, that under a different mode of treatment from that or- dinarily employed, this complication would be much less frequently observed; as in numerous instances I have known it to be induced clearly by the use of purgative medicines. If ever there was a case in which we should be cautious in giving medicines of this description, it is in incipient or threatened phthisis, on account of the great liabi- lity that exists to inflammation and ulceration of the digestive tube ; yet, in all those cases, which, in conformity with the prejudice of the day, are supposed to arise from a disordered state of the stomach—of the digestive apparatus—a depraved state of the biliary organs—atony of the chylo- poietic viscera, &c, &c, a set of terms invented to cloak ignorance, and conveying no single clear idea to the mind, this practice is constantly pur- sued—a diarrhoea is established, and the digestive apparatus becomes indeed disordered, more from the remedies than the disease." (Dublin Journal of Med. and Chem. Science, vol. ii. p. 59, 60.) The very prevalent use of active doses of calo- mel and strong purgatives in delicate strumous children is productive of a degree of mischief which is not sufficiently known: the great error in the administering of such medicines is their excessive dose and too frequent repetition. Where they are given simply as laxatives, and their repe- tition is regulated according to the nature of the case, especially when a course of alterative medi- cine forms' a part of the treatment, they may be made very useful in the correction of the strumous habit; but no class of remedies requires to be ex- hibited with more caution in young delicate per- sons of a strumous constitution. 3. Tonics.—In a disease in which debility is one of the principal features, it is not surprising that tonics should suggest themselves to the mind both of the medical attendant and the patient. There are two periods during which this class of remedies proves useful;—the first, that which precedes the local deposition of tuberculous mat- ter ; the second, the advanced stage of pulmonary disease, when the debility and exhaustion are great. In this latter period in particular, tonici often afford great temporary support. Chalybeates have an excellent effect in some young persons of a tuberculous constitution. In those who have a languid circulation, a soft re- laxed state of muscle, and a pale bloodless appear- ance, they are superior to every other remedy with which we are acquainted; but the indiscriminate exhibition of them in all cases of debility is pro- ductive of much mischief. Before benefit can be derived from chalybeates, the digestive organs must be free from irritation ; otherwise they will generally do harm, however great may be the de- bility attending such a state. When such de- rangement of the digestive organs prevails, proper antiphlogistic measures will he necessary to ren- der chalybeates admissible; and if the case in other respects does not contra-indicate their use, they may then be exhibited with great benefit. But we repeat, that the indiscriminate manner in which the preparations of iron are too commonly prescribed in all cases of scrofula and debility is productive of more injury than is usually ima- gined : although they may give a temporary sup- port to the system, they will not fail, when inju- diciously employed, to confirm the functional de- rangement, which it should be our first object to remove. In the advanced stages of phthisis, when the expectoration is copious and the patient is greatly debilitated, without suffering much from gastric irritation or fever, we have seen remarkable effects from sulphate of iron in improving the patient's strength, and abating the expectoration; these were the cases in which Griffith observed so much benefit from his celebrated steel and myrrh mixture. The vegetable tonics are also useful at this period. The sulphate of quinine in small doses, either alone or combined with sulphuric acid, forms one of the best medicines of this class. 4. Bathing.—As a means of giving tone to the system, and enabling it to bear the vicissitudes of climate, the Cold Bath forms a very valuable remedy. We would strongly recommend that it should be used by children and young persons of a scrofulous constitution during the summer, as one of the best tonics they can employ. Sea- water is to be preferred when it can be obtained, and the air of the coast forms no unimportant part of the benefit which is generally experienced from a course of sea-bathing. The same remarks apply to the cold bath as to internal tonics;—un- less the functions of the internal organs are in a healthy state, little advantage will be derived from it. It is always necessary, therefore, before pre* TUBERCULAR PHTHISIS. 555 scribing this remedy, to ascertain that the digestive I functions in particular are well performed; and when there are strong indications of abdominal congestion, or a dry harsh state of the skin, it will be proper to employ the warm bath as a prelimi- nary measure. But notwithstanding these pre- cautions, there are some children who cannot bear the shock of the cold bath, and are positively injured by it; hence its effects on children must be closely watched. Unless it is succeeded by a glow, a feeling of increased strength, and a keen appetite, it will do no good, and ought to be at once abandoned, and the warm or tepid sea-water bath substituted. Delicate persons who cannot bear the cold plunge or shower-bath, will often derive great be- nefit from having the body rapidly sponged with cold water. This is particularly serviceable to young children, and should in all cases be suc- ceeded by friction over the whole surface. The practice of sponging the chest with sea-water or salt and water daily is also highly useful, and should generally be adopted by delicate persons through- out the whole year. It is a powerful tonic, and a most effective means of diminishing the suscep- tibility to the impressions of cold. While on the subject of cold bathing, we must not omit to notice the beneficial effects of swim- ming. When accompanied with this invigorating exercise, the cold bath becomes doubly serviceable. Every boy, as Locke recommends, ought to be taught smimming as a part of his education. The Romans attached so much importance to it, that not to be versed in the art was considered by them as great a reproach as ignorance of reading; nee literas didicit, nee natare. In very delicate children much more benefit will be derived from the tepid than the cold bath. It is, in truth, to them what the latter is to the more robust. The powers of warm and tepid bathing in the treatment of scrofulous children are not suf- ficiently valued. One of the most powerful means which we possess of relieving abdominal conges- tion, improving the functions of their skin, and giving tone and vigour to their whole system, is a course of warm sea-bathing, with active friction over the whole surface after each bath ; the tem- perature of the bath towards the termination of the course being gradually reduced till it becomes tepid. The opinion that warm baths generally relax, is erroneous ; they are no doubt debilitating when used by persons of a weak and relaxed con- stitution, or when continued too long, but on the contrary they invariably give tone when employed in the cases to which they are properly applicable. We have already remarked that warm bathing greatly promotes the action of alterative medicines; these two remedies should therefore be combined, when possible. Of medicated baths we have had no practical experience: common salt and the carbonate of soda are the only substances which we have used in this way, and from both we have observed good effects. Baths of malt, of bark, of hemlock, and other substances supposed to have specific effects, have been particularly mentioned by foreign au- thors. Hufeland states that he has seen surprising benefit derived from hemlock baths, repeated daily for weeks, in removing glandular swellings, cica- I trizing ulcers, &c.; and he considers bark and other astringents, when employed in this way, much more useful than when administered inter- nally. The excellent article Bathing is so full of in- formation, and lays down such judicious rules on the employment of baths generally, that we con- sider it unnecessary to enter further upon the subject. 5. Travelling, Sailing, Climate. — These are valuable means of improving the health of persons of a tuberculous constitution; and when no local disorder exists to prevent their beneficial influence on the system, they may be made powerful reme- dies for correcting the disposition to tuberculous disease. But these measures must be used for a long period; a residence for a few months only in the finest climate, or travelling under the most favourable circumstances, cannot be expected to do much in correcting a constitutional disorder which may have existed from birth. Their posi- tive advantages also will depend upon their being adapted to the circumstances of the individual case, and upon a strict attention to those regula- tions respecting regimen, exercise, &c, which are deemed proper; for neither these nor any other measures which act on the system generally will prove of much permanent benefit, unless those local derangements which almost invariably exist in the scrofulous constitution are removed before they are adopted. It is from a want of due con- sideration of these circumstances, and from an over-confidence in the unaided effects of the mea- sures to which we have alluded, that so little benefit is often derived from them. When proper regard is paid to all the circum- stances of the patient, and the measure is adopted with the necessary precautions, travelling will be attended with many advantages. Independently of its physical effects, the change of scene and the constant succession of new objects presented to the young traveller, exerts a direct and most bene- ficial influence on the mental constitution ; the mind is thereby engaged, the nervous system is soothed, and a just harmony is established be- tween the various functions of the whole economy. If he happens to be fond of natural scenery, or to take delight in the practical pursuit of any branch of natural history, the beneficial effects of a resi- dence in a mild climate may be much augmented. For this reason we think that a taste for botany, geology, and similar pursuits, which necessarily induce the invalid to take exercise in the open air, should always be encouraged in young persons of a delicate constitution; the study of marine botany and of the various branches of zoology which can only be pursued on the sea-shore, also contributes greatly, when used with proper precautions, to amend the health. When more distant journeys or voyages cannot be accomplished, short and repeated voyages and excursions, within the limits of our own country, may be made beneficial during the continuance of mild weather. It is chiefly with the view of avoiding tho winter that foreign residence is re- commended; but this will be more fully con- sidered when we treat of the effects of climate in incipient phthisis. 556 TUBERCULAR PHTHISIS. Sect. XIII.—Treatment of Phthisis. In entering upon the consideration of the treat- ment, with a view to lay down rules for its appli- cation to the different stages of phthisis, we beg to refer the reader to a former part of this article, in which the disordered states preceding and ac- companying the local deposition of tuberculous matter are fully described. We have there en- deavoured to pourtray the characteristic features of the tuberculous constitution, and we would now simply observe, that a familiar acquaintance with these is of the first importance to the practi- tioner, inasmuch as they will assist him greatly in forming a correct judgment of the case, more especially when the signs of local disease are equivocal or obscure. The condition of those organs and functions which are more immediately connected with nutrition claims our particular attention, for it seldom happens that they do not manifest evident derangement; and when such derangement exists, we may feel assured that we shall make little progress in the treatment of the pulmonary affection until it is removed or cor- rected. There is, no doubt, considerable variety in the manner in which the digestive organs are disordered in tuberculous persons, depending in a great measure on the nature of the causes which have induced such disorder. But there is one prevailing form in which the dyspeptic symptoms have their origin, and which we have already no- ticed in describing the tuberculous constitution, and referred, for a more full account of it, to the article Indigestion, Strumous Dyspepsia. We may, however, observe, that as we consider it to depend on congestion of the whole abdominal ve- nous system and on an irritated state of the mu- cous surfaces, it will, we believe, be remedied by whatever allays irritation, promotes the various secretions and excretions of the chylopoietic vis- cera, and induces a more active state of the cuta- neous circulation. But these remedial measures, as well as all others which are applicable to the treatment of incipient phthisis, require to be modi- fied according to the predominance of particular symptoms. Thus, in some cases, the disorder of the digestive organs, in others the morbid state of the skin, is the most prominent derangement:— again, in some there is a torpid and inactive con- dition of the whole system, with a languid circu- lation and deficient nervous sensibility, while in others the converse of all these prevails. Hence it is apparent that the treatment must be varied to meet the circumstances of each case, although the principles upon which it is conducted are the same, and the same general objects are to be attained in all. The most efficient general means of correcting the tuberculous constitution and removing func- tional derangement, have been described in the last section; we shall, therefore, proceed to con- sider those measures which have been thought to possess particular powers in the cure of phthisis. 1. General Remedies.—It would far exceed the proper limits of this article to enter into an ac- count of all the remedies which have been at va- rious times extolled as capable of curing phthisis. The greater number of them had their origin in empiricism; and although they obtained some renown in their day from the credulity of the public, they were, in general, found utterly inade- quate to accomplish the cures promised by the ignorant or deceitful pretenders who introduced them. Passing over, therefore, a long list of nc* trums which have justly been banished from mo- dern practice, we shall merely notice those reme- dies whose beneficial effects are tolerably esta- blished, either in the treatment of the disease generally, or in the relief of particular symptoms. 1. Bloodletting.—Small and frequently-repeated bleedings have been recommended by various an> thors as a means of curing incipient phthisis, Morton employed bleeding in the early stages of the disease and for the prevention of haemoptysis, to the extent of from six to ten ounces, and re- peated it two or three times at proper intervals, when its repetition was indicated. He considered that it was not only ill adapted, but positively de- structive in the confirmed stage of phthisis; but when employed in due season, and aided by the judicious exhibition of other necessary remedies, it was most successful in guarding against inflam- mation, congestion, and subsequent ulceration of the lungs, and even phthisis itself, with cough, dyspnoea, and its other train of fearful symptom (Op. cit. lib. ii. ch. 2.) But the practice of re- peated bleedings was first brought into general notice in this country by Dovar, whose extrava- gant partiality for the remedy, and excessive em- ployment of it, probably led to its unmerited dis- use. His plan was to bleed to the amount of six or eight ounces every day for the first fortnight, and gradually to increase the period between each repetition of the measure by employing it at the respective intervals of every second, third, and fifth day for the three successive fortnights. (The Ancient Physician's Legacy to his Country, by Thomas Dovar, M. D. p. 26, Lond. 1733.) Mead speaks strongly in favour of the same practice;— "I have seen cases," he says, "judged almost desperate, where this method of practice succeeded well." (Monita et Praicepta Med. c. i. s. x.) Sii John Pringle says, " In the first stage of a con- sumption, when the patient complains of pains in his side, constriction at the breast, or hot and rest- less nights, I have trusted most to small and re- peated bleedings: the quantity of blood drawn was from four to seven or eight ounces, once in eight or ten days; and sometimes a vein was opened after shorter intervals." (Observations on the Diseases of the Army, part iii. ch. 3.) Dr. Monro says that the plan of " taking away from four to eight ounces of blood whenever the pain of the breast was troublesome, or the patient was hot and restless at nights from the hectic fever, gave the greatest relief of anything we tried; and these repeated small bleedings were so far from wasting the patient's strength, that they rathei ' seemed to prevent its being exhausted so fast as otherwise it would have been, by allaying the force of the hectic fever." (Account of the Dis- eases in the British Military Hospitals in Ger- many* &c. p. 131.) It is to be recollected that Pringle and Monro were army-physicians, and that their patients were more likely to require and derive advantage from bleeding than the ge- nerality of consumptive patients in private life. Fothergill always found benefit from repeated venesection, except in delicate constitutions; and TUBERCULAR PHTHISIS. 557 Stoll considered it the best remedy that could be employed. More recently several physicians have spoken favourably of the practice of bloodletting. Dr. Hosack of New York states that he has " in many instances employed it with the most happy effect in incipient phthisis, even when strong he- reditary predisposition existed." (American Med. and Philos. Register, vol. ii. p. 470.) Dr. Cheyne of Dublin has also lately written a paper in which he give? a very favourable opinion of this practice in haemoptysis, and also in incipient pulmonary phthisis: in both of which he states that «these small bleedings may be practised with safety, and often, if I mistake not, with more advantage than any other remedy in use." (Dublin Hospital Re- ports, vol. v. p. 351 et seq.) Dr. Cheyne's view in adopting this practice is to subdue the inflam- matory state of the lungs produced by the irrita- tion of tubercles, and to arrest the progress of the disease in its early stage: he employs small bleed- ings once every week or ten days in those cases which he conceived to be incipient phthisis, " and with a degree of success which forbids the relin- quishment of that practice." The greater number of the advocates of this practice evidently adopted it not only after tuber- culous disease of the lungs had taken place, but after this had become complicated with inflamma- tion. Before the disease has advanced thus far, the circumstance which calls chiefly for venesec- tion is pulmonary congestion. In this case a moderate bleeding will always, we believe, be useful; and when employed as soon as the con- gestion is evident, will often prevent hemorrhage and inflammation, and perhaps the deposition of tuberculous matter. When the patient has been subject to natural discharges of blood from the nose or otherwise, bloodletting is the more neces- sary. It rarely happens, we believe, that general bleeding requires to be frequently repeated if the patient be put upon a proper regimen, and the necessary remedies are employed to diminish ab- dominal plethora. When it is frequently repeated, the quantity abstracted should be diminished each time, and the intervals increased. We have a high opinion of the beneficial effects of Local Bleeding in cases of this kind, and we believe that the abstraction of small quantities of blood from the chest by cupping will be the most effectual way of relieving the inflammatory action which accompanies tuberculous disease of the lungs, after congestion of the large vessels has been diminished by one or more general bleed- ings. 2. Emetics.—The effects of emetics appear to be so important, and their utility in pulmonary diseases has been so highly commended by some of our best practical writers, that we think it pro- per to devote some space to the consideration of the practice. From an early period in the history of medi- cine, emetics have been employed in the treatment of phthisis; and, although they were prescribed with various views by different practitioners, their beneficial effects when judiciously exhibited have been generally acknowledged. Some considered them chiefly useful in unloading the stomach and biliary system; some used them as the means of suppressing pulmonary hemorrhage and inflam- 2w* mation; while others regarded them as capable of curing phthisis in its early stages. It is our present purpose to examine the grounds upon which this last opinion rests. We have the positive testimony of several prac- tical physicians in favour of the remarkable bene- fit derived from the use of gentle emetics repeated at short intervals during the early stages of tuber- cular phthisis. Morton states that after bleeding they are of great utility in the cure of this dis- ease, and that they will often check it in its early stages; the opinion of this eminent physician is so clearly and strongly expressed that we shall give it in his own words: " A qua vomitione non tantiim ventriculus humorum saburra oppressus relevari, et nausea inde nata tolli, et digestio res- titui possint, (qua? omnia non sunt flocci habenda,) veriim etiam moles humorum jam pulmonibus impactorum, harum partium exagitatione inter vomendum, insigniter expectorari solet, una. cum notabili relevatione ponderis gravativi a mole ista effecti. Atque hoc ritu non tantiim plurimos empiricos vidi, cum successu felici, sese omnem incipientem phthisin curaturos gloriari, veriim etiam ipse ego ratione et experiential fretus saepis- sime phthiseos incipientis progressum, eodem modo, brevi temporis spatio, prapedivi." (Op. cit. lib. ii. cap. viii.) Again, in regard to cases complicated with hysteria and hypochondriasis, he says, «vomitoria vero lenia, et a?gri viribus a?qualia, opitulando cerebro et nervis, in principio morbi, instar miraculi hujusmodi phthisicos rele- vare solent." (Ibid. lib. iii. cap. iv.) Since Mor- ton's time, emetics have been recommended by several eminent physicians; Dr. Simmons warmly advocates their use, and lays down some excellent directions for their employment; he believed that " the earlier in the disease they are had recourse to, the more likely they will be to do good, and the less likely to do harm." (Pract. Obs. on the Treatment of Consumption, p. 67.) Dr. Parr says that " no remedy is so generally useful as a slight emetic frequently repeated; and could phthisis be ever cured, it would be by the joint action of emetics and blisters." (London Med. Diet. art. Emetics.) Dr. Bryan Robinson, (Ob- servations on the Virtues and Operations of Medi- cines, 1752, p. 146, et seq.) Dr. Thomas Reid, (Essay on the Nature and Cure of the Phthisis Pulmonis, 1782), and Dr. Marryat, (Therapeutics, or, the Art of Healing, 1817, p. 45), have urged the employment of emetics in still more forcible language, and have fully confirmed by their own experience the value of the remedy in the early stages of phthisis. Dr. Dumas, of Montpellier, one of the translators of Dr. Reid's work, also cites several cases in corroboration of the practice; and more recently Bayle, a high authority, has mentioned emetics, frequently repeated, among the most valuable remedies in the early stages of phthisis. The most recent experiments with emetics are those by Dr. Giovanni de Vittis, chief physician to the military hospitals of the Neapolitan army. In the military hospital at Capua, where the greater number of phthisical patients of the army are sent, antimonial emetics were tried in every case. From the 1st of May, 1828, to the 18th of January, 1832, there were sent out of the hos- 558 TUBERCULAR PHTHISIS. pital perfectly cured (perfettaments guariti) forty cases of chronic catarrh, forty-seven of phthisis in the first stage, one hundred and two in the second, and twenty-seven in the third, making a total of two hundred and sixteen cures, of which one hundred and seventy-six were cases of phthi- sis. The mode of treatment consisted in giving every morning and evening a table-spoonful of a solution containing three grains of tartarized anti- mony in five ounces of infusion of elder flowers, and one ounce of syrup. The patients were at the same time put upon a light farinaceous diet, composed chiefly of rice, chocolate, and biscuits. A second spoonful of the emetic mixture was given at the end of a quarter of an hour when the first dose did not produce vomiting. If it ex- cited brisk purging, it was omitted for some days, and roasted ipecacuan and digitalis, which are said to produce wonderful effects in curing this diarrhoea, were administered in the proportion of one grain of the roasted ipecacuan powder to one of digitalis, and repeated every hour or oftener, until the diarrhoea ceased. We give this report from an Italian medical journal,* as we have not yet been able to procure Dr. Giovanni's work. Although we may be permitted to entertain doubts as to the validity of the cures, especially of those in the advanced stage, we cannot doubt that the practice must generally have produced very bene- ficial effects. The extent to which vomiting was carried by the advocates of this practice surprises the prac- titioner of the present day. Robinson states the case of a consumptive patient, subject to repeated attacks of ha?moptysis, who was kept alive for eight years by taking three ipecacuan emetics every week during that period; Reid says that they may be taken every morning and evening with perfect safety for months; and Ritchter gives the case of a woman, aged forty, who took six hundred emetics in ten years. There can be no doubt that the physicians who employed emetics thus extensively were fully assured of the advan- tages which they produced, and their patients must have been equally sensible of the benefit de- rived from them, otherwise it is scarcely credible that a practice so disagreeable would have been prescribed, or persevered in, for so long a period. But if such marked effects were observed to follow the employment of this remedy, it may well ex- cite surprise that it has been allowed to fall into disuse ; for at present emetics are merely used as palliatives, and are by no means generally consi- dered of importance in the cure of phthisis. Two causes may be adduced in explanation of this fact; the first, the disagreeable nature of the re- medy ; the second, the want of firmness and de- cision on the part of the physician in enforcing a practice, the value and operation of which he could not satisfactorily comprehend. If we can succeed in removing the latter objection by show- ing how emetics may be made the efficient means of preventing phthisis, the former difficulty will be easily overcome. * Annali Universal! di Medicini, Dicembre, 1832.— " Osservazioni ed esperienze sulla tia polmonare seguite da un metodo particolare per la cura di tal malattia; del dottor Giovanni de Vittis, primo medico degli Ospedali militari dell' armata di terra di S. M.—Napoli, 1832." The minute researches of Dr. Carswell on the morbid anatomy of tubercle, have satisfied him that tuberculous matter is first deposited on the free surfaces of mucous membranes, such as the bronchial membrane in the lungs, and that of the biliary ducts in the liver. It is very probable, as Dr. Carswell remarks, that tuberculous matter is equally deposited, on the surfaces of all mucous membranes, but is speedily removed from many, such as the intestinal canal, by the constant action kept up in them by the passage of foreign sub- stances ; while the structure of the lungs is such as to favour the retention of the morbid deposit For a full account of Dr. Carswell's views on this subject, see the article Tubercle ; the clear manner in which he has there explained the cause of the more frequent occurrence of tuber- culous matter in the lungs than in other organs, and in the upper lobes than in the other parts of the lungs, is so satisfactory, that it is unnecessary for us to enter more into the subject here. The power of emetics in augmenting the bron- chial secretion and ejecting it from the lungs ii well established; and, therefore, we can easily conceive how the repeated action of emetics may prevent the deposition, or at least the accumula- tion, of tuberculous matter in the bronchial rami- fications and air-cells, and thus prevent the locali- zation of the disease, and give time for the cor- rection of the constitutional disorder. In this manner, it is not improbable that a judicious use of emetics may prove a powerful means of pre- venting the deposition of tuberculous matter in the lungs. We cheerfully acknowledge that our attention was first particularly directed to the benefit which may be derived from emetics in phthisis, by Dr. Carswell's researches into the primary seat of tubercle, and whatever advantage may be hereafter experienced from the adoption of the practice, the merit justly belongs to him. If the researches of this enlightened pathologist had led to no other result than the establishment of the important fact, that tuberculous matter is first deposited on mucous surfaces, and that it may be expelled from them in the way we have described, he would have conferred a great benefit on mankind.-)- Although we regard the action of emetics on the pulmonary system as one of their most valu- able effects, we are not disposed to limit their utility to this, but consider that their determining the circulation to the surface, and promoting the biliary secretion, constitute very important parts of their operation. They equalise the circulation, restore the secretions which are usually deficient in the tuberculous constitution, and tend to di- minish abdominal congestion ; hence emetics may be ranked, as Dr. Reid justly observes, among the most powerful alterative medicines which we possess. Having said thus much on the subject of erne- t We are aware that all morbid anatomists are not satisfied of the correctness of Dr. Carswell's views, and we have seen objections urged against them in the peri- odical press and otherwise: but the arguments which have been adduced have little weight with us, who know the minute and patient researches of Dr. Carswell, aw) the pure spirit of philosophical inquiry which directs them; and we hesitate not to predict, that the more thoroughly the subject is investigated, the more folly will his views be borne out and established. TUBERCULAR PHTHISIS. 559 tics and their operation, it is right to state that j our own experience of the practice has not yet been very considerable; but we think we shall be held justified in earnestly calling the attention of the profession to it, as one which holds out to us the rational hope of being made one of the most efficient means of preventing the localization of tuberculous disease in the lungs in many cases, and perhaps of removing it in some others. For ourselves, we do not hesitate to say that, resting on the discovery of Dr. Carswell, and on the strong testimony of the respectable writers whose authority we have cited, we shall continue to avail ourselves of every fair occasion to put the practice to the test of experience. That it is a safe practice when adopted with discernment, we have abundant proof, even when it is carried to an extent which we deem unnecessary. If the observations which we have made should bring into more general use the employment of gentle and frequent emetics in the early stage of phthisis, we trust that the measure will not be adopted without that judgment and circumspec- tion which can alone render any active practice useful, or even safe. To have recourse at once to emetics in every instance of threatened phthisis, without fully inquiring into all the circumstances of the case, would be highly injudicious : we shall find, that although emetics may be freely given in one class of cases, they cannot be safely exhibited in another without preparing the patient for them by bleeding, purgatives, and proper antiphlogistic measures; and that in a third class, where gastric irritation is a prominent symptom, they may be altogether inadmissible. There is a state of the mucous membranes of the alimentary canal which frequently attends phthisis even in its earliest stages, and which we consider as strongly contra- indicating the use of emetics. We have already described this state in a former part of this article, but we may observe here that it is attended with the following symptoms:—the whole internal fauces are red, congested, and swollen, the poste- rior part of the pharynx, as far as the eye can reach, is also of a deep red, and often partially dry and shining; there is thirst, and generally epigastric tenderness on pressure, with redness of the tongue. We have at this moment two young patients in this state under observation, and although they are in the incipient stage of phthisis, we have not ventured to employ emetics, considering them dangerous when these symp- toms are present. We would confine the use of ipecacuan in such cases to minute doses, with the view of promoting the secretion of the bronchial membrane. When tuberculous matter is deposited in the lungs to any considerable extent, the case will require much more attention before the employ- ment of emetics; tho abstraction of blood, both generally and locally, and a discharge established j over the part by blisters or other means, will be j useful, and may be even necessary in many such cases, as preliminary measures, before emetics can be safely administered ; and when there is a dis- position to pulmonary inflammation, small doses of tartarized antimony, along with those remedies which favour a free secretion of the bronchial mucous membrane, may be employed with benefit, and, in some cases, may be preferable to actual vomiting. Alkalies have been considered valuable medicines in promoting the secretion of the mu- cous surfaces, and may, therefore, be advantage- ously prescribed during the use of emetics. In short, while recommending a cautious employ- ment of emetics in the early stages of phthisis, we would not be understood to advise emetics alone, but merely that they should constitute a part of the treatment. The other remedial means which are adapted to the circumstances of the case must be employed at the same time: indeed, it is no small recommendation of the practice of emetics, that it need not interfere with the general treat- ment which may be considered most suitable to the condition of the patient. The choice of emetics, the period of employing them, and the frequency with which they may be repeated, are not matters of indifference. Morton preferred and generally prescribed squills; that used by Marryat, and called by him the "dry emetic," consisted of one grain of tartar-emetic and three of ipecacuan, taken fasting, without drinking any liquids during its operation. When the diarrhoea was severe, his emetic consisted of four grains of ipecacuan and one of sulphate of copper. Reid preferred gentle doses of ipecacuan, sufficient to puke once or twice; and Simmons recommends sulphate of copper as superior to any other. We consider ipecacuan the safest and best emetic for repeated use; it is proper to give it so as to produce a very gentle effect, and we think a very small quantity of fluid only should be taken to promote its action. When the biliary system is much loaded, an antimonial emetic may be use- ful in the first instance, as it appears to possess more power than ipecacuan in promoting a free discharge of bile. Morton thought it best to administer the emetic towards evening, and to repeat it every third or fourth day, three or four times, when the patient could bear it and its repetition was indicated. Simmons, Marryat, and Reid regarded t|ie morn- ing as the best time : and when it is considered that the bronchial secretions accumulate during sleep, there are certainly good reasons for coin- ciding in their opinion as a general rule; although circumstances may occur to render evening the proper time for the exhibition of the emetic: if given before going to bed, it may prevent fever and promote sleep in some cases. Simmons began by administering emetics twice a week until the symptoms were relieved, and then repeated them every second day, or even every day, for several days together, with good effects. Marryat gave his dry emetic twice or thrice a week : Reid employed ipecacuan every morning, repeating it occasionally in the evening; and he says that this plan may be continued for several months with perfect safety. The repetition of the emetic must, in our opinion, be regulated accord- ing to the nature of the case. When it is given with the view of preventing the deposition of tu- berculous matter, it may, perhaps, be sufficient to repeat it once or twice a week. When the case is more urgent, and the patient is threatened with the deposition of tuberculous matter in the lungs, or when the presence of this is already suspected, emetics may be much more frequently repeated : 560 TUBERCULAR PHTHISIS. but in all cases it will be necessary to watch their effects on the gastric system, and to suspend the use of them the moment they appear to excite irritation there. During the interval between the emetics, it may promote the end we have in view, to give ipecacuan, alkalies, and other medicines which have the effect of promoting the bronchial secretion, in minute alterative doses. 3. Digitalis. — There is not, perhaps, a medi- cine in the Materia Medica, concerning the vir- tues of which in phthisis medical writers have dif- fered so much as digitalis; some regarding it as possessed of powers beyond all other remedies, others considering it to have very little efficacy, while a third class have even condemned it as pernicious. No better instance can, perhaps, be adduced of the difficulty of estimating the effects of a medicine. We find Dr. Beddoes affirming that, in general, when he had all possible evidence of the existence of tubercles, the exhibition of digitalis has been perfectly successful: — "If I specify," he adds, " that it has succeeded in three such cases out of five, I believe I much underrate the proportion of favourable events." (Essay on Consumption, p. 118.) Now it is not to be cre- dited that Beddoes would have spoken of digitalis in such terms unless he had observed some very remarkable effects produced by it. At present we may be permitted to doubt his having all possible evidence of the existence of tuberculous disease of the lungs in many of his cases; yet, making due allowance for this, and for his warm imagination and sanguine character of mind, we cannot doubt that he experienced very beneficial effects from digitalis. Its utility in dropsy may afford us some explanation of its effects in abdominal and pulmonary congestion. But, whatever be its ef- fects in phthisis, the medicine has wonderfully fallen in the estimation of the profession since the time of Beddoes; and it is now, we believe, only employed in haemoptysis, or with the view of re- ducing increased action of the heart, and of there- by abating inflammation of the lungs and general excitement of the system. A series of experiments has lately been made in Paris for the purpose of ascertaining the efficacy of digitalis, but they have not added much to our means of accurately estimating its virtues. Medica! authors in general are agreed in regard to the power of this medicine in suppressing pulmonary hemor- rhage, but differ greatly with respect to its influ- ence in phthisis. We are ourselves equally una- ble to pronounce a decided opinion. Like several other remedies that have been loudly proclaimed almost as specifics in certain diseases, digitalis has failed to maintain, in the hands of others, the cha- racter with which it was introduced to notice by Drake, Beddoes, &c.; and we would require a series of careful observations to enable us to ascer- tain its real virtues. Digitalis is evidently a medicine of great power, although it is quite clear that we are not yet ac- quainted with the peculiar circumstances under which it may be employed with advantage in phthisis. Of its powers in haemoptysis there can be little doubt; it also possesses considerable effi- cacy in abating febrile excitement and excitability of the nervous system, and in regulating the ac- tion of the heart; hence, when phthisis is com- plicated with disease of this organ, it is a medi- cine of great utility. 4. Iodine.—The beneficial effects of iodino in scrofulous diseases have led to the belief that it might prove useful in phthisis; and several au- thors have recommended it in this disease. We have abundant testimony of the alterative powers of this medicine in various forms of scrofula, par- ticularly in those affecting the skin and external glands.* We have experienced its good effects in scrofulous children, but have never used it in phthi- sis, although we think it very probable that when employed as an alterative it may prove a valuable remedy in correcting the tuberculous diathesis. Its action seems to be exerted chiefly on the nu- tritive functions, and its beneficial effects in some cases have been made apparent by the improved health of the patient while taking it. But the reverse of this has been too often the consequence of its imprudent employment, or its exhibition in cases to which it was not adapted.-}- In the recent work of Dr. Morton, an American physician, which has just been put into our hands, we find the strongest testimony in favour of iodine in phthisis that we have yet met with. He states that hav. ing used it extensively; he is able to express an unequivocal opinion respecting it. "In a large number of instances," says Dr. Morton, " it has appeared, especially in incipient consumption, to arrest or suspend the tubercular secretion, and with it the hectic, marasmus, cough, dyspnoea, and other urgent symptoms. There are some constitutions in which it does not appear to pro- duce any obvious effects, either for better or worse; but in a majority of cases, even in the second stage of phthisis, I have been much grati- fied with the results. Thus it often relieves the dyspnoea, improves the complexion, and restores the appetite, even when the advanced progress of the disease precludes all hope of recovery. In some instances it has so obviously improved the nutritive function, that patients have increased in flesh by its use, and at the same time recovered, in a considerable degree, a naturally florid com- plexion." (Illustrations of Pulmonary Consump- tion, &c. by Samuel George Morton, M. D., Philad. 1834, p. 130-31.) Dr. Morton is physician to a public hospital, and seems to have had considera- ble experience. He prescribes the iodine in the form of a solution containing three grains of iodine, and six grains of hydriodate of potash in an ounce of distilled water, from three to five drops of which are given every morning, noon, and night. The result of the experiments made with iodine in this country does not by any means correspond with that of Dr. Morton. Dr. Baron was, we be- lieve, the first English physician who employed iodine in phthisis; he found good effects result from it in some cases, but whether more extensive subsequent experience has confirmed the favour- * See the medical researches on the effects of iodine by Alexander Manson, M. D.; the experiments nfl.ugoi, and the excellent report by M. Baudelocque in the Revue Medicale, already cited. t For an account of the injurious effects of iodine when injudiciously employed, see Dr. Jahn's Report, " De la maladie iodique, ou des desordres qu'entraine a sa suite 1'emploi trop long temps contin de l'iode. —Journ. Complement torn. xxxv. TUBERCULAR PHTHISIS. 561 able anticipations which he formed of the effect of iodine in this disease, we are not aware. (Illus- trations of the Enquiry respecting Tuberculous Diseases, p. 228, et seq.) Dr. Bardsley, in his excellent Hospital Reports, after stating the valu- able effects of the medicine in scrofula, remarks, " It has been my aim to establish the real virtues of iodine in a tuberculous state of the lungs. In fifteen well-marked examples of incipient phthisis, I employed this medicine with a strict attention to its effects. In five instances, it appeared at first to arrest the further progress of the disease, but the amendment was only temporary, for the tuber- cles passed slowly but progressively through their several stages, and death was the consequence of the extensive disorganization which occurred in the lungs. (Hospital Facts and Observations, &c. p. 123.) We are of opinion that this medicine, adminis- tered as an alterative, may prove highly useful, when we are better acquainted with its mode of operation and with the cases in which it is parti- cularly indicated. [The writer has used it to a considerable extent, especially in public practice, in the form of the ioduretted iodide of potassium, which is as valu- able a form as any; in that of the iodide of potas- sium ; of the tincture of iodine; of the iodo-hy- drargyrate of potassium, the iodides of mercury, &c.; but the most careful and accurate examina- tion has not enabled him to say, that any beneficial effect was induced, which could be unhesitatingly referred to these preparations. Codliver oil—Oleum Jecoris Aselli—which con- tains, it is affirmed, a minute quantity of iodine, and which has been highly extolled in scrofula, has been given in tuberculosis, and, it is asserted, with advantage. The dose, to an adult, is from half a spoonful to three spoonfuls, two or three times a day, in coffee or with lemon-juice, or in the form of emulsion. The writer has had no ex- perience of its effects. It is extremely nauseous.] 5. Climate.—We have already entered so fully into this subject (see article Climate), and have given such a particular account of the comparative merits of the various places resorted to by pulmo- nary invalids, that we have little to add here be- yond the application of climate to the different stages of tuberculous disease. a. Since the nature of phthisis has been more fully understood, the ecpectations from climate as a means of cure have greatly abated, and hence it is much more justly considered at the present time simply as a preventive of the disease. When adopted with this view, climate is certainly one of the most powerful remedies we possess for im- proving the tuberculous constitution, and enabling us to correct the predisposition to the disease. When, therefore, the tuberculous diathesis is strongly manifested, it is most desirable that this measure should be adopted in early life. Children and young persons of a tuberculous constitution, more especially those who suffer much from damp weather, and are very liable to catarrh in this country, escape this by a residence in a mild and drier climate; and by a continued residence therein for several successive winters, their constitution may be so much improved as to enable them to resist the influence of this season on their return. Vol. IV___71 i If we were to select the two periods of life at | which such a change appears to be most beneficial, j we should probably specify that between the third and seventh year, and again that towards the ap- proach of puberty. If the health of the child from the third to the seventh year is maintained in a good state, he is then capable of taking more active I exercise in the open air, and various means may ! be employed to strengthen his constitution, which are inadmissible at an earlier age. The period of puberty in persons of a tuberculous constitution is a very critical one; and a residence in a mild cli- mate towards the approach of this important epoch [ will prove highly beneficial in favouring the full 1 development of the body, and the establishment of those functions which are naturally called into I action at this period of life. But although a change of climate is attended [ with such decided benefit at the two ages we have here mentioned, no measure promises greater ad- vantages at any time when tuberculous disease is threatened. One winter at this time spent in a mild climate will do more as a preventive of phthisis than several winters when the health is 1 more disordered. b. During the Incipient Stage of phthisis, that is, after tuberculous matter is deposited in the lungs, the power of climate is much less, and much more caution is necessary in prescribing it. j A careful and minute examination of all the symp- toms of the case is imperatively called for on the [ part of the medical attendant, before he recom- | mends a measure necessarily attended by the ex- I citement and exposures which are in some degree inseparable from a long journey or voyage. Proper preliminary means must be adopted to remove pulmonary congestion and bronchial irritation, when these exist, and to induce a healthy state .of the functions of the chylopoietic viscera; in i short, if due precautions are not taken to improve the local functional derangements before the pa- i tient leaves this country, the measure may prove highly injurious. Even under the most favourable circumstances, change of climate ought only to be considered as j a means of placing the patient in a more favour- I able position for adopting such measures as may | be proper for his condition; those remedial means and those plans of treatment, which are required in his particular case during his residence at home, will in all probability be required in that to which he may migrate; but he will derive this additional advantage from the change, that those measures which would have availed him little in his own country, are likely to prove highly useful I under the favourable influence of his new position. Hence it will be apparent that this change must not be allowed to interfere with the use of the various remedies which have been suggested in this and the preceding section. c. In the Advanced Stages of phthisis, when tuberculous disease of the lungs exists to a con- siderable extent and hectic fever is established, ' change of climate will be of little avail, and will probably be prejudicial, unless adopted under very favourable circumstances. There are, notwith- 1 standing, some chronic cases in which the measure may prove useful at any period of the disease, ' even when tuberculous cavities exist in the lungs: 562 TUBERCULAR PHTHISIS. we allude to those forms of the disease, already described, in which the tuberculous deposit is very limited, and passes through its various stages of softening, &c. without exciting much local or con- stitutional irritation. But, at whatever period the change is adopted, it is of the highest importance to impress upon the mind of the patient and his friends, that if the measure is attended with favourable effects, it ought, in a large proportion of cases, to be conti- nued for several successive years, in order to pro- duce a full and permanent influence upon the constitution; and must at the same time be aided, as has been already remarked, by the adoption of such a regimen and the use of such remedies as are known to improve the general health and cor- rect disordered functions. d. Particular Climates. — A full account of the various places in the south of Europe, in the islands of the Northern Atlantic, and in our own country, which have been resorted to by invalids, will be found in the article Climate ; our re- marks, therefore, in this place will be very gen- eral. Of all climates with which we are acquainted, that of Madeira is the best for consumptive per- sons. We have every year an opportunity of becoming acquainted with its effects upon a con- siderable number of persons who repair to it in different conditions of health, and we see no rea- son to change the high opinion we have given of it in the article alluded to. The beneficial effects of a residence for one or two winters in Madeira have become much more apparent since the public have been impressed with the necessity of adopt- ing change of climate rather as a preventive than as a means of cure. A few years ago, it was a matter of little moment to select a climate for the consumptive patient, because he was generally in the advanced stage of the disease, without hope of recovery, before the measure was proposed or adopted ; and its fatal termination was not infre- quently accelerated by the only means to which he looked for safety. Dr. Renton's report of the effects of the climate of Madeira on the invalids who passed the last winter there has just reached us. The total num- ber of pulmonary invalids who arrived there during the season of 1833-34 was 66. Of this number 15 died ; 43 returned to their homes ; and 8 still remain in the island. "Of the 15 fatal cases," says Dr. Renton, » 13 ought not to have left their homes; of the 43 who left the island for England or other parts of the world, 36 were very much improved; indeed I may say a large majority of them went away well." The result was very J different a few years since, when persons were only sent to Madeira in the advanced stage of the I disease. (See the account of Madeira in our work " On the Influence of Climate.") In point of climate the Bermudas and Canary I Islands approach nearest to that of Madeira. The West Indies may be suited to some constitutions as a preventive; but when tuberculous disease exists in the lungs, we can only repeat, that the concurrent testimony of all the medical men whom we have consulted on the subject, and whose op- portunities of judging were ample, establishes the fact that consumptive cases sent thither from this country proceed much more rapidly to a fatal ter- mination than in temperate climates. In Italy, Rome, Pisa, and A/>e, afford the best climates for consumptive patients during the win- ter ; but no part of Italy is favourable to such in- valids during the summer. In the south-east of France, Hycrcs possesses the best climate; in the south-west, the climate of Pau is the mildest and most favourable, particularly during the spring. In this country, Torquay presents, on the whole, more advantages than any other situation as a winter residence. Its peculiar position on the southern declivity of a range of limestone-hills by which it is protected from the north and east, the excellent accommodations for the invalid, and the facility of exercise in the sheltered and picturesque country by which it is surrounded, are all advan- tages which are enjoyed in an equal degree in no other place in our island. From the extent of sheltered country which the neighbourhood affords, it is also well adapted for exercise on horseback, which we deem of so much importance in the treatment of pulmonary disease. Undercliff, in the Isle of Wight, possesses great natural advantages, and when suitable accommoda- tions are provided for invalids, and upon a superior scale to those which have been hitherto attempted, it will scarcely be exceeded in this country as a winter residence for the pulmonary invalid. Clif- ton affords a good winter residence for those cases in which the digestive organs are much deranged, and the climate of Torquay might prove too relax- ing. Hastings and St. Leonards are the most sheltered situations on the southern coast; but during the autumn months we consider that the climate of Brighton possesses more Advantages in a large proportion of cases than any other part of that coast, or perhaps of England. On this ac- count it will be advantageous to many invalids to pass the autumn at Brighton and the winter at St. Leonards or Hastings. The western shores of our island, as the Isles of Bute and Man, although mild, are too humid to afford good residences to the pulmonary patent. [St. Croix, in the West Indies, is often visited by the phthisical from this country; and those of the northern states frequently seek the sea- coast or the interior of Florida, Georgia, Ala- bama, or Louisiana, to escape the rigours of their own variable atmosphere. The writer has, how- ever, expressed himself so fully elsewhere on the subject of the summer and winter retreats of the consumptive, that he will not repeat his observa- tions here.—See art. Climate, vol i. p. 449 of this work ; Practice of Medicine, 2d edit. ii. 380, Philad. 1844; and especially his Human Health, p. 144, 176, Philad. 1844, where the whole sub- ject is examined at length.] Our observations on climate have hitherto had reference chiefly to the winter. During the sum- mer, our own country affords a variety of residences; but a frequent change of place during this season is much more useful to persons threatened with consumption than a continued residence in the best situation. The interior and mountainous dis- tricts during the summer, and the sea-coast in the autumn, afford the best succession of changes. But a tour on the continent, during the summer months, will be productive of still greater benefit. TUBERCULAR PHTHISIS. 563 If the tour be made in the more romantic and picturesque countries, the pleasing and continued excitement which is produced by the great variety and beauty of the scenery exerts a more beneficial influence on tho whole economy, in a limited space of time, than any other measure with which wc are acquainted. Of course, we now allude to persons free from local disease; when this is estab- lished, such a tour must be conducted with more precaution. Regulated temperature___The great object of removing to a milder and more sheltered situation is to enable the invalid to be as much as possible in the open air. Change of climate, therefore, presents much fewer advantages to the confirmed phthisical invalid, who must keep within doors during the greater part of the winter wherever he may reside, and who will find the comforts of home in general much more than a compensation for any additional mildness of temperature. Such patients will derive advantage from maintaining their apartments at an equable temperature, and when this can be accomplished throughout the whole house, it will be far more beneficial than confining the patient to one or two warm rooms. This measure is chiefly suited to cases of chronic phthisis in delicate females and in persons in advanced life; but in the young at that stage of the disease when wc may reasonably entertain a hope of recovery, such confinement is rarely advi- sable,— indeed it forms an obstacle to the best means of improving the patient's health. [The late Dr. Parrish always ascribed his reco- very from phthisis at an early period of his life to the employment of vigorous exercise in the open air,—the exercise being pushed so as to amount even to labour, and not allowing the dread of taking cold to confine him on every occasion, when the temperature was low or the skies over- cast. This course he recommended to others; and it has been often followed with salutary effects. (Parrish, North Amer. Med. and Surg. Journal, for 1829 and 1830; Morton's Illustrations of Pulmonary Consumption, p. 142, Philad. 1839; and Wood's Memoir on Parrish.) The general rule should be to take exercise in the open air whenever it is dry, and the temperature, even if cool, tolerably equable. On several occasions, the writer has advised this course, and has never wit- nessed any disadvantage to accrue from it. On the contrary, the invalid has always been benefited by the revulsion. At every exacerbation of his complaint—as Dr. Billing has remarked, (Princi- ples of Medicine, Amer. edit. Philad. 1842), he says he has « caught fresh cold," but the same thing happens when he is kept in rooms the temperature of which is regulated by the ther- mometer.] II. Local Remedies. — The numerous local remedies which have been employed in the treat- ment of phthisis may be considered under two heads; those which are applied to the external parts of the thorax, and those which act immedi- ately upon the lungs by means of inhalation. 1. Local bleeding. — External remedies have been employed in pulmonary phthisis chiefly with the view of preventing or removing congestion and inflammation of the lungs: the abstraction of blood by means of copping or leeches is one of the most effectual of these applications, and there are I few cases in which they may not be productive of benefit at some period of the disease. In young persons disposed to phthisis, and in those cases in which pulmonary congestion is indicated, we con- [ sider cupping on the upper parts of the chest a i very useful practice. Two or three ounces may be abstracted from time to time, and dry cupping may be also employed over the whole of the upper ! parts of the chest. If necessary, this practice may he frequently repeated ; and when tuberculous deposits are present in the lungs, such small bleed- ings may be made very beneficial. We consider cupping a more effectual mode of abstracting blood from the chest than leeches, and the dry cupping, which we always employ at the same time, we think of considerable utility. Leeches, however, are perhaps equally beneficial in irritation of the bronchial membrane; and when the larynx or trachea is affected, they may be applied nearer the seat of disease. We would, however, take this opportunity of cautioning the young practi- tioner not to be too free in the application of leeches in laryngeal irritation ; we have known a patient lose his voice entirely by the application of a dozen leeches to the region of the larynx. It is congestion and sub-acate inflammation only which are generally present in consumptive patients, and local bleedings must be employed with circumspec- tion. 2. Counter-irritants.—Among the various re- medies which have been employed in phthisis, counter-irritants have long occupied a chief place. They differ considerably in effect; some produce a temporary irritation only, without any discharge, as the common rubefacients; others, as cantha- rides, excite a copious serous discharge; and others, as tartar-emetic, produce deep pustular eruptions; while setons or issues cause a more permanent puriform discharge from the subcutane- ous tissue. All the applications which we have mentioned, however different in their action, are useful; and each of them is applicable to particu- lar circumstances. The simple rubefacients, such as camphorated spirits and spirit of turpentine, are chiefly employ- ed in the very early stages with the view of exci- ting the action of the cutaneons vessels, and may be applied daily over a great part of the chest. We think that they are of considerable use in an inactive state of the skin, accompanied with an irritable condition of the bronchial membrane ; they will also often afford relief in slight local pains. Plaisters composed of Burgundy pitch and other substances of a similar kind, may be ranked under rubefacients, as they operate chiefly in exciting irritation of the skin ; but they also act by effectually protecting the part from cold. We apply them by preference between the scapula?; they are less inconvenient in that situation, and moreover leave the chest clear for other appli- cations, such as cold sponging, friction, &c. After rubefacients, blisters are in most general use, and when applied in the cases to which they are adapted, and at the proper period, they seldom fail to produce marked benefit. In slight inflam- mations of the pleura, and in the catarrhal attacks of phthisical patients, blisters give essential relief. In cases where the abstraction of blood, either 564 TUBERCULAR PHTHISIS. local or general, is necessary, blisters should for the most part be avoided until the practitioner is satisfied that the further employment of bleeding is unnecessary; this is, in our opinion, the proper period for the application of blisters. Even in catarrh, they should not be applied early in the disease, nor before the febrile excitement has been reduced by the proper remedies; their effects are then very remarkable in removing the remains of the disease; but if employed in the early stage of inflammatory action, they frequently increase the evil by exciting irritation in the system, especially in consumptive subjects; indeed, we consider that the prevailing error in the use of blisters is their too early application. A succession of blisters is often recommended in phthisis, and when the skin is not irritable, and the patient does not suffer much inconvenience from their operation, they may be of some use; but we never saw them beneficial when they ex- cited much pain and irritation ; and in a disease which is attended with so many distressing symp- toms, we ought not unnecessarily to add to these by the injudicious application of external irritants: the less uneasiness blisters give, and the greater the discharge they occasion, the more benefit is derived from them. Blisters, applied to persons with a thin irritable skin, should be covered with a piece of fine muslin, moistened with oil; and they should be removed at the end of six or eight hours : in this way they will produce less irrita- tion. ' The tartar-emetic ointment has been more gen- erally employed of late as an external irritant than any other application, and in general it answers well; although the sanguine expectations enter- tained by Dr. Jenner of the effects of this remedy are, we fear, far from having been realized. (See his Letter to Dr. Parry on the Influence of Artifi- cial Eruptions, &c.) [The writer often employs a saturated solution of the tartrate of antimony and potassa, which may be rubbed on twice a day, until the peculiar eruption is induced. Croton oil is prescribed as a liniment with the same view. To the saturated solution of the tartrate of antimony and potassa, iodide of potassium has been added, with the effect of rendering it more irritating, and perhaps, ac- cording to Dr. Williams, (Op. cit.) of acting favour- ably on the constitution by being partially absorbed. Some practitioners apply one revellent and some another—ammoniated liniments of various degrees of strength; moxas, sponging the whole chest once or twice a day with brandy and salt, or strong vinegar, or the linimentum catharidis of the Phar- macopoeia of the United States, or with a liniment of oil of turpentine and acetic acid, as recommend- ed in Bronchitis, (q. v.)] Setons and Issues.—Discharges of matter from the subcutaneous tissue have been generally em- ployed in phthisis, although, in general, their ap- plication has been confined to, or at least most frequently adopted in, the late stages of the dis- ease, when they could be of little utility. Issues may be useful in the state of tuberculous cachexia before the deposition of tuberculous matter in the lungs; and even after this period such discharges may have some effect in checking the further pro- gress of the disease, while means are at the same time employed to improve the general health- They are strongly recommended in this stage of the disease by Mudgc. " In this critical and dan- gerous situation," says that judicious practitioner, " I think I can venture to say, from long experi- ence, that, accompanied with change of air and occasional bleedings, the patient will find his greatest security in a drain from a large scapulary issue, assisted by a diet of asses' milk and vege- tables." The cases in which issues are more particularly indicated are full gross habits of body, with little sensibility; and if the patient has been subject to cutaneous diseases or ulcers, so much the more advantage may be expected from them. In such cases issues generally discharge freely, and give little pain ; and we agree with Mudge, that when they are applied, they should be so large as to en- sure an abundant discharge. In irritable, sensitive, or spare persons with a thin skin, issues, or any other form of external discharge, will not prove of much use; the irritation and distress which they occasion more than counterbalance their good effects. Indeed, we think that local discharges of all kinds must be employed with certain restric- tions. When they excite little constitutional irri- tation, they are most beneficial; but, on the con- trary, when they produce long-continued pain, increase the action of the heart, or prevent sleep, we cease to continue them, being well assured that their effects on the system are more likely to do mischief than they can otherwise do good. In regard, therefore, to the class of external stimulants and discharges, we consider that, with due attention to the restrictions we have laid down on the subject of their application, very great ad- vantage may be derived from their employment in allaying pulmonary irritation, and thus affording time for the adoption of such means as are calcu- lated to improve the general condition of the sys- tem. He who expects more from these remedies will, we believe, be generallly disappointed. For a full account of this subject, see Counter- maiTATioN. 3. Inhalation. — The inhalation of volatilized substances, in the form of dry fumes or vapours, has been supposed to be beneficial in phthisis, from their being applied directly to the seat of the disease. Dry fumigations.—The inhalation of the fumes of resinous and balsamic substances is a very an- cient practice. From the time of Galen and Rhazes, such fumigations have been employed in the treatment of pulmonary disease; they were particularly advocated in this country by Bennet and Mead, but have gradually fallen into disuse in modern times. It will not be necessary to go much into detail upon this practice, nor to dwell long on the ad- vantages which have been ascribed to it in the cure of phthisis. In chronic bronchial disease, or even in chronic tuberculous disease, the applica- tion of gentle stimulants of this kind to the bronchial membrane may be useful; but before we can decide on the particular cases to which they are applicable, we would require a series of experiments conducted by practitioners well ac- quainted with the nature of pulmonary diseases. The only substance applied in the way of TUBERCULAR PHTHISIS. 565 fumigation which has attracted much attention in modern times is Tar. The vapour of this sub- stance was first recommended to the notice of the profession by Sir Alexander Crichton, who was induced to try it by a conjecture of Mudge, that the salutary effect of sea voyages is greatly assisted by the perpetual inhalation of an atmosphere im- pregnated with the volatile parts of the resinous and terebinthinate substances in and about the vessel. The vapour is obtained by heating the tar over a spirit-lamp, a small proportion of sub- carbonate of potass being previously added to neutralize any pyroligneous acid which the tar may contain. The heat should be moderate, and the vapour diffused equally over the chamber of the patient, which should also be carefully main- tained at an equal temperature. The success of the tar-vapour appears to have been remarkable in some cases of pulmonary disease accompanied with cough and expectoration; while in others, which were apparently of a similar nature, it pro- duced no sensible benefit, and was sometimes injurious by irritating the lungs or provoking hemoptysis. In the appendix to the last edition of Crichton's work, an account is given of some experiments made with this remedy in the hospital of La Charite at Berlin, by Drs. Hufeland and Neumann; it appears " that of fifty-four patients, labouring under pulmonary consumption, four were cured, six left the hospital in a state of con- valescence at their own request, sixteen did not receive any benefit from the remedy, twelve ap- peared to get worse under the treatment, and sixteen died." (Op. cit. p. 243, et seq.) We are not aware that any well-conducted ex- periments on tar-vapour have been made on a large scale in this country, except those of Dr. James Forbes, which were not in favour of it, (Remarks on Tar Vapour as a Remedy in Dis- eases of the Lungs, Med. and Phys. Journ. Oct. 1822) ; and it is reasonable to believe that the general result of the trials has not been such as to encourage the continuance of the practice. Dr. Morton of Philadelphia, in the work already quoted, gives the following favourable opinion of the efficacy of tar fumigation. " After a fair trial with various substances there is no one which I have prescribed in this form with equal success to tar in combination with subcarbonate of potash, in the manner recommended by Sir Alexander Crichton. In truth, I have seen it act like a charm." In chronic catarrh he knows of no plan of treatment that can vie with this. He also states, that the fumigation was employed by the late Dr. Rush of Philadelphia upwards of thirty years atro. For a full account of the effects of tar vapo.ir, and the mode of employing it, we beg to refer to Sir Alexander Crichton's excellent and sensible work, which will repay tho reader, inde- pendently of the information it will afford him on the particular subject in question. Watery and medicated vapours.—The inhala- tion of the steam of water, either pure or impreg- nated with the virtues of emollient medicines, is also a practice of some antiquity. Bennet and others recommended the respiration of watery vapours arising from decoctions of emollient herbs in cases of phthisis unattended with expectora- tion ; but the inhalation of vapour was not much 2x employed until the publication of Dr. Mudge's sensible work, in the middle of the last century, introduced it to public notice as a remedy for a catarrhous cough and inflammatory affections of the lining bronchial membrane. (A Radical and Expeditious Cure for a Recent Catarrhous Cough, p. 131 et cet.) After trying the effects of various pectoral ingredients, he found no vapour so inof- fensive and grateful to the lungs as the simple steam of warm water; the apparatus which he employed for its inhalation is still in use, and is ! generally known by the name of " Mudge's in- [ haler," but much improved by Mr. Reid, the inventor of the stomach-pump. In a very irritable state of the bronchial mem- brane, this author occasionally combined opiates with the warm inhalations, and with great relief of the symptoms. The inhalation of warm water impregnated with narcotic substances has been recommended as useful in allaying irritation of the mucous membrane of the larynx and bronchi; but we are inclined to believe that the principal part of the benefit derived from the inhalation of medicated vapours has, in many cases, been pro- duced by the simple effects of the vehicle. When the air of a consumptive patient's room is very dry, the cough frequently becomes more trouble- some, and some advantage is derived from a basin of warm water placed near the patient; tho vapour softens the air, and renders it less exciting to the irritated surfaces of the air-passages, and saves the patient the irksome labour of inhaling. Chlorine.—About ten years ago M. Gannal, a French manufacturer, having observed that con- sumptive patients experienced relief while breath- ing an atmosphere charged with the chlorine disengaged in the manufacture of printed cottons, suggested it as a remedy for phthisis; and since that time numerous experiments have been made with chlorine in France and this country. M. Gannal, in several memoirs presented to the Aca- demy of Medicine, relates numerous cases in which marked relief was obtained from its employ- ment (See Potter's Translation of Gannal's Me- moirs, Lond. 1830); and a case is given by M. Cottereau, in which a cicatrix was found after death in a part of the lung where pectoriloquy and " gargouillement" were distinctly heard eighteen months before :—the patient died of gastric fever. (Journ. Hebdom. t. ii. 1831.) Numerous other instances of apparent success of the remedy have been recorded in the French periodical publica- tions. (See Archives Generales de Medecine.) In this country, however, the trials made with chlorine have not been attended with such bene- ficial results: it has frequently afforded great relief, but rarely effected a cure. We have tried it in many instances, and it has in several appa- rently suspended the progress of the disease ; but the cases in which we employed it were in the advanced stage, when tuberculous cavities already existed in the lungs. Many of the cases recorded by others were also far advanced ; and there can be no doubt that the cures which have been related as effected by the inhalation of chlorine occurred in persons whose lungs were diseased to a very limited extent only. The symptom which we have found chlorine most decidedly relieve is dyspnoea; in all the cases 566 TUBERCULAR PHTHISIS. in which it was beneficial, the freedom of breath- ing which it produced was one of its most obvious effects;—it also appeared to allay the cough in some cases;—in others we were obliged to aban- don its use from the irritation which it excited; and in the majority of the cases it produced no sensible amelioration of the symptoms. The mode which we adopt in the use of chlo- rine is to direct the inhalation to be continued for live minutes only, and to be repeated frequently in the course of the day. We find that a longer period produces a sensation of fatigue, and the patient returns to it with less readiness. We begin with five drops, and gradually increase the quantity to forty, but rarely go beyond this. The inconveniences which we have observed from it are soreness of the mouth and an increase of the bronchial irritation. As a palliative, chlorine may be employed in combination with other remedies calculated to abate pulmonary irritation. These observations will, we think, apply with equal or greater force to the inhalation of Iodine and substances in the gaseous form. [The addition of a little tincture of conium was found by Sir Charles Scudamore (London Med. Gazette, Feb. 17, 1838, p. 804, and Feb. 7, 1840, p. 750. See, also, Dr. J. E. Coxe, Practical Treatise on Medical Inhalation, pp. 51-85, Phil. 1841,) to be beneficial in subduing the irritating qualities of the gas. The writer's experience is not favourable to iodine in this form, and such has been the case with that of others. It has been suggested by Mr. A. Leigh, (Lond. Med. Gaz. May, 1841,) to apply a sufficient quantity of iodine ointment on the ribs and under both axilla?, and to cover the head with the bed-clothes, in order that the iodine, volatilized by the heat of the axilla?, may be breathed. This method is stated to have arrested the progress of the disease. (See the writer's New Remedies, 4th edit. p. 389, Philad. 1843.)] Hydrogen and carbonic acid gases, and even oxygen and nitrous oxide, have been employed in phthisis, but without any such advantages as en- title them to consideration. When more rational and just views of the pathology of phthisis are generally entertained by the profession, we shall cease to hear it asserted that this disease is to be cured by local applications. We do not, however, condemn such measures as useless ; on the con- trary, we consider them valuable as palliatives, and of great service as adjuncts to those remedies which are directed to amend the condition of the general health, and to correct the tuberculous diathesis: but we certainly disapprove of any local remedy being relied on as the principal means of curing a disease which depends upon a morbid state of the constitution. Such an error is founded on imperfect views of the real nature of tubercular phthisis, is productive of much mis- chief in practice, and cannot be too strongly re- probated. [Arsenic.—An able therapeutist, M. Trousseau, has advised the employment of arsenic in phthisis in the way of inhalation. The remedy is not new—the sulphuret of arsenic having been ad- ministered in fumigation centuries ago. M. Trous- seau recommends that the arsenious acid should be used in the form of Cigarettes arsenicales, which are made in the following manner:—A sheet of white paper is dipped in a solution of one part of arseniate of soda, and thirty parts of water. The paper is then made into small cigars of the length of a finger, and the patient is di- rected to smoke one or even two daily, so that the fumes may pass into the lungs. The cigars burn readily, the arseniate facilitating the combustion; and in this manner " the empyreumatic oil of the paper is inhaled, united with the metallic arsenic, reduced by the contact of the charcoal formed by the burning of the cigar." M. Trousseau does not pretend to cure pulmonary tubercles by this agent, but he thinks the general symptoms may be so far modified by it as to produce decided im- provement in the condition of the patient; which may, however, be questioned.] III. Treatment of Particular Symptoms, Cough.—The relief of this symptom is one of the first indications in the treatment of phthisis; but before we employ any remedies for allaying it by abating the sensibility of the respiratory organs, it will be desirable to examine into the causes which produce the cough, with a view to adopt more effectual means to palliate or remove it. If we find that it depends upon bronchial irri- tion, which is usually the case, the application of leeches followed by rubefacients and blisters ovei the upper part of the sternum, are the most direct remedies which we can employ. In other cases when it depends upon gastro-hepatic irritation and congestion, leeches and a few alterative doses of mercury with laxatives will be the best means of relieving it. But it does not often happen that the cough is severe at this early period of the disease; it is as this advances and the local disorganization extends, and this symptom becomes frequent and distressing. In addition to the general means employed in the treatment of the disease, it will then be necessary to give medicines to abate the cough and procure sleep ; with this view, the usual narcotic medicines should, we think, be tried before recourse is had to opium, which, though it is one of the most valua- ble medicines we possess in the treatment of phthisis, should be used as sparingly as possible in the earl)' period of the disease, in order that it may be more beneficial In the later stages. One of the greatest errors committed in the treatment of phthisis is, in our opinion, a too early and too frequent use of opium in large doses : we have often obtained the full effects of an opiate from four or five drops of the solution of the muriate of morphia without any subsequent inconvenience; indeed it is always desirable to begin with the smallest doses, because, as the disease advances, it is generally necessary to increase the quantity, and vary the preparation, as it often becomes in the last stages the chief solace of the patient amidst his multiplied sufferings. When the cough is kept up by an accumulation of mucus in the bronchi, and the patient has much difficulty in expectorating, a gentle emetic will often afford great and almost immediate relief, and save the patient hours of harassing cough, and a restless night. Hxmoptysis. — The pulmonary hemorrhage which attends the early stages of phthisis, we be- lieve to be in almost every case dependent upon TUBERCULAR PHTHISIS. 567 congestion of the lungs, and hence we consider venesection the most effectual remedy. The quantity of blood abstracted must be regulated by the urgency of the symptoms and the constitution of the patient; and when due attention is paid to these circumstances, we believe that venesection is always useful and generally necessary. Until the sanguineous congestion and the increased action of the heart which generally attends active hemorrhage is somewhat abated, medicines given with the view of suppressing the hemorrhage will for the most part produce little effect. We have never had occasion to regret the employment of bleeding, nor have we observed in our practice any evil consequences result from it. The quan- tity of blood abstracted need not in any case be great; but if the hemorrhage should return, and especially if the excitement of the circulation should continue, venesection niay be required fre- quently, and at short intervals, before the hemor- rhagic action ceases. When there exists a dispo- sition to frequent returns of haemoptysis, small bleedings repeated from time to time form the most effectual and, in some cases, the only means of arresting the hemorrhage. One of the most striking cases illustrative of the efficacy of this practice is recorded by Dr. Cheyne, in the fifth volume of the Dublin Hospital Reports. As the gentleman who was the subject of this case was under our care for some time before he became Dr. Cheyne's patient, and his case is altogether a very interesting one, we shall give some account of it here. This gentleman had been subject to haemoptysis for many years; but, after his return from Italy, where he had been for some time under our care, it greatly increased. During four months he had every day from three to four attacks, and at the end of February, 1825, was reduced to such a state of weakness and emaciation that he was unable to move from his chair to his bed without assistance. It was in this condition, after having experienced the inefficacy of other reme- dies, that Dr. Cheyne had recourse to frequent small bleedings. Six ounces of blood were taken from the arm, which had the effect of suspending the return of haemoptysis for four days, when he had a slight relapse; six ounces were again ab- stracted, and no return of haemoptysis occurred for ten days. From this time three or four ounces of blood were regularly taken from the arm every week for a year, and once every month or six weeks for another year. During the first eighteen months the blood was invariably cupped and huffy, but after that time it assumed the natural appearance. The pulse during the whole period of the complaint was never much accelerated ; the most unpleasant symptom was a sensation of weight in the chest in the recumbent posture. Another circumstance deserves notice:—the di- gestive organs, which had been constantly de- i ranged during his illness, improved immediately after the bleedings were commenced and the hae- moptysis was checked. In reviewing the whole history of this case, we have little doubt that the abdominal circulation was the primary seat of congestion : the early attacks of haemoptysis were preceded by constipated bowels, and the patient suffered from pain in the region of the liver, with dyspepsia, headach, and depression of spirits. We are enabled, by a communication just re- ceived from this gentleman, to give an account of his health subsequent to Dr. Cheyne's report (1827). He states that he enjoyed good health, with the exception of an occasional slight attack of haemoptysis, for which the lancet was used, up to April 1830, when the hemorrhage returned in a greater degree, and continued to recur frequently for two months unchecked by bloodletting. When reduced to great weakness he tried carriage exer- cise in the country, which appeared to have the most beneficial effects in allaying the hemonhage; and in the course of two months he was able to return to his clerical duties. In May 1831 he had another attack, and again in December 1832; since which time he has had no serious return, and has not used the lancet since December, 1833. He adds that he is now, October 8, 1834, quite well, between twelve and thirteen stone weight, takes much exercise on horseback, and feels no inconvenience whatever from reading the service and preaching twice on the same day. There cannot be a stronger instance of the beneficial effects of small bleedings in suspending hemor- rhage than this case affords, and if this practice had not been so judiciously adqpted by Dr. Cheyne, the patient must inevitably have sunk under the continual recurrence of pulmonary he- morrhage. But we are disposed to think the re- medy was relied on too exclusively in this case; and the faith of the patient in its efficacy is now somewhat shaken. The practice of small bleedings may be adopted, we believe, in other hemorrhages with advantage, as in hemorrhage from the bowels, menorrhagia, epistaxis, &c. Local bleeding, especially by leeches, in the early stage of haemoptysis, or even when there exists a congestive state of the lungs, with a dis- j position to haemoptysis, is, in our opinion, a dan- [ gerous practice, and likely to produce the effect it is intended to remove or prevent. This was ex- emplified in the patient whose case we have just recorded: while at Rome, leeches were applied to the anus, with the view of relieving abdominal plethora, and before they had ceased to bleed, the patient was attacked by copious hemorrhage from the lungs, which it required several general bleed- ings to subdue. In a slighter degree we have frequently observed this effect produced by leeches, and we consider the practice of abstracting blood in this manner from a person threatened with haemoptysis or apoplexy not free from danger. In all cases where the object is to relieve congestion of the large vessels, general bleeding is the proper mode of abstracting blood in the first instance: when, on the other hand, we wish to promote or restore suppressed secretions in plethoric persons, local bleeding by leeches is the best measure. After the plethora has been reduced by one or more general bleedings, local bleeding may often be employed with advantage. Various medicines have been used in haemop- tysis from a belief in their specific powers in checking hemorrhage: (see article Hemoptysis.) When the circulation is excited, and more espe- cially when there is reason to apprehend pulmo- nary inflammation, tartarized antimony combined with nitre forms one of the most efficient remedies;- 568 TUBERCULAR PHTHISIS. it is recommended by Dr. Cheyne as superior to all others " in cases of haemoptysis with inflam- matory symptoms." It may be given to produce nausea: a quarter or often an eighth of a grain with five to ten grains of nitre every hour will generally prove sufficient to abate the increased action of the heart and induce some nausea. The other remedies in most estimation for the cure of haemoptysis are digitalis, superacetate of lead, ipecacuan, nitre, sulphuric acid, and opium, which last is often useful when there is much nervous irritation or alarm. We consider purgatives of great utility in pulmonary hemorrhage, which in the consumptive constitution is often connected with hepatic congestion ; and accordingly we have found that the hemorrhage did not generally cease till the biliary secretion assumed the natu- ral appearance ; hence in all cases of haemoptysis we would recommend attention to the functions of the liver. Aperients of the least irritating kind deserve the preference; the saline laxatives gene- rally answer best. After bleeding and other means have checked haemoptysis, there is some danger of inflammation supervening; and a blister will be beneficial in preventing this. Even during the continuance of the bleeding, blisters are often useful. We consider the application of cold water or ice to the chest a very doubtful measure; and the cold affu- sion over the whole body, which has been recom- mended, highly objectionable. Ice, or iced water, may be given internally with advantage. When the hemorrhage has been great and the patient's strength is much reduced, mild tonics may be employed with benefit as soon as the hemorrhage has ceased. Bark with sulphuric acid we consider the best tonic in such cases: in the slighter forms of haemoptysis, the preparations of iron are good remedies. The cure of pulmonary hemorrhage in persons threatened with phthisis, is not merely to be con- sidered as the removal of a symptom; it may be the means of preventing the occurrence of phthi- sis, if advantage is taken of the removal of pul- monary congestion to adopt such measures as shall prevent its return, and at the same time im- prove the general health; the means by which this may be best effected have been already pointed out. It is particularly necessary to watch the state of the pulmonary circulation after an attack of haemoptysis; and when congestion of the lungs is indicated, a small bleeding, employed in season, may prevent a return of the haemoptysis. Pain of Chest.—The pain which occurs during the progress of phthisis is seldom very severe, un- less when it is complicated with acute pleuritic inflammation. The abstraction of a few ounces of blood by cupping, or the application of leeches or a blister, will generally be sufficient to remove it; but of all local applications we have found the mustard poultice most convenient and effective in relieving the pains which accompany the latter stages of phthisis. In persons with a very irrita- ble state of skin, we find a warm poultice of lin- seed meal with a very small proportion of mustard have considerable effect in mitigating pain with- out exciting much external irritation. When the pain is fixed, a plaister of burgundy pitch applied over the part will be very useful; and in slight i pains, friction with stimulating or opiate lini- I ments, or the application of aether, will often re- i lieve them. Dyspnma.—Severe dyspnoea, except during the last weeks of the disease, is not productive of much distress. During the paroxysms which I occur at this period, a combination of aether and I opium often proves useful; and if they are very I harassing and the pulse admits of depletion, a small quantity of blood may be abstracted with advantage. Laennec recommends belladonna in these cases, but we have never seen it produce decided relief; we have found the extract of stra- monium, given in small doses of a quarter or a half a grain every day in cases where the dys- pnoea was constant, a far more efficacious remedy. I External applications are sometimes beneficial, particularly when the dyspnoea returns in par- oxysms ; a mustard poultice is quickest in its operation, and may be applied either to the chest, I arms, or feet. When the stomach is loaded, an emetic will afford more relief than any other remedy : the inhalation of aether, either alone or combined in solution with some narcotic sub- stance, is also occasionally useful; but in the last \ stage of the disease, when the oppression of ! breathing often becames very distressing, espe- cially towards night, we have found opium and aether afford more effectual relief than any other remedy. Nausea and Vomiting. In a small proportion of phthisical cases, this forms a very distressing and obstinate symptom. Indeed there is no symp- tom more difficult of relief than the extreme irri- tability of the stomach which occasionally accom- panies phthisis: we have known it prevail for years, the quantity of food retained during the whole of that period being wonderfully small. All the cases of this affection which we have seen, have occurred in young females of a strongly marked tuberculous constitution. A strict ad- herence to a mild diet, the avoidance of every thing which is found by experience to irritate the stomach, and the use of food in the smallest pos- sible quantity at a time, will often relieve the vomiting or reduce its frequency. In some cases we have derived decided benefit from the use of prussic acid, and in others from lime-water or liquor potassse. Seltzer water is also occasionally useful. External remedies, such as blisters and sinapisms, produce temporary relief only. Hectic Fever.—When this symptom occurs in the early stages of phthisis, and especially when it is accompanied with pain or tightness of the chest, it may be necessary to have recourse to venesec- tion; but in general small doses of tartarized anti- mony combined with nitre or saline medicines will be the most effectual remedies. When the hot stage is strong, sponging the hands and feet with tepid vinegar and water will afford relief; but the cold fit frequently forms the principal and most distressing part of the febrile paroxyim- Bark occasionally relieves this stage, although its effects aro generally temporary. When the chill comes on at a particular hour of the day, its seve- rity may often be abated by keeping the patient warmly covered in bed till the paroxysm has passed. But the best means of controlling the hectic fever is a well-regulated diet. TUBERCULAR PHTHISIS. 569 Perspirations. — The copious perspirations of the consumptive patient during sleep form one of his most distressing symptoms during the advanced stages of the disease. In many cases medicine has little power in di- minishing these perspirations. Sulphuric acid is commonly used for this purpose; and when the debility is great, and there are no objections to its exhibition, much advantage will be derived from a combination of the acid with an infusion of bark, or with small doses of sulphate of quinine ; small quantities of this medicine being much more beneficial as a tonic than the larger doses. When there are objections to the bark, infusion of sage may be advantageously combined with the acid; and accctic acid may sometimes be substituted for the sulphuric. Fouquier thinks that acetate of lead possesses a specific effect in diminishing night- sweats: the dose in which he usually gave it was from four to eight grains, increased even to twelve grains a day. We have seen the expectoration di- minish under the influence of this remedy, but we have not used it much in perspirations. The most ef- fectual plan of moderating the perspiration consists in regulating the patient's diet.which should be mild and moderate : and much warm fluid, particularly towards night, should be avoided. When the perspirations are very copious, the patient should sleep in flannel or calico; and it is often necessary, and at all times a great comfort to him, to be wiped with warm flannels, and to have his clothes changed frequently. Diarrhoea—Although the bowels are frequently irritable and easily deranged during the whole progress of phthisis, diarrhoea in general docs not occur in a severe degree till an advanced period of the disease: the expectoration is generally abundant, and the perspirations are copious before it appears. In the earlier stages diarrhoea often depends on an irritated and loaded state of the alimentary canal, produced by errors in diet or other causes. This will be remedied by gentle aperients, such as rhubarb combined with carbonate of soda; or when the stomach is much oppressed, an emetic may be preferable; and a strict attention to regi- men will very generally prevent its return under such circumstances. But when the diarrhoea depends on ulcerated bowels, which happens in a large proportion of cases, as we have already shown, it becomes of course very obstinate, and stimulants and rough astringents aggravate and increase it; while a mild diet, consisting chiefly of farniceous food, such as rice, arrow-root, and sago, soups, milk, and light animal food, diminish it and even prolong the patient's life. It is not sufficiently considered that the diarrhoea of the latter stages of phthisis depends upon diseased bowels ; and that the almost constant existence of internal ulcerations forbids the practice of loading the stomach with large quantities of chalk mixture, kino, catechu, and stimulating aromatics and exciting food, but rather calls for the employment of a mild regimen and soothing medicines. Ipe- cacuan in combination with some mild narcotic, or with the compound ipecacuan powder, forms a very useful medicine ; sulphate of copper is also occasionally useful; and an enema of starch and opium frequently suspends the diarrhoea for a con- Vol. IV. —72 2x* siderable time, and produces sleep more effectually than any other remedy. External applications, such as stimulating and opiate liniments, will often give relief to the uneasy sensation in the bowels which sometimes remains long after an evacuation. Complications.—The treatment of the various diseases which complicate phthisis in its progress, such as laryngeal irritation, bronchial inflamma- tion, catarrh, pneumonia, &c. does not differ from that usually employed in those diseases ; and we refer for full particulars respecting it to the articles under those heads. It must, however, be kept in mind, in treating all the intercurrent diseases which attend phthisis, that they are merely com- plications, and require cautious treatment in pro- portion to the advanced state of the tuberculous disease and the debility of the patient. IV. Treatment of the advanced stage.— As phthisis advances, the case becomes more com- plicated, and consequently the treatment requires to be more varied. The extension of the tubercu- lous disease in the respiratory organs renders them less capable of performing their functions: the pulmonary circulation is carried on with in- creasing difficulty, the lungs are more subject to congestion and inflammation, and hence the in- crease of cough, dyspnoea, and pain, — symptoms which generally become more urgent with the progress of the disease. With the extension of the local disease, the hectic fever, and especially the perspirations, increase : the digestive organs, partly from sympathy, but more from the advance of tuberculous disease, become deranged; and nausea, vomiting, and still more frequently diar- rhoea, add greatly to the patient's sufferings. Ac- cording to the predominance of one or more of these symptoms, must the means of relief be varied : hence the treatment of the advanced stages resolves itself chiefly into the treatment of particu- lar symptoms, which has been considered in the last section. We would only observe, that the patient's life may be prolonged, and the remaining term of his existence deprived of much of its dis- comfort and distress by observing a strict adherence to a mild regimen, avoiding whatever excites the circulation or irritates the digestive organs. If these precautions are neglected, the hectic fever, the perspirations, and the diarrhoea will be increas- j ed; the patient's mind also becomes irritable under an exciting regimen, and he is fretful and impatient under his sufferings; a circumstance which adds | not a little to his own uneasiness, and is moreover most painful to the feelings of those around him: hence the great object of our treatment should be to soothe and tranquillize both mind and body. V. Regimen.—The great difficulty of direct- ing the regimen of persons of a tuberculous con- stitution depends upon the discrepancy which ex- ists between the wants of the system and the pow- ers of the digestive organs. The former appears to call for a strongly tonic diet; while its em- ployment never fails to aggravate the weak and irritable condition of the latter, and depress still further the powers of the constitution : hence it is evident that the food which is best adapted to the digestive organs, is that which will ultimately con- tribute most effectually to the strength of the sys- tem. A disregard to this obvious law of the eco- 570 TUBERCULAR PHTHISIS —TYMPANITES. nomy has given rise to the great diversity of opin- ion which still prevails respecting the regimen of tuberculous patients. We have already stated our opinion regarding the diet of children, and alluded to the prevailing error of over-feeding young persons of the strumous constitution. The strongest and most exciting kinds of animal food frequently constitute their diet, whether their sto- machs are strong or weak, irritable or otherwise; the delicate puny girl of seven years of age has the same dinner as the robust lad of seventeen, and both are generally fed upon a kind of meat which is adapted only to persons of adult age and matured strength, who take active exercise the greater part of the day in the open air. During the early stage of phthisis the diet ought to be mild, and in cases where there is a tendency to pulmonary congestion it should be strictly antiphlogistic; but the diversity of the prevailing symptoms renders it impossible to lay down any general rule on the subject. We would simply remark, that when, from any cause, it is necessary to reduce the diet, its subsequent increase should be made with great caution and very gra- dually. As phthisis advances, the diet must be regulated according to the circumstances of each case: one person will bear and derive advantage from a diet that would excite fever in another; and, therefore, any general rule that could be laid down on this subject would be weakened by so many exceptions that it would be useless. Too much importance is attached to the food, and too little to the state of the digestive organs; and hence it is most erro- neously supposed that the emaciation and wasting of the patient may be checked by an additional quantity and richer quality of food; by which means derangement of the digestive organs is in- duced along with a new train of symptoms, which tend to complicate the case and add to the distress of the patient. Although a mild diet is that which is most ge- nerally suited to the advanced stages of phthisis, cases may occur in which it is advisable to adopt a more exciting regimen; and instances are on record where the consumptive patient, after long lingering under a spare diet, has rapidly improved in strength and been apparently cured by a diet of an opposite quality. That this has occurred we do not doubt; but the patient has probably been as much indebted to the mild diet as to that which followed it. The patients who have been cured in this manner have no doubt been persons in whom the tuberculous disease of the lungs was limited, and advancing to a cure before the change of regimen was adopted. In many such cases, however, a change from a mild to a stimulating diet would do mischief, and interfere with the curative process going on in the lungs; indeed the proportion of cases is very small in which it will prove useful, and even then much judgment and discernment will be necessary on the part of the practitioner in deciding on the proper period for its employment. When such a change of diet is made, it should generally be accompanied by an increase of exercise in the open air; Salvadori combined his salt meat and generous wines with exercise on horseback, and promoted perspiration artificially by placing his patients near the fire. The cases that are likely to be cured by the sti- mulating plan of treatment,—by beef-steaks and porter,—bear so small a proportion to the many that will be injured by it, that we do not consider it deserving of further notice in this place. Many more patients have been preserved by the early adoption of a milk and vegetable diet, with a resi- dence in the country ; and there are numerous in- stances in which this regimen, adopted in the very commencement of tuberculous disease, proves more suitable than any other. The jelly of some of the mosses has been recommended as a nutri- tious article of diet for the cure of consumption; of these the Iceland moss jelly has been generally preferred: it affords a light form of nourishment, and its bitter qualities render it useful in some states of the stomach. Asses' milk and goat's whey are well-known articles of diet in such cases j but on this part of our subject it is unnecessary to go into detail in this work. In bringing this article to a conclusion, we feel that, although we have exceeded the limits which we had originally assigned to it, the subject, in the extended view which we have taken of it, is one of such deep interest, involves so many im- portant considerations, and embraces so wide a range, that we may have omitted some things, and passed lightly over others; but we believe that we shall be found to have attached its due value to every point which is of real consequence. If, in the accomplishment of our object, we have dwelt more particularly on some parts than on others, we have been induced to do so from a full conviction of their paramount importance. Out great aim has been to point out the sources of tuberculous diseases, and to impress upon our medical brethren the necessity of directing their chief attention to the origin and causes of phthisis, a knowledge of which can alone lead to the means of preventing that disease, and of diminishing the frequency of tuberculous diseases generally James Clark. [TUBERCULOSIS.—See Tubercle.] TYMPANITES, from rifntavov, a drum, oc- casionally referred to by the early writers under the term of dry dropsy, and classed by them with anasarca and ascites.* Emphysema tympaniticum. Young,- emphysema abdominis, Good. Disten- sion of the parietes of the abdomen, continuing the same under different positions of the body, not yielding readily to pressure, but, when that is ap- plied, returning immediately to its former state on its removal, and, when struck, emitting a sound like that produced by a drum, the distending me- dium being air confined within or external to the alvine canal: there is consequently no sense of fluctuation, and that of weight is infinitely less to the feelings of the patient than the increase of bulk would lead him to expect. By these charac- ters tympanites is to be distinguished from phys- conia and other tumefactions of the abdomen, the absence of the symptoms of each of which will further serve for its identification. * Atque ejus (fitywjia) tres species sunt. Primum Tvniravirijv : secundum \tvKoqi\typ.arlav vel Ito oaota , tertium ao/cirr/v Graci uominarunt. Celsus, lib. iii. cap- xxi. TYMPANITES. 571 Nosology has been encumbered by the enume- ration of several species of tympanites, distinguish- ed according to the locality in the abdomen occu- pied by the distending volume of air. The most natural, and those which have been generally adopted, have referred to its presence either within or external to the alvine canal, and have been named accordingly tympanites intestinalis and tympanites abdominalis. Sauvages has given the name of tympanites enterophysodes to the presence of air between the coats of the intestines; a very rare occurrence, and still more rarely, if ever, we conceive, existing to such an extent as to occasion tympanites: if it has, it is probable that it has been secondary to tympanites intestinalis, the air having been derived from the canal; an accident which seems possible if the mucous membrane were eroded, even though the quantity should not be excessive. It has been regarded as a fourth species when the tympanites intestinalis and tym- panites abdominalis have been co-existent; but it may be presumed that the former has always been the primary condition, and erosion or rupture of the intestines an intermediate occurrence. The combination of tympanites abdominalis with ascites has been enumerated by Sauvages as a fifth spe- cies, under the name of tympanites asciticus; hut although in most examinations after death of bodies in which tympanites has been present, serum has been found in the sac of the peritoneum, it would be inconsistent with every purpose of nosology to discuss such a combination as a distinct form of disease. To obtain a clear view, however, of tympanites in its several relations, it will be well to consider the modes in which air is received and collected in the abdomen, as well as the means by which its riddance is effected. It may not be inappropriate also to this place to record our know- ledge of the nature of the intestinat gases, for it is possible that it may hereafter suggest more ra- tional methods of relieving those who suffer from their presence in excess than any that have been hitherto devised. A chief source of air developed in the aliment- ary canal is undoubtedly the aliment which is received into it, and of this, from abundant expe- rience of its effects within the body, and from knowledge directly as well as indirectly obtained from without, we are certain that it is extricated in greatest quantity from vegetable substances: these, it is well known, contain it in variable pro- portions, and are freed, as are the constituents of diet generally, from considerable quantities of it by culinary processes, through the medium of the heat to which they are subjected. In a healthy state of the digestive function, and with due care as to the selection and preparation of food, the air belonging to it for the most part disappears after it is taken into the stomach, and is probably trans- ferred, still in its combined state, with the chyle to the blood, the latter being known to contain it in considerable proportions ; according to Hales and Haller, as one part in thirty-three, and all the other fluids in variable proportions. When diges- tion, however, is imperfect in consequence of a faulty state of the organs concerned in that func- tion, or of improper food, air is extricated in such quantities asx to lead to an uncomfortable disten- sion of different parts of the alimentary canal, j The stimulus of distension excites in the first place the vermicular and peristaltic action of the parietes of the canal to transfer it, in aid of its own elasticity, from one portion to another, and eventually to the riddance of so much of it as has remained unabsorbed. In failure of this effect, the muscles of the abdomen are excited to the same end, and irregular actions are also induced, such as singultus, eructations, &c. When the increase in the volume of the confined air becomes still more excessive, accumulates, and is retained, the state induced constitutes tympanites intestinalis. But besides the extrication of air immediately from the ingesta, John Hunter conceived that it I might be derived from the blood-vessels by a pro- cess analogous to or in every respect incidental with that of secretion. This hypothesis, which | has been generally admitted, is founded on the established fact of air being detected in localities into which it could not have been introduced di- rectly from without the body, and where it could not be referred to putrefaction.* 2dly. On the analogy afforded by certain kinds of fishes pos- sessing a sound or bladder commonly used for the purpose of balancing, and next apparently for that of raising themselves to the surface of the water; and the presence of which cannot be accounted for as in the bones of birds, where an immediate communication is to be traced with the air-cells of the lungs. Lastly, on the constant separation and absorption of gas by vegetables, as proved directly by multiplied experiments, and furthei confirmed by the well-known fact of the inflation by air of the pods and capsules of a variety of plants common in our gardens. In the act of deglutition it is probable, that be- sides the air contained in the food, a small portion is swallowed with it. Dr. Gosse of Geneva (and several physiologists have repeated his experiments with the same results) has shown that even large quantities of it may be swallowed ; and Gerardin, in his essay on intestinal gases, has related an in- stance in which, by this faculty, an individual was enabled to simulate tympanites so as to deceive several respectable practitioners. The manifestation of sudden and excessive evolutions of gas in the alimentary tube, particu- larly in some instances of hysteria, has been re- ferred, and apparently with reason, to the secreting process; but when we reflect on the immense volume of air which is separated from vegetable substances in a state of fermentation,! to which, moreover, they are partially subjected in the ani- mal body in defect of healthy digestion, the ne- cessity of any other source is at least not very obvious. The nature of the gases that are found in dif- ferent parts of the alimentary canal has been ex- ♦Magendie and Gerardin included a portion of intestine between two ligatures and returned it into the abdomen : air, nevertheless, was found occupying it, although care had been taken that it should be divested of any matter containing it. Cambalusier, Belg, and Glisson have made similar observations. Diet, des Sc. Med. article Pneumatose. Division of the pneumo-gastric nerves is often followed by an accumulation of air in the stomach, as demonstrated by the experiments of Willis, Ducrotay de Blainville, Haller, and Dumas. Ibid. t It appears from the experiments of Dr. Hales, that an apple, and many other kinds of aliment, give out six hundred times their own bulk of an elastic gas durine fermentation. 572 TYMPANITES. amined by Jurine and Chevreul. Jurine's results showed, that as we recede from the stomach, the proportion of oxygen and carbonic acid decreases, while that of nitrogen increases; and that the proportion of hydrogen is greater in the large than in the small intestines, and less in these than in the stomach. (Mem. Roy. Med. Soc. t. x. p. 72 et seq.) M. Chevreul analysed the gas in the stomach, the small and large intestines, with the following results. In the stomach. Oxygen.......................11. Carbonic acid....................14. Hydrogen....................... 3.55 Nitrogen........................71.45 100.0 In the small intestines in three different subjects: Oxygen......... 0.0 ____0.0____ 0.0 Carbonic acid____24.39____40.0____25.0 Hydrogen.......55.53____51.15____ 8.4 Nitrogen........20.08____8.85____66.6 100.00 100.00 100.0 Gas in the great intestines of the three first sub- jects : Oxygen......................... 0.0 Carbonic acid....................43.5 Carburetted hydrogen, with a trace of sulphuretted ditto............... 5.47 Nitrogen........................51.03 100.00 Of the second: Oxyen........................... 0.0 Carbonic acid.....................70.0 Hydrogen and carburetted hydrogen... 11.6 Nitrogen................ ........18.4 100.0 In the caecum of the third: Oxygen.......................... 0.0 Carbonic acid.....................12.5 Hydrogen........................ 7.5 Carburetted hydrogen...............12.5 Nitrogen.........................67.5 100.0 In the rectum of the same : Oxygen..........................0.0 Carbonic acid....................42.86 Hydrogen....................... 0.0 Carburetted hydrogen..............11.18 Nitrogen........................45.96 100.00* We are not aware of any analysis having been made of the intestinal air in cases of tympanites; but there is no reason to presume that any pecu- liar variation in the nature of its constituents is a condition of this disease, although their propor- tions are constantly subject to the modifying ef- fects of different kinds of food, and respond to the * System of Physiology, by John Bostock, M.D.,vol. ii. p. 491. Magendie, Phys. t. ii. p. 85, 104, 5, 112,3. fluctuating condition of the secreted products of other organs of the body. Tympanites intestinalis sometimes occurs in fevers accompanied with much cerebral disturb- ance ; [it is one of the prominent symptoms of the typhoid affection ;] and in this, as well as in other diseases in which the nervous system is par- ticularly implicated, it has been observed to take place very suddenly: under such circumstances it has received the particular appellation of meteor- ismus, a condition which, to a certain extent it least, may be accounted for by a suspension of nervous stimulus to the muscular coat of the ali- mentary canal. Tympanites is symptomatic also of gastritis, of enteritis, and of peritonitis; dis- eases in which it is obvious that the propelling power of the intestines is impeded, although from a different cause. In acute diseases of the thoracic as well as of the abdominal viscera, tympanites occasionally occurs, and is to be accounted for by an excessive extrication of air from the food, in consequence of the common suspension of the digestive powers under such circumstances, and the impediment offered to the action of the muscles auxiliary to the function of the canal itself. In obstinate constipation, and other mechanical ob- structions, direct impediment to the transfer of the gaseous fluid occasions its accumulation, and sometimes excessive distension of some part of the alimentary tube. In ulcerations of it, and other local diseases, its vermicular and peristaltic actions are arrested, and a tympanitic state of the intes- tines is a consequence. In ileus and hernia it occasionally produces extreme discomfort; but in these, and under the before-mentioned circum- stances, its consideration belongs to that of the disease from which it arises; and though relief may be afforded by some of the means presently to be pointed out, their selection must be subject to the principles on which the original disease is to be treated. Whether tympanites intestinalis should be regarded as a disease distinctly idiopathic has been questioned, and, as we conceive, not with- out reason. The deference, however, which is so largely due to the authority of Cullen, and the conviction that he has faithfully pourtrayed a chain of symptoms of occasional occurrence and demanding particular consideration, induce us to give a place to his description of it as such in this article. " I cannot perceive," observes this writer, " that it arises in any peculiar temperament, or depends upon any obvious predisposition. It oc- curs in either sex, at every age, and frequently in young persons. Various remote causes of it have been assigned ; but many of these have not com- monly the effect of producing it; and although some of them have indeed been the antecedents, I can in few instances discover the manner in which they produce the disease, and, therefore, cannot certainly ascertain them to have been causes of it.' The following he states to be the phenomena of the idiopathic form of intestinal tympanites. The distension sometimes takes place suddenly, and seldom in the slow manner of ascites; occasionally, however, its advance is gradual, and is accom- panied by the various manifestations of flatulence, frequently together with colic pains, especially TYMPANITES. 573 about the umbilicus, and upon the sides towards Mhe back ; but generally with the progress of the disease these pains become less considerable, and " there is almost a constant desire to get rid of air, but it is effected with difficulty; and although : with some relief to the sense of distension, such relief is commonly very transient. When this kind of tympanites is coming on, some inequality of swelling and tension is perceptible in different parts of the belly ; but the latter soon becomes equal over the whole, and exhibits the charac- teristic phenomena already mentioned. At this ■ time, as well as during its progress, the bowels are constipated, and the faeces generally dry and hard. The urine at first is usually very little ' changed in quantity or quality, but after a time it is so in both these respects; sometimes strangury and even ischuria come on. It has seldom ad- vanced far before the appetite is much impaired and digestion ill performed ; and the whole body o (the abdominal distension continuing) becomes considerably emaciated. Together with these symptoms there is thirst, an uneasy sense of heat, and a considerable frequency of pulse, which con- tinues throughout. When the distension is con- siderable, the respiration becomes difficult, and is - attended with a frequent dry cough ; the strength : declines, and the febrile symptoms daily increas- ing, death at length ensues, sometimes probably : in consequence of the intestines becoming gan- grenous. This form of disease is generally, but not rapidly, fatal. Errors in diet, the long-continued and exclusive use of crude vegetable aliment, the abuse of spirituous liquors, repelled eruptions, and the suppression of customary evacuations, have been considered chiefly conducive to its oc- currence. With regard to its pathology, Cullen, in com- mon with other writers, and consistently with prevailing opinion, refers it to a loss of tone in the muscular fibres of the intestines. « Even in those cases of tympanites," he observes, " which are attended at their beginning with flatulent dis- orders in the whole of the alimentary canal, as we know that a firm tone of the intestines both moderates the extrication of air, and contributes to its re-absorption or ready expulsion, so the flatulent symptoms which happen to appear at the coming on of a tympanites, are in my opinion to be referred to the loss of tone in the muscular fibres of the intestines, rather than to any fault in the digestive fluids." It is probable, he adds, that the passage of air along the course of therintestines is in some places interrupted, in consequence of spasmodic constrictions in certain parts of them ; but whether these arise as a consequence of the remote causes of the disease, or of some degree of previous atony, he acknowledges himself at a loss to determine. Examinations of the bodies of those in whom tympanites has been present immediately before death, have shown the intestines to be very con- siderably larger in their calibre than natural, but most generally the caecum and colon. De Haen (Nation. Med. p. ii. cap. 5,) refers to the dissec- tion of a male subject who died after three years' suffering from this affection : the colon, he states, was greatly dilated, so that in some places it was equal in size to the arm, in others to the thigh of a man ; and all the smaller intestines, as also the stomach, were twice or thrice the natural size; so that from excessive distension the shape of the thorax was much altered, and both the lungs and heart were compressed. In some instances, after excessive distension, rupture of the stomach has been known to take place. (Diet, des Sc. Med. art Pneumatose.) The treatment of tympanites intestinalis con- sists in procuring present relief by the removal of the distending volume of air, and in the substitu- tion of a healthy state for that condition of the alvine canal on which its regeneration and accu- mulation depend. It is obvious that whenever any morbid state to which this condition jLs secon- dary can be recognised, the treatment of the tym- panites must be secondary to that of the original disease, whatever it may be; but under any cir- cumstances the relief of distress arising from excessive distension should, if possible, be effected. Dr. Darwin has proposed for this purpose that a pipe (such, for instance, as is commonly used for the injection of enemata) should be introduced into the rectum, so as to take off the resistance which in some cases is offered by the contraction of the sphincter ani muscle. Trnka (Historia Tympanitidis, 4to. Vindobonae, 1788,) proposed that the removal of the gas should be effected by an air-pump; and the practicability of this reme- dial measure has been most satisfactorily demon- strated by Dr. Osborne, in Sir Patrick Dun's Hospital in Ireland. The patient, a female, aged twenty-two, was admitted on the 23d of January, 1831, into Dr. Osborne's ward, on account of various hysterical symptoms, attended with ob- stinate constipation; these, although relieved, were followed by tympanitic distension, which produced the greatest distress, and for which the employment of leeches, carminatives, and various other remedies proved wholly unavailing. It be- came an object of importance to examine the abdominal viscera, in consequence of some symp- toms of doubtful import which at different times had occurred. Dr. Osborne having introduced a gum elastic tube of nearly three feet in length, with a button and hole at its extremity, and ap- plied to it an air-tight stomach-pump, proceeded to pump out the gas, and was enabled to do so with but few interruptions, which were speedily overcome either by shifting the place of the tube in tho intestine, or by injecting warm water to clear the holes from accidental stoppages. In about an hour the abdomen was reduced to nearly the natural size, with complete relief of the pain- ful distension, and thus an opportunity was af- forded of ascertaining that no visceral enlargement had taken place. In passing the tube through the rectum and sigmoid flexure, it was occasion- ally retarded by folds of the mucous membrane, but was soon freed by injecting warm water, and thus procuring distension at those parts. Very little inconvenience was experienced by the pa- tient, although she felt the end of the tube in the left hypochondrium. The same process was re- peated upon her more than once, and with the same effects. Dr. Osborne remarks, that portions of the intestines distended by flatus beyond their power of contraction, resemble the bladder when 571 TYMPANITES. reduced to a paralytic state in consequence of a ' retention of urine, and cannot contract effectually until a diminution of their contents is first ob- ' tained ; hence it is probable that this method may not only prove a temporary relief, but may con- tribute to the permanent removal of many cases of torpidity of the bowels.* In some instances it seems not improbable that relief may be obtained by similar means applied to the oesophageal ex- tremity of the canal. The extreme distension which is occasionally caused in the stomachs of cattle in consequence of the sudden extrication of air from green succulent food which they have consumed too greedily, familiar to agriculturists by the term hoven, is commonly indeed relieved by the simple introduction of a flexible tube through the gullet into the stomach, which is allowed to remain for some length of time, and affords a convenient passage for the excessive quantity of air which is generated. [Instantaneous relief is often afforded by pass- ing up a hollow bougie through the annulus of the rectum into the colon ; after which a tight bandage may be applied round the abdomen to prevent re-distension of the coats of the intestine, by affording them adequate pressure. A good plan would probably be, to force air into the in- testinal canal, and then suddenly withdraw it.] Temporary relief may further be attempted by the medicines commonly termed carminatives, the sensible qualities of which, and their sudden vola- tility, render them instantaneously stimulant to the fibrous structure of the alimentary canal, ena- bling it to overcome the distension, to dispel the distending gas, and perhaps partly to lead to its absorption. The aromatic vegetables containing much essential oil, such as juniper-berries, the seeds of anise, caraway, coriander, and carda- moms ; cloves, also; the roots of ginger and zedoary, the volatile oils themselves, and prepara- tions of these, will be adapted to the purpose. To these may be added stimulant and antispas- modie medicines, such as the carbonate and com- pound spirit of ammonia, ether and its prepara- tions, camphor, assafoetida, and the other strongly odoriferous gums, combined or not, according to circumstances, with opium or some of its prepa- rations. The more general treatment by which the cure of tympanites intestinalis is to be attempted is, by restoring to the alimentary canal its lost or dimin- ished power; and this has appeared to us so gene- rally consequent to disordered function of the liver when tympanites, either partial or complete, has been present, that although we do not profess to consider it in its secondary relations in this place, we cannot but observe, that to secure the natural secretion from this organ, if it should have been defective, is an essential preliminary to the cure of the morbid condition we are more imme- diately considering. The accumulation of excre- mentitious matter, which must add to the difficul- ties already existing by exhausting the contractile power of the intestines, is to be prevented by warm aperients, which will be further conducive to the same end by promoting the due digestion * Lond. Med. Gaz., v. vii. p. 825. Dr. Graves has no- ticed the efficacy of similar means in two cases. See Lect. in Lond. Med. and Surg. Journ. v. ii. p. 7cl. of the food; for this purpose purgative doses of spirits of turpentine, either alone or combined with castor oil, the compound decoction of aloes, combinations of the powder with compound tinc- ture of rhubarb, the compound pill of aloes and myrrh, combinations of the compound extract of colocynth with hard soap, and the addition of a drop or two of the volatile oil of juniper or of caraways, or of cloves, will be suitable. Their operation may, if occasion require, be assisted by gentle enemata, and by rubbing the abdomen with soap liniment, oil, soap-lather, &c. The wants of the constitution generally, and the presumed loss of tone in the muscular fibres of the intestines, alike suggest the use of tonics* and their efficacy being well established in the common forms of abdominal distension from flatus, they have been commonly resorted to in that ex- treme degree of it which constitutes tympanites, The preparations of steel have been found espe- cially useful in disorder of this kind, as have also the aromatic bitters. The recorded experience of their use in tympanites, however, has been too scanty to enable us to draw conclusions in favour of particular preparations; and from its very rare occurrence the superiority of one above another remains to be determined. An instructive case of tympanites was published by Dr. Graves in the first volume of Medical Facts, p. 90, in which he attributed the cure, and apparently with good reason, to the internal use of eighteen grains of prepared steel (ferri carbonas) twice in the day; in three or four days the distension having con- siderably diminished, and two days afterwards entirely disappeared. The only sensible operation it produced was violent and frequent eructations of wind, and that immediately after the first dose had been swallowed. Three grains of calomel and a scruple of rhubarb had been given as a pre- paratory dose. Dr. Monro has also left a case on record, accompanied with irregular menstruation, in which recovery soon followed the exhibition of steel; simultaneously, however, with assafoetida and other anti-hysteric medicines, so that it is im- possible to appreciate the precise advantage ob- tained by this medicine. A combination of four grains of carbonate of iron with two grains of rhubarb, two of powdered ginger, and two of ex- tract of gentian, taken three times a day, (a sug- gestion obtained some years ago, we believe, from the London Medico-Chirurgical Review, we have found particularly useful in cases of flatulent dis- tension occurring in dyspepsia ; and according to the present state of our knowledge, it is on medi- cines adapted to corresponding forms of the last- mentioned disorder that our reliance is to be placod in the treatment of tympanites intestinalis. (See Indigestion.) It is to be remembered, however, that the sub- stantial forms of medicine will in most instances be preferable to their simple solutions, as the reme- dial action of the former will be continued to a greater distance in ihe tract of the alvine canal than could reasonably be anticipated from the lat- ter. « But as no tonic remedy," says Cullen, "is more powerful than cold applied to the surface of the body, and cold drink taken into the stomach ■, so such a remedy has been thought of in this disease. Cold drink has been constantly pie- TYMPANITES —URINE, (INCONTINENCE OF) 575 scribed, and cold bathing has been employed with advantage : and there have been several instances of the disease being suddenly and entirely cured by the repeated application of snow to the lower belly." (First Lines: See Cambulusier, Pneu- mato-pathol. p. 428 et seq.) The use of a thin flannel bandage or belt drawn with moderate firm- ness round the abdomen, in cases of distension from flatus, is often productive of much comfort, and reason points it out as an article of essential advantage in excessive states of it. The diet should be selected from those articles which are not prone to fermentation, or otherwise to the extrication of large quantities of air; hence vegetable food in general, but especially peas, beans, turnips, greens, &c. as well as the various fermented liquors, sweet wines, pastry, and the like, should be avoided ; and in furtherance of the same view, the bulk of a meal, even of animal food, should be small, and accompanied with the usual dietetic stimulants. In obstinate and desperate cases the operation of paracentesis has been proposed ; but for the mere evacuation of any present quantity of air in the intestines, the advantage it promises is infi- nitely inadequate to the hazard which must attend it. We know only of one instance in which it has been performed with success, and that entirely dependent on constipation, of which it is rather to be considered an example than of tympanites. The patient, a female, was seventy years of age, and after a diarrhoea of four months' duration, be- came constipated to such a degree that the strong- est purgatives were exhibited without effect; the belly swelled and became painful. Evident symp- toms of gangrene supervened, and death seeming inevitable, it was determined that the operation should be tried. Mr. Fine, an eminent surgeon in Geneva, cut into the most prominent part of ihe swelled abdomen, and retaining the intestine on the surface of the wound by means of a thread, which was passed through the mesentery, and fixed on the sides of the belly with sticking-plais- ter, he opened the intestines and gave passage to a large quantity of faeces; the tympanites and symptoms of gangrene subsided, and, with the inconvenience only of an artificial anus, the pa- tient was enabled to attend to her usual avoca- tions for a wholo year. She then became dropsical and died. On examination of the body, a tumour was found compressing the rectum at its origin, so as entirely to obliterate the passage. (Manuel de Med. Pratique, par Louis Odier. D. et. P. M. Edin. Med. and Sur. Journal, vol. ii. p. 452.) Tympanites abdominalis, independent of perfo- ration of the alvine canal, is a morbid condition, of the occurrence of which during life considera- ble doubt has been entertained; and those who have admitted it acknowledge that it has been very rare. Cullen observes, " from several dissections it is unquestionable that such a disease has some- times occurred;" " nor can we suppose," says Good, " such accurate pathologists as Heister, (Wahrnehmungen, I. art. xv.), Lieutaud, (Hist. Anat. v. p. 432), and Bell, (On Ulcers and Tu- mours, vol. ii.), who have respectively given ex- amples of it, to have been successively deceived upon the subject. Admitting it to be produced by secretion, its occasional causes are still very obscure. It has been said to follow upon jaundice and morbid affections of other abdominal viscera ; upon debility produced by fever; upon hysteria, violent passions, or other emotions of the mind." The ordinary natural cure, continues the last- mentioned writer, seems to consist in an escape of air from the umbilicus, by an outlet produced by an abscess or ulceration of this protuberant or- gan, or a sudden and fortunate rupture of its in- teguments. Morgagni and several later writers (Guisard, Pratique de Chirurgie, torn. i. p. 134) give us well-authenticated cases of an occurrence of the first of these, and Stoerck of both. (Ann. Med. p. 190, 193, 194.) From the protruded state of the umbilicus, the lancet may conve- niently be introduced at this point. The belly should at the time of the operation be well swathed with a broad girth, which may be tight- ened at option, and should be kept as tight as the patient can well bear it, as well for the purpose of general support, as for that of expelling the air within and preventing its entrance from without. Van Swieten dissuaded his pupils from this operation, (Ad sect. 1251,) and Cambalusier (Pneumato-Pathol. p. 503; Dusseau, Journ. de Med. 1779) and a few others have since asserted that it does not answer. But in most of these cases, observes Good, the seat of the disease was mistaken, and the flatus was situated in the intes- tinal canal rather than in the sac of the peritoneum. Antecedently, however, to the operation of pa- racentesis, it has been recommended to try the effect of electric shocks to the abdomen ; of cold applications also, and of cold drinks. The latter plan is said to have answered occasionally. (Thedeu, N. Bemerkungen und Erfahrungen, ii. p. 251.) It is obvious, adds the writer to whom we are much indebted for our remarks on this part of the subject, (Mason Good, M. D., Study of Medicine, first edit. vol. iv. p. 432,) that a tonic regimen, with free exercise, particularly equitation, and, where it can be had recourse to, sea-bathing, should be entered on as soon as the tympany is dispersed. -„,• Tr r William Kerr. [TYPHOID AFFECTION. —See Feveh, vol. ii. p. 169.] TYPHUS.—See Feveh. URINE, INCONTINENCE OF.—Enuresis, from ivovpiu). History of the Disease. — In man, the ex- crementitious secretions, although taking place continually, are discharged from the body only at intervals ; and some of them have appropriate reservoirs for their reception. To this law there are two exceptions, the cutaneous perspiration and the exhalation from the lungs. The saliva, the schneiderian mucus, and the tears may be con- sidered as finding their way, in part at least, down the gullet, and are retained in the body by the sphincter of the alimentary canal. The urinary bladder constitutes an important reservoir of this nature, which by the due performance of its reten- tive function, saves us from a very loathsome and painful infirmity, named incontinence of urine. In every case where the urine, though but a small quantity be collected in the bladder, is forced off without the voluntary effort of the individual, or flows from him unconsciously, he is truly said to 576 URINE, (INCONTINENCE OF) labour under incontinence of it, or enuresis. The urine thus constantly escaping from the bladder, soon produces in the surfaces with which it comes in contact, redness, minute vesicles, pustules, ex- coriations, and at length ulcerations. The patient's clothes, being kept moistened with the same fluid, exhale an offensive ammoniacal odour ; and thus he is not only subjected to the distressing itching and pain of the excoriations, but becomes an in- supportable annoyance to those around him. The urine being decomposed by exposure to the air, the phosphates are formed and deposited in the surface over which it flows, and hence we have often in cases of enuresis small particles and thin crusts of gravelly substance, which serve to in- crease the irritation of the excoriated parts. Incontinence of urine exists in different de- grees, being in some cases so complete that the fluid drains off continually by the mere effect of gravity, as if the bladder and urethra were without life; in others it is discharged at short intervals in small quantities, by the involuntary contraction of the bladder; or this occurs only during sleep; or the urine is retained by the patient while at rest, but when he moves about, it flows off, not- withstanding all his efforts to retain it. Some- times the degree of exercise required to produce incontinence of urine is considerable, as in the in- stance of a woman cured of vesico-vaginal fistula, who was a servant in a small tavern : she could retain her urine perfectly excepting on market- days, when she was subjected to much fatigue, running up and down stairs. (Edin. Med. and Surg. Journal, vol. xxi. p. 62.) Causes. — The immediate cause of enuresis is in all cases a greater or less defect in the muscular fibres which close the external orifice of the blad- der, and to which the name of sphincter may with perfect propriety be applied.* This defect in the muscle which opposes the escape of the urine may be either positive or relative. Positive defect in the sphincter may consist in a debilitated or para- lysed state, or in its inefficiency from an aperture existing in some part of the bladder. Relative defect in the sphincter, on the other hand, con- sists in its inadequacy to resist the strong and sudden contractions of the expulsor of the urine, which thus overcomes the closing muscle, and re- duces matters to the same state as if the sphincter were actually debilitated. But we are inclined to think, that in most of those cases where the body of the bladder is morbidly irritable and prone to contract on a slight stimulus being applied, the sphincter is in like manner prone to dilate and to yield to the pressure of the urine, which indeed is quite in accordance with the natural sympathy of the parts. Paralysis of the sphincter of the bladder arises from the various diseases and injuries of the brain and spinal cord which give origin to other pal- sies; and it is occasioned likewise by injury or disorganization of the nerves which immediately supply the neck of the bladder. A state of de- bility, or an approach to paralysis of this part, may arise from injuries inflicted upon itself or its immediate vicinity: such as the operation of litho- * See Treatise on the Urethra, See., by Sir Charles Bell, for the true anatomy of the sphincter of the bladder. tomy, the dilatation of the part in the extraction of calculi without incision, repeated laborious par- turition, suppurations in the vicinity of the neck of the bladder, the operation for fistula in ano, injury of the bladder by its displacement, as in cystocele, prolapsus of the uterus and rectum, pressure from the gravid uterus. Many females in the latter stages of pregnancy cannot cough or laugh loudly, or make any sudden movement without causing the involuntary discharge of a small quantity of urine. The sphincter of the bladder may also be so weakened as to produce enuresis, by a long continuance in the cold bath, by habits of immoderate indulgence in sexual in- tercourse, and by solitary vice; the first of these causes acting as a direct sedative; the two last as indirect ones, by inducing at intervals excessive and prolonged turgescence of the genital organs, and consequent debility. The retaining power of the sphincter of the bladder is completely destroyed by the formation of an aperture in that organ in or beyond its neck ; as in vesico-vaginal fistula, in fistulous openings between the bladder and rectum, or be- tween the bladder and the external surface of the abdomen, and in fistula communicating with the ureters or kidneys. The same will be the effect in all those cases of deficient congenital formation where the cavity of the bladder communicates directly with the surface of the body, (Duncan. Edinburgh Med. and Surg. Journal, vol. i. Baillie, Morbid Anat. Meckel, Handbuch der Patholog. Anat. b. i.) and where the urachus remains open with an orifice at the umbilicus, or has become so in the progress of disease. Instances of the relatively deficient power of the sphincter of the bladder are presented by most of those cases of nocturnal emission of urine which are met with in children; and the same morbid sensibility of the bladder occurs also in old men, and is productive of the same conse- quence—enuresis. The irritability of the bladder may be aug- mented by many causes, of which the most fre- quent are calculus and disease of the prostate gland; fungous growths within the bladder have also the same effect; and it is produced likewise by the presence ot worms within the rectum, and by other irritations of neighbouring parts. Enu- resis depending on a convulsive contraction of the muscular tissue of the bladder takes place during the paroxysm of epilepsy, and, in a less severe degree, occasionally in chorea and hysteria; also from the sudden impression of cold in the genitals, and from the influence of sharp unexpected pain. It is told of an Italian coachman that, when he wished his horses to stale, he seized their ears be- tween his teeth and bit them smartly, which never failed to produce a flow of urine. The effect of piercing sounds, as the notes of the Scotch bag- pipe, in causing involuntary contraction of the urinary bladder, has often been remarked; and common observation must convince us how pow- erfully this organ is influenced by fear and anxiety of mind. Enuresis in children usually ceases after the second dentition, and very rarely persists beyond the full development of the genital organs at pu- berty ; except, indeed, in cases of mental imbecilityi URINE, (INCONTINENCE OF) 577 where its continuance is to be referred to the same cause which produces the inability to retain the saliva, and the tottering step and awkward move- ments of the idiot. Incomplete enuresis may also be produced by a diminution of the cavity of the bladder, which renders it impossible for the person to retain more than a very small quantity of urine; and in such cases there usually exists at the same time a mor- bid irritability of the body of the organ. Treatment. — In enuresis, as in most otheT symptoms of disease, the mode of treatment will depend on the cause of the affection ; and by its removal we shall in general accomplish a cure. When the power of the sphincter of the bladder is positively weakened, we must employ the most approved means of restoring the nervous energy of the part, as friction, rubefacients to the loins and sacrum, the affusion of cold water on the spine, blisters to the lumbar and sacral regions, electricity, galvanism, stimulating enemata; the internal use of cantharides, [especially when as- sociated with tincture of opium or tincture of hyoscyamus, (Guy, Lond. Med. Gazette, Sept. 30, 1841), internal and external use of] strych- nine, tonics, such as quinia, nitrate of silver, ar- senic, steel, copper, zinc, and the vegetable bitters. When incontinence of urine depends on the ex- istence of a fistulous opening in any of the urinary cavities, the aid of surgery must be called in; but if all attempts at a cure fail, one of the many ingenious mechanical contrivances for such cases must be had recourse to, and the situation of the patient rendered as comfortable as this distressing infirmity will permit. Under these circumstances the greatest attention must be paid to personal cleanliness ; and the ammoniacal smell which is so liable to be produced ought to be corrected by meaio of one of the vegetable acids, such as the acetic or tartaric. In almost all cases of enuresis from malformation, this palliative plan is the only one which affords any prospect of benefiting the patient. When enuresis proceeds from a disproportion between the contractile power of the body of the bladder and that of the sphincter, or, in other words, from a morbid sensibility of the bladder to the stimulus of the urine, attention to the general health and to the state of the bowels is especially required. The irritability of this organ must be allayed by large doses of opium and hyoscyamus gi\en in enema or suppository, and, if necessary, by the mouth ; and all irritations of neighbouring parts, such as from worms in the rectum, must be removed. As this form of involuntary discharge of the urine occurs most readily during sleep, cer- tain precautions are required before the patient goes to rest. Nothing of a diuretic nature should be taken at any time of the day, and no liquids swallowed for some hours before bed-time: ihe patient's bed should consist of a mattress with a moderate co- vering of bed-clothes, and he should recline on his side and rather on his face, for the contrac- tions of the bladder seem to be excited by the urine resting on the sensitive surface between the , orifice of that organ and the openings of the ure- ters. (C. Bell, Treatise on the Urethra, &c.) I Nocturnal enuresis occurs under different circum- I Vol. IV. —73 2t stances—from the sleep being so profound tha the child is not awakened by the stimulus of dis- tension which precedes the expulsion of the urine, or from his dreaming of voiding it, or, lastly, from an indolent disposition, which prevents him from attending to the first call to evacuate the bladder. The importance and necessity of cleanliness must be carefully impressed on the youthful mind; for by mistaken indulgence we may prolong the habits of early infancy into the period of advanced child- hood. We are, therefore, clearly of opinion that when the frame is not debilitated, and when the precautions already noticed have been taken, a little wholesome chastisement will in such cases of enuresis be highly proper : it will render the sleep less profound, the dreams less delusively vivid, and serve to dispel the apathy of the indo- lent and the slothful. But far be it from us to recommend the revival of those punishments in- vented by the cruel ingenuity of former times, such as causing children subject to this infirmity to crush mice to death in their hands, to submit to the loathsome infliction of having live toads suspended from their necks, and to sit by the bed- sides of the dying. When the habit of nocturnal enuresis is deeply rooted, punishment, even the mildest, cannot be frequently repeated; but an attempt should be made to correct it by calm ad- monition, and endeavouring to awaken a sense of shame. If increasing years do not bring with them a cure, great benefit will be derived from forcibly confining the urine within the bladder: it will tend at once to interrupt the habit, and to j rouse the irritability of the sphincter. Where the jugum penis has failed, a speedy cure has been accomplished by strapping a bougie along the lower surface of the penis, so as to render the J canal quite impervious to the urine. (Hyslop, London Medico-Chir. Trans, vol. vi.) The urethra of females being short, and the I bladder often subjected to great distension, enuresis is with them sometimes very obstinate, and re- quires for its cure a certain turgescence of the genital organs. Thus, when the disease does not i yield to the change produced at the period of pu- ( berty, it may be removed by the internal use of , cantharides and by marriage. The following fact [ will serve to illustrate the efficacy of turgescence ! of parts on the functions of the bladder. A mid- I die-aged female, who had suffered for years from calculus, and was voiding her urine in driblets every few minutes, had the stone extracted by dilatation, and for a fortnight thereafter retained her urine like one in health; but when the swell- ing from the operation subsided, incontinence came on, and continued for months to resist the various remedies employed for its cure. When enuresis in the aged depends on a mor- bid sensibility of the bladder, we have found great benefit from the use of balsam of copaiba; but in many of these cases the functions of the bladder are disordered by habits of intemperance, which must be corrected before we can expect any re- medy to produce permanent relief. [In very obstinate cases, where all other means have failed, it has been advised to introduce a bougie into the bladder; and some have recom- mended, that it should be coated at the point with a stimulating substance, as the tincture of cantha- ■578 URINE, (SUPPRESSION OF) rides, applied in layers, one coat being permitted to dry before the other is laid on. The cases must be rare indeed where such a severe remedy could be considered necessary; and the same may be said of the different juga, and other mechanical contrivances which have been applied for the pur- pose of preventing the discharge of the urine. Some risk always attends their employment, and they do not strike at the root of the mischief. Dr. Willis (Urinary Diseases and their treat- ment, Amer. edit. p. 220, Philad. 1839), thinks the best of the mechanical contrivances is that in which a firm, but not a hard, pad is kept applied, by means of a spring, to the urethra in the peri- naeum. It has been proposed to apply the nitrate of silver to the orifice of the urethra, so as to excite acute inflammation of the part,—and a successful case has been reported. When the urine passed over the inflamed surface, the pain produced by it was sufficient to awaken the patient, and arouse the sphincter vesica to the more energetic exer- cise of its function. The caustic was repeated, and a cure shortly effected.] W. Cumin. URINE, SUPPRESSION OF, Ischuria Re- 'nalis.—The generic term ischuria has been employ- ed not only by medical writers in general, but by professed nosologists, men of high reputation, to designate two very different affections. Thus by Sagar, ischuria has been defined " retention or sup- pression of urine secreted by the kidneys, or sup- pression of the secretion in thekidneys." Sauvages, in his definition, uses the term retention,- Cullen, that of suppression only. The first of the above- mentioned authors seems indeed to have recognised a distinction between the one and the other affec- tion, though he has not laid it down with sufficient perspicuity. Sauvages and Cullen evidently re- garded retention and suppression as equivalent terms; yet to distinguish them accurately is of great importance, and, in treating of the only spe- cies of ischuria which belongs to the province of the physician, it shall be our endeavour to avoid confusing the one with the other. We would tread in the steps of modern writers, eminent for the soundness of their views and justness of dis- crimination ; of Dr. Good, among others, who has assigned to complete suppression of urine the ap- pellation of « paruria inops," while to obstruction or retention of the secretion in the kidneys he has given the name of «< paruria retentionis renalis." In accordance with his view of the subject, yet retaining the term ischuria as one more familiar to the medical world, we may speak of the former under the title of ischuria renalis suppressionis, and of the latter under that of ischuria renalis re- tentionis. Suppression or destitution of urine may occur as an idiopathic affection, or as the result of other local or general disease. The causes of idiopathic suppression are involved in considerable obscurity; probably, however, they are to be sought for in some affection of the brain and nervous system, producing palsy of the kid- neys, or in a congested state of the emulgent veins. Cases of idiopathic suppression are certainly rare, though perhaps not so rare as some authors have imagined them to be. The affection may be described, sufficiently for every practical purpose, in very few words. In an individual, generally one of full habit, inclined to corpulency, and past the meridian of life, the secretion of the kidneys becomes suddenly and completely suspended; but as there has existed little or it may be no previous indisposition, as there is no provocation to pass water, no pain or sense of weight in the lumbar region, no fulness of the hypogastric region, or of any part of the abdomen, the patient probably disregards the suppression for several hours, till, being seized by a rigor, or experiencing an unu- sual degree of heaviness and oppression, he deems it prudent to resort to medical advice. The me- dical man finds his patient complaining of some nausea, and of torpitude of the whole system, and with a pulse somewhat slower than natural, yet still with so little pain and so free from distension or any other very distressing or urgent symptom, as to entertain no apprehension respecting the re- sult himself, and to be regarded perhaps by his friends as fanciful and nervous. The catheter is employed, it passes freely into the bladder, but no urine follows. At this juncture, whatever may be the impression of the patient or his family, or of unscientific observers, the experienced practitioner will descry no small danger. His prognosis will be decidedly unfavourable. He is well aware that the constituent principles of the urine cannot long be retained in the blood without being productive of serious mischief. To save the patient, the kid- neys must be roused to action, and that speedily; they must resume their functions, or their import- ant office must be assumed by some other organ. Now to stimulate the palsied kidneys to action is by no means an easy task, and the remedial efforts of nature or the resources of art may prove too feeble or too tardy to compensate effectually for the destitution of the discharge from the kidneys. In a few hours vomiting and hiccup supervene, the torpor of the system increases, the brain espe- cially is oppressed, and generally on or about the second or third day from the commencement of the suppression, the patient dies comatose, as in a state of apoplexy. In some of these cases a strong urinous smell is perceptible before death, evidently proving that nature was endeavouring to convert the exhalanta of the skin into a substitute for the palsied kid- neys, but was not able completely to succeed. Such, usually, is the rapid and fatal course of idiopathic suppression of urine, which, as has been already observed, is generally a disease of elderly people. Cases, however, are on record where the suppression continued for a much longer period without danger, and the subjects of which were young persons or children. As a striking exam- ple of these chronic and less dangerous cases may be adduced one, copied from a foreign journal into the Medico-Chirurgical Review for April of the present year. The subject of this singular his- tory was a boy, twelve years of age, who, it is stated, secreted no urine for seven weeks, though all that time he partook freely of liquids. The bowels acted naturally every second or third day; there was no increase of perspiration, but the con- trary ; the appetite was tolerable, the sleep sound, the boy was to all appearance healthy. It IS added that there was no suspicion of deception URINE, (SUPPRESSION OF) 579 either on the part of the patient or of his friends. At the end of the seven weeks, turpentine injec- tions and frictions were employed, and balsam of copaiba was administered internally. Why these remedies were not had recourse to earlier is not explained; it would appear, however, that they had the effect of exciting the action of the kidneys in two days. To this certainly marvellous rela- tion the able editor of the Medico-Chirurgical Review has subjoined one very similar, which fell under his own observation. In this latter case it was impossible deceit could be practised; the catheter was introduced almost every day, but a few drops of blood only followed. There was no affection of head, nor is any mention made of in- creased perspiration or of diarrhoea. Various other instances of complete suppression of urine, which subsisted for a long time, and were unat- tended with danger, arc recorded by Dr. Parr, Dr. Richardson, &c. Nay, some cases have been mentioned where the affection has been coeval with tho birth of the individual. May it not, however, be suspected that a more severely critical examination of such cases would have led to the discovery that some urine (a very small portion it might have been, but that some urine) was se- creted and passed 1 We must always remember, as has been justly remarked by Sir Henry Hal- ford, that a very small measure of urine is suffi- cient for the exigencies of the constitution, and that it is the total cessation of the secretion that is so uniformly fatal. Or, if it be conceded that in these cases not a drop of urine was passed by the natural channel, or discharged at any foreign outlet; if, in a word, it be conceded that no urine whatever was se- creted, might not more accurate investigation have determined them to belong to the ischuria suppleta of Sauvages ? It may be proper in this place to say a few words respecting this latter variety of ischuria renalis, in which the want of the secretion in the kidneys is compensated by a vicarious discharge, as also of that variety in which urine itself is thrown off by some foreign outlet. Cases of either description are uncommon, and, among those which have been published, some perhaps have been simulated ; yet a sufficient number, distinctly related, and by writers of good authority, remain to entitle the ischuria suppleta of Sauvages and the paruria erratica of Dr. Good to our con- sideration. The more usual emunctories which take up the office of the kidneys, are the skin and bowels; and several well-authenticated histories are to be met with in which we are assured that while not a drop of urine was secreted in the kidneys, there were most profuse perspirations, or diarrhoea, to such an extent as would, under different circum days. The relation occurs in the Medicina Prac- tica of Sennertus, lib. iii. cap. 10. That the suppression of the proper secretion of the kidneys should sometimes be compensated by a vicarious discharge, or, in other words, a se- cretion of a different kind, may not appear very extraordinary or difficult to comprehend; but when we approach the subject of erratic urine, there is much which we are at a loss to explain. If we suppose the kidneys not to secrete at all, how or where are we to imagine the urine to be separated from the blood ? If we adopt what seems the more probable conclusion, that in cases of uropla- nia the fluid is first secreted in the kidneys, and afterwards is re-absorbed by the increased activity of the urinary lymphatics, still how are we to account for its being carried to the salivary glands. to the stomach, to the axillae, &c. ?—how are we to explain the fact of its having been detected in the ventricles of the brain ? By what path and in what manner is it conveyed to the foreign out- let or the remote situation 1 In the treatment of idiopathic suppression of urine, we should bear in mind the great probability of its depending upon a congested state of the brain or of the vessels of the kidneys themselves; and, if the subject of the affection be a person of full habit, if the pulse be slow and full, if there be a considerable oppression of head, we should not hesitate to employ general bloodletting, and that freely ; if the above-mentioned symptoms be less marked, and the patient less plethoric, cup- ping from the neighbourhood of the head or from the loins may be sufficient. The abstraction of blood should be promptly followed up by the ex- hibition of a brisk purgative, as calomel with the compound gamboge-pill, succeeded, if need be, by a saline cathartic draught. In the event of these or other purgative medicines being rejected, remedies of a similar description must be admin- istered in the form of enema, as, for example, oil of turpentine with castor oil. Having premised these general remedies, our attention should be next directed to the kidneys more particularly. We should employ stimula- ting diuretics, as small doses of oil of turpentine or balsam of copaiba, repeating them at short in- tervals ; or, should these medicines prove offensive to the stomach, the tincture of cantharides, with spirit of nitric ether in camphor mixture, may be given. Of the rest of this class of remedies the most important, perhaps, are the infusion and spirit of horse-radish, squill, and spirit of juniper. Of the pyrola umbellata and certain other reputed diuretics, our experience is far too limited to ena- ble us to speak with confidence; and in an affec- tion so important, and generally so quickly fatal as idiopathic ischuria renalis, we should scarcely think of resorting to remedies so little known, stances, have reduced the patients to an alarming while others of acknowledged efficacy are within degree. Occasionally the system has been re lieved by vomiting of a fluid resembling urine as to colour, but yet altogether devoid of urinous smell or taste. But one of the most singular cases of vicarious discharge is that quoted by Sennertus from Platerus, of a girl thirteen years of age, in whom the secretion of the kidneys was compensated by a very copious flow of serous fluid from the right ear, which continued during several our reach. Digitalis has been recommended ; but the only form in which its diuretic powers can be depended upon is that of infusion ; and where a great disposition to nausea exists, we should be cautious in advising its exhibition in that form. If digitalis be employed at all in the present dis- ease, it should be in combination with spirit. aetheris nitrici, tinctura cantharidis, spirit, armorac. comp., or other stimulants. 580 URINE, (SUPPRESSION OF) Opium has been proposed, under the notion of spasm existing in the vessels of the kidneys. Under such a view we should not have recourse to it, but in its combination with some other me- dicines, as ipecacuan for example, it may prove useful ; for in the treatment of the disease under consideration, we must ever recollect that the ex- cretions of the skin may assist those of the kid- neys, and that, therefore, it is an important part of our duty to endeavour to excite the former, by active diaphoretics, to take upon themselves for a time the office of the latter, and carry off the urea which should be discharged by the kidneys. Before concluding this part of our subject, we must strongly insist upon the importance of ex- ternal remedies; of these the principal are elec- tricity and galvanism, blisters, cataplasms of mus- tard and horse-radish, and terebinthinate frictions. The hot-bath may also be employed, or the suda- torium ; the use of the latter, followed up by a full dose of Dover's powder or other powerful diaphoretics, will seldom fail to excite profuse per- spiration. But suppression of urine may occur as a result of other local or general disease; and then, of course, it will be attended by several symptoms in addition to those which are observed in the idio- pathic affection. Thus, when it arises in conse- quence of renal inflammation, there will necessa- rily be considerable pain and tenderness in the lumbar region, with other symptoms of nephritis, hereafter to be noticed when we come to speak of that disease more particularly. When it proceeds from transferred gout, there will also be severe pain in the loins; and when it is caused by cal- culus, there will be weight and dull pain. Sup- pression of urine may also take place at the com- mencement of inflammatory fever. In all these cases our remedial measures must be directed to overcome the original disease. In proportion to the intensity and duration of the latter, will be the degree and duration of the suppression : with the cessation of the primary disease the suppression will cease. Suppression of urine sometimes occurs towards the fatal termination of certain diseases. Under such circumstances, nothing can be done. Retention of I'rinc in the Kidneys.— We have now briefly to notice retention of urine in the kidneys. In this, as in the affection we have just been considering, there is no flow of urine; but in other respects it differs materially from suppression. In suppression the kidneys no longer secrete ; in retention the secernents are not inactive, but the secreted fluid is obstructed in its passage. The obstruction may arise from a va- riety of causes. It may arise from spasm, from inflammation, abscess, or scirrhus of the kidneys ; from hydatids from calculous concretions, gru- mous blood, or viscid mucus in them; or from spasm or inflammation of the ureters; from cal- culi or other matters filling up their cavities; from their obliteration in consequence of ulceration ; from tumours pressing upon them. The urine, though secreted in sufficient abundance, may be prevented from flowing into the pelvis of the kid- ney, or from thence into the bladder, by great en- largement of the gland. The same effect may also be produced by considerable extenuation of the kidney. Under this latter circumstance, though a small portion of urine may still be separated from the blood, yet, as the sinus of the organ con- tracts with its body, not a single drop may be able to pass into the ureter. In most, if not in all, of the cases above men- tioned, there will be dull pain, or a sensation of weight and uneasiness in the loins; and some- times, as, for example, when the kidneys are greatly enlarged, there will be a fulness percepti- ble to the touch, or even to the eye; generally, however, owing to the peculiar situation of those organs, no intumescence is to be detected. Complete renal retention is a very serious dis- ease, inasmuch as it rarely takes place unless either both kidneys are simultaneously obstructed, or, one having previously been rendered incapable of performing its functions, the other, which had done double duty, becomes completely obstructed. It is not a common occurrence for both kidneys to be simultaneously affected; and in cases of ab- solute retention we may therefore conclude, or at least we may strongly suspect, that one of those glands has for some time been useless, or that one ureter has been impervious. Still, however, we must recollect that fatal retention has occasionally happened, though one kidney and its ureter have been wholly free from disease. For this we can account in no other manner than by supposing that the sound kidney is affected by sympathy; the irritation produced by calculous concretions or other causes in the one organ may excite spasm in the other. In the management of renal retention of urine we must be regulated by the cause, so far as we are able to ascertain it. Thus, if from the accom- panying fever, and the violence of the pain, we judge it to arise from inflammation, we must em- ploy general or topical bleeding, followed by mild aperients, and relaxants, and anodynes. If it ap- pear to depend on calculus, mild aperients and relaxants may be all that the case demands; but here also, if there be considerable pain, venesection must not be neglected ; and after venesection re- course must be had to anodynes. If the retention be in consequence of enlargement or hypertrophy of the kidney without evidence of inflammation, we are not to expect much from medicine. If both kidneys be thus affected, the case may indeed be regarded as hopeless. If one only be enlarged, the other probably will, for a time, take upon itself the whole duty ; and a cure of the diseased organ may be attempted by the persevering exhi- bition of small doses of mercury, and the applica- tion of the emplastrum ammoniaci cum hydrargyro to the lumbar region. The well-known power of iodine in promoting absorption would point it out as an appropriate remedy in this state of disease; it may be employed in the form of its tincture; the dose being at first five or six minims, which may be gradually and cautiously increased to twenty minims or more,* three times a day, or * The words, or more, are added because we know much larger doses have been given, and, it i» **io, with impunity. Our own experience, however, if again" large doses of that powerful medicine. Our astonish- ment has been very great on reading the treatment ol a case of epilepsy by Dr. Franklin of New York, who, ii seems, gave one hundred drops thrice a day for a monto See Lancet for July 30, p. 554. URINE, (MORBID STATES OF THE) 581 the ointment of iodine, or of hydriodate of potass, may be rubbed in twice a day over the region of the enlarged gland. If from the course of the pain, and the sense of weight, together with numbness of either lower extremity, and retraction of testicle, we suspect the obstruction to exist in the ureters, the only remedies from which we are to expect relief are relaxants and opiates. In this variety the reten- tion is very rarely complete, for it is extremely uncommon for both ureters to be obstructed at the same time, or, when one is obstructed, for the other to be so affected by sympathy as to offer a total impediment to the flow of urine. H. W. Carter. URINE, MORBID STATES OF THE.— The urine is the fluid which is secreted by the kidneys, and after being deposited for some time in the bladder, is discharged by the urethra. It is one of those secretions to which the term excre- mentitious has been applied, from its having been supposed to consist essentially of the substances which are separated from the mass of the circu- lating fluids, for the purpose of being discharged from the system as superfluous or useless, and, if retained, producing injurious effects. (Blumenbach, Inst. Physiol, sec. 34. Adelon, in Diet, de Med. t. xxi. p. 64. Bostock's Physiol, vii. p. 371. [Dunglison's Human Physiology, 5th edit., ii. 281, Phil. 1844.]) The kidney has been considered as among the most important of that class of organs which have been styled vicarious or compensating—those which pos- sess the power of temporarily fulfilling the office of some other organ. Thus, for example, if the cu- taneous perspiration be suppressed, the aqueous matter is discharged by the kidney ;* if an unu- sually large quantity of fluid be received into the stomach, and taken up by the absorbents, the kid- ney is the organ through which it finds a natural exit; and even with regard to various articles of food or medicine, although the intestinal canal affords them the most obvious means of being removed from the system, a portion of their ele- ments is generally carried off by the kidney. It must be considered as in some degree owing to this circumstance, as well as to the specific office of the kidney, that the urine is the most compound of all the animal secretions, and, at the same time, the most variable in its contents. This latter pro- perty is further increased by the nature of the proximate principles which enter into its compo- sition, many of which are readily decomposable, while they are likewise disposed to act on each other, and, during their continuance in the blad- der, are placed in a situation which is favourable to this action. These various circumstances would naturally lead us to conclude that the urine must differ considerably in different individuals, and that, in the same individual, under the various circumstances in which he is placed, both those of ordinary occurrence, and more especially in the morbid conditions of the body, these differences would exist, and would be indicative of the causes ' * Wc have an interesting series of observations by Li- ning, on the relation between the urine and the cutaneous perspiration in the different seasons; Phil. Trans, for j 1743 and 1745. Observations of a similar kiud have been made by other physiologists, but perhaps we have none that are equally numerous and correct 2r* by which they are immediately produced. We accordingly find, that observations on the patho- logy of the urine were among the first which were noticed by the ancients : that they have at all times occupied a considerable share of attention among the most intelligent medical practitioners;-)' and that, by the vulgar and the uneducated, they have even been considered as alone sufficient to ascertain the nature of a disease, and as superseding all other pathognomonic symptoms. On the present occasion, we propose to com- mence by an account of the urine in its healthy state, and after attempting a classification of its morbid states, to offer some remarks on their im- mediate cause, and the relation which they bear to the derangements of the system. We do not think it necessary to enter upon the consideration of the medical treatment, because, on this subject, little would remain for us but to refer to the vari- ous articles which have appeared in the preceding volumes of this work, where the state of the urine has formed a characteristic symptom of disease, or an indication of the effect of remedies upon it. 1. Of the healthy Urine.—It will be unne- cessary to describe at length the appearance and external characters of the urine in its ordinary state. Its quantity varies much in different indi- viduals, and in the same individual under different circumstances, and this without exceeding the limits of what may be strictly regarded as the state of perfect health. Physiologists have attempted to form an average estimate of the quantity voided during the diurnal period; but this investigation, simple as it may appear, is attended with consid- erable difficulty. Haller, after collecting a number of observations made by different individuals, fixed the quantity at forty-nine ounces. (Elem. Phys. 26, 4, 6.) The writer of this article, proceeding principally upon the observations of Rye, which appeared to him the most numerous and the most accurate on record, was induced to lower it to forty ounces; (Rogers on Epidemic Diseases, Ap- pendix to Med. Chir. Tr. vol. iii. p. 110 ;) while Dr. Prout, whose opinion on every point connect- ed with this subject is of the highest authority, reduces it to thirty-two ounces. (Inquiry into the Nature of Gravel, &c, p. 35. [On the Nature and Treatment of Stomach and Renal Diseases, Amer. edit, from the 4th London, Philad. 1843.) On the average, it may perhaps be estimated at 2£ pounds.] The specific gravity of urine, as might be sup- posed, is at least as variable as its quantity. It has been found, in some cases, not very much to exceed that of water, being as low as 1005, while. in others it rises as high as 1040 or even 1050. (Cruickshank, ubi supra. Berzelius, Traite de f With respect to the ancients, it will be sufficient to refer to the Becond book of Hippocrates's treatise De Prae- dict., and to Galen's De Crisibus. As we approach to our own times, we may select from the more celebrated of the moderns, Willis's Exerc. de Urinis, and Bellini's work DeUrinisetPulsibus. Since the improvements of modern chemistry made us acquainted with the constitution of the urine and the nature of its constituents, the atten- tion of many of our most eminent pathologists has been directed to this subject with much success. Among the first and most valuable of their productions, is the essay of Cruickshank, "On the manner of distinguishing Dis- eases by the Urine," which contains, in a short compass, much accurate and original observation. Rollo on Dia- betes, and Tilloch's Phil. Mag. vol. ii. p. 240 et seq. 582 URINE, (MORBID STATES OF THE) Chimie, par Esslinger, t. vii. p. 342.) Both these extremes, however, especially the latter, are to be regarded as indicating a diseased state of the sys- tem, in which not only tho relative proportion of the solid and the fluid part of the urine is affected, but where the nature of the solids themselves is changed. Dr. Henry is disposed to consider 1030 as a fair average of what may be regarded as healthy urine, (Elements of Chemistry, vol. ii. p. 490,) while Dr. Prout makes it no more than 1025, (Inquiry, p. 5) ; perhaps we shall not be able to fix upon a standard more likely to be gen- erally applicable than 1020, which is not far from the mean between these numbers. (Brande's Ma- nual, vol. iii. p. 191; Berzelius adopts the estimate of Dr. Prout, ubi supra. [See, also, The Kidneys and Urine, translated from Berzelius, by M. H. Boye and F. Learning, M. D., Philad. 1843.) Dr. T. Thomson (Brit. Annals of Medicine, p. 5, Lond. 1837,) found it in an individual, from 50 to 60 years of age, and in perfect health, to be, on the average, 1013,—the lowest specific gravity, during ten days, being 1004, and the highest 1026. (For various estimates, see the writer's Human Physiology, 5th edit., ii. 294, Philad. 1844,)] With respect to the chemical constitution of the urine, notwithstanding the elaborate examinations of it which have been made by chemists of the first eminence, there would appear to be still some degree of uncertainty. The analyses of Dr. Henry and of Berzelius, who have cultivated the depart- ment of animal chemistry with so much success, although essentially coinciding, differ in several minute points, both as to the substances which are actually present in the urine, and the mode of their combination. According to Dr. Henry, there are twenty-one substances which " have been sat- isfactorily proved to exist in healthy urine," (Elem. p. 490); the list of these we subjoin, and compare it with that given us by Berzelius,* which, as will be seen, is somewhat different: Henry. Berzelius. I. Water. Water. 2. Free phosphoric acid. 3. Phosphate of lime. Phosphate of lime. 4. Phosphate of mag- Phosphate of magnesia. nesia. 5. Fluoric acid. 6. Uric acid. Uric acid. 7. Benzoic acid. 8. Lactic (impure ace- Free lactic acid. tic) acid. 9. Urea. Urea. 10. Gelatine. 11. Albumen. 12. Lactate (acetate) of Lactate of ammonia. ammonia. * Traite, p. 392, 3. Berzelius arranges the substances found in urine under the two heads of the ordinary con- stituent principles, and the accidental principles; but the latter are chiefly composed of the substances that are found in the urine in its various morbid states : p. 343 and 399. Mr. Brande reduces " the substances that are always found in urine," to twelve; water, carbonic acid, phosphoric acid, uric acid, phosphate of lime, phos- phate of ammonia, phosphate of soda, phosphate of mag- nesia, common salt, sulphate of soda, albumen, and urea; Manual, v. iii. p. 191. Fourcroy extends the number to thirty, but the existence of some of these he considers as doubtful, at least in the natural and recent state of the urine; System of Chem. Knowledge, by Nicholson, v. x. p. 185, 13. Sulphate of potash. 14. Sulphate of soda. 15. Fluate of lime. 16. Muriate of soda. 17. Muriate of ammonia. 18. Phosphate of soda. 19. Phosphate of am- monia. 20. Sulphur. 21. Silica. Sulphate of potash. Sulphate of soda. Chloruret of soda. Chloruret of ammonia. Phosphate of soda. Biphosphate of ammo- nia. Silex. Extract of meat in alcohol. Extractive matters solu- ble only in water. Mucus of the bladder. On comparing the two lists, we find that of the twenty-one ingredients enumerated by Dr. Henry, fourteen may be considered as recognised by Ber- zelius, while there are seven, viz. uncombined phosphoric acid, the fluoric and benzoic acids, the fluate of lime, albumen, gelatine, and sulphur, which are not included by him. On the other hand there are three substances, extractive matter soluble in alcohol, extractive matter soluble in water, and the mudtas of the bladder, which are enumerated by Berzelius, but are not recognised by Dr. Henry. On these discrepancies we shall venture to remark, that there appears to us to be scarcely sufficient evidence of the existence of uncombined phosphoric acid in healthy urine, and that the presence of benzoic acid, in human urine,-}- of the fluoric acid,$ and of course of fluate of lime, may be regarded as somewhat pro- blematical. The existence of sulphur in urine, although omitted by Berzelius, appears to be fully established by the experiments of Proust. (Ann. Chim. t. xxxvi. p, 258-60.) With respect to two of the additional substances introduced by Berzelius among the constituents of urine, we feel disposed to admit of their existence; the extractive matter soluble in alcohol we believe to be either identical with, or to be very similar to the uncoagulable matter of the serosity of the blood, and to be nearly related to the proximate principle which has been styled osmazome. The mucus of the bladder, if not an essential constituent of the urine, we believe to be very generally present in it; and although it is not admitted by Dr. Henry into his list, yet he remarks, in a subsequent paragraph, that it exists in healthy urine. (Elem. v. ii. p. 493.) As to the " extractive matters soluble only in water, we confess that we are altogether uncertain to what principle or substance Berzelius here refers, t The principal authority for the existence of benzoic acid in human urine is Thenard; Ann. Chim. t. lu. P- 270. Dr. Prout, however, remarks " that it does noi exist in healthy human urine ;" Inquiry, p. 19. Berzelius informs us that the substance which had been supposed to be benzoic acid is a compound of this acid with urea, to which he gives the name of uro-benzoic acid, p. .)?■>■ it may be presumed, however, that he does not conceive it to exist ready formed in the urine, as he does not place it in his list of its constituents. See also some experi- ments of Liebig, who detected a peculiar acid in jne urine of the horse, but which appeared not to be me benzoic; p. 365. We may remark that Fourcroy ana Vauquelin admit of its existence, but in an extremely minute quantity ; Ann. Chim. t. xxxi. p. 62, 3. t The fluoric acid seems to have been admitted on the authority of Berzelius; Ann. Chim. t. Ixi. p. 256; a'»° Med. Chir. Tr. v. iii. p. 25a He, however, as aPP*8™ above, does not enumerate it among the constituents oi urine in his last work. URINE, (MORBID STATES OF THE) 583 nor can we well conceive of any to which this de- scription can be considered as appropriate. Besides the substances mentioned above, there are others which have been supposed by some chemists to enter into the composition of healthy urine. This is the case with the carbonic and the acetic acids, the former of which, if not essen- tially present, is at least frequently detected in urine that exhibits no other morbid character;* while the latter, which has been announced by Proust, Thenard, and others, (Thenard, Traite de Chimie, t. iii. p. 728, and Ann. Chim. t. lix. p. 275; Henry, v. ii. p. 493; Berzelius, t. vii. p. 361, 2,) we may conceive to be the same substance with the lactic acid of Berzelius. To these we may add a certain principle or principles, which give the urine its peculiar colour and odour, neither of which would appear, from the experi- ments of Dr. Prout, to be necessarily connected with the urea.j- We may further remark on the constitution of the urine, that we doubt whether albumen should be considered as forming one of its constituents while in the healthy state, and that we are not acquainted with any experiments which afford unequivocal evidence of the presence of gelatine. The urine in its natural and healthy state always exhibits acid propensities, as is shown by its effects on test-papers. We are disposed, how- ever, to agree with Dr. Prout, that this excess of acid arises, not from any portion being in an un- combined state, but that certain of the alkaline and earthy bases are not neutralized, Tmt are in the state of super-salts. This remark applies equally to the lithic and the phosphoric acids; the former of which we conceive exists in the form of 6uper-lithate of ammonia, and the latter in the same state of combination with the alkalies, and probably also with the earths that are present in the urine. The same remark may apply to the lactic and the acetic acids ; for in this case, as in the former, if we conceive them to be absolutely uncombined, they would precipitate the whole of the lithic acids. (Prout's Inq. p. 11-15.) One of the most important circumstances con- nected with the chemical constitution of the urine is the state of solution in which the phosphate of lime is held, in consequence of the excess of acid to which wc have referred above. If this excess be neutralized by the addition of ammonia, the phosphate of lime is precipitated without decompo- sition, in the form of a white impalpable powder. The phosphate of magnesia is likewise precipita- ted without decomposition, but it unites with a portion, of the ammonia, forming a triple salt, the ammoniaeo-magnesian phosphate, as it has been usually termed. These two salts enter largely into the composition of certain urinary calculi, and it may be presumed that the deficiency of acid in the urine is, in this case, the immediate cause of their formation. Dr. Henry informs us that the average quantity of phosphate of lime in urine is * Proust, Ann. Chim. t. xxxvi. p. 260, 1; Vogel, ibid. t. xciii. p. 71 et seq.; Marcel, in Calc. Dis. p. 168-70; Prout's Inq. p. 19; Henry, v. ii. p. 495; Brande, Manual, v iii. d. 192. 1 Mod. Chir. Tr. v. viii. p. 509, and Inq. p. 8-10; Berzeli- us. Traite, t. vii. p. 371, 2. and Journ. Roy. Inst. v. i. p. 401. See also Wohler's r\\n riments on the mode of ob- taining pure urea, in Ann. Chim. t. xliii. p. 04. et. seq. about half a grain in each ounce of the fluid, (Elem. vol. ii. p. 491,) thus affording nearly twenty grains per day; a quantity amply sufficient to lay the foundation of a calculous concretion, were there not an appropriate solvent provided. The presence of sulphates in the urine is clearly ascertained by the appropriate tests, (Berzelius, in Med. Chir. Tr. vol. iii. p. 259-62) ; and as neither the sulphuric nor the phosphoric acids exist in the blood, it has been conjectured, with great plausibility, that one essential office of the kidney is to acidify the bases of these acids, (Ber- zelius, ubi supra; Prout's Inq. p. 30, 1,) the ultimate object of which may probably be, to re- move the excess of earthy matter which remains after the employment of that portion of it which is necessary for the formation and support of the bones. A much more important office of the kidney, what may perhaps be distinguished as its appro- priate function, is the removal from the system of the superabundant nitrogene. (Bostock's Phy- siol, vol. ii. p. 372.) It appears to be essential to the existence and well-being of the animal fabric that an ample supply of this element should be always at hand, in order to contribute to the for- mation of the various solids and fluids into which it enters, as one of the most abundant constituents. The main source of this supply is introduced through the medium of the digestive organs; but as it is necessarily very variable, in consequence of the difference both in the quantity and in the quality of the ingesta, it follows that, on ordinary occasions, the supply is greater than the demand. The superfluous quantity is separated from the blood by the kidney under the form of the urea, the substance which may be regarded as the spe- cific secretion of the organ, and as composing the essential ingredient in healthy urine.}: It will not be necessary, nor would it indeed be proper for us in this place, to enter upon a minute de- scription of urea, or of its relation to the various chemical re-agents; it will be sufficient to observe, that nitrogene enters more largely into its compo- sition than into that of any other organic body, constituting very nearly one-half of its weight.^ t We are indebted to Cruickshank for our knowledge of the urea as a distinct proximate principle: Rollo on Diabetes, and Tilloch's Phil. Mag. ubi supra ; its proper- ties were afterwards more fully ascertained by Fourcroy and Vauqnelin : Ann. Chim. t. xxxi. p. 68-71. The only other specific secretion of the kidney is the lithic acid : for a full account of this substance and its chemical rela- tions, we may refer our readers to the valuable inaugural dissertation of Dr. Henry, De Acido Urico, and to the abstract of it in the second volume of the Manchester Memoirs. § The ultimate analysis of urea has been made by Ge- rard, Dumas, and Dr. Prout: these two latter eminent chemists agree very nearly in their estimate, the former making the nitrogene 469 per cent., Ann. Chim. t. xliv. p. 273 et seq.; and the latter 46-66; Med. Chir. Tr. vol. viii. p. 535, and vol. ix. p. 483; Henry's Elem. vol. ii. p. 430; and Berzelius, Traite, t. vii. p. 378. According to the analyses of Henry, p. 49C, and Berzelius p. 392 3 the urine, in its average state, contains 3 percent, of urea, which will be very nearly 15 per cent, of nitro- gene. Taking the specific gravity of the urine at 1020, and assuming that two pounds and a half are voided in the diurnal period; we shall have not much less than one ounce weight of nitrogene removed from the system daily. A portion of nitrogene, although very inconsider- able compared to that in the uroi, is likewise carried off from the system under the form of lithic acid, of which it composes between 30 and 40 per cent.; Marcet p. 73, Berzelius, p. 350. The nitrogene discharged in this way will not exceed two-thirds of a grain daily. 584 URINE, (MORBID STATES OF THE) Another important circumstance to be attended to in the chemical constitution of the urine is its tendency to spontaneous decomposition, and to the reciprocal action of its various constituents upon each other. When the urine has been voided, and left at rest for some hours at the ordi- nary temperature of the atmosphere, it generally begins to deposit a portion of the salts which it previously held in solution, The immediate cause of this effect would appear to be the generation of a quantity of ammonia, arising from the par- tial decomposition of the urea; the ammonia thus produced is in part united to carbonic acid, which is also generated, while another portion of it satu- rates the excess of the acids in the super-salts, and in this way precipitates the lithic acid and the earthy phosphates. This process is considerably promoted by an increase of temperature; and it appears that it is carried on, to a certain extent at least, in the bladder, when the urine is by any cause detained for an unusual length of time in that cavity. (Fourcroy and Vauquelin. Ann. Chim. t. xxxi. p. 58, 60. Berzelius, t. vii. p. 342.) At the same time that these changes are going on, or perhaps in a later stage of the process, a quantity of acetic acid is also generated, which unites with another portion of the ammonia; thus the acetate and the carbonate of ammonia, the neutral phosphate of lime, and the ammoniacal phosphate of magnesia, constitute the immediate products of the spontaneous decomposition of the urine. If we admit the speculation of Berzelius, which appears to be supported by many powerful considerations, that the kidney is the general out- let by which the effete or decomposed materials of the system are removed from the body after they have discharged their respective functions, (View of Animal Chemistry, p. 16, 82 ; Traite, t. vii. p. 339,) we shall have an additional source of diversity in the composition of the urine, and also, in proportion to the heterogeneous nature of its constituents, we may expect that there will be an increased tendency in its component parts to react upon each other.* [The appearances presented by the urine under the microscope, have been referred to under the head of Calculi, Urinary (vol. i.) Further details are contained in the productions of Donne, Cours de Microscopie, p. 213, Paris, 1844) ; Dr. Gold- ing Bird, (Lond. Med. Gaz. Feb. 10,1843, p. 678, * For a more minute account of the properties of the urine than would be consistent with the object of this article, as well as for an historical detail of the succes- sive discoveries which have been made respecting it, the reader is referred to Aikin's Diet., in loco ; Thomson's System, vol. iv. p. 551 et seq.; Henry's Elements, vol. ii. p. 489 etseq.; Brande's Manual, vol. iii. p. 190 et seq..; Turner's Elements, p. 775 et seq. ; Thenard, Traite de Chimie, t. ni. p. 723 et seq.; Berzelius, Traite, t. vii. p. 3:19 et seq.; and Med. Chir. Tr. vol. iii. p. 257 et seq.; Montfalcon, in Diet, des Scien. Med., article Urine; to which is appended a copious list of references bv Vaidv, which is very complete for the earlier writers, but less so for the more recent authors, and especially for the Eng- lish ; t. Ivi. p. 332, 4; Orfila, in Diet, de Med., article Urine, in loco; Andral. ibid, article Urine Semeiotique, in loco; we have a series of valuable experiments on the urine, many of them of a statical nature, by Chos- sat, in Magendie's Journ. t. v. p. 65 et sen. Fourcroy's great work contains a most minute account of the urine at the period when it was written, but later discoveries and experiments have led to an alteration or modifica- tion of many of the statements; System, vol. x. p. 129 j et seq. j and in his work entitled " Urinary Deposits, their diagnosis, pathology, and therapeutical indica- [ tions, Lond. 1844) ; Mandl, (Manuel eTAnato- i mie Generalc, p. 504, Paris, 1843), and Prout, I ( On the Nature and Treatment of Stomach and Renal Diseases, 4th edit. p. 517, Lond. 1843, or I Amer. edit. Philad. 1843.)] II. lUorljiil states of the Urine. — Before we attempt an arrangement or classification of the morbid states of the urine, it will be necessary to form a clear conception of the nature of those changes in the fluid which may be entitled to this appellation. It would probably be impossible to form a classification which should include every casual or temporary alteration in the properties of the urine, nor if it could be accomplished, would its value be in any degree commensurate with the difficulty of the execution. Our object must be to characterize those conditions of the urine which are well marked, which have a certain duration, where its constituents bear a new chemical rela- tion to each other, and where this is connected with an altered state of one or more of the animal functions. Proceeding upon this basis, we shall endeavour to arrange all the morbid states of the urine under the seven following species, naming them from the circumstance from which they de- rive their most obvious properties: 1. the aqueous; 2. the sub-aqueous; 3. the lithic; 4. the phos- , phatic; 5. the purpuric; 6. the albuminous; 7, the saccharine. To these we must add, as a kind j of appendage, an eighth section, in which we may I include various miscellaneous or incidental cir- ! cumstances connected with the constitution of the urine, which are not capable of being reduced to any assignable or recognised species. 1. Aqueous Urine.—[Hydruria.] — This may be characterized as a state of the secretion, where 1 tho proportion of the fluid to the solid contents is morbidly increased, and which is frequently, al- : though not necessarily, attended by an increased quantity of the urine that is discharged. And i here we must be careful not to confound those in- ! cidental or temporary changes in the state of the '. fluid, such as are produced by the application of cold to the surface of the body, or by certain men- I tal emotions, with the watery urine, which pro- ceeds from a permanent or constitutional cause. Among the causes of this description, perhaps the most frequent and the most efficient is that state of the system which has been denominated the nervous temperament, and more especially the I peculiar modification of it which gives rise to the I hysteric paroxysm. Here we have an unusually large quantity of urine discharged, and this often j containing less than the ordinary proportion of l solid matter, and as far as has been ascertained, without any other essential change in the nature I or proportion of its constituents. The aqueous urine will be often found to exist in that state of the system, where, without any specific disease, the powers both of the mind and the body begin to decline, and when the gradual dec%y of all the organs indicates the approach of old age.-)- Here t The late Dr. Heberden, in his invaluable volume, enumerates the frequent passing of urine among the symptoms of what he styles Valetudo Conquassata: Comment, chap. 94; in this state we believe the mine will be found to be much increased in quantity, and to be aqueous. URINE, (MORBID STATES OF THE) 585 the functions of the kidney are among the first to feci the effects of that decay, which gradually un- dermines every part of the system, and which ter- minates in its dissolution. We are not aware of any specific cause of this particular condition of the urine, independently of the general irritability and debility of the system ; nor do we know that it leads to any specific indication either of prog- nosis or of treatment. We believe, however, that it is an actual and not a very unfrequent occur- rence, and that it is one to which the attention of the practitioner may be advantageously directed, as it may assist him in forming an opinion re- specting the general state of the vital energies of the system, and of the degree in which the organs of digestion and assimilation are capable of per- forming their functions. 2. Sub-aqueous Urine. — This, in its specific character and its appellation, may be considered as directly the reverse of the former state, and yet, in its pathological cause, is somewhat closely con- nected with it. In certain cases of increased dis- charge of urine, it will be found, that besides an augmentation in the quantity of the secretion, it contains even more than the ordinary proportion i of solid contents, and thus, both from its quantity and its quality, carries off from the system an un- usually large proportion of the ingredients which ought to be applied to its growth or support. The sub-aqueous urine is sometimes found to exist in the decline of life, and would appear to be one cause among others by which a premature state of decay is effected. But it more frequently occurs at an earlier period in constitutions that have been debilitated by various causes, and par- ticularly by excesses of all kinds ; by long-con- tinued violent exercise, by stimulating diet, and especially by large potations of wine and fer- mented liquors, and perhaps, more than any other cause, by excessive sexual indulgence. This state of the urine is occasionally met with in persons whose constitutions have been injured by a resi- dence in tropical climates. The sub-aqueous urine is often found to be con- nected with the albuminous, or to alternate with it; and it would appear to be, to a certain extent, the result of the same causes acting upon a dif- ferent constitution, and exhibiting themselves in a more chronic form, consequently with less of febrile action, and without the specific derange- ment of any particular organ. To this species we are disposed to refer the variety of diabetes which has been termed insipidus, where we have an increased flow of urine, of high specific gravity, with the constitutional symptoms of the disease, both as to the state of the digestive organs and the skin, hut where the urine does not contain any saccharine matter.* We believe it will be I found upon examination that the sub-aqueous ' state of the urine is not unfrequently a precursor of its saccharine state, and that, in some cases, which may be correctly styled diabetes, the dis- * The writer of this article presented a case of this de- scription to the Mi dico-Chirurgical Society, where the urine contained no saccharine matter, but where its specific gravity was 1034, while the quantity discharged daily amounted to five quarts. By an analysis of the urine it appeared that the patient was discharging daily Bcven and a half ounces of urea, which may be con- sidered as at least three times the natural quantity Med. Chir. Tr. vol. iii. p. 107 et seq. Vol. IV. — 74 ease never proceeds beyond this state, in conse- quence of some change being effected in the con- stitution, either by natural causes or by the operation of remedies. 3. Lithic urine, [Lithuria.]—This is charac- terized by the spontaneous deposition of lithic acid, constituting the principal part of what is ge- nerally termed the sand or gravel of urine. The immediate cause of this deposition is the presence either of some other acid in the urine, which may precipitate the lithic acid naturally contained in it, or merely an increased quantity of the lithic acid itself, or rather the super-lithate of ammonia, so as to be more than can be held in solution in the urine, especially when it is reduced in tempe- rature, after being discharged from the bladder. It appears, that this latter, which is the simplest form of the disease, is also the most frequent, and in fact that there are few individuals in whom it does not occasionally exist, (Prout's Inquiry, p. 121) : we find, indeed, that any cause which de- ranges the digestive process or interferes with its due action, may produce the deposit of lithic acid. Among the most frequent of these causes we may enumerate an excessive quantity of food taken into the stomach, food of an indigestible nature, exercise taken immediately after a full meal, the application of cold to the surface of the body or to the feet during digestion, an undue quantity of liquid taken into the stomach. In the most simple form of the disease there is a deposit from the urine, as it cools, of a brown sediment, which is either pulverulent, or consist- ing of a mixture of the powder with minute crys- talline spiculae. When this deposit, as is fre- quently the case, assumes a pink or purple colour, it depends upon a combination of the purpuric with the lithic state of the urine. In the less simple form of the disease there would appear to be an additional agent in the urine, besides the superabundant lithic acid, which produces the de- posit in question. Dr. Prout supposes that the precipitation may be effected by various acids, but most generally by the phosphoric, and occasion- ally by the sulphuric, the nitric, or the carbonic, as well as by some other acids which are the pe- culiar product of the renal secretion. (Inquiry, p. 128.) In this case the lithic acid is precipitated in more or less of a crystalline state, and forms the greatest part of what has been termed urinary gravel. This gravel, like the sand in the former variety, may be tinged of a pink or purple colour, depending in like manner upon the combination of the purpuric with the lithic urine.j- With respect to the pathology of the lithic urine, it may be generally considered as a symp- tom of an imperfect state of the digestive organs, either induced, in each individual case, by a spe- cific cause acting upon the stomach and the chy- lopoietic viscera, or by a peculiar condition of the t For a very complete account of this variety of the urine, and of the state of the system which produces it, the reader is referred to the valuable treatise of Dr. Philip, first published separately in the year 1792, and afterwards, in an altered form, in the sixth volume of the Transactions of the College of Physicians, and to the third chapter of the second section of Dr. Prout's Inquiry Both these writers refer to a work, published nearly half a century ago by Forbes, which appears to possess very considerable merit, when we consider the imperfect state of chemical science at that period. [See, also, Willis on Urinary Diseases, and their Treatment, Philad. 1839.] 586 URINE, (MORBID STATES OF THE) constitution, more especially by the gouty diathe- sis.* It is this state of the urine which lays the foundation for a large proportion of the calculi which are occasionally formed in the bladder, or other parts of the urinary organs. We find, by chemical analysis, that the most frequent species of these concretions consist essentially of lithic acid, and that in many others, where the bulk of the calculus is composed of the phosphates, the nucleus consists of lithic acid.-f- (See Calculus.) 4. Phosphatic urine [Ceramuriu.]—This, when considered in its chemical relations, may be regarded as the opposite state to the lithic, con- sisting essentially in an excess of the phosphoric salts, and essentially of the phosphates of lime and of magnesia, with a comparative deficiency of the lithic acid. Hence it is characterized by the de- position of the phosphates in the form of a sedi- ment, which is generally white, and of an earthy or chalky appearance, although occasionally as- suming the crystalline state. The chemical con- stitution of the phosphatic urine appears to differ considerably in different cases, all of which, how- ever, agree in the characteristic circumstance of the excess of the phosphoric salts. Sometimes there is a deficiency of the urine in proportion to the saline ingredients, and at other times there is an absolute deficiency of both the urea and the salts, reducing the urine to the aqueous state, but still maintaining the relative excess of the phos- phates. The pathological condition of the system which produces the phosphatic urine is less easily cha- racterized than the lithic, as it would appear that a variety of circumstances, which have no very obvious connection with each other, both of a con- stitutional and a local nature, agree in producing this morbid change in the state of the urine. The phosphatic urine is frequently observed in sickly and ill-fed children, in those that inherit a scrofu- lous constitution, or where we have reason to sus- pect the existence of diseased mesenteric glands. Again, in the decline of life we find that various circumstances, which contribute to break down the constitution, and affect the digestive and assimila- tive functions, diseases of the glandular system, and especially local injuries of the parts contigu- ous to the kidney, are among the frequent causes or concomitants of the phosphatic urine. It would appear also to be produced by mechanical irritation of the bladder; for it has been observed that a considerable number of the calculi, which are principally composed of the phosphates, pos- sess a nucleus of lithic acid, or some substance * We are indebted to Wollaston for the discovery of the chemical nature of the gouty concretions, which had been previously termed chalk stones, as consisting of the lithate of soda. Phil. Trans, for 1797, p. 389. These bo- dies had been previously examined by Berthollet; but it j appears that this eminent chemist, who on most occa- sions is so remarkable for his accuracy, in this instance proceeded rather upon theory than actual experiment. He supposed that the urine of gouty patients was defi- cient in phosphoric acid, and that the acid was deposited in the joints in combination with lime. Journ. Phys. t. xxviii. p. 275. In connection with the subject of gouty urine we may refer to the work of Sir C. Scudamore, who performed a series of experiments on this subject. t Fourcroy and Vauquelin, Ann. Chim. t. xxxii. p. 217; Philip, Trans. Coll. Phys. v. vi. p. 170; Pearson, in Phil. Trans, for 1798, p. 38; Marcet, ch. v.; Prout's Inq. p. 95 et seq; Henry, Med. Chir. Trans, v. x. p. I'M; Smith, Med. Chir. Trans, v. xi. p. 10; Egan, in Tilloch's Phil. Mag. v. xxiii p. 199 et seq. which has been accidentally introduced into the bladder, and which appears, by its action upon that organ, to have contributed to the production of the excess of the phosphates, and their conse- quent deposition. As in the case of the lithic urine, so the phosphatic is sometimes connected with the purpuric state, thus affording deposits of various shades of colour.^ We also find that the lithic and the phosphatic urine not unfrequently alternate with each other: it is this state of things which gives rise to one of the species of calculi which have been termed, from their me- chanical formation, alternating. (Marcet, pp. 59, 96.) Upon the whole, we must consider the phosphatic urine as indicating a greater derange- ment of the system, and one which is less under the influence of curative means, than the lithic.§ 5. Purpuric urine [Porphururia], — This is characterized by the colour of its deposit, which, in its ordinary state, has obtained the name of the lateritious sediment. It was recognised as the in- dication and concomitant of the febrile state of the constitution, among the earliest observations that were made on this fluid, and one which has always been regarded as among the most decisive pathognomonic symptoms of an increased action of the arterial system. The first attempt to ascer- tain the immediate cause of the change of the urine appears to have been made by Proust, (Ann. Chim. t. xxxvi. p. 265-9,) but not with any great success, as he does not appear either to have ascertained the exact nature of the change, or the means by which it is effected. For the more cor- rect information which we possess on the subject, we are indebted to Dr. Prout, who investigated it with his accustomed acuteness, and proved that a new substance, possessing the properties of an acid, is produced in the urine, which, from the colour of its combinations with the alkaline bases, he termed the purpuric acid. (Phil. Trans, for 1818, p. 420 et seq., and Med. Chirurg. Trans. vol. ix. p. 481, 2.) He also rendered it probable that all the shades of colour which were observed in the urinary deposits, from reddish brown to pink and purple, may be referred to the mixture of the purpuric with the lithic acid, or with the phosphates of lime and magnesia. With respect to the pathology of the purpuric urine, it may be simply characterized as the urine produced by that increased action of the arterial system which constitutes inflammatory fever; which, therefore, may occur either in its simple state, or in combination with the lithic or the phosphatic urine, when any circumstance induces febrile action while either of these states is pre- sent. It has been supposed that the purpuric urine is more immediately connected with the dis- eases of certain of the abdominal viscera, but we conceive there is reason to doubt whether this opinion be tenable, and we undoubtedly find that I The combination of the phosphatic and the purpuric deposits may in most cases be distinguished from that of the lithic and the purpuric, by the latter being linged with the brown colour of the lithic acid, while the former being a mixture of a white and a purple substance, are of a purer pink colour. § Perhaps one of the most valuable parts of Dr. Prout's work in his chapter on what he styles " the phosphatic or alkaline diathesis ;" although, were we inclined lobe hypercritical, we might object to the term alkaline as applied to this state of the urine. URINE, (MORBID STATES OF THE) 587 the purpuric urine exists, in the most marked form, I where we have been unable to discover any traces of local inflammatory action. The existence of the purpuric urine in its various shades and com- binations is almost as frequent an occurrence as the lithic, and is in many cases produced by very slight derangements of the system. But when, on the other hand, it exists in a high degree, and continues for a long time without interruption, it indicates a morbid derangement of the functions, which it is often difficult to remove, and which must be regarded as leading to an unfavourable prognosis. 6. Albuminous urine [Albuminuria] is dis- tinguished by its exhibiting the presence of the proximate principle from which it derives its spe- cific appellation, when the appropriate tests are applied to it. The albumen sometimes exists in so great a quantity as to render the fluid more or less opaque when it is discharged from the blad- der ; but it may be frequently detected in the fluid by exposing it to heat or to certain chemical re-agents, when it is not otherwise visible. It seems to have been first distinctly brought into view by Cruickshank, in the essay to which we have referred above (Rollo on Diabetes, and Til- loch's Phil. Mag. vol. ii. p. 248): it was afterwards very carefully described by Blackall, who consi- dered it as a pathognomonic symptom of a pecu- liar species of dropsy, which, as he conceived, required a specific mode of treatment,* and has more lately been made the subject of consideration by Dr. Bright, in the series of his valuable patho- logical observations.^ So ample an account of these observations, and of the discussions con- nected with them, has been given in the former parts of this work, and more especially in the article Dropsy, that it will be necessary for us to do little more in this place than to refer to them. We shall only remark that the albuminous urine is symptomatic of increased action of the arterial system, connected with visceral derangement; generally of the kidney, (when it is frequently attended by dropsy,) and occasionally of the liver, so as to constitute a very formidable disease. In other instances, however, it would appear to be produced simply by a morbid condition of the di- gestive organs, unconnected with any structural disease, and in this case to be of transient occur- rence, and to be indicative of a slight derangement of the functions. 7. Saccharine urine [Melituria], like the albu- minous, derives its specific name from the presence of the proximate principle which is found to exist in it, and which constitutes the most remarkable pathognomonic symptom of the ordinary form of diabetes. The disease has been very correctly described by the ancients; but although they no- ticed the increased flow of urine, its peculiar con- dition, as containing a quantity of saccharine matter, was first pointed out by Willis. Of late years, since the chemical constitution of the ani- * Observations on Dropsy. We have a judicious critique on this work in the Edin. Med. Journ. vol. ix. p. 334 et seq. fin connection with the account of the albuminous urine, which is contained in Dr. Bright's Medical De- ports, the reader is referred to Dr. Christison's remarks in the Edin. Med. Journ. vol. xxx. p. 107 et seq. and to the observations of Dr. Gregory in vol. xxxix- p. 54 et aeq. mal fluids, both in their healthy and their morbid states, has been more attended to and better under- stood, the saccharine urine of diabetes has been the subject of very numerous experiments. The result appears to be, that the urea is in a great measure deficient, while in its place the kidney secretes a substance which has every property of sugar, both as ascertained by the spontaneous changes which it undergoes, and by the action of chemical re-agents upon it-4 With respect to the pathology of the saccharine urine, we may make the same remark as in the last section, that it has been so fully and ably dis- cussed in the former part of this work in the ac- count of Diabetes, that nothing remains for us but to refer our readers to that article, where they will find detailed every circumstance of importance connected with the peculiar state of the urine, the symptoms and prognosis of the disease, and its treatment. The only point on which we feel it necessary to offer any remark respects the nosolo- gical question, whether it be proper to confine the term diabetes to that state where the urine con- tains sugar, and which has been styled the diabetes mellitus. We have already given it as our opinion that we believe a state of the constitution exists which is intimately connected with the diabetes mellitus, and is indeed frequently the commence- ment or first stage of it, where we have every symptom of the disease, both general and local, except the saccharine state of the urine. As a question of technical nosology, it may be of little importance; but we are disposed to think that, if the practitioner were aware of the possibility of such an occurrence, he might perhaps, in some cases, be able to check the disease at the outset, and prevent it from acquiring the saccharine state, when it becomes so formidable in its symptoms, and so extremely difficult to remove. 8. In this section, devoted to the consideration of the various miscellaneous or incidental circum- stances connected with the state of the urine, we shall merely enumerate some of the substances which are stated to have been occasionally ob- served in this fluid. Of these we may mention blood in its entire state, perhaps, in some instances, the red particles alone, without the other consti- tuents, pus, mucus, bile, and various articles of food or medicine, or rather certain principles im- mediately derived from them. To these we may add certain substances which have not hitherto been noticed among the ordinary constituents of urine, which enter into the composition of some of the urinary calculi, all of which we may pre- sume exist in the urine in some part of its course from the kidney to the urethra. These various occurrences are all of them more or less important, and deserve to be noticed by the pathologist and the practitioner, as indicating the existence of de- rangements, either constitutional or local, and as consequently directing us in our prognosis and guiding us in our treatment. The only general conclusion which we can form on the subject is, that the renal secretion is peculiarly liable to be affected by causes, both internal and external, of t In the eighth volume of the Med. Chir. Trans, p. 537, Dr. Prout has given the analysis of the saccharine urine: see also Chevreul, Ann. Chim. t. xcv. p. 319, and Bostook's Physiol, vol. ii. p. 361. 588 URINE, (MORBID STATES OF THE) — (BLOODY) all descriptions; and that, although the observa- tion of its changes has been frequently resorted to as the means of imposing on the credulity of the vulgar, there is perhaps no one circumstance con- nected with the animal economy, which is more worthy of the attention of the enlightened prac- titioner, and which is more likely to repay his re- searches by affording him an indication of the state of the functions, and of the effect of the cura- tive means by which he endeavours to correct their various morbid states. [In disease, it is often of importance to distin- guish between the substances that cause some of the various colours possessed by the urine: and the following table has been drawn up by Dr. Golding Bird with this view. (Urinary Deposits, &c. p. 24, Lond. 1844.) Eed. A. Purpur- ime. Blood. Brown. C. Concen- tration. Greenish- brown. F. Grass- green. H. Blood. Bile. Excess of Sulphur? Nitric acid pro- duces a deposit of uric acid almost immediately;—no change by heat.— Alcohol digested on the extract ac- quires a fine crim- son colour. Den- sity moderate. Becomes turbid by heat and ni- tric acid, its co- lour changing to brown. The microscope discovers floating blood-discs. Nitric acid pre- cipitates uric acid readily. Density high. The addi- tion of hydrochlo- ric acid to some of the urine pre- viously wanned, produces a crim- son colour. See B. Coagu- lation by heat and nitric acid less marked. A drop of nitric acid allowed to fall in the centre of a thin layer of urine on a white plate, produces a transient play of colours, in which green and pink predominate. See B; occurring in alcaline urine. SeeE; occurring in very acid urine. Unchanged by heat or nitric acid. Portal conges- tion ; it is gene- rally connected with organic mischief of li- ver or spleen. Hemorrhage in some part of the urinary pas- sages. Fever. Obstruction to the escape of bile from the li- ver or gall-blad- der; and the presence of some or all the elements of bile in the circula- tion. Presence of cystine.] J. BoSTOCK. URINE, BLOODY; Hxmaturia, (from o^a, sanguis, and olpla, mingo,) mictus cruentus ,- bloody urine; hemorrhage from the urinary or- gans. The name of hematuria has generally, since the time of Sauvages, been applied to this kind of hemorrhage, but with somewhat different latitude of meaning by different authors.* Ac- cording to its etymological sense, it should be re- stricted to cases in which blood is effused by the * In the nosological system of Vogel, hmmaturia de- notes hemorrhage from the kidneys exclusively; that from the bladder being termed cystirrhagia. Sauvages includes under hxmaturia every discharge of blood from the urinary organs. vessels of the kidneys, ureters, or bladder, and dig. charged along with the urine; excluding from the definition urethral hemorrhage, in which the blood flows by drops or in a continuous stream from the orifice of the urethra, which is not a mictus cru- entus. We shall, in the present article, treat of hematuria in this restricted acceptation, for which we have the authority of Frank ; and, independ> ently of correctness of nomenclature, it is more convenient to adopt this distinction, because ure- thral hemorrhage, both as regards its causes and its treatment, belongs entirely to the province of the surgeon, and its consideration does not there- fore properly come within the plan of this work. Haematuria, therefore, in the sense in which we are to employ the term, includes hemorrhage from the kidneys, ureters, or bladder. The most common cause of such hemorrhage is the irrita- tion or mechanical lesion of the texture of these organs occasioned by calculous formations. Less frequently it is the consequence of other diseases of these organs, as of the malignant degeneration of the kidney termed fungus haematodes, and of various forms of disease or chronic irritation of the bladder. It is also met with as a symptom in some diseases affecting the general system, and particularly in adynamic fevers, confluent small- pox, purpura, and scorbutus. In other instances, its cause is less evident, and it can only be re- ferred to local congestion, as in the case of hsma- turia supervening on suppression of habitual hemorrhoi's in males, or the suppression or cessa- tion of the menses in females. In some cases of this kind, and in others where the hemorrhage has appeared to belong to that class termed constitu- tional, (see Hemorrhage,) it has been observed to recur at regular periods, or at distant and un- certain intervals, without any detriment to the health of the individual. Such cases, however, are of rare occurrence. The existence of idiopathic hematuria was doubted by Cullen ; and the extensive clinical experience of Frank shows it to be at least ex- tremely rare. Out of four thousand patients in the clinical wards of Pavia, only six cases of "spontaneous hsematuria" were observed. In the clinical institution of Vienna, 1913 patients af- forded only a solitary case; and in the general hospital of that city, one only, out of 13,647 deaths, was recorded to have ensued from this disease. (Frank, de Curandis Homin. Morbis, torn. i. pars ii. p. 250.) It should also be kept in mind, as Cullen justly observes, that from the fre- quent obscurity of the causes of hematuria, and especially of the symptoms denoting calculus or other diseases of the kidneys, it may often be sup- posed to be a primary affection, where in reality it depends on an undiscovered cause, and in par- ticular on a calculus, or organic disease, the existence of which is only revealed by dissection. (See Calculous Diseases, and KinuEis, dis- eases of.) The diagnosis of hsematuria consists, first in ascertaining the presence of blood in the urine; and, secondly, when this has been ascertained, in determining the organ from which the hemorrhage proceeds. But our inquiries are incomplete, until we further satisfy ourselves as to the cause, whether of a local or general nature, which gives URINE, (BLOODY) 589 rise to the hematuria; as on the knowledge of this, the rational indications of treatment will chiefly depend. Bipod is met with in the urine in large or small quantity, fluid or coagulated, more or less in- timately mixed with the urine, and sometimes accompanied with pus, mucus, or calculous de- posits, according to the circumstances in which the hemorrhage takes place, and the organ from which it proceeds. When the blood is in con- siderable quantity, and separates readily from the urine, there can never occur any difficulty in recognising its presence. When the proportion of blood is scanty, and it is intimately blended with the urine, or when its fibrin and colouring matter are deposited in an altered condition, some attention and care will be requisite to discriminate between the appearances which it presents and those which arise from morbid changes in the constituents of the urine. When this fluid is of a deep or reddish colour, in consequence of the excess of its saline ingredients, and especially of lithic acid, it is transparent when expelled from the bladder, and becomes turbid on cooling. Blood, on the contrary, in however small quantity, renders the urine less transparent from the first; and the application of heat, instead of restoring its transparency, coagulates the albu- minous portion of the blood. A reddish tinge, easily to be recognised, is imparted to a piece of linen immersed in the urine, if it contains even a small quantity of blood. These simple tests will, in general, prove with sufficient accuracy the presence of blood in the urine, and supersede the necessity of any more elaborate chemical investiga- tion. When blood is poured out in small quan- tities by the kidney, it is sometimes coagulated in the ureter, and is found in the urine in the form of threads or tubes of fibrin, moulded to the shape of that canal, and which have not unfrequently been mistaken for worms. It has also occasionally happened that a bulky coagulum has been formed in the bladder, occasioning sensations of weight and uneasiness referable to that organ, and some- times giving rise to retention of urine. We now proceed to the next step in the diag- nosis, the investigation of the symptoms which denote the hemorrhage to have proceeded from the kidney, ureter, or bladder respectively, and of the causes on which hemorrhage from each of these organs more particularly depends. Hemorrhage from the kidney, it is probable, scarcely ever takes place except in consequence of calculus or organic disease. It has already been noticed, that the symptoms of renal disease are frequently so obscure as not to lead the prac- titioner to a knowledge of its existence. But where there is reason to believe that calculus or any other disease of the kidney exists, and hsema- turia suddenly occurs after any violent exertion, or after exercise which particularly affects the muscles of the loins, as riding on horseback or in a carriage, it may be suspected to have its source in the kidney, especially if the flow of blood be copious, and if it be generally diffused through the urine, particularly if the bladder does not appear to labour under any disease. Hemorrhage from the ureter probably never takes place except in consequence of the passage of a cal- 2z cuius, or its becoming impacted in some part of this canal, in which case it will be attended by the symptoms which denote the descent of a calculus, viz. nausea, vomiting, rigors, pain shooting down in the direction of the ureter towards the thigh, and retraction of the testicle. Hemorrhage from the bladder is of more frequent occurrence, as this viscus is liable to be affected by more numerous causes of disease. When a calculus is lodged in the bladder, particularly if its surface is rough, and when it lies loose in the cavity, it is very liable, on any motion of the body, to produce abrasion of the vascular mucous mem- brane, and consequent hemorrhage. When it has remained in the bladder for some time, its irri- tation causes an abundant secretion of glairy mu- cus, which in some degree defends the membrane, and renders hsematuria a less frequent accident. The calculus becoming fixed, either from its large size, or from the formation of a cyst, it is also less liable to excite hemorrhage. (See Calculous Diseases.) The symptoms denoting the existence of a -cal- culus in the bladder are too distinct to leave any doubt as to the nature and seat of hsematuria pro- ceeding from this cause. In other diseases of the bladder, such as the fungous excrescences de- scribed by Dr. Baillie, and in the different forms of chronic cystitis, or, as it has been usually termed, catarrhus vesicx, the urine is not unfre- quently tinged with blood; but no considerable hemorrhage occurs in these cases. (See Cysti- tis.) The hsematuria which occurs in conse- quence of suppressed hemorrhoid, or from other constitutional causes, most probably takes place from the mucous membrane of the bladder, though in such cases there are no symptoms indicating an affection of this organ. In fevers, purpura, &c, the blood may be poured out by the vessels both of the bladder and of the kidneys, and it is the result of a general hemorrhagic tendency ; but it probably proceeds chiefly from the extensive mucous surface of the bladder. The name of hemorrho'ides vesicx was given by the older writ- ers to a form of hematuria occurring in hemor- rhoidal subjects, attended with symptoms of pain- ful congestion around the neck of the bladder, which are relieved by the occasional or periodical occurrence of hemorrhage. It was considered by Frank as a milder form of chronic cystitis. From what has now been stated respecting the causes and symptoms of renal and vesical hsema- turia, it may be understood that, unless there exist evident symptoms of a morbid affection of the kid- ney or bladder respectively, it will often be difficult to determine from which of these organs the he- morrhage proceeds. Affections of the kidney, even of the most serious kind, are often, as we have seen, unattended by evident symptoms. From the greater sensibility, as well as the more super- ficial situation of the bladder, its diseases are more easily recognised. We must, however, in all cases, keep in mind the sympathy which prevails between all the parts of the urinary system, and the readiness with which not only the sensations of pain, heat, weight, &c, which indicate disease, but also disease itself, is propagated from one part of this system of organs to another. Hence, even where the symptoms appear to indicate the blad 590 URINE, (BLOODY) der or the kidney respectively to be the seat of the hemorrhage, we cannot draw from them a certain conclusion. Provided, however, that the state of the constitution, and the cause of the hemorrhagej as far as this can be ascertained, be kept in view, this uncertainty will not be attended with any material difficulty or disadvantage with regard to the treatment. The predisposing and exciting causes of haematuria are mostly referable to those of the local or constitutional diseases of which it is a symptom. General plethora, and the other com- mon causes of hemorrhage; hereditary predisposi- tion to calculous complaints, or to hemorrhoidal congestion; intemperance; hard riding ; hot cli- mates ; excessive venereal indulgences; may be enumerated among the most usual predisposing causes of hsematuria. The exciting cause, in cal- culous cases, is commonly over-exertion, or long- continued exercise affecting the loins or pelvis, especially riding on horseback, or the motion of a carriage over rough roads or pavements. The same causes, perhaps, sometimes excite hsematu- ria, where no calculous complaint exists. Con- tusions or penetrating wounds, in which the uri- nary organs are implicated ; the wounding of the bladder by a sound or other instrument rashly or unskilfully introduced ; acrid substances received into the stomach, particularly those which have a specific action on the urinary organs, as cantha- des and turpentine; all these act as occasional causes of hsematuria. Both sexes are liable to hsematuria; but males are more generally exposed to the action of the causes which produce it. It never occurs in young children, except in conse- quence of a calculus. It is chiefly an affection of middle life, though in its more chronic forms old men are subject to it, from their proneness to disease of the bladder. Prognosis*—Hematuria, when it arises from any slight occasional cause, or when it appears to be vicarious of a suppressed constitutional hemor- rhois, is not attended with danger. Instances are related of its having proved fatal from the profuse- ness of the hemorrhage; but such are exceedingly rare. Yet in old and enfeebled subjects, it must be considered an unfavourable occurrence. In febrile diseases, it has perhaps sometimes occurred as a salutary crisis; but much more frequently, especially in adynamic fevers and confluent small- pox, it denotes serious lesion of the vital powers, and is a symptom of the most unfavourable cha- racter. In purpura, it seems to have in some instances proved salutary, or at least to have been followed by recovery; but where the prostration of strength is great, and much previous hemor- rhage has occurred, it is a symptom of great dan- ger. When hsematuria arises from calculus, the prognosis will necessarily depend on the circum- stances of the primary disease. When it is de- pendent on organic disease of the kidney or blad- der, we need not add that the case is hopeless. Treatment.—In most cases of hsematuria, the treatment must be almost exclusively directed to the primary disorder. When it appears as a constitutional hemorrhage, it does not, unless it becomes excessive, require the interference of medicine. When it arises from suppressed haemor- rhois or interrupted menstruation, it will be best combated by having recourse to the most effectual and safe means of restoring these evacuations. When there is evidence of general plethora, or of an inflammatory diathesis, venesection, mild purga- tives, and an antiphlogistic regimen will of course be advisable. Topical bloodletting, by cupping or leeches, will be proper where the symptoms of local congestion or irritation are considerable, though they do not amount to actual inflamma- tion. In all cases of this kind, copious draughts of diluent liquids will be beneficial, but especially in calculous cases, and in those in which hssmaturia has been occasioned by the ingestion of acrid sub- stances, such as cantharides. Rest, or the gentlest exercise on foot, are to be enjoined in all, but es- pecially in calculous cases; and the greatest caution as to exercise, especially on horseback, should be recommended to patients who have suffered from calculous hsematuria. When the discharge is pro- fuse, has continued for some time, and has put on a passive character, astringents must be resorted to as in other cases of passive hemorrhage. Of internal astringents, Dr. Elliotson gives a decided preference to oil of turpentine in moderate doses, as from twenty to thirty drops every four or six hours. He does not hesitate to employ this remedy, even in cases of hsematuria connected with organic disease of the kidney ; combining it with opiates to allay irritation and pain, and to procure rest. (Medical Gazette, xii. 723.) [The iodide of iron may be found, in such cases, a valuable agent. It possesses not only tonic properties, but adds to the coagulability of the blood,—increases, in other words, the action of the system of nutrition of the vessels, and prevents their parietes from being so permeable; and, by increasing the consistence of the blood, renders it less penetrative. The tincture of chloride of iron has likewise been strongly recommended in such cases.] In this, as in other forms of passive hemorrhage, it will be essential to employ proper means of sup- porting the strength of the patient. Where the profuseness of the hemorrhage requires more powerful means to arrest it, which is not often likely to be the case, the administration of enemata of cold water, and the application of cold water and vinegar to the loins and pubis, will be proper, if employed with due moderation and caution. When the blood has coagulated in the bladder, and forms an obstacle to the passage of the urine, it will be necessary to have recourse to surgical aid for its removal. This must be attempted in the first instance by the introduction of a catheter of large size ; and if this expedient is not success- ful, tepid water should be injected into the bladder, to break up and dissolve the coagulum. George Goldie. URTICARIA. An exanthematous eruption of the skin, so called from the resemblance which its patches or wheals bear to those produced by the contact of the common nettle, (urtica dioica)- This is now accepted generally as the classical appellation, but the disease is distinguished in authors by various titles. The Arabians first called it essera, or rather, according to Good, eshera, a word which has descended to recent times, and been employed for its designation by URTICARIA. 591 Heberden and Underwood. It is the febris urticata l division which, we may remark, is founded on of Vogel, purpura urticata of Juncker and the ; three distinct pathological conditions. In other scarlatina urticata of Sauvages. The French articles on cutaneous disease, (see Lepra, Liches, commonly denominate it fievre ortiie or porce- and Scabies,) we have given reasons for adopting laine; and its German name, Nesselauschlag, is ! the specific divisions as well as the general arrange- synonymous with our vulgar English, nettle-rash, ment of Willan. He resolved urticaria into six Urticaria is an affection very distinct in its species, for which division, (admitting, as we have phenomena and history, from other diseases of the ; done, the advantage of his principle,) we find no skin, and especially from those called exanthema lous. Its general characteristic is an assemblage of large patches somewhat elevated above the skin, and contrasting with the latter by a pale red colour. These elevated patches have in their centre a white speck, resembling a flat vesicle, and by running into each other form what are called wheals, the appearance of which is ac- companied by an intense itching and tingling heat, entirely similar to that produced by the stinging of nettles. The disposition of the patches is irregular; at one time they affect a round form with well-defined edges; at another they run out into long streaks, and occasionally they form con- siderable knobby swellings which disfigure the face, and produce alarming symptoms by the tumefaction and pressure of the skin of the neck. The invasion of the eruption is for the most part sudden, and its duration indeterminate ; the indi- vidual patches are generally fugitive, fading and reviving often in the course of a few hours. It is not communicable by contagion, and is for the most part secondary to irritation in the stomach and alimentary canal, although in some cases this cannot be established. The fever which most frequently accompanies it is of a remittent type, and is very varied in its acuteness. The circumstance which is probably of the greatest importance in considering the nosological division of uticaria, is the being accompanied, or not, with fever. There are, however, many other phenomena comprehended in its history, which deserve to be prominently distinguished. The different writers of authority who have treated of this disease, have seized, some on one and some on another of these phenomena as the basis of their arrangement, but they are all referable to differences in the form and disposition and the duration of the eruption. J. P. Frank recognises fever as a dis- criminating condition worthy of attention ; but considering the uncertainty of its presence, and the variety of its character, he gives it no place in his division, which he founds entirely upon the form of the exanthem. He comprises its descrip- tion under three species, viz. urticaria maculosa, vesicularis, and tuberosa. Rayer, whose work appears to us to be founded chiefly on the labours of Willan and Bateman, generally modifies their subdivisions. He has accordingly given its history without observing any specific distinction, or only alluding to them en passant. Mr. Plumbe, whose plan is so widely different from the artificial method, makes his also one gen eral description necessity for substituting any other. Urticaria febrilis. --------evanida. perstans. — conferta. — subcutanea. tuberosa. They have all some distinctive marks, which entitle them to a separate notice; and although, if we judge rigidly, it must be confessed that some of them stand on a weak support to constitute species, yet there is a great facility afforded to the description and to the study of the disease by this subdivision ; and, moreover, it seems to us that by contracting it we deprive ourselves of the chief benefit of an artificial arrangement, some sort of which, however, by the practical admission of all accurate authors, is indispensable to the faithful delineation of the disease. Urticaria Febrilis, Febrile Nettlerash.—The eruption of this form generally consists of wheals arising in the midst of'irregular patches of a red efflorescence. In other instances, there appears only a rash of crimson papula?, not unlike the form of those of lichen, but deeper in colour. It is for the most part defined by the elevation of the patch above the rest of the surface, and circum- scribed by a border caused by the swelling of the skin within the inflamed area. The appearance of the rash is accompanied by great heat and itch- ing, which incommodes the patient, especially during the night, or on exposing the parts to cold air; for it seems to be a peculiarity of this erup- tion, as remarked by Vogel, that it comes out more in the cold, and is rather allayed by heat. Before the rash makes its appearance, the indi- vidual is affected for two days or more with head- ach and languor, together with pains in the limbs, slight shiverings, and sickness in the stomach. The anxiety and oppression are, in some cases, exceedingly great; and not uncommonly, in severe cases, syncope takes place. The feverish symp- toms, particularly the pain and sickness of the stomach, are invariably mitigated by the coming out of the eruption; and throughout the course of the disease there generally exists an inverse pro- portion between the internal disorder and the cu- taneous exanthem. During the day-time, the fever as well as the eruption mostly subsides; but on the return of the evening, both re-appear, and con- tinue during the night, which is spent in restless- ness and anxiety, on account of the heat and itching. While the febrile action is present, the He testifies, however, to the pulse is full and frequent, but seldom strong ; and utility of Willan's arrangement, and subjoins the \ during the remission it sometimes sinks evenbelow consideration of urticaria according to his species, the healthy standard. In the work of Cazenave and Schedel, derived j The extent of the eruption is indefinite; it ap- mainly from Biett's lectures, the classification of pears and disappears on different parts of the body Willan is preserved, with this difference, that the irregularly, one day affecting the extremities, and six species of the latter are compressed to three, the next the face and neck, or the chest and belly; viz. urticaria febrilis, evanida, and tuberosa,—a j and indeed, while the fever lasts, it may be excited 592 URTICARIA. by friction or scratching on the parts where it had not previously shown itself. The ordinary dura- tion of the disease is six or seven days, at the conclusion of which period the feverish symptoms have ceased to recur in the evening. It is no un- common case for the malady to be abruptly termi- nated about this time by a copious sweat; and we have observed a slight discharge of blood by stool to have apparently the same critical effect. The final disappearance of the eruption is generally suc- ceeded by a slight exfoliation of the cuticle. Febrile nettlerash may occur at all ages. It most usually affects young persons, especially those of a fine and delicate skin, and those whose occu- pations are of a sedentary nature. In adults it often occurs amongst those who indulge in the gratifications of the table; and it is observed that moral affections, such as grief and anxiety, render those of a nervous temperament liable to it. Un- derwood (Diseases of Children;) says that it fre- quently occurs in children under two years of age. They continue screaming for some time before the cause is discovered, when, upon examining the body and the lower limbs, they are found covered with large wheals: the fever, however, is much less in them than in adults, and the whole affection shorter in its duration. The disease has been oc- casionally observed to assume an intermittent form, and to be accompanied with severe symptoms. In cases detailed by Bricheteau, (Journal compl. des Sc. Med. tome xxxvii. p. 266,) the tertian type was so accurately presented, that it appeared doubt- ful whether the primitive disease was really urti- caria, or whether the cutaneous eruption which appeared and departed with the intermittent par- oxysm, was not to be considered as a mere epi- phenomenon to the latter. The question is not without pathological interest, but it does not add any difficulty to practice, as the treatment which is proper for the affection is precisely that which is most efficacious against ague. This febrile species of nettlerash appears to have been regarded by authors as the type of the disease. It is it more particularly which Juncker, Sauvages, and Vogel, intended in their description under the names we have before mentioned. It corresponds with the maculosa of Frank, and is the same which Sydenham described under the title febris erysipelatosa~ The remarkable form of urticaria which is pro- duced by the use of certain articles of food, espe- cially some kinds of fish, is usually described by authors under this species. It agrees with it, in- deed, in the existence of fever, and the bare enu- meration of symptoms is not much different. They possess, however, a much greater intensity of character than in the common febrile nettlerash, and the general features of the affection are so much modified by the exciting cause, that it de- mands a distinct notice. Wo shall, therefore, advert to it in connection with its source, when considering the causes of urticaria. Urticaria Evanida: evanescent nettlerash.— The regularity of an exanthem is entirely want- ing in this species, and it is unaccompanied by fever. The eruption consists of rounded wheals, which sometimes extend in long streaks, resem- bling those produced by flagellation. These ap- pear at irregular intervals, sometimes in one situ- ation, sometimes in another; but probably the face and arms are most frequently affected with it. They disappear at the end of a few hours, but arc easily reproduced by change of temperature, ex- ercise, or other trivial causes. Their colour scarcely differs from that of the general skin, and they do not rest upon a red base like those of the febrile urticaria. A violent itching attends the eruption, which is most troublesome on undressing. A case is in our memory in which it used to come out in the head of a boy during the night for some time, and caused such excessive irritation by its tingling heat, that the bed-hour was dreaded by the young patient. He used to start out of sleep, violently scratching his head, and rolling his eyes wildly, he would exclaim that " his head was bursting," and that he should " go mad." This species of nettlerash is usually a chronic affection, but the greatest diversity obtains with respect to its duration. It may be dispersed in two or three days, or last for months and even years. Heberden (Commentarii,p. 132,ed. Frankf, ad. Msen. 1804,) relates that he has observed it continue with few intermissions for two, in some seven, and in others for ten years. While neither age nor sex is exempt from it, females and young men of a sanguine temperament and soft skin are more liable to it. In itself it can be said to pro- duce no disturbance except what arises from the pruritus, but those affected with it arc likewise liable to suffer from headach, languor, and flying pains, which have no more connection with the urticaria than that they are generally all symp- toms of a disordered state of the chylopoietic vis- cera. Urticaria Perstans: stationary nettlebrash. —Except in the unimportant circumstance that the wheals of this species are permanent, while those of the evanida depart and return frequently during the course of the disease, there is little dif- ference between them. It is to be remarked, how- ever, that it is much more easily eradicated than the former species, and these characteristics we think sufficiently justify Willan in allotting it a separate position. Urticaria Confcrta t confluent nettlerash.— The eruption belonging to this species is similar in form to that of the febrile nettlerash, but the wheals are surrounded by a more inflamed base, As its name implies, moreover, they coalesce in many situations, and form irregular figures. These marks, however, would have been by no means a sufficient reason for their separation, if this were not decidedly afforded by the absence of the ex- anthematic fever in the conferta, which is the peculiar character of the febrilis, and by its chronic duration. Bateman affirms that it " chiefly affects persons above forty years of age, who have a dry and swarthy skin, and seems to originate from violent exercise, or from indulgence in rich food and spirituous liquors." Urticaria Subcutauca i sabcutaneous nettle- rash.—This is a form of the affection which « accompanied by the tingling and stinging of the other species, but it differs from them in this re- markable particular, that no eruption of wheals appears. Although we have adopted Willan i appellation, it does not seem to be warranted, fo' there is no proof that any rash makes its appear- URTICARIA. 593 ance under the skin more than on its surface. Urticaria latens would have more correctly de- signated this species, if it were indeed necessary to distinguish it from the former on account of the non-appearance of the cutaneous rash. A similar deviation occurs not unfrequently in scar- latina, and probably in the other exanthemata; but in this it is a more striking circumstance, inas- much as the heat and stinging is not less trouble- some (sometimes resembling the pricks of needles) than in the cases which present the most vivid eruption to the eye. Urticaria Tuberosa: tumid nettlerash.—This is a rare form of the disease, but one which, from its severity and peculiar symptoms, was properly distinguished from the others by Frank. It is characterized by the eruption of red swollen patches, of the breadth of the hand, accompanied by a pruritus of such an intolerable severity as sometimes to cause fainting. They rapidly in- crease, and take the form of tuberosities of con- siderable size, which extend deeply, and are so tense and hard as to interfere with free motion, for they generally spread to a great extent over the whole surface, commencing often on the face, and affecting more particularly the inferior extremities. The tuberosities come out in the evening, con- tinue during the night, and disappear in the morn- ing, leaving the patient weak and sore, " as if he had been bruised or much fatigued by exercise." They have the same property of being increased by exposure to cold air, and diminished by the heat of bed, as the wheals of the other forms of urticaria. This species is accompanied by much general disorder. It occurs usually in those addicted to excesses at table, either in eating or drinking, and has been observed to succeed rapidly upon a de- bauch. During the coming out of the swellings, a smart rigor and much anxiety are generally pre- sent. Cases are recorded in which the erethism of the skin proceeded to such a pitch as to threaten rapid suffocation by the tumefaction of the neck and chest, which at once caused compression of the trachea, constriction of the motions of the tho- rax, and disturbance of the action of the heart and larger vessels. Its duration is not to be defined : in some instances it may be got rid of by proper treatment, in the course of one or two days ; but as it occurs commonly in constitutions impaired by excess, it is more frequently a tedious and ob- stinate affection. Causes. — As a general fact, it may be stated that urticaria is always secondary to some internal irritation, of which, for the most part, the seat is the stomach and bowels. In children it is often connected with those disorders of the latter which are produced by dentition. The same principle is true with respect to its occurrence in adults, in whom also it can be usually traced to some cause producing temporary irritation in the stomach. We are inclined to doubt that it has ever been, properly sjieaking, idiopathic, although in some persons of very irritable skin, and in spring and summer, when its functions and sympathies are in increased activity, an amount of internal disor- der almost imperceptible may be sufficient to give rise to it. It has been known to occur also as a symptom of cancer of the uterus, and other internal Vol. IV. —75 2z* diseases. We should state, however, that Good considered that it sometimes did arise idiopathic- ally, and that Heberden was inclined to believe that the skin itself is often the chief seat of the disorder, and that the stomach and the system only suffer secondarily. (Study of Medicine, vol. iii. p. 36.) It is never contagious. It is well known that urticaria often originates from the taking into the stomach certain sub- stances to which it has been unaccustomed, or which seem to operate upon some idiosyncrasy of the individual. To this must be referred the oc- currence of it from the use of valerian and some other articles of the materia medica, and also after certain articles of aliment, as cucumbers, mush- rooms, almonds, honey, &c. The connection be- tween such substances and the nettlerash is not at present ascertainable; it is worth remarking, however, with respect to the subject, that there are individuals of highly excitable temperaments, who are liable to sympathetic affections of a pecu- liar nature from certain impressions on their ner- vous system, and that the nettlerash is observed to occur amongst those. Dr. Autenrieth notices this subject, and illustrates it by some cases, and especially by a remarkable one, which has an im- mediate reference to the matter alluded to. He knew a woman who was possessed of such un- common irritability that the application of a sina- pism threw her into a violent fever, with an erup- tion of bullse over the whole body ; the sting of a bee produced a terrible cutaneous swelling, with such an affection of the spirits, that she wept the whole day ; and finally, on eating crabs, or other fish, or even potatoes, she was attacked with fever, accompanied by general erysipelatous inflamma- tion* and profound languor. It arises, however, so frequently after some kinds of fish are partaken of, that they must de- cidedly be reckoned as exciting causes, independ- ent of individual predisposition. A great variety might be mentioned as having been known to produce it, but that which by universal observa- tion stands most in connection with it is the mussel. After this may be enumerated lobsters, crabs, mackarel, salmon, some species of pike, tench, carp, and barbel. Many of the tropical fishes have this property also in a very intense degree, as the kingfish, the yellow-billed sprat, barracuda, porgee, the Otaheite eel, &c. The action of many of these on the economy is so in- jurious that the urticaria which follows is to be regarded as amongst the less severe symptoms : and with respect to the nature of the deleterious influence which the fish exerts, a little acquaint- ance with the history of its effects makes us accede to the universal opinion that it is a genuine poi- son. This, indeed, has been long known; the only question agitated for many years has been, what constitutes the poisonous qualities of such fish. It was referred at one time to a diseased condition of the fish; at another a chemical ex- * Autenrieth, Ueber das Gift der Fische. Tubingen, 1P33, p. 116. We give here the words of the author, but that he means nettlerash we have no doubt. In other places he uses ambiguous phrases where it is decidedly intended ; and again, we find that the word Rothlaufs- entzxindung is often freely employed to signify any efflo- rescence of the skin with heat, itching, and fever. See Raimann'g Pathologic und Therapie, v. I. p. 4DG. 594 URTICARIA. planation was proposed, namely, that it depended on the impregnation of the fish with copper. Some writers believed it a sufficient explanation to refer it to a putrefactive state of the fish, and others considered that the deleterious principle was contained in some of its secretions, or in some particular organ. The most recent investi- gator of the subject is Autenrieth, and although the composition and origin of fish-poison still re- main a mystery, his researches are an approxima- tion to the truth, and tend much to clear away error. We refer to his work for several interest- ing details, and must be content here to give the conclusion he arrives at. Having traced its ana- logy with old cheese and rancid sausages in smell, taste, and effects, he concludes that the poisonous property of fish is contained in a bitter principle which is found in combination with a fatty matter in the fish, usually passed into a state of rancidity, and he compares the connection between this bitter and the fatty matter to that which subsists between pyroligneous acid and its bitter principle (kreosote), or between prussic acid and the vola- tile oil of bitter almonds. This appears to exist in some fish before death, in others only when decomposition has already commenced. It is also established that most of the fish are only poison- ous at particular seasons of the year, which is found in some to be the spawning time,—a fact which must have the same explanation as that in many fish only certain organs are poisonous, and those are invariably found to be the parts in which oily matter most richly abounds. We add that it seems probable that the deleterious influence of animal substances in general in a state of putre- faction may be owing to the development of this poisonous fatty principle, as their pathological effects are strikingly similar to that of fish-poison. In considering the operation offish-poison, Auten- rieth divides it into three forms, which may be called the choleric, the eruptive or urticose form, and the paralytic or collapse form. The first two of these consist of those cases in which the im- pression of the poison is followed by a violent re- action of the general system, and they differ from each other in that the first exhibits its effects mainly in the internal organs, especially the sto- mach and bowels, while the second manifests itself upon the cutaneous periphery. The third form is named paralytic or collapse, because in it the poison acts with such intensity on the nervous system as to take away all power of reaction, so that the patient sinks under a gradual exhaustion of the vital powers. It is beside our purpose to proceed further; but as we did not describe the peculiar characters of urticaria arising from fish- poisons in the general history, we subjoin here a sketch of its symptoms as constituting the second or eruptive form of Autenrieth:— " The phenomena commence usually a short time after the repast which causes them, and are ushered in by a sudden and vehement excitation ! of the vascular system, with a remarkable rushing ©f blood to the head. Whilst the carotids pulsate and the eyes grow red and turgid with fluid, the J patient becomes affected with giddiness and the' most violent and rending pain in the head. The eyes roll wildly in their orbits, and the eyelids are held spasmodically open. At the same time the I face swells up, as do the buttocks and the Kmbs, and a scarlet redness or an urticose eruption over lays the whole body, accompanied with severe burning itching. In rare instances large vesicles or bullse rise upon the skin. The patient perhapa plunges his hands into cold water to mitigate the heat, but each time he does so he experiences a peculiar stinging or prickling in them, and also in the nose. With this eruption at one time is com- bined fever with hard frequent pulse, tightness of the chest, and general shivering; at another violent pains in the limbs or the back, or on the other hand, with loss of sensation, and even total immobility of the limbs. The inner surface of the body also takes a part in the morbid excite- ment, although in a much less degree in this the eruptive than in the choleric form of the affection. Pains in the stomach and bowels soon set in, which are followed by griping, purging, and vomiting. For the most part in the milder cases, when these evacuations take place, the erethism of the vessels gradually subsides, the cutaneous swelling sinks, the pulse loses its hardness and becomes smaller, and at length a favourable sweat comes, which puts an end to this short malady. It is frequently followed by exfoliation of the cuticle." In the cases, however, which occur after the partaking of the poisonous fish of the hot climates, the recovery is not so rapid, and the disease of a much deeper cast. " For besides that the fore- mentioned symptoms are far severer, the heat and itching being intolerable, and the eruption of an erythematous form, and the giddiness increased to a vertiginous reeling, still further phenomena ap- pear. Dreadful cramps in the limbs and in the intestines rack the patient; a peculiar constriction with a prickling heat occurs in the pharynx, and a painful tenesmus, with strangury and retention of urine, supervene. To these in some instances is added an icteroid hue of the skin and urine, and even the sweat is known to stain the linen. But what is perhaps the most oppressive to the patient are the shooting pains in the swollen knee- joints, wrists, and the instep, and in the periosteum of the cylindrical bones. When he has, under these symptoms, for a long time vibrated between life and death, their violence at length diminishes, and when this occurs the skin peels off in several places, the hairs fall out, and even the nails drop. Occasionally abscesses form under the skin, which, although coming at the close of the disease, have not the same critical importance as those which are so favourable a termination to typhus; and they appear to be rather a purulent dissolution of the cellular tissue under the skin than a regulnr phlegmonous abscess." (Autenrieth, Op. cit. p. 131.) Even this laborious recovery, however, sometimes fails, and the patient sinks rapidly un- der the violence of the symptoms, or else, having made a rally through them, dies exhausted by the weakness succeeding them, which is in some cases aggravated by excessive suppuration of the skin. After death the stomach and pharynx have presented marks of a high state of inflammation. Diagnosis. — It is not a difficult matter to dis- criminate between urticaria and other cutaneous eruptions, yet while this is the case, it is necessary to be well versed in the distinguishing marks on URTICARIA 595 which its diagnosis rests, as instances occur in which it is important. Those are furnished by the characteristic form of wheals which the erup- tion assumes, by the peculiar stinging heat of its pruritus, and by its fugitive character. There exists a possibility of confounding it with the other exanthematous diseases, rubeola, scarlatina, and erythema. This, we apprehend, however, could only occur through inattention ; therefore it only requires to refer to the wide dif- ference which the characteristics of the latter pre- sent in contrast with those we have just laid down as belonging to urticaria, at the same time in- timating that error would be prejudicial both to the patient and the physician. Two forms of erythema, the paputatum and nodosum, have been noted as presenting some characters which might impose on the observer at the first glance. But besides the papular nature of the first, in contrast with the wheals, it is to be remembered that erythema is not fugitive or remittent in its progress, but continuous ; and examination of the papula; discloses the violet tint, which is never present in any variation of urticaria; although, as we have seen, the febrilis sometimes presents pa- pulse instead of wheals. The elevated nodosities of the erythema nodosum have nothing in com- mon with any form except the urticaria tuberosa, in which also the skin is raised into tuberosities. The external character of these, however, is en- tirely different; the erythema presents scattered isolated swellings, while those of this form of net- tlerash are aggregated, and rising in the midst of the swollen skin; but a reference to the severe symptoms which accompany the latter will furnish at once a decisive criterion. A species of lichen, the urticatus, has also been contrasted with it for the sake of diagnosis. Its papula; are round, small, and little elevated ; they are also firmer under the finger, and their colour is deeper. Their chief distinction is, however, their persistent character, as it is this which ren- ders it at all desirable to separate this affection from urticaria, with which in other respects, as its name implies, it has much affinity. With respect to the diagnosis of that more severe variety of the disease which arises from fish poison, the circumstances under which it occurs, and the symptoms to which it gives rise, will sufficiently protect it from being confounded with any other disease. It is of much importance, however, that no obscurity should exist with regard to it, for it happens that the only affections which resemble it are the effects of the mineral poisons, arsenic or copper, or else the disease of which symptoms are not very dissimilar to the latter — cholera. The possibility of confounding it with the former was indeed proved by a legal case, in which a woman was suspected of having administered poison to her husband, who died suddenly after eating mussels. (Bateman's Sy- nopsis, p. 132, note.) Prognosis and treatment. — In its ordinary forms, urticaria is not attended with danger ; but instances occur in which it becomes a very severe affection, and may take a dangerous turn. We are not acquainted with the constitutional condi- tions which give it an unfavourable impress, but that such idiosyncrasy exists is proved beyond doubt by many observations. It obtains even in that produced by the poisonous fish, as out of a large party who have partaken of the latter, the majority sometimes escape altogether, whilst amongst those in whom it occurs some are severely, others but slightly affected. It seems to be under such circumstances that some chronic nettlerashes are exceedingly intractable, but it is of more practical interest to know that inter- ference by a perverse treatment may render cases so which in themselves had nothing to prevent a favourable course and speedy termination. The febrile urticaria has a period, as before stated, of about seven days ; and it seldom is in the power of medicine to disperse it before that time; and, indeed, it will be the more prudent aim of the physician rather to moderate its symp- toms than to attempt by the exhibition of strong measures of any kind to cut it short. His inter- ference in many cases need be very little, und he has occasionally to exercise both judgment and delicacy in withholding it. The remitting nature of the fever, and the itching, is a cause of anxiety and disappointment to the patient, which is best obviated by warning him of its character. In cases where a suspicion is entertained that the stomach retains any offensive matter, it will be propento commence the treatment by the exhibi- tion of an emetic of ipecacuanha, after which the patient should be placed in bed, where he ought ! to remain, even during the remission, until the I affection subsides. His bowels should be kept moderately free by the use of gentle laxative me- dicine, but strong cathartics are uncalled for and ' improper. We have known the use of one, which I moved the bowels three times, produce such a I weakening effect, that deliquium took place after each evacuation. Small and repeated doses of the : acid infusion of roses with sulphate of magnesia, i will be found to suit well as an aperient. In lax habits this end may probably be as conveniently answered by a draught composed of equal parts (ten to fifteen grains) of magnesia and rhubarb 1 in an ounce of cinnamon water, with the addition | of twenty drops of aromatic spirit of ammonia. In some cases it will be preferable to use enemata with castor oil. Some authors recommend warm bathing ; we apprehend that while the fever lasts its use might be better dispensed with ; but at its subsidence warm bathing has an excellent effect in restoring the vigour of the skin, and renovating the general health of the patient. The cinchona or sulphate of quina with sulphuric acid in small doses should be administered also at this period as a tonic. In the cases, however, which assume a genuine intermittent type, this remedy must be administered from the time that this can be verified. No endeavour should be made to repel the eruption in any of the acute forms of nettlerash, by the application of cold, nor should the practi- tioner countenance its use in any way, even for the temporary allaying of the heat and itching. Frank notices (Op. cit. lib. iii. p. 112,) cases that have been recorded, in which fatal metastasis to the brain was the consequence of urticaria repelled by cold. An instance was also known to Dr. Macintosh, (Practice of Physic, vol. i. p. 155,) in which the application of Goulard-water for the 596 URTICARIA —UTERUS, (PATHOLOGY OF THE) same object was instantly followed by fainting, and the patient narrowly escaped with life through a dangerous fever. The employment of tepid baths for the mitigation of excessive pruritus is I recommended by several, and if cautiously used they are unobjectionable, and much more effective than cold. In children no other treatment is necessary than attention to the state of the teeth and bow- els. The employment of common absorbent me- dicines and alteratives will be found quite sufficient to combat it. Amongst these the pulvis contra- yervse compositus is extolled by Underwood. We have found no powder have so uniformly a fa- vourable action with children, as one composed of from two to five grains of hydrargyrum cum creta, with an equal proportion of rhubarb, and a quarter of a grain of ipecacuan. In the chronic forms of nettlerash the treatment is often a matter of much greater difficulty, as these affections depend frequently upon internal causes, which it is not easy to appreciate. They are sometimes connected with the habitual use of some disagreeing article of diet, and Willan found that the only way of at once detecting their cause and eradicating them was to direct the persons so affected to omit, first one, and then another article of their food and drink. The offending substance was different in different persons: «in some it was malt liquor; in others spirit, or spirit and water; in some white wine; in others vinegar ; in some fruit; in others sugar; in some fish ; in others unprepared vegetables." He acknowledges, however, that " in some cases a total alteration of diet did not produce the least alleviation of the com- plaint." (Bateman's Synopsis, p. 136, edit. 1829.) In such cases, instead of having recourse at once to mineral acids or other tonics, as Bateman advises, it will be more prudent to investigate strictly the condition of the internal organs, as it is probable that it depends on some latent irritation of the gastro-intestinal canal or the liver, of a more per- manent description than mere disturbance of the digestive function. If on examination such a sus- picion be at all warranted, the application of six leeches to the epigastrium once or twice may do more towards its removal than any other means, and when the local abstractions of blood have somewhat reduced the internal congestion, bitter, alkaline, or acid tonics may be advantageously employed, as in the case of gastritic dyspepsia. With respect to bathing, although in the chronic urticaria danger is not to be apprehended from it as in the acute, much benefit is seldom found to accrue from it; the good effects of the vapour- bath entitle it, however, to trial. In these forms also, lotions of cold water with spirit and vinegar, or of water with small quantities of camphorated spirit, are sometimes found grateful applications for allaying the pruritus. In the severe form produced by fish-poison, the urticaria, although intense, with respect to the treatment must be considered as a secondary mat- ter. The first object to be attempted is the freeing of the stomach and bowels of the exciting cause. In doing this the West Indian physicians prefer the sulphate of zinc to any other emetic, as it operates more rapidly and depresses the strength less than any other; on which account the tartar- emetic is never employed by them. For the same reason the most gentle means are to be used for promoting evacuations from the bowels ; castor oil and repeated laxative injections are to be pre- ferred to saline purgatives. The further treatment is to be founded upon the decision which the physician comes to upon the important question, whether the stage in which the patient is brought under his notice be that of sinking of the vital powers by the direct agency of the poison, or, on the other hand, the stage of reaction. It is obvious that in the first case the practice must consist in the exhibition of stimulants to support and revive the powers of life, and that in the latter, the indi- cation is to reduce the erethism of the vascular and nervous systems. The most approved stimu- lant is madeira wine; carbonate of ammonia is also to be used, and capsicum is much extolled by Dr. Clarke, a physician of Dominica. With re- spect to the stage of reaction, it is to be kept in mind, that however high the erethism may mount, it is not to be combated by the powerful antiphlo- gistics which a free inflammation of the same degree would demand. Venesection should nol be resorted to except in the case of young pletho- ric individuals; leeches may be sparingly applied to the organ which appears most oppressed, but we must be contented to rest for the fulfilment of this indication on the exhibition of acid diluents, such as lemon-juice, or lime-juice, vinegar, &c. together with keeping the patient in cool air. A more ample development of this subject belongs, however, to the head of Toxicologt rather than to urticaria. J. Houghton. UTERUS AND ITS APPENDAGES, PA- THOLOGY OF THE—The sexual system of the human female consists of the uterus, and of its internal and external appendages. Before the age of maturity, the uterine organs are small, exert but little influence on the constitution of the female, and are not liable to many diseases. From the age of fourteen or fifteen, when menstruation is usually established, until the middle period of life, the functions of the uterus are subject to se- rious derangements; and at a more advanced period of life, its structures are often destroyed by diseases of a malignant nature. In extreme old age, the uterine system, without any organic dis- ease, undergoes a great diminution of volume, and not unfrequently the canals of the Fallopian tubes and upper part of the cervix uteri become imper- vious. Various irregularities in the formation of the human uterus have been described in the works of different authors under the terms bilocular, bicorned, bifid or double uterus, in all of which, without a single exception, the uterine append- ages have been simple, or have consisted of one ovarium or one Fallopian tube annexed to each cornu of the uterus, and not of two ovaria and two Fallopian tubes, as the term double uterus would seem to imply. In the examination of a great number of children at the Maternite of Paris, the division of the uterus, as in some of the lower orders of mammalia, was often met with. Pr0" fessor Chaussier has described the case of a wo- man who was delivered in the Maternite of net UTERUS, (PATHOLOGY OF THE) 597 tenth child, in whom it was found after death that the right side of the uterus only existed, with one ovarium and one Fallopian tube. (Bulletin de la Faculte de Medicine, Paris, 1817.) Littre, in dissecting the body of a little girl, found the vagina divided by a fleshy perpendicular septum, as in most of the ruminant animals. The vagina is sometimes divided by a thin perpendicular mem- branous partition. Vallisnieri relates the history of a woman who was poisoned with cantharides, in whom two uteri were found to exist, one of which opened into the vagina, the other into the rectum. (Esperienze ed Osservazione Spettanti all' Istoria Naturale, etc. I. iv.) M. Cassan has referred to numerous other ex- amples of similar malformations of the uterine or- gans, and to those more particularly the histories of which are contained in the Memoirs of the Royal Academy of Sciences. (Recherches sur les Cas d'Uterus double et de Superfcetation, par M. L. Cassan, Paris, 1828.) In the Museum of the Royal College of Surgeons in London, there is a specimen of bifid unimpregnated uterus, and another was preserved in the collection of Mr. Brookes, in which the fundus, cervix, and os uteri were all divided by a thick septum. Similar cases have been recorded by different writers. Messrs. Lauth and Cruveilhier have reduced all the malformations of the uterus to the four follow- ing varieties: 1. where the uterus and vagina are separated into two cavities by a septum running in the direction of the mesial line, while the ex- ternal configuration presents nothing unusual; 2. where the fundus and body of the uterus are divided into two cornua, the cervix, os uteri, and vagina remaining in the normal state; 3. where the uterus is bifid, as above, while the cervix and vagina are divided by a septum ; 4. where the vagina forms a single canal with a double os uteri. These deviations from the natural formation of the uterus do not prevent impregnation. Morand, Bartholin, Purcell, Ollivier, and many other writ- ers have recorded cases of double uterus in which conception had taken place, and the fcetus had been retained till the full period. " Num mulie- res," inquires Riolan, « quse superfoetare solent aut plures foetus quam duos generant, uterum biparti- tum habeant]" (Schola Anatomica, Parisiis, mcviii. p. 317.) M. Cassan has also recently speculated upon this subject, but there are certain facts which prove that the doctrine of superfceta- tion, if well founded, cannot be explained on the supposition that the uterus is double or bifid. The author has related a case of impregnated double Uterus, in which an organized deciduous mem- brane, in the form of a shut sac, lined the unim- pregnated cornu, and rendered superfcetation and menstruation impossible. (Med. and Chir. Trans. vol. xviii. p. 475.) The uterus has been found wanting in some women; others have had the ori- | rice closed by a membrane or a dense fleshy sub- '• stance, or the os uteri has opened into the rectum. The vagina is also sometimes malformed. Its \ orifice has been impervious from unusual strength of the hymen, or a considerable portion of the j canal has been closed, within the os externum, by a thick fleshy substance. Cases have been re- corded in which the whole vagina has been filled j up with a dense solid mass. An extreme narrow- ness and shortness of the canal has also been re- peatedly observed, and in some it has been alto- gether wanting. In the neck of the bladder, ure- thra, and parts situated around the orifice of the vagina, many varieties of malformation have oc- curred. We ascertain the presence of disease in the uterine system chiefly by the uneasy sensations of the patient, by the disordered functions of the organs, and by the changes in their situation, form, and sensibility. The mammse, stomach, brain, and nervous system are all sympathetically affected in many of the diseases of the uterus, and in most of the organic affections of the organ and its appendages there is severe burning or lancinat- ing pain experienced in the hypogastrium, or dull gnawing pain in the sacrum, loins, pubis, and upper part of the thighs. There are often sick- ness and vomiting, loaded tongue, impaired appe- tite, and other signs of gastric derangement. There are frequently also dull pain, sense of giddiness, confusion of head, and many irregular nervous affections. The mammse sometimes become en- larged and painful, as in the early months of preg- nancy. The functions of the uterus, more parti- cularly of menstruation and conception, are inter- rupted or disturbed. There is frequently an al- tered secretion of the lining membrane of the ute- rus and vagina, and instead of the mucus which lubricates the passages, serum, pus, or blood are poured out in greater or smaller quantity from the parts. When a female after the middle period of life suffers from an habitual discharge of a serous, sanguineous, or purulent nature from the vagina, with pain in the back and irritation within the pelvis, an internal examination should be made to determine the condition of the uterus. If our object is to ascertain the condition of the lower portion of the uterus, the patient should remain in the erect position with the back resting against the wall while the forefinger is carried through the vagina to the os uteri. When the finger reaches the uterus, pressure should be made with the left hand over the hypogastrium, that the sensibility, | form, and weight of the organ may be accurately ascertained. It is necessary for the practitioner to j recollect that there is great variety in the form of i the os uteri in different women, without disease. In some individuals its length is remarkable, and in many women who have had children, in whom l labour has been natural, there are irregularities or [ fissures from laceration, where there is no organic after repeated labours, the lips of the os uteri do not project, the orifice occupying directly the upper part of the vagina like a funnel. This we have repeatedly found to be the state of the os uteri in aged females, whether they have had children or not. Sometimes the orifice is so large as to ad- mit the point of the finger prolonged backward and to the left by an oblique fissure with round edges. Not only should the smoothness, hardness, and regularity of the lips of the os uteri be exa- mined, but the degree of dilatation of the orifice should be ascertained, if any exists, and whether it is giving passage to a tumour of any descrip- tion. The size and weight of the uterus should also be determined, and whether the fluid cover- ing the finger be mucous, serous, sanguineous, or 598 UTERUS, (PATHOLOGY OF THE) purulent. The condition of the vagina should likewise be accurately explored, for there are few diseases of the uterus of a cancerous or malignant nature, in which some change is not perceptible in the coats of the vagina. It is by an examina- tion per vaginam that we become acquainted not only with the alteration of structure in the os and cervix uteri, but with the numerous displacements to which the organ is liable. The speculum uteri has been much employed on the continent in the exploration of the diseases of the uterus; and in some cases of inflammation and superficial ulceration of its orifice, important information may be obtained by its use. In many more, however, and particularly in tumours and cancerous affections of the uterus, we are fully persuaded that little information can be obtained from the employment of it; its introduction is painful, and where the vagina is diseased, it has produced most injurious effects. In a case of ma- lignant ulceration of the os uteri and upper part of the vagina, which came under our observation, the introduction of the speculum produced hemor- rhage, which proved fatal in the course of twenty- four hours. We now propose to give a short account of some of the more important diseases. I. Of the Fallopian tubes. II. Of the uterus. III. Of the vagina and organs situated around its orifice. The structure, functions, and diseases of the ovaria have already been fully described in a pre- ceding part of this work.—See Ovaria, Diseases OF THE. I. Diseases of the Fallopian Tubes. The Fallopian tubes are two slender tortuous canals, about four or five inches in length, which extend between the ovaria and the superior angles of the uterus. They consist, like the uterus, of a peritoneal, muscular, and mucous membrane, and they perform the office of conveying the spermatic fluid from the uterus to the ovaria, and, after im- pregnation, of carrying back the germ or ovulum to the cavity of the uterus. They are liable to attacks of acute and chronic inflammation, both in the unimprcgnatcd and puerperal states. Their fimbriated extremities are frequently, in conse- quence of acute or chronic inflammation, firmly united to the ovaria, posterior part of the uterus, omentum, and other contiguous parts. The struc- ture of the fimbrise is often completely destroyed, and the tubes terminate in a cul-de-sac. The canals of the tubes are also sometimes obstructed, and sterility is the result. The obstruction may be partial or complete. One of the most frequent morbid appearances which the writer has observed in the bodies of young subjects after death, is ad- hesion of the Fallopian tubes to the ovaria by short, firm, adventitious membranes, or by long, slender, transparent filaments. After parturition, when inflammation attacks the peritoneum, the Fallo- pian tubes in most cases become red, vascular, and partially or completely imbedded in pus or lymph. Their ovarian extremities not unfrequently become softened, of a deep red colour, and deposits of pus in a diffused or circumscribed form take place within their cavities or in their sub-peritoneal tis- sues. Their lining membrane also becomes in- flamed, and the canals throughout their whole extent filled with pus. A case of abscess" of the Fallopian tube communicating with the rectum, has been observed by M. Andral. The woman, after suffering from constipation, had vomiting, pains in the right side of the abdomen, then in the left, and in the right thigh ; a tumour gradu- ally formed in the left flank, with fever, emacia- tion, and purulent diarrhoea. On opening the body, the effects of inflammation of the bowels were observed ; the left Fallopian tube, consider- ably dilated, opened into the rectum by an opening which would admit a writing-quill. A purulent fluid, or a thick viscid matter, like cream, is fre- quently found in their cavities, where there has been no previous inflammation of their coats. The cavities of the tubes are also found in some cases distended with scrofulous matter, and the same deposition is occasionally observed within the cavity of the uterus. The coats of the tubes are frequently much thickened, and of a red or dark colour, when affected with scrofula. All these affections produce barrenness, but there are no symptoms by which we can positively determine their existence during life. In the article Ovabu, the author has expressed his belief that in many cases of painful menstruation there exists a state of great congestion or inflammation of these organs, and there can be little doubt that the Fallopian tubes often participate in the same disease. In such cases, and in others, where there is reason to suspect the existence of inflammation of the uterine appendages, leeches, warm fomentations and poul- tices to the sides of the hypogastrium, and other antiphlogistic means, should be had recourse to. Accumulation of fluid sometimes takes place within the cavities of the Fallopian tubes. Dr. Hooper has termed this affection hygroma, and he observes that the Fallopian tubes are not unfre- quently found distended by a serous fluid; "I have never seen," he says, " more than seven fluid ounces in one tube; from one to two ounces is the most usual quantity. When a hygromatoua tumour is formed in these tubes, the fimbria; are generally destroyed, and the abdominal openings obliterated. The sides of the tubes are distended into complete bags, which have a long tortuous or pyriform shape, being always much the largest at the loose extremity. The tube of both sides ia mostly in the same state of disease, and there are generally traces of pre-existing inflammation, as thickened portions, here and there, and many ad- ventitious membranes and adhesions to neigh- bouring parts." (Morbid Anatomy of the Human Uterus.) Sometimes the Fallopian tube is suddenly en- larged by fluid at the ovarian extremity, when it resembles a horn, or has a pyriform or spherical shape, and it may there acquire enormous dimen- sions. De Haen relates a case in which the Fal- lopian tube weighed seven pounds, and the cavity contained twenty-three pounds of fluid. In other cases the quantity has been still greater. It is difficult or impossible during life to distin- guish dropsy of the Fallopian tube from cysts formed in the ovaria, and it would not be of much practical importance if the diagnosis could be drawn. All internal remedies are equally unavail- ing in both diseases. De Haen states that death has UTERUS, (PATHOLOGY OF THE) 599 followed the operation of drawing off the fluid from the Fallopian tube by a trochar, and that the viscid state of the fluid, rendering its escape im- possible through the opening, makes the operation unsuccessful. Monro states that hydatids may produce the same effect. Boivin and Duges re- late a remarkable case from Frank, in which a pint of fluid escaped daily by the uterus and vagina till the patient died of consumption. On exam- ining the body, thirty-one pounds of a watery and gelatinous fluid were found in the left Fallopian tube. The disease was referred to a violent blow received upon the hypogastrium. Similar cases have been recorded in which the fluid accumu- lated in the Fallopian tubes has escaped by the uterus and vagina. When the catamenia are retained from imper- foration of the hymen, vagina, or os uteri, the cavity of the uterus not only becomes much dis- tended, but also the cavities of the Fallopian tubes, which may become ruptured by ulceration. (Traite Pratique des Maladies de l'Uterus, t. ii. p. 587.) The same authors believe that some cases of leucorrhcea may depend on a chronic catarrh of the lining membrane of the Fallopian tubes. Our repeated examinations of the uterus after death have rendered it certain that in many instances of leucorrhcea, the fluid secreted by the lining membrane of the uterus, and not by that of the Fallopian tubes, or vagina. Small pedunculated cysts are very often found suspended from the fimbriated extremities of the Fallopian tubes, even in women under the age of twenty. Rupture of the Fallopian tube in the unim- pregnated state is a rare occurrence. Boivin and Duges have cited a case of this description, in which the accident arose from a violent effort, and death soon followed from effusion of blood into the abdomen. This hemorrhage, they observe, must have been excited by a violent fit of rage into which the woman had been thrown. The tube is sometimes, they add, the seat and the source of a sanguineons exhalation without any apparent rupture of the coats, and this happens most frequently in puerperal women, or in those who have miscarried, and in conjunction with metroperitonitis. Duges relates the following as an example of this rare occurrence. A woman, who had recently miscarried in the early months, was seized with inflammation of the uterus and peritoneum, of which she died; the ovarian ex- tremity of the left Fallopian tube was as large as a hen's egg, and adhering to the ovarium, which it in a great part enveloped ; it was red, very vas- c'.d.ir, and contained a bloody fluid ; the walls of the sac were half a line in thickness. The right Fallopian tube was obliterated at the loose extre- mity, as large as the finger, destitute of fimbria;, and adhering to the ovaria by some cellular fila- ments. (Op. cit. torn. ii. p. 585.) Rupture of the Fallopian tube most frequently takes place in the third or fourth month of preg- nancy, and the ovum sometimes escapes entirely into the cavity of the abdomen; at other times it continues within the tube. It is probably in con- sequence of some imperfect action of the tube that the ovum is not transmitted along its canal to the uterus, as in ordinary cases. The Fallopian tubes ; having a structure similar to the uterus, admit of the development of the ovum within their cavity for a certain period, generally to the third or fourth j month; after this, the ovum still continuing to • enlarge, they become ruptured in consequence of their incapability of undergoing further distension. A violent pain is then suddenly experienced by the woman in the region of the uterus; this is I followed by faintness, coldness of the extremities, and other symptoms of internal hemorrhage, and death usually takes place in a few hours. On opening the body, a quantity of blood is found in the sac of the peritoneum, and the tube which contained the ovum is found lacerated or laid open by inflammation and sloughing. When ruptured, it does not possess a power like the uterus to close the exposed vessels after the separation of the placenta, and the blood is poured out from the laceration until the woman perishes. In cases of Fallopian tube conception, an organized deciduous membrane is often found lining the inner surface of the uterus, the volume of which is much in- creased. In other cases, one of which came under our own observation, the cavity of the uterus is lined with a soft flocculent albuminous matter, which is not organized. In two cases about the end of the fourth month, which we have recently ' examined, no deciduous membrane lined the cavity of the uterus; the fundus and body were both considerably enlarged, and their inner surface coated with a layer of soft albumen. In Sax- torph's case of Fallopian tube conception, though the patient went to the end of the ninth month, the uterus was not enlarged, but its cavity was lined with a white tenacious mucus, which closely adhered to the lining membrane. (Acta Societ. Reg. Med. Havnien. torn, v.) Mr. Langstaff ex- amined a case in which there was no deciduous membrane, and Dr. Blundell has seen two in which the decidua was likewise wanting. The Fallopian tubes are sometimes affected with cancerous or malignant disease. This may commence in the tubes themselves, or it may extend to them from the ovaria or other parts of the uterine system. Considering the similarity of structure which exists between the uterus and Fallopian tubes, it appears singular that fibrous tumours should be so seldom met with in these organs. In no case have we met with a fibrous tumour in the walls of the Fallopian tubes. " I have seen a hard round tumour," observes Dr. Baillie, " growing from the outer surface of one of the Fallopian tubes. This, when cut into, exhibited precisely the same appearance of structure as the tubercle which grows from the surface of the uterus, con- sisting of a hard white substance intersected by strong membranous septa. This, however, I be- lieve to be a very rare appearance of disease." (Morbid Anatomy, p. 360.) "A more uncommon situation for this tumour," says Dr. Hooper, «is the cavity of the Fallopian tube. It is occasionally seen, very small, deposi- ted in the cellular tissue under the peritoneum of the tubes; and I once found it in the cavity or canal itself, about the size of an olive; the fimbriae were destroyed, and the tube terminated in a cui- de-sac." (Morbid Anatomy of the Human Uterus,, 600 UTERUS, (PATHOLOGY OF THE) &c. p. 15. [See, also, Churchill, On Diseases of Females, 3d Amer. edit, by Dr. Huston, Phil. 1844.]) II.—Diseases of the Uteiuts. The most important diseases of the human uterus, accompanied with sensible alteration of structure, may be divided into three classes : — 1. Those which are produced by inflammation of one or more of the textures which enter into the composition of the uterus. 2. Those which arise from the formation of tumours in the parietes of the organ, or from enlargement of the glands situated in its orifice, and have no tendency to degenerate into a malig- nant form, and do not contaminate the surround- , ing structures. 3. Those diseases which result from a specific or malignant action of the uterus, by which its different textures and the adjacent viscera become ' disorganized. 1.—Of Inflammation of the Unimpregna* ted Uterus. In the article Pcerpkral Fever a full account has been given of the symptoms and treatment of uterine inflammation in puerperal women. In j the unimpregnated state the uterus is also liable to attacks of congestion and of acute and chronic inflammation, which, though less dangerous than j after parturition, are nevertheless productive of great distress, and are often but little under the control of medicine. Inflammation of the lining membrane of the uterus. — The lining membrane of the uterus in the healthy state is smooth, and moistened with a tenacious mucous fluid of a yellowish white colour. Not unfrequently it is of a deep red colour and ecchymosed, and a little blood escapes from it on pressure. These appearances we have often observed in women who have died suddenly from affections of the brain and other organs, and in whom there had been no symptom of uterine in- flammation except an increased discharge of mucus from the vagina. Inflammation of the lining membrane of the uterus sometimes produces merely an increase of the natural secretion of the part; in other cases pus is secreted, as in inflammation of the mucous membranes of other organs. In some women who menstruate with pain, there is a membrane somewhat like the decidua, though essentially different in structure, discharged from the cavity of the uterus at each monthly period. It is sometimes of a triangular shape, the inner surface being smooth and filled with fluid, while the exterior, which had been adherent to the uterus, has a rough flocculent appearance. In other cases this membrane is passed in flakes like coagulable lymph, and does not present any appearance resembling the decidua. Women who are afflicted with this peculiar disease of the uterus suffer more or less from uneasiness in the region of the organ in the intervals of menstruation, and they seldom become pregnant. According to Dr. Denman, the disease does not depend upon any peculiarity of constitution or disposition to any other complaint. The false membrane is probably formed between the monthly periods, by a peculiar and specific inflammation of the mucous coat of the uterus. The symptoms would lead to the I inference that the substance of the uterus is also | affected. Morgagni was the first writer who described this disease, and he was aware how little it is under the control of remedies. Denman has recommended for its treatment mercury to saliva- tion, the ammoniated tincture of cinchona, infusion of burnt sponge with bark, myrrh, and the different preparations of iron; the Tonbridge or Spa waters, the liquor potassse, and all the remedies usually termed tonic?. In one case injections of ihe aqua zinci vitriolata cum camphora had a good effect, Denman admits that none of these remedies have been attended invariably with success. Dr. Burns says time in general removes the disease better than medicine, which is only to be advised for the relief of pain, weakness, or any other symptom which may attend or succeed to this state. Dr. Dewees states that he has seen a portion of membrane discharged from the uterus not much larger than the nail, after severe suffering; at other times he has witnessed as much as would fill a small tumbler. The period employed for the ex- trusion of the substances is various; sometimes requiring but a few hours, at other times several days. The degree of suffering is not always in proportion to the quantity of substance expelled; indeed, the pain would rather appear to be less when much is discharged. Dewees thinks there are two varieties of the disease; one where the mamma sympathise with the uterus, and become tumid and extremely painful; the other where there is no such affection induced. In this affec- tion, he says there is almost always a permanent pain in the back, hips, and loins, which indicates the presence of a highly congested, if not an in- flamed state of the lining membrane, and probably also of the middle coat of the uterus. For the relief of pain in this affection, which is the first object of treatment, he states that he has found the following combination of remedies more useful than any other. R Gum. camphor, ^i. Spirit, vin. rectif. q. s. fiat pulvis: add. Pulv. G. Arab. ~ji. Sacchar. alb. q. s. Aquse cinnam. simpl. §i. M. One-half of this draught is to be given the instant pain is experienced ; and if not relieved in an hour or two, the other is to be given. This quantity, however, is not always sufficient to subdue pain ; in this case let the mixture be repeated, or the same quantity of camphor may be finely powdered and given in ten-grain doses every hour, entangled in a little syrup of any kind, until relief is pro- cured. The ergot, as might have been expected, has failed to afford relief. Warm baths, pediluvium, and bleeding, have also been prescribed, but he declares that nothing has succeeded so well as camphor. The injection of tepid narcotic fluids into the vagina would probably be attended with advantage, and the application of leeches to the os uteri in the intervals of the monthly periods, when the membrane is forming within the cavity of the uterus. As a means of affording permanent relief in this painful disease, Dewees has recommended the use of volatile tincture of guaiacum, in doses of a , drachm three times a day. In some cases it has UTERUS, (PATHOLOGY OF THE) 601 been useful, in others altogether useless. He sup- poses the inflammation to be rheumatic, but of this there is no satisfactory evidence. The pathology and treatment of this affection of the uterus, it must be admitted, are but imper- fectly understood. The occasional local abstrac- tion of blood from the region of the pelvis, by cupping or leeching in the intervals of menstrua- tion, when there are symptoms of congestion of the uterus present, the exhibition of calomel, Do- ver's powder, and camphor, with rest in the hori- zontal position, and the frequent injection of tepid narcotic fluids into the vagina, are the remedies which have afforded the greatest relief in the cases which have come under our care. When the lower portion of the uterus is chiefly affected with inflammation, there is an uneasy sensation or pain experienced in the back, hypo- gastrium, and loins, aggravated by pressure and bodily exertion, and chiefly by riding and walk- ing. In this disease there is usually an increased secretion of mucus from the vagina, or there is a discharge of white opaque mucus, " like a mixture of starch and water made without heat, or thin cream ; it is easily washed from the finger after an examination, and it is capable of being diffused through water, rendering it turbid." " A morbid state of the glands of the cervix of the uterus," continues fSir C. Clarke, " probably gives rise to this discharge; at least the cases in which it comes away are those in which the symptoms are referred to this part; and when pressure is made upon it, the woman complains of considerable pain." (Ob- servations on the Diseases of Females which are attended by discharges, part ii. 5.) When an internal examination is made, the uterus is often found hanging unusually low in the vagina; the os uteri is neither hard nor irre- gular, but it is swollen and puffy, and is painful on pressure. There is more or less irritation in the bladder and rectum, and the symptoms are usually aggravated before and subsequent to men- struation. When the substance of the fundus and body of the uterus are inflamed, the pain, which is constant, occurs also in paroxysms, and is aggra- vated by the erect posture, and by pressure over the hypogastrium. The milky discharge from the vagina, which is often present, when there is no inflammation of the uterus, and which Dr. Clarke considers as a pathognomic symptom of inflamma- tion of the os uteri, is wanting, according to his observation, when the substance of the unimpreg- nated uterus is inflamed. It is sometimes observed in young females soon after marriage, and is most frequently referable to violence, or to the applica- tion of cold during menstruation. There is often little effect produced upon the constitution in this disease. In other cases, con- stitutional disturbance, more or less marked, ac- companies chronic inflammation of the uterus. The pulse is soft, but easily accelerated, particu- larly in the evening. The digestive organs are deranged, the appetite becomes impaired, and the bowels are confined. The urine is discharged with pain and difficulty. The anus is sometimes re- i traded. Menstruation is frequently disturbed, and if the disease continues long, and the powers of I the system are much impaired, it is entirely inter- Voi.IV. —76 3 a rupted. In many cases, it is impossible during life to distinguish this affection from incipient malig- nant disease, and other organic diseases of the uterus, of a totally different nature. Dr. Gooch and M. Genes maintain that all the symptoms of chronic inflammation of the uterus may be present without inflammation, or without any sensible de- rangement of the uterus. This view does not, however, rest on accurate and extensive patho- logical research; and the heat, swelling, and ex- quisite sensibility of the neck and body of the uterus, prove that in the disease or group of dis- eases described by the former of these writers under the name of irritable uterus, a state of the organ exists closely allied to inflammation or congestion. In more than one case, which had been considered and treated as simple irritability of the uterus with- out inflammation, organic disease of a malignant nature was subsequently developed. The presence of fibrous tumours in the walls of the uterus has likewise in some individuals given rise to that pe- culiar series of symptoms which has been described as characteristic of irritability of the uterus, with- out inflammation or disposition to a morbid altera- tion of structure. " What is the nature of the irritable uterus }" inquires Dr. Gooch. " It is not acute inflamma- tion, for that would run a far shorter course, and end in certain known consequences. It is not chronic inflammation, for that is a disorganizing process, and slowly but surely alters the structure of the organ in which it goes on. Both in chronic inflammation, and in the disease which I am de- scribing, there is a morbid state of the nerves, in- dicated by pain, and sometimes at least a morbid state of the blood-vessels, indicated by their ful- ness ; but the substances effused by chronic in- flammation show that in this there is something additional in the actions and consequently in the state of the vessels. The disease which I am de- scribing resembles a state which other organs are subject to, and which in them is denominated irri- tation. Thus surgeons describe what they call an irritable tumour of the breast. It is exquisitely tender; an ungentle examination of the part leaves pain for hours ; it is always in pain, but this is greatly increased every month immediately before the menstrual period. Although apprehen- sions are entertained of cancer, it never terminates in disease of structure. It is represented as a very common disease. Mr. Brodie describes a similar state in the joints. It occurs chiefly amongst hysterical females; it is attended by pain, at first without any tumefaction, but the pain in- creases and is attended with a puffy, diffused, but trifling swelling; the part is exceedingly tender ; this assemblage of symptoms lasting a long time, and being often little relieved by remedies, occa- sions great anxiety, but there never arise any ulti- mate bad consequences. «The disease,' says Mr. Brodie, < appears to depend on a morbid condition of the nerves, and may be regarded as a local hysteric affection.' These painful states of the breast and of the joints appear to be similar to that which I have been describing in the uterus ; similar in kinds of constitutions which they at- tack ; similar in pain, in exquisite tenderness, in resemblance to the commencement of organic disease, and in proving ultimately to be only dis- 602 UTERUS, (PATHOLOGY OF THE) eases of function." (An Account of some of the most important Diseases of Women, by Robert Gooch, M. D., Lond. 1S31, p. 306.) Dr. Dewees, whose attention has been particu- larly directed to the pathology of this affection, does not consider this view of the subject to be correct, and it is certainly very difficult to discover any analogy between a tumour of the female breast or joints and an affection of the uterus depending solely upon a morbid state of its nerves. Chronic congestion and inflammation of the uterus appear to arise most frequently from expo- sure to cold and fatigue during menstruation, and subsequent to abortion or parturition. It is an obstinate disease, and often resists the effects of all remedies for many months, or even years. The patient should remain in the horizontal position if the pain is constant and severe. Blood must be drawn from the arm or from the uterine region by leeches, or by cupping-glasses. When the circu- lation is undisturbed, as is most frequently the case, local is to be preferred to general blood-let- ting. Some think that cupping affords decidedly more relief than leeches, and that the glasses should be applied over the sacrum, or to the part to which the pain is referred. Dr. Dewees applies them to the inside of the thighs. The bowels should be regulated by castor oil, infusion and electuary of senna, super-tartrate of potash, and Epsom salts. To subdue the pain the tepid hip-bath, warm fomentations, and narcotics must be had recourse to; and camphor, combined with extract of hyoscy- amus, henbane, or poppy, should be administered twice or thrice a-day. A belladonna plaster should be applied over the sacrum. Warm decoction of poppy, or lukewarm linseed tea, or eight or ten grains of opium dissolved in a pint of hot water, or solution of starch, may be thrown up the vagina, and an ounce of warm milk with a drachm of laudanum may be injected into the rectum, after the bowels have been evacuated. An alterative course of mercury has afforded decided relief in some cases. Like all the other chronic phlegma- sia;, when the disease has lasted long, relief some- times follows a different plan of treatment, viz. the employment of exercise, bitters, tonics, sul- phurous and chalybeate waters. Where the sto- mach has suffered much, the phosphate of iron may be given with advantage. Chronic inflammation of the uterus does not degenerate into cancer, as many suppose, and it rarely terminates in suppuration of the muscular tissue of the uterus. Cases of abscess of the walls of the unimpregnated uterus have been de- scribed by writers, but they are very seldom met with. Mr. Howship has a uterus in his possession, in the muscular coat of which, or in the cellular membrane between its layers, was an abscess which contained about an ounce of pus. The symptoms were not ascertained before death. This is the only example of abscess of the walls of the uterus from simple inflammation that we have seen ; those abscesses in the uterus described by Dr. Hooper were connected with malignant disease of the organ. Where a collection of pus has taken place within the cavity of the uterus, there has also in most cases been present a ma- lignant organic affection of the os and cervix uteri. The following case, related by Dr. John Clarke, illustrates this fact. " On the 12th of January, 1812, I visited Mrs. A. B. about 6ixty-five years of age, who had ceased to menstruate many years. A few weeks before I saw her, she had informed Mr. Brande, who attended her, of her having a small sanguineous discharge from the pudenda. The discharge was not attended by any pain. After this she had a discharge like fluor albus,and small, but which afterwards became of a brownish colour, offensive to the smell, and greater in quan- tity. A very short time before I saw her, she had experienced a more considerable sanguineous dis. charge, but without any pain. I found, on ex- amination per vaginam, the os uteri very rigid and much harder than usual. The cervix was of the usual length, but harder to the touch. From the upper part of the cervix a tumour bulged out in all directions, so as to occupy nearly the whole space from the os pubis to the os sacrum. On the 3lst January she was suddenly seized with violent pain in the lower part of the abdomen, and a sensation as if something had suddenly given way there, and she was still in great pain. She could not pass her urine; she was now in a state of extreme weakness and faintness, like a person nearly expiring, having a small thready-like pulse, great paleness of the surface of the body, and coldness of the extremities. She died soon after this. On opening the abdomen, seven ounces of a most offensive purulent fluid were found in its cavity. The small intestines were inflamed. On raising the intestines to expose the contents of the pelvis, a tumour appeared in a gangrenous state, with an opening in the upper part of it, through which, on the slightest pressure, a quan- tity of offensive pus oozed, similar to that which was found in the cavity of the abdomen. The bag containing it appeared to be in contact with the quantity which still remained in it, probably about five ounces. This matter being removed, the bag was discovered to be the uterus in a dis- tended state. Both its external and internal sur- face were of a dark colour, exhibiting nearly the appearance of a mortified part. On the internal surface there was an appearance like half coagu- lated lymph, but there was no trace of any cyst, so that the fluid was contained in the cavity of the uterus itself. The internal surface of the uterus had a honeycomb-like appearance. The orifice between the cavity and the cervix was closely contracted, so as not to have allowed the contents of the uterus to be discharged through it." (Trans, of a Society for the Improvement of Med. and Chir. Knowledge, vol. iii. p. 560.) Inflammation of the follicles of the os uteri. — Granular inflammation of the os uteri is the term employed by Madame Boivin to designate this disease, which she states to be little under- stood, and only to be detected by using the specu- lum. The os uteri is swollen, red, ecchymosed, morbidly sensible when touched, and disposed to bleed. There is often present a leucorrhceal dis- charge from the vagina, and a state of excitement bordering upon nymphomania. In some cases the affection has been misunderstood, from the absence of local symptoms, or because it has been accompanied with more severe lesions. The granulations, when hard, are usually very small like grains of sand or the seeds of the poppy J if UTERUS, (PATHOLOGY OF THE) 603 they arc larger, their softness prevents them from being discovered, except by a very experienced practitioner. These granulations are found in a subacute or chronic state. In the former they are seen on the lips of the os uteri, sometimes in small numbers like peas, firm and white; more frequently in great numbers, like grains of millet-seed, also white and soft, and vesicular, without roots. It is from their interstices that the blood flows which escapes into the vagina when they are touched, or when the bowels are evacuated. In the chronic state the enlarged follicles or granulations are hard, small, and white, and rest on soft, red, miliary elevations, in one case like varicose veins. The causes of this affection are not the same in all cases ; they are often obscure, like the causes of all uterine diseases. In some cases, the affection seems to have been produced by syphilis or some cutaneous disease, or by the presence of a fibrous tumour in the uterus. In the examination of dead bodies we have repeat- edly seen the appearances described by Boivin, and we agree with her in thinking that they de- pend on an enlargement of the mucous follicles of the os uteri. We have seen numbers of these bodies much enlarged, both in the vagina and os uteri, when individuals had died from chronic disease unconnected with any morbid state of the uterus. Emollients and local bloodletting are the reme- dies recommended by Boivin in the subacute stage of the disease. The treatment must be stimula- ting in the chronic stage, and afterwards, in the greater number of cases, derivatives must be had recourse to. The greatest advantages have re- sulted from their use in many cases. Where the disease is syphilitic, mercury must be employed. Whether physometra and tympanites are al- ways the result of inflammation of the uterus is not at present ascertained ; but as they may some- times arise from that cause, we may here notice them. The existence of tympanites and dropsy of the unimpregnated uterus might be called in question, if cases of the disease had not been re- corded by some authors of undoubted veracity. As no example of either of these affections has come under our own observation, we shall give a short account of their history and treatment as we find them recorded in the works of different writers. Mr. J. Hunter endeavoured, without success, to elucidate this subject. " I have been informed," he says, (at p. 206 of his work on the Animal OSconomy,) " of persons who have had air in the uterus or vagina without having been sensible of it but by its escaping from them with- out their being able to prevent it, and who, from this circumstance, have been kept in constant alarm lest it should make a noise in its passage, having no power to retard it, as when it is con- tained in the rectum. This fact being so extra- ordinary made me somewhat incredulous, but rendered me more inquisitive, in the hope of being able to ascertain and account for it: and those of whom I have been led to inquire have always made the natural distinction between air passing from the vagina and by the anus: that from the anus they can feel and retain, but that in the vagina they cannot; nor are they aware of it till it passes. A woman whom I attended with the late Sir J. Pringle informed us of this fact, but mentioned it only as a disagreeable thing. I was anxious to determine if there was any com- munication between the vagina and rectum, and was allowed to examine, but discovered nothing uncommon in the structure of these parts. She died soon after; and being permitted to open the body, I found no disease either in the uterus or vagina. Since that time I have had opportunities of inquiring of a number of women, and by three or four have been informed of the same fact with all the circumstances above mentioned : how far they are to be relied upon, I will not pretend to determine." Denman never saw a case in which wind was collected in the cavity of the uterus in such a manner as to resemble pregnancy, and to produce its usual symptoms ; but many cases occurred to him of temporary explosions of wind from the uterus. " When no injury has been done to the parts in former labours, I presume," he says, " that the complaint happens to women with feeble constitutions, and some particular debility of the uterus." (Introduction to the Practice of Midwifery, vol. i. p. Ill, London, 1788.) Dr. Hooper once saw a case of flatulent tumour of the uterus in the living subject, but never post-mortem. " Air is formed in this organ," observes Dr. Gooch, " but instead of being retained, so as to distend the uterus, it is expelled with a noise many times a day. It has been doubted whether it really came from the uterus; but in one of my patients there was a circumstance conclusive on this point: she was subject to this infirmity only when not preg- nant ; but she was a healthy and breeding woman, and the instant she became pregnant, her trouble- some malady ceased. She continued entirely free from it during the whole of her pregnancy ; but a few weeks after her delivery, it returned." In all these cases there is no positive proof that the air was not accumulated in the vagina only. In by far the greater number of cases the dis- ease has arisen from the decomposition of bodies contained within the cavity of the uterus, and not from any disease of the uterus itself. After tho extraction of a dead fcetus from the uterus, an offensive gaseous fluid sometimes escapes from its cavity. M. Leduc had scarcely extracted the body of a putrid fcetus with the crotchet, when there escaped with impetuosity from the uterus a gas having a sulphureous smell, which burnt with a violet-coloured flame. (Dictionnaire de Medecine, t. xvii. p. 198.) But it is more particularly after delivery, when some portion of the placenta or of the foetal membranes has remained within the uterus, and the orifice is closed by a coagulum of blood, that a true uterine tympanites takes place. The uterus then admits of distension by the gaseous fluid, and it may acquire a volume equal to that which it had before delivery. Two cases of this description occurred to M. Deneux, the histories of which have been related by M. Chomel. A woman, whose lochia had been suppressed on the fourth day after delivery, became comatose on the fifth, with turgescence of the face and extreme difficulty of respiration. M. Deneux found the abdomen tense and resonant when struck, as in intestinal tympanites. By an examination per vaginam he discovered that a fibrinous coagulum 604 UTERUS, (PATHOLOGY OF THE) occupied the orifice of the uterus. Scarcely was this clot displaced, when an offensive gaseous fluid escaped with an explosion from the vagina. The abdomen immediately diminished in volume. It completely subsided when, by a new effort, the clot had been drawn out, and with it another dis- charge of gas and a quantity of very fetid blood. In twenty-four hours the patient became conscious, and in a few days she was convalescent. In the second case a portion of the membranes closed the uterine orifice, and the uterus presented the same volume which it usually presents towards the fourth month. The extraction of the foreign body was followed by the expulsion of a large quantity of fetid gas. M. Chomel states that cases have occurred in which the fcetus has been expelled from the uterus twenty-four hours after the death of its mother, by the extrication of gas. In some cases, without the concurrence of any of those causes now men- tioned, there takes place gradually within the uterus an accumulation of gas, which augments the volume gradually, like the product of conception. Delamotte relates a case where pregnancy was suspected ; but when the woman reached the end of the ninth month, all the symptoms disappeared after the escape of a gaseous fluid from the vagina. An analogous case has been cited by Boivin and Duges from the Transactions of the Medico-Chi- rurgical Society of Bologna. A woman, forty years of age, believed herself pregnant; the menses were suppressed, the belly enlarged, and the uterus at the fifth month was on a level with the umbilicus. On stooping down, air escaped in great quantity from the vagina, and the swell- ing of the abdomen immediately disappeared. The distension of the uterus by air gives rise, ac- cording to Chomel, to peculiar phenomena; the patient feels more or less uneasiness in the hypo- gastrium ; the pains extend into the loins, the groins, and thighs. A tumour is felt in the hypo- gastrium, reaching to the navel. This tumour is elastic, and sonorous on percussion : by passing the finger into the vagina it can readily be ascer- tained, while the other is over the hypogastrium, that the tumour is formed by the uterus. Some authors affirm that this tumour can be felt to be light. Sometimes the catamenia continue to flow. When the distension of the uterus is considerable, the neighbouring parts suffer from their pressure, and their functions are deranged; the alvine eva- cuations become scanty, and are passed with diffi- culty ; there are frequent calls to void the urine; the respiration is confined. The escape of air by the vulva affords relief: a copious discharge re- moves the disease. The treatment recommended by M. Chomel consists in removing the mechanical obstacle, if any exists, by the finger introduced into the os uteri, by hip-baths, injections, and the abstraction of blood. Boivin and Duges recom- mend cleanliness, baths, lotions, injections of warm water, or weak solution of chloruret of lime. Dropsy of the uterus [Hydrometra.] — Accu- mulation of a serous fluid within the cavity of the uterus has only been found where the os uteri has been closed by adhesions from preceding inflam- mation, which is a very rare occurrence, or has been obstructed by malignant disease or some morbid growth. Dr. A. T. Thomson has related a case in which the cavity of the unimpregnated uterus contained eight quarts of a fluid of a dark brown colour. The woman appeared as large as if six months gone with child. An indistinct fluctuation was perceptible in the tumour, and the least pressure on it excited pain. She died from dry gangrene of the left lower extremity. The internal surface of the uterus was found, on dis- section, to be neither more irregular nor more spongy than in its natural state; but none of the orifices could be found, for even the os uteri was interiorly as completely obliterated, as if it had never existed ; and although its situation could be traced in the vagina, yet even there it was very faintly marked. (Med. Chir. Transact, vol. xiii. p. 175.) In cases of this description the only remedy admissible is to open the os uteri with a bougie or trochar. Hydrometra gravidarum, or dropsy of the am- nion, forms one of the most distressing complica- tions of the gravid state, and has not unfrequently given rise to dangerous errors in practice. In the works of the earlier writers on the diseases of pregnancy, and particularly in those of Mauriceau and Lamotte, we find cases recorded of dropsy of the uterus. Similar cases are to be met with in the writings of Baudelocque and Gardien; and these authors are the first who seem to have been acquainted with the fact that the fluid in this af- fection is contained within the cavity of the am- nion. It was not, however, until the publication of M. Mercier's essay on this subject in 1809, that any attempt was made to determine the true pa- thology of the disease by an accurate examination of the contents of the gravid uterus. (Obscrvatio de acuto amniosis hydrope, aut amniosis inflam- matione, qua; evasit, etc.; Journal General de Medecine, t. xliii. and xlv.) His paper contains the histories of three cases of acute dropsy of the amnion ; and from the appearances observed in the fcetal membranes, he has deduced the general inference that the inordinate secretion invariably depends on inflammation of the amnion. We have examined the fcetal membranes in eight examples of this affection, without discovering any appearance of inflammation of the amnion. In a recent case which came under our observa- tion there was an accumulation of fluid in the ventricles of the brain of the child, and it lived only a few hours. When unconnected with a dropsical diathesis in the mother, we are disposed to regard it merely as one of the numerous dis- eases of the fcetus in utero, which arise indepen- dently of any disease of the uterus or any obvious constitutional disorder in the parents, and with the causes of which we are wholly unacquainted. The diagnosis of hydrometra gravidarum is most difficult in the simple form of the disease, when the effusion has taken place to a great extent, and when complicated with ascites. In both these cases fluctuation, more or less distinct, can be perceived on percussion of the abdomen; but we can obtain from this sign no positive in- formation to enable us to determine whether the fluid be contained in the cavity of the peritoneum or amnion, or in both these membranes. In the simple form of dropsy of the amnion, where the quantity of fluid is not excessively great, the fluc- tuation is obscure, deep-seated, or wholly imper- UTERUS, (PATHOLOGY OF THE) 605 ceptible. The presence or absence of fluctuation is, therefore, no certain test of the existence of the disease ; and the only mode of arriving at a cor- rect diagnosis, both in its simple and complicated forms, is by instituting an examination per vagi- nam. By this proceeding we shall not only be able to ascertain the changes in the uterus con- sequent on impregnation, but the accumulation of a preternatural quantity of fluid in the mem- branes of the ovum. This latter circumstance is known by the enlargement of the body of the uterus, by the state of its cervix, which is almost entirely obliterated, by the ballottement of the fcetus, and by the sense of fluctuation in the vagina on percussion of the abdomen. In ascites complicated with pregnancy, Scarpa has observed that the symptoms are entirely dif- ferent from those of hydrops amniosis. The re- gular form of the fundus and body of the pregnant uterus, he states, is not evident to the touch in these cases, from the enormous distension and prominence of the hypochondrium, arising from the great quantity of fluid interposed between the fundus and posterior part of the uterus and abdo- minal viscera. The urine is scanty and lateri- tious, and the thirst is constant. The abdomen upon percussion presents a fluctuation obscure in the hypogastric region and in the flanks, but sufficiently sensible and distinct in the hypochon- dria, and strong and vibratory in the left hypo- chondrium between the edge of the rectus muscle and the margin of the false ribs. These symp- toms, with the previous history of the patient, may afford us in doubtful cases some assistance in the diagnosis; but our principal dependence, as we have before said, must be placed on the informa- tion acquired by a careful examination of the state of the cervix and body of the uterus. Having ar- rived at a correct diagnosis, the treatment of dropsy of the amnion becomes simple. Our only aim is to relieve the urgency of the symptoms oc- casioned by the over-distension of the abdominal cavity ; and the only feasible mode of giving this relief is by puncturing the membranes and evacuat- ating the superabundant liquor amnii. The arti- ficial rupture of the membranes, if the operation be carefully performed, is not more dangerous than the spontaneous rupture; and if the ease and safety of the mother can be insured, we ought not to be induced to delay its performance by ap- prehension for the life of the child, since, from its diseased state in the greater number of instances, it will be still-born. The only difficulty that can arise respecting the treatment is in cases of dropsy of the amnion complicated with ascites. Even here we would recommend the evacuation of the liquor amnii as the best remedial measure that can be had re- course to, since it relieves the leading symptoms produced by the pressure of the excess of fluid in the peritoneum and amnion on the neighbouring organs, which are, in fact, the only symptoms we have to counteract, and is followed by the expul- sion of the contents of the uterus. After delivery, the effusion into the peritoneal cavity, if it depend on utero-gestation, will spontaneously disappear: if it be the effect of hepatic or other visceral dis- ease, it may be treated by appropriate remedies. Scarpa recommends paracentesis abdominis in 3a* this disease. He not only dreads no evil conse- quence from this dangerous operation in preg- nancy, but supposes the gravid uterus itself may be safely punctured, and supports this opinion by cases related in the writings of Camper, Bonn, Languis, and Reiscard. We cannot, however, under any circumstances, be justified in perform- ing either of these operations, which the experi- ence of others has proved to be so hazardous, if, by the simple means now recommended, relief can be obtained. From what we have observed in several recent cases of dropsy of the amnion, we are disposed to believe that the administration of diuretics and other remedies has a considerable influence in controlling the disease. In a lady who had suf- fered repeatedly from dropsy of the amnion, the further effusion of fluid seemed to be prevented by the use of mild cathartics, of squill and supertar- trate of potash, and by surrounding the abdomen with a soft flannel roller. When there has been unusual sensibility of the stomach, the repeated application of leeches has not only relieved the pain, but apparently diminished the secretion of liquor amnii. 2.—Of tumours and enlargements of the glands situated in its orifice, which are not of a malignant nature. In a paper on fibro-calcareous tumours and polypi of the uterus, which will appear in the second part of the eighteenth volume of the Me- dico-Chirurgical Transactions, we have described four varieties of uterine tumours, none of which are malignant or cancerous in their nature. First, the fibrous; secondly, the follicular, or glandular : thirdly, the cystic, or vesicular; and, fourthly, the mucous tumour of the uterus. The fibrous tumour is usually of a globular form, and varies greatly in size. It has generally a cartilaginous and fibrous structure, and the fibres are often disposed in a concentric or converging manner. This tumour has sometimes a granular appearance, or seems to consist of a congeries of smaller tumours, of different densities, each hav- ing a thin capsule of cellular membrane. When large, the tumour is often unequal, lobulated, or divided by deep fissures, and arteries and veins of considerable magnitude can be traced into its sub- stance. Cavities containing a bloody or dark- coloured gelatinous fluid are sometimes formed in the central parts of the tumour, by a process of softening which its substance undergoes. In other cases the tumour does not manifest a dispo- sition to become softer as it enlarges, but its den- sity gradually increases until the whole mass has become cartilaginous, without arteries or veins containing red blood; or calcareous depositions are gradually formed in the substance of the tumour, until it is partially or completely converted into a concretion of phosphate or carbonate of lime. This is generally of a light yellow colour or nearly white, soft, and porous, like pumice-stone ; but in- stances have occurred where it has become so hard as to admit of being polished like marble or ivory. These deposits usually first take place in the most dense points of the tumour. In a few rare cases, they have been formed on the surface of the tumour, and have inclosed it likethe shell of an egg. Gardien states that the smallest tumours most frequently 606 UTERUS, (PATHOLOGY OF THE) undergo this transformation. Andral, on the authority of Brugnatelli, states that carbonate and phosphate of lime, with an animal or gelatinous matter, enter into the composition of these bodies. Dr. Turner, professor of chemistry in the London University, had the kindness to analyze, at our request, two years ago, a small concretion, which was passed during life from the uterus of a female above sixty years of age. This was found to con- sist entirely of carbonate of lime and animal mat- ter. Dr. Bostock has more recently analyzed se- veral specimens of uterine concretions, and he has found them principally to consist of phosphate and carbonate of lime with animal matter. (Med. Chirurg. Transact, vol. xviii, part ii. p. 313.) In several cases of fibro-calcareous tumour of the uterus which have come under our observa- tion, and of which we have related the histories in the paper referred to, little uneasiness was ex- perienced during life; but in another case there was also malignant ulceration of the uterus, and portions of the calcareous tumour were discharged from the vagina long before the disease proved fatal. Many months previous to her death this patient had attacks of hemorrhage and excruci- ating pains in the uterus before the concretions were passed. There were also sallowness of the complexion, and great irritability of stomach, as in cases of malignant disease. A somewhat similar case of malignant ulcera- tion of the uterus with calcareous tumour has been recorded by M. Louis, in the second volume of the Memoirs of the Royal Academy of Sur- gery. A lady long felt a sense of weight in the uterus, and for three years had suffered acute pain with constant leucorrhcea. Six weeks before death, which happened on the 27th of May, 1744, a foreign body which presented in the vagina was removed with a pair of forceps. This concretion, which was shown to M. Levret, was large, and had the form of a hen's egg. Its consistence was like plaister. On the following day a small body of the same character was removed. The patient had borne several children before she began to ex- perience these pains. During the last months of her life the contents of the bladder and rectum passed through the vagina. On dissection, a gangrenous ulcer was found at the orifice of the uterus, and had destroyed the septum between the rectum and vagina. The fundus uteri was healthy. " The symptoms and the accidents," observes M. Louis, « which these concretions of the uterus produce, do not affect this organ exclusively. Their situation with respect to the bladder may greatly derange its functions. The following ob- servation will show that difficulty in passing the urine, and even retention of urine may be occa- sioned by the presence of a concretion in the uterus. A woman, seventy-two years of age, died at Lille in 1688. She had been afflicted for fifteen or sixteen years with difficulty in voiding the urine, insupportable pains in the region of the loins, os pubis, and perineum. The cause of the symptoms was referred to the kidneys or bladder, but accidentally the uterus was examined, and it appeared to be ecirrhous. A large hard stone filled its whole cavity, which was considerably dilated by this foreign body. The outer layer of this stone was of a friable matter, which was easily detached. The interior was more solid but very porous, for this stone was very large compared with its weight, which was only four ounces; it would have weighed a pound if the matter had been more condensed, and the volume equal." M. Louis relates the case of another woman sixty-two years of age, who died of a diseaso of the chest in the Salpetriere, on the 16th April, 1744. On opening the body the uterus was found as large as a hen's egg, and low down in the vagina. Its orifice was not dilated, and its cavity was completely filled with a white hard substance which weighed ten drachms and a half, and a month after only six. This woman for some years before death had suffered from a disa- greeable sense of weight in the region of the ute- rus, with pains in the loins and thighs. She had also suffered severely from pruritus pudendi and upper part of the thighs. (Memoires de l'Acade- mie de la Chirurgie, t. ii.) Schenkius has collected together, from the works of Hippocrates, Vallesius, Salius, and Marcellus Donatus, the histories of some extraordinary cases of stones discharged from the uterus during life, and discovered in the organ after death. Some of these histories are probably authentic, and if so, they prove that the disease now under con- sideration has existed from the earliest ages. (De aliis Uteri Affectibus, lib. iv. p. 717.) Hippocrates relates the history of a woman of Larissa who, when young, suffered pain during intercourse, and never became pregnant. When sixty years of age, she was attacked with pain-like labour, after eating a quantity of onions. " The pain became so intense," he adds, « that she faint- ed, and during this state of deliquium, another woman, perceiving a rough body protruding from the vagina, removed it with her hand. The pa- tient ever afterwards enjoyed good health. (Lib. v. de Morb. Popular, sect, vii.) Salius relates the case of a nun sixty years of age, who suffered violent pains in the uterus for several months. The pains, which were alleviated by no remedies, ceased after the escape of a con- cretion the size of a duck's egg. The patient af- terwards died from the exhaustion produced by the putrid suppuration of the uterus. (Salius ad C. 113, Pract. Altom.) Marcellus Donatus states that Hippolita Gaeta died after having long suffered from uterine pains and fever; and that a stone of an incredible size, having the consistence of gypsum, and floating in a quantity of black fluid, was found in the uterus on dissection. " Cujus rei (he observes) nos multos habemus testes." (Hist. Mirab. lib. iv. c. 30.) About the year 1070, in a village of the Sois- sonnais, according to the chronicle of Antonin as quoted by Louis, a pregnant woman, who had been three weeks in labour, was delivered of three stones. One was of the size of a goose's egg, the other was as large as a hen's egg, and the third was like a nut. The child immediately followed, and the woman was freed from her pains. Ambrose Pare states that persons who have stones in the uterus experience violent pains in it, and that they have bearing-down efforts similar to those of labour. UTERUS, (PATHOLOGY OF THE) 607 Michael Morus cites the case of a woman up- wards of forty years of age, who died of a pleurisy, and had suffered for a long time severe pains of the hypogastrium, for which all remedies had failed to procure relief. On examination, a hard- ness was felt in the uterus. There escaped from the vagina an acrid discharge, like the washings of putrid flesh. Thirty-two stones were found in the uterus, the smallest of which was the size of an almond. Different folds of the uterus retained them, and some of them were in the Fallopian tubes. He believed these concretions to be of the same nature as bezoars ; and he affirms that he saved the lives of several patients by their use. From his statement, that the stones were in the Fidlopian tubes, and that they were retained by different folds of the uterus, we are disposed to think that they were uterine phlebolites which he saw, and not fibro-calcareous concretions of the uterus. With the origin of calcareous tumours of the uterus, pathologists do not appear to have become acquainted, till a comparatively recent period. Walter has given engravings of these bodies in his Annotationes Academica, published in 1786 ; and be states that calculi are sometimes present with polypi of the uterus and vagina. It does not appear, however, that he discovered the intimate relation which exists between them; and from a recent examination of some of the preparations in the Hunterian Museum at Glasgow, we are dis- posed to believe that Dr. William Hunter was the first who was acquainted with the different situa- tions which fibrous tumours occupy in the uterus, and with the various changes which they undergo in the progress of their development. From an examination of a single specimen of the disease, Dr. Baillie was led to suspect, in 1787, that calcareous concretions of the uterus commence as fibrous tumours. " In the cavity of the uterus," he observes, " a bony mass is some- times found. When this is the case, I suspect that the hard fleshy tubercle within the cavity of the uterus, such as I have already described, has been converted into bone. This, at least, had taken place in the only instance which I have known of this disease; for a great part of the tubercle Ptill remained unchanged, and I think it very pro- bable that such a change most frequently happens where these bony tumours are found." (Morbid Anatomy, t. ii. p. 331.) Dr. Baillie refers to the works of Lieutaud for proof of the fact that stones have been found in the cavity of the uterus. "These are described by authors," he adds, " as varying in their appear- ance, some being of a dark, others of a light colour. They are silent about their nature, and I can say nothing of it from my own knowledge, as it has never occurred to me to see an instance of this disease. Such concretions are probably formed from matter thrown out by the small arteries which open on the internal surface of the uterus, and arc in some degree analogous to the concretions formed in some glands of the body." (Morbid Anatomy, p. 332.) Bayle, Bichat, Roux, Breschet, Andral, and many other pathologists, have long been fully aware of the fact, that fibrous tumours occasion- ally become calcareous, or, as they have impro- perly been termed, bony. Whether all the con- cretions reported to have been found in the cavity of the uterus are formed by deposits in fibrous tumours, and whether the substance of the uterus itself is ever converted into bone, as reported b) Verdier, we are not at present in possession of facts which enable us satisfactorily to determine. When calcareous concretions of the uterus are discovered to exist by an examination per vaginam, and where they are loose, they may be removed artificially with a pair of forceps, or with the fin- gers. Incisions into the os uteri, as in the case related by M. Louis, do not offer much prospect of relieving the patient. When attacks of inflam- mation of the uterus are produced by these con- cretions, the symptoms should be relieved by leeching and other appropriate remedies, and irri- tation diminished by anodynes. M. Bayle has described the fibrous tumours of the uterus as fleshy and of a red colour at their commencement, then as becoming cartilaginous, and in the last stage osseous. This may be the fact with a few rare examples of the disease, but we are satisfied it is not uniformly so, and that the greater number of these tumours never exhibit a muscular or fleshy appearance at any period of their existence, but have a fibrous structure equally distinct when not larger than a pea, and when exceeding in magnitude the head of the human adult. Sometimes we find only one tumour present in the walls of the uterus; at other times several are met with of different sizes, and not unfrequently they are combined with cysts and tumours of the ovaria. They have no disposition to ulcerate, nor to degenerate into a malignant form, though they are not unfrequently observed in individuals who have cancerous affections of the uterus, mamma;, liver, and other organs. They have seldom, if ever, been observed before the age of puberty, and Bayle affirms that they are most frequently met with in the bodies of those women in whom the physical signs of virginity are present, and that in twenty out of one hundred women taken indis- criminately after the middle period of life, the fibrous tumour, more or less developed, is found on dissection imbedded in the walls of the uterus. Fibrous tumours are developed either in the cellular membrane under the peritoneal coat of the uterus, or they are formed between the layers of its muscular or middle coat, or immediately below its internal or mucous membrane. When under the peritoneum, they often hang by a very slender neck, and the peritoneum covering them is highly vascular, when no blood-vessel can be perceived in their substance. When situated under the peritoneum, while their volume is small, they produce no change in the form of the uterus, and they give rise to no irritation, hemorrhage, or derangement either in the uterine functions or general health, and their existence even can only be guessed at during life. But when they attain a large size, and come to occupy a great part of the abdominal cavity, they produce all the injurious consequences of enlarged ovaria, from which indeed during life they are distinguished with the greatest difficulty, and death ultimately takes place from interrupted circulation and long-con- tinued pressure on the bladder and other contigu- 608 UTERUS, (PATHOLOGY OF THE) ous viscera. When situated under the peritoneum of the uterus, fibrous tumours do not prevent im- pregnation, because they do not interrupt the com- munication between the vagina and ovaria; but when adherent to the posterior part of the body or neck of the uterus, they sometimes produce fatal consequences both to the mother and child by impeding the progress of the latter through the pelvis, or by giving rise to hemorrhage and inflam- mation after delivery. (Med. Chir. Transact, vol. xviii. part ii. p. 387.) " When fibrous tumours are formed between the strata of muscular fibres of the uterus, we have also observed that they attain a large size; the fundus, body, and orifice of the uterus usually become hypertrophied as during pregnancy, and greatly altered in shape. If situated midway between the peritoneal and mucous membranes, they press equally in all directions as they slowly enlarge, and separate the muscular fibres, and cause the uterus to project both on the external and internal surfaces. When a thin stratum of muscular fibres is interposed between the tumour and peri- toneum, the projection is observed only on the corresponding peritoneal surface on the uterus, and the cavity of the organ remains unchanged." (Ibid.) Tumours situated in the muscular structure cannot be recognised until they have attained a large size. The disorders they produce, M. Gardien states, are least after the critical age. Women who have fibrous tumours imbedded in the proper tissue of the uterus are frequently barren, or if they become pregnant, abortion takes place in the early months, in consequence of the uterus being incapable of undergoing tho requisite development. Where the ovum is not prematurely expelled, death may take place from uterine hemorrhage soon after delivery. M. Chaussier saw a woman die from flooding soon after giving birth to a full- grown child. There was a fibrous tumour of great size in the posterior walls of the uterus. This body was not situated, however, so as to present an obstacle to the passage of the child through the pelvis, but soon after delivery it was perceived that the uterus had not the power of contraction. Profuse hemorrhage took place from that part of the uterus in which the tumour was lodged, the flow of blood could not be arrested, and the patient died. On the 12th of February, 1823, a woman, aged forty-two years, residing in Cumberland Street, Middlesex Hospital, was delivered by embryotomy of a still-born hydrocephalic child. The liquor amnii amounted to sixteen pints. Profuse uterine hemorrhage followed the extraction of the placenta, and on the third day after delivery death took place from inflammation of the peritoneal and muscular coats of the uterus. We examined the body, and found a hard fibro-cartilaginous tumour in the muscular coat, where the placenta had adhered to the uterus. We have recorded a similar case which occurred to Dr. Chowne. Another case of the same description has been given by Dr. Outrepont. Dr. Marshall Hall relates the case of a woman who died after parturition from inflammation and suppuration of fibrous tumours of the uterus. (Principles of Diagnosis, Lond. 1834, p. 307.) There are no symptoms by which we can positively determine during life the presence of fibroin tumours in this situation ; they may, however, be suspected to exist in those individuals who, being advanced beyond the middle period of life, .suffer habitually from leucorrhoeal discharge, who men- struate profusely, and have attacks of menorrhagia, with irritation in the region of the uterus and adjacent organs. After unusual exertion, chronic inflammation of the uterus is not unfrequently produced by them ; and from what we have observ- ed in some cases, we have been led to believe that what is termed irritable uterus, which is supposed to arise from a nervous affection of the uterus without any change of structure, is in some women referable to the presence of fibrous tumours in the walls of the organ. But the fibrous tumour is sometimes developed immediately beneath the lining membrane of the uterus, or with a layer of muscular tissue inter- posed. It is in this manner that the greater number of uterine polypi originate. As the tumour of polypus enlarges, the cavity of the uterus becomes distended as by the ovum during gestation, and its walls are excited to contract and expel the tumour, which pushes before it through the orifice of the uterus that portion of the lining membrane of the uterus by which it is covered, in a manner somewhat analogous to what takes place in hernia when the peritoneum is pressed forward by the intestine or omentum through the inguinal or crural canals. By the constant and powerful action of the uterus, the tumour is gradually forced into the vagina, where it undergoes various impor- tant changes of structure, both in its covering membrane, peduncle, and deep-seated parts. lis mucous membrane is sometimes pale, and presents little sensible change of structure, but more fre- quently it becomes highly vascular, hypertrophied, softened, and inflamed, or it ulcerates and sloughs and gives rise to a sanguineous, purulent, and fetid discharge from the vagina, and to all the otbei symptoms of malignant disease of the uterus. In some cases the diagnosis between a large fibrous tumour in this stage filling the vagina, and a ma- lignant fungous disease of the os uteri, is extremely difficult. Dupuytren believes that fibrous tumours in the vagina sometimes become cancerous; but this fact has not been satisfactorily established. We have observed in the same volume of the Medical and Chirurgical Transactions, that if the tumour be covered only by the lining membrane of the uterus, little difficulty is experienced in ex- pelling it from the cavity, and the pedicle is slen- der, consisting only of thickened lining membrane, a little cellular substance, and some small blood- vessels; but when the tumour is covered also with a layer of muscular tissue of the uterus, the root is thicker, often as large as the wrist in cir- cumference, and consists not only of lining mem- brane and blood-vessels, but chiefly of muscular coat. A longer continuance of uterine action « here required to force the tumour into the vagina, and not unfrequently the patient expires from the loss of blood before the tumour has descended sufficiently low to admit of the application of a ligature around its root. We are disposed to be- lieve, from preparations in our possession, that It UTERUS, (PATHOLOGY OF THE) 609 is not on the primitive state of the tumour or I the commencement of labour a tumour was disco- polypus, as Herbiniaux and Dupuytrcn have sup- vered in the vagina. After the rupture of the posed, that the consistence and form of the pedun- membranes, as the child did not advance, it was cle depend, but on the quantity of muscular fibres i delivered by turning, and was born alive. The carried before the tumour, and that in most cases placenta was spontaneously expelled, but some where the peduncle is thick and short, it will be j hours after a soft round tumour was found press- found to be composed not only of mucous mem- j ing on the os externum. Violent expulsive pains brane and blood-vessels, but of hypertrophied mus- | continued for many hours after delivery. A large cular structure of the uterus. This account of the formation of uterine polypi, which is con' firmed by the observations of Dr. Sims, Cruveil- hier, and Boivin, will satisfactorily explain why it fleshy tumour, which presented the appearance of an inverted uterus, had been forced out of the vagina. She continued to suffer during the whole of this day, and died in the evening. The body is unnecessary, as many have supposed, to pass j was examined the following day. The uterus the ligature for the removal of polypi close to was contracted, but its mouth was dragged down the uterus; and it also explains a circumstance ■ as low as the external orifice by a tumour, which pointed out by Clement and Puzos, that the root of the polypus which remains never grows again after the general mass of the tumour has been re- moved. The fibrous tumour is developed under the lining membrane of the fundus, body, cervix, or grew from it by a broad base. It was attached to the posterior part of the mouth of the womb, and some way up the neck was of a livid colour, and weighed three pounds fifteen ounces. The pa- tient had borne her last child before easily and naturally, but some time before her present preg- os uteri, and the symptoms are modified according nancy, she looked as large as if seven months with as it is situated in one or other of these situations Inversion of the unimpregnated uterus is some- times produced when a large fibrous tumour is formed in the walls of the fundus uteri, near the inner surface. Dr. William Hunter and Dr. Den- inan have both related cases of this description, which terminated fatally in consequence of the ligature having included a portion of the inverted uterus. It occasionally happens, when the fibrous tu- child. (Dr. Merriman's Synopsis, &c. Lond. 1820. p. 225.) M. Deneux gives the history of a case of fibrous tumour of the uterus expelled into the vagina. after an abortion at the fourth month, and mis- taken for after-pains. The lady, aged thirty, after the second child observed the abdomen larger than natural; menstruation became irregular, and she had occasional attacks of menorrhagia. She again became pregnant, and miscarried at the fourth mour is large, and is formed under the lining j month. The after-birth was expelled with diffi- tuembrane of the cervix uteri, that it is suddenly expelled from the vagina, and produces appear- ances which strikingly resemble those observed in cases of chronic inversion of the uterus. The fibrous tumour and inverted uterus being both covered by the same mucous membrane, and being liable to the same changes of structure from pres- sure, interrupted circulation, and inflammation, without an accurate acquaintance with the pre- vious history of the case, and the progress of the symptoms, the diseases might readily be con- founded together. Levret, Herbiniaux, and other writers, infer that most of the cases which have been reported of amputated uterus, have been cases of large polypi or fibrous tumours, which had escaped from the vagina. Two cases have come under our observation in which large fibrous tumours of the cervix uteri, having passed through the ostium vaginsB, gave rise to appearances which could not be distinguished from inversion of the uterus during life. A case has been recorded by Klingberg of a large fibrous tumour of the cervix uteri being treated as a case of prolapsus. A great wax pessary had been passed into the vagina to give it support. (Acta Reg. Societ. Hav. vol. p. 31.) Dr. Merriman relates the history of a pregnant woman in whom a fibrous tumour of considerable size was connected with the os uteri. A ligature was applied around the peduncle, and in a few days the tumour fell off. The general health of the patient improved after the operation ; she went to the full time, but the child was still-born. Dr. Gooch relates a case which occurred in the practice of Mr. Borrett of Yarmouth, in 1799, which terminated fatally soon after delivery. At Vol. IV.— 77 culty. The uterus remained larger than usual. Fever followed, with pain of abdomen. After some days a soft fleshy body was perceived at the vulva, and this was supposed to be the placenta. The febrile symptoms continued. It was found impossible to remove this body, and it was disco- vered to be a fibro-cartilaginous tumour. It was removed by a ligature applied round its neck, but the patient died. On examining the tumour, which was of the size of the fist, its form was found to be irregular, and it was composed of two distinct parts: 1st, an exterior covering, in a putrid gangrenous state; 2dly, a central portion, white, fibrous, lamellar, presenting an appearance of little cells, hard and resisting when cut with the knife. Uterine and abdominal inflammation followed. The tumour had sprung from the inner part of the anterior wall of the uterus. The ligature had been applied to the proper tissue of the uterus. A smooth cavity was found in the anterior wall of the uterus, which was lined with a fine mem- brane, a portion of which was enclosed in the ligature. The uterus was healthy in other re- spects. M. Deneux cites cases from Delius, Ruleau, Lamotte, Frank, and Arnaud, in which bodies putrefied within the uterus, and he points out the importance of exploring the vagina and uterus, to determine whether this is so when the lochia are offensive. (Repertoire General d'Anatomie, &c. torn. vii. 1829.) Though it has been demonstrated that the greater number of uterine polypi are merely fibrous tumours which have been developed under the lining membrane of the uterus, and a layer of its muscular fibres, we are not entitled to infer, as 610 UTERUS, (PATHOLOGY OF THE) some writers have done, that these are the only ] tumous which pass from the cavity of the uterus i into the vagina, and which are not of a malignant j nature. We have pointed out other three varieties ! of tumours of the uterus, to which the term poly- pus has been applied: first, a tumour with a broad base, and generally of a flattened form, originating I in a morbid growth of the lining membrane of the organ, and resembling nasal polypi; secondly, a tumour formed under the mucous coat of the uterus, which is composed of a congeries of small cysts or vesicles filled with a clear or yellow- coloured ropy fluid ; thirdly, a tumour of the os and cervix uteri arising from a morbid enlarge- ment of the mucous follicles and glands of the part. (Med. Chir. Trans, vol. xviii. part ii.) History of fibrous tumours und polypi of ihe uterus. Before the middle of the eighteenth century, few facts of any importance had been ascertained respecting the origin and structure of polypus of the uterus. The older writers included under the term polypus all the different tumours of the uterus which have now been described, the greater .number of the organic affections of the os and cervix uteri of a malignant nature, and also fleshy moles or ova in a morbid state. The confusion and obscurity in which the pathology of uterine polypi has so long remained, may be attributed in a great measure to the circumstance that few op- portunities have been enjoyed of investigating their structure before it has been destroyed by in- flammation and sloughing produced by artificial or natural means. In 1696 Saviard examined the body of a woman who died of uterine hemorrhage in the Hotel Dieu. He found a fleshy mass as large as the heart of j an ox adhering to the fundus uteri and filling its cavity. This tumour, which had a slender neck or root, was covered with a membrane which ap- i peared to be an expansion of the internal mem- brane of the uterus. Four branches of arteries ' and veins were distributed to the tumour. The arteries were small, but the veins were as large as the crural veins ; and when the tumour was laid open, a considerable cavity was formed in its ' centre, extending from the apex to the base. The | lower end of the tumour had a contused and gan- grenous appearance, and Saviard believed that the hemorrhage which had destroyed the woman pro- ceeded from the veins. (Levret, Observ. sur les Polypes Uterines. Paris, 1749. 8vo. p. 31.) A woman died at Orleans in the year 1716, who had a tumour hanging from the vagina, which was supposed to be cancerous. M. Levret examined this tumour after death, and found it similar in structure to the tumour described by Saviard. It contained arteries and veins, and was covered on the outer surface by an expansion of the membrane which lines the inner surface of the uterus. A great number of varicose veins were observed on its surface. On laying open the tumour, no other cavities were perceived in it except those of some blood-vessels, the largest of which did not exceed the fourth of a line in dia- meter. In colour and consistence the tumour resembled boiled cow's udder. M. Levret divides all polypi peculiar to females into those which arise from the uterus, and those which grow from the walls of ihe vagina. He subdivides uterine polypi into three species, ac- cording as they are attached to the fundus, the cervix, or the margin of the os uteri. He con- sidered hemorrhage an invariable symptom, after the tumour had passed the orifice of the uterus. M. Levret observed that nature had the power in some cases to rid herself of the disease by detach. ing and expelling the tumour, and he attributed this result to the orifice of the uterus binding and strangling it, like a ligature applied around its neck. When polypi are attached to the os uteri, it sometimes happens, he observes, that the body of the polypus, which is in the vagina, is not every where isolated and surrounded by the os uteri. The finger cannot be carried completely round the tumour, and the point where the resist- ance is met with is situated a little higher than the remaining portion of the circumference of the orifice of the uterus. He was aware that pro- lapsus and inversion of the uterus were liable to be confounded with polypus, and suspected that in several of the cases in which the uterus was said to have been amputated, a large polypous tumour had only been removed. The diagnosis and the treatment of uterine polypi were both much improved by Levret, but he did not con- tribute any fact to elucidate their anatomical struc- ture which had not previously been pointed out by Saviard. The treatise of Herbiniaux contains a much more complete account of the symptoms, diagno- sis, and treatment of polypus of the uterus, than is to be found in Levret's work, and the distinction is accurately drawn by him between the malignant excrescences of the os uteri, and those tumours which have no tendency to become cancerous. He has also described, with greater minuteness, the varieties of form which uterine polypi assume. He says they are not all of a pyriform shape; some are round, others flat, smooth, rugous or in bumps, and the same variety is seen in their roots, some being long and slender, some thick and short. The difficulty of distinguishing polypus uteri from inversion and prolapsus of the organ, and certain organic affections to which it is liable, ii illustrated in a striking manner by Herbiniaux's cases, and he has pointed out the importance of the maxim of Levret, " de ne jamais traiter les femmes ni les filles afrligees d'hemorrhagies habit- uelles sans les faire visiter, surtout si ces hemor- rhagies sont accompagnees d'ecoulemens putrides ou screux, n'importe de quelle couleur." (Traite, &c. Bruxelles, 1782, torn. ii. p. 6.) Walter had a very imperfect acquaintance with the structure and origin of uterine polypi. They are produced, he says, by an irritation in the ori- fices of the vessels which are distributed to some point of the surface of a mucous membrane. " Polypi uteri tunc semper nascentur, si in extre- mitatibus vasculorum membrana; interna; uteri, per aliquod ibi habitans irritamentum, succus qui- dam luxurians secernitur coagulabilis, qui in dies singulos magis tcnax evadit, et spissus tandemque in veram telam cellulosam commutatur. Hac progenita nunc tela cellulosa, quam firmissime vascula ilia conjungens cum illis arctissime coha> ret. Vasa membrana; interna; uteri eodem mouo elongantur quo vasa pleura; et peritonei, qua; w- UTERUS, (PATHOLOGY OF THE) 611 terdum itaprolongantur, ut cum vasis exhalantibus pulmonum et viscerum abdominalium sese con- jungunt. Tali modo uteri polypi vasa accipiant nutrientia, quorum ope de die in diem magis ma- gisve adcrescunt, ita ut talis cellulosa qualis fun- gus appareat, et prsegrandem nonnunquam adipis- cetur magnitudinem." (Annotationes Academ. Berolin. 1786, p. 6.) Dr. Baillie was the first pathologist who had a among these latter the true polypi from the fun- gosities of the mucous membrane. Though Levret has crowned himself with lasting glory in devising means for the application of ligatures around polypi, yet he has left every thing to desire as to the results of his observations from the ex- amination of dead bodies, and of the anatomical details which he might have collected from women who had perished by the disease. Those who precise knowledge of the fact that fibrous tumours followed him are to be reproached with like indif- of the uterus have no relation to cancerous tu- j ference in not availing themselves of opportunities mours. Dr. Baillie was also the first who disco-1 which they must have enjoyed to interrogate na- vered that the most common kind of polypus is ture, and supply the deficiencies of our informa- hard, and consists of a substance divided by thick ; tion respecting the pathology of polypus of the membranous septa, like the fleshy tubercle of the uterus." Bichat and Roux compare the structure uterus. " When cut into," he says, «it shows precisely the same structure as the tubercle of the uterus just described, so that a person looking on a section of the one and the other out of the body could not distinguish between them. This sort of polypus varies very much in its size, some not being larger than a walnut, and others being larger than a child's head. It adheres by a nar- row portion or neck, which varies a great deal in its size and in its proportion to the body of the polypus. The largest polypus I ever saw was suspended by a neck hardly thicker than the thumb; and I have seen a polypus less than the fist adhering by a neck fully as thick as the wrist. " The place of adhesion also differs considerably. It is most commonly at the fundus uteri, but it may take place in any other part; and I have seen a small polypus adhering just on the inner lip of the os uteri. When a polypus is of any con- siderable size, there is generally one only ; but I have occasionally seen on the inside of the uterus two or three small polypi, and in some instances several polypi have been known to grow from the uterus in succession. " Another sort of polypus forms in the uterus, which consists of an irregular bloody substance with a number of tattered processes hanging from it. This, when cut into, exhibits two different appearances of structure ; the one appearance is that of a spongy mass, consisting of lamina; with small interstitial cavities between them ; the other is that of a very loose texture, consisting of large irregular cavities." (Morbid Anatomy, vol. ii. 1828, p. 327.) In 1802, M. Bayle published a memoir on fibrous bodies of the uterus, in which he pointed out their structure, situation, and symptoms more accurately than had previously been done, and clearly distinguished them from scirrhous tumours of the uterus. He was perfectly acquainted with the fact that the fibrous polypus and fibrous tu- mour of the uterus are the same disease. (Jour- nal de Medecine, t. v. p. 62, and Diet. des. Sc. Med., art. Corps fibreux de la Matrice, t. vii. p. 59.) Bichat and Roux published, in 1809, an essay on the organization of uterine polypi, and their surgical treatment. « Until the present time, they observe, all practitioners have confounded under a common denomination many affections essentially distinct. The word polypus has served to designate the various excrescences of the pitui- tary membrane and the pediculated tumours which are developed in the interior of the womb and of the vagina. Further, all have not distinguished j of fibrous tumours of the uterus to intervertebral cartilage in old men, and to prove the fibrous structure of polypi they adduce the fact that they frequently become cartilaginous. " Whatever," they observe, " be the external disposition which these tumours present, of which we now treat, they have all a similar organization. We cannot, however, irrevocably pronounce that there cannot be formed in the walls of the uterus, tumours, or rather diseased productions, differing from those of which we here speak. Perhaps further obser- vations may make these known to us, but at least at the present time, the great number of specimens procured from dead bodies enable authors to es- tablish a perfect identity in the nature of all uterine polypi." (CEuvres Chirurg. de T. I. De- sault, t. iii. p. 370, 8vo. Paris, 1809.) " A polypus does not appear to be regularly organized like a natural part of the body: it most probably arises in this way: a blood-vessel is rup- tured, the blood from it coagulates, and into this various vessels shoot, and there, as living matter, it may grow by powers of its own." This is understood to have been the opinion entertained by Dr. J. Clarke respecting the origin of uterine polypi. (London Practice of Midwifery, p. 42, 5th ed. 1823.) Sir C. Clarke defines a polypus of the uterus to be « an insensible tumour attached to the internal part of the viscus by a small neck, forming a disease of a very important character." (Observ. on the Diseases of Females, 1821, p. 243.) Its insensibility, he says, distinguishes it from inverted uterus, and the regularity of its sur- face from cauliflower excrescence of the os uteri. On the structure of uterine polypi he has offered no remark. Dr. Cusack distinguishes uterine polypi into soft and hard. In a case of soft poly- pus, Dr. Cusack states that it was exquisitely sen- sible to the touch, a circumstance which, he says, had previously been pointed out by Dr. Johnson, in the Dublin Hospital Reports, who shows the fallacy of founding a diagnosis between polypus and inversion of the uterus upon the tenderness of the uterus in the case of inversion, "The most frequent kind of polypus is of a firm semicartilaginous structure," according to Dr. Burns, » and is covered with a production of the inner membrane of the womb, and indeed it seems to proceed chiefly from a morbid change of that membrane and usually subsequent enlargement of the diseased portion,- for the substance of the uterus is not necessarily affected. The enlarge- ment is generally greatest at the furthest extremity of the tumour, and least near the womb ; so that 612 UTERUS, (PATHOLOGY OF THE) there is a sort of pedicle formed, which sometimes contains a pretty large blood-vessel, and the tumour is pyriform. But if the membrane of the uterus be affected to a considerable extent, and especially if the substance of the uterus be diseased, then the base or the attachment of the polypus is broad. The vessels are considerable, especially the veins, which sometimes burst; in every instance, I be- lieve, if the patient live long, the tumour is dis- posed to ulcerate." Dr. Gooch defines " a polypus of the uterus, when discovered, to be a tumour in the vagina attached to some part of the uterus. It is round, smooth, firm, and insensible." " The internal structure of polypus, in most cases, exactly resem- bles the internal structure of the large white tu- bercle of the uterus, commonly called the fleshy tubercle." » They are the same disease, differing only in the seat and mode of their attachment, and consequently in the symptoms which they produce." " On cutting into them, we see a hard white substance, intersected by numerous parti- tions. This, however, is not always its structure; it is sometimes of a much softer and looser con- sistence, and sometimes has considerable cavities." Dr. Craigie thinks there is nothing satisfactory known respecting the nature and mode of develop- ment of uterine polypus. " It appears," he says, " to consist in a deposition of matter entirely new, either in the mucous chorion or submucous fila- mentous tissue. The tumour is almost invariably covered by a thin pellicle, similar to mucous mem- brane, but much more vascular. It appears on the whole to be much of the nature of vascular sar- coma occurring in other textures. It is generally vascular, often traversed by varicose veins, is liable to frequent hemorrhage, and occasionally degene- rates into destructive ulceration. It ought not, however, to be confounded with cancer." Dr. Hooper observes, that " uterine polypi are organized fleshy fungous substances found attached to the surface of the cavity of the uterus, or that of its cervix, or the surface of the vagina." " Some of them," he says, " are a subcartilaginous, hard, elastic substance, of a dirty brownish colour, which presents, when cut through, an appearance that approaches very much to that of the subcartilagi- nous or fibrous tumour. In this, which often ac- quires a great size, there are several small irregular cavities filled with a serous fluid. There is an- other polypus, which, when cut, presents a smooth compact surface, and a more obviously gristly structure. It also has cavities, but not the cords which the former has. Other polypi Dr. Hooper describes as having a different structure, being soft, spongy, very little elastic, the cut surface smooth and vascular, and its colour fleshy." Dr. Hooper likewise includes, under the term polypus, hcmatoid and brain-like tumours of the uterus. Dr. Davis states, that " polypi arc adventitious structures, which have been known from time immemorial. Without regard to any precise defi- nition of polypi, modern writers have distributed tumours of this class into several principal vari- eties, founded for the most part upon these more obvious physical and structural properties, as soft, hard, vascular, fibrous, fleshy," &c. Dr. Davis refers all uterine polypi to the four following va- rieties :—soft, fibrous, muco-lymphatic or cellulo- fibrous, and spongy-granular. (Principles and Practice of Obstetrical Medicine, p. 599. Lond. 1834.) " When the polypi of the uterus," observes M. Dupuytren, " are divided immediately after their excision, they present a dead white appearance; they resemble exceedingly interstitial substance, being eminently fibrous; but they also contain another tissue—I mean cellular membrane—gene- rally, however, more dense than elsewhere; some- times these two are in about equal proportions, but occasionally one preponderates over the other, and it is on this preponderance that the subsequenl changes depend. If the fibrous element abounds, the polypus does not degenerate ; or if at length it does so, it passes into an ossific state. If, again, the cellular tissue abounds most, the polypus de- generates into carcinoma." (Lecons Orales, re- ported in the Lond. Med. Gazette, p. 190.) Treatment of fibrous and other Tumours of the Uterus, which are not malignant in their nature.—When formed under the peritoneum and between the muscular fibres of the uterus, fibrous tumours are but little under the influence either of external or internal remedies. Iodine and mer- cury have little effect either in arresting their growth or promoting their absorption. The in- creased determination of blood which often takes place to the uterus when these bodies are formed in its walls, should be relieved by local blood- letting, anodynes, and rest in the recumbent posi- tion ; and when profuse hemorrhage occurs, it should be controlled by rest in the recumbent po- sition, cold applications to the hypogastrium, the tampon, and the superacetate of lead. The un- easy sensations from pressure on the blood-vessel9 and nerves of the lower extremities may some- times be slightly relieved by certain changes of posture; and if the tumour be movable and oc- cupies the hollow of the sacrum, and compresses the bladder and rectum, it may be removed from this situation by pressing it above the brim of the pelvis. In most cases, fibrous tumours cannot be removed by art while they remain within the cavity of the uterus. When the hemorrhage en- dangers life, some authors recommend us to dilate the os uteri artificially, and to remove the tumour. Lisfranc has recorded a case, in which incisions were made through the os uteri, and the tumour removed. When fibrous tumours are formed under the lining membrane of the uterus, and have passed through its orifice into the vagina, constituting polypi, they may be removed by a ligature, oi their root may be divided with a knife, or they may be twisted off. Since the invention of the double canula by Levret, various instruments have been employed for passing ligatures around the stems of uterine polypi. For polypi of ordinary dimensions, the instruments of Goerz, improved by Niessen and Dr. Gooch, are the best that can be employed. When the tumour is of large di- mensions, a curved rod or tube is preferable. When the two silver canula; are made use of, a strong ligature must be introduced through both tubes, so that its two ends may hang out of their lower apertures, while the middle portion forms a noose between the two upper apertures. Thus armed, the canula must be passed over the globular part of tM UTERUS, (PATHOLOGY OF THE) 613 ttmoor, the fore-finger of the left hand having previously been introduced as a guide to the in- strument. One of the tubes is then to be kept fixed, while the other tube is to be carried slowly round the circumference of the root of the tumour until it reaches the opposite side of the tube, which haa been kept in the same place. The ligature must be tightened until the neck of the tumour is completely cut across. When the tumour becomes putrid, and many days elapse before its root is divided by the ligature, the tumour should be drawn down, and the peduncle should be divided with the knife or scissors. The greatest attention should be paid to cleanliness, and the offensive discharge should be washed away by injection of tepid water and solutions of the chlorurets. This operation is not without danger. In a case which occurred in St. George's Hospital, under the care of Mr. Babington, the patient died of uterine phlebitis. M. Blandin saw a case terminate fatally from the same disease. Cases have repeatedly terminated unfavourably from ulceration being excited in that part of the uterus to which the tumour had adhered. Dupuytren states that he has met with eight or ten cases where patients were destroyed after the application of a ligature around the root of a polypus of the uterus, and where the symptoms were those produced by the absorption of pus into the system. M. Dupuytren has removed two hundred uterine polypi by ex- cision, in the course of the last twenty years. In this large number, hemorrhage has only taken place twice, and in both these instances it was permanently arrested by plugging. In eight cases, M. Velpeau has never met with hemorrhage. Many other distinguished continental surgeons prefer the excision of uterine polypi to their re- moval by the ligature; and our experience inclines us to prefer the former method. Where the root of the tumour is largely supplied with blood-ves- sels, as in a recent case which came under our observation, to obviate the danger of hemorrhage after its division, a ligature should previously be firmly applied around it, at a short distance from the uterus. Dubois affirms that even this does not secure the patient from hemorrhage. Du- puytren seizes the tumour with the forceps of Museux, and draws it down till the os uteri can be seen at the entrance of the vagina : a pair of curved scissors is then conducted along the finger to the root of the tumour, and it is divided. It is only in cases where the neck of the polypus is slender and of soft consistence, that it can be safely twisted off. 3. Of the Malignant or Cancerous Diseases of the Uterus. Scirrhus, carcinoma, hsematoma, cephaloma, fungus hsematodes, cauliflower excrescences of the os uteri, excrescences vivaces, corroding or phage- denic ulcer of the os and cervix uteri, are some of the terms which have been employed by different authors to designate the varieties of malignant or cancerous disease of the uterus. That there is no essential difference between these affections is proved by the fact, that the morbid alterations of structure by which they are characterized are sometimes found blended together in the same uterus, and they have all this common tendency, that they invariably proceed after a longer or 3b shorter period to destroy the different textures of the uterus and the adjacent viscera. When the os uteri is affected with that form of malignant disease termed carcinoma, it generally becomes thick, hard, irregular, and the lips are everted and painful on pressure. One or both lips of the os uteri become projecting, or they are changed into hard irregular knobs or tumours, which frequently bleed when touched. In the greater number of cases of malignant disease, the os and cervix uteri are the parts first affected, but the opinion is incorrect that the cervix uteri is in- variably the part first attacked, and that the dis- ease commences in the glands of the part. In some cases the lining membrane of the fundus or body of the uterus is extensively disorganized by malignant disease before any change has taken place in the lower portion of the uterus. The cavity of the uterus may be distended with a large, hard, carcinomatous tumour, adhering to the fundus, or with a soft fungous mass growing from the lining membrane of the body of the uterus, while the os and cervix have undergone no sensible alteration of structure. The prepara- tions in our collection illustrate these facts in a striking manner, and they demonstrate also that it is not in the glandular structure of the os and cervix uteri that carcinoma generally commences. Dr. Montgomery observes that " the disease, in- stead of first showing itself in the cervix or os uteri, very frequently commences in some of the appendages of the uterus, involving the surround- ing tissues, or in the upper part of the organ, and thence spreading downwards, manifests itself last in the cervix." (Dublin Hospital Reports, vol. v. p. 457.) Breschet and Ferrus have likewise stated that they have observed cases of extensive malignant disease of the uterus in which the os and cervix were the last to become disorganized. It also follows from these facts that we cannot, in all cases of cancer of the uterus, detect the disease by an examination per vaginam, nor does it admit of relief by excision of the os and cervix uteri. In carcinoma of the uterus, ulceration of the os and cervix takes place as the disease advances, and all the textures of the part are completely de- stroyed. The fundus and body of the uterus, which are often much enlarged, also lose the natu- ral appearance, become hard like cartilage, and in- tersected by a dull white or pale yellow-coloured fibrous or cellular tissue. In other cases, when cut, the uterus resembles a slice of raw or boiled pork: this has been called the Iardaceous degene- ration of the organ ; when it presents, as it some- times does when cut, the appearance of firm jelly, it forms the matiire colloide of the French patho- logists. In other cases, as the softening and ulce- ration proceed, the appearance termed hematoma, fungus hsematodes, or encephaloid cancer, is ob- served to take place. The diseased mass has a soft consistence, like brain, a spongy texture, a lobulated irregular form, and bloody appearance. When cut into, it resembles coagulated blood, with an admixture of albumen, and a soft pulpy substance, which adheres to the knife. Some parts are vascular and fibrous, but the lighter- coloured parts are more firm and fleshy. (Hooper's Morbid Anatomy of the Uterus.) In other specimens of malignant disease of the 614 UTERUS, (PATHOLOGY OF THE) uterus, brain-like masses, as large as an orange, are formed around it, and in these a substance like milk or cream is occasionally found. In va- rious parts of the diseased mass, or around it, por- tions of a dark-brown or black colour, constituting melanosis, are occasionally observed. As the disease proceeds to a fatal termination, irregular-shaped fungous growths of harder or softer consistence, and sometimes as large as a moderate-sized apple, and which bleed profusely when touched, spring from the ulcerated surface and fill up the vagina. Occasionally these malig- nant fungous growths seem to be produced before ulceration has taken place ; and as they increase, they sometimes fall off by sloughing or ulceration, and are speedily reproduced, or leave a deep ex- cavated ulcer, with hard irregular edges. Copious fetid discharges of thin serum, pus, and blood take place from the vagina. The fetor is so great in some individuals that we recognise the existence of malignant disease of the uterus before examin- ing per vaginam. There is a variety of malignant diseases of the uterus which some have considered as essentially different from the preceding, but which is a mere modification of the varieties already described. It has been called the phagedenic or corroding ulcer of the os uteri. Sometimes the ulcer, which is of a deep violet colour, is quite superficial, without much thickening, induration, or enlargement of the part. The ulcer begins like any other malig- nant ulcer on the surface of the body, and it gra- dually proceeds until the greater portion of the cervix has been destroyed, or removed by ulcera- tive absorption, and openings are formed into the bladder and rectum. The portion of uterus which remains after death is sometimes not much altered in appearance: more frequently, however, it be- comes softened in texture, and assumes a yellow or reddish-brown colour. Soft fungous excres- cences of a cauliflower shape also sometimes grow from the ulcer, and undergo changes similar to those observed in other varieties of malignant disease of the uterus. It is now, we believe, ad- mitted by all pathologists that the cauliflower ex- crescence of the os uteri, as it was termed by Dr. J. Clarke, and the excrescences vivaces of Levret and Herbiniaux, are merely varieties of malignant disease of the uterus, and have nothing in their structure resembling the vascular structure of the placenta, as many have supposed. But frequently the ravages of these destructive diseases are not confined to the mucous and mus- cular coats of the uterus; the peritoneal coat is affected, and great changes are produced in all the contiguous viscera. When the cancerous ulceration reaches the peritoneum, inflammation of this membrane is excited, and the patient per- ishes from an attack of acute peritonitis. This is one of the most common terminations of the dis- ease, and the appearances observed after death do not differ from those observed in cases of fatal puerperal peritonitis. Death sometimes also takes place by perforation of the peritoneal coat of the uterus, as in cancer of the stomach and other hol- low viscera. A case occurred several years ago to Mr. Jones of Carlisle-street, in which the perito- neum of the fundus uteri had been perforated by gangrene. Destructive peritonitis was the conse- quence. In a case which we saw with Mr. Prout, the cancerous ulceration of the peritoneum of the fundus uteri had been closed by a portion of ileum becoming united to it by lymph. The malignant affection did not then cease to extend, but it per- forated the ileum, and for many months before death the faces did not pass along the colon, but into the vagina through the opening in the ileum. The uterus, when affected with malignant dis- ease, frequently becomes fixed to the surrounding parts in the pelvis, and hangs low down, near the outlet. The vagina most frequently becomes early involved in the disease; its coats become indurated and contracted, and affected with malignant ulce- ration. When the finger is introduced, it passes into a hard contracted ring in the vagina, beyond which there is often a great ulcerated excavation, communicating with the cavities of the bladder and rectum. From the thickening and induration of the coats of the rectum, constipation is often experienced to a distressing degree. Important changes are likewise produced in the coats of the bladder, which are often perforated, and the urine passing by the opening, the urethra becomes im- pervious. The cancerous thickening of the coats of the bladder closes the openings of the ureters, and complete suppression of urine sometimes takes place. The ureters frequently become distended to a great degree, so as to resemble a piece of in- testine, and the structure of the kidney is greatly changed. In one case which we examined after death, there was a large soft fungous tumour in the posterior part of the bladder, the disease having extended from the neck of the .uterus to the blad- der. Around this fungous growth the mucous membrane of the bladder was raised into white, hard, irregular knobs. The iliac and lumbar glands become hard, or of a cheesy consistence; or large and soft, like brain or lard. The sur- rounding blood-vessels and nerves are involved in the cancerous disease, and not unfrequently the iliac and femoral veins become inflamed, and all the phenomena of puerperal crural phlebitis or phlegmasia dolens are produced. Malignant diseases of the uterus seldom com- mence till after the middle period of life, but there are exceptions to this observation ; and Breschet and Ferrus relate a case of cancer uteri which proved fatal at the age of twenty-two. The author saw a woman twenty-eight years of age, who had the os and cervix uteri destroyed by malignant ulceration, and an opening established between the bladder and vagina. He saw a case of fatal carcinomatous ulceration of the os and cervix uteri in a woman aged twenty-four, who was under the care of Mr. Stodart of Golden-square. Though most frequently observed about the period when menstruation ceases, cancerous disease of the uterus may occur at the most advanced old age as well as in early life: we have observed it in one individual above eighty. It is stated to be nearly as frequent as cancer of the mammse, and to be about one-half less frequent from thirty to forty, and from fifty to sixty, than from forty to fifty It appears to occur with nearly equal frequency ui chaste women, and in those of an opposite cha- racter ; in those who have had children, and in those who have never been pregnant." (Diet. de> Sciences Med. torn. iii. p. 387.) UTERUS, (PATHOLOGY OF THE) 615 The duration of malignant affections of the uterus varies in different cases; their progress is accelerated by violence. Some women die from a superficial ulceration of the os uteri, while others survive for a considerable time the destruction of the greater part of the organ. The disease may run its course in a few months, or the sufferings of the patient may be protracted for several years. They have in some cases made great progress be- fore they have been suspected to exist. " In wo- men who live temperately," observes Dr. C. Clarke, "the disease may continue for a long time with- out producing many symptoms, if any judgment can be formed from the cases of patients who apply for medical aid on account of symptoms under which they have not long laboured. On examination there is often found in such women a considerable alteration in the structure of the parts, which most probably could not have hap- pened in a short time. The examinations made from time to time of patients labouring under this disease who will consent to follow a proper regi- men, frequently prove the very trifling change which will take place in the complaint even in the course of many years." (On the Diseases of Fe- males, vol. i. p. 212.) In women who still menstruate, cancer uteri is usually announced by some irregularity of the menstrual discharge. The secretion becomes more copious, returns at shorter intervals, and continues longer than usual. In those who have ceased to menstruate, there is sometimes a profuse discharge of blood from the vagina, or there is an oozing of blood from the uterus, which continues for several days and then ceases, but reappears at longer or shorter intervals, and in so regular a manner as to lead the patient to believe that it is a recurrence of menstruation. At other times the discharge of blood takes place at irregular intervals, after any unusual mental or bodily exertion. In most cases, from the very commencement of the attack there is pain more or loss acute, sometimes of a burning or lancinating kind, experienced in the uterus, back, inside of the thighs and groins, with serous, mucous, puriform, or sanguineous dis- charge from the vagina. One of the first symp- toms of the disease is pain experienced during intercourse, followed by a slight sanious discharge. As the disease advances, the sense of burning or lancinating pain in the uterus increases, great irritation is experienced in the rectum and bladder and external parts, the mamma; net unfrequently become hard and painful, and there is constant nausea or vomiting. Sooner or later the symptoms appear, to which the term cancerous cachexia has been applied, and of which Bayle and Cayol have given the fol- lowing description : » The colour is pale and yel- low ; emaciation makes rapid progress; certain bluish patches are observed in the face ; the flesh is soft, the tone and energy of all the organs are diminished, and the principal functions are seri- ously disturbed. Constipation or excessive diar- rhn-a tak< s place, with febrile attacks. The pains of the sacrum, loins, and haunches become excru- ciating, so that the patient cannot stand up with- out fainting. Some perish at this period from hemorrhage or peritonitis, others of fever or con- vulsions. If life is not cut short by some of these accidents, a general puffiness or true oedema of the inferior extremities takes place. The dis- charge becomes putrid, and coagula of blood, with a fetid putrilage, flow from the parts. The urine and fseces pass out from the vagina, mixed with the ichorous suppuration of the ulcer, which ex- tends its ravages to the bladder and rectum and all the surrounding parts. In this deplorable state gangrenous eschars take place on the sacrum and genitals, which accelerate the fate of the patient. Aphthae at last occur in the mouth." (Article Cancer Uteri, Diet, des Sciences Medicales.) This is not, however, the invariable course of the disease; for cases have repeatedly come under our observation, where, with little local or general disturbance, there has existed extensive malignant disease of the uterus. A fatal case of true carci- nomatous ulceration of the os and cervix uteri, with great induration, recently came under the notice of the writer, in which there was copious fetid, puriform, and bloody discharge from the vagina; yet the patient made no complaint of un- easiness in the region of the uterus, and continued to take food to a short period before death. Dr. Montgomery has also related cases where the suf- ferings of the patient were inconsiderable, even after the disease had made great progress in dis- organizing the uterus. In most cases there is a peculiar lurid or sallow hue of the face, observed very early in the disease, but in others there is little or no perceptible change in the countenance; and death takes place before there is any consider- able degree of emaciation. There are various diseases which are distin- guished with difficulty from cancer uteri. Fi- brous tumours which have passed through the os uteri, when their surface ulcerates and sloughs, give rise to the same fetid, purulent, and bloody- discharges from the vagina which are observed in malignant diseases of the uterus. It is only by a careful examination of the tumour and os uteri that the diagnosis can be accurately drawn. Fetid leucorrhaea, the unnatural lengthening of the neck of the os uteri in some women, its subsequent swelling, and chronic inflammation of the os uteri, may all be mistaken for malignant disease of the uterus; and it is only by a careful examination per vaginam, by time, and watching the effects of re- medies, as Bayle and Cayol have observed, that we can arrive at the knowledge of the true nature of the complaint. Scrofulous and venereal ulcer- ations of the os uteri are also distinguished with difficulty from the cancerous. Causes.—It is often an hereditary disease. It is not produced by inflammation, but inflamma- tion is often excited in its progress, and when produced, hastens the fatal termination of the af- fection. Mechanical injury has been enumerated among the causes of malignant disease of the ute- rus ; but we have never met with a case where it could be distinctly referred to violence of any kind. Treatment of malignant diseases of the uterus. —There are no means by which we can prevent or remove these diseases. They do not depend upon common inflammation, but on a specific action of the parts which proceeds invariably, sooner or later, to the destruction of the patient. Considerable relief to the sufferings of the patient 616 UTERUS, (PATHOLOGY OF THE) may be procured against those attacks of plethora and inflammation which occur in the progress of carcinomatous degeneration of the uterus ; and perhaps the progress of the disease may be some- times rendered more slow by certain modes of treatment. To remove plethora, leeches should be applied to the vulva or anus, or blood in suffi- cient quantity should be drawn from the loins or sacrum by cupping-glasses. If there should be acute pain with inflammatory symptoms about the pelvis, venesection should be performed. Great relief for a time followed a profuse hemorrhage from the uterus in a case of malignant fungus of the orifice, produced by an unsuccessful attempt to enclose the growth in a ligature. Spontane- ous hemorrhages, though they tend to weaken the patient, often procure temporary relief; and it is better to allow the blood to flow till a decided effect is produced upon the pulse. The applica- tion of leeches to the os uteri by a speculum has also, according to some writers, been had recourse to with decided benefit. To alleviate the agoniz- ing sufferings of those afflicted with these diseases, narcotics must be employed, and the most import- ant of these are opium, conium, belladonna, &c. which should be administered in doses propor- tioned to the severity of the sufferings of the pa- tient. One of the best modes of employing the opium is in the form of suppository, or starch and laudanum glyster, or laudanum in warm milk. The doses of the opium must be gradually increased. Frictions and embrocations should also be em- ployed, and a belladonna plaister laid over the sacrum. In some cases morphia procures rest when all other remedies fail. But there are cases in which every narcotic fails to procure relief for the sufferings of the unhappy patient. When hemorrhage occurs, we must suspend the use of opiates, and have recourse to mucilaginous and astringent remedies. To allay the irritability of the stomach, hydrocyanic acid has been recom- mended. An injection of the chloride of soda is often of great use in relieving the foetor of the discharge. The tepid hip-bath and warm injec- tions of decoction of poppy should also be em- ployed. No permanent benefit can be expected to result from the application of a ligature around the root of a malignant fungus of the os uteri. From what has been stated in the course of these observations, it must appear unnecessary to pass a sentence of condemnation upon the prac- tice of removing the uterus, either wholly or partially, when affected with malignant disease. The operation appears to us equally cruel and unscientific. III. Diseases of the Vagina axd Vilva. Vagina*—The mucous membrane of the vagi- na is liable to attacks of common and specific in- flammation. When inflamed it is red, swollen, and painful; and the patient experiences uneasi- ness in the part when the urine is voided and when she moves. When the inflammation is severe, pus is secreted from the affected mem- brane, or abscesses are formed in the walls of the vagina. In other cases its structure is rapidly destroyed by gangrene, sloughing, or ulceration ; and fistulous communications are formed between it and the bladder and rectum. In several cases which have come under our observation, where there had been a white discharge like pus from the vagina during life, we found on dissection a thin, pale, false membrane coating the lips of the os uteri and a considerable portion of the upper part of the vagina. The mucous membrane under this layer of lymph was red, rough, and granular, and clusters of enlarged mucous follicles were perceptible. The application of cold, mechanical violence. and specific poisons appear to be the most com- mon causes of inflammation of the vagina. Where the affection is of a mild form, it admits of relief from the occasional employment of the tepid hip- bath, fomentation, or emollient and anodyne in- jections, mild cathartics, and low diet. After the acute symptoms have been removed, a solution of nitrate of silver, or some astringent substance, thrown up the vagina, often produces beneficial effects. If the inflammation be intense, warm cataplasms to the external parts and local and general bloodletting may be required in addition to the remedies now specified. When suppura- tion takes place in the parietes of the vagina, or in the surrounding cellular membrane, the mattei should be early evacuated. If a contraction of the canal of the vagina, preventing sexual inter- course, follows sloughing and ulceration, it can generally be overcome by the use of metallic bougies. The dilatation should, however, in this as in cases of natural contraction of the part, be very gradually performed, lest fatal peritoneal in- flammation should be excited. The vagina is also sometimes closed by the presence of an impervious hymen, or from a membrane stretching across the vagina at a greater or less distance from its orifice. No inconve- nience results from imperforate vagina before the age of puberty, when the menstrual fluid, being unable to escape, accumulates, and distends not only the cavity of the vagina, but in some cases the uterus and Fallopian tubes. This distension produces pain in the loins and region of the uterus, difficulty in evacuating the bladder and rectum, and other signs of mechanical irritation of the parts within the pelvis: no discharge ii observed at the expected time. The symptoms are aggravated at each monthly period; and if the disease is not recognised, and the membrane divided, the abdomen becomes swollen, and vio- lent contractions of the uterus, like those expe- rienced in labour, are set up. In some cases the symptoms have been referred to pregnancy or chlorosis ; and if an examination is not permit- ted, it will be difficult to discover the actual con- dition of the patient. When the nature of the disease is ascertained, the inconvenience is re- moved by making a crucial incision through the hymen. Scrofulous, syphilitic, and cancerous ulcerations are met with in the mucous membrane and folli- cles of the vagina. In several individuals who have been cut off by tuberculous phthisis, wc have found numerous scrofulous ulcers in the vagina. In one case the purulent discharge had not proceeded from the surface of the vagina, as was suspected before death, but from the lining membrane of the uterus, which was red, greatly thickened, and much softer than natural. Dr. UTERUS, (PATHOLOGY OF THE) 617 Carswell has given a representation of scrofulous ulcers of the vagina; and he has informed us that it is not a disease of frequent occurrence. Dr. Hooper observes that " this assumes the character of scrofula in other parts. The sides of the ul- cerations are tumid: solid puriform depositions are found about them between the membranes in the cellular structure; and there are perhaps fis- tulous communications with the urinary bladder, rectum, or psoas muscle." (Morbid Anatomy of the Human Uterus.) The different excrescences of the vagina which appear near its orifice are supposed by M. Murat to be of a syphilitic origin, whilst he considers those to be of a cancerous nature which spring from the walls of its cavity. He admits this diagnosis to be extremely difficult, and in many cases impossible. In the mucous membrane of the vagina there are orifices leading to simple or compound lacunse and glands, which differ in size. In the natural state they nre small, but they become enlarged by disease. These lacunse and glandular bodies are more numerous at the orifice and at the interior part of the vagina than in the remainder of its surface. The milky discharge in many cases of leucorrhcea proceeds from these mucous follicles when affected with inflammation of a chronic cha- racter. It has also been demonstrated that many tumours of the vagina, and probably the greater number of polypi, originate in a morbid enlarge- ment of its mucous follicles. Portal states that the vagina is sometimes very narrow, and even obliterated ; and then not only intercourse cannot take place, but sometimes the flow of the menses is prevented. This may either be the effect of acute inflammation, or of such an increase of the volume of the glands of the vagina that they may fill the cavity, as has been observed in some venereal and cancerous affections. Portal like- wise observes that the canal of the vagina may be narrowed, or even obstructed, by hydatids. We saw a case, with Mr. Lawrence, about a year ago, where there was a tumour at the orifice of the vagina like a prolapsus vesica;, and which had been treated as such by the introduction of a large pessary. A viscid dark-coloured gelatinous fluid escaped from the opening which we made into the most prominent part of the tumour with a lancet: the fluid never collected again, and the patient recovered in a short period. Mr. Law- rence pointed out to us the following description of an analogous case which occurred to Mr. Hun- ter .-—"From an obliteration of the ducts of Cow- per's glands, I have seen a very large tumour formed at the entrance of the vagina. I once saw one very large, which had been mistaken for a rupture: both in this and the former case an opening should be made as nearly as possible to the former opening of the duct; this should be either a crucial incision or a round opening made with caustic, which may serve in future for an artificial duct." (Hunterian Reminiscences, by Mr. James Parkinson, p. 142.) The following interesting case of this disease has been related by M. Pelletan. « Une femme, agee de vingt-quatre ans, se presenta, en 1807, a. PHotel Dieu, pour y etre traitee d'une tumeur qui l'incommodait par sa saillie dans le vagin et dans le rectum, l'obligeait ii marcher les cuisses Vol. IV. —78 3b* ecartees, et la genait dans des travaux habituels. La tumeur occupait la partie gauche et posterieure du vagin, et etait couverte par sa membrane rau- queuse : elle etait ronde, et de la grosseur d'un ceuf de poule. La toux semblait augmenter son volume, et la poussait vers Porifice du vagin, ou elle se presentait egalement quand la malade restrait long-temps debout: alors on la repoussait aisement a Pinterieur, on la sentait aussi avec le doigt introduit dans le rectum. Cette tumeur etait sans douleur; elle genait la sortie de Purine et des raaticres stercorales. Plusieurs personnes pensaient que cette tumeur etait une hernie; elles s'en laissaient imposer par la mollesse de son tissu et la facilite avec laquelle on la repoussait, sans, cependant, la faire disparaitre. M. Pelletan en jugea autrement: il parvint a parcourir toute sa circonference, et a Pamener a Pentree du vagin, en portant deux doigts derriere elle: ii fut con- vaincu par la qu'elle n'avait aucune continuite avec les parties circonvoisines. II reconnut sa mollesse pour une fluctuation : et sa mobilite lui persuada que le fluide etait renferme dans un kyste recouvert du vagin, et entoure d'un tissu cellulaire assez lache. Une incision de deux pouccs de longueur, faite aux parois de cette tumeur, donna issue a un demiverre d'une matiere puriforme, blancheverdatre, et la tumeur fut eva- cuee. L'ecoulement fut assez abondant pendant quelques jours. Le pansement ne consista que dans des injections detersives dirigees dans le vagin. La malade fut parfaitement guerie vingt- six jours apres Poperation." (Clinique Chirurg. torn. i. p. 250.) Sir A. Cooper has described a similar case, in which the tumour originated in a morbid enlarge- ment of a mucous follicle just before the meatus urinarius. Mr. Hemming states that he examined the bodies of two women, in whom he found tumours projecting into the vagina. In one there were two of these follicular tumours; in the other there was a single one as large as an egg. On a minute examination of their internal structure, it was evident that they consisted of obstructive lacuna;, which had thereby become dilated into a cyst and distended with a gelatinous fluid. Mr. Hemming infers that the greater number of tumours which obstruct parturition are of this description. (Edin. Med. and Surg. Journal, v. xxxv. p. 82.) We have previously shown that fibrous tumours of the uterus and ovarian cysts and tumours often impede the progress of the fcetal head through the pelvis. Fibrous tumours, ac- cording to certain authors, are also sometimes developed in the walls of the vagina, and when they have attained a considerable size, clear the vulva. M. Baudies has given the description of a tumour, ten pounds and a half in weight, which grew from the vagina. M. Dupuytren relates two cases in which fibrous tumours of enormous size were developed in the vagina. Varicose. and aneurismal tumours sometimes form around the vagina, and give rise, when injured, to profuse hemorrhage. M. Murat observes " that tumours of different kinds are met with in the vagina; some being fatty, others fibrous or encysted, and not a few of a carcinomatous or malignant nature. I have found tumours in the vagina which con- tained pus, water, air, calculi, &c. Some of these 618 UTERUS, (PATHOLOGY OF THE) tumours are developed in the thickness of the walls of the canal, or on its surface ; others are in some degree foreign to it, though they come to project into its cavity." (Diet, des Sciences Med. torn. lvi. p. 468.) No case of fibrous tumour or fibrous polypus of the vagina has come under our observation, and the rarity of the disease probably depends on the absence of a muscular coat in this canal similar to that in the uterus. Between the rectum and vagina fibrous tumours similar to those in the uterus are sometimes formed. M. Pelletan has related two cases of this description, where an incision was made through the walls of the vagina, and the tumours, which were of large size, were removed with success. The carunculx myrtiformes sometimes become inflamed from violence. At the orifice of the vagina, tubercles of a conical form and of a deep brown, rose, or pale colour, are sometimes met with. Boivin and Duges 6tate that these some- times become excessively inflamed, and interrupt intercourse. The usual local means for subduing inflammation should be employed. The carunculse are also susceptible of becoming elongated and hypertrophied. M. Dubois has seen cases of this description where they were mistaken for venereal excrescences. The clitoris and nymphx are also liable to attacks of inflammation from common and specific causes. They sometimes become much enlarged by hypertrophy and malignant disease, and require extirpation. In some cases hypertrophy of the nymphse seems to be produced by syphilis. Urethra and Meatus Urinarius*—Around the orifice of the female urethra, several excretory canals of mucous glands open, and within the urethra there are also ducts which lead to mucous follicles. Portal believed that some varieties of gonorrhoea and leucorrhcea depended upon inflam- mation and an increased secretion from these glandular bodies. (Anatomie Medicale, t. v. p. 475.) Some of the vascular excrescences con- nected with the female urethra probably also ori- ginate in a morbid state of these bodies. The female urethra has certain longitudinal folds which facilitate its dilatation, and render it much more extensible than the urethra of the male. Its short- ness and dilatability in the female render the in- troduction of foreign bodies into the bladder, and their removal, much more easy than in men. Large calculi have been extracted from the female bladder by gradual dilatation of the urethra with sponge tents and other appropriate means. (Med. Chir. Trans, v. i. p. 123.) Irritation of the female urethra is sometimes connected with disease of the kidneys ; in other cases it is symptomatic of some affection about the neck of the bladder, or of calculi in that viscus. Mr. Howship has seen cases depending on the presence of uric acid calculi in the kidneys. Dr. Bateman states that prurigo urethralis sometimes occurs in women without any manifest cause, and is removable by the use of bougies. (Practical Synopsis of Cutaneous Diseases, 8vo. 1813, p. 22.) In hysteria and other severe affections of the nervous system, the urethra and neck of the bladder are sometimes spasmodically contracted. The pressure of the head of the fcetus during labour may give rise to severe irritation and in- flammation of the urethra ; it can then be felt like a hard cord running along the upper part of the vagina, and is painful on pressure, or when the urine flows. Local bleeding, anodynes, gentle cathartics, and tepid fomentations are the remedies which afford the greatest relief in cases of irrita- tion and inflammation of the lining membrane of the urethra. In some cases of malformation of the parts, the orifice of the urethra opens into the vagina. In other cases a communication is formed between the vagina and urethra by sloughing, from inju- rious pressure during parturition. The direction of the canal of the urethra is sometimes altered by displacements of the uterine organs, and by the pressure of ovarian tumours. Stricture of the female urethra is a rare dis- ease. Dr. Cusack mentions a case where a con- tracted state of the urethra gave rise to all the symptoms of diseased bladder, which were relieved by the frequent introduction of the bougie. (Dub- lin Hospital Reports, vol. v. p. 506.) Sir Benja- min Brodie has a preparation in his collection of morbid parts where stricture of the female urethra existed, and the following is the account of the case: " The patient was admitted into St. George's Hospital, labouring under an exceeding difficulty of making water. The urine was voided almost in drops with much effort and straining. The internal orifice of the urethra was so much con- tracted that it could scarcely admit a small probe. It was, however, dilated by means of bougies, and the patient voided her urine in a moderate stream. Some time after she was seized with an attack of fever, which proved to be dependent on inflamma- tion of the peritoneum covering the liver, uncon- nected with the stricture, and of this she died. The stricture is quite at the extremity of the urethra, occupying about half an inch of the canal." A small, florid, vascular tumour or excrescence sometimes grows from the lining membrane of the female urethra, or from the edge of the meatus urinarius, which gives rise to severe irritation in the part. At first the tumour resembles a pro- lapsus of the inner membrane of the urethra, and it may be returned wholly or partially within the canal. It soon, however, enlarges, becomes of a bright red colour, extremely painful when irritated by any foreign body, or the passage of the urine, and bleeds when touched. The tumour often as- sumes a flattened oval form, with a thick broad root, or it has a slender pedicle. Its sensibility a not increased in proportion to the increase of its size, though its scarlet hue becomes more and more vivid as it enlarges. It may attain the size of a horse-bean or cherry, when the movements of the body and the voiding of the urine occasion intolerable pain. It is seldom of a firm consist- ence, and the surface is sometimes smooth, at other times irregular or granulated. All the excrescences which grow from the female urethra have not the same florid red colour. We have recently seen a young married female, with Dr. Forbes, who had two painful excrescences growing from the ostium vagina; on the left side, and another from the lower part of the margin of the urethra and a portion of the mucous mem- brane of the urethra. They were smooth, were UTERUS, (PATHOLOGY OF THE) 619 not of a florid colour, had thick bases, and were exquisitely painful when touched. The root of the tumour, which grew from the meatus urina- rius, bled profusely after being removed with the scissors. There is sometimes with this affection an in- creased secretion of mucus from the parts, but this does not take place in all cases, and the symptom is not characteristic of the affection. Morgagni was the first who described this dis- ease. " In urethra; osculo," he observes, " cor- pusculum prominebat rubellum: quod ipsa se- cundum longitudinem incisa, nihil aliud esse vidi nisi intimam ejus tunicam, qua; cum supra a sub- jectis vasculis sanguine distentis tota nigricaret, ima parte se extrorsum invertens exstabat; quod et in alia a claudicatione scribam nemini vidisse. Utramque autem cum de urinae difficultate agerem commemorasse, et parvi illius vitii causam quse- ivisse." (De Causis et Sed. Morb. Epist. 1. No 51.) Sir C. Clarke was the first author who gave a full account of the symptoms and treatment of the affection. Sir C. Clarke, Dubois, Cullerier, and Lacha- pelle, have all seen many cases of this disease, both in single and married women, and in those who had never been affected with syphilis. Mr. Wardrop has informed the writer that he saw a case of vascular tumour of the meatus urinarius in a girl previous to the age of puberty. The excrescence was removed with the scissors, but was soon reproduced. Morgagni saw it in a girl fifteen years of age. We have seen examples of this affection in two married ladies, who were under twenty-two years of age, and who were in consequence unable to cohabit with their hus- bands. We have likewise observed the disease in individuals beyond the age of sixty. A wo- man aged sixty-two was supposed to be afflicted with prolapsus uteri, and a pessary had been in- troduced into the vagina, and retained there for several months, which greatly aggravated all the symptoms. The patient had for a long period never enjoyed undisturbed sleep, and had become greatly emaciated from her sufferings. There was constant sense of pain in the urethra, and the in- cessant desire to pass the urine, with sense of burning heat in the passage, prevented her from enjoying undisturbed sleep. She could not taste either warm food or drink, or swallow even a small quantity of any stimulating fluid without experiencing great aggravation of all her symp- toms. These were all immediately relieved by excision of the tumour, and it never returned. In a case of vascular tumour of the urethra which we saw with Dr. Burder, the symptoms were similar to those usually witnessed in cases of ma- lignant disease of the uterus, and without a care- ful inspection the true nature of the affection could not have been detected. The tumour should be seized with a pair of forceps, and drawn out, and its root divided by a pair of probe-pointed scissors. When the bleed- ing has ceased, the cut surface should be touched with nitrate of silver or potassa fusa. Like growths and excrescences from other mucous sur- faces, this tumour is sometimes reproduced, and a second or third operation is required. Where the disease has been connected with a considerable portion of the mucous membrane of the urethra, bougies should be introduced and retained in the urethra until the tumour has been destroyed. A case has been related by Dr. D. Davis, in which the whole lining membrane of the urethra was affected, and the disease was completely relieved by the use of bougies of gradually increasing size. Madame Boivin (vol. ii. p. 668), has also related an instance of fungous tumour of the meatus urinarius, in which there was a painful sensation experienced after the passage of the urine, and a sero-sanguinous discharge from the vulva. The symptoms, as in Dr. Burder's case, led to the sup- position that there was a malignant disease of the uterus. Mad. Boivin advised the patient to use an elastic catheter three inches long, of a conical shape, the extremity of which was two lines in diameter, and the base eight lines. This part, which had several small apertures, was fixed to a piece of sponge two inches thick. This apparatus was retained in its situation by a T bandage. The presence of this sound in the urethra at first pro- duced very acute pain. Every time the sound was withdrawn, it was covered with a cerate con- taining opium before being re-introduced. The pain became gradually more supportable, and in fifteen days the tumour had lost a part of its so- lidity, so that a larger sound could be introduced. The portion of the tumour which remained was removed by excision on the twenty-second day, and the sound, surrounded by a portion of agaric and sponge, was introduced, and the affection was relieved in fifteen days. It is difficult in this case to discover why the fungus in the first instance was not removed with the scissors, and afterwards treated with a common bougie. It is requisite in all cases, after this operation has been performed, to recommend the patient to remain for a week or ten days in a state of rest, and to live on spare diet. This we do from hav- ing observed death take place from obscure abdo- minal inflammation twelve or fourteen days after the excision of a vascular tumour from the mar- gin of the meatus urinarius. Indeed, after all operations upon the external uterine appendages there is some danger of inflammation being ex- cited in the peritoneum. In some women there is a thickening of the cellular membrane surrounding the urethra with a varicose state of the vessels of the part. It is accompanied with a sense of dull pain, increased by pressure, in the situation of the urethra, and frequent desire to pass the urine, and difficulty in voiding it. If the finger be introduced into the vagina and carried along the urethra, it is felt tender, hard, and swollen; and if the patient presses down, the swollen and vascular condition of the urethra becomes apparent. In this affection Sir C. Clarke recommends us first to unload the vessels by leeches or by punctur- ing them with a lancet, and to do this repeatedly until the symptoms are relieved. Solutions of lead, or of muriate of ammonia, or sulphate of zinc, are afterwards to be applied to the parts. Pressure should afterwards be made by introducing a piece of wax-candle, or a small roll of linen, which has previously been dipped in the lotion. Labia. — The inner surfaces of the labia are liable to become excoriated and ulcerated. Phieg- 020 UTERUS, (PATHOLOGY OF THE) monous inflammation of the labia, which is most frequently produced by mechanical violence or the application of cold, is accompanied with pain, heat, swelling, and sometimes with pyrexia.— Where it is not subdued by the early application of leeches and other appropriate means, warm fomentations and poultices should be employed to promote suppuration. The labia are also some- times affected with erysipelatous inflammation, which requires appropriate treatment. Dr. Percival, Mr. Ward, and Mr. Kinderwood have described a fatal disease of the labia pudendi and other external parts in children, which is pre- ceded by pyrexia for several days. The patients then complain of pain in voiding the urine, and the genital organs are found to be enlarged and inflamed. The inflammation is of a dark colour, and soon extends over the clitoris, nymphm, and hymen. Ulceration succeeds, and the parts are progressively destroyed. M. Ollivier, of A^ger, has traced an analogy between this affection in children and gangrene of the mouth and cheeks. Great enlargement of the labia is occasionally produced by blows and falls, and by extravasation of blood into their cellular substance during labour. One of them becomes suddenly distended with blood, either during the progress of labour or soon after the birth of the child. It is generally confined to one labium, and in the practice of Dr. Dewees it has always occurred after the birth of the child. The source of the hemorrhage in this affection has not been positively ascertained. Encysted and solid tumours are sometimes formed in the labia, and the labia are liable, like all the other external parts, to become affected with malignant induration and ulceration. Warts and excrescences are often seen about the labia and orifice of the vagina. They are referable to gonorrhoea or syphilis in many cases, and they are accompanied with much uneasiness and an offensive discharge. Their removal with the knife, scissors, or escharotics is often necessary. Some women suffer severely from irritation of the labia and mons veneris. Dr. Bateman states, (Synopsis, p. 24,) " that prurigo pudendi muliebris is sometimes connected with ascarides in the rectum, and sometimes with leucorrhcea, but is most violent when it occurs soon after the cessa- tion of the catamenia. The itching about the labia and os vaginse is constant and almost intoler- able, demanding incessantly the relief of friction and cooling applications, so as to compel the patients to shun society, and even sometimes to excite at the same time a degree of nymphomania." " This condition," Dr. Bateman adds, «is gene- rally accompanied by some fulness and redness of the parts; sometimes by inflamed papula;, and sometimes by aphthse. Saturnine and saline lotions, lime-water, with calomel, vinegar, and oily liniments prepared with soda or potass, are beneficial, especially in the milder case6; but the most active remedy is a solution of the oxymuriate of mercury in lime-water, in the proportion of two grains, or a little more, to the ounce. As in the cases before mentioned, however, the presence of rhagades or excoriations will require palliation before it can be employed." In some cases of this affection the mucous membrane of the vulva and vagina is likewise inflamed, and there is a copious leucorrhceal dig. charge. Lorry has given a vivid description of the intolerable sufferings of women afflicted with this disease. It frequently indicates, as has already been stated, the existence of carcinomatous disease of the uterus, and this intolerable itching of the pudendum is sometimes the first and most distress- ing symptom of which women complain who are labouring under malignant organic disease of the cervix uteri. The irritation of the external parts being merely symptomatic, our attention should be chiefly directed to the affection of the uterus. Prurigo of the pudendum is one of the most dis. tressing symptoms experienced by some women during gestation ; and most benefit is derived from the employment of bloodletting, and the adminis- tration of calomel and opium with cathartics, Temporary relief is obtained by saturnine lotions, solutions of the chlorurets of lime or soda, cold water, or ice and water to the parts. But the disease sometimes continues to harass the patient in spite of all the remedies we can employ until she is delivered. The diet should be light, and in all cases of this description the utmost attention should be paid to regular ablution of the parts. Wine and fermented liquors of all kinds should be disused, and where there is leucorrhceal discharge, the tepid hip-bath, and tepid lotion of Goulard, and decoction of poppies, should be applied occa- sionally to the parts. The uterus is liable to several important dis- placements, as inversion, retroversion, and prolap- sus ; but the consideration of these diseases properly belongs to surgery. [It may be well to remark, that Dr. Simpson (Lond. and Edinb. Monthly Journ. of Med. Sci- ence, June, August, and November, 1843,) has recommended the employment of a uterine sound or bougie, by means of which, when introduced into the uterine cavity, it is possible, he says, "to ascertain the exact position and direction of the body and fundus of the organ ; to bring the higher parts of the uterus in most instances within the reach of tactile examination, and to ascertain va- rious important circumstances regarding the os, cavity, lining membrane, and walls of the viscus." The instrument resembles a common male sound, but is rather smaller : it has a bulb on the extre- mity, to prevent its injuring the uterus, but tapers gradually from the handle to the bulb, being one- fifth of an inch in diameter at the former,—one- tenth of an inch at the latter situation. The bulb is one-eighth of an inch in diameter; the stem nine inches long, and it is graduated in order to measure the dimensions of the uterus. A small knob exists on the stem, two inches and a half from the bulb, that being the ordinary length of the uterus; and the further graduation of the in- strument is effected by a series of shallow double grooves, half an inch or an inch from each other. The introduction of the instrument is 6aid to be usually attended with but slight uneasiness, and in a few cases only with a feeling of sickness. The occurrence of actual pain indicates that the lining membrane of the uterus is not in a healthy state.] Robert Lee. VACCINATION.—Towards the close of the eighteenth century, small-pox continued, notwith- VACCINATION. 621 itanding every effort, to be the source general ter- ror to mankind. The progress of intelligence, and the great improvements which had been effected in the art of inoculation, combined indeed to extend prodigiously that practice, to the great benefit of individuals, but unhappily without any correspond- ing diminution of the general mortality. The prudent were preserved by it, but the careless and the improvident, who will always form the bulk of mankind, had their dangers increased. The sources of infection were multiplied, and small- pox, which formerly used to visit country districts only at long and uncertain intervals, was now to be met with in all parts at all times. In London the evil effects of inoculation were felt in their full- est force. Inoculation was there widely diffused among the lower ranks of society, but without the precaution of seclusion ; in consequence of which the contagion of small-pox was daily encountered in the open streets. The deaths by small-pox in the metropolis at this period, according to the bills of mortality, averaged 2000 annually, or about one-tenth of the total mortality. In 1796 small-pox pre- vailed epidemically in London with such extraor- dinary severity, that 3549 lives are recorded as having fallen victims to it. The total deaths by small-pox throughout England were estimated at about 45,000 annually. Inoculation was prac- tised almost universally among the higher ranks of society; and the general impression upon the minds of men was, that every individual born must expect at some period of his life to become the subject of this loathsome and too often fatal disorder. Such was the state of public opinion, when, in the summer of 1798, Dr. Jenner, a provincial physician of established reputation, favourably known to the scientific world by his investiga- tions in natural history, announced his discovery of a means whereby all this mass of evil might be effectually removed, and mankind relieved from the painful necessity of undergoing small-pox. It is not to be wondered at that the public should have hailed with avidity so gratifying a prospect, held out to them, not by a youthful and too con- fident aspirant to fame, whose proposal was the impulse of a moment, but by one whose character was at stake, and who announced his discovery as the result of much thought, and of deliberation matured through the long period of twenty years. The eagerness with which vaccination was adopted formed a singular contrast to the events which eighty years before marked the introduction of variolous inoculation into England. A compari- son of the spirit in which that proposal was re- ceived, with the encouragement which vaccina- tion experienced from all classes of persons within twelve months after the announcement of the dis- covery, will redound greatly to the credit of the present age. While it shows how much educa- tion has opened the minds of the people at large, it exhibits at the same time, on the part of medi- cal practitioners, a praiseworthy promptness to acknowledge the merits of one whose name was almost unknown to them; a benevolence which could sacrifice without a murmur a large share of most profitable practice, and a candour which could renounce at once the prejudices of early education. The circumstances which led to the original discovery of vaccination, and which attended its introduction into general use, are deserving of particular inquiry, not merely as matters of histo rical interest, but because they contributed to in fluence, in a very remarkable manner, public opin- ion as to the merits of the new discovery. We shall enter, therefore, with some degree of minute- ness into the details connected with the early his- tory of vaccination, and trace the causes of that singularly rapid hold which it took of public opin- ion. History of Vaccination. — Edward Jenner, third son of the Rev. Stephen Jenner, was born at the vicarage of Berkeley in Gloucestershire, on the 17th May, 1749. Very early in life he evi- denced a strong taste for the study of natural his- tory, which probably had an influence in deter- mining the choice of his profession. He was in- structed in the elements of surgery and pharmacy by Mr. Ludlow, an eminent surgeon practising at Sudbury near Bristol. While engaged as his ap- prentice, Jenner had his attention frequently called to a popular notion current in the dairy districts of Gloucestershire, that cows were subject to a disorder called the cow-pox, which was sometimes communicated to the milkers, who became thereby protected from the small-pox. One such occasion is particularly recorded. A young countrywoman came into the shop to seek advice. The subject of small-pox was mentioned in her presence: she immediately observed," I cannot take that disease, for I have had cow-pox." (Baron's Life of Jen- ner, p. 121.) This little incident riveted the at- tention of Jenner. Young as he then was, he dwelt with deep interest on a communication thus casually made to him by an uninstructed peasant, and foresaw in some degree the vast con- sequences which might result from so extraordi- nary a fact. In the year 1770, being then twenty- one years of age, Jenner went to London to pro- secute his medical studies at the school, and under the immediate eye, of John Hunter. To that en- lightened man he repeatedly mentioned the popu- lar rumours concerning cow-pox, but it does not appear that he received from his master much en- couragement to prosecute the inquiry. In 1775, being then established in practice in Gloucester- shire, he gave more attention to it, but found many difficulties besetting his path, such as would probably have deterred most men from persevering in the task. Among the country people whom he was called upon in the course of his practice to inoculate for the small-pox, some resisted every effort to give them the disease. (Jenner's Origin of the Vaccine Inoculation, page 5.) They were milkers, who had undergone cow-pox. But some of those who appeared to have undergone cow-pox, and whose security might have been anticipated, received small-pox in the usual way. These oc- currences led him to make inquiries among the medical men of the district, all of whom knew of the cow-pox and its reputed powers, but they agreed in opinion that it was not to be relied on as a certain preventive of small-pox. They ima- gined that the phenomenon depended upon some peculiarity in the constitution of the individual who escaped rather than upon any efficacy in the disorder received from the cow. They attached 622 VACCINATION. no value to the facts adduced by Jenner, and thought that a farther prosecution of the subject would only terminate in doubt and disappoint- ment. These obstacles damped for a while, but did not extinguish, Jenner's ardour in his favour- ite pursuit. He now ascertained that the cow was subject to a variety of eruptions on the teats, all of which received indiscriminately the name of cow-pox. He learned to distinguish the one of these from the others, and was led to entertain the belief that one only was possessed of specific power over the human body. This he called the trite cow-pox; the others the spurious. The next step of the inquiry convinced him that the true cow-pox itself was liable to undergo progressive changes, and that it was only at one period of its course, in its acme of intensity, when it was endowed with specific and preventive, or anti-variolous properties. During the investiga- tion of this branch of the subject, Jenner was struck with the idea that it might be practicable to propagate the disease, by inoculating, first from the cow, and finally from one human being to another. At what precise period of his career this brilliant thought first occurred to him is not accurately known, but it was probably early in 1780; for in the month of May of that year we find him speaking of it to an intimate friend, and this was probably the first glimpse of that reputa- tion which he ultimately attained. (Baron's Life of Jenner, p. 128.) In 1788 Jenner visited Lon- don, and carried with him a drawing of the casual cow-pox, as seen on the hands of the milkers, which he showed to Sir Everard Home and others ; but the physiologists and physicians of London saw in this nothing but a curious and barren fact. Hitherto Dr. Jenner had taken no decisive step to ascertain the practicability of inoculating for the cow-pox, upon the success of which his whole scheme mainly rested. It is worthy of mention in proof of the slowness with which the philo- sophic mind of Jenner ripened into conviction, that in November, 1789, he inoculated his eldest son with the small-pox. Soon after this period, however, his confidence in the preservative powers of cow-pox rapidly strengthened. He spoke and wrote about it to many friends, and nothing was wanting but an opportunity of putting his ideas to the test of experiment. This at length pre- sented itself. Cow-pock matter in an active state was found, and parents were met with possessing sufficient confidence in Jenner to submit their children to the important trial. On the 14th of May, 1796, the decisive experiment was made. James Phipps, eight years of age, was vaccinated with matter taken from the hands of Sarah Nelmes. He passed through the disorder in a manner per- fectly satisfactory, and was tested with variolous matter on the 1st of July following. The small- pox inoculation, though carefully conducted, took no effect. Jenner now prepared to communicate to the world the result of his long and anxious investi- gations concerning cow-pox. His work was ready in June, 1797, but he delayed the publication of it for a twelvemonth, partly that he might profit by the advice of his friends, and partly in the hope of strengthening his argument by additional experiments. This he was happily enabled to do in April, 1798; and the new trials having been equally successful with the first, he felt justified in announcing to the world the discovery of vac- cine inoculation. His original essay, published in London in June, 1798, is entitled, "An Enquiry into the causes and effects of the Variola; Vaccina a disease discovered in some of the western coun- ties of England, particularly Gloucestershire, and known by the name of the cow-pox." In thin work twenty-three cases are detailed, viz. sixteen of the casual, and seven of the inoculated dis- ease, with coloured drawings of the appearances in both. Dr. Jenner, in this work, first treats of the causes of cow-pox. He announces his belief that this disorder does not originate with the cow, but is in all cases communicated to that animal from the horse, where it appears on the heels, and is known to farmers by the name of the grease; the hands of the milkers and farm servants being the medium of communication. He next throws out the suggestion, that the small-pox itself may have been originally morbid matter of the same mild kind, which accidental circumstances had changed, and aggravated into that contagious and malig- nant form, under which we now commonly see it. He then states his conviction that the cow-poi, when it has once passed through the human body, leaves the constitution for ever after secure from the infection of small-pox. The essay concludes by describing four classes of persons, to whom the discovery of cow-pox inoculation holds out the prospect of great benefit. First, those who from family predisposition may be presumed likely to take small-pox unfavourably: secondly, those whose constitutions are predisposed to scrofula: thirdly, those who from some peculiarity of habit resist small-pox inoculation in early life: fourthly, those who are labouring under forms of chronic disease, in which counter-irritation is desirable. An unassuming tone and philosophic spirit per- vades this first essay on vaccination, which is very striking, and which, no doubt, contributed essen- tially to promote the great cause in which the author had embarked. Dr. Jenner's first publication excited in a re- markable degree public attention. It may be men- tioned, however, as a singularly strong proof of the distrust with which any new invention' is re- ceived, that during a period of nearly three months that Dr. Jenner remained in London superintend- ing the publication of his book, he could not pro- cure one person on whom to exhibit the disease. In the end of July, Mr. Cline made the first ex- periment with cow-pox in London, which suc- ceeded perfectly; soon after which trials were multiplied in every quarter, and a general rush in favour of vaccination succeeded, which con- trasted strongly with the apathy displayed by the medical profession during the infancy of Dr. Jen- ner's investigations. The early career of vaccination, however, wa= not without its drawbacks. A few, but happily a very few, opposed the new practice with a degree of rancorous malignity which carried with it its own cure. Professional jealousy, too, was excited, and a systematic attempt was made to wrest from Jenner's brow the laurels which he had so fairly VACCINATION. 623 won. It was proved, indeed, that rumours of the preservative efficacy of cow-pox were general, and that the attention of Sir George Baker had been specially called to the subject, about the year 17H2, by the Rev. Herman Drew, of Abbots in Devonshire, and Mr. Bragge, a surgeon of Ax- minster. The investigation, however, was never followed up, nor was Dr. Jenner ever made ac- quainted with the circumstance. Sir George Baker had been, not long before, engaged in a very trou- blesome inquiry respecting the endemical colic of Devonshire, and was probably unwilling to come forward again as a controversial writer. There were other physicians, well disposed to the cause of vaccination, and who ultimately became its strenuous and most efficient supporters, who yet brought it at first into much discredit by their rashness and carelessness. A series of experiments on the cow-pox was undertaken at the Small-Pox Hospital, in the spring and summer of 1799, by Dr. Woodville, with the praiseworthy object of establishing the Jennerian discovery. In the course of these experiments, the variolous and vaccine poisons became mixed, and much confusion en- sued. But in December of the same year, the difficulty was explained and obviated ; and the nineteenth century opened most honourably for science and for this country. An antidote against adreadful pestilence had unexpectedly been brought to light by the scientific researches of an English physician. It would have been well for the cause of vacci- nation, if its early supporters had satisfied them- selves with a general statement of its acknowledged advantages, and left the rest to time and to future opportunities of observation. Unfortunately, they announced at once that henceforth small-pox was disarmed of all its terrors, and that its complete extermination might not unreasonably be contem- plated. The brilliant prospect thus held out added at the moment prodigiously to the splendour of Jenner's fame, but it ultimately did harm. It raised unreasonable expectations, and occasioned disputes in after-times, which brought on one party the charge of prejudice and obstinacy, and on the other that of disaffection to the cause of humanity. The friends of vaccination, however, were certainly justified, by the whole tenor of Dr. Jenner's writings, in encouraging this belief in the adequacy of vaccination to exterminate small- pox. Yet it was a notion which facts at the time little warranted, and which subsequent experience has proved to be fallacious. In his second pub- lication, indeed, dated April 1799, Dr. Jenner judiciously recommended " that the investigation should be conducted with that calmness and mo- deration which should for ever accompany a phi- losophic research." But in his third (dated 1800), he expresses his confidence that " the cow-pox is capable of extirpating small-pox from the earth;" and his fourth work, printed in May 1801, con- cludes with the statement, «that it is now too manifest to admit of controversy, that the anni- hilation of small-pox, the most dreadful scourge of the human species, must be the final result of this practice." (Origin of Vaccine Inoculation, p. 12.) Whatever allowances we may make for Dr. Jenner's zeal, (and great allowances ought undoubtedly to be made for him), still it must ever be a matter of regret, that such sanguine anticipa- tions should have been indulged at a time when the cow-pox had been known to the world scarcely three years, and had been the subject of general observation not more than two. Vaccination advanced with extraordinary ra- pidity. Dr. Jenner states, (Continuation of Facts and Observations, 3d edition, p. 146,) " that in 1801 upwards of six thousand persons had been vaccinated, by far the greater part of whom had been tested with small-pox and exposed to its in- fection, in every rational way that could be de- vised, without effect." In 1799, the practice of vaccination was introduced into America, through the agency of Dr. Waterhouse. In the same year, a strong testimonial of confidence in the virtues of the cow-pox was signed by thirty-three of the most eminent physicians, and by forty distinguish- ed surgeons of London. In 1800, vaccination was introduced into France. The earliest sup- porter of vaccination on the continent of Europe was Dr. De Carro, of Vienna, whose exertions in the cause were beyond all praise. Dr. Sacco, of Milan, distinguished himself, not merely as an active propagator of the new practice in Italy, but by his pathological investigations into the origin of cow-pox. Great difficulties were experienced in transmitting vaccine matter to India ; but this object, so ardently desired by Dr. Jenner, was at length effected through the ingenuity and zeal of Dr. De Carro. In June 1802, vaccine lymph, in an active state, reached Bombay from the Persian Gulf, and was thence rapidly disseminated over the continent of India. In 1802, a committee of the House of Com- mons investigated and reported upon the utility of vaccination, and upon Dr. Jenner's claims to the discovery; and upon the 2d June in that year, Parliament voted him £10,000. In 1807, this matter was re-considered, and an additional sum of £20,000 awarded to him. In 1808, vaccina- tion was taken under the direct protection of the government. The National Vaccine establishment was then formed, which continued for many years to superintend with much success the practice of vaccination in this country. Dr. Jenner died, in 1823, at Berkeley, in Gloucestershire, the sceae of his early labours, for ever rendered memorable as the birth-place of vaccination. During the latter years of his life, he continued to devote much of his time and attention to this subject, but he did not publish any thing of much importance concerning it subsequent to the year 1803. In 1833, a committee of the House of Commons, appointed to inquire into the constitution of this establishment, extended their investigations into the effects of vaccination generally, and the volume of evidence published by them (Report and Evi- dence of the Select Committee on the Vaccine Board, 1833, folio,) contains the latest information to be met with on this interesting subject. Phenomena of Vaccination. We now proceed to a detail of the phenomena of vaccination, which we shall treat of in the fol- lowing order:—cow-pox in the cow, casual cow- pox in man; and the inoculated cow-pox. 1. Of Cow-Pox in the Cow—This disease is not of frequent occurrence: it is epizootic, and rarely, if ever, shows itself except where cattle 624 VACCINATION are collected together in herds. It then breaks out at irregular periods, and from causes not at all known. Dr. Jenner's early experiments concern- ing it were frequently interrupted by its complete cessation among the herds. During the year 1828 the National Vaccine Board made numerous inquiries through their extensive correspondence with practitioners in the dairy counties of Eng- land ; but no tidings could be learned of the dis- ease in the cow. (Marshall on Vaccination, 1830, p. 7.) The latest observations on it were made in India in 1832. (See Macpherson's "Experi- ments relative to Vaccination," in Calcutta Medi- cal and Physical Transactions, vol. iv. p. 175.) Some Italian physicians, in the year 1830, ob- served the disease among the cattle of the Pied- montese Alps. (Griva sulP Epidemia Vaiuolosa del Torino, p. 102 ; also London Medical Gazette, vol. ii. p. 323.) Dr. Jenner's earliest statements (Inquiry, p. 3,) led to the belief that cow-pox in the cow was ge- nerally a local disorder, confined to the udder. More recent observations, however, have shown that it is really a constitutional febrile disease, ac- companied with eruption, and sometimes extremely severe, and even fatal. According to Dr. Jenner, (Inquiry, p. 4,) the true cow-pox shows itself on the nipples of the cow in the form of irregular pustules. At their first appearance they are com- monly of a palish blue colour, or rather of a colour approaching to livid, and surrounded by an erysipelatous inflammation. They frequently degenerate into phagedenic ulcers. The animal appears indisposed, and the secretion of milk is much lessened. The cow is subject to other pus- tulous sores on the nipples, which are of the nature of common inflammation, and possess no specific quality. These are free from all bluish or livid tint. No erysipelatous redness accompa- nies them. They desiccate quickly, and create no apparent disorder in the animal. Such a com- plaint is frequent among cows in the spring sea- son, and when the calf is suckling. This disease was called by Dr. Jenner the spurious cow-pox. The following description of the cow-pox in the cow, as observed at Moorshedabad in August 1832, is given by Mr. Macpherson. (Calcutta Medical and Physical Transactions, vol. iv. page 175, 1833 ; also, London Medical Gazette, vol. x. p. 510.) The animals for a day or two appeared dull and stupid. They were then seized with dis- tressing cough, accumulation of phlegm in the mouth and fauces, and loss of appetite. On the fifth or sixth day pustules made their appearance all over the body, especially on the abdomen, ac- companied with fever and much general distress. These went on to ulceration, the hair falling off wherever a pustule ran its course. The mouth and fauces appeared to be the principal seat of the disease, being, in bad cases, one mass of ulcera- tion, which impeded mastication, and proved fatal apparently from inanition. The mortality in this severe epizootic was calculated at from fifteen to twenty per cent. 2. Casual Cow-pox in Man. — This affec- tion, caught by the milkers from the affected cow, appears on the hands and wrists in the form of inflamed spots, which run on to suppuration. The pustules assume a circular form, having edges elevated above their centre, and are of a colour inclining to blue. (Jenner's Inquiry, p. 5.) Aftn a time absorption takes place, and swellings appear in the axilla. Fever succeeds, accompanied with headach, vomiting, and sometimes delirium. The constitutional symptoms decline in three or four days; but the sores on the hands often remain, very painful, and difficult to heal. No eruption of the skin follows the decline of the feverish symptoms. 3. Phenomena of the Inoculated Cow* pox.—When vaccination has been successfully performed on a healthy child, the incision may be felt elevated on the second day, and on the third, if examined with a magnifying-glass, appears surrounded by a slight efflorescence. On the fifth day a distinct vesicle is formed, having an elevated edge and depressed centre. On the eighth day it appears distended with a clear lymph. The vesi- cle, on this, its day of greatest perfection, is cir- cular, and either pearl-coloured or slightly yellow. In its form and structure it resembles the pustule of small-pox. Its margin is turgid, firm, shining, and wheel-shaped. It is composed of a number of cells, by the walls and floor of which the spe- cific matter of the disease is secreted. On the evening of the eighth day an inflamed ring, or areola, begins to form around the base of the vesi- cle, which continues to increase during the two following days. This areola is of a circular form, and its diameter extends from one to three inches. When at its height on the tenth day, there is con- siderable hardness and swelling of the subjacent cellular membrane. On the eleventh day the areola begins to subside, leaving, as it fades, two or three concentric circles of a bluish tinge. The vesicle before this has burst, and its surface ac- quired a brown colour. The lymph which remains becomes opaque, and gradually concretes; so that about the end of the second week the vesicle ii converted into a hard round scab of a reddish brown colour. This scab contracts, dries, blackens, and about the twenty-first day falls off, leaving a cicatrix, which is permanent in after-life, circular, somewhat depressed, striated, and indented with six or eight minute pits, corresponding to the number of cells of which the vesicle had been composed. The constitution generally sympathizes about the seventh or eighth day. The child is restless and hot, and the bowels are more or less disor- dered. This commonly subsides in two or three days. A few children pass through the disorder without the slightest indication of constitutional disturbance, which is not to be looked upon as by any means essential to the success of the vaccine process. About the tenth day a papulous erup- tion of a lichenous character frequently shows itself on the extremities, and sometimes extends to the trunk of the body. It continues for a week, and occasionally lasts after the scab has fallen off. This vaccine lichen is chiefly met with in children of full habit, where numerous vesicles had been raised on the arm, which dis- charge freely. It is an accidental occurrence, which, like the constitutional irritation, indicates a full effect upon the system, but is not deemeJ requisite to ensure it. Cow-pox in the adult exhibits the same succes- VACCINATION. 625 sion of phenomena. The vesicles, however, are thinner and more easily ruptured. The lymph is usually of a yellowish tinge, and the areola is more extensive. The glands of the axilla, too, frequently swell, which is rarely observed in chil- dren. Constitutional irritation commonly runs higher. The secondary lichen is less observable. Some observations, recently made by Dr. Heim, of Ludwigsburg, (London Medical Gazette, vol. xiv. p. 513,) tend to show that adult lymph is more energetic than intantile lymph; but the facts require further investigation. Of the irregular Vaccine Vesicle—The regular or normal progress of the vaccine vesicle now de- scribed is liable to be disturbed by various causes and in various ways. Imperfect vaccination is not characterized by any uniform sign or criterion, but exhibits in different cases different appearances, such as pustules, ulcerations, scales, and irregular vesicles. The most common form of irregular vesicle is marked at its commencement by very troublesome itching, so great as to provoke scratch- ing or rubbing, to which the subsequent appear- ances are generally, but most unfairly, attributed. The vesicle throws out a premature efflorescence, and advances too rapidly ; so that on the fifth day it has attained its height, when it will be found raised on a hard inflamed base. It is acuminated or conoidal, and gives the appearance of a common festering sore produced by a thorn. It is generally of a straw colour, and contains, instead of a clear transparent lymph, some opaque matter or pus. The succeeding scab is small, and of an amber colour, and drops off by the tenth day. The causes of this irregular vesicle are various. It is sometimes dependent on the state of the atmo- sphere. We infer this from the fact, that many cases are observed about the same time, and more frequently on the approach of winter than either in the spring or summer months. Sometimes it may be traced very distinctly to a bad quality of the lymph employed; that is to say, three or four children vaccinated from the same source shall exhibit these irregular appearances: yet the vesicle itself from which the lymph is taken shall show no apparent deviation from the healthy state. (See London Medical Gazette, vol. xiii. p. 441.) Many practitioners have been of opinion that such an irregularity of the vaccine vesicle as we have just described arises from the employment of lymph taken at too late a period of the disease, that is, on or after the tenth day. (See Willan on Vaccine Inoculation, p. 32.) To this doctrine, however, we cannot yield an unqualified assent. The facta we believe to be as follows: After the tenth or eleventh days, the virus becomes so diluted with the common serum of the blood as to reproduce the disease with great difficulty. But of a dozen incisions made with such a thin lymph, not more than one perhaps will prove effective; but that one is just as good, and just as effectual in preserving from the small-pox, as a vesicle raised from lymph of an earlier age and greater i intensity. The unanswerable argument in favour of this position is, that the scabs of cow-pox, moistened with a little lukewarm water to the consistence of mucilage, will often produce the disease in all its purity; but out of twenty or Vol. IV___79 3 c thirty incisions made with such a virus, not more than one or two will be found to take effect. Lastly, irregularity of the vaccine vesicle is sometimes attributable to a bad habit of body,—to what the old authors would have called a foul state of the blood and humours. The proof is, that one child only out of many vaccinated with the same lymph shall show the anomalous form of cow-pox. It is a singular but very important fact, that an imperfect vesicle, the offspring of a perfect one, degenerated by some peculiarity of habit in the individual vaccinated, shall sometimes reappear in all its original purity and perfection, when transplanted into a healthy well-predisposed subject. Other anomalous Appearances.—Cow-pox oc- casionally presents some other anomalies. In some instances the specific inflammation or areola is very violent, extends from the shoulders to the elbow, invades the trunk of the body, and requires to be assuaged by cold lotions and active purga- tives. The vesicle, instead of hardening into its proper black scab, is, under these circumstances of local irritation, converted into an ulcer, dis- charging profusely. The inconvenience thence resulting is, however, only temporary. Such ex- tensive inflammation, provided it has begun at its proper period, does not appear to lessen, or in any degree interfere with, the protective virtue of the cow-pox. Occasionally, the vesicle about the fifth or sixth day becomes scaly. A species of psoriasis takes place of areola. In some few cases true erysipelas supervenes. Such anomalies as these, it is needless to say, deprive the cow-pox of all claim to specific properties. A much more frequent but less important variety is the retarded cow-pox. The advance of the vaccine vesicle is without any apparent cause suspended. The areola does not form before the tenth or twelfth day, but ultimately the process is completed. In these cases the success of the vaccination is in no degree prejudiced. Complications of Cowpox,—It sometimes happens that a child is vaccinated after imbibing the germ of measles or scarlatina. Under these circumstances the cow-pox is generally retarded. (Jenner's "Facts and Observations," pp. 137 and 170.) In a case which we have recorded in the London Medical Gazette, (vol. x. p. 440,) cow- pox was retarded sixteen days, while the measly germ was making the circuit of the constitution. The genuine chicken-pox (varicella lymphatica) will run its course along with cow-pox, and not interfere with any of its phenomena. (London Medical Gazette, vol. ii. p. 633.) The modifica- tions which cow-pox undergoes when small-pox invades the constitution at the same time are very curious and interesting, and have excited much attention. They are subject to considerable va- riety, but the following are the phenomena most commonly observed. Cow-pox occurring along with Small- po*«—When cow-pox is inserted during the in- cubative stage of the casual small-pox, while the small-pox is still latent, the vaccine vesicle for the most part does not advance, or advances tardily and imperfectly. There are exceptions, however, to this rule, and cow-pox and casual small-pox 026 VACCINATION. may sometimes be seen running their full course in the same person at the same time. In no case, however, does the cow-pox so inserted alter or modify the course of the small-pox. When the variolous and vaccine fluids are inserted into the arms on the same day, each disease occasionally proceeds, preserving its original character. At other times, however, they mutually restrain and modify each other. The vaccine vesicle is smaller than usual, and irregular in its progress, while the variolous pustules which follow are of the kind denominated variolx verrucosx, vulgarly swine-pock, stone-pock, or horn-pock (Willan on Vaccine Inoculation, p. 5) ; that is to say, they are hard and shining, surrounded with little in- flammation, and they suppurate imperfectly. The small quantity of matter they contain is absorbed, leaving the cuticle horny and elevated for many days afterwards. Upon the extremities the erup- tion does not pustulate at all, but is minute and papulous, and terminates by desquamation. It will be found in most cases that even though the eruption be modified in its character, there is nevertheless considerable disturbance of the gene- ral system under the joint influence of the vario- 3ous and vaccine poisons. When the insertion of the vaccine lymph pre- cedes that of the variolous by a period not ex- ceeding four days, both diseases advance locally. Sometimes an eruption of small-pox papula; fol- lows. At other times the variolous fever is slight and unaccompanied by eruption. Under these circumstances, matter taken from the primary vesicles shall sometimes communicate cow-pock and small-pox respectively, but more commonly the variolous poison predominates, and conta- minates the lymph of the vaccine vesicle. It was ignorance of this phenomenon in the mutual ac- tion of the vaccine and variolous poisons, which occasioned Dr. Woodville's mistakes at the Small- Pox Hospital in 1799, and not the variolated atmosphere of the hospital, as he himself at first supposed, and as some persons still persist in believing. (See Report of " the Select Committee on the Vaccine Board," pp. 119 and 124.) Vario- lous matter inserted into the arm at any period not exceeding a week from the date of vaccina- tion will take effect and be followed by a pustule. After that time no effect is produced. Mr. Dun- ning entertained the idea that a hybrid disease might be formed by the simultaneous inoculation of small-pox and cow-pox, but there is no founda- tion whatever for this notion. Dr. Woodville on several occasions inoculated with a mixture of the variolous and vaccine poisons. The result was not to be depended upon, but in general pure small-pox succeeded. When small-pox inoculation precedes by three or four days the insertion of vaccine lymph, the vaccination advances, but after the tenth day the fluid in the vaccine vesicle becomes purulent; and in that state will communicate small-pox. (Wil- lan on Vaccine Inoculation, p. 8.) Those who have in early life undergone small- pox inoculation are for the most part unsusceptible of cow-pox. Under such circumstances, however, vaccination sometimes produces a certain degree of effect. The disorder manifests itself, but in an imperfect or modified form. The fluid in the resulting vesicle cannot be trusted to for repro- ducing the genuine cow-pox. Recurrent and modified cow-pox. — When cow-pox has once completed its regular course the constitution is always left, for a considerable time at least, unsusceptible of the same disorder. But this law does not hold good when the renewed application of the virus takes place at very short or at very distant intervals. If vaccine virus be re-inserted on the fourth, fifth, or sixth day after a regular primary vaccination, the vesicles of the second vaccination are hurried forward in their course, so as to overtake the first crop, and the j whole maturate and scab together. The second crop of vesicles, however, are not more than one- fourth of their normal size, and the areola sur- rounding them is equally contracted. Mr. Bryce, in 1802, very ingeniously proposed to avail him- self of this circumstance, and by testing with j vaccine matter on the fifth day, to give a security that the system was under the full influence of the vaccine disorder. This plan has since been extensively pursued, and is known by the name of Bryce's test. Mr. Bryce considered that this test afforded as clear and well-defined a mark of constitutional affection in cow-pox, as the vario- lous eruption does of successful inoculation. (Bryce on Cow-pox. Edinburgh, 1802.) To obtain this criterion in the greatest perfection, he advises that the second application of the virus should take place between thirty-six and forty- eight hours before the primary areola begins to appear (end of the fifth or beginning of the sixth day). If no acceleration of the second crop of vesicles be observed, it is to be concluded that no constitutional action has resulted from the first insertion of the virus. The second is then to be regarded as the primary affection, which in its turn is to be tested with a third, and so on until we are satisfied that the full measure of constitu- tional effect has been produced. Some persons have claimed for this suggestion the highest honour, and have even considered Dr. Jennen discovery as incomplete without it. (See Mon- ro's » Observations on Small-pox." Edinburgh, 1818. p. 113.) Dr. Jenner, however, never laid much stress upon it. In doubtful cases it is un- doubtedly a prudent practice, but in our opinion it has been extolled far beyond its real merits. It shows whether or not constitutional influence has been exerted by the primary vesicle, but it does not determine what has been the degree of such influence : — in other words, it does not show whether the constitutional effect has been complett or otherwise. As a test, therefore, of the stability of the vaccine protection in after life, (in which light alone it can be valuable,) Bryce's test is ab- solutely nugatory. Re-vaccination. — The effects of re-vacci- nating at distant intervals from the date of the primary vaccination are deserving of attention. Dr. Jenner, in his original essay, (Jenner's In- quiry, p. 21), announced that the human body after a time had the susceptibility of cow-pox re- newed. We have noticed four different effects resulting from the operation of re-vaccination. (London Medical Gazette, vol. i. p. 590.) In many cases, especially where the interval from the primary to the secondary vaccination has not ex VACCINATION. 627 ceeded five years, the skin appears completely in- sensible to the vaccine poison. The inoculated point takes on no inflammatory action, and no greater effect is produced than if the lancet had been dipped in the serum of the blood. More commonly, however, especially at intervals ex- ceeding ten years, the virus irritates locally. In three, or at furthest four days from insertion, an areola of irregular shape appears, surrounding a minute, itching, acuminated, and angry vesicle. Frequently the glands in the axilla swell, and in particular habits of body, especially in adult fe- males, irritative fever to a considerable extent is superinduced. A scab forms on the eighth day, which soon falls off, leaving no permanent cica- trix. In a third set of cases, a vesicle forms more gradually, without either local or constitutional irritation. A slight areola succeeds, and the vesi- cle yields, on the seventh day, a considerable quantity of thin lymph; but this lymph will be found, on trial, incapable of propagating the dis- ease. In a fourth set of cases, the second vacci- nation runs a perfectly regular course. A true circular areola forms on the eighth day, and the lymph will be found to propagate a good and genuine cow-pox. It is difficult to avoid enter- taining the notion, that those who exhibit the first set of appearances now described would have ef- fectually resisted the infection of small-pox; that those under the circumstances last mentioned might have undergone small-pox in some of its ordinary forms; and that the remainder would, under circumstances favourable to the develop- ment of small-pox, have undergone it in the form which we have elsewhere in this volume desig- nated and described as the varicella variolodes. Surgery of Vaccination.—In the perform- ance of this simple operation many circumstances require attention. Failure in the operation is always harassing to the parent, and is frequently urged as a pretext for dangerous delays. Of the Bources of failure some have reference to the mode of operating, some to the selection of lymph, and others to the system of the individual operated upon. Wherever it is possible, vaccine lymph should be inserted in a recent state. It should be per- fectly clear and limpid, and the earlier it is taken the better, for effective lymph must always be in a certain state of intensity. A fifth-day vesicle will often afford a minute drop of lymph of.great energy. Lymph may be taken, however, with every prospect of success, up to the eighth and ninth days. On the tenth day the virus is often so much diluted with the serum of the blood as to be unfit for reproduction. The same thing, too, frequently happens to vesicles of the seventh or eighth days, when the lancet of the operator is applied to them too often, or with an undue degree of roughness. A vesicle should always be handled very gently. After the tenth day the virus is scarcely fluid, and never can be relied on. It is of the utmost consequence to the success of the operation that the lancet be clean and per- fectly sharp. Failure often arises from a peculiar toughness of the child's skin, which a blunt lan- cet penetrates with difficulty. The lymph is con- sequently thrown back upon the shoulder of the lancet, and not a particle of it enters the wound. A good vaccinating lancet should have a broad shoulder as well as fine point, for an instrument of this shape best retains an adequate portion of virus. The skin should be kept perfectly tense during the performance of the operation by grasp- ing the arm firmly. Six or eight punctures may be made at convenient distances and to a mode- rate depth. Much importance has been attached to the quantity of blood drawn, it being held that the escape of blood must necessarily wash away the virus. This, however, is a mistake. Pro- vided that a genuine lymph of due intensity has once come in contact with the absorbing surface of the cutis vera, it is a matter of perfect indiffer- ence whether little or much blood flows from the wound. The quantity of blood that escapes de- pends more upon the child's habit than upon the operator. A child full of blood always bleeds freely when vaccinated; but such children exhibit subsequently the most perfect appearances. Care should be taken, as far as possible, that the child to be operated upon should be in perfect health. During the presence of any disease,—at the period of dentition,—when the bowels from any cause are disordered,—or the skin preoccupied by some eruption, whether herpetic or scaly, vac- cination should be delayed, unless from the pressure of some extreme necessity. The best age for vac- cinating is between the third and fifth month after birth, when the child has acquired plumpness, and before dentition has commenced. Preservation of Vaccine Lymph. — The importance of using fresh lymph need not be in- sisted on ; but occasionally no other resource pre- sents itself than preserved lymph. Being a fluid of extreme delicacy, and very liable to spontaneous decomposition, as well as to other changes which impair its efficacy, great difficulty has always been experienced in preserving it, and more especially in transmitting it in an active state to tropical climates. The following are the modes of pre- serving lymph which are now adopted. 1. It may be preserved fluid for several days, between two pieces of glass, about an inch square, which fit each other accurately. Lymph thus preserved, even when dry, will often, if carefully moistened with the breath, propagate the disease. 2. Vaccine lymph may be preserved on ivory points shapen like the teeth of a comb. These should be twice dipped in the fluid of the vesicle, and allowed to dry slowly. When used, they should be retained in the wound made by a sharp lancet for about half a minute. They are very effectual. Some vaccinators give the preference to platina points. 3. Vaccine lymph may be kept fluid in small capillary tubes, having a bulb at one end, (in shape like a thermometer). They admit of being hermetically sealed. To prevent spon- taneous decomposition, the lymph should be col- lected only in minute quantities. 4. Mr. Bryce announced, in 1802, that vaccine scabs may be made use of to communicate the disease ; and it has since been ascertained that this is the most certain mode of transmitting the cow-pox to hot countries. They are prepared for use by rubbing to powder, and moistening with a little lukewarm water to the consistence of a thin mucilage. Punc- tures made with this artificial lymph ought to be very numerous. 5. Dr. Jenner occasionally em- 628 VACCINATION. ployed dossils of lint saturated with the fluid of an eighth-day vesicle. These he placed between glasses, one surface of which has a small central cavity. The glasses should be tied together, their edges sealed and the whole covered with sheet- lead. Preserved in this manner, vaccine lymph will retain its fluidity and efficiency for a consider- able length of time. THEORT OF VACCINATION. Identity of the Vaccine and Variolous Poi- sons. — The confidence with which Dr. Jenner originally announced vaccination as an antidote to the small-pox, was mainly founded on the specu- lations in which he had so long indulged concern- ing the common origin of human and epizootic maladies. Into the details of this curious but un- inviting branch of medical theory we do not pro- pose to enter; but we may mention that, according to Dr. Jenner, the most remarkable malady which affects equally man and the brute creation, is that which in its most malignant form we call small- pox, and in its milder forms swine-pox, chicken- pox, and cow-pox. It is a matter of curiosity at least, if not of more serious reflection, that the vulgar, in their nomenclature of diseases, should have acknowledged the doctrine of a common origin to the disorders of man and beast. Jenner not only believed that the small-pox and cow-pox were essentially the same disease, but that the former was a malignant variety of the latter, the parental disorder being the cow-pox. This theory was pointedly marked by the phrase variolx vac- cinx, under which cow-pox was first introduced to the notice of the scientific world. As it has found both supporters and opponents in later times, a few observations upon it may not be mis- applied. Diseases that mutually produce each other are clearly referable to the same source : the identity of swine-pox and small-pox, therefore, is univer- sally admitted. The cow-pox, however, is differ- ently circumstanced. In man, cow-pox never produces small-pox; nor does small-pox, however mild, approach to the character of cow-pox. It remains, therefore, a very questionable point, whe- ther these disorders can be essentially the same,— in other words, whether cow-pox can be considered a permanent, as swine-pox is a temporary modifi- cation of variola. It has been argued, in favour of this hypothesis, first, that the cow-pox in the cow is a constitutional and sometimes malignant disorder, approaching in its characters to variola, and in various countries called and considered as variolous : 2dly, that cow-pox contaminated by small-pox sometimes loses its virulence, ceases to produce eruptions, and at length takes on the true vaccine character. (Baron's Life of Jenner, p. 245.) Dr. Jenner never brought forward any direct experiment in favour of this opinion; but attempts have recently been made to support it by proving that small-pox can be communicated from man to the cow. Experiments, it is said, have been instituted by Dr. Sonderland, at Bremen, (London Medical Gazette, vol. ix. p. 162,) show- ing that cows may be infected by inhaling the effluvia of blankets saturated with small-pox mat- ter. Other experiments are stated to have been made in Egypt by medical men, showing that a cow may be inoculated with small-pox matter, and that the result is a fine active vaccine virus. (Ibid. vol. i. p. 673.) From the loose way in which these experiments are detailed, (Ibid. vol. ix. p. 500,) and from the fact of their having been repeated carefully under our own observation at the Small-Pox Hospital, (Ibid. vol. i. p. 781;) it Utrecht, by M. Numann, (Johnson's Medico-Chi- rurgical Review for January, 1834, p. 209 ;) and by Mr. Macpherson, (London Medical Gazette, vol. xiii. p. 511,) in India; we may fairly presume that they are incorrect, if not altogether fabulous. It is a singular circumstance, that hitherto, so far as our observation extends, no distinct experiments have proved that cow-pox can be communicated from man back to the cow. (London Medical Ga- zette, vol. i. p. 781 ; also Calcutta Medical and Physical Transactions, vol. vi. p. 174.) The theory, therefore, which would explain the pre- servative power of cow-pox on the principle of its being small-pox, which, in passing through the body of the cow, had become modified, is still unsupported by direct experiment. It is presuming too far to say that these experiments have been carried to their furthest reasonable limit; but enough has been done to show that the commu- nication of small-pox from man to the cow is most uncertain, and that the hope entertained by some sanguine physiologists, that in the possibh loss of the present stock of cow-pox, small-po> might be made to furnish its own antidote, is alto gether illusory. [More recent experiments, however, by Messrs Ceely, Thiele, and others, seem to show convinc- ingly, that the cow may be inoculated with the matter of small-pox, and that in passing through the body of the animal, the matter is converted from small-pox into vaccine.] Identity of the Cow-pox with the grease in horses. — In Dr. Jenner's original essay on vaccination, not only was the connection between cow-pox and the grease in horses prominently put forward, but it was confidently stated that cow- pox never occurs in dairy countries except where there is access to horses. (Inquiry, p. 47.) In other words, Jenner denied the spontaneous origin of the disease in the cow. We cannot help think- ing that the stress thus laid upon the equine origin of cow-pox was injudicious. The facts bearing upon the question were then very imperfectly known; and the opinion itself was, as Dr. Jenner himself confessed, unsubstantiated by any direct experiment. (Ibid. p. 46.) Even if most satis- factorily proved, it could not have tended in any degree to strengthen public confidence in the vir- tues of cow-pox; and being a doubtful point, it gave a handle to the opponents of vaccination of which they were not slow to avail themselves. For several years this question was the source of controversy. Dr. Baron acknowledges that in 1803 all the principal medical men in London were adverse to the opinion. (Life of Jenner, p. 584.) Later observations, indeed, have established the identity of the two affections, cow-pox and grease; but they have shown at the same tinw the incorrectness of some of Jenner's original views. It has been satisfactorily established, foi instance, first, that cow-pox does originate in the cow without access to horses, ( Griva, " Epidemia Vaiuolosa del Torino," p. 102); and, secondly. VACCINATION. 629 that cow-pox is communicable to man from the horse without the intervention of the cow, and with nearly equal facility as from the cow itself. Dr. Jenner held that the direct communication of the disorder from the horse to man was undeter- mined and uncertain, and that the active quality of the greasy virus is greatly increased after it has acted on the nipples of the cow. (Inquiry, p. 52.) This branch of the theory of vaccination has been investigated with great diligence by Dr. Loy of Whitby, (Observations on the Origin of Cow an utter unsusceptibuity" to the vaccine virus. This position opens a wide field of curious inves- tigation, as we have elsewhere attempted to ex- plain. (See London Medical and Physical Jour- nal, Nov. 1827, p. 381.) In a certain number of children subjected to careful vaccination, the vesicles will be found small, their progress slow, the areola faint, and the constitutional disturbance trifling. In such habits the absorbents of the arm are inactive, and not more than one out of eight or ten punctures advances. In other words, the disposition in the constitution to receive the vaccine pox, 1801,) Dr. De Sacco of Milan, (Baron's Life : virus and to bring it to perfection are identical. of Jenner, p. 250,) and Dr. Carro of Vienna. The last-named author (see Monro " On the Pre- valence of Small-pox," in Edinburgh Journal of Medical Science, vol. i.) states " that the matter in use at Vienna from 1799 to 1825 was partly British vaccine, and partly originated from the grease of a horse at Milan without the interven- tion of a cow. The effect was so similar in every respect, that they were soon mixed; that is to say, after several generations, and in the hands of innumerable practitioners, it was impossible to distinguish what was vaccine and what was equine." " The whole British settlements in In- dia," he adds, " were equinated,- for the first liquid drop sent thither was the second generation of Milanese equine, or greasy matter, transplanted at Vienna." Protective influence of Cow-pox.—After an experience of thirty-four years in the efficacy of vaccination, and with the knowledge that that practice has extended over every quarter of the globe, and is still almost universally adopted, it would be a waste of time to enlarge upon the extraordinary power which it possesses of pre- serving the human body from the assaults of small-pox. Sir Gilbert Blane (On the true Value and present State of Vaccination, p. 14,) most truly and eloquently observes, « that, viewed as a mere phenomenon in the natural history of the animal kingdom, it is highly interesting. The physiologist finds himself lost in astonishment when he contemplates the singular fact, that a mild virus taken from a domestic animal should shield the body from one of the most fatal and cruel maladies to which it is subject; while the philanthropist sees in it benefits to mankind which in his most sanguine moments he could never have dreamed of." How great, then, how unre- quitable are the obligations of mankind to the in- dividual who first drew the secret from the dark recesses of rural tradition, and rendered it availa- ble to the whole human race ! Time, which has fully corroborated the general truth of the important law of the animal economy first promulgated by Jenner, has shown also that it is subject to several modifications. These we next proceed to investigate, seeking to determine, so far as observations have hitherto gone, their number and extent. Constitutional inaptitude to Cow-pox.__ One of the most important principles bearing upon the great question of vaccine influence is to be found in the fact that the predisposition to receive cow-pox is not equally great in all persons, nor at all times; and that in some individuals there exists, either through life or for a limited period, 3 c* From hence it follows that the mode of vaccina- ting and the supply of lymph being the same, the proportion of successful to unsuccessful incisions affords a fair criterion of the degree to which the constitution is predisposed to nourish and profit by the vaccine virus. Some of the children who re- ceive vaccination with difficulty are obviously sickly, and labouring under some disease weaken- ing the body generally. In others, this atony of the absorbent system is displayed in conjunction with slowness of dentition, an imperfectly ossified head, and an emaciated aspect of body. On the other hand, it will frequently be found that a con- stitutional inaptitude to cow-pox coexists with the most healthy aspect. We may assume, there- fore, that it is sometimes dependent on idiosyn- crasy. In the former case, the indisposition to receive cow-pox is only temporary ; in the latter, so far as we have had opportunities of observing, it continues, and probably through life. Mr. Cross calculates that about one in fifty of mankind are unsusceptible of the vaccine virus. (On the Va- riolous Epidemic of Norwich, p. 32.) An interesting question here presents itself. Does the constitutional inaptitude to cow-pox de- note a like inaptitude to small-pox? It would require a very extended sphere of observation to give a decided answer to this question; but expe- rience seems to show that the predisposition to the two complaints is the same, and that a child who has altogether resisted the vaccine virus will be found equally unsusceptible of small-pox. (Gre- gory on the Recurrence of Exanthematous Fevers, in London Medical Gazette, vol. viii. p. 494.) The difficulty of giving cow-pox in a perfect form may be traced in some instances to the state of the atmosphere. At Turin, in August 1829, the number of cases in which vaccination failed was so great, that it was proposed to intermit vac- cination altogether. (Griva, Op. cit. pp. 63 and 100.) The phenomena appeared to depend upon the state of the weather, which caused a hot, dry, and furfuraceous state of the skin, that impeded both absorption and exhalation. Dr. Jenner was well aware that the condition of the skin fre- quently offered an insurmountable obstacle to suc- cessful vaccination (On the Varieties and Modifi- cations of the Vaccine Pustule, 1806); but he does not appear to have connected this with any atmospheric changes. The difficulty of keeping up a supply of genuine lymph in tropical coun- tries has long been known, (See Ferguson on "Vaccination as practised at Sierra Leone," in London Medical and Physical Journal, vol. lix. p. 195,) and admits of an easy explanation on this principle. 630 VACCINATION. Occurrence of Small-pox after Cow-pox. —The number of persons who have taken small- pox after undergoing cow-pox [varioloid] in a sat- isfactory manner is now so great, that it becomes necessary, with a view to forming an impartial estimate of the value of vaccination, to investigate the subject very carefully. Previously, however, we must revert for a short time to the views ori- ginally entertained by Dr. Jenner concerning the complete efficiency of vaccine protection. Popu- lar rumour, we have seen, attributed to cow-pox a certain degree of protecting power over small- pox, but it was only in a certain degree; and the reason why Jenner, prior to 1798, failed in con- vincing his medical friends of the justness of his views, was, that in their judgment the quantum of protection afforded by the cow-pox was insuf- ficient. « We have all heard," they would say, " what you speak of, and we have seen examples which certainly do give countenance to your opi- nions ; but we have also known cases of a per- fectly different kind. We have seen persons re- ported to have had cow-pox who have subse- quently caught small-pox. The evidence in favour of the protective power of cow-pox, therefore, appears to us both inconclusive and unsatisfactory." (Baron's Life of Jenner, p. 125.) Jenner, we have seen, took a different view of the nature of vaccine influence, and confidently announced the complete and permanent security afforded by it, provided the disease was received in its perfect form. His petition to Parliament in 1802 stated, " that he had discovered a disease attended with the singularly beneficial effect of rendering, through life, the person inoculated with it perfectly secure from the infection of small-pox." It is certainly curious that Dr. Jenner should thus have acknow- ledged the full value of the popular opinion re- garding the security afforded by cow-pox, but should have rejected o'r treated lightly the qualify- ing clauses. Experience has now shown that common observation was not less deserving of attention in the one case than in the other; and it is probable that in the outset a more moderate estimate of the prospective advantages of vacci- nation would have obviated much of the difficulty which has lately been experienced, without mate- rially lessening the public zeal in its favour. It is well worthy of remark, that in Dr. Jenner's original essay no mention is made of any cases in which cow-pox failed to afford protection in after life; nor should it be forgotten that the confident announcement then made of the permanency of vaccine protection was founded exclusively upon cases of the casual disorder. It was not until his third publication, in 1800, that Jenner alluded to the chances of failure, which he did in the follow- ing words (Continuation of Facts and Observa- tions, 1800, p. 32) :—« Some there are who sup- pose that the security from the small-pox obtained through the cow-pox will be of a temporary na- ture only. This supposition is refuted, not only by analogy with the habits of diseases of a simi- lar nature, but by incontrovertible facts, which appear in great numbers against it." Proportion of the Vaccinated who take Small-pox.—Various attempts have been made to ascertain the actual proportion of those who are effectually and permanently secured by vaccina- tion, to those who subsequently receive small-pott but on this point there is great difficulty in attain- ing even an approximation to the truth. The loose statements frequently made in reference to this question would lead to great errors. Thus we read in one of the reports of the National Vac- cine Establishment, (Report of the National Vac- cine Establishment, dated May 18, 1820,) "that of more than sixty thousand persons vaccinated in London and its vicinity in the course of twelve years by that establishment, five only are reported to have been subsequently affected with small- pox." But it must be obvious that twelve years would serve to scatter a large portion of such per- sons over the face of the globe ; and if one-tenth or one-twentieth of them took small-pox in after life, there is little probability that the news of i| should reach the ears of the members of the board. Mr. Cross, of Norwich, calculates (Variolous Epi- demic of Norwich, p. 192,) " that of the vaccin- ated, not more than one in twenty will be in any way affected by the most intimate exposure to small-pox contagion; and less than one in fifty will have the disease in a form answering to the generally received descriptions of modified small- pox." These calculations, however, are grounded on very imperfect data. [The following tables by Dr. George Gregory, (Tweedie's Library of Medicine, 2d Amer. edit., i. 325, Philad. 1842,) taken from the records of the Small-pox Hospital, London, exhibit the com- parative mortality in the varieties of regular small- pox, at different ages, during the epidemic of 1838, They further show the degree of protection and the diminished mortality after vaccination. NORMAL UNPROTECTED. VACCINATED." small-pox. Admitted. Died. Admitted. Died Confluent........295 149 56 21 Semi-confluent____ 78 8 42 4 Distinct......... 19 0 20 0 392 , 157* 118 25 ABNORMOUS UNPROTECTED. VACCINATED. small-pox. Admitted. Died. Admitted. Died. Confluent modified... 2 0 38 4 Semi-confluent do.... 1 0 28 1 Varicelloid.........1 0 114 1 Total abnormous___4 0 180 6 Grand total.......396 157 298 31f . UNVACCINATED. VACCUUTSD. AGES- Admitted. Died. Admitted. Died. Under 5 years........42 20 0 0 From 5 to 9, inclusive 37 11 5 0 10 to 14, « 30 8 25 0 15 to 19, " 104 32 90 6 20 to 24, « 115 50 106 16 25 to 30, « 45 23 55 8 31 to 35, «12 7 13 1 Above 35 years of age, 11 6 4 0 Total..........396 157 298 31 The ratio of mortality of small-pox after vacci- nation, according to Drs. Geo. Gregory and Heim, (Brit, and For. Med. Rev. Jan. 1839.) is the same in London and in Germany, namely, 7 pet * Of these there died of fever and superadded erysipe- las, 14. t Of these there died of fever and superadded disease, 10. VACCINATION. 631 cent.; but in France, it would appear to be much less than this: thus, according to the report of M. Villcneuve, of 365 cases of confirmed small-pox, occurring in persons who had been successfully vaccinated at some previous period, there were only 8 that proved fatal, giving a proportion of about 1 in 45 or 46; and more recently, M. Gaulthier de Claubry infers, that varioloid de- stroys 1 in 100; whilst the mortality from small- pox is 1 in 8.5. The writer—as elsewhere re- marked, (Practice of Medicine, 2d edit. ii. 567, Philad. 1844), has never met with an unfortunate case; but he has seen numbers in which the face was scarred. The tables, above given, show the effect of time in diminishing the amount of protection afforded by vaccination. Of the 298 previously vaccinated cases that presented themselves at the Small-pox Hospital in London, during the epidemic of 1838, none were under 5 years of age: 5 were between 5 and 9, inclusive; 25 were between 10 and 14 ; 90 between 15 and 19 ; 106 between 20 and 24; 55 between 25 and 30; 13 between 31 and 35; and 4 above 35 years of age; and, more recently, Dr. Gregory has stated it to be worthy of record, j that among 120 cases of varioloid, occurring sub- i sequent to vaccination, at the Small-pox Hospital in 1840, 11 only were under 16 years of age. j The youngest person admitted under such circum- stances was aged 7; and the first occasion on which he had ever known a child under five years of age admitted with small-pox after vaccination, occurred the week before he wrote:—facts which would seem to encourage the view that after a certain time the protective power of vaccination is greatly diminished; yet it will be observed, that after 35 again, the subsequent occurrence of va- riola is extremely uncommon.] Characters of Small-pox after Vaccina- tion.—This subject has been already adverted to. (See Small-pox.) We have now only to remark concerning it, that ample experience has demon- strated that small-pox, as it occurs subsequent to vaccination, is for the most part a mild and tract- able disorder. The pustules are generally small, hard, and tuberculated. Few of them maturate perfectly ; but at the same time the small quantity of matter which they do contain will give, both casually and by inoculation, small-pox to others. It is neither followed by pits and scars, nor by injury to the general health. Severer cases un- questionably do occur, and fatal cases are on record; but this ought not to surprise us. When small-pox and its accompanying fever once take possession of a weak, delicate, and scrofulous frame,—when it attacks persons advanced in life and of plethoric habit, or those who are recovering from other disorders,—when its inroads are syn- chronous with some other affection, as pneumonia, enteritis, or phthisis,—it would be difficult to set bounds to its injurious tendencies. The eye of the practised physician, indeed, may distinguish between the specific and the accidental modes of death in small-pox ; but this nicety can never be made intelligible to the public mind, which, in the event of the patient dying within thirty days from the invasion of small-pox, will always be inclined, and not without some justice, to attribute death to that cause. Within a very few years after the discovery of vaccinations, physicians began to record cases of succeeding small-pox; but in almost all these in- stances there was either some doubt as to the correctness of the vaccine process, or the disease was so mild as to suggest doubts of its being really variola. In process of time these cases became both more numerous and less equivocal, and now they are familiar to every one engaged in practice. The experience of the Small-Pox Hospital during the last twenty years furnishes many useful facts which bear upon this question. It has shown, for instance, how much more frequent small-pox after vaccination is among adults than children. Very few children have been received into the hospital under such circumstances; and those few have invariably had a mild disease, more allied to chicken-pox than to small-pox: whereas all the severe cases, and the greater proportion of the mild ones have occurred in adults, in whom an interval varying from ten to thirty years (the average eighteen) had elapsed since the date of vaccination. [It has been affirmed by M. Levret, from observation of between 1700 and 1800 cases of small-pox in his private practice and in the hos- pitals, that cases of a second attack of small-pox were as numerous in proportion as attacks of small-pox after vaccination.] Causes of Small-pox after Vaccination. —The attention of Dr. Jenner was early directed to investigate the circumstances which interfered with the protective power of cow-pox. Wc have already had occasion to remark, that in his earliest publications he adopted the notion of a true and a spurious cow-pox, the produce of the cow, one of which afforded protection, and the other none. When he afterwards ascertained that the true cow-pox itself could not always be depended upon, he took up the theory of local action, and contended that cow-pox virus originally good might become, from a variety of causes, so de- teriorated in quality as to produce a local disease but no such constitutional influence as is necessary to ensure protection against small-pox. Towards the close of his life Dr. Jenner enlarged the theory of imperfect vaccination, and considered that the grand impediment to successful vaccination was pre-occupation of the skin by herpetic or other eruptions during the development of the vaccine vesicle. In the course of years, when some of those took small-pox, who had been declared by competent judges, even by himself, most perfectly vaccinated, a third explanatory principle was adopted, which we may designate as the doctrine of variolous diathesis. Other pathologists had early suggested a fourth explanatory principle,— the decay of vaccine influence in the lapse of years; but this was resolutely opposed by Jenner even to the last. This general sketch of the sup- posed sources of vaccine failure may serve as an introduction to that more detailed inquiry which the frequency of the occurrence in recent times appears to demand. 1. Deterioration of the vaccine virus.—It has been repeatedly urged as one mode of accounting for the occasional occurrence of small-pox after vaccination, that the vaccine virus deteriorates by passing through a succession of human bodies. 632 VACCINATION. This idea was never countenanced by Dr. Jenner, and is not generally received by medical men, at least in this country, but it is a favourite doctrine with the public. We see no grounds whatever for adopting such a notion. It has neither reason nor analogy in its favour. Those who take cow- pox naturally, or by direct inoculation from the cow, are as open as others to the chance of sub- sequent small-pox. Persons vaccinated by Dr. Jenner himself in the very infancy of the practice, before such deterioration could possibly have com- menced, have yet been attacked by small-pox in after life. It is contrary to the analogy of small- pox virus, which has undergone no such change, but remains as virulent as in the days of Rhazes and Avicenna. If appearances can be trusted, they are all against such a notion. The elevation and pearl-like aspect of the vesicles of the present day, the extent and shape of the areola, the colour and form of the resulting scab, — all correspond precisely with the earliest delineation and descrip- tions of Dr. Jenner. So far from believing in any deterioration of virus from successive inoculations, there is reason to believe that by a careful selec- tion of well predisposed children, the pock may even be restored from an imperfect to a perfect state, and by proper care, therefore, may be re- tained indefinitely in that condition. If children are successively vaccinated from each other, all of whom are from various causes ill-disposed to take on the perfect disease, the virus may un- questionably degenerate, and at length wear out altogether. In tropical countries, and in confined localities, such an occurrence certainly takes place, but this is very different from the notion of a virus deteriorated by the mere influence of time. 2. Imperfect vaccination----This was the favourite theory of Dr. Jenner, and as such alone it would deserve attention. But it has other and more legitimate claims to our consideration. Vac- cination is said to be imperfect, when any con- siderable deviation from the ordinary course of the vaccine vesicles takes place. The impediments to perfect vaccination, according to the supporters of this theory, are principally the following :—1. Spurious matter, by which is understood, not a spurious virus as originally taken from the cow, but matter taken from the arm at an improper period of the process. 2. An insufficient number of vesicles. 3. Preoccupation of the skin by some disease in which a fluid is poured out capable of conversion into a scab, such as tetter, ringworm, scaldhead, erysipelas, or even a whitlow on the finger. 4. Robbing the vesicle incautiously of its contents, particularly where one only has come to maturity. 5. External violence done to the vesi- cle, (such as rubbing or scratching it,) more especially during its early stages. That these circumstances may, and do in some cases, materi- ally interfere with the success of the vaccine pro- cess, cannot be questioned; but many strong arguments have been adduced to prove that the in- fluence attributed to them has been overrated (See Edin. Med. and Surg. Journ. vol. xvi. p. 235) ; and that the theory itself is neither so well founded in general reasoning, nor so far justified by experi- ence, as to afford a satisfactory explanation of the phenomena. It has been shown, for example, by numerous and well-marked instances, that vac- cination, which according to all rule should have been called perfect, has given only imperfect security ; while, on the other hand, cases in which the process was interrupted, have notwithstanding afforded perfect security. The instances in which single vesicles have preserved from small-pox both casually and by inoculation, are so numerous, that no reliance whatever can be placed on the notion which would connect the security of the individual with the number of maturating vesicles. It has been remarked that a case of small-pox after vaccination will seldom be seen without ob- serving that several persons under precisely the same circumstances, that is to say, belonging to the same family, vaccinated by the same practi- tioner, in the same manner, having similar marks on the arm, and equally exposed to contagion, escaped entirely. It has been proved, too, that persons have taken small-pox after being subjected to Bryce's test, the only mode hitherto invented to ascertain that a perfect constitutional affection had resulted from the original vaccination. 3. Variolous diathesis.—At various times, and by persons high in authority, (See Report of the National Vaccine Board for 1821,) the opinion has been put forward, that small-pox occurring after vaccination may be ascribed to some pecu- liarity of constitution identical with that which renders some persons liable to second attacks of small-pox. This theory is still upheld by some, and great importance has even been attached lo it, as an explanation of vaccine failure. Its validity depends upon the assumption that small- pox and cow-pox are essentially the same disease, a position which we have already shown to be objectionable, even if at all tenable. The great, and as it appears to us, unanswerable argument against it is this; — small-pox occurring a second time was so rare, that its occurrence was actually denied by three of the oldest and most expe- rienced physicians of the last century ; viz. Van Swieten, Dr. Heberden, and Dr. Monro, (See Thomson on Varioloid Diseases; Appendix, p. 8,) while small-pox after cow-pox is an event of daily occurrence. One-third of the total admis- sions into the Small-Pox Hospital for several years past has consisted of persons who in early life have undergone vaccination. During the twelve years ending December 31, 1833, one thousand and six patients have been received into the hospital having small-pox after reputed vac- cination, while in the same period the total num- ber of cases of secondary small-pox has amounted only to fourteen. This statement, however, is not intended to convey any comparison between the preservative effects of inoculation and vaccination. The two processes are in their nature and object* so essentially different, that no fair comparison can really be made between them. The former is calculated, by ensuring one attack of small-pox, to prevent a second. The object of the latter is to prevent any attack of small-pox whatever. A person is not inoculated to prevent a second at- tack of small-pox, but to give a first. A com- parison between the two processes, therefore, m like instituting a comparison between the relative frequency of first and second attacks of small-pox. It may with propriety be undertaken by those who VACCINATION. 633 believe that cow-pox is only small-pox in a milder i that the changes effected by each of these means form ; but those who believe, with us, that cow-1 in the constitution, loosen to a certain degree the pox and small-pox are as essentially distinct as hold which vaccination has upon the system, and small-pox and measles, may be excused from pro- j thus pave the way for the inroad of small-pox. sccuting such an inquiry. It has been observed! The late experiments of Dr. Heim would tend to that, as a measure of prevention, inoculation is connect the subsequent susceptibility of small- the most severe, but the most certain; — vaccina- | pox simply with the development of the adult tion the most mild, but the least certain. This' constitution. (London Medical Gazette, vol. xiv. probably expresses the exact state of the question p. 517.) as to the relative value of vaccination and in-' Such a doctrine will probably be conceded even oculation in the fewest words, and in the clearest by the staunchest advocates of Dr. Jenner, when manner consistently with our present knowledge, it is applied only to cases of doubtful vaccination ; 4. Decadence of vaccine influence.—There was but the question, to be met fairly, should be fur- no doctrine to which Dr. Jenner was so resolutely j ther extended and put thus: Does the doctrine opposed as that of a gradual decay in vaccine in- [ of a limitation in the period of vaccine security fluence in proportion as life advanced. His great' apply at all (and if it does, in what proportion), argument against it was that it was contrary to the. to those cases in which the primary process is analogy of small-pox inoculation, which was uni-' complete in all its stages,—when every insertion versally allowed to sustain no diminution of energy I takes effect,—when the vesicles are large, pearly, by the lapse of time. But here again the force of and elevated,—when the areola reaches its acme the argument depends on the presumed identity on the tenth day,—when the constitution at that of the vaccine and variolous poisons. If this' period gives evidence of internal derangement,— principle be not conceded, there is as much reason when the scabs remain adherent to the twenty- in supposing that the influence of vaccination may ' first day,—and, lastly, when the resulting cicatrix gradually subside, as that it may continue perma- is well defined and permanent in after life 1 Years nent through life. In such a case, experience must elapse before this question can be answered alone, not analogy, can determine the fact. i beyond the possibility of doubt or cavil. In the Should we even be inclined to admit the truth | meantime, however, we are warranted in saying of the Jennerian doctrine so often quoted, " that i that, if such limitation does apply to such cases, when once the human frame has felt the full force it is only to a small proportion of them,—in other of genuine and perfect cow-pox, it was never j words, that in the present state of our knowledge afterwards assailable by small-pox," the question [ permanent security is the law of the animal eco- still recurs, what is the law which regulates the ! nomy and temporary security the exception. subsequent liability to small-pox, when the vaccine ] Remedies for the Imperfection of Vacci- process has been imperfectly gone through, and: nation.—Whatever difficulty there may be in when, from some peculiarity of habit, the system . •determining the exact proportion in which vacci- receives only a portion of that salutary influence nation fails to impart that perfect and permanent which cow-pox is capable of imparting. Dr. Jen- \ security against small-pox which was its early ner held that, under such circumstances, " small-! attribute, it is clear that the cases of vaccine fail- pox would recur, and that the degree in which its ure are very numerous, for they have forcibly at- phenomena were modified was proportioned to the ' traded public attention, and several plans have degree of perfection which the vaccine vesicle as-1 been suggested, some of them emanating from the sumed during its development." (Willan on public rather than the profession, having for their Vaccine Inoculation; Appendix, p. v.) The re- j object to obviate the real or supposed imperfections suits of our own observation lead to the belief ; of vaccination. Four different proposals have that, even under these unfavourable circumstances, been made with this view, viz:—Recurrence to the susceptibility of small-pox does not recur im- ! the cow; re-vaccination; inoculation at short in- mediately, but that imperfect cow-pox gives tem-. tervals from the date of vaccination; and inocu- porary security. lation at distant intervals from the date of vacci- Dr. Willan adopted without change the notions nation. Each of these is occasionally practised. of Dr. Jenner concerning the permanency of vac- Each becomes in its turn the favourite of" the day. cine influence when the process was complete They will, therefore, require separate investiga- ted, p. 72); and many of the more iecent tion. writers on cow-pox have expressed the same opi- 1. Recurrence to the Cow.—For many years nions. The public, however, have become fami- past it has constantly been urged upon the profes- liarized with the notion that the influence of cow- sion in this country, as well as abroad, to revert pox wears out in the course of years. Some have ' more frequently to the cow for supplies of lymph. even attempted to define accurately the period The proposal is certainly specious, but in our during which vaccination gives this " charmed" opinion by no means to be recommended. The life ; arjff seven, ten, and fourteen years have been j following arguments appear to us to be conclusive respectively announced as the limit of its protec-; against its general adoption. It is by no means live power. We see no grounds for upholding! easy to find the true cow-pox, even in a large the doctrine as thus propounded, but we are dairy. Years often elapse before it is met with. strongly disposed to believe that the susceptibility ' There must always be a doubt as to the purity of small-pox does return in many cases, more es- \ and genuineness of the new stock, until the ex- pecially when favoured by certain concurrent cir- j periment of variolous inoculation has been subse- cumstances. Of these the most energetic hitherto quently made, which parents are very seldom dis- ascertained, are change of climate and the period posed to allow. Further, the true vaccine lymph, of puberty. It is not an unreasonable supposition as first taken from the cow, is frequentlv verv Vol. IV. —80 ' 634 VACCINATION. acrid, producing glandular swellings and local in- flammation, and thus occasions distrust rather than increased confidence. Lastly, it is not found that cases of small-pox are more frequent in those re- cently vaccinated, than in those vaccinated in the infancy of the practice. The experiment was tried in Italy upon a large scale in 1829. (Griva, Op. cit. p. 104.) The result was, that there was no perceptible differ- ence between the course of the old and the new, the primitive and the humanized lymph. More recent experiments in India tend to show that the measure may on some great occasions be adopted with advantage, (Calcutta Medical and Physical Transactions, vol. vi. p. 177), but it is clear even from these statements, that recurrence to the cow is not lightly to be recommended, nor adopted without great and multiplied cautions. 2. Re-vaccination.—The practice of re-vacci- nating at distant intervals from the date of the primary process is one from which no harm and much benefit may be expected. The operation is simple and free from risk. If no effect follows, the security of the individual is rendered doubly sure. If vesicles arise, and the disease goes through all or some part of its usual course, that security may reasonably be considered as renewed. The only objection that can be urged against it is the difficulty of applying it on a large scale and the fear lest the general adoption of such a remedy should serve to unhinge and disturb the public mind on the subject of vaccine security. To its application in individual cases no reasonable ob- jections can be offered. The practice has been carried to a very great extent in Germany since the year 1829. (Lond. Med. Gazette, vol. xiv. p. 515.) [At the time when the re-vaccinations published by Dr. Heim, (British and Foreign Med. Rev., Jan. 1839, p. 186,) were practised, the population of Wiirtemberg was 1,363,298; and it appears, that during the period of five years, 208,322 chil- dren were vaccinated, leaving only the insignifi- cant number of 271, above three years of age, still unvaccinated. The total number of cases of small- pox that occurred during the same period, was 1677, of which 354 were cases of genuine small- pox, and 1043 modified or rendered milder by previous vaccination,— being about one case of failure in every 217 persons. The total number of persons vaccinated a second time, after the lapse of a certain number of years, was 44,009 ; of this number, upwards of 20,000 took the disease per- fectly ; 9,006 imperfectly, and 15,000 not at all. It might be inferred from this, that little more than one-third of those vaccinated in infancy could be regarded as protected from small-pox ; but although probable, it is not proved, that a susceptibility for cow-pox is the same thing as a susceptibility for small-pox; for, if this be admitted, it would seem to follow, that the proportion of persons liable to a second attack of small-pox must be greater than is commonly believed. Thus it appears, that of 297 persons who had previously had small-pox and were pitted, 95 received the cow-pox in a perfect form, and 76 in a modified form, whilst 126 re- sisted it altogether. The results of re-vaccination in the Hanoverian army, in the years 1837-8-9, according to Miihry, were similar. Of 112 pitted with small-pox, 16 received complete re-vaccination, 21 incomplete, and 75 none at all; in other words, the susceptibility of re-vaccination existed in no less a degree than in those who had been vaccinated. On the other hand, it appeared, that after varioloid scarcely any were susceptible of revaccinntion; for of 34 who were subjected to the operation, one only showed any result, and that was imperfect. It resulted from the Wiirtemberg experiments, that the proportion of persons who took the cow- pox well, on the second vaccination, progressively increased with the distance of time from the first vaccination. Thus, in some of the departments of the kingdom, where the re-vaccinated were chiefly children, the proportion of cases in which the operation succeeded was comparatively small; among the military, 14,344 in number, where the subjects were nearly all about the age of twenty. one, a much greater number received the disease; whilst in a whole department, in which the per- sons re-vaccinated were thirty years old or up- wards, a still larger proportion was affected. All these results bear strongly on the expediency of a second vaccination: they have been urged, in- deed, as rendering re-vaccination absolutely ne- cessary for the protection of the public, and it must be admitted, that all the experience we yet have tends decidedly to countenance this view; besides a strong argument in its favour is, that it may be productive of benefit, whilst no harm can possibly result from it One very important fact would seem to be fully established, — that the existence of a cicatrix or mark of the primary vaccination in the arm is no test whatever of the immunity of the individual from small-pox, — it having been found in Wiir- temberg and Hanover (Heim and Miihry) that those with, and those without, the mark, were equally susceptible of cow-pox on the second trial. Thus, of the 14,334 re-vaccinations among the military in Wiirtemberg, 8,845, or more than half, showed what are usually considered good marks of previous vaccination ; and, of this num- ber, the success of re-vaccination was complete in 31 per cent.; modified in 29 per cent.; and it failed altogether in 40 per cent.; whilst of those of imperfect marks, the re-vaccination was com- plete in 28 per cent.; modified in 26 per cent.; and total failure occurred in 46 per cent. In the year 1840, there were vaccinated in all the regiments of the Prussian army, 43,522 per- sons. On these, the cicatrices from previous vac- cinations were distinct in 34,573; indistinct in 6177; not discernible in 2772. The pustules produced by the vaccinations were regular in their course in 20,952; irregular in 8820; and no effect was perceptible in 13,750. The unsuc- cessful vaccinations were repeated successfully in 2831 cases; unsuccessfully in 8958; and the number of genuine pustules produced was from 1 to 5 in 10,021 cases; 6 to 10 in 5875; 11 to 20 in 4171; and 21 to 30 in 885. Of all the re- vaccinations, 48 per cent, were successful — the proportions varying between 40 per cent, and 60 per cent, in different regiments. (Lohmeyer, Bert. Medicinisch. Zeitung, April 22, 1840, and Brit. c\ For. Med. Rev., July, 1840, p. 276.) In 1841 the proportion was 52 per cent. It is diffi- cult to account for this difference, as well as for VACCINATION. 635 that observed in different countries. In the Hano- verian army, the proportion of perfectly success- ful cases is stated to have amounted to upwards of Js; in the Prussian army, as just remarked, to nearly A; in Wiirtemberg, in the army, to about ^; and among civilians to nearly A. The proportion of imperfectly successful cases was, on the contrary, greatest in the Hanoverian army : in it, it was more than A_; in the Prussian army, A; in the Wiirtemberg army, less than j; and in the people, ^; but taking the successful and imper- fectly successful cases together, the results were nearly the same in all. (Miihry, loc. cit.) Results, similar to the above, have been ob- tained elsewhere. Small-pox and varioloid having been unusually prevalent in Philadelphia during the spring of 1840, the then physician of the House of Refuge and of the Pennsylvania Insti- tution for the Instruction of the Blind, Dr. T. S. Kirkbride, (Amer. Journ. of the Med. Sciences, Jan. 1841, p. 109,) was induced to re-vaccinate the inmates of those institutions. Two hundred and nine children were re-vaccinated. In all, a perfectly formed, rounded, stellated, or punctuated cicatrix was found. All others, on whom this in- dication of previous vaccination was not disco- vered, were excluded from the report. Of the total number, 134 were boys, and 75 girls; — the average age was 12,—the extremes being 6 and 20. The dry vaccine scab was used in every in- stance to communicate the disease. Of the 209 children with perfect cicatrices, 44, or rather more than 21 per cent., had the disease perfectly. The results of re-vaccination in France give even a less proportion than this. Of 2199 cases, in which, according to M. Villeneuve, it was per- formed on persons of different ages and sexes, who had been successfully vaccinated at some previous period of their lives, the operation took effect in 223 cases only, — which would give the proportion of about I to 13 or 14. (See, on all this subject, the interesting observations of Dr. Condie : A Practical Treatise on the Diseases of Children, p. 460, Philad. 1844.) It has long been a prevalent idea, that vaccine matter may lose some of its efficacy in passing through so many human bodies, and that it would, therefore, be advisable to recur to the original source; and although it has been maintained, that this view is questionable, and that vaccine matter, in its most recent state, possesses no more preventive efficacy, in reference to varioloid, than that which has been in use since the discovery of vaccination, the opposite opinion is steadily gain- ing ground under better opportunities for observa- tion. The Royal Jcnnerian Institution, it is said, employs the same lymph now that has been in use since its first foundation, in 1806. The Small-pox Hospital, however, changed their stock of lymph in 1837, and a marked improvement, we are told by Dr. Gregory, (Tweedie's Library of Medicine, 2d Amer. edit. i. 346, Philad. 1842,) was perceptible in the resulting vesicles. The local inflammation was more severe; the constitu- tional symptoms were more violent; the virus was more energetic; the most minute incision took effect, and the lymph, secreted in the pock on the 9th and 10th day, was still in an active state, j Such has been the effect of vaccine matter ob- tained fresh from the cow, in the year 1838, by Mr. Estlin, of Bristol, England. By Mr. Estlin and Dr. Carpenter, of Bristol, the writer was favoured with a few points of lymph, eleven re- moves from the cow; and it was extensively used by him, and by his friends, Professors Huston and Meigs, and by Drs. Bridges and Kirkbride, of Phi- ladelphia, and others. (Amer. Med. Intelligencer, for 1838-9, pp. 275, 290, 303, 363 and 373.) It was with this lymph that Dr. Kirkbride per- formed the re-vaccinations referred to above; and he remarks, that although some members of the profession appeared disposed to reject the new virus, from the severity of the symptoms which it induces, yet, except in three cases, he never wit- nessed sloughing or other unpleasant effects. His own observations, he adds, induce him to put more confidence in its prophylactic powers than in the old virus, " although this point can only be settled by time, and an enlarged experience by the profession generally."] 3. Inoculation at short intervals from the dale of Vaccination.—Very early in the history of vaccination it was proposed to inoculate with the variolous and vaccine virus at the same time, or within such short periods, that the two influences might coexist, the object being to produce artifi- cially that mild form of small-pox which we now so often meet with casually, and at long periods after vaccination. The proposal was revived in 1825 by Dr. Ferguson, (Letter to Sir Henry Hal- ford, &c. London, 1825), and has since been most ably criticised and combated by Mr. Ed- monston of Newcastle. (Observations on Cow- pox, 1828. Pages 107 to 119.) The plan con- sists in allowing vaccination to take the lead of inoculation by four days. The result is, that in some cases no variolous eruption whatever follows, and in other cases the succeeding eruption is of a mild or modified character. At first sight this measure appears to be a philosophical application of the facts and principles already adverted to, but the difficulties which oppose its introduction into practice are great, and in fact insurmountable. It proceeds upon the principle of keeping alive pure small-pox and pure cow-pox. But if the practice were to become general, pure cow-pox would soon become extinct, for the ordinary supply would be contaminated, and recurrence to the cow we have already seen to be both troublesome and preca- rious. Its application, therefore, at best, could be only on a very limited scale. 4. Inoculation at distant intervals from the date of Vaccination.—The early experiments of Jenner and Woodville sufficiently proved that, for two or three years at least after the insertion of the vaccine virus, the human body is unsuscepti- ble of small-pox by inoculation. These testings, however, have long ceased to be made, and very little is known experimentally as to the possibility of communicating small-pox to the vaccinated by inoculation at distant intervals from the date of vaccination. It is extremely difficult to find per- sons advanced in life willing and able to afford the time requisite for such investigations, independent of the degree of risk thereby entailed. It cannot be doubted that a series of experiments carefully conducted, showing the effects of small-pox in- oculation upon persons vaccinated from the year 636 VACCINATION—VARICELLA. 1800 to the present time, would be eminently useful. They would settle indisputably the ques- tion as to the permanency or fugitive nature of vaccine influence, and, as we believe, would strongly fortify the public mind in favour of vac- cination. The experiments conducted under our own observation with this view have been too few to warrant any decided conclusions. A fortuitous combination of circumstances may, perhaps, some day afford an opportunity of instituting such ex- periments, which at present it would be both use- less and foolish to recommend. Extermination of small-pox.—Dr. Jenner ori- ginally suggested the notion, which has been re- iterated by Sir Gilbert Blane and others, that cow- pox possesses powers adequate to the complete extirpation of small-pox from the face of the earth. Dr. Jenner's statement was, (Petition to Parlia- ment, 1802,) that from its nature it must finally eradicate that dreadful disorder. Sir Gilbert Blane remarks, (Statement of Facts, 1820, p. 8,) "that it is now matter of irrefragable historical evidence, that vaccination possesses powers adequate to the great end proposed by its meritorious discoverer, namely, the total extirpation of small-pox." This notion naturally made a strong impression upon the public mind, and contributed in no small de- gree to encourage that ardour in the cause of vac- cination which is so honourable to the country of its birth. We cannot, however, understand, how such an event could be brought about by the means proposed. Parents vaccinate their children to escape the dangers of small-pox. Should this disease subside, and its dangers become less known, the necessity of any precaution against it would become less apparent, and the preservative practice would ultimately fall into neglect. And so, in fact, it has always proved in small isolated communities where small-pox is rarely seen, and even in larger towns where government does not enforce vaccination under penalties. This fact is strikingly illustrated in Mr. Cross's valuable his- tory of the variolous epidemic which ravaged Nor- wich in 1819. The doctrine that cow-pox pos- sesses an exterminating power, assumes, first, that small-pox arises invariably from contagion ; se- condly, that the susceptibility of cow-pox is uni- versal in mankind; and, thirdly, that the influence of vaccination is permanent through life. All these are questionable points, and therefore on physiological grounds the notion must be aban- doned. It has, indeed, been confidently urged in support of this position, that in some foreign coun- tries the great object of extermination has actually been attained. This, however, is a complete error. In Ceylon, Sweden, Italy, and Austria, countries that have often been referred to as free from small- pox, that disease has recently raged with great violence ; and both in Russia and Germany, where the exertions of the government in support of vaccination have been most energetic, not only does small-pox exist, but much uneasiness has lately been displayed on the question of vaccine security. Vaccination, then, we may confidently affirm, can be maintained only by having small- pox constantly before our eyes; and nothing war- rants us in the expectation of banishing the bane by even the most liberal application of the anti- dote. [From accurate statistical accounts taken by the Registrar-General of England, it would appear, that in 1837 there were only five diseases more fatal in England, and that the deaths throughout England and Wales amounted to about 12,000 an nually. Since then, the number has fluctuated from 16,268 in 1838 to 9,131 in 1839. (W Farr, Third Report of Registrar-General, 1841.)] In the remarks which we have now brought to a conclusion on the momentous question of vac- cine protection, we trust not to be misunderstood, The spirit and tendency of them has been to show that small-pox and cow-pox must exist together and that the history of vaccination offers no ex- ception to that general law of our physical and moral nature by which good and evil are blended. Although unable to eradicate small-pox, we have in vaccination a powerful means of lessening its virulence and contracting the sphere of its rava- ges. It has been our further object to show that the study of the laws which regulate vaccine in- fluence is both intricate and interesting; and while on the one hand much has been done towards ex- plaining them, much still remains to excite and reward the labours of posterity. George Gregory. VARICELLA.—History of Varicella. — The milder forms of varioloid eruption attracted atten- tion at very early periods. Rhazes, the first ac- knowledged author on small-pox, noticed a mild or spurious eruption which gave no protection from that disease when it prevailed epidemically. (De Variolis et Morbillis, cap. v.) Ingrassias, a Sicilian physician, described such a disorder in 1550 with considerable accuracy, (De Tumoribus contra Naturam, tr. i. cap. i.) and he has, conse- quently, been dignified as the original writer on varicella. The claim, however, may be disputed in favour of Vidus Vidius, who about the same period alludes to the disease under the title of chrystalli, in the following explicit terms:—" Sunt qui, prseter duas species (variolas scilicet, et mor- billos,) chrystallos adjiciant. Sic enim appellant quasdam veluti vesiculas, plenas aqua, instar chrys- talli splendentes, quibus cutis variis locis dislin- guitur. In quas non ita incurrunt omnes homines, sicut in variolas et morbillos, neque sub ipsis ita affliguntur." (De Chrystallis, 1550.) This dis- order, he adds, the Italians called then, as now, ravaglione. Nearly a century afterwards, (namely, in 1646,) Riverius quotes this description, and gives, chiefly from Ingrassias, the following account of the malady: —« Est et tertium pustularum genus, pueris familiare, et variolis simile quoad magni- tudinem et figuram; sed in eo ab iis distinguilui quod variola? cum rubore et inflammatione appa- reant. Has vero albae sint, et veluti vesicular, seroso humore repletaa, qua? intra triduum disrum- puntur, et exsiccantur, nullumque afferre solent periculum, et plerumque sine febre erumpunt. Id pustularum genus a nostratibus fasminis la vero- lette nominari solet." Sydenham, at a somewhat later period, passes varicella over almost without notice ; but Morton, in 1690, (Opera, torn. iii. p. 58,) details several cases of it under the title of variolx maxime be- nignx, and to him we are indebted for introducing VARICELLA. 637 into medical nomenclature the name by which it was then, and has since been familiarly known, the chicken-pox. The authors of this early period concurred in opinion that such a disorder afforded no protection from small-pox, but with regard to its nature, they differed, some regarding it as allied to small-pox, others viewing it as altogether dis- tinct from that disease. The principal writer on varicella during the eighteenth century was Dr. Heberden, who, in 1767, published in the first volume, page 427, of the Transactions of the Royal College of Physi- cians, a description of the disease, professing to give a full and accurate account, not only of its symptoms, but of its pathological relations. Dr. Heberden paid little attention to the statements of preceding writers ; his descriptions and doctrines are obviously drawn from his own extensive ex- perience, and in such repute was he held, that for a long series of years this paper was looked upon as the standard authority on the disease. The leading characters of chicken-pox, as given by Dr. Heberden, are as follows. The initiatory fever is slight. The eruption is vesicular, terminating on the fifth day by minute crusts. It occurs both prior to and after small-pox. It is a different dis- ease from small-pox, and gives no protection from it. It arises from a specific contagion, and affects the same individual but once during life. It is capable of being transmitted by inoculation. The eruption thence resulting may, with hasty and in- experienced observers, pass for the small-pox, and mistakes have in consequence arisen. It is curious to observe that, notwithstanding his conviction of the essential differences between chicken-pox and small-pox, Heberden applied to the former disease the name of variolx pusillx. The term varicella was first employed by Vogel in 1764. In 1805, Dr. Frank of Vienna undertook an investigation of the subject. (De Curandis Ho- minum Morbis Epitome, vol. iii. p. 167.) He carefully distinguished the several kinds of spu- rious small-pox, and by way of distinction applied to them the names of pemphigus variolodes vesi- culates, and solidescens. His description of the former disease corresponds accurately with the complaint hitherto called chrystal-pock, water- pock, and chicken-pock. In 1809, a very detailed account of varicella was published by Dr. Heim of Berlin, (see Cross on the Variolous Epidemic of Norwich. Appendix, No. 1); but much con- fusion is occasioned by his applying the same term to designate three kinds of spurious small- pox, the water-pock, the horn-pock, and the swine- pock. In this paper it is affirmed that matter taken from a subject who has chicken-pox will only produce chicken-pox, and afford no protec- tion from small-pox. It is also stated that the cicatrices left by varicella are different from those of variola, and that a careful inspection of them is alone sufficient to distinguish the one disorder from the other. Dr. Willan, in 1806, contributed a little to our knowledge of varicella by some observations pub- lished in the seventh and eighth sections of his work. (On Vaccine Inoculation 4to. p. 86.) He therein describes, with great minuteness, the ap- pearances of varicellous eruption, which he sub- 3s divides into three varieties, the lenticular, conoidal, and globate. In 1820, Dr. Thomson of Edin- burgh, in a work of much labour and research, (Account of the Varioloid Epidemic of Scotland 1820,) again opened the questions connected with, the subject of varicella. During his investigation of the epidemic which prevailed in Edinburgh and other parts of Scotland during the years 1818 and 1819, he was led to the belief that the chicken- pox of Morton and Heberden was only a modifi- cation of variola. This opinion, which is, in fact, but the revival of a very old doctrine, has since found some supporters, and the notion of a common origin of chicken-pox and small-pox is the princi- pal point in the pathology of the disease to which our attention will be directed. Before however, we can with propriety enter into an examination of the arguments for and against it, the phenomena of varicella must be described. Description of the Varicella Lymphatlca. —This disease, called by Vidus Vidius chrystalli, by Heberden variolx pussilx, and by others variola? spuria?, lymphatica?, and volaticae, the chicken-pox of Morton, the pemphigus variolodes vesicularis of Frank, the varicella of Willan, is a complaint chiefly observed in infants and children of tender years. It generally shows itself without symptoms of premonitory fever. Such, at least, is the opinion of Heberden, Plenk, and Bryce, and with it our own observation corresponds; but Dr. Willan, whose authority on all subjects of cutane- ous disorder is deserving of respect, remarks (Op. cit. p. 91,) that he does not remember to have seen any case of varicella without some prior dis- order of the constitution, lasting one, two, or even three days. The symptoms then observed, he says, are languor, a disposition to sleep, a furred tongue, hot skin, quick pulse, a sore throat, with pains in the head, back, or limbs. The eruption of chicken-pock usually commences on the shoul- ders, neck, and breast. The scalp and back are almost invariably occupied with eruption, while the face, which never escapes in small-pox, is for the most part but very slightly affected in chicken- pox. The eruption is composed, from the very first, of vesicles, about the size of a split pea, perfectly transparent, and covered simply by the cuticle. When very copious, the body has the appearance of having been exposed to a shower of boiling water, each drop of which had occasioned a minute blister. The vesicles of chicken-pox vary in shape. Dr. Willan has described them as being lenticular, conoidal, or globate. They are usually very numerous but distinct. Mr. Ring is, we believe, the only author who has described a case of con- fluent varicella. (See London Med. and Phys. Journal, vol. xiv. p. 141. 1805.) They are sur- rounded by a very slight degree of superficial redness or areola. Successive crops of them appear for two or three days, and while the new vesicles are forming, the first are beginning to shrivel. The contained fluid is at first thin and perfectly transparent. On puncturing the vesicle at the period, the clear lymph is evacuated, and the cuticle falls to the level of the surrounding skin. There is no hardness in the subjacent cutis vera. Many of the vesicles burst spontane- ously or are broken by the second or third day. 638 VARICELLA. In those that remain after that period the lymph becomes of a light straw colour, or slightly opaque, so as to resemble whey. The vesicles are often accompanied with a sense of tingling. When itchy and irritated by rubbing, they sometimes take on sufficient inflammation to convert the lymph on the third day into an imperfect pus. The scabs of varicella are small and gummy, formed by the concretion of tne exuding lymph. They desiccate very quickly, and fall off, not in a mass, but in minute grains. In a few cases super- ficial marks or cicatrices are left by them, which, however, are rarely permanent in after life. The whole course of the disease seldom if ever exceeds a week. During the progress of the eruption to maturity, there are no constitutional symptoms of the slightest importance. The tongue is clean, the pulse of natural frequency, the appetite good, and the rest undisturbed. Diagnosis of Varicella Iiymphatica.—The only disease with which chicken-pox is liable to be confounded is that which we have already de- scribed under the title of modified small-pox, or varicella variolodes. There are two principal and characteristic points of difference between the disorders. First, in the true lymphatic varicella there is no premonitory fever. In even the mildest form of varioloid varicella there is fever, and very often severe affection of the brain and nervous system (headach and delirium) preceding for forty-eight hours the development of the eruption. Secondly, in the true chicken-pox the vesicles have not that regular organization which we have described as belonging to, and actually essential to the existence of, variola, even in its mildest aspect. The vesicles of chicken-pox have neither a hard papuliform base, nor cells, nor central depression. They are mere elevations of cuticle, of irregular and unde- termined shape. Such are the essential diagnostic characters. Other points of distinction between chicken-pox and modified small-pox have been mentioned, such as the comparatively greater rapidity in the progress of the former, the greater firmness of the resulting scab in the latter, the shape and permanency of the cicatrix, &c: but these are less to be relied on. There are some circumstances', indeed, connected, not with the aspect of these diseases, but with their origin and mode of propagation, which are important as con- tributing to establish a correct diagnosis; but these will be better discussed under the head of pathology. We may sum up the whole in the following words. When there is little or no perceptible premonitory fever ; when the eruption is distinctly vesicular from the earliest period ; when the punc- tured vesicle falls completely to the level of the surrounding skin ; when the crusts which succeed are yellowish, scaly, irregular in shape, and not elevated, the disease is the true chicken-pox. On the other hand, when, after a period of feverish disturbance, the eruption exhibits in its earliest stage the appearance of a solid tumour ; when, on the third day, after discharging the contents of the vesicle, a firm tubercle is found beneath it; when the resulting crust is brown, compact, defined, of a clear horny smoothness, and sensibly elevated above the surface of the skin, the disease is small- pox under some of its modifications, capable of communicating small-pox to others, both by ino- culation and infection. Pathology of Varicella IJy«>phatlca.~ This disease is almost peculiar to infantile life. It seems as if the fine and delicate skin of the infant was requisite for its development. Willan, how- ever, has described (On Vaccine Inoculation, p, 91) an undoubted case which occurred in the per- son of a gentleman thirty years of age; and in one instance at the Small-Pox Hospital we observed the disease, in a very genuine form, attacking an adult female. Chicken-pox occurs to persons once only in the course of life. This opinion was first avowed by Dr. Heberden, and its correctness has since been generally acknowledged. Many per- sons, however, pass through life without undergo- ing it. It may sometimes be seen running ita course along with, and uninfluenced by, perfect vaccination. (See London Medical Gazette, vol. ii. p. 633.) The points in the pathology of varicella lympha- tica which have been principally disputed are, 1. its communicability by inoculation; 2. its origin, whether by specific contagion or by a contagion common to it and to variola. These topics will require distinct investigation. 1. Inoculation of Chicken-Pox.—Dr. He- berden does not appear to have witnessed any in- stance of inoculating with varicellous lymph, but he implies that such a mode of communicating the disease is possible, because he says that mis- takes have thence arisen. Dr. Willan has a chapter expressly devoted to the inoculation of varicella; but the evidence on which the author relied as establishing the fact is slender and un- satisfactory. Four cases only are recorded. In two of these the experiment was confused by vario- lous inoculation being practised at the same time, In one case no result followed. In the only case which can be in any degree relied on as affording a presumption that chicken-pox is communicable by inoculation, a small vesicle raised upon a red and somewhat hard basis was discernible on the twelfth day, followed by two small vesicles on the shoulder, which disappeared in two days. (Op. cit. p. 98.) It is obvious that nothing satisfactory can be deduced from such an occurrence. The experiments of Mr. Bryce, to determine the question of varicellous inoculation, are far more decisive. This author states, (See Thomson on Varioloid Diseases, p. 74,) that " he has taken lymph from the vesicles of true varicella, wilh the greatest care, at all periods of the disease and at all seasons of the year ; that he has himself inocu- lated and seen others inoculate with it, children who had never undergone either small-pox or cow-pox, to the number of thirteen, yet in none of these was this disease, nor any thing like small- pox, ever produced. In one or two cases a slight degree of redness was observed for two or three days; but in all the rest no effect followed." These experiments are now justly considered as having settled the question, and satisfactorily shown the impossibility of propagating the genuine lympha- tic or infantile chicken-pox by inoculation. 2. Common Origin o'f Chicken-Pox and I Small Pox.—All authors are agreed that chicken- I pox is readily communicated from one child to VARICELLA-VEINS, (DISEASES OF THE) 639 another (not having previously undergone it) by casual infection. It is a disorder often observed to spread epidemically, affecting in succession all the younger branches of a family or school; and it is generally affirmed that the contagious quality of chicken-pox is of a peculiarly diffusible nature. Dr. Thomson of Edinburgh, as we have already remarked, has taken much pains to revive the no- tion suggested at a very early period, and openly avowed by Van Swieten (Commentarii, vol. v. p. 10) and Sauvages, (Nosologia, vol. i. p. 423,) that the contagion of chicken-pox is not sui ge- neris, but merely a modification of the variolous virus; in other words, that the mildest lymphatic chicken-pox and the worst confluent small-pox have a common origin. (Account of the Vario- loid Epidemic of Scotland, Edinburgh, 1820.) The principal arguments which Dr. Thomson brings forward in support of this position are,— first, that he finds in the records of medicine no unequivocal examples of chicken-pox prevailing epidemically without cases of small-pox appearing at the same time,- 2dly, that the most strictly vesicular eruptions have occurred after exposure to variolous contagion, and where, in point of time, it was reasonable to refer the disorder to such a source ; 3dly, that he had never witnessed chicken-pox in those who had undergone small- pox ; 4thly, that chicken-pox and modified small- pox run into each other by such minute shades of difference, that no unerring diagnostic marks between them can possibly be assigned. Upon the first of these arguments, (the non- occurrence of chicken-pox without simultaneous small-pox,) Dr. Thomson placed great reliance; but since the date of his publication facts have come to light which completely disprove it. Thus, for instance, it has been ascertained that from the year 1809 to 1823, chicken-pox was annually ob- served at Copenhagen without concomitant small- pox. Since that time both diseases have prevailed at intervals epidemically, but always under cir- cumstances which satisfied the physicians of the town that their sources were distinct. (Dr. Mbhl, De Varioloidibus et Varicellis. Copenhagen, 1817. Also Edin. Med. and Surg. Journal for January, 1828, No. xciv. p. 186.) The further arguments which have been ad- duced in favour of the specific nature of varicel- lous contagion are these— 1. It is contended, in opposition to Dr. Thomson, that the characteristic marks of chicken-pox, particularly during the first three days of eruption, are well-defined and easily distinguished. 2dly, That chicken-pox is not pro- pagable by inoculation; whereas every case of eruption elevated on a solid tuberculous base, and possessing a cellulated structure, however mild in its aspect and accompanying symptoms, is yet capable of communicating genuine small-pox to others by inoculation. (See Willan on Vaccine Inoculation, p. 52-5.) Several cases corroborat- ing this position have occurred within our own observation. 3dly, That the vesicular chicken- pox occurs equally in those who have and those who have not been vaccinated; that prior vacci- nation in no degree alters its character or course, while, on the other hand, vaccination proceeds with perfect regularity after the occurrence of chicken-pox ; a circumstance that never happens after small-pox. These arguments appear sufficient to establish the doctrine that small-pox and lymphatic chicken- pox are in reality different diseases, arising from different poisons. Treatment of Chicken-pox.—On the treat- ment of a disorder so mild in its nature, and so free from all sympathetic disturbance of the sys- tem, it is unnecessary to add much. The exhibi- tion of any mild aperient medicine (such as rhu- barb and magnesia) during the progress of the eruption, and again towards its decline, includes all that is essential. George Gregory. VARIOLOID.—See Vaccination. VEINS, DISEASES OF THE.—In most of the different textures and organs of the body the capillary branches of the arteries terminate in cor- responding minute radicals of the veins, and these, by uniting and re-uniting into larger venous branches and trunks, come at last to form the two vena? cava?, through which the whole stream of dark-coloured refluent blood passes into the right auricle of the heart. The larger veins consist of three distinct membranous layers or coats, the outermost of which is formed of condensed cellu- lar membrane. The middle or proper coat of veins is of a red or brown colour, thin, soft, and more elastic in the longitudinal direction than the corresponding arterial tissue. The internal or lining membrane of veins which is continuous with that lining the auricles of the heart, adheres very firmly to the middle coat, is thin, smooth, of a bluish colour, and more distensible than the in- ternal coat of arteries. The inner or common venous membrane is the most extensive and the most uniform of all the venous tissues. «It is the only one which is found in the substance of organs, and is present where the cellular and pro- per membrane is wanting. This is the case not only with venous branches and minute canals as they issue from the substance of muscles, bones, and such organs as the liver, kidneys, spleen, &c. but is also very remarkably observed with regard to the venous canals of the brain." (Pathological Anatomy, by David Craigie, M. D., 8vo. p. 115. Edin. 1828.) Valves of a lunated shape, which are formed of a duplicature of the lining membrane, are met with in the veins of the extremities, in the azygos, internal jugular, and facial veins, while they are wanting in the veins of the heart, kidney, liver, spleen, intestines, and generally in the uterus and ovaria. Bichat and Travers have showed that the internal tunic of veins is not divided by the application of a tight ligature around the vessel. Mechanical stimuli produce no sensible effects on the coats of veins, but the application of concen- trated acids and chemical stimulants, according to the same authors, excite them to contraction. Minute blood-vessels and small nervous filaments can be traced into the larger veins from the sur- rounding cellular substance, and when the coats of veins are inflamed, their vasa vasorum can rea- dily be filled with injection. There is, perhaps, no circumstance in which the arteries and veins resemble one another more 640 VEINS, (DISEASES OF THE) closely than in the facility with which the circu- ] lation is carried on by the anastomosing branches where a large trunk has been permanently ob- structed. There is much less resemblance, how- ever, to be traced between the diseases of the ar- terial and venous system than we might have been led to expect, from the similarity which exists in the structure of their coats, the continuity of their canals, and the function they perform in the body. Diffuse inflammation of the lining membrane of veins, which is a frequent and fatal disease, occurs so seldom in arteries, that Mr. Travers states he has never seen the internal tunic of an artery coated with lymph, and even when lymph is de- posited in quantity sufficient to obstruct the cur- rent of blood, the deposit occupies a narrow de- fined space, and the inflammation, by whatever cause excited or however acute, is small and cir- cumscribed. One of the most common morbid appearances observed in the dead bodies of aged persons is the conversion of the arterial tunics into calcareous matter, but the writings of pathologists contain the history of a few examples only in which the coats of the vein had undergone this change. In the present article we propose to give a suc- cinct account, 1. of inflammation of veins; 2. of phlebolites, vein-stones, or calculi in the veins, and conversion of the coats of veins into calca- reous matter; 3. of obliteration of veins; 4. of varicose veins; and, 5. of of rupture and perfora- tion of veins. 1. Of Phlebitis, or Inflammation of Veins. — Inflammation of the lining membrane of veins was unknown to all the writers on medi- cine before the year 1784, when many of the most important facts relating to this dangerous affection were pointed out by Mr. Hunter, in a paper which he read to a Society for the Improve- ment of Medical and Chirurgical Knowledge, and which was published in the first volume of their Transactions in 1793. " I have found," observes Mr. Hunter, " in all violent inflammations of the cellular membrane, whether spontaneous or in consequence of acci- dent, as in compound fractures, or of surgical operations, as in the removal of an extremity, that the coats of the larger veins passing through the inflamed part become also considerably inflamed, and that their inner surface takes on the adhesive, suppurative, and ulcerative inflammation: for in such inflammations I have found in many places of the veins adhesions, in others matter, and in others ulceration. Under such circumstances the veins would have abscesses formed in them if the matter did not find in many cases an easy passage to the heart along with the circulating blood, so as to prevent the accumulation of the pus: but this ready passage of the matter into the common circulation does not always happen. It is in some cases prevented by the adhesive inflammation taking place in the vein between the place of sup- puration and the heart, so that an abscess is formed, as will be further observed; where the inflammation is most violent, there we find the vein most inflamed; there also, after suppuration, we find the purest pus; and as we trace the ves- sels from this part either further from or nearer to the heart, we find the pus more and more mixed with blood, and having more and more of the co- agulated parts of the blood in it. As these ap- pearances are only to be seen in dead bodies, they cannot be described but from thence ; but it is so common a case, that I have hardly ever seen in instance of suppuration in any part furnished with large veins where these appearances are not evi- dent after death. I have found them in the bodies of those who have died from amputation, com- pound fractures, and mortification." These circumstances led Mr. Hunter to suspect that the fatal effects sometimes succeeding to vene- section, which had usually been attributed by authors to injuries of tendons and nerves, depended on inflammation of the internal coat of the veins. He observed similar morbid appearances in the veins of the arm after bleeding, and he has stated that in many cases the inflammation and suppu- ration are not confined to the part, from the adhe- sion not having taken place, and that an abscess is frequently formed which occupies a considera- ble length of the vein, both between the wound and the heart, and between the wound and the extreme parts. « Upon examining the arm of a man who died in St. George's Hospital, Mr. Hun- ter found the veins, both above and below the orifice, in many places united by the adhesive in- flammation. He also found, in many parts of the veins, that suppuration had begun as on inflamed surfaces, but had not arrived at ulceration; and in several other places ulceration had taken place, so as to have destroyed that surface next the skin, and a circumscribed abscess was formed. The veins near to the axilla had taken on suppuration, beyond which adhesion had not formed, and thus had given a free passage for the matter into the circulation, of which most probably the patient died." Mr. Hunter likewise observed fatal inflamma- tion of the jugular veins in horses after bleeding, extending into the chest. " Many horses," he says, " die of this disease, but what is the peculiar circumstance which occasions their death I have not been able to determine; it may either be that the inflammation extends itself to the heart, or that the matter secreted from the inside of the vein passes along the tube in considerable quantity to the heart, and mixes with the blood. I am in- clined to believe that the exposure of cavities of the larger veins in cases of accidents and also of operations, is often the cause of many of the ex- tensive inflammations which sometimes attend these cases, and indeed may be the reason why inflammations extend or spread at all beyond the sphere of continued sympathy." (Trans, of a Society for the Improvement of Med. and Chir. Knowledge, vol. i. Lond. 1793.) Mr. Abernethy, who was a pupil of Mr. Hun- ter, described three cases of phlebitis in the arm, but in none of these did suppuration take place. In the first, about three inches of the tube inflamed both above and below the orifice, it was accompa- nied with much tumour, redness, and pain of the covering integuments, and much fever; the pulae was rapid, and the tongue furred. In the third case the inflammation was not continued in the course of the vein towards the heart, but extended as low as the wrist. Mr. Abernethy offered the following explana- VEINS, (DISEASES OF THE) 641 tion of the manner in which the constitutional symptoms of phlebitis are produced. " When the inflammation of the venous tube is extensive, it is indeed very probable that much sympathetic fever will ensue, not merely from the excitement which inflammation usually produces, but also, because irritation will be continued along the membranous lining of the vein to the heart."' (Surgical and Pathological Essays. Lond. 1793.) About the same time it was pointed out by Dr. John Clarke and Mr. Wilson that inflamma- tion sometimes occurs in the uterine veins of j puerperal women. " Upon cutting into the sub- stance of the uterus," observes Dr. Clarke, " pus is often found, which in all the cases, I have met with, is situated in the large veins." (Practical Essays on the Management of Pregnancy, &c. by J. Clarke, M.D., 1793.) In dissecting the body of a woman who died several weeks after delivery, Mr. Wilson found the uterine veins thickened I and partially obliterated. The iliac, emulgent, | and spermatic veins exhibited the usual effects produced by inflammation. The coats of the vena cava were thickened and adherent to the surround- ing part, and the vessel, which was contracted below the entrance of the hepatic veins, contained about four ounces of pus. (Trans, of a Society for the Improvement of Med. and Chir. Know- ledge, vol. iii. p. 65.) Mr. Wilson met with similar appearances in the bodies of two women who died soon after parturition, and the uterine veins also contained pus. Meckel communicated to Sasse the history of a case of puerperal fever, in which he found on dissection " all the veins which surround the uterus, the hypogastric trunks, and the vena cava, enlarged in volume. The place where the placenta had adhered was distin- guished at the posterior part of the uterus by a fungous mass. The veins, whose exterior ap- pearance had arrested the attention, were exa- mined with care; they were separated from the surrounding cellular substance, and in this state the whole system of uterine and spermatic veins presented an extraordinary augmentation of the calibre of the vessels and thickness of their coats ; when opened, there escaped from them a true purulent fluid. The vena cava, where the right renal vein entered, presented a resisting tumefaction; and when laid open, its coats were of double the natural thickness, and the cavity was filled with pus, and a polypus formed of pseudo-membranous and puriform concretions." (De Vasor. Sanguif. Inflammat. auct. J. Georg. Sasse. Halle, 1797.) Not long after this period, Professor Osiander found the lungs inflamed, and the umbilical vein from the navel to the liver filled j with a yellow purulent fluid, in a child who died j of erysipelas shortly after birth. In the body of a child who died seven days after birth, Meckel found the umbilical vein inflamed, and its inner j membrane covered with a layer of pus and perforated with small ulcerations. In another child, attacked soon after birth with vomiting, colic, diarrhoea, jaundice, and fever, and who died on the tenth day, he found the peritoneum inflamed, and puri- form effusion in the abdominal cavity. The branches of the vena porta?, and those of the um- bilical vein were swollen and their coats much thickened. M. Breschet and the writer of this Voi. IV—81 3d* article have repeatedly observed this inflammation of the umbilical vein extending into the substance of the liver and vena cava?, in the bodies of chil- dren who died a few days subsequent to birth ; and they are disposed to consider this organic lesion as the sole causes of infantile erysipelas and death in many fatal cases 60on after delivery. (Diet, de Med. t. xvi. p. 400.) Palletta published in 1807 an observation which he had made in 1787, of a case of inflammation of a pelvic vein, from which he was led to suspect that pus, which had been secreted by the lining membrane of the vessel, had been carried into the circulation, and produced the abscesses in the lungs and other organs which were discovered on dissection. " Si itaque ha?c transvectio causa est apostematum in memoratis visceribus observatorum; nonne idem sentiendum est de abscessibus, qui post graves capitis lesiones in hepate, liene, pulmone pericar- dii consequuntur ? Possint utique sanguinea? vena? ob ictuum vehementiam et capitis concus- sionem, &c. inflammationi ut alia? partes esse ob- noxia?." (Exercitationes Pathologica?, cap. ii. 1807.) With the researches of Mr. Hunter on inflam- mation of veins, the French pathologists appear to have remained almost entirely unacquainted for many years. It is truly a remarkable circum- stance that Bichat, whose Anatomie Generale ap- peared in 1801, and which contains a minute ac- count of the origin, structure, and functions of veins, should have said nothing respecting diffuse suppurative inflammation of their lining mem- brane ; and but for the acuteness of Mr. Hunter's powers of observation, it seems not improbable that the disease might have remained much longer undiscovered. The following case of phlebitis;,- after venesection, cited by Mr. Arnott, is the only- one, as far as we have been able to discover, w hich was recorded in the French journals between the years 17S4 and 1815, when Mr. Hodgson's va- luable Treatise on the Diseases of Arteries and Veins was published. In this case some of the. more remarkable secondary effects of phlebitis are described. " Gasper Goldinger, subject for the last six weeks to epilepsy, was bled twice from the arm on the 1st of November, 1806 ; on the. 8th from the foot, and on the 10th and 13th from the jugular vein. On the 16th he was again bled from the arm (the right), which on the following day felt painful; some redness and tension were observed round the aperture ; 15th, arm very painful and swollen from the shoulder to below the elbow; edges of the puncture red ; face and skin of the body of a yellowish colour, pulse feeble and frequent; 19th and 20th, fever more intense; tongue dry and coated; great pain in the arm; 21st and 22d, lies supine; prostration of strength; heat of skin; tongue dry; pain in the right side of the chest; respiration short; 23d, tension of the arm diminished, some pus flowed from the wound made in bleeding; respiration shoit. Died at night, seven days after the receipt of the wound in the vein. " Dissection.—The wound in the cephalic open; the vein filled with pus through its whole length, i. e. from where it terminates in the axillary to the bend of the elbow, where it divides into the median cephalic and supeificial radial; the latter 642 VEINS, (DISEASES OF THE) of which contained pus for two inches below its origin. The coats of the vein were much thick- ened, indurated, and red. In the interfibrilear cellular tissue of the pectoral muscle of the right side was a quantity of thick greenish pus. Eight or ten ounces of a yellowish opaque serosity were contained in the right sac of the pleura. The lung of this side was unadherent, that of the left was adherent over its whole surface by a delicate false membrane. Both lungs presented a number of hepatized portions, varying in size from that of a nut to that of a large walnut, gorged with fluid, which in some of them was puriform. The arachnoid membrane was opaque, thickened, and indurated; effusion of fluid between it and the pia mater, and into the texture of the latter. Some yellowish serum into the ventricles." (M. Le Herisse, Journal de Medicine, torn. xii. p. 417, Paris, 1806.) Even in the medical literature of this country few cases of phlebitis were recorded in the interval above-mentioned, and the great importance of Mr. Hunter's observations does not appear to have been perceived before the publication of the essays of Hodgson, Travers, and Carmichael, (Transac- tions of King's and Queen's College of Physicians in Ireland, vol. ii. Dublin,) on venous inflamma- tion. After relating the history of a fatal case of phlebitis from venesection, in which there had been a high degree of constitutional irritation, with symptoms which strikingly resemble typhus, the first of these authors observes, that " several cases of extensive inflammation of veins after the operation of venesection have been communicated to me, and I have seen one in which the symp- toms and appearances upon dissection, although not so extensive, were similar to those described in the preceding case. The symptoms were very like those of typhus fever, and the appearances on dissection were in some places adhesion and ob- literation of the vessels, in others effusion of co- agulated lymph or pus into their cavities, with great induration, thickening, and adhesion of the surrounding parts." "The constitutional irrita- tion," Mr. Hodgson adds, " which takes place in extensive inflammation of veins is attended with symptoms of greater debility than acute inflamma- tion in general. This circumstance may probably arise from the extent of the inflamed surface, but it is not improbable that it may be an effect pro- duced upon the nervous system by the pu:; which is secreted into the vessel, being mixed with the circulating blood." (A Treatise on the Diseases of Arteries and Veins, by Joseph Hodgson. Lon- don, 1815, p. 515.) Having inquired into the essential points of distinction between veins and arteries, as far as regards their texture and properties, and con- sidered the relative pathology of these vessels, Mr. Travers observes that " the contrasted character of the inflammation of arteries and veins above- mentioned explains the active constitutional sym- pathy peculiar to the latter. This corresponds with our observations of the difference in this respect presented by the bounded and undefined inflammation of joints, the peritoneal or pleural cavities, and the other shut sacs of the body. The constitutional symptoms excited by inflamed veins resemble in type those of diffused inflamma- tion in other organs. They are similar to those of inflamed absorbents, which vessels also resemble the veins in their disposition to continuous inflam- mation." Respecting the manner in which the constitutional symptoms are produced, Mr. Tra- vers further observes that " there have been many conjectures respecting the cause of the fatal termi- nation of these cases, at which I confess I fee] surprised. Among others, the inflammation by extension to the heart or the membranes of the brain, and the conveyance of pus into the circula- tion, have been mentioned. Not to insist on the innocuous quality of pus, it should be observed that the most rapidly destructive inflammation is that which has the true adhesive progress, in which no pus is secreted. But if we consider the importance of the veins in the economy, the ex- tent of surface which the collective area? of the venous trunks afford, larger I imagine than any of the shut sacs of the body, and the diffused dis- organizing character of the inflammation, we can surely be at no loss to account for the disturbance of the system. It is an error to suppose that any greater sympathy exists between the constitution and the venous than the arterial or absorbent system. j I say this because I have observed something like that superstitious alarm which is excited by events that we do not expect and cannot explain, has been produced by the fatal catalogue of tied veins, and a comparison of these with the generally suc- cessful cases of tied arteries. All the mystery of veins is, as I have attempted to show, that they are indisposed to inflammation but when excited to inflammation by continuity, and therefore it is that the constitution sympathises so deeply. (Cooper and Travers, Surgical Essays, vol. i. London, 1818.) The essay of Mr. Travers contains the histories of several examples of venous inflammation after venesection and the application of a ligature, and he has also related a case of obliteration and ulce- ration of the internal jugular vein, communicating with an abscess and tumour situated deeply over the right side of the trachea, and covering the great vessels. In the course of the last fifteen years numerous important observations have been made in this country and on the continent of Europe on in- flammation of veins, whereby the symptoms and causes of the disease have been more accurately ascertained, and many obscure pathological phe- nomena satisfactorily explained. In the articles Puerperal Fever and PiitEfl- masia Doless, the author has given a full his- tory of the local and constitutional symptoms, the alterations of structure, the causes and tho treat- ment of inflammation of the veins of the uterus, and of those which bring back the blood from the lower extremities. Inflammation has likewise been [ observed in the superficial and deep-seated veins of the upper extremities, in the vena cava, splenic, spermatic, renal, and vesical veins, azygos, vena porta?, vena innominata, jugulars, sinuses of the brain, pulmonary veins, and in the veins returning the blood from the larger bones of the body. Red- ness of the lining membrane of a vein is an appear- ance often produced, as in arteries, without inflam- mation. W hen inflamed, the coats of veins become VEINS, (DISEASES OF THE) 643 vascular and thickened, and their lining membrane coated with lymph or pus. Their cavities are also obstructed by coagula of lymph and of the fibrine of the blood. When permanently obstructed, their coats are gradually converted into ligamentous cords, and the circulation of the blood is carried on by the collateral vessels. When inflammation takes place in the veins of the arm after venesection, it may proceed up- ward in the direction of the heart, or toward the distal extremity of the limb contrary to the cur- rent of blood circulating in the vessel. The same circumstance takes place in crural phlebitis ori- ginating in the branches of the internal iliac vein, the inflammation spreading upwards along the common iliac to the vena cava, or in the opposite direction from the trunk to the branches along the external iliac and femoral veins to the thigh and leg. In traumatic phlebitis of the arm, the wound which had been made with the lancet in the vessel becomes painful and festers, and there flows from it either a small quantity of red- coloured serous or puriform fluid, or a small crust forms over the opening. Along the course of the inflamed vein, a hard, painful, sometimes knotty, cord, which rolls under the finger when pressed, can be distinctly traced, and more or less redness, swelling, and stiffness take place in the soft parts covering the vein. Sometimes the whole inner surface of the arm or even the entire limb be- comes tense, swollen, red, painful, as in erysipe- latous inflammation of the parts. Not only are the coats of the vein inflamed in some cases of phlebitis, but the cellular membrane, skin, and other contiguous parts participate in the disease, and suffer from the usual consequences of inflam- mation. The severity and extent of phlebitis vary considerably in different cases. In some it is of an adhesive character, and produces only a thickening of the coats of the vessel and oblitera- tion of a small portion of its canal. In diffuse suppurative phlebitis, however induced, severe constitutional disturbance is speedily excited, and death not unfrequently follows, whatever plan of treatment be adopted. The researches of recent pathologists lead to the conclusion that, in the greater number of cases of phlebitis, death does not result from the extension of the inflammation of the vein to the heart, the inflammation having been sometimes limited to a few inches only of the vessel. From the resemblance which the symptoms of phlebitis bear to those produced by injecting acrid and poisonous fluids into the veins of animals, and from pus being generally found in the veins of those who have died of phlebitis, the conclusion seems legitimate that the constitutional symptoms of venous inflammation generally, though not in- variably, depend on the introduction of a fluid into the circulation, which contaminates the blood and operates as a poison. Recent pathological researches likewise prove that phlebitis is gene- rally the cause of the formation of abscesses in the liver, joints, lungs, cellular membrane, &c. after injuries of the head, parturition, amputation, and other great surgical operations. ] M. Cruveilhier states that phlebitis of the bones | is one of the most frequent causes of visceral abscess, the consequence of wounds and opera- ! tions in which the bones are interested. In 1814 he examined the medullary membrane of the long bones of those who died after amputation in the Hotel Dieu, with typhoid symptoms and visceral abscesses. In the greater number of these there was suppuration of the medullary membrane ; sometimes this occupied the whole length of the bone. Operations upon the bones, M. Cruveilhier says, are extremely liable to produce phlebitis. The constitutional symptoms are referred by him to a miasmatic infection of the whole mass of fluids. However extensive the phlebitis may be, if the pus does not enter the circulation, he affirms that no accident follows from it, but as soon as the impediment formed by the coagula is re- moved, atonic adynamic fever, preceded by intense | shivering, takes place, and is speedily followed by | death. Mr. Arnott, to whom we are so deeply indebted for his observations on phlebitis in the fifteenth volume of the Medical and Chirurgical Transac- i tions, and who has contributed more than any other writer to elucidate the phenomena of the disease, has given the following account of the general effects of" inflammation of veins. " In from two to ten or twelve days after the | receipt of the injury, the secondary or constitu- . tional symptoms of phlebitis manifest themselves, j and they may be thus briefly characterized. Great restlessness and anxiety, prostration of strength and depression of spirits, sense of weight at the pra?cordia, frequent sighing or rather moaning, | with paroxysms of oppressed and hurried breath- j ing, the patient at the same time being unable to refer his sufferings to any specific source. The common symptoms of fever are present; the pulse is rapid, reaching to 130 or 140 in a minute, but is in other respects extremely variable. There is often sickness and violent vomiting, especially of bilious matter. Frequent and severe rigors almost invariably occur, sometimes to the number of three or four in the course of a few hours. The general irritability and deep anxiety of coun- tenance increase; the manner is quick, and the look occasionally wild and distracted. When left to himself, the patient is apt to mutter inco- herently, but on being directly addressed, is found clear and collected. The features are pinched, and the skin of the whole body becomes of a sallow or even yellow colour. " Under symptoms of increasing debility, and at a time when the local affection may appear to be in a great degree subsiding, secondary inflam- mations of violent character, and quickly termin- ating in effusions of pus or lymph, very frequently take place in situations remote from the original in- jury [consecutive abscesses, metastatic abscesses] ; the cellular substance, the joints, and the eye have been affected ; but it is more particularly under a rapidly developed attack of inflammation of the viscera of the chest that the fatal issue usually occurs. Whether this is observed or not, death is always preceded by symptoms of extreme ex- haustion, such as those of a rapid feeble pulse, dry, brown or black tongue, teeth and lips covered with sordes, haggard countenance, low delirium." [See Abscess, Internal, and Dance, art. Abces Mvtastatiques in Diet, de Medecine, i. 87. Paris, 1832.] G44 VEINS, (DISEASES OF THE) Causes of phlebitis. — Inflammation of veins rarely takes place in any part of the body where it cannot be referred to a wound or some specific cause, externally applied to the coats of the vessels. Exposure to the cavities of veins by phlebotomy, amputation, and the separation of the placenta from the uterus in parturition, are the most fre- quent causes of this disease. It has arisen also in many cases from the application of a ligature around the coats of a vein, or after their division for the cure of varix in the lower extremities; and in some instances phlebitis has been produced by the application of cold to the limbs, or by chil- blains or gangrene affecting a part. Mr. Hodgson mentions two cases in which the division of a varicose vein terminated fatally ; the first on the morning of the fourth day, the second on the seventh or eighth day. He likewise relates a case which came under the observation of Mr. Freer, in which the ligature of a varicose vein was followed by violent pain in the left side of the chest, laborious breathing, and a violent vomit- ing of blood, four hours after the operation. The ligature was removed from the vein by dividing the noose which surrounded the latter. The symptoms were immediately relieved; she became easy, and her pulse rose from sixty to eighty. On the sixth day the swelling and pain in the knee had subsided. On the eighteenth day the limb was painful: the vein appeared to be impervious below the part which had been tied, and several varices upon the calf of the leg were harder than before the operation. About six weeks after the operation, a large vein, a little above the outer ankle, was tied with a single ligature, which was immediately removed; she became feverish soon after, and vomited twice. During the follow- ing day her pulse was natural; on the third day after the operation, the vessels to which the liga- ture had been applied were found to be impervious; but as other veins in the limb were varicose, and caused great pain and inconvenience, two of the largest of them were tied in a similar manner. The operations were performed nine weeks after the last which has been described. The ligatures were cut away immediately after their application. In three hours the patient vomited a fluid slightly tinged with blood. On the second day her pulse was almost imperceptible, and she was attacked with delirium and severe vomiting. On the third day the symptoms had increased; the pulse was scarcely to be felt on the fourth day. On the sixth she was delirious and oppressed; after a bleeding from the arm the pulse became fuller, and she began gradually to recover; the incision healed, and obliteration of the vein was produced by a ligature, which was immediately removed. Mr. Oldknow relates a case in the fifth volume of the Edinburgh Medical and Surgical Journal in which death took place from the application of a ligature around a varicose saphena vein. Mr. Travers has given the history of a fatal case of ligature in a wound of the femoral vein. Many other eases are to be met with in the writings of different authors, which prove that the application of a ligature around a vein may produce fatal phlebitis, and the same result has frequently follow- ed the division of the saphena with a cutting instrument for the removal of varix. Sir Astley Cooper has informed the writer that he met with a tumour upon the saphena major vein. The tumour was laid open or removed, and inflammation of the vein soon succeeded, which destroyed life. A lady having a varicose enlargement of the vena saphena above the ankle, Sir Astley cut it out, compressed the vein below, and desired her to keep quiet. Three or fout days after, she was labouring under high constitu- tional irritation, and had an erysipelatous appear- ance in the leg. The great saphena vein became inflamed as high as the groin, and the patient died. Another lady had a fungoid tumour just below the knee; in removing this, Sir Astley found the saphena passed through its centre. The saphena vein was cut through, and the portion removed which was imbedded in the tumour. In three days she had great inflammation in the leg low; high constitutional irritation ; in different branches of the saphena below there was a disposition to form abcesses, with very little corresponding in- flammation above, and she died in a week. Other similar cases have been related to us by Sir A. Cooper, and Breschet observes that the modern history of surgery contains multiplied observations of accidents produced by incision, excision, or the ligature of varicose veins. In all cases it is phlebitis which takes place, and which occasions the danger. Mr. Abernethy believed that moving the arm soon after bleeding produced the disease. Dr. J. Thomson of Edinburgh thinks the state of the lancet as to sharpness has a considerable share in producing the morbid effects. A bad lancet, says Mr. Abernethy, may contribute to produce the disease, yet this is not sufficient to account for the accident without supposing a peculiar irritability of the constitution to be present. From the frequent occurrence of phlebitis at particular sea- sons, certain unknown conditions of the atmosphere have probably a more powerful influence than any other cause in the production of traumatic and other varieties of phlebitis. M. Breschet states that punctured wounds, particularly when the instrument is charged with some putrid or irritating matter, are often followed by inflammation of the deep-seated veins, and he attributes the greater frequency, at present than in former times, of inflammation of the veins of the arm to the circumstance that many persons bleed with the same lancets which they have employed in vaccination. A powerful cause of phlebitis, though less common than that of vene- section, he considers to be the inoculation of a deterious matter under the skin or in a vein during the dissection of putrid bodies, and of those more particularly who have died of peritonitis. The same effect is produced by the immersion of the hands in animal fluids, more or less acrid. Several persons connected with the Faculty ot Medicine at Paris became affected with phlebitis from plunging their hands when excoriated into water containing portions of a dead body. The pus of some ulcers, and the fluid discharged from certain blisters, are likewise considered as so many causes of inflammation of veins. M. Bres- chet quotes the case of a distinguished young phy- sician (Dr. Jerrin) who died of plebitis with ab- scess and suppuration of the cellular tissue of the VEINS, (DISEASES OF THE) 645 arm and armpit, from a prick of a pin employed in dressing a blister. M. Dance has published an account of the death of a young physician from phlebitis which was produced by puncturing a small phlegmon on his hand with a bistoury which he had employed a month before to lay open an anthrax, and which had been very care- fully wiped. A young veterinary surgeon like- wise perished from puncturing his hand while dis- secting the body of a man who had died of gan- grene. (Dictionnaire de Medecine, torn. xvi. p. 396.) Dr. Carswell has related to us a case of gan- grene of the sole of the foot, in which, after death, he found the cellular sheath of the veins proceed- ing from the part filled with pus, and the coats of the veins greatly thickened. In Mr. Howship's collection there is a fine spe- cimen of inflamed varicose saphena vein. The vein is tortuous and elongated, and connected with it are several pouches formed by the coats of the vessel, which are filled with coagulated blood. At the bottom of one of these sacs, which has been laid open, there is a small circular opening, which communicates with the cavity of the vein. Mr. Howship informed the writer that the individual from whom the diseased vessel was removed after death, had an attack of gout in the foot, and that the gouty inflammation was suddenly transferred to the saphena vein, and extended a considerable way up the limb. Chronic ulcers of the legs, of the rectum, uterus, &c, have given rise to inflammation of the coats of their veins. The application of cold, internal violence, or even simple pressure, or the long-con- tinued pressure of tumours, may produce inflam- mation and obstruction of the superficial veins of the extremities. Mr. Travers succeeded in oblite- rating a varicose saphena behind the inner con- dyle of the knee in a labouring man, by means of adhesive plaister applied in stripes around the limb, with as much firmness as could be borne. The vein took on inflammation, became hard, tense and painful, and afterwards perfectly impervious. Mr. Travers relates another case where this change took place spontaneously, and was accom- panied by like symptoms and consequences. The saphena, spermatic, and epigastric veins were se- veral years afterwards greatly distended and tor- tuous. Mr. Travers considers this as an example of the phlebitis produced by arrest of the circula- tion in the vein, and he refers to Mr. Hodgson as being the first who observed the fact that blood occasionally deposits strings of coagulum in vari- cose veins, and that the vessel in such a case be- comes firm, and incapable of being emptied by pressure. " I have seen four cases," observes Mr. Hodgson, " in which this event terminated in a spontaneous cure of varices. In these instances it is probable that the coagulum accumulated until it completely filled the varix or the upper portion of the vein communicating with it; the blood, being unable to pass forward, coagulated in the vessel to a considerable extent. This coagulum was gradually absorbed; as its absorption ad- vanced, the coats of the vein contracted ; the vessel was ultimately obliterated, and the blood was con- veyed through collateral channels." In these cases the coagulation of the blood in the veins was pro- bably the consequence and not the cause of phle- bitis. Cases of spontaneous inflammation of the veins of the extremities, and also of the veins of the great viscera, have occurred. Cruveilhier relates a case which came under his own observation, in which suppuration had taken place in the cellular sheath of all the divisions of the vena porta?, the vein itself remaining sound. Broussais states that the veins are often inflamed in small-pox, measles and scarlatina. Purpura hemorrhage is also affirmed by some writers to depend on inflammation of veins. According to Ribes, erysipelas is seated in the extremities of veins; and Bouillaud has re- ferred the phenomena of typhous fever to phlebitis. A case occurred about a year ago in this metropo- lis, where fatal inflammation of the great dental and maxillary veins followed the extraction of a tooth. Pus was also found in the veins of the brain. Treatment of phlebitis.—Mr. Hunter applied firm compresses above the wound in the arm after bleeding to produce obliteration of the canal of the vessel, by bringing its sides into contact; but observation has not proved this practice to be suc- cessful in arresting the progress of the inflamma- tion. Our chief reliance in the treatment of this affection at the commencement should be placed on the vigorous employment of local antiphlogistic remedies. Almost all the cases of traumatic phle- bitis which have been treated with stimulants have proved fatal. The arm should be supported and preserved in a state of rest, and leeches ap- plied along the course of the inflamed vessel. Their number should be proportioned to the se- verity of the attack, and their application should be repeated until the inflammation is subdued. This is by far the most important part of the treatment, and the leeches should be repeatedly applied in large numbers. The arm should after- wards be covered with an emollient or saturnine poultice, or an evaporating lotion. Diaphoretics and cooling saline purgatives should also be ex- hibited. " With respect to general treatment when the primary inflammation alone is to be considered, I apprehend," observes Mr. James, " that it cannot be too decidedly antiphlogistic; when, from the continuance of the disease or other symptoms, secondary inflammation may be suspected, this mode of treatment is more questionable, and its results often unfavourable. General bloodletting is certainly a remedy of great efficacy where it is proper, but opinions are much divided on this head ; and at all events, when the secondary in- flammations are running into rapid suppuration, it is likely rather to expedite the process than to prevent it. Mr. Sanson has treated phlebitis with tartrate of antimony with success : it is at all events a safer mode than bleeding." (Observa- tions on Inflammation, by J. H. James, p. 458. Lond. 1832.) It must be acknowledged that no treatment of the constitutional symptoms has yet been disco- vered on which much reliance can be placed. When the symptoms indicate great depression of the system, recourse must be had to winer ammo- nia, quinine, camphor, and other stimulants, as we 646 VEINS, (DISEASES OF THE) have already fully described in the article Puer- ] teral Fever. 2. Of Phleholites, Vein-stones, or Cal- cnli in the Veins, and conversion of the : Coats of Veins into Calcareous Matter.— j Phlebolites have been found most frequently in the veins which return the blood from the uterine j organs, the bladder, prostate gland, and rectum ; { but they have been met with also in the veins of the spleen, spermatic cord of aged men, the ante- rior and posterior tibial veins, and in varicose sub- cutaneous veins of the leg. Otto found them most frequently in the veins of the uterus, vagina, and bladder of persons who were more than fifty years of age. He discovered them once within the veins of the prostate in an old man. In all the cases the veins were varicose, and contained coagulated blood. In two instances gouty concre- tions existed at the same time in the joints; and such was the case in the man in whom the calculi were found in the veins of the prostate. Otto refers to Realdus Columbus for an example of phlebolites in the hemorrhoidal veins, and to Bar- tholin, Tulpius, and Walter, for the history of cases where they were found in the renal, mese- raic, dorsal, and vesical veins. Mr. Langstaff saw three calculi as large as peas in the veins of the uterus, and he has observed them also in the veins of the prostate, and he thinks they are formed most frequently in those who have diseases of the prostate and bladder. (Hodgson's Treatise, p. 522 : 1815.) Lobstein has found them in the veins of the testicle, uterus, bladder, rectum, and once in the veins of the spleen. (Traite d'Ana- tomie Pathologique : Paris, 1829.) Tiedemann found numerous concretions in the varicose veins of both spermatic cords of a man fifty-one years old. There were fifteen of these calculi in the right; in that of the left twenty-one. They were of different sizes, of a round or oval form, had a yellowish-white colour, and lay loosely imbedded in coagulated blood. Some were, however, ad- hering to the inner coat of the vessel by a fine transparent membrane. In one case the writer discovered several phle- bolites in the spermatic veins of a lady who died at the age of thirty-five, and who had suffered repeatedly from abortion, and once from inflamma- tion of the uterus. In a case which we examined with Mr. Holbertoh of Hampton Court, where the mucous membrane of the rectum was ulcerated, we found several phlebolites in the left hemor- rhoidal and vaginal veins. One of these was as large as a pea, and smooth on the outer surface; there were two others much smaller, which were deposited in the centre of small clots of the fibrine of the blood. The fibrine surrounding these was formed into thin concentric layers. The coats of the veins surrounding these bodies were healthy, but between these points and the ulcerations in the rectum their coats were disoiganized by in- flammation. We have repeatedly met with phle- bolites perfectly or imperfectly formed in the sper- matic and hypogastric veins of women who had died from malignant disease of the uterus. While engaged in writing this article, 24th of July, 1833, we found a phlebolite of un oval shape, smooth on the outer surface, and about two lines in diameter, in the anterior tibial vein of an aged woman, who died in the St. Marylebone Infirmary of cancerous ulceration of the bones of the face. The coaU of the veins enclosing the concretion were thin and pellucid : over the tibia, two inches nearer the ankle, there was the cicatrix of a large ulcer. An aged female, with varicose veins, now under our care, has a large phlebolite in the anteriot tibial vein of the right leg, which produces little or no uneasiness. In the right common iliac vein of Lord Liverpool there was contained a cylindri. cal concretion, an inch or more in length. Sir Astley Cooper, to whom the writer is indebted for an opportunity of examining this rare specimen, believes the deposit of calcareous matter lo have taken place within the vein, and consequently that it is not an example of ossification of tho coats of the vessel, as had originally been sus- pected. The iliac and femoral veins of Lord Liverpool, on the opposite side, had been com- pletely disorganized by inflammation. It does not appear that phlebolites have yet been observed in the sinuses of the brain. Phlebolites often attain the size of a common pea; more frequently they are smaller, and some- times they do not exceed a millet-seed in size. Otto states that he saw one in the anatomical museum at Strasburgh of the size of a hazel-nut. They are usually of a yellow colour, and consist of concentric lamella?, and are more frequently of an oval than round shape. According to the analysis of Iohn and Gmelin, they are principally composed of carbonate and phosphate of lime with animal matter. Dr. Prout has more recently analysed some of these concretions, and his results are nearly the same. A difference of opinion has prevailed respecting the mode of their formation. Mr. Hodgson thought it not improbable that phlebolites were formed in the surrounding parts, and made their way into the veins by progressive absorption, Meckel entertained an opinion that they were formed like encysted tumours. Andral states that calculous concretions sometimes push the internal membrane before them, and descend with them into the cavity of the vein. The membrane, he adds, becomes thin, and forms a true peduncle to the concretion. There is the closest analogy, M, Andral thinks, between these pedunculated con- cretions and those concretions sometimes met with in the interior of the joints; and he inquires whe- ther it may not be possible for these bodies some- times completely to detach themselves from the coats of veins, and become loose in the cavity. Tiedemann believes them to be formed from the blood itself: this opinion Otto states is also sup- ported by the observation of Errhman, according to which some of the concretions were still soft and appeared to be formed from the fibrous matter of the blood, a mode of formation which Cruveil- hier had previously noticed. That this view of the mode in which phlebolites are formed is correct does not admit of dispute, and Dr. Cars- well has executed drawings to illustrate the van- ous stages of their formation. The observations of Dr. Carswell prove that there is first formed a small coagulum of blood in the vein, and that in the centre of this clot a little nucleus with con- centric layers gradually appears. By-and-by the red part of the blood is partly absorbed, and the VEINS, (DISEASES OF THE) 647 fibrine makes its appearance with the usual phy- sical characters. Then a certain arrangement can be perceived taking place in the fibrine forming lamella?, the central one first formed apparently becoming cretaceous; and this cretaceous indura- tion takes place throughout the different lamella? until the whole is converted into a solid phlebo- lite. In the point towards the distal extremity of the vein there is sometimes a little nucleus of blood or fibrine, which becomes a concretion; and thus the phlebolites sometimes get a caudal extremity. But in what manner the blood becomes coagu- lated in the veins so as to give origin to the form- ation of phlebolites, it is not so easy to determine. That this is sometimes the result of a slight degree of inflammation or irritation propagated from dis- eased organs along the vessels is highly probable from the facts already noticed respecting the con- sequences of phlebitis. It must, however, be ad- mitted that at the part where the phlebolite is formed there is in general no perceptible alteration of structure in the surrounding coats of the vein, although it has been employed in bringing back the blood from a diseased organ. The conversion of the tissues which compose the veins into calcareous matter takes place so seldom that Bichat questioned the possibility of its occurrence. The lining membrane of veins, he observes, does not become ossified in aged persons, as we observe in the arteries ; its organ- ization prevents it from being penetrated by the phosphate of lime. When it does happen, it is an unnatural condition; whereas ossification of Ihe common membrane of red blood is a state al- most natural to the aged. (Anatomie Generate, t. ii. p. 404.) Morgagni has, however, related a case in which the coats of the vena cava were in great measure cartilaginous, and even in some degree bony. (Morgagni, letter lxiv. art. ix.) Dr. Baillie mentions an instance where a consi- derable ossification was found in the coats of the vena cava inferior near its bifurcation into the two iliacs. (Transactions of a Society for the Improvement of Medical and Chirurgical Know- ledge, vol. i. p. 134.) Dr. Macartney informed Mr. Hodgson that he met with several depositions of calcareous matter in the external saphena vein in a man who died of a diseased liver. There was an ulcer on the leg; but the depositions of calca- reous matter appeared to have no immediate con- nection with the ulcer. One of the depositions was nearly an inch in length, and was situated on the internal surface of the vessel. (Hodgson's Treatise on Disease of Arteries, &c, p. 521.) Beclard found the femoral vein ossified at one point where it was in contact with the crural artery, which was converted into bone. M. Andral likewise found in one part of the thickened walls of a varicose femoral vein a very hard concretion, of the size of a small nut, formed by a deposit of phosphate of lime. (Andral, Precis d'Anatomie Pathologique, t. ii. p. 411.) M. Otto, after allud- ing to various other authors who have observed ossification of the coronary veins, vena porta?, the brachial vein, &c, states that he has never him- self met with ossification of the veins, but that he saw, in the Museum of Pathological Anatomy at Vienna, a splenic vein, a vena porta?, the brachial I and femoral veins of an old man and woman, and also, in the Veterinary school at Munich, the pre- putial veins of a horse ossified. (South's Trans- lation of Otto's compend. of Pathol. Anatomy, 8vo. 1831, p. 350.) 3. Ofohliterationofthe cavities of Veins. —This is one of the most frequent consequences of phlebitis ; and it would be difficult to prove that obliteration of the cavities of veins which nature intended should remain pervious through life, ever takes place but as a consequence of inflammation. In the umbilical vein, the ductus venosus, and the ductus arteriosus, which is properly a venous, and not arterial canal, which are not designed to re- main open after birth, obliteration of their cavities takes place, it is true, without our having any ground to suppose that inflammation existed. Coagulation of the blood takes place in the umbi- lical vein after it has been tied; the red particles become gradually absorbed, the fibrine which re- mains is slowly converted into a fibrous tissue, and that tissue, according to Dr. Carswell's ob- servations, becomes organized, and unites with the walls of the vein. The sudden mechanical arrest of the blood circulating in a vein might also give rise to the formation of a clot of fibrine in the vessel between the obstructed part and the nearest collateral branch, and subsequent complete ob- struction without inflammation, but this must be a rare occurrence; and where we meet with an obliterated vein, it ought generally to be considered as the result of phlebitis, however induced. 4. Of Varicose Veins.—The term varix sig- nifies simply a swollen vein, and does not, there- fore, express the precise nature of the disease. When a vein becomes varicose, it has a blue co- lour, becomes dilated, knotty, and irregular, and winds in a serpentine manner under the skin. i The actual state of the coats and valves of a vein affected with varix has not, perhaps, been satisfac- torily ascertained. Mr. Hodgson thinks it proba- ble that the valves are ruptured in this affection ; but this does not appear to be demonstrated by observation, nor is it proved that the valves are thickened. In some cases strings of coagula form in the veins; and this may be either the cause or the consequence of inflammation of the coats. Spontaneous obliteration of the vein sometimes results from a phlebitis thus produced. Mr. Stan- ley had an opportunity of opening a varicose vein, and the valves were in a healthy condition, thin and transparent. In one part of the vein, where there was externally an appearance of tortuosity, he found internally a pouch projecting from the side; precisely the same pouch in the vein which occurs in an artery producing a true aneurism. This pouch had formed at some distance from the valves and below them. There was no coagulated blood in the pouch, as has been observed in other similar cases. There was an appearance of cir- cular fibres in the lining membrane of the vessel. Mr. Langstaff has likewise examined varicose veins, and perceived an appearance of circular muscular fibres in their lining membrane. The valves he also found healthy in their structure, but not sufficiently large to close the vein. On the 14th August 1833 we examined the body of a man who had died of cholera in the Saint Marylebone Infirmary. There was a large 648 VEINS, (DISEASES OF THE) varicose ulcer situated over both the right and left tibia, and there were several branches of the sa- phena veins tortuous and apparently greatly di- lated, which extended above the knee. We cut down to the trunk of the left saphena, where it was about to enter the femoral vein, and intro- duced the pipe of a syphon and threw water into the vessel, which immediately distended the trunk and all the varicose branches along the tibia. On removing the vein, its coats were found to bo hy- pertrophied and thickened like those of an artery, and the inner surface of the vessel was rugous in the longitudinal direction. The valves were thin, pellucid, and perfectly healthy in appearance, though insufficient to close the vessel. Two en- larged and indurated glands pressed on the trunk of the saphena were entering the femoral vein. Around the cicatrix there was a large cluster of pnlarged veins, and passing from these, through the fascia, was a large branch, which formed a communication with the deep-seated veins of the leg. Andral admits six different varieties of varix, and he states that varix may exist with the coats of the veins in three different conditions : 1. sim- ple dilatation, without any other alteration, ex- tending through their whole length or at inter- vals: 2. dilatation of veins with thinness of the walls of the dilated points : 3. uniform dilatation of veins with thickening of their coats : 4. dilata- tion at intervals with thickening of the coats in the points where the enlargements exist. In these two latter varieties the capacity and length of the vein are both increased, and it becomes tortuous in consequence: 5. dilatation of veins with the development of septa in their interior, which divide the vein into little cells (locules), where the blood accumulates and coagulates: 6. the same disposition exists as in the last species ; but besides there are numerous small openings in the walls of the vein which communicate with the surrounding cellular tissue more or less changed. In dissecting many true hemorrhoidal tumours, M. Andral found nothing but one or other of these varieties of varix ; and the same is the case, he observes, with many other veins. (Precis d'Ana- tomie Pathologique, t. ii. p. 402.) Where the veins of a part become varicose, all the evil consequences of interrupted circulation are experienced, as swelling and sense of weight, heaviness, and numbness in the limb. 03dema often takes place, or inflammation of the skin and cellular membrane, and sometimes ulceration and hemorrhage ensue. Chronic inflammation of the coats of the vein itself probably also takes place. The disease is rarely met with in the deep- seated veins. Most frequently it is observed in the veins of the lower extremities; but it has also occurred in the upper extremities, where the veins have been obstructed from pressure, inflammation, or any other cause. Varix has been observed like- wise in the vena azygos, internal jugular, and right subclavian vein. The veins of the sperma- tic cord and scrotum are also not unfrequently affected from pressure and from supporting a long column of blood, and varices sometimes appear around certain tumours, more particularly those of a malignant nature. The morbid condition of the veins constituting I varix is produced in almost all cases by the pre sence of some cause which obstructs the free cir- culation of the blood in the vessel. Obliteration j of the cavities of veins by inflammation and the pressure of tumours, and the pressure of the gravid uterus, are perhaps the most frequent causes of t the disease in the lowet extremities. The vein becomes over-distended with blood from the point of pressure to the capillaries; the minute venous capillaries gradually become congested and dilated by the arteries pushing forward their blood into them with the usual force; and in consequence of this, the extreme branches of the vein first as- sume the varicose appearance. This gradually extends until the branches and trunk of the vein are affected to a greater or less extent, and some- times it proceeds until nearly all the superficial ; veins of the limb are diseased. If this view of the manner in which varix is produced be correct, it will follow that the disease does not arise from i thickening or rupture of the valves, and their in- capability of approximating and closing the ves- sel, but from the dilatation of the coats of the j vein from the undiminished impetus of the blood ; in the capillary arteries, and the obstruction to its free circulation in the capillary veins. Treatment of Varicose Veins.—After what has been stated respecting the causes of phlebitis, it will be unnecessary to say more in condemnation of the ancient practice of destroying varicose veins of the lower extremities by excision or the appli- cation of the actual cautery. The division of the varicose vein with the knife, practised by modern surgeons, however effected, is so hazardous a prac- tice, that it also has been almost universally aban- doned of late years. In the milder forms of the disease, permanent compression by means of rollers, bandages, or laced stockings, is sometimes an effectual remedy. When the vein becomes inflamed, recourse must be had to leeches and soothing applications, as emollient cataplasms, with tepid or cold lotions, j and rest in the horizontal position. When these means fail, caustic may be applied so as to pro- | duce a slough of the skin, cellular membrane, and coats of the vein. Sir Charles Bell has informed I us that this plan was practised many years ago by Mr. Cartwright extensively and with great ! success in the Middlesex Hospital. Mr. Mayo has treated upwards of fifty cases in this way, and j he has assured us that in not one instance has any bad symptom been produced by the caustic Mr. Berry has, however, related to us a case where phlebitis and death followed its use; and as the caustic must act in all cases by producing inflammation of the coats of the vessel, care should be taken to excite this only in a mild degree. The following is the method in which the caustic is applied by Mr. Mayo to the varicose veins of the lower extremities; and in a case which we saw under treatment at the Middlesex Hospital in August, it promised the best result, many of the enlarged veins having disappeared. "The method which I employ consists in applying potassa fusa, made into a paste with soft soap, to the integu- ments covering the vein. I cut a hole one-third of an inch in depth, and of the requisite length, (from an inch to two inches,) in a piece of leather, upon which adhesive plaister has been spread: VEINS, (DISEASES OF THE) 649 the plaister is then applied to the skin, so that the length of the aperture is transverse to the vein or veins I would obliterate. The hole in the plaister is then filled with the caustic paste; and a piece of adhesive plaister, and a roller applied over that, prevents its shifting. In seven hours the roller, plaister, and paste arc removed, the part washed with warm water, and a linseed poultice applied. In about ten days the slough produced by the ac- tion of the caustic separates; in a week to ten days more the sore is cicatrized, and the cavity of the vein is found to have become obliterated. " For the first two days after the application of the caustic paste, the adjoining part of the vein is hard and sore upon pressure; to relieve this, no- thing has been necessary besides desiring the patient to remain at rest, with the leg on a sofa, to take opening medicine, and to live upon broth and tea, and to apply to the part the liquor plumbi dilutes as a lotion. The flow of blood through the vein has commonly ceased about the fifth or sixth day: sometimes I have found, on tapping with my hand the swollen vein below the caustic, that by the second day the fluctuation has ceased to be communicated to the blood in the part above. In a few instances, when the slough of the in- tegument has separated, the vein has been seen as a second slough, traversing the bottom of the ulcer. The vein always appears to be obliterated for some little distance above and below the part exposed to the action of the caustic. "I have applied caustic thus upon the great saphena vein above the knee, but more commonly to the same vein below the knee; to a part evenly dilated, and across a knotted part; to the saphena minor, immediately below the knee, and to the saphena major in two places at once, near the knee and near the ankle: it has never failed to obliterate the vein in any case which I have wit- nessed ; no hemorrhage has ever taken place ; no local inflammation more than I have described ; no symptomatic fever; and I think it may be con- sidered as a useful addition to the means com- monly employed in the treatment of varicose veins of the lower extremities." (Med. Gazette, vol. ii. p. 813. 1828.) Tincture of iodine, it is reported, has recently been employed by Mr. Guthrie with success in the treatment of varicose veins. In the treatment of varicose ulcers, Sir Astley Cooper observes that the recumbent posture must be strictly enforced. Lint wetted by the mercurial wash should be laid on the ulcer, oil-silk over this, and then the limb should be well and regularly bandaged, beginning at the foot. Opening the veins about twice a week, if necessary, Sir Astley Cooper adds, is a very safe and effective practice: then applying a bandage, und keeping the parts wet by means of an e\aporating lotion. If the punctures at any time should fret, and should not unite, but pass into ulcers, the black wash should be applied. In varix of the veins of the scrotum and sper- matic cord, M. Breschet applies pressure to the veins, so as to produce obliteration of their canals, by iron forceps, the branches of which are ap- proximated with a screw. Slight pain and in- flammation followed their application to the veins of the scrotum, and as the branches of the forceps were brought closer to each other, they produced Vol. IV. — 82 3 e a true eschar, which soon became converted into ! an ulcer. The ulcer healed in a few days with- out having discharged any blood, and the vein was gradually obliterated, leaving no trace of its existence either by its colour or size. A larger pair of forceps was required for the veins of the cord, and its application was attended with more difficulty than pain. 5. Of Rupture and Perforation of Veins. —The vena cava superior within and exterior to the pericardium, the vena cava inferior, the jugular and subclavian veins, the veins of the extremities, intestinal canal, and spleen, and the vena porta?, have all been ruptured spontaneously or after violent muscular exertion and external injury. The coats of the vessels have in some of these cases presented no morbid appearance, but in others around the opening in the vein different alterations of structure, as softening and ulcera- tion, have been observed. Bichat (Anat. General, t. ii, p. 415) says these ruptures have happened in the veins of the inferior extremities during pregnancy, and that there are examples of the superficial veins of the head being ruptured in violent attacks of cephalalgia. He thinks the extreme tenuity of the walls of the cerebral veins exposes them frequently to be torn by violent blows upon the head. We are disposed to believe that the sudden extravasation of blood into the labia during labour, which occasionally happens, is to be attributed to a rupture of a large vein from the violent muscular effort required to pro- pel the child. When the effusion is into the cavity of the arachnoid membrane, it can have no other source, he believes, but the venous trunks. Haller cites examples of rupture of the larger veins; and Portal relates the case of a young woman who died suddenly, while in a cold bath, from rupture of the vena cava superior, imme- diately above the right auricle. (Anat. Med. t. iii. p. 355.) Senac also relates cases of death taking place in the cold stage of intermittents from bursting of the veins. Mr. Hodgson has seen two cases in which a vein on the calf of the leg was ruptured during violent attacks of cramps in the gastro-enemius muscle. Accumulations of blood underneath the skin were the consequence. Andral has given the history of a fatal case of rupture of the abdominal cava. The edges of the perforation had an appearance of being torn, but around it the walls of the vein were in a sound state. The accident happened in a healthy man, who in the heat of a quarrel suddenly fell down in a state of insensibility and expired. (Precis d'Anat. Pathol, p. 399.) Hemorrhage from the bowels sometimes arises from rupture of the he- morrhoidal veins. Malignant ulceration of the stomach and uterus sometimes also gives rise to perforation of veins and the extravasation of a large quantity of blood. The same occurrence has followed the perforation or rupture of a vari- cose vein. Mr. Cline described a case of this kind, in which it occurred in the internal jugular vein. It is highly probable, though it has not been clearly ascertained, that in most of these cases some morbid alteration of structure had previously taken place in the coats of the ruptured veins. Robert Lee. 650 VENTILATION. VENTILATION. — Air confined within a limited space is generally subject to the operation of causes which affect its salubrity in various ways. The respiration of living beings and the processes of combustion which take place in most dwellings, are gradually consuming its oxygenous or vital portion ; the effluvia from healthy human bodies, and still more from those labouring under disease, if allowed to stagnate, are very injurious to life ; whilst certain animal and vegetable de- compositions, from which few of even cleanly houses are totally exempt, are depriving the limited atmosphere of its oxygen, and adding to its deleterious gases. Nature, ever vigilant for the preservation of her offspring, is unceasingly endeavouring to remedy these sources of disease and decay, by pouring in through every aperture a supply of fresh air to replace that which is be- coming effete or deleterious. This is effected by means of the greater coldness, condensation, and consequently superior gravity of the external air, compared with that within the dwelling, — a superiority which for obvious reasons is much more decided in the colder than the warmer regions of the earth. In these last, however, the deficiency is amply compensated by a freedom of ventilation which establishes almost a community of atmospheric temperature and mobility without and within a dwelling. This extreme of perfla- tion is, however, totally inadmissible in cold climates; but in England the gradual change of the column of atmosphere which is perpetually taking place by the introduction of cold air from the exterior through the small apertures left by the best-adjusted doors and windows, whilst a current of heated air is forced up the chimney, is sufficient to preserve the families of the comfort- able and the opulent in good health in their spa- cious dwellings during winter; whilst in summer a more liberal system of ventilation is perfectly consistent with warmth and comfort. In the crowded dwellings of the poor, however, situated often in narrow lanes and alleys where the ex- ternal air is frequently heated and confined, the supply through accidental apertures is inadequate to the preservation of health ; and hence in ordi- nary seasons the deficient supply of pure air is one of the many causes which deteriorate the health and vigour of the poor, whilst during the prevalence of epidemics the same cause is instru- mental both in the production and diffusion of pestilence. Whilst we admit that the houses of the re- spectable classes of the community of this country furnish sufficient security to their inhabitants against any evils arising from defective ventila- tion, we must acknowledge that the mode adopted of warming them is not the best calculated to im- part that uniform temperature and exemption from partial currents which are most conducive to health. As Dr. Arnott happily expresses it, " in England the apartments, with their open chim- neys, may be compared to great aerial funnels, constantly pouring out their warm air through a large opening, and constantly requiring to be re- plenished ; and where, from the irregularity of the supply or of the discharge, the temperature is constantly fluctuating." (Elements of Physics, vol. i. p. 387.) The blazing and cheerful fire has, however, such charms for Englishmen, and goal fuel is so abundant in this island, that we see little chance of the sea-coal fire, with its unequal temperature but very free ventilation, being sup. planted by the uniform and economical, but cer. tainly close warmth of the stove. ( [The subject of warming and ventilating houses and especially large establishments—legislative halls, hospitals, penitentiaries, &c, has recently received great attention. Nothing, indeed, has been more defective than the plan usually adopted in our dwelling-houses of leaving the halls and bed-rooms at a freezing temperature, whilst the parlours are comfortably and perhaps inordi- nately warmed. The strong individual may not suffer from this; but to the invalid it is a mon- strous evil. They who have lived for a time in St. Petersburg actually suffer less during the win- ter than they do in England or this country, be- cause all the arrangements adopted there are to guard them against cold. Sir George Lefevre, who spent a long time in the Russian metropolis, in a small work which he has published, urges upon his countrymen the necessity (and his re- marks are also applicable to us,) of a greater attention to the preservation of warmth and the protection against cold. Speaking of the peasants dwelling in Russia, he says (Thermal Ctmfort, Amer. edit. New York, 1844, p. 15) : » A log hut, made of entire trees, the corners dovetailed into each other, the spaces between the bulks filled up with moss or oakum (caulked) ; no breath of air can penetrate the room, for its boundaries pre- sent no crevices. His door shuts close, his win- dow frames are double, two feet by three, the glass or oiled part fixed in. In the corner of his room is a stove, whose chimney finds exit through the roof, no wide space open to allow of heat to as- cend, and cause a continual draft of air. His hut is insupportable to those who are unaccustomed to such indoor temperature. The flies, congre- gated in some corner, hang down like a swarm of bees, happy and buzzing in the winter season. He himself lies prostrate on his stone, which serves him for a bedstead. This man is a rare subject for consumption. Still, I repeat, it is not the man who resists the cold. It is the man's clothing; it is the prevention he makes against the cold. Herein lies the proof. Remove him from his sphere of life, put him in livery, let him remain for hours behind a carriage in the winter season; let him imprudently traverse the ceurt- yards without his hat, and with no clothing be- yond what he wears in the warm halls, and then what awaits him 1 Pleurisy, dropsy, slow death!" And he adds : " Ascending higher in the scale, how does the man in easy circumstances sustain the cold 1 By opposing to it its fell antagonist warmth, — not himself; he knows better. You enter his chamber—" How warm your rooms are, Ivan Ivanowitch." " Slava Bogu Gospadin" — Heat breaks no bones. You dare not, as in Eng- land, enter his parlour with a great-coat upon your back. That would be a woful offence,—a reflection upon him,— as much as to say, "^ou have economized your fuel; you have not heated your stoves." Such conduct would be an abso- lute misdemeanour. On quitting his rooms, ho does not leave warmth behind him. He conveys VENTILATION. 651 , it about with him, close confined, in a fur pelisse, whose non-conducting qualities will neither suffer animal heat to escape from within, nor cold to penetrate from without. These precautions are not regulated by whim or pleasure. They are peremptory." The following remarks of the same writer are worthy of marked attention. « The introduction of double windows is certainly one of the most essential points towards securing an equable tem- perature in chambers. It constitutes a desideratum in English houses, but as it can be effected only in few instances, and as double windows must be the portion of the affluent, so I would simply suggest that the single windows in all houses should be made air-tight, and that the casements should not rock, as many of them do. This, par- ticularly with respect to the bed-room windows, for that is the frugality of an English house. The windows in the bed-room of an invalid should be made air-tight by good carpenters' work, but where old casements rattle, they should be made steady by a nail or two driven into the sides of the sash, and then paper should be pasted or glued all around, so as to prevent any wind from coming in at the sides. The sash must be provided with a little door, which may be opened at pleasure,— when the room is arranged in the morning,—but not left open too long, so as to reduce the tem- perature too low. Here, I am well aware, I have to contend with the strong and general national prejudices of a cleanly people. There is «no- thing like fresh air.' If the room have a close smell, the windows are opened until the apart- ment gets down to the freezing point, and much below it, and then it < smells wholesome.' That is true; but still it is death to tender lungs, and many a soul is sent to its long home by the cur- rents of air in an English house. The expression of natives may be bandied about, for there is truth in them. « Your rooms have a close, musty, sickly smell," says the English traveller in St. Peters- burg. «On est toujours dans un air coulant,' said a lady to me who had passed two years in London and Edinburgh. " The juste milieu, so difficult to be accom- plished in the political world, may be found in the physical; and as foreigners in Russia do not sacrifice all their old habits, but blend them with those of the natives, so I think the same may be done in England with very great advantage; and in this respect attention to the window-frames is of the first importance. The Russian rooms are provided with stoves, but these are not necessary. A well-built fire-place, which throws the heat into the room, and allows only the smoke to go up the chimney,—not one of the old-fashioned sort, which takes in half of one side of the dining- room,—but a well-constructed, well-fitted grate, is quite sufficient to keep the apartment warm, pro- vided that the doors and windows be air-tight; but there must be no rattling of casements, no gust of wind from under the doors to make the carpet dance, or adieu to comfort. This English word, so little understood by foreigners, is not even so by ourselves, as regards either the con- struction of our houses or the mode of heating them. In cold weather, fires should be kept up day and night. Tho secret consists in keeping j the enemy out of the house. If he enter, it is difficult to turn him back. By well-regulated fires, Russian stoves may be dispensed with. The air is more pure, too, in rooms where there are grates; and if the room and windows be tight, there will be no draft of consequence. The room which requires the most attention, and which is always the most neglected, is the ante- room or hall, or long passage, or that space into which the street-door opens. There a warm stove is imperative. Who is not acquainted with the sound of the instantaneous, spasmodic, choking cough, which seizes the invalid in his transit from the warm parlour through the cold hall and up the chilly staircase. This is a cruel experiment for tender lungs,—an anti- dote to all the good which medicine can effect. Here is the comfort of a day destroyed in a few seconds, and a night of cough and uneasiness en- sues which might be avoided. It is in this re- spect, that Russian houses are so preferable. The hall is the warmest of all the apartments, for it is the most heated, in order to defy the admission of the greatest cold. How is this to be accom- plished in English houses 1 It is not easy to alter their construction. A stove will, however, warm the ante-room ; and it might be so constructed as to allow of a long chimney, which could be car- ried along the wall and up the staircase. The wealthy only can accomplish these comforts, but by so doing they may remain more securely at home than by seeking warmth under Italian skies. No houses are so ill-constructed for invalids as the English. The Scotch flats are infinitely prefera- ble, and will allow more easily of all these im- provements ; but the inhabitant of an English house has to descend to the drawing-room, to the parlour, whence, again, to the former; thence, perhaps, mounting two flights of cold stairs, to the bed-room. Health may brook the varieties of temperature to which these operations expose us, but very delicate beings cannot, and the patient may fall a sacrifice." In this country many of the houses are warmed by means of heated air, and in this manner an equable temperature may be preserved in the dif- ferent apartments, f up must be taken, however, that proper ventilation be effected.] In public institutions, the crowded state of which renders the means adopted in private dwellings inadequate to their perfect ventilation, various plans are employed for securing to their inmates a sufficient supply of air, the nature of certain of which we shall endeavour to make the reader acquainted with. The ventilator invented by Dr. Hales has en- joyed as high a reputation as any apparatus of this sort. It consists of a square box of any size: in the middle of one side of this box a broad partition or midriff is fixed by hinges, and it moves up and down by means of an iron rod at- tached at a proper distance to the other end of the midriff, and passing through a small hole in the cover of the box. Two boxes of this kind may be employed at once, and the two iron rods may be fixed to a lever moving on a fixed centre, so that, by the alternate raising and pressing down of the lever, the midriffs are also alternately raised and depressed, by which these double bellows are 652 VENTILATION. at the same time both drawing in air and pouring it out through apertures with valves made on the same side with, and placed both above and below, the hinges of the midriffs. These valves are eight in number in each box, and are so constructed that certain of them open inward to admit the air to enter, whilst others allow the air to pass out- ward. The air enters through the valves num- bered 1, 3, 6, 8, and escapes through valves 2, 4, 5, 7. Before these last valves there is fixed to the ventilator a box as a common receptacle for all the air which is discharged through them, which air passes off by a trunk through the wall of the building. By this apparatus the old prison at Newgate, where it was worked by a small wind-mill at the top of the building, was rendered much more healthy than it had been for years. The venti- lators were placed there by a worthy magistrate in 1752 after the fatal occurrence, with which our readers are well acquainted, arising from the dirty and ill-ventilated condition of the jail. The ventilator is recommended by Dr. Hales as a means of preserving pure the holds of vessels, particularly those of ships of war and transports, for the accomplishment of which object he deems the common wind-sail, from their crowded state, often inadequate ; mines, barracks, hospitals, &c; but for a full account of the instrument and the purposes to which it may be applied we beg to refer the reader to the author's " Description of the Ventilators, 8vo. London, 1743." The structure of the wind-sail is very simple. It is made of canvass, and is in the form of a cylinder or obtuse ending cone, and is adapted to the size of the ship. Four breadths of canvass are sewed together, and the outer salvages are joined with an inch seam, leaving one cloth four feet short of the top. A three-inch tabling goes round the top and bottom. It is kept distended by cir- cular hoops made of ash, sewed to the inside, one at top, and one at every interval of six feet. The upper part or top is covered with canvass, and a small rope sewed round the edge; into which are spliced, at the quarters, the ends of two pieces of rope, that are sewed up to the middle, and an eye is formed by " seizing the bights." The length of a wind-sail is taken nine feet above the deck to three or four below the lower hatchway. These, of which there are generally three or four in our first-rate ships of war, have the ad- vantage of taking little room, of requiring no labour in working, and are of a simple construc- tion, so that they can fail in no hands; but they cannot be put up in hard gales of wind, and are of no use in dead cairns, when the air most requires renewal. [An excellent article on the ventilation of ships is contained in the recent valuable work of Dr. D. B. Reid: (Illustrations of the Theory and Practice of Ventilation, with remarks on warming, exclusive lighting, and the communication of sound, p. 348, London, 1844.) See also Dr. Ure, Recent Improvements in Arts, Manufactures, and Mines, p. 258. Lond. 1844.] It would be tedious to describe all the con- trivances which various individuals have adapted to buildings to secure to their inmates an adequate supply of fresh air. We believe that the most successful attempts of this sort arc those founded on what may be justly termed the great principle of ventilation, rarefaction of tho internal air U the agency of heat. Apartments, though coo. siderably crowded, in which a fire is kept con- stantly burning, require no means of ventilation but apertures properly situated, either designedly formed in the walls, or afforded by windows and doors. Rooms in which this perpetual consump. tion of fuel is inadmissible, may be made to com- municate with a fire or stove wherever situated within the building; and the mode of accomplish- ing this, suggested by Dr. Hawthorne, seems well calculated for the attainment of the object in view, This gentleman suggests that in an hospital, the common kitchen, with a fire constantly burn- ! ing in it, should be, as is usual, on the ground | floor. A tube of from six to twelve inches in diameter, for the purpose of admitting a sufficient supply of pure air to every apartment, opening without, and at that side of the building from which the purest air is likely to be obtained, j should pass through some place so contiguous to the fire, that the air which it conveys might be heated from 60 to 100 of Fahrenheit, according to the magnitude of the building which it is de- 1 signed to heat. The tube thus heated, passing - along and ascending, should send off a commu- nicating branch to every apartment in the build- ing. Each of these communicating branches be- ing again subdivided into three smaller tubes, should open into one end of each apartment, about a foot from the floor—one in each corner, and the third in the middle. " A second tube, of the same dimensions, for the purpose of admitting pure air in the warm sum- mer season, opening in like manner outside the building, should unite with the former tube, at a proper distance from the fire, and before it gives off the first communicating branch. An air-tight sliding valve should be placed in each of these, at some distance from their point of union. These valves are to be used for the purpose of cutting off all communication with the cold air in winter and the hot in summer. This part of the tube should be made of earthenware, or some such in- oxydizable substance. It is not very important, however, of what material it be constructed, pro- vided it be perfectly air-tight; as no metal which might answer the purpose, at any of the degrees of temperature pointed out, is likely to be acted upon so as to produce any disagreeable smell, or to be oxydized so as to decompose or at all dete- riorate the air which may pass through it. The air might be heated equally well by causing it to pass through a tube kept constantly surrounded with hot water. As this plan, however, would be attended with some additional labour, and as it does not seem to possess any decided advantage over the other, I prefer the former." The following are the means to be employed for causing air to circulate through the apartments, and for carrying it off after it has been vitiated:— " Two tubes, from six to twelve inches in dia- meter, according to the size of the apartment, should open, one about three feet from the floor, the other at the ceiling; and both tubes exactly in the middle of the end of each apartment opposite to that at which the heating tubes entered. VENTILATION —WAKEFULNESS. 603 c. I'hese tubes should terminate in one common , runk, extending from the upper to the under ..' loor of the building. k "This trunk, after arriving at the under floor ; if the building, and extending a few feet hori- \:ontally, should pass in an ascending direction up ■ hrough the fire; and then rise perpendicularly, to lischarge its contents either into the funnel, or at .he top of the building. "The beds of the patients should be arranged along the middle of the wards, in a direct line between the heating and ventilating tubes, and . not along the side-walls, as is generally the case. A wire-net screen, of a close texture, placed about four or six inches from the wall, rising from the . floor four feet high, and closed in at the top, should extend across all that end of the ward out of which the heating tubes open, so that the cur- rents may be spread equally over every part of the ward." (A New Mode of Ventilating Hospitals, Ships, Prisons, &c, by G. Hawthorne, M. D., p. 39 et seq.) [The progress of ventilation received a great impulse from the appointment of a committee of the House of Commons on Acoustics and Ven- tilation, in the year 1835. Numerous parliament- ary documents, connected not only with the houses of parliament, but with other public build- ings, with private dwellings, and with mines, ships, and manufactories were the result of this impulse. "It constitutes," says Dr. Reid, (Op. cit. preface ix.) " one of the most important items to which the attention of the Health of Town's Commission is directed. The various statistical and sanitary reports that have been issued from the Home Office, and from the Medical Depart- ments of the Army and of the Navy, under the direction of Sir James M'Grigor and Sir William Burnett, add much interesting information on the same question. And if we look to the medical profession generally, the observations of Sir James Clark on consumption, and on the sanative influ- ence of climate, the remarks of Dr. Combe, Dr. James Johnson, Dr. Forbes, Dr. Southwood Smith, and numerous others, and the ingenious sugges- tions and improvements introduced by Dr. Arnott, all show how poorly the necessity of improved ventilation is appreciated, more especially since Tredgold had the merit of placing this subject in a more consistent position than it had ever pre- viously presented." The work of Dr. Reid is the most valuable trea- tise on the subject of ventilation that has ever ap- peared, and must be consulted by all who desire to be scientifically acquainted with the subject.] We do not profess in this article to have de- tailed every plan that might be devised for sup- plying with pure air every form of building to whatsoever purpose appropriated. The particular means must have reference to the plan of the building and the number of its inmates ; but the principle once understood, much difficulty will not be experienced in its application to individual cases. T _ Joseph Brown. WAKEFULNESS, dypvirvia, [Agrypnia,] per- vigilium, insomnia.—Interrupted sleep is but a symptom of disease, yet it is one of the most im-1 3e* portant of symptoms, and, in chronic diseases, it requires as much attention as interrupted breath- ing and interrupted pulse do in acute; in short, there is no more important subject in symptoma- tology. In sound sleep, the function of the mind is thought to be suspended; the organs of sense, and the muscles by which voluntary motion is carried on, are nearly inactive; while those functions which depend upon the involuntary muscles, such as respiration, the circulation of the blood, diges- tion, secretion and absorption, are carried on with- out interruption. In unsound sleep the reasoning powers are not always suspended : some indivi- duals will answer when spoken to, and will show that they have an apprehension, although it may not be perfect, of the subject propounded to them; j many walk and talk in their sleep, and even ad- • minister to their wants, change from an uneasy to i an easy posture without waking, and express dis- comfort or gratification. We knew an individual who took snuff during sleep, and who, when his I snuff-box was removed from under his pillow, where he kept it, after betraying dissatisfaction, j invariably awoke. There have been instances in which the intellect has been successfully employed | during sleep, in which problems have been solved, ! or verses composed, which the sleeper was able to reduce to writing when he awoke. Some have imagined that the mind is never altogether in- . active,—an opinion which we have no intention , of discussing, but which appears to derive support from the following considerations, viz., that when we are roused from incipient sleep, we can gene- rally recollect a train of incoherent thought which | had occupied the mind; that when roused from sound sleep, we have a recollection of the mind having been engaged, even when the subject which engaged it has left no trace behind; and lastly, that a sort of displeasure, similar to that which is caused by unseasonable interruption, is felt whenever sleep is broken. In order that sleep may refresh the wearied body and exhausted mind,—may exercise a resto- rative influence over the functions of life, certain conditions are requisite : 1st, that it should take place at a stated hour ; 2d, that it should continue for a certain period of time; 3d, that the position of the body should be easy; and 4th, that the vital and natural functions should be undisturbed. Who has not experienced that sleep, when ob- tained at an unusual hour, so far from being uni- formly refreshing, often leaves the body torpid, and the mind in a state of languor; and that when our usual portion of sleep during the night is abridged, we are frequently good for nothing next day 1 It is well known to those who have been obliged to travel in the night, how very uncom- fortable the feelings are upon first awaking from sleep which may have overtaken them in a car- riage, in a cramped position of body, and with cold feet. Moreover, every one knows that sound sleep is incompatible with increased action of the heart and arteries, heat of surface, oppressed re- spiration, and disturbed digestion. In order, there- fore, to secure refreshing sleep, we ought to retire every night at the same hour, having, during the day, spent a reasonable portion of time in the open air, in active but not violent exercise, the 654 WAKEFULNESS. food and drink being suited to the powers of the stomach, the chamber being airy and dry, and neither hot nor cold, free air and quiet being en- sured, and light excluded; and, lastly, the gar- ments which were worn during the day being taken off, the bed being of uniform firmness, but not hard, and the bed-clothes light, but sufficient to maintain proper warmth. The amount of sleep necessary to preserve health varies according to the state of the body and the habits of the individual. Infants pass much the greater portion of their time in sleep; children sleep twelve or fourteen hours ; the school- boy generally ten; in youth a third part of the twenty-four hours is spent in sleep; while in advanced age many do not spend more than four, five or six hours in sleep. We have known indi- viduals idly consume one-half of their life in sleep, while other individuals, on the contrary, have not slept more than a sixth part of it, both being ap- parently in good health. As there are many persons whose bowels are not moved more than once in three or four days, and yet who are with- out any symptom of indigestion, so four or five hours sleep may be sufficient for the exigencies of many ; and were a physician, in either case, to endeavour to alter the habit of his patient, he would probably rather injure than improve the health. Our observations on wakefulness are meant to apply to that state only in which it is a symptom of disease, which it always is when an individual who has been accustomed to pass seven or eight hours in sleep is reduced to two or three. Disease or uneasiness of any kind often causes a sort of unsound sleep, in which all consciousness of existence is not destroyed. For hours, it is true, the clock is not heard, nor the watchman's rattle, nor the sentry's challenge, and yet the individual affirms that he has not slept one minute during the livelong night. We are convinced that they who are said not to have slept for weeks or months, pass a considerable portion of time in this unsound sleep, which, however unsatisfactory, in a measure strengthens the body and prevents the utter destruction of the mind. Wakefulness may be symptomatic of either acute or chronic disease, and under this simple division we mean to consider the subject. I. The acute diseases of which wakefulness is symptomatic are chiefly the various forms of fever, inflammatory disorders, and some cerebral diseases. Wakefulness is symptomatic of the early stage of those fevers in which the brain and nervous system are principally affected; but it is still more so of gastric and enteric fevers. The latter are productive of much more of this kind of distress than the former, inasmuch as, in the former, stupor and insensibility often occur at an early period of illness, and take the place of wakefulness; while, in the latter, wakefulness is often unmitiga- ted during the course of a prolonged disease. In fevers, both continued and eruptive, there is a combination of uneasy symptoms, which render the night wakeful, as dryness and heat of the skin, thirst, an unpleasant taste, and depression of mind. In eruptive fevers, wakefulness is chiefly pro- duced by heat, itching, and tingling of the skin, and does not altogether subside till the eruption it completed. In the phlegmasia?, wakefulness is the conn. quencc of pain in the inflamed organ, togethat with uneasiness caused by those symptoms of general fever, especially heat of skin, thirst, &c„ which the local disease gives rise to. In acute diseases, agrypnia requires great variety of treatment. In fevers in which in the earlier stages the brain is much affected, wakefulness will often be relieved by those means which relieve vascular congestion in that organ, and consequent headache; as, for example, general or topical bleeding, shaving and sponging the head. It is perhaps not generally known that headache in the beginning of fever, and wakefulness concurring with it, will resist cold, and yield to warm appli- cations. In the intense headache to which we allude, if a warm or rather tepid embrocation is found to soothe the patient, it ought to be con- tinued for an hour or two, and be repeated when headache with pervigilium returns. The efficacy of a blister to the nucha, in relieving the headache with which fever begins, is well understood. Long-continued fomentation of the inferior extre- mities, and immersion of the hands in tepid water, will often, by equalizing the circulation and relax- ing the skin, relieve headache and dispose to sleep, especially if employed at the usual hour of going to bed. One of the most effectual remedies for the wakefulness which is so distressing a symptom of fever with evening exacerbations, is the tepid shower-bath. When taken late in the evening, especially in the earlier stages of the disease, the surface of the body will be softened by thus reduc- ing its temperature, and the state of the patient will be rendered comparatively easy. We may be permitted to extend an observation which we formerly made, viz., that when a patient in afflu- ence is attacked with fever, various provisions, not always attended to, ought to be made by his physician for abating the sufferings, especially those arising from sleeplessness, which necessarily accompany that disease. If two adjoining bed- chambers can be obtained, we would have the patient removed from the one to the other morning and evening. If this arrangement is unattainable, two beds ought to be placed in the largest and most airy bed-chamber in the house, or in the back drawing-room. A shower-bath ought to be brought into the dressing-room, and the sick-nurse ought never to be left in the sole charge of the patient. For a good many years the writer of this article was attending or consulting physician to a number of his professional brethren, in a city in which fever is a prevalent disease; and whenever a phy- sician, surgeon, or even a medical student con- tracted fever, there was found no difficulty in obtaining, for the night, the willing aid of a medical friend or companion to assist the sick-nurse in removing the patient from one bed to another; to ensure personal cleanliness and comfort; statedly, as the disease advanced, to inspect the back and hips; to keep off pressure from a surface threatened with ulceration and gangrene, by changing the position of the body ; to administer an enema; to attend to the condition of the bladder, with a view to the introduction of a catheter; to exhibit or to WAKEFULNESS. 655 withdraw wine, cordials, or nourishment; to over- see the preparation of drinks; to promote sleep by fomentations or the application of a foot- warmer on the one hand, or on the other by the removal of a blanket, or by sponging part of the surface with cold water or with an aromatic embrocation. Very simple expedients, when judi- ciously employed, will often soothe and gratify a restless patient, and inspire confidence. Even the letting down of the sash, or shutting it up, will, by change of temperature, shortly be followed by tranquillity and sleep. We recollect having heard the late Dr. Monro say, " When attending cases of fever along with Cullen, I have told him, 'You may have the pen, Doctor, if you will give me the window,' which he agreed to, provided it was kept shut while he was in the chamber with the patient, for he had a great dread of a current of cold air." So much importance did Dr. Monro attach to complete ventilation and properly regu- lated temperature, as a means not merely of pre- venting restlessness, but of promoting recovery. In the more advanced stages of petechial fever, in which the sensorium is much affected, a very obstinate and dangerous form of pervigilium oc- curs as a symptom of maniacal delirium, and sometimes terminates in fatal convulsions. In this form of pervigilium, we apprehend the treat- ment ought to resemble that which is applicable to delirium tremens, viz., spirituous embrocations to the shaved head, and opium in accumulating doses, with or without mercurial purgatives. Opium, as usually administered in the wakeful- ness which accompanies genuine mania, is of more than questionable utility. This variety of wakefulness admits of relief from blistering the nucha, cold applications to the head, and a com- bination of camphor, nitre, and James's powder in free doses; and sometimes from leeches and blis- ters to the head itself. When sleep is forced by the use of opium, without these preparatives, in the early period of mania, the paroxysm is gene- rally aggravated when the patient awakes. The fever with which paroxysms of mania often begin, is of a mixed inflammatory and ner- vous kind, being characterized by heat of surface, flushed face, red glancing wild eyes, furred tongue, heavy breath, anorexia, great thirst, red and scanty urine, rapid full pulse, in addition to the violent rambling delirium and wakefulness which more generally belong to the disease. All these febrile symptoms, however, subside after a variable period of time, the skin becoming cool, the pulse quiet, the tongue clean, the urine clear and pale, the appetite natural, and the patient presenting the usual signs of health with the exception of a de- ranged mind, which persists with little interruption until the end of the attack. When opium was prescribed by our judicious friend, Dr. Adair Crawford, while he was in charge of the Rich- mond Lunatic Asylum, Dublin, during the febrile stage of mania, either in small or large doses, with a view of quieting the excessive cerebral ex- citement and procuring rest, it always failed, and sometimes aggravated the delirium. It became evident, therefore, if benefit was to be derived from opium, that this could be expected only in the second stage, when there is no increased vas- cular action, and the maniacal delirium depends chiefly on cerebral irritation of a nervous charac- ter. No decided advantage even in this stage was obtained from opium, when given at night only, how large soever the dose. Then the plan of repeated doses throughout the day was tried, commencing with a grain every four hours, and gradually increasing or lessening the dose accord- ing to the effect produced. Dr. Crawford soon observed that very large doses of opium could be taken without making the slightest impression on the delirium, and without any apparent effect on the system. Eight, ten, or twelve grains were taken in the twenty-four hours, without affecting the state of the appetite, condition of the tongue, regularity of the bowels, or disturbing the circu- lation. It seemed as if the cerebral excitement protected the constitution from the ordinary influ- ences of the remedy. By persevering in the use of cautiously graduated doses of opium in every case, the delirium was sooner or later overcome. The patient first appeared drowsy, and then be- came calm and rational. In some cases he suf- fered for a day or two from nausea, thirst, consti- pation, and vertigo, and the other usual offects of opium, which however soon disappeared. It is remarkable that the remission of delirium thus obtained was not merely temporary; in several cases the relief was permanent, and the patient left the hospital cured. In some the delirium re- turned after a remission of several days, but was again subdued by opium, and the paroxysm of mania was ultimately cut short. The quantity of opium borne was proportionate to the violence of the delirium; the largest dose to which the re- medy was carried, was sixteen grains in twenty- four hours. It is remarkable, that while there was a great tolerancy of opium in the second stage of mania, there is an equally great tolerancy of tartar-emetic in the first or febrile stage; and there is no more simple and effectual means of subduing the febrile action than by full doses of the latter remedy. Some of the observations applied to the treat- ment of pervigilium in fevers apply to the treat- ment of that symptom in the exanthemata. The great restlessness which attends scarlatina, and which arises from itching or from a tingling sen- sation of the skin and gastric irritation, may be alleviated by an affusion of tepid water over the whole of the body, which is also very useful in moderating pyrexia in the early part of that dis- order. In the small-pox, during the first five days, sleep will best be promoted by venesection, purgatives, cool rather than cold air, and cooling drinks, the best of which is the potus tartari in copious libations, a remedy earnestly recommended in the eruptive stage of small-pox by an able pre- decessor of the writer of this article, the late Dr. Harvey, physician-general to the forces in Ireland. In the second day after the eruption has begun, opium will be found the best remedy for sleep- lessness. For wakefulness as accompanying measles, we must seek relief chiefly from the tepid bath. We ascertained that the frequent application (two or three times a day) of the tepid bath was the chief remedy employed when the measles prevailed, some years ago, in the Foundling Hospital, Dub- lin, and when, to the best of our recollection, all 656 WAKEFULNESS. the children recovered. If a slipper-bath cannot be obtained, a hip-bath, or even a pediluvium, may be substituted. When infants are thrown into a violent paroxysm of fear by being plunged into a bath, the body may be wrapped in a cradle- blanket, wrung from warm water, and changed every four or five minutes. During this process, the child will often fall into a sound and refresh- ing sleep. Wakefulness, as occurring during the phleg- masia?, will in general yield only to antiphlogistic treatment; if it should continue after the inflam- mation is subdued, opium will almost always re- store sleep. Long after acute diseases, especially fevers, have terminated, there are instances in which the patient continues sleepless, and does not regain strength. We have reason to think that this state generally arises from irritation of the mucous mem- brane of the alimentary canal. Even when appe- tite for food returns, assimilation must be imper- fect, as the patient continues to emaciate. Ripe fruits, milk, farinacea, changes of scene, exercise in the open air, and in due time travelling and voyaging, together with that best of cordials, hope of recovery, will remove this description of wake- fulness, provided there be no incurable organic disease. II. We have now to consider wakefulness as a symptom of chronic diseases—as belonging to a declining state of health; and we may here be permitted to observe, that, when it is considered how much the performance of the most important duties of life depends upon the vigour of mind and body which is derived from sound sleep, it would seem wonderful that so little attention has been bestowed on that subject. An intimation of a wakeful night may often be discovered in the evening, by that overpowering sense of restlessness which is vulgarly called " the fidgets," technically dysphoria, which consists in irritability, dissatisfaction, and a sense of fulness in the extremities, as if they were injected with stagnant blood ; uneasiness is felt both in the hands and feet, sometimes running in the course of the ulnar and sciatic nerves. This state leads to an expectation of relief from any change of posture, and the sufferer is constantly throwing his arms and legs from one position into another ; but the relief thus obtained is of the most transient kind. The cincture of the clothes feels almost in- tolerable ; and hence, instead of getting up and pacing through the room, or walking in the open air for half an hour, ease is in general unwisely sought for by going to bed before the usual time; after obtaining a short slumber, all the uneasy feelings return, to which are added a pungent heat, with tension and dryness of the skin, some uneasiness of the stomach, and a copious secretion of urine, which, by irritating the bladder, calls the sufferer frequently out of bed. This state often continues for many hours, nor does it subside be- fore two or three o'clock in the morning; after which, the surface of the body becomes perspir- able, and a few hours of heavy sleep are obtained, which, however, leaves the frame languid and re- laxed, and unequal to encounter the exertions of the day. Agrypnia often occurs as one of the most trou- blesome symptoms of anomalous gout and anoma- lous hysteria. Hence, when it occurs in males advancing in life, and in the upper classes, inch an inquiry must be instituted as will detect the gouty diathesis, if it exist. If we discover that the patient has a birth-right to gout; if he is liable to vertigo, irregularity of the pulse, cramps in the inferior extremities, occurring especially after midnight; and there be dyspepsia, marked by sudden failure of appetite at or before meals nausea, or rather a sense of sinking at the sto- mach, cardialgia, acidity or flatulence, deep-seated ophthalmia, ha?moptoe, in which the blood is more of a venous than arterial complexion, or sponta- neous gonorrhoea; then we may consider agrypnia as symptomatic of irregular gout. In like manner, if any of the symptoms of anomalous hysteria should occur, we may conjecture that agrypnia is one of its symptoms. Agrypnia is symptomatic of that affection be- longing to advancing age, first introduced to pub- lic notice by Sir H. Halford, under the title of climacteric disease. There is a similar affection of declining life, in which, however, the appetite, so far from being impaired, is keen, at the same time that there is urgent thirst, which remits at certain periods of the day, and in which there is an in- creased flow of urine, which also has remissions. In this affection there are so many symptoms of the climacteric disease, — for instance, the quick pulse, emaciation, and dryness of the skin, change of expression, confined bowels, and a disposition to oedema, — that probably it is but a variety of that disorder. At present we allude to this latter affection, which has also many things in common with diabetes, chiefly on account of the agrypnia, which is one of its most distressing symptoms. Probably, however, the simplest way of con- sidering wakefulness in connection with chronic diseases, is not to refer to these diseases seriatim, but rather to direct our attention to the uneasinesses which pertain to them, whether of the digestive organs, nervous system, skin, or of the mind, upon which that symptom more immediately de- pends. 1st. Impatience of temper, bursting through the restraints of affection or politeness; oppression of the breathing; palpitation of the heart; fidgets, are as certainly symptoms of indigestion, as flatu- lent distension, acidity, heart-burn, or sickness, Nay, there is another set of symptoms, by which sleep is disturbed, considered as purely nervous, which are also the result of indigestion,—namely, despondency without any mental cause, angina, oppressed breathing from the nostrils becoming dry and stuffed, and cramps, which we have known to take place uniformly when malt liquor or wine 1 was taken during the day, and not when such stimuli were laid aside. Profluvium urina? equally depends upon indigestion. If we are told that | these are all nervous symptoms, we would admit | that they occur in persons of a nervous diathesis, I but at the same time we would maintain that their proximate cause will be found in a disordered state of the stomach, &c. Let us inquire into one of the symptoms just j alluded to, very subversive of sleep, which is gen- erally considered as purely nervous—an excessive secretion of pale urine. The urine in an hysteric WAKEFULNESS. 657 patient may sometimes be reduced to a third part of the quantity usually passed in the night, by a judicious change in the patient's diet even for one day, or by medicine given* at bed-time, by which the action of the stomach is invigorated, and the gecerning functions of the alimentary canal im- proved. There is another fact to which we may allude, which bears upon this point. When the appetite is craving, and more food is taken than is needful, instead of passing off by the bowels in larger or more frequent stools, constipation is some- times produced, and the kidney assumes increased activity, so that urine passes off by quarts instead of pints. In order to obviate wakefulness from dyspepsia, we must look to the condition of the kidney : it will be found that the nervous dyspeptic will gen- erally pass his nights well or the contrary, accord- ing as the flow of urine is moderate or excessive; and that, by attending .to the state of that excre- tion, the physician will be better able to regulate the diet of such patients so as materially to im- prove their sleep : it will be found that those ar- ticles of food will digest the easiest, and prove most nutritious, which are least provocative of urine. When agrypnia is supposed to proceed from indigestion, the points to be ascertained before we can hope to relieve that symptom, are, 1st, Whe- ther indigestion is maintained merely by diurnal imprudence with respect to the quality, or by ex- cess in the quantity of the ingesta. 2dry, The organ primitively affected, whether the stomach, liver, or intestines. 3dly, The stage of dyspepsia. 4thly, Whether the dyspepsia, when traceable to the floating viscera, is of a nervous or inflamma- tory kind. To the wakeful from dyspepsia, the benefits are very great which arise from strong food, tonics, and stimulants, aided by change of residence, and relaxation from care, when once the acute stage of dyspepsia is subdued. (See Dr. Johnson's valuable work.) Distension of the bowels from flatulence will often interrupt sleep. But this and other conse- quences of indigestion, arising from a mixture of incompatible articles of food, will generally be corrected when the sufferer discovers that there is more enjoyment in digestion unattended with dis- turbance of body and mind and calm refreshing sleep, than in gratification of the palate. Those who are wakeful from indigestion ought to be taught to experiment upon their food: they may thus discover that some unsuspected article of their accustomed ingesta, such as a draught of cold water at bed-time, malt liquor, wine, or mixed spirits, at or after dinner, tea, often the cause of fidgets, or coffee in the evening—something, in short, which agrees perfectly well with nineteen stomachs out of twenty, may disagree with theirs, and require to be given up. Some require the stomach to be nearly empty when they lay them- selves down to sleep; others sleep best when there is food to be digested. We have known some who were obliged to have food by their bedside, to take in the night when their sleep was interrupt- ed, otherwise they would have remained awake. We have an impression that many persons who are wakeful might, under the direction of their physician, form a rule of diet, by adhering to which Vol. IV. —83 they might sleep soundly, instead of passing their nights in sleepless disquietude. When those who have been accustomed to sleep equally well on either side of the body, find that their sleep when on one side is disturbed, a phy- sician ought to be consulted, as this may be a symptom of commencing disease in the heart or liver. Dyspeptics generally find the right side most favourable to quiet rest. Heartburn, pre- venting sleep, will sometimes subside upon turning from the left to the right side. 2dly. As regards the condition of the skin,— itching, which is the most troublesome symptom of many affections of the skin, characterized by scales, papules, pustules, &c, is an inveterate ene- my to sleep. But as these diseases and their ap- propriate treatment are ably described in this work, we will pass them by, and limit our observations to certain other uneasy sensations ; as, for exam- ple, excess or defect of heat, tingling, smarting. pins and needles, fidgets, &c. We attended a lady, who attained her eighty- fifth year, who was unable to sleep when her feet were warm; when they were covered even in the - depth of winter with more than a sheet, her rest was broken, which was the only exception to the rule we have ever known, that cold extremities prove unfriendly to sleep. Many a delicate female, from going to bed with cold feet, is deprived of hours of sleep in the early part of the night, and thereby falls into nervous complaints, obstinate dyspepsia, and uterine irregularity, who might have escaped, had the circulation of the surface of the body been properly sustained by the tepid bath or semicupium, frictions of the extremities, and the use of Merino, Angola, or Shetland stockings, or of a very soft pillow placed within the sheets for the feet to rest upon, and proper covering. We often discover that rest is broken by ting- ling heat of the extremities, fugitive pains, which would seem to be seated very superficially, proba- bly in the skin, and by fidgets already described. These are often merely symptoms of indigestion, and may be prevented by attention to diet. They may often be removed by magnesia and ammonia in some of the distilled waters, or perhaps camphor julep ; or by half a bottle of soda water added to twenty-five or thirty grains of the carbonate of soda. But much discomfort may also be obviated by exposing the person to cool air, or, according to the advice of Franklin, by a change from one bed to another, the bed occasionally slept in being as little like the bed generally slept in as possible, having sheets of different texture, with some dif- ference in the warmth of the bed-clothes. When the fidgets affect the upper extremities, we have known instant relief obtained from the immersion of the hands and arms in water; when the lower extremities are attacked, the passing of a sponge, squeezed after it has been dipped in water, and damp rather than wet, rapidly over the lower ex- tremities, in these cases will be found even more efficacious than Dr. Franklin's air-bath. Those who are delicate and susceptible of cold may have, in their dressing-room, a supply of tepid water whereby a foot-bath may be obtained, by means of which the action of the skin may be altered more effectually and safely. 658 WAKEFULNESS—WATERS, (MINERAL) 3dly. In various ways is wakefulness produced by disturbance or over-activity of the mind. Ex- hausted by the fatigues and cares of the day, the eyelids will often be sealed by solicitude ; but as, by most men of the middle ranks in these coun- tries, the game of life is played for an excessive stake, so when sleep is casually broken, the mind is too anxious to admit of its being restored—self- reproach, carking care, or blighted hope, will destroy all that composedness upon which rest so much depends—a promise imprudently given, a debt thoughtlessly contracted, suretyship, reputa- tion threatened, conscience wounded, will render a pillow of down hard and uneasy. When sleeplessness arises from over-activity of the mind, the faculty generally in exercise is the imagination. When this is the case, an endeavour must be made to change the current of thought. But if our endeavour to introduce new and less «xciting subjects of thought should fail, we ought to procure a light and a book suited to the occa- sion. Sometimes the best procedure is to present to an excited imagination some work of fiction so agreeable as to divert the mind from its engrossing object; and this, when accomplished, may be fol- lowed up by a change to a graver or duller nar- ration. While the condition of the mind with respect to sleep is before us, we would beg to add that sensitive persons ought to avoid every occasion of excitement for some time before going to bed... In fine weather, a walk in a garden at eventide, and such a course of meditation as may lead to a quiet mind, will be an excellent preparative for repose. Beddoes, when alluding to the importance of the frame of mind in which we close our eyes, ob- serves, " that the chapter on this subject which is commonly to be found in books of practical piety ought to be transferred to those of medicine." If every other means of courting a return of sleep should fail, it will be better to get up and dress, and engage in reading, writing, or some other appropriate occupation for an hour or two, than to have recourse to the usual alternative of an ophite. This ought ever to be the last resource of the wakeful, and when taken, it ought not to exceed six or eight drops of the Lancaster black- drop, or as many minims of Battley's liquor in some camphor julep; or instead of this draught, an eighth or a sixth part of a grain of the acetate, or what is preferable, the muriate of morphia. To conclude, wakeful persons are recommended to pay more attention to the construction of their bed, which ought to be ample. An elastic mat- tress ought to be laid over a well-stuffed bed, so as to ensure an equable surface and a slight ele- vation under the shoulders. The head and foot- boards ought to be well padded, the padding of the former deepest below. The sheets ought not to be too fine; the counterpane ought to be laid aside; and on no account must blankets, which have been frequently washed, be retained. J. Cheyne. WATERS, MINERAL.—The epithet mineral is applied to all waters which contain a sufficient quantity of foreign matter in solution to affect the taste or smell, or which differ from the common spring or river water of the country in which they occur by a difference in their temperature. Heat heing one of the most remarkable cir- cumstances by which one spring is distinguished from another, seems first to have attracted the attention of mankind; accordingly it is to hot waters that we find the earliest allusion in ancient writers. The Greeks, who possessed various hot springs, considered them as presents from a di- vinity, and they were all dedicated to Hercules, Hippocrates mentions hot springs, which, in his opinion, were impregnated with copper, silver, gold, sulphur, bitumen, nitre; and forbids them to be used for the common purposes of drink. Waters containing various saline substances in solution, occur in such abundance in almost every part of the world that they must have soon drawn the attention of mankind. Accordingly we find them mentioned and even celebrated for their cures at a very early period. Aristotle attempts an explanation of their nature, and Strabo notices a mineral water, which, he assures us, possessed the property of dissolving urinary calculi, and of causing the evacuation of gravel when it was lodged in the kidney or bladder. The ancients even distinguished the different kinds of mineral waters, and applied to them different names. Thus Pliny mentions an acidulated water in Macedonia, which, he assures us, possessed in- toxicating properties. (Lyncestis aqua, qua; vocatur acidula, vini modo temulentos facit: lib. ii. c. 103.) This was obviously a water impreg- nated with carbonic acid gas. Horace celebrates the waters of Baia?, (Epist. lib. i. Epist. 15, line 7,) which are still much resorted to and well known under the name of sulphureous, being impregnated with sulphuretted hydrogen gas. The ferruginous and saline waters were equally dis- tinguished by the ancients, and celebrated for the cures which they performed; and different mine- ral waters both in Italy and France, which still remain unchanged, were frequented by them; as for example, Barege, Aix, Mont d'Or, and pro- bably Bath. It has been already observed that the Greeks and Romans were in the habit of consecrating the various mineral springs which they frequented to a divinity. This introduced priests and a ritual, which was observed in making use of the waters; and the priests had address enough to persuade their votaries that the various cures produced by the waters were the result, not of the medicinal properties of the waters, but of the immediate ac- tion of the divinity under whose protection they were. This circumstance occasioned an universal desertion of mineral waters as soon as the inhabit- ants of the Roman empire became Christians, the use of them being considered as a kind of acknow- ledgment of the power and authority of the hea- then divinities. This neglect, or rather abhorrence, of mineral waters continued till the reign of Charlemagne in the ninth century. This prince was so delighted with the mineral waters of Aix-la-Chapelle, that he constructed a large basin as a bath for himself and his family, and was in the habit of holding his levees there. This naturally drew the atten- tion of the French to mineral waters in general; WATERS, (MINERAL) 659 but the death of this great prince, and the subse- quent division of his vast dominions among his descendants, again plunged the south of Europe into ignorance and barbarism. From the term Akemaneeastre, (city of afflicted men,) applied to Bath by the Saxons, it is probable that about the same time it was resorted to by the inhabit- ants of England, though it did not come into high repute as a watering-place till the reign of Charles the Second. It was towards the end of the fifteeth century that mineral waters began to recover their ancient celebrity; and it was in Italy, at that time the great centre of science and literature, where the revival of their reputation commenced. In the year 1498, Savonarola of Padua published a work on baths, and upon all the hot mineral waters of Italy. In 1596, (or about a century later,) Bac- cius, likewise an Italian physician, gave to the world a treatise on the most celebrated hot springs in France. In England various attempts were made to analyze mineral waters, and to point out the diseases which they were capable of curing, as early as the reign of Charles II. or even earlier. Thus we have Dr. Jones On the Virtues of Bux- ton Water, printed in 1572; and Simpson's Che- mical Anatomy of the Scarborough and other Spaws in Yorkshire, published in 1669. But we are not aware of any attempt to describe the English mineral waters in general till Allen pub- lished his " Natural History of the Mineral Wa- ters of Great Britain," in the year 1711. It was he that first detected the presence of gypsum in mineral waters. The labours of Dr. Shaw and Dr. Short succeeded after an interval of some years; and Dr. Rutty's Methodical Synopsis of Mineral Waters, which appeared in the year 1757, was an excellent book at the time of its publica- tion. Indeed, we are not aware of much addition to the history or analyses of Irish mineral waters since that period, distant as it is. In Germany, Taberna?montanus, one of the most eminent botanists of his time, and physician to the Elector Palatine, enumerates, towards the end of the sixteenth century, various mineral wa- ters, among others the Seltzer. (Bergmann, Opusc. 1. 69.) Perhaps the first person who attempted to de- termine the constituents of mineral waters was Dominic Duclos, who, in the fourth volume of the Memoirs of the French Academy of Sciences, in- serted two dissertations on the subject. In the first, he gives an account of the methods employed by him to determine the constituents of the differ- ent mineral waters ; and in the second, the result of a set of experiments made by the members of the French Academy during the years 1670 and 1671, to determine the compositions of sixty-eight different kinds of mineral waters from various places of France. Common salt and carbonate of soda (which Duclos calls the nitre of the an- cients) were detected in many mineral waters; but alum and green vitriol, he says, they met with in none of those that they examined. Dif- ferent species of nitre and common salt were dis- tinguished ; but from the little progress at that time made in the knowledge of salts, nothing very satisfactory could be expected. The acidulous waters were particularly noted and distinguished by the name of vinous,- though nothing was made out respecting the nature of the substance to which this quality was due. It must be admitted, how- ever, that the experiments lelated in these papers do great credit both to the industry and sagacity of Duclos and his associates in the Academy. If they did not succeed in determining the true con- stituents, they went fully as far as the infant state of chemistry permitted them. About the year 1680, as we are informed by Bergmann, Urban Hjerne made an attempt to an- alyse the mineral waters of Sweden by no means contemptible. He seems to have attended chiefly to the gaseous or volatile ingredients of mineral waters, and neglected what remained after distil- ling off the water as a sediment of no consequence. He divided mineral waters into three classes, namely, acid, vinous, and those that contained an occult acid. His analyses were continued and made public at different intervals down to the year 1685. In the year 1684 Mr. Boyle published his Natu- ral History of Mineral Waters. It consists merely of a set of observations pointing out the best way of determining the constituents of mineral waters, with hints respecting the nature of these consti- tuents, and animadversions upon the methods employed commonly at that time to detect them. But we find no analysis of any particular mineral water, nor any classifications of them such as had been attempted by Duclos and Hjerne. Boyle first employed the sulpho-hydrate of ammonia as a re-agent in the analysis of mineral waters. Various re-agents were introduced by different chemists as means of detecting the presence of different constituents of mineral waters. Thus Boulduc proposed the use of lime-water and of sugar of lead; Burlet, the solution of alum, lit- mus paper, and the tincture of roses. In 1707 Geoffroi substituted open glass evaporating dishes for the glass alembics previously employed in the evaporation of mineral waters; and in 1726 Boul- duc pointed out a method of precipitating several of the saline contents of mineral waters by con- centrating them to a certain point, and then mix- ing them with alcohol. This method was after- wards practised by Lavoisier in his analysis of the waters of the Dead Sea. The different saline constituents of mineral waters were detected successively. Sulphate of magnesia was known as a constituent of the spring at Epsom as early at least as the year 1610; but its nature was not understood till after the publication of Dr. Black's celebrated essay on lime and magnesia in 1755. Before that time Epsom salt was usually called nitre, or calcareous nitre, when it was met with in mineral waters. The chloride of magnesium was first discovered in waters by Margraaff in 1759. The chloride of calcium had been detected in 1752, by Le Roy, in the springs of Balaruc. (Mem. Paris, 1752, p! 630.) The discovery of carbonic acid gas, and the property which water has of imbibing it, and of thus becoming acid and brisk like cider or champagne, which were pointed out by Caven- dish and Priestley soon after 1765, was a great step towards the analysis of mineral waters, be- cause it accounted for the peculiar properties of acidulous waters, and explained why lime and 660 WATERS, (MINERAL) oxide of iron held in solution by certain waters disappeared when these waters were heated, or even left exposed to the air. Bergmann's dissertation on the Method of Ana- lysing Mineral Waters, published in 1778, to- gether with his analysis of various cold mineral waters, of sea-water, &c. and his essay on the method of preparing artificial hot mineral waters, constitutes an important era in the history of the investigation of important springs. In that dis- sertation he gives a list of all the different salts which occur in such waters; he analysed these salts, determined the proportion of their constitu- ents, and pointed out the method of detecting their presence and determining their quantity. In this country, Mr. Kirwan's work on mineral waters was not without its utility, though his methods were too complicated to be followed by practical chemists, or to lead to the requisite pre- cision. Dr. Murray, of Edinburgh, was occupied during the last years of his life in analysing various mineral waters, and he gave a general formula for the analysis of mineral waters of every species. This formula has been condemned by Dr. Marcet, (who distinguished himself by the number of analyses of mineral waters which he made, and by the accuracy with which his ana- lyses were conducted,) as likely to mislead. It is certainly possible that Murray's formula may sometimes lead us to false conclusions; yet it is the rdle which has always in some measure regu- lated chemists in their analyses, and by which their conclusions have been determined. The formula or rule of Dr. Murray, in fact, reduces itself to this:—determine all the acids and all the bases which exist in a mineral water: these acids in the water are each combined to saturation with a base. Now, in Dr. Murray's opinion these combinations were such that the salts formed are always as soluble as possible. Suppose we find in a mineral water— Sulphuric acid......5- Muriatic acid.......4-625 Lime..............3-5 Soda..............4- If we evaporate this water to dryness, and re- dissolve the residue in a little water, we shall find that common salt will be dissolved while sulphate of lime remains in the state of a white powder. According to Dr. Murray the mineral water did not contain sulphate of lime and common salt, but sulphate of soda and chloride of calcium. During the evaporation a double decomposition took place, and the two new salts were formed. Now this opinion of Dr. Munay is probably not always correct; but it is undoubtedly frequently so, as is obvious from no deposit of sulphate of lime falling when the water is concentrated beyond the point of crystallization of that salt. Dr. Saunders's work on mineral waters is a book of considerable value, especially in a medical point of view. The analyses in the second edition of that work were chiefly by Dr. Marcet, and greatly superior in point of precision to those contained in the first edition. Dr. Monro's list of mineral waters in the second volume of his Medical Che- mistry is much more complete than that of Dr. Saunders, but his analyses are necessarily much less accurate, as they were made before 1788, the date of the publication. Dr. Scudamore's book on mineral waters, published in 1822, is very valuable and accurate so far as it goes; but we do not consider it as necessary to notice, in this his- torical sketch, all the latter labourers in this fertile field. We shall state their experiments when we come to treat of the particular mineral waters to which their attention was directed. Our object in this article is to consider mineral waters in a medicinal point of view. Now, u medicines, these waters may act either as simple water, or in consequence of an augmentation of temperature, or from some foreign ingredient or ingredients which they may contain. We shall therefore divide this article into five sections. We shall in the first place make a few very brief re- marks on water in general, and then treat of mine- ral waters, distinguished, in consequence of the most remarkable substances which they hold in solution, into saline, chalybeate, sulphureous, acidulous, and tepid or hot. These are the usual subdivisions of mineral waters; and though not very precise, they will sufficiently answer our present purpose. We must premise, however, that we have no intention of attempting a descrip- tion of all the mineral waters which have been noticed in Great Britain, far less on the Continent The British and Irish mineral waters noticed by Rutty and Monro, exceed one hundred. Those in France are not fewer than eighty; while Ger- many is richer in these medicinal springs than either Britain or France. There are many in Italy, Spain, Greece, Turkey, Sweden, Russia, and Switzerland. Even a cursory notice of the whole would form a large work; and the in- formation gained by such a universal enumeration of all the mineral springs on the face of the earth, even if it were possible, would not repay the la- bour of a perusal; because many of them bear a striking resemblance to each other in their saline contents, and of course their medicinal virtues are similar. Hence the observations made upon one will, in general, apply to the whole of a class. We shall, therefore, satisfy ourselves with a few remarks on the general characters of each class, and an enumeration of the constituents of the most remarkable waters belonging to it in Great Britain or on the continent. We will, however, premise a few observations on common or simple water. Water is a transparent, colourless liquid, desti- tute of smell, and having but little taste. It boils when heated to 212° under the mean pressure of the atmosphere, and freezes into ice when cooled down to 32°. A cubic inch of water at the tem- perature of 60°, when weighed in air by brass weights, weighs almost exactly 252$ grains. Un- der the mean temperature and pressure, it is about 810J times heavier than the same volume of at- mospherical air. It is a compound of eight parts (by weight) of oxygen, and one part of hydro- gen, or of one volume of oxygen gas and two volumes of hydrogen gas. Water, whether in ponds, rivers, or wells, al- ways contains a quantity of atmospherical air- Now, common air is a mixture of four volumes of azotic gas and one volume of oxygen gas. One hundred cubic inches of water under the mean pressure of the atmosphere absorb 3-7 cubic inchw WATERS, (MINERAL) 661 of oxygen gas, and 2-5 cubic inches of azotic gas; and this absorbability is not altered by varying the density of these gases. In air the density of azotic gas is 4-5ths of what it would be if no oxygen gas were present, while the density of oxygen gas in air is only l-5th of what it would be if the azotic gas were absent. Hence 100 cubic inches of water, left a sufficient time ex- posed to the air, will contain Cubic, inches. 4-5ths of 2-5 cubic inches = 2 of azote. l-5th of 3-7 cubic inches = 0-74 oxygen. 2-74 Whoever will take the trouble of examining the water of lakes or rivers, will find that every 100 cubic inches of it contains 2-74 cubic inches of air composed as above staled, which is very nearly Azotic gas 73 Oxygen gas 27 100 Thus the air contained in water is somewhat purer, or contains a greater proportion of oxygen gas than atmospherical air. But this rule does not hold good when the water is stagnant, or when it is impregnated with vegetable or animal matter. For example, the water of the Thames at London contains so little oxygen gas, that phosphuretted hydrogen gas may be left standing over it for twenty-four hours without losing its combustibility ; while a very short exposure over the water of the Clyde destroys the spontaneous combustibility of this gas. It is to the presence of air that water is indebted for its agreeable fla- vour ; for when boiled and thus deprived of its air, its taste is vapid and much less agreeable. Well-water not unfrequently contains carbonic acid gas, which contributes still more to render water an agreeable beverage. When water con- tains the remains of animal or vegetable sub- stances, it may contain azotic gas and carbonic acid gas without any trace of oxygen gas, because these substances combine with the oxygen gas, and of course abstract it. For the same reason oxygen gas is never present in water impregnated with sulphuretted hydrogen; though azotic gas is pretty generally found in such waters in small quantity. The reason obviously is, that the oxy- gen portion of the air contained in the water has combined with the sulphuretted hydrogen, while the azotic gas has remained unaltered. The ex- istence of carbonate of iron in water is also in- compatible with the presence of oxygen gas in it. It is universally known that water constitutes a most important and essential part of the food of man, as well as of all animals and vegetables. Even of the solid food which we eat, water con- stitutes not less than four-fifths. It may be said, without any exaggeration, that nine-tenths of the whole of our food is nothing else than pure water. Such being the case, it is needless to remark that water must constitute a very important article of food, and that therefore the proper use of it is re- quisite for the maintenance of health. There is another circumstance which may con- tribute to the value of water when taken into the stomach; and that is, the property which it has 3f of diluting those articles which are of too stimu- lating a nature, and which, on that account, when taken by themselves, are apt to injure the tone of the stomach by urging it to over-exertion ; for it is a well-known property of living bodies that all over-exertion, all undue action, is followed by a corresponding languor and debility. Many indi- viduals are accustomed to indulge in too great a quantity of food, and in order to enable their sto- machs to digest it, they mix it with wine or spirits, or some equally stimulating substances. These gradually exhaust the tone of the organ, and pro- duce a state of languor, which must at last termi- nate in disease. Dilution with water corrects tho stimulating property of these substances, and ren- ders them comparatively innocent. Hence, a course of water-drinking to those who are accus- tomed to live high and indulge in wine or spirits, must frequently be attended with the most bene- ficial effects. [Guersent, art. Eaux Minerales, in Diet, de Medecine, xi. 35, Paris, 1835, and Osann, art. Mineralquellen, in Encyclopad. Wor- terb. der Medicin. Wissenschaft. xxiii. 499, Ber- lin, 1840; also, J. Bell, On Baths and Mineral Waters, Philad. 1831.] I.—Of Saline Mineral Waters. When a spring of water contains in solution a sufficient quantity of saline matter to alter its taste and physical qualities, and to render it unfit for the common purposes of life, it is called a mineral water. The salts thus held in solution are probably in most cases derived from the soil through which the water flows. In some cases there may be beds of certain salts, which are par- tially dissolved by the water while it passes over them. In this way the brine springs are formed by passing over beds of common salt. In the same way alkaline springs may owe their origin to beds of carbonated alkali, over which they flow. The salts hitherto most commonly found in saline mineral waters, are the following :— 1. Chlorides of sodium, calcium, magnesium. 2. Sulphates of potash, soda, lime, magnesia, alumina. 3. Carbonates of potash, soda. 4. Bicarbonates of lime, magnesia, strontia. 5. Certain silicates. 6. Nitrates of potash, magnesia. 7. Acetate of potash. 8. Iodide of sodium. 9. Bromide of sodium. 10. Subphosphate of alumina. The sulphate of potash, sulphate of alumina, carbonate of potash, the nitrates, the acetate of potash, the bromide of sodium, and the subphos- phate of alumina are very rare, or at least exist in such minute quantities that it is impossible to detect their presence. The chloride of sodium, chloride of calcium, and chloride of magnesium are exceedingly abundant. The sulphate of soda and sulphate of lime are also very common in mineral waters; and the same remark applies to the carbonate of soda and the bicarbonate of lime and of magnesia. The salts which exist most commonly and in greatest abundance in mineral waters possess pur- gative qualities. Hence it happens that saline waters aie generally purgative. The salts which 662 WATERS, (MINERAL) they contain being usually diluted with a great quantity of water, act more mildly than purgatives generally do, and frequently remove indigestion, &c. without the debilitating consequences that sometimes follow the long-continued use of eva- cuant medicines. In determining the nature of saline waters, the first step is to ascertain their specific,gravity, their taste, and their smell, and to observe whether they be transparent and colourless, or muddy and co- loured. The specific gravity of distilled water is 1-0000. That of river water rarely exceeds 1-0002 or 1-0003; but that of mineral waters is sometimes as high as 1-028, or even higher. The next step is to determine the quantity of foreign matter which the water under examina- tion contains. For this purpose, the best vessel that can be employed is a common eight-ounce phial. Balance a clean dry eight-ounce phial in a pair of scales, and mark its weight upon its sur- face with a diamond, then introduce it into 1000 grains of the mineral water. Place it in a sloping direction on a sand-bath, so that its mouth (which must be open) is a little more elevated than its bottom, to preclude the possibility of any being spilled. Then continue the heat of the sand-bath till the whole water is evaporated, and nothing remains but the saline residue, which must be ex- posed to a heat of about 500°, in order to drive off the whole of the water. The advantage of this method is, that if the water be made to boil during the evaporation, none of it is lost. The small drops, as they rise, strike the side of the phial and run down again. Nothing makes its escape but the portion of water which is really in the state of vapour. The phial being now weighed a second time when nearly cold, it is ob- vious that the excess of the weight above that of the empty clean phial must represent the weight of the saline residue from 1000 grains of the water. The next step in the examination is to deter- mine the nature of the saline constituents which it may contain. When the water is very strong, we may employ it in its natural state; but in general it requires to be concentrated before we subject it to examination. Indeed, the quantity of some of the ingredients is so small that their presence can scarcely be ascertained unless we concentrate the water. Thus the saline mineral water of Dumblane and of Airthrey, in Scotland, contains magnesia, but in such a minute propor- tion that we would search for it in vain, with the most sensible reagents, in its natural state. But if these waters be concentrated to the tenth part of their natural volume, and tested for magnesia (after being freed from lime), the presence of that substance becomes very evident. 1. Sulphuric acid is detected by mixing with a little of the water, put into a watch-glass, a drop I or two of the solution of chloride of barium. A | white heavy powder precipitates, which is not re- dissolved by the addition of nitric or muriatic acids. 2. If the white precipitate by chloride of barium were re-dissolved by nitric or muriatic acid, it would indicate the presence of phosphoric acid in the water. 3. When nitrate of silver throws down a white precipitate in heavy flocks, which are re-dissolved by the addition of ammonia, the presence of chlo- rine or muriatic acid is indicated. Iodine and bromine would also occasion a precipitate with nitrate of silver, but differing somewhat in the shade of colour. It is, however, a very rare thing to find iodine or bromine in a mineral water in such quantity as would cause a precipitate with nitrate of silver. 4. To determine whether a water contains nitric acid, reduce it by concentration to one-tenth of its natural volume. Introduce the concentrated water into a flask, with a piece of gold leaf, while a little sulphuric acid is introduced at the same time. Heat the flask : if nitric acid be present, the water will gradually dissolve some of the gold, and ac- quire a yellow colour; but if no nitric acid be present, no gold will dissolve, and the liquid will continue colourless.* 5. When a mineral water has an acidulous taste, and when it loses that taste by boiling, we may in general conclude that it contains carbonic acid gas. When paper stained blue by litmus is dipped into a water containing uncombined car- bonic acid, it is reddened, but recovers its original blue colour on exposure to the air. The best method of determining the quantity of carbonic acid gas in a mineral water containing it, is to put a given weight of the water (2000 grains, for example) into a retort with a long beak. Into a receiver sufficiently secured from all contact with the external air, put a solution of chloride of calcium or chloride of barium, mixed with a certain quantity of caustic ammonia. Plunge the beak of the retort into this solution; then heat the liquid contained in it, and keep it for some time at the temperature of about 180°. When gas ceases to come over, raise the liquid in the retort to a boiling temperature, and boil it briskly for a quarter of an hour; then suddenly withdraw the beak from the liquid in the receiver, to prevent any of that liquid from making its way into the retort, which would happen were the heat with- drawn before the beak of the retort was freed from the liquid. Close the receiver with its contents, and set it aside. The carbonic acid which passes over unites to the lime or barytes in the liquid contained in the receiver, and the carbonate thus formed precipitates in the form of a white powder. When this powder has subsided, draw off the clear liquid with a syphon, and then fill up the receiver as at first with distilled water which has been re- cently boiled, and cork it up as at first. When the carbonate of lime or barytes has subsided, draw off the clear liquid again with a syphon. Repeat this washing till nothing remains but the carbonate ; then collect it on a filter, dry it, and expose it to an incipient red heat, and weigh it. If the powder be carbonate of lime, the carbonic acid which it contains amounts to 1 l-25ths or 0.44 of the weight. If it be carbonate of barytes, the carbonic acid amounts to ll-49ths or 0.224 of the weight. Many other methods have been practised; but we have found the preceding on the whole the simplest and easiest. * Should the water happen to contain no chlorine of muriatic acid, which, however, is a very rare occurrence it will be necessary, in applying this test, to dissolve a little common salt in the water. WATERS, (MINERAL) 663 To convert a given weight of carbonic acid into volume, is attended with no difficulty. The spe- cific gravity of carbonic acid gas is 1-5277, that of air being reckoned 1. Now, at the temperature of 60°, and when the barometer stands at 30 inches, 100 cubic inches of dry air weigh 31-1446 grains; hence 100 cubic inches of carbonic acid gas, at the same temperature, and under the same pressure, weigh 47-4691 grains, or one cubic inch weighs 0-474691 grains. Therefore, if the weight of carbonic acid found be a, we have 0-474691 : o : : 1 : 0~Jm»»i ■= ^0 number of cubic inches of carbonic acid found in the quantity of water examined. 6. Acetic acid, when it happens to be present in a mineral water, is best detected by the smell. but we must first get rid of the muriatic acid or chlorine, which might, by its greater abundance, overpower the smell of the acetic acid, and prevent us from perceiving it. The best method of pro- ceeding is this : reduce a portion of the water in which you suspect the presence of acetic acid, to a tenth part of its volume, by evaporation at a low heat; then add a solution of sulphate of silver till all the chlorine is thrown down. Evaporate the liquid (after having filtered it) to the consist- ence of a syrup, and then mix it with alcohol. All the sulphates will be precipitated; but the acetate will be dissolved in the alcohol. Filter, introduce the alcoholic liquor into a retort, and distil off the alcohol (previously adding a little water, if necessary); then add sulphuric acid, change the receiver, and distil nearly to dryness. The presence of acetic acid in the liquid in the receiver will easily be perceived by the smell. 7. The presence of iodine in a mineral water is recognised by means of starch. Boil a little starch with water, so as to form a thin paste of the consistency of a syrup; mix a few drops of this with the liquid supposed to contain iodine; then pour over its surface (taking care not to mix) a little water impregnated with chlorine: cover the surface of the vessel with a lid, and set it aside. If iodine be present, we shall perceive within less than twenty-four hours a thin diaphragm of blue colour in the plane of contact of the mineral water and chlorine water. 8. The presence of bromine may be detected in a similar way. It has the property of giving an orange colour to starch instead of a blue. But we have never had an opportunity of trying the delicacy of this test The common mode hitherto followed of detecting the presence of bromine in a mineral water, is to concentrate the liquid, and to mix it with some sulphuric acid and native black oxide of manganese, and distil. Bromine, if present, is indicated by the formation of red vapours. Such are the methods by which the presence of the acids, or simple bodies which act the part of acids in mineral waters, may be ascertained. We shall now state the way of distinguishing the presence of the different bases. 9. The presence of strontian or barytes in a mineral water is incompatible with that of sul- phuric acid. Hence their presence must be very rare, for very few mineral waters exist which con- tain no traces of that acid. 10. When oxalate of ammonia dropped into a mineral water occasions a white precipitate, or renders the liquid milky, the presence of lime is indicated. Should no precipitate appear on the addition of oxalate of ammonia, we must not at once conclude that the liquid contains no traces of lime. We must take a new portion of the water, and reduce it by gentle evaporation to one- tenth of its original bulk, and repeat the experi- ment again. It will often happen that oxalate of ammonia will give a precipitate with the concen- trated liquid, though it had no sensible action on the water, in its original state. When this takes place, we may conclude that the water contains a salt of lime, though the quantity is but small. In some cases we have been obliged to reduce the water by evaporation to the hundredth part of its original volume, or even further, before the pre- sence of lime became sensible to the test of oxalate of ammonia. 11. If a mineral water, after being boiled to expel any free carbonic acid which it may contain, be mixed with lime-water, and a white flaky pre- cipitate fall, we may conclude that it contains a salt of magnesia. When we obtain such a pre- cipitate, in order to make ourselves certain of the presence of magnesia, the best way is to reduce a quantity of the water by evaporation to one-tenth of its volume, to heat it, and then drop into it the quantity of oxalate of ammonia which from pre- vious trials is known to be just sufficient to throw down the whole of the lime. Filter; and to a few drops of the clear liquid put upon a watch- glass, add a drop or two of solution of phosphate of ammonia and then a drop or two of carbonate of ammonia. If a precipitate immediately falls we may conclude that magnesia is present in some quantity; if there be no immediate precipitate, draw lines with a glass rod upon the bottom of the watch-glass. In two or three minutes (if any magnesia be present) these lines will become visi- ble to the eye in consequence of the deposition of ammonia-phosphate of magnesia upon them. When no precipitate whatever appears, we may conclude that the waters contain no sensible quantity of magnesia. 12. When alumina is present in a mineral water, it is thrown down from the concentrated liquid by means of ammonia or carbonate of am- monia. But as ammonia throws down also oxide of iron, and may likewise throw down some mag- nesia, and as carbonate of ammonia will throw down lime, magnesia, oxide of iron, and barytes and strontian, this precipitation alone would not be sufficient to prove the existence of albumina in a mineral water. Collect the precipitate on a filter, wash it well with water, and then boil it in a solution of caustic potash in water for some time. Decant off the potash ley, saturate it with muriatic acid, and pour carbonate of ammonia into the saturated solution. If a precipitate fall, it is a proof that the mineral water contains alu- mina. The weight of this precipitate after igni- tion gives us the weight of alumina in the quan- tity of water which was subjected to examination. 13. We have now stated the mode of determi- ning all the constituents of a saline mineral water, except the potash and soda. The way of proceeding with respect to these alkalies is this:— 664 WATERS, (MINERAL) precipitate the lime (if any) by means of oxalate of ammonia, and then, after filtration, evaporate the liquid to dryness, and expose the dry residue to a red heat. Re-dissolve the residue thus treated in water. If any chloride of magnesium was present, the magnesia of that salt will remain un- dissolved. The solution will contain the sulphates of potash and soda and magnesia (supposing them present), and the chlorides of potassium and so- dium. The greatest part of the magnesia may be precipitated by carbonate of ammonia. If we have recourse to that method, we must filter the liquid, evaporate it to dryness, ignite the residue, and re-dissolve it in water. Mix this solution with a little chloride of platinum, and evaporate the solution till it is reduced to a small quantity. If the alkali present be potash, a precipitate will fall; if it be soda, there will be no deposit. Sup- pose a precipitate to appear, we must next ascer- tain whether soda may not be present as well as potash. For this purpose evaporate the liquid to dryness at a low temperature, and digest the resi- dual salt in alcohol of the specific gravity 0.896. The chloro-platinate of potassium will remain un- dissolved ; but the chloro-platinate of sodium will be dissolved by the alcohol. Evaporate the alco- holic solution to dryness, and expose the residual ^alt to ignition. The platinum will be reduced to the metallic state. Digest the residue in water; it will take up the chloride of sodium and leave the metallic platinum. Evaporate the solution: the salt obtained will be chloride of sodium, 8-15ths of which represent the weight of soda in the water, or the sodium (supposing it to have existed in that state) amounts to 2-5ths of the chloride obtained. In the same way may the potash be determined, the potassium being 10-19ths and the potash 12-19ths of the weight of the chloride of potassium obtained. Such is the method of determining the nature of the constituents of saline waters, or the quali- tative analysis, as it is called by modern chemists. The next process is to determine the weight of the different constituents in a given weight of the mineral water. There are various methods of accomplishing this, each of which has its advan- tages. A pretty common method is to concen- trate the water to be analysed till it is reduced almost, but not quite, to dryness. The residual liquid, which has the consistency of a thick syrup, is now digested in alcohol of about the specific gravity 0-830, and the whole is ihrown upon a filter, and after the alcoholic liquid has passed through, the saline matter remaining on the filter is to be washed repeatedly with alcohol, till that liquid passes through pure. By this process the chlorides of calcium, magnesium, and part of the chloride of sodium or potassium (if it be present) are dissolved, while all the sulphates are left upon 'the filter. The alcoholic liquid is drawn off by distillation, and the dry residue is exposed to a strong red heat. The magnesia is by this process disengaged, and remains, while the alkaline chlorides and that of calcium are dissolved. The lime is thrown down by oxalate of ammonia. The precipitate, after being washed and dried, is ignited in a platinum crucible. What remains is carbonate of lime. The lime constitutes 0-56 of the weight of this carbonate. The liquid thus freed from lime ami magnesia is to be evaporated to dryness and igw nited. The salt remaining consists of chloride of sodium or chloride of potassium, or of a mixture of the two. These chlorides are to be separated from each other, and the quantity of each deter- mined by the methods already explained. Every 2-5 of magnesia is equivalent to 6 of chloride of magnesium, and every 3-5 of lime is equivalent to 7 of chloride of calcium ; or if we multiply the magnesia by 2-4 and the lime by J, the product will be the equivalent quantities of chlorides corresponding to the weight of each. The objections to this method of separating the chlorides from the sulphates by means of alcohol are—1. that the whole alkaline chlorides are sel- dom or never dissolved by the alcohol; a portion remains among the sulphates, and requires a sepa- rate process to determine it. 2. If the mixed chlo- rides be exposed to too high a temperature, a por- tion of lime may be disengaged as well as the magnesia; while, if the temperature has been too slow, the whole of the magnesia may not be dis- engaged, but a portion may still remain in the slate of chloride. The sulphates remaining undissolved by the alcohol may consist of sulphates of lime, magne- sia, and soda, and very rarely of sulphate of pot- ash. They may be dissolved by digestion in about 450 times their weight of water. Heat the solu- tion, and mix it with a sufficient quantity of oxa- late of ammonia, to throw down the whole of the lime. Let the precipitate subside, draw off the clear liquid, and then wash the precipitate with distilled water. Collect it in a small platinum crucible, the weight of which has been previously ascertained : expose the oxalate of lime to the heat of a spirit-lamp, till the oxalic acid is destroyed, It is now carbonate of lime, every 6-25 grains of which is equivalent to 8-5 grains of anhydrous sulphate of lime. If we therefore multiply the weight of carbonate of lime obtained'by 1-36, the product will give us the weight of sulphate of lime present in the saline mixture under exami- nation ; or we may add to the carbonate of lime in the crucible an excess of sulphuric acid, and after digesting till all effervescence is at an end, expose the crucible to a strong red heat to drive off' the excess of acid. The lime is now in the state of sulphate, and has only to be weighed. For the sake of exactness, both of these methods of determining the quantity of sulphate of linn may be taken; the one will serve as a check OS, the other. The magnesia may be precipitated from Ihe residual solution by means of carbonate of am- monia, and after being well washed, may be ex- posed to a strong red heat. If we now determine its weight, and multiply that weight by three, the product will represent the anhydrous sulphate of magnesia present in the water. The liquid thus freed from lime and magnesia is to be evaporated to dryness, and exposed to a heat sufficiently high to draw off the amnioniacal salts. It may be then dissolved in water, and after separating the clear liquid from the sedimeoV if there should be any, evaporate it to dryness, and expose the dry salt to a red heat. It will be sul- phate of soda or sulphate of potash, or it may con- WATERS, (MINERAL) 665 sist of a mixture of the two. The proportion of each may be determined by the method formerly described. The above method of proceeding may appear at first sight simpler and more precise than any other, because it enables us to separate the sul- phates and chlorides, and to analyze each set sepa- rately. But we are by no means sure that we do riot alter the nature of the salts held in solution in saline waters by our process of concentrating them. It not unfrequently happens that when we evaporate a given bulk of a mineral water to dry- ness, and then digest the saline residue in a quan- tity of distilled water equal in bulk to that origi- nally present, we do not obtain a complete solu- tion. A portion of sulphate of lime often con- tinues undissolved, and requires for complete so- lution a considerably greater quantity of water than was originally present. In such cases it is clear that the lime in the original condition of the water was not in the state of sulphate, but com- bined with some other acid, while the sulphuric acid was also united to some other base. In the original water the lime was probably in the state of chloride of calcium, and the acid in that of sul- phate of soda. By concentrating the liquid, the particles of each salt were brought nearer and nearer to those of the other, till at last they reached the distance at which they were capable of acting on each other. Double decomposition is then the consequence, sulphate of lime and chlo- ride of sodium being formed. Nor are we certain that no change is induced upon the salts contained in mineral waters by the action of the alcohol. It is not at all unlikely that the alcohol may have a tendency to hasten these kinds of decompositions, or to carry them to a greater extent than would otherwise take place. These reasons lead to the inference that the salts contained in mineral waters may not in all cases be those which we extract from them. Nor have we any method at present of deciding by satisfactory experiment what the salts really are which constitute the saline constituents of mineral waters. We can do nothing more than determine the nature and quantity of the different acids and bases that exist in a water. If the salts present be neutral, it is clear that these acids and bases must naturally saturate each other; there can be no redundancy of the one and deficiency of the other. The simplest method of proceeding, therefore, seems to be to determine separately the weight of each acid and each base, and then to suppose them combined in the way most conformable to the known affinities of the acids and buses, or to the known properties of the water. Thus, if a water be eminently purgative, and if we extract from a certain quantity of it chlorine, sulphuric acid, sodium, and lime, it is much more likely from the purgative nature of the water, that these bodies are so combined in it as to produce sul- phate of soda and chloride of calcium, both of which are eminently purgative salts, than that they constitute sulphate of lime and chloride of sodium, salts much less eminently purgative than the preceding, and one of which indeed is quite inert, or nearly so. The method which we are in the habit of following, while it is simpler and | Vol. IV. —84 3F» easier than the one just described, seems also to be equally accurate. We take a certain quantity of the liquid, usually 1000 grains, and after reducing it by evaporation to about one-fourth of its original volume, the chlorine is thrown down by nitrate of silver. The chloride of silver, washed, dried, and fused, gives the quantity of chlorine in the 1000 grains of liquid; every 18.25 of chloride indicating 4.5 of chlorine; or we obtain the chlorine by dividing the weight of chloride by 4.055. To the liquid thus freed from chlorine add a little common salt, to get rid of any excess of nitrate of silver that may have been added. Then throw down the sulphuric acid by chloride of ba- rium. Wash, dry, and ignite the precipitate: it gives the quantity of sulphuric acid in 1000 grains of the liquid. Every 14.5 grains of sulphate of barytes indicates five grains of sulphuric acid. Therefore, if we divide the weight of the sulphate of barytes obtained by 2.9, the quotient will be the weight of sulphuric acid which it contains. When the qualitative analysis has indicated the presence of nitric acid in the water, we may proceed in this way to determine its quantity. The chlorine from 1000 grains of the water is to be thrown down by means of sulphate of silver. The liquid freed from chlorine is to be evaporated to dryness, mixed with its own weight of sulphu- ric acid, and cautiously distilled in a small retort, taking care not to apply so much heat as to drive over any of the sulphuric acid. The liquid in the receiver will contain the whole nitric acid in the 1000 grains of the water. Saturate it exactly with barytes water, and then evaporate to dryness. The weight of nitrate of barytes thus obtained in- dicates the quantity of nitric acid ; for 16-25 nitrate of barytes contain 6-75 nitric acid. Hence, if we divide the weight of the nitrate of barytes by 2-4071, the quotient will indicate the weight of nitric acid contained in 1000 grains of the mineral water. The lime may be thrown down by oxalate of ammonia from another 1000 grains of the liquid previously concentrated and heated. The mode of determining the quantity of lime from the oxa- late has been already stated. When that oxalate is heated to redness, it is converted into carbonate of lime, every 6-25 of which is equivalent to 3-5 of lime. If, therefore, we divide the quantity of carbonate of lime obtained by 1-7857, the quotient will be the quantity of pure lime contained in 1000 grains of the water. The 1000 grains of concentrated water thus freed from lime may be used to obtain the mag- nesia also. Add to it a little phosphate of ammo- nia, and afterwards a few drops of carbonate of ammonia, and then evaporate till the liquid is re- duced to a very small quantity. The magnesia is precipitated in the state of ammonia phosphate. Wash the precipitate with water, then dry it and expose it to ignition. The weight of biphosphate of magnesia thus obtained indicates the quantity of magnesia in 1000 grains of the water. Every 11-5 grains of the biphosphate contain 2-5 grains of magnesia. If, therefore, we divide the weight of the biphosphate of magnesia by 4-6, the quo- tient will be the quantity of magnesia contained in it. 666 WATERS, (MINERAL) Iodine and bromine are best estimated by con- verting them into iodide and bromide of silver. Let us suppose a mineral water to contain chlo- rine, iodine, and bromine all at once. To 1000 grains of it previously sufficiently concentrated, add nitrate of silver. The three chlorides preci- pitate together. Digest the precipitate in caustic ammonia, the chloride and bromide of silver will dissolve; but the iodide will remain unaltered. Wash it and dry it. Every 29-5 of it contain 15-75 of iodine. Hence, if we divide the weight of iodide of silver obtained by 1-873, the quotient will be the weight of iodine contained in 1000 grains of the water. To the ammoniacal solution arid nitric acid in slight excess. The bromide and chloride of silver precipitate. Wash this precipitate and put it into a phial with a ground stopper, containing water saturated with chlorine, and agitated frequently for twenty-four hours. Then add some sulphuric ether, and agitate again. When the phial is left at rest, the ether floats on the chlorine liquid, and speedily acquires an orange or reddish colour. This ether may be decanted off and a new portion added. To these ethers introduced into a retort add barytes water, and distil off the ether. Eva- porate the residue to dryness. Ignite the dry matter remaining, and digest it in alcohol of the specific gravity 0-810. The bromide of barium alone dissolves. Evaporate to dryness, and weigh the bromide of barium remaining; every 18-5 of it contains 10 of bromine. If, therefore, we divide the weight of the bromide of barium obtained by 1-85, the quotient will give the quantity of bro- mine contained in 1000 grains of the mineral water. The silica, which most waters contain, is easily obtained by evaporating a given weight of the water to dryness, and digesting the saline residue, first in a sufficient quantity of water, and after- wards in aqua regia. What remains undissolved is silica. Such is a sketch of the method of analysing saline waters. The processes are not difficult; but they require either to be performed on a large scale, that is to say, with several gallons of water reduced by evaporation to a manageable quantity; or, if we employ smaller quantities, very great at- tention must be paid to precision, and the balance used must be capable of weighing with precision to the hundredth of a grain, even when loaded with the small platinum crucibles in which the sediments are contained. [The saline aperient waters contain chiefly sulphate of soda, sulphate of magnesia, chloride of sodium, and chloride of magnesium, singly or associated. Most of these are cold springs—as those of Kissingen, Marienbad, Franzensbad, Chel- tenham, Leamington, Harrowgate, and Scarbo- rough; and, in this country, the White Sulphur, Salt Sulphur, and Red Sulphur, of Virginia. Thermal saline waters are found at Wies- baden, and Baden-Baden in the neighbourhood of Wiesbaden. The Hot Springs and Warm Springs of Virginia contain but little saline impregnation. All these waters act as cathartics and diuretics; but they require to be taken with caution; for, if used too freely, they bring on fever with gastro- intestinal irritation, and a sense of fulness in the head. Their protracted use, too, may be of great advantage in diseases that require the employment of saline eutrophics. The important ingredients in the alkaline waters are bicarbonate of soda and carbonic acid. Vichy is the most celebrated of these. It is thermal alkaline; and so are Mont-Dore, Ems, Tuplitz, Schlangenbad, and Roisdorff. The alkaline springs of this country are cold. Those of Saratoga and Balston are the most celebrated. The iodcretted waters always contain a salt of iodine associated with chloride of sodium. The chief springs of this kind are those of Sara- toga and Ballston, in this country; of Woodhall, near Ashby de la Zouch, in England; and of Creuznach, in Germany. The properties of these waters are, therefore, dependent upon the united influence of the iodine and the chloride of sodium; and their prolonged use is beneficial in scrofula, and in other cases in which the eutrophic agency of iodine, or of chloride of sodium, or of both, is indicated.] We shall now take a view of the most remark- able saline waters in Great Britain and on the continent. I. Cheltenham. Cheltenham is situated in a sandy vale in Glou- cestershire, surrounded by hills of a moderate height, in the midst of a fertile and well cultivated country. The mineral waters which it contains were first noticed about a century ago, and gradu- ally attracted the attention of the public. At first only one scanty spring was known, the old well; but as the number of visitors increased, it became insufficient to supply them. This led to a farther search, in consequence of which three new wells were discovered in the immediate neighbourhood of the original spa. Between the years 1770 and 1780, the mineral waters of Cheltenham acquired so much reputation, that the town became a great place of resort for invalids from all parts of the kingdom. It was soon found that the wells could not supply the additional demand. In the year 1788 a new well was sunk by order of George III., known by the name of the King's Well. At first the supply from this well was very abundant, but it afterwards decreased so much that it was often drunk out by the company in half an hour. In 1806, a gentleman of the name of Thomp- son, who had purchased a great part of the land in the vicinity of Cheltenham, determined to search for mineral water on his own estate, and to try to supply the deficiency so much complained of. The success which he met with soon induced him to think of turning his discovery to his own advan- tage ; and accordingly a new pump-room was erected, and no exertions were spared till a suffi- ciency of water was obtained for the supply of whatever company might resort to the room and neighbourhood. Six different wells were discovered by him, to which he gave the following names: L Strong chalybeate saline water. 2. Strong sulphuretted saline water. 3. Weak sulphuretted saline water. 4. Pure saline water. 5. Bitter saline water. 6. Saline chalybeate. But from the analyses of these waters by Dr. WATERS, (MINERAL) 667 Scudamore, it does not appear that these names are very appropriate. There is another pump-room, situated between the old well and Thompson's Spa, called the Sher- borne Spa. To it are attached four pumps, be- longing to as many wells, which appear, from Dr. [Sir C] Scudamore's observations, to correspond very closely with the analogous wells at Thomp- son's Spa. Thus the different wells at present at Cheltenham amount to fourteen. We shall now give the constituents of these different wells, so far as they have been determined by analysis. 1. The Original Spa, or Old Well.—The four springs belonging to this spa were analysed in 1820, by Dr. [Sir C] Scudamore assisted by Mr. Garden. They were distinguished by the follow- ing names:— 1. Strong aerated chalybeate saline. 2. Strong sulphureous chalybeate. 3. Magnesian saline. 4. Pure saline. The specific gravities of these waters were as follows:— 1. 1-0091. Taste mildly saline. 2. 1-0089. Taste saline and very slightly cha- lybeate. 3. 1-0083. Taste saline and chalybeate. 4. 1-0122. Taste strongly saline. The saline constituents in an imperial gallon of each of these waters, according to the analysis of Dr. Scudamore, are as follows:— No. 1. Common salt..................561-17 grs. Chloride of calcium............. 59-89 Chloride of magnesium.......... 24-49* Sulphate of soda............... 140-41 785-96 No. 2. Common salt........-..........217-95 grs. Chloride of calcium............ 35-49 Chloride of magnesium.......... 49-76 Sulphate of soda...............504-57 807-77 No. 3. Chloride of sodium.............169-73 grs. Chloride of calcium............ 29-70 Chloride of magnesium......... 31-83 Sulphate of soda...............416-62 647-88 Oxide of iron, probably a grain in the gallon. No. 4, Chloride of sodium.............460-98 grs. Chloride of calcium............ 41-38 Chloride of magnesium......... 70-40 Sulphate of soda..............570-92 1143-68 Oxide of iron, a trace. The wells belonging to Thompson's Spa were analysed by Messrs. Brande and Parkes in 1817; * The chlorides are given by Dr. [Sir C.l Scudamore as muriates. Probably, therefore, the numbers may be in excess; but as no details of the analysis are given, we have not ventured to alter the original numbers of Dr. [Sir C.j Scudamore. The same observation applies to all the subsequent analyses of the same gentleman. and the analysis was again repeated by Dr. [Sir C] Scudamore and Mr. Garden in 1820. The results of these two analyses are so different as to occasion considerable surprise. If both be accu- rate, we must conclude that in the short space of three years these waters have totally altered their saline nature. This is so uncommon a circum- stance in the history of mineral waters, that it is very desirable that a new analysis of these waters should be made, that we may be enabled to judge whether the alteration is still going on, or whether one or other of the experimenters has not fallen into mistakes with respect to the conclusions drawn regarding the saline constituents of these waters. The following table exhibits a view of both analyses:— 1817. 1820. No. 1. Sp. gr.........1-0092.......1-0085 2..............1-0085.......1-0065 3.............. 1-006.......1-0067 4............. 1-010.......1-0077 5.............. 1-008.......1-0065 6.............. 1-004.......10098 It appears from this table that in three years the specific gravity of the first, second, fourth, and fifth of these springs has diminished considerably; while that of the sixth well, which is 126 feet in depth, has very much increased. All the other waters are from wells, but much less deep. No. 1 is 48 feet deep; Nos. 2 and 3 (the same well but at different depths) 48 feet; Nos. 4 and 5, each 50 feet. An accurate geological description of the strata through which these wells are sunk, might throw some light upon the alteration in the saline constituents of their waters. No. 1. 1817. Imperial gallon. Common salt..................398-30 grs. Sulphate of soda...............221-12 Sulphate of magnesia........... 57-86 Sulphate of lime............... 24-11 Carbonate of soda and iron...... 14-47 Carbonic acid gas 1820. 715-86 . 2-5 cubic inches. Common salt..................535-24 grs. Chloride of calcium............ 31-92 Chloride of magnesium.......... 20-45 Sulphate of soda...............210-24 797-85 Oxide of iron, a minute portion. No. 2. 1817. Common salt..................337-54 grs. Sulphate of soda...............206-63 Sulphate of magnesia........... 48-22 Sulphate of lime............... 11-57 Oxide of iron.................. 2-89 606-85 Sulphuretted hydrogen gas 24-11 cub. in. Carbonic acid...........14-46 668 WATERS, (MINERAL) 1820. Common salt..................247-85 grs Chloride of calcium............ 31-92 Chloride of magnesium......... 14-66 Sulphate of soda...............209-85 504-28 Oxide of iron, a minute portion. No. 3. 1817. Common salt..................144-66 grs Sulphate of soda...............135-02 Sulphate of magnesia........... 48-22 Sulphate of lime............... 14-47 Oxide of iron.................. 4-82 347-19 Sulphuretted hydrogen 24-11 cubic inches. Carbonic acid........14-46 1820. Common salt..................298-96 grs, Chloride of calcium............ 17-74 Chloride of magnesium......... 19-77 Sulphate of soda...............209-85 546-32 Oxide of iron, a trace. No. 4. 1817. Common salt..................482-20 grs. Sulphate of soda...............144-66 Sulphate of magnesia...........106-08 Sulphate of lime............... 43-40 776-34 1820. Common salt..................447-48 grs. Chloride of calcium............. 29-61 Chloride of magnesium.......... 19-48 Sulphate of soda...............276-20 772-78 No. 5. 1817. Sulphate of magnesia...........350-81 grs. Chloride of magnesium.......... 86-80 Common salt.................. 91-62 Sulphate of lime................ 33-75 Oxide of iron................. 9-64 572-62 1820. Common salt..................226-63 Chloride of calcium............. 47-35 Chloride of magnesium.......... 34-81 Sulphate of soda............... 374-19 682-98 No. 6. 1817. Common salt..................212-17 grs. Sulphate of soda............... 96-44 Oxide of iron.................. 14-47 32308 Carbonic acid...........96.44 cubic inches. 1820. Common salt..................734-39 grs. Chloride of calcium............. 29-61 Chloride of magnesium.......... 29-12 Sulphate of soda................112-06 905-18 Oxide of iron, a minute portion. Some of the differences in these two sets of analyses are owing to the different modes of esti- mating the nature of the salts; but there are others for which no such difference can account, and which serve to throw doubts upon the accu- racy of the experiments. Thus, the saline consti- tuents of No. 4, by both analyses, amount to nearly the same weight; yet there is a consider- able difference in the specific gravity of the two liquids; that analysed by Brande was 1-01, while that analysed by Scudamore was only 10077. On the contrary, in No. 3 there is a great differ- ence in the weight of the saline contents found by the two analists, yet the specific gravity of the water was nearly the same. It is evident from the preceding analysis that the Cheltenham waters possess cathartic proper- ties. The chief salts to which they are indebted for this effect are common salt and sulphate of soda. The first of these in a concentrated solution acts as an emetic; but when more diluted, it pos- sesses the properties of a strong purgative. This is the well-known effect of sea-water when taken internally. The purgative qualities of sulphate of soda are universally known. The chlorides of calcium and of magnesium, which are also present in small quantities, are powerful purgatives, and when much diluted with water, as they are in the Cheltenham springs, they constitute a very excel- lent purgative. All these salts in the Chelten- ham waters are very much diluted—a circumstance which greatly enhances their virtues by rendering thein exceedingly mild, so that they may be per- sisted in for a length of time without bringing on debility. It is this diluted state that constitutes the chief excellency of saline mineral waters. They can only be imitated by administering a mixture of various purgative salts in a similar state of dilution. It will be found upon trial that when three or four purgative salts are mixed together and administered in a state of great dilu- tion, they may be persisted in for a considerable time without inducing debility ; whereas concen- trated solutions of the same salts very speedily reduce the strength of the patients. Cheltenham has been chiefly resorted to by those invalids who have resided long in hot cli- mates, and who labour under a diseased liver. Such persons not unfrequently derive much benefit from a judicious use of Cheltenham water. The individuals who have been in the habit of carrying the pleasures of the table to excess, and whose stomachs are debilitated from being habitually overloaded, likewise derive much benefit from the use of these waters. II. Leamington. Leamington is situated about two miles east from Warwick, in a flat, but rich, beautiful, and highly cultivated country. Its name is derived from the Leam, a torpid stream, which passes through it. The existence of saline springs in this place was known to Cambden and Speed, who lived about the end of the sixteenth century: but it did not attract much notice till about the WATERS, (MINERAL) 669 year 1786. Since that period it has advanced with almost unexampled celerity, and is now a magnificent watering-place, scarcely inferior to Cheltenham itself. The wells, as at Cheltenham, are situated in the new red sandstone formation, in which, indeed, most of the saline springs in Great Britain take their rise. There are no fewer than eleven springs, all of them saline, but some of them containing, also, iron; and one or two of them slightly impregnated with sulphuretted hydro- gen. The first analysis of these waters was made by Dr. Lambe in 1797. He published, in the fifth volume of the Manchester Memoirs, an account of the constituents of two of the springs, under the name of the water of the old baths, discovered in 1786, and of the new baths, disco- vered in 1790. Dr. [Sir C] Scudamore, in 1820, published an analysis of eight of the springs; and in 1828, Dr. Loudon, in his Practical Dissertation on the Waters of Leamington Spa, gave the ana- lysis of the whole eleven. The saline constituents of these waters were determined by Dr. Thomson of Glasgow, and the gaseous constituents by Dr. Louden himself, with the assistance of Mr. Gossage, chemist, of Leamington. The following table exhibits the specific gravity of these various springs, as determined by Dr. [Sir C] Scudamore in 1820, and Dr. Thomson in 1827. Scudamore. Thomson. LoVd Aylesford's......1-0093____1-0098 Mr. Smith's..........1-0085____1-01015 Mr. Wise's..........1-010____1-01017 Mr. Robbins's........1-0118____1-00825 Mr. Reid's (sulphureous).........1-00736 Do. (saline)................1-00995 Imperial Fount (cha- ? 4 lybeate,).....) Do. (saline)......1-0054____1-00858 Do. (sulphureous) .1-011 ____1-00900 Pump-room (sulphuO lJm2 A.Q01U , reous).......3 Do. (saline)......1-0119____1-01223 It is obvious from these specific gravities that the water is liable to undergo changes in its strength at different times. We shall now give the constituents in an im- perial gallon of each of these waters as determined by the analyses of Dr. [Sir C] Scudamore and Dr. Thomson. The differences between them are doubtless owing in part to differences in the strength of the waters at different times; though errors in the analysis may also have an effect in rendering the constituents more different than they otherwise would be. 1. Lord Aylesford's. Scudamore. Imperial gallon. Chloride of sodium.............118-14 grs. Chloride of calcium............272-35 Chloride of magnesium.......... 50-34 Sulphate of soda...............317-86 758-69 Thomson. Sulphate of soda...............323-19 grs. Chloride of sodium.............32616 Chloride of calcium............164-49 Chloride of magnesium.......... 26-93 840-77 Oxygen gas........... 0-6 cubic inches. Azotic................ 4-296 Carbonic acid..........16-830 2. Mr. Smith's. Scudamore. Chloride of sodium.............219-88 grs. Chloride of calcium............194-19 Chloride of magnesium......... 50-34 Sulphate of soda...............271-57 735-98 Thomson. Sulphate of soda...............321-87 grs. Chloride of sodium.............382-92 Chloride of calcium.............158-18 Chloride of magnesium.......... 16-97 879-94 Oxygen gas...........0-36 cubic inches. Azotic................ 5-264 .Carbonic acid..........20-025 25-649 3. Mr. Wise's. Scudamore. Chloride of sodium.............292-21 grs. Chloride of calcium............207-54 Chloride of magnesium.......... 50-34 Sulphate of soda...............322-50 872-59 Thomson. Sulphate of soda...............315-66 grs. Chloride of sodium.............212-88 Chloride of calcium............149-90 Chloride of magnesium..........180-74 859-18 Oxygen gas............ 0-704 cubic inches. Azotic................ 3-904 Carbonic acid..........17-440 22-048 4. Mr. Robbins's. Scudamore. Chloride of sodium.............450-86 grs. Chloride of calcium.............165-88 Chloride of magnesium Sulphate of soda...............300-85 917-59 Thomson. Sulphate of soda...............228-95 grs. Chloride of sodium.............282-80 Chloride of calcium............188-09 Chloride of magnesium.......... 67-75 767-59 Oxygen gas............ 0-600 cubic inches. Azotic................ 4.464 Carbonic acid..........18.850 23-914 670 WATERS, (MINERAL) 5. Mr. Reid's (sulphureous.) Thomson. Sulphate of soda...............264-52 gTS. Chloride of sodium.............204-84 Chloride of calcium............126-22 Chloride of magnesium.......... 77.56 63314 Oxygen gas.......... 0.200* cubic inches. Azotic gas............ 3-400 Carbonic acid.........25-250 Sulphuretted hydrogen.. 9-152 38-002 6. Mr. Reid's (saline). Thomson. Sulphate of soda...............244-88 grs. Chloride of sodium.............343-38 Chloride of calcium.............143-90 Chloride of magnesium.......... 86-55 Silica........................ 7-78 Peroxide of iron................ 2-12 828-61 • Oxygen gas............. 0-20 cubic inches. Azotic.................4-52 Carbonic acid...........17-30 22-02 Imperial Fount (chalybeate). Scudamore. Chloride of sodium............. 71-17 Chloride of calcium............. 88-72 Chloride of magnesium.......... 30-19 Sulphate of soda...............107-01 297-09 Thomson. Sulphate of soda...............274-35 Chloride of sodium.............442-17 Chloride of calcium.............200-47 Chloride of magnesium.......... 31-42 Silica........................ 68-64 Peroxide of iron................ 68-64 1085-69 Oxygen gas............. 0-60 cubic inches. Azotic................. 5-16 Carbonic Acid____■......26-35 32-11 8. Imperial Fount (saline). Scudamore. Chloride of sodium..............89-97 grs. Chloride of calcium..............29-61 Chloride of magnesium...........65-29 Sulphate of soda................7947 Oxide of iron................... 1-00 26534 • There is no doubt a mistake in this statement of oxygen gas, as it is well known that oxygen gas and sul- phuretted hydrogen cannot exist together in the same water. The origin of the azotic gas, so generally found in sulphureous waters, is probably this:—these waters absorb air in the usual proportion ; but the sulphuretted hydrogen unites with the oxygen and leaves the azote. Thomson. Sulphate of soda...............275-48 Chloride of sodium.............116-27 Chloride of calcium.............140-56 Chloride of magnesium..........208-40 740-71 Oxygen gas............ 0-784 cubic inches, Azotic................ 6104 Carbonic acid..........25-250 32-138 9. Imperial Fount (sulphureous). Scudamore. Chloride of sodium.............144-66 grs, Chloride of calcium............. 76-77 Chloride of magnesium.......... 31-82 Sulphate of soda...............111-87 365-12 Oxide of iron, a minute portion. Thomson. Sulphate of soda...............248-90 grs. Chloride of sodium.............58-41 Chloride of calcium............314-44 Chloride of magnesium..........155-98 Silica........................ 28-96 Peroxide of iron................ 4-24f 810-90 Oxygen gas............0-960$cubic inches. Azotic................ 4-896 Carbonic acid..........28-250 Sulphuretted hydrogen ... 9-136 43-242 10. Pump-room, (sulphureous). Scudamore. Chloride of sodium.............144-66 grs. Chloride of calcium............. 76-77 Chloride of magnesium.......... 31-82 Sulphate of soda...............111-87 365-12 Thomson. Sulphate of soda................44-37 grs. Chloride of sodium..............41-16 Chloride of calcium..............6-92 Chloride of magnesium.......... 9-25 121-69 Oxygen gas............ 0-512 cubic inches. Azotic................ 3-984 Carbonic acid..........25-250 Sulphuretted hydrogen .. 9-120 38-866 t Peroxide of iron being incompatible with sulphuret- ted hydrogen, it may be requisite to state that the saline contents of the water were determined in Glasgow. The water, when examiner), contained no sulphuretted hy- drogen, and the peroxide of iron was found combined with the silica. Nothing is predicted respecting the state of the iron in the spring. \ This must he considered as a mistake, as oxygen gas is incompatible with sulphuretted hydrogen. WATERS, (MINERAL) 671 11. Pump-room, (saline). Scudamore. Chloride of sodium.............518-36 grs. Chloride of calcium.............276-20 Chloride of magnesium..........193-42 Sulphate of soda............... 75-51 1063-49 Thomson. Sulphate of soda..............261-95 grs. Chloride of sodium............542-26 Chloride of calcium............167-22 Chloride of magnesium......... 98-91 Silici........................ 8.36 Peroxide of iron............... 7.65 1086-35 Oxygen gas........... 0-528 cubic inches. Azotic............... 4-704 Carbonic acid.........23-600 28-832 Upon comparing the saline contents of these waters with those of Cheltenham, we cannot avoid observing a striking similarity. Nor is this surprising, when we consider that both are situated in the same formation, the new red sandstone or red marl, as it is frequently called by British geo- logists. Sulphuretted hydrogen gas occurs in both waters in small quantity, and the same re- mark applies to oxide of iron. It is obvious from this that the waters of Leamington will be useful in the same diseases as are cured or alleviated by Cheltenham waters. The two watering-places are 60 nearly on a par, that invalids may repair to each with equal advantage. Convenience or ca- price, therefore, may be left to decide the differ- ence between them. III. Scarborough. The town of Scarborough is situated at the foot of a very high cliff on the Yorkshire coast, over- looking a spacious bay, surrounded by lofty rocks. It has been long famous for two mineral springs, which issue from the bottom of a large cliff, about a quarter of a mile south from the town. These springs have been long frequented ; and many attempts to analyse them were made before the science of chemistry had advanced sufficiently to enable the experimenters to draw any accurate inferences respecting the true constituents of the water. Simpson's analysis of the Scarborough Spa, published in the reign of Charles II., may be mentioned as an unsuccessful attempt to rectify previous errors. The Scarborough wells are two in number, and are distinguished by the names of the North and South Wells. They are, to a certain extent, impregnated with iron; but as the protoxide of iron in these waters is held in solu- tion by carbonic acid, they cannot be carried to a distance without losing their chalybeate qualities. They owe their celebrity chiefly to their purging nature, for which they are indebted to their saline contents ; and as they are weaker than the purg- ing waters of Cheltenham and Leamington, the town of Scarborough has become less frequented since these places have risen into celebrity. Of the two Scarborough wells, the south is the strongest. The specific gravity of each, as deter- mined by Dr. Thomson, is as follows:— North Well.........1-003354 South Well.........100349 The following table exhibits the saline contents of an imperial gallon of each, as analysed by Dr. Thomson. The analysis was made in Glasgow : the quantity analysed was a wine-bottle full of each, sent for the purpose from Scarborough to Glasgow. Of course, neither the quantity of iron which the waters originally contained, nor their gaseous contents, could be determined. 1. North Well. Sulphate of magnesia..........105-94 grs. Sulphate of lime.............. 47-64 Chloride of calcium............ 38-00 Common salt................. 7-23 198.81 2. South Well. Sulphate of magnesia.......... 22-41 grs. Sulphate of lime..............147-12 Chloride of sodium............ 25-36 Chloride of magnesium........ 3-88 Carbonate of lime............. 9-97 208-74 But though the South well be most impregnated with salts, as more than three-fourths of these con- sist of sulphate of lime and carbonate of lime, it is obvious that, as a purgative, the North well must act much more powerfully. Accordingly, it is always stated as the strongest, though both the specific gravity and the quantity of salts are greatest in the water of the South well. IV. Spltal Water. The village of Spital lies on the south side of the Tweed, very near Tweedmouth, which may ; be considered as a suburb of Berwick. There is | a mineral spring in this village, possessing purg- ing qualities, which has been long resorted to by the people in the neighbourhood, and has been found useful in those diseases for which saline waters are had recourse to. The water of this i spring rises from the coal formation which consti- | lutes the surface of the earth in that part of the country. It is transparent and colourless, and has a slightly saline and unpleasant taste. Its specific gravity was found to be 1-00312. The saline contents in the imperial gallon, as deter- mined by Dr. Thomson, are as follows:— Chloride of calcium............ 71-92 grs. Sulphate of soda.............. 145-39 Sulphate of lime.............. 31-60 Carbonate of lime.............. 15-87 264-78 Carbonic acid............ 14.3 cubic~in~ches. The analysis was made in Glasgow. Hence it is probable that the quantity of carbonic acid gas originally contained in the gallon of this water, exceeded 14-3 cubic inches. This was the quan- tity necessary to keep 15-87 grains of carbonate of lime in solution. Of course it was necessarily present. 672 WATERS, (MINERAL) V. Pltkaithley, Airthrey, and Dunblane. These three watering-places in Scotland are situated at no great distance from the Ochil Hills, a beautiful range of mountains which adorn the southern part of Perthshire, and in the neighbour- hood of which some of the finest tracts of land in Scotland are situated. It is curious that all the three sets of springs rise in the new red sandstone formation, and in this respect resemble the waters of Cheltenham and Leamington. It is in this formation that the great deposits of common salt occur. It is in it, also, that the gypsum beds are situated, which constitute so abundant a deposit in Germany, though they are almost wanting in England. This makes the origin of these saline waters less remarkable than would otherwise be the case; for almost all the purging salts noticed in these waters are to be found in greater or smaller quantity mixed with common salt, both in the sea and in those beds which occur in the new red sandstone. Pitkaithley lies near the Earn, a little west of the spot where it discharges itself into the Tay, and distant about four miles from Perth, from the valley of which it is separated by the hill of Mon- crief. This mineral water has been longest known; and the locality being provided with suitable and genteel accommodations for visitors, it is better frequented perhaps than any other Scottish water- place. How long it has been ,in repute as a me- dicinal spring we do not know; but the first no- tice of it which we have seen was by Dr. Donald Monro, in the Philosophical Transactions for 1772, page 15. It appears from that notice that Pit- kaithley water was well known and much fre- quented as a mild purging water in the year 1770. Dr. Monro even attempted to determine its saline constituents ; but from the imperfect state of ana- lytical chemistry at that period, his results were unsatisfactory. It was analysed by Dr. Murray of Edinburgh about the year 1815, who found its saline contents in the imperial gallon as follows: Common salt..................128-67 grs. Chloride of calcium ............187-15 Sulphate of lime............... 8-64 Carbonate of lime.............. 4-80 329-26 Dunblane is situated at the western extremity of the Ochils, and not far distant from the Gram- pians. The saline springs were discovered in 1813, from the frequent resort of a flock of pi- geons to the ground were they break out. There are two different springs situated about half a mile north from Dunblane. Nothing has been done by the proprietor for the accommodation of visit- ors, and no houses have been erected near the spring; yet notwithstanding these discouraging circumstances, such is the celebrity which the water has acquired, and such the opinion enter- tained of its salutary properties, that many inva- lids repair to it every summer, being obliged to put up with such accommodations as they can procure in the village of Dunblane. If able, they walk every day to the springs; if too feeble for so long a walk, the water is regularly brought to their lodgings and used by them as a purgative. The water is saline, with 6ome bitterness. It is transparent and colourless, and destitute of smell as it issues from the ground. There are two springs ; the one situated a little to the north of the other, and the most northern is rather the strongest. The specific gravity of these waters, as determined by Dr. Murray, is as follows:— North spring......1-00475* South spring......1-00419 We have two analyses of this water. It was first analysed by Dr. Murray in 1814. In 1821 it was a second time subjected to analysis by Dr, Thomson of Glasgow. The following table «. hibits the saline constituents in the imperial gallon according to these analyses. 1. North spring. Murray. Common salt..................231-46 grs, Chloride of calcium............173-59 Sulphate of lime............... 33-75 Carbonate of lime.............. 4-82 Oxide of iron ................. 1-64 445-26 Thomson. Common salt..................320-96 grs. Chloride of calcium............174-36 Sulphate of lime............... 48-55 Chloride of magnesium......... 2-41 546-28 2. South spring. Murray. Common salt..................216-99 gro, Chloride of calcium............154-30 Sulphate of lime...............22-18 Carbonate of lime.............. 2-89 Oxide of iron..........i...... 1-45 397-81 Airthrey is situated at the bottom of one of the most westerly of the Ochil hills, about two miles north from Stirling, and commands a magnificent prospect of one of the richest districts of Scotland. The view to the west is bounded by the Gram- pians, which are seen to greater advantage from Stirling and its vicinity than from any other place, forming a vast amphitheatre equally remarkable for the boldness of the outline and Ihe beauty and height of the most prominent mountains. The Ochils bound the prospect on the north, beginning apparently where the Grampians recede from the view, and continuing without interruption to the east as far as the eye can reach. These moun- tains, though very steep on the south side, are mostly covered with wood or with grass, and pre- sent a back-ground at once lovely and magnificent, while they shelter the villages situated at their southern base so effectually that they have been always considered as the warmest spots in Scot- land, and resorted to accordingly by the consump- tive as a last resource. The Touch mountains on the southwest skirted with wood ; the numerous little hills that rise like castles from the carse of Stirling; the Forth flowing majestically through the level ground, and winding in so intricate a * Dr. Thomson found it 1001901. WATERS, (MINERAL) 673 manner between Stirling and Alloa, that the eye, even in the most favourable situations, cannot trace its course, and spreading out into an exten- sive frith, which may be followed without inter- ruption till it mingles with the eastern horizon— all these, and a thousand other beautiful, rich, and picturesque objects which it would be vain to at- tempt to particularize, render the view from Air- threy at once one of the most magnificent and beautiful that Great Britain has to boast of. The roads, during summer, are excellent in every di- rection. The rides both to the west, east, and south, possess numerous beauties to attract the attention of the man of taste ; and being the spots where many of the most eventful actions connect- ed with the history of Scotland were performed, they have claims upon our curiosity of no ordinary nature. Sir Robert Abercrombie, the proprietor of the wells, had formed a resolution to build a pump- room, and to erect suitable conveniences for the accommodation of the numerous visitors who an- nually resort to them; but he unfortunately died before he had time to put his plans in execution. His successor, Lord Abercrombie, has unfortun- ately imbibed a prejudice against the existence of a watering-place so near his park and dwelling- house. The consequence has been that no houses are allowed to be erected at the wells. The visitors are obliged to lodge at the bridge of Allan, a vil- lage about a mile and a half from the mineral spring; yet such is the beauty of the country, and such the opinion entertained of the salutary vir- tues of the Airthrey mineral waters, that during the greatest part of the summer every lodging- house is crowded, and many visitors are obliged to leave the place for want of accommodation. The mineral springs at Airthrey are six in number. They all contain the same saline consti- ents, but differ considerably from each other in their relative strength. They were analysed by Dr. Thomson of Glasgow in 1827, at the request of Sir Robert Abercrombie. The specific gravity of these springs at that time was as follows:— Sp. gr. No. 1, 1-00915 2, 1-00714 3, 1-00611 Sp- gr. No. 4, 1-00346 5, 1-00984 6, 1-00984 These springs are all transparent, and destitute of smell; their taste is saline and bitter, and they act as purgatives when drunk in sufficient quan- tity. The following table exhibits the saline con- tents in an imperial gallon of each, as determined by Dr. Thomson. No. 1. Common salt..................423-843 grs. Chloride of calcium............411-551 Sulphate of lime............... 50-578 Chloride of magnesium......... 6-075 892-047 No. 2. Common salt.................359-616 grs. Chloride of calcium............329-560 Vox.. IV. —85 3o Sulphate of lime............... 18-341 Chloride of magnesium......... 4.168 711-685 No. 3. Common salt.................263-948 grs. Chloride of calcium............185-655 Sulphate of lime............... 29-776 Chloride of magnesium......... 1-597 480-976 No. 4. Common salt..................135-792 gTS. Chloride of calcium............122-280 Sulphate of lime............... 9-798 Chloride of magnesium.......... 9-546 277.416 No. 5. Common salt.................513060 grs.. Chloride of calcium............253-349 Sulphate of lime............... 28-134 Chloride of magnesium.......... 13-713 808-256 No. 6. Common salt..................537-567 grs. Chloride of calcium............282-769 Sulphate of lime............... 26-084 Chloride of magnesium.......... 2-438 848-858 Airthrey water is nearly as strongly impreg- nated with salts as the waters of Cheltenham or Leamington; but the nature of the salts is differ- ent. The Airthrey springs contain a great quan- tity of chloride of calcium, which exists but spar- ingly in the Cheltenham and Leamington wells; while they are altogether destitute of the sulphate of soda, which constitutes the most important of the purgative salts in the wells of the two Eng- lish watering-places. There can be no doubt that the mineral waters of Pitkaithley, Dunblane, and Airthrey, are equally valuable with those of Chel- tenham and Leamington, and may be employed in the same kind of diseases. Pitkaithley is by far the weakest of the three; but this constitutes no valid objection against its use; for the purga- tive salts which constitute the principal ingredi- ents in these waters,—namely, common salt and chloride of calcium, require very considerable dilu- tion before they can be used internally with any advantage to the patient. VI. Innerleithen. This water, situated near the Tweed in the classic country of Scottish song, has of late years become rather a fashionable place of resort to the inhabitants of the south of Scotland. This, we believe, is chiefly owing to Sir Walter Scott's ro- mance of St. Roman's Well, the scene of which is understood to be Innerleithen. It was analysed by Dr. Fyfe of Edinburgh about ten years ago. There are two springs situated at a little distance from each other. Dr. Fyfe has not given the specific gravity of the water, nor any description of its characters, but the following table exhibits 674 WATERS, (MINERAL) the saline contents found by him in an imperial gallon of each spring. Strongest spring. Common salt.................150-712 grs. Chloride of calcium............ 91-320 Carbonate of magnesia ........ 49-107 291-139 Weakest spring. Common salt ................101-787 grs. Chloride of calcium............ 45-612 Carbonate of magnesia........ 25-447 172-846 The constituents of these springs are the same as those of Pitkaithley, Dunblane, and Airthrey, with the exception of carbonate of magnesia in- stead of chloride of magnesium and sulphate of lime. But the Innerleithen water is much weaker than the other three. It is probable that the car- bonate of magnesia found in it by Dr. Fyfe is in the state of bicarbonate when the springs issue from the ground. If this be the case, about 55-2 cubic inches of carbonic acid must ejist in the strongest spring, and about 28-6 cubic inches in the weakest. It is not unlikely, then, that Inner- leithen may be a slightly acidulous water; but this can be determined only on the spot. Innerleithen water will be found useful in the same kind of complaints for which saline waters in general are recommended. VII. Sea-water. As the ocean surrounds Great Britain, and as no part of the island is at any great distance from the sea, we may without impropriety con- sider sea-water as one of the saline waters of Great Britain. It is a favourite resort, especially for bathers, and is deservedly considered as bene- ficial to the health as any saline water whatever. Sea-water is transparent and colourless; it has a disagreeable bitter taste, and a specific gravity which varies from 1-0269 to 1-032. It has been often subjected to analysis, and its constituents vary somewhat in different places. The Mediter- ranean contains more salt than the Atlantic in the same latitude; the Baltic, the Black Sea, and the Caspian contain much less. The specific gravity of the sea-water surrounding Great Britain may be rated at 1-0285. The following table exhibits the constituents in the imperial gallon of it, ac- cording to the best analyses hitherto made. Common salt................1915-70 grs. Sulphate of soda.............. 335-50 Chloride of magnesium........ 371-06 Chloride of calcium........... 88-70 Sulphate of potash............ 36-00 Sulphate of lime, trace Sal ammoniac, trace 2746-96 Doubtless many other salts exist in sea-water, though in quantities too minute to be detected. When the sea-water on the west coast of Scot- land is sufficiently concentrated, distinct evidence may be obtained that it contains both bromide and iodide of sodium- The great constituent is com- mon salt or chloride of sodium, which constitutes about two-and-a-half per cent, of the weight of sea-water. When sea-water is introduced into the stomach, it acts as a purgative; but the administration of it is disagreeable. Common salt, when in a con. centrated solution, acts as an emetic, and was much employed in that way by the ancients; but as an emetic it has been long almost laid aside. It is chiefly as a bath that the use bf sea-water proves beneficial to the invalid. (See the article Bathisg.) The saline mineral waters hitherto enumerated constitute the most celebrated of those which exist in Great Britain. We think it needless to con- tinue the enumeration, because the constituents and the properties of the remaining saline springs approach very nearly to some one or other of those which have been given. This is our reason for leaving out Epsom, Gilsland, &c. But there are a few foreign saline waters which have ac- quired so much celebrity that they must be noticed. VIII. Seidlitz. Seidlitz is a village in Bohemia in the circle of Elnbogen, about nine miles from Prague. Bohe- mia abounds in mineral waters, and those of Seidlitz must have been remarked in all ages for the great bitterness of their taste. But they were neglected by the country-people till Hoffmann gave them celebrity about the year 1721. The springs of Seidlitz are transparent and colourless, destitute of smell, and distinguished by a bitter and saline taste; their temperature is 59°, and their specific gravity, as determined by Hoffmann, 1-016. Like other saline waters they are purgative, and they owe their purgative qua- lities chiefly to the presence of a notable quantity of sulphate of magnesia. Hence that salt in Germany was frequently termed Seidlitz salt, just as in England it was called Epsom salt. We have no later analysis of this water than that of Bergman. Patissier gives the following as the constituents of an imperial gallon of this water :— Resinous matter............. 5.787 grs. Carbonate of magnesia......... 9-645 Sulphate of magnesia.........2176-200 Sulphate of soda............. 53-161 Sulphate of lime............. 40-700 Carbonate of lime............ 14-971 2300464 Carbonic acid..........19-507 cubic inches. Seidlitz is much frequented by invalids, espe- cially those who, from the delicacy of iheir con- stitutions, cannot be subjected, though they re- quire evacuations, to a course of more energetic medicines. IX. Seydschutz. The town of Seydschutz is situated at a little distance from Seidlitz, and the mineral waters which belong to it possess the same characters, and are considered by Hoffmann as originating from the same source, and as containing the same saline contents, as the former. They are of course applied to the same purposes, and require no particular discussion. [The saline waters of Balston and Saratoga^jn New York, have been subjected to analysis, and have yielded the following constituents:— WATERS, (MINERAL) 675 Balston Spa, San Souci Spring: in a wine gallon, according to Dr. Steel :— Chloride of sodium ............143-733 grs. Bicarbonate of soda............ 12-66 --------- of magnesia........ 39-1 Carbonate of lime.............43-407 Carbonate of iron.............. 5.9*5 Iodide of sodium.............. 1-3 Silica........................ 1 Saratoga. — 1. Iodine Spring: in a wine gallon, according to Prof. Emmons :— Gaseous Contents. Carbonic acid.............336 cubic inches. Atmospheric air........... 4 340 Solid Contents. Chloride of sodium..............187 grs. Carbonate of magnesia........... 75 Carbonate of lime............... 26 --------- of soda............... 2 --------- of iron................ 1 Iodine......................... 3-5 294-5 2. Pavilion Spring.- in a wine gallon, accord- ing to Dr. Chilton :— Gaseous Contents. Carbonic acid..........359-05 cubic inches. Atmospheric air........ 5-03 364-08 Solid Contents. Chloride of sodium............243-620 grs. Carbonate of magnesia......... 84-265 ---------of lime............. 41-600 ---------of soda............. 12-800 --------- of iron............. 5-452 Iodide of sodium or iodine...... 3-600 Silica and alumina............. 1-570 Bromide of potassium, a trace. 392-907 3. Congress Spring: in a wine gallon, ac- cording to Dr. Steel:— Gaseous Contents. Carbonic acid.............311 cubic inches. Atmospheric air........... 8 318 Solid Contents. Chloride of sodium.....•......385 grs. Iodide of sodium.............. 3-5 Bicarbonate of soda............ 8-982 ---------- of magnesia........ 95-788 Carbonate of lime............. 98.098 ---------of iron............. 5.075 Silica....................... 1.5 Bromide of potassium, a trace. 597-943] II.—Of Chalybeate Mineral Waters. Chalybeate waters are easily recognised by their inky taste, and by the property which they have of striking a black or a purple when mixed with the infusion of nutgalls or an infusion of tea. They are by far the most abundant of all the classes of mineral waters, doubtless because iron is scattered more profusely through the mineral kingdom than any other metal. These kinds of springs are particularly abundant in coal coun- tries, on account of the pyrites balls which so commonly accompany that mineral, and which mostly undergo spontaneous decomposition when exposed to the air, and thus give origin to the formation of sulphate of iron.* Iron in mineral waters is always in the state of oxide, most com- monly, though not always, in the state of prot- oxide. It is held in solution in the water most frequently by carbonic acid, but sometimes also by sulphuric acid. When the water, by simple ex- posure to the air or by being heated, is found to deposit the whole of the iron which it contains, we may be sure that it has been held in solution by carbonic acid. The sulphate of iron is not decom- posed completely either by exposure to the air or by boiling; but the colour of the water impreg- nated with it becomes gradually yellow or even red, if the quantity held in solution be consider- able. It is but rarely that chalybeates contain a great quantity of salts in solution ; though there are examples, which will be given afterwards, of waters containing a very great proportion of sul- phate of iron, sulphate of alumina, and persul- phate of iron. Mineral waters impregnated with iron, possess considerable activity as medicines. They are de- cidedly tonics. A course of them has a tendency to render all the functions more active, especially digestion, circulation, and absorption. They gene- rally produce a feeling of heat upon the surface of the body, and give an activity and energy to the patient which is sometimes very remarkable. Chalybeates have the tendency to render the stools of those who drink them black. This is of no consequence in itself; but the patient ought to be warned of it beforehand, because it is apt to pro- duce alarm. When a mineral water has an inky taste, when the infusion of nutgalls occasions, if mixed with it, a purple cloud, which gradually passes into bluish-black, and when a solution of prussiate of potash dropped into it strikes a blue colour, we may be certain that it contains iron. I. Tunbridge. Tunbridge Wells, the most celebrated of all the chalybeate waters in England, is situated in Kent, about thirty-six miles south of London, a few miles distant from the village of Tunbridge. It is placed in rather a barren part of the country ; but being well wooded, and the surface being hilly, it possesses considerable beauty. The chalybeate rises from the ferruginous sand, which constitutes the lowest of the three beds into which the forma- tion of green sand lying immediately under the chalk is divided. It is well known that the coun- ties of Kent, Sussex, and a portion of Surrey, are * One of the places most remarkable for these pyrites balls is slate-clay, or shale, which alternates with the only coal-bed wrought at Hurlet, about five miles south- west of Glasgow. The pyrites balls undergo sponta- neous decomposition when exposed to the air, and have been employed about eighty years in the manufacture of copperas. They are composed of 4 atoms bisulphurate of iron..........30 1 atom sulphuret of iron.............. 5-5 355 676 WATERS, (MINERAL) nearly surrounded with chalk-hills, and that the central part of these counties constitutes a valley, from which the chalk (supposing it originally de- posited) has been removed, and consequently com- posed of the formations immediately under the chalk. How long the mineral waters of Tunbridge- Wells have been a fashionable place of resort we do not know; but they are mentioned by the old- est of our writers on mineral waters, and in such terms that it is evident they had been known long before their time. Many chalybeates exist in this place, but the only one in use rises into a large marble basin ; the water overflows through an aperture into a channel connected with a chalybeate cold bath, depositing in its progress a reddish-brown sedi- ment. The temperature of the water as it issues from the spring is 50°, which is the mean temperature of that part of Kent, showing that the spring issues from a considerable depth below the sur- face. The supply is not great, and is in some measure dependent on the weather, the smallest supply being about a quart, and the greatest about two gallons and a half per minute, according to the measurement of Sir Charles Scudamore. Its specific gravity, as determined by Dr. Babington in 1792, was 1-0014; but in 1816 it was, ac- cording to Sir Charles Scudamore, only 1-0007 at the temperature of 50°.* The fresh water is perfectly transparent, and does not give out air-bubbles. It has a smell dis- tinctly chalybeate. Its taste is also strongly marked; but it is neither acidulous nor saline. It has an agreeable freshness, and is by no means unpalata- ble. When heated to 68°, it gives out a few air- bubbles, and in about an hour a delicate white pellicle appears on its surface, which gradually thickens and becomes shining, and by degrees an ochrey precipitate falls, and the water loses its cha- lybeate taste. The following table exhibits the constituents of an imperial gallon of Tunbridge-wells water, ac- cording to the analysis of Sir Charles Scudamore: Common salt................... 1-5 grs. Sulphate of soda................1-768 Chloride of calcium..............1-848 Chloride of magnesium...........0-348 Carbonate of lime...............0-328 Protoxide of iron................2-748 Manganese, silica, &c.............0-528 9-068 Carbonic acid gas..........9-66 cubic in«hes. Oxygen gas..............0-60 Azotic acid..............5-70 15-96 The weight of 9-66 cubic inches of carbonic acid gas is 4-585 grains. Now, 2-748 grains of protoxide of iron to keep them in solution would require 3-358 grains, and 0-328 grains of carbon- ate of lime requires to keep it in solution 0-144 grains of carbonic acid. Thus, the whole carbonic * The specific gravity of the water brought Mito the village of Tunbridge-Wells for domestic purposes is 1-00023 at 60°. acid necessary to keep the protoxide of iron and the lime in solution, amounts to 3-502 grains. So that there is a surplus of one grain of carbonic acid. From the preceding analysis it is evident that the only constituent to which Tunbridge Wells owes its activity as a medicine, is the carbonate of iron. The other saline constituents exist in such minute quantity that they must be quite in- significant in a medical point of view. The quan- tity of iron is also small, not exceeding 0-14 grains in the usual dose of half a wine pint. Yet it has a decidedly stimulant effect, and has been frequent- ly taken with great benefit, especially in dyspepsia, chlorosis, uterine debility, and similar affections. It usually occasions constipation of the bowels, and requires, therefore, to be accompanied by the use of some laxative medicine. Several of the mineral wells both at Leaming- ton and Cheltenham contain more carbonate of iron than the water of Tunbridge Wells; and as they contain at the same time a notable quantity of purging salts, they are perhaps better adapted for internal use. The analysis of these waters has been already given while treating of saline mineral waters. , Many other chalybeates occur in England; but it seems unnecessary to give a description of these, as they are but little employed, and as their nature approaches very nearly to that of Tunbridge. II. Hartfell Spa. This mineral water springs from the base of Hartfell, a mountain distant about five miles from Moffat, and the highest in the south of Scotland, its summit being elevated about three thousand three hundred feet above the level of the sea. The spring rises at the bottom of a deep and narrow ravine, the sides of which are laid bare to the top, so as to exhibit to the view of the geologist the whole structure of the mountain; the country is transition, and the mineral water originates in a species of alum slate, a black soft slaty rock, con- taining abundance of iron pyrites. Hence, doubt- less, the origin of the salts with which the spring is impregnated. The Hartfell Spa was discovered in 1748, by John Williamson, a farmer in the neighbourhood, and a very eccentric character. He considered it as unlawful to destroy animals for the sake of food, and on that account fed entirely on vegetables. He died in 1769, and was buried in the old church- yard of Moffat. The Hartfell Spa water is transparent and free from smell. Its taste is sweetish and astringent, and its specific gravity, as determined by Dr. Thomson, 1-0007. This water was subjected to a chemical analysis by Dr. Garnet, in the year 1797, the result of whose experiment is, that the imperial gallon of it con- tains the following salts:— Sulphate of iron.................100-8 grs. Sulphate of alumina.............. 14-4 115-2 Azotic gas..................6 cubic inches It was subjected to a new analysis by Dr. Thom- son, of Glasgow, about the year 1825. He had only a wine-bottle full of the water to examine, WATERS, (MINERAL) 677 and could not succeeed in detecting in it any com- mon salt, or any alumina ; though Dr. Garnet states sulphate of alumina as one of the constitu- ents. The water contains sulphuric acid and chlo- rine in very sensible quantities, and exhibits abun- dant evidence of the presence of protoxide of iron and lime. The result of the examination of Dr. Thomson is, that the imperial gallon of this water contains,— Protosulphate of iron............36-747 grs. Chloride of calcium.............33-098 69-845 both of these salts being considered as anhydrous. Had a gallon of the water been concentrated down to a tenth or twentieth of its bulk, it is not unlikely that common salt might have been discovered. But the quantity is certainly small, since it cannot be discovered in the unconcentrated water. The apparent excess of sulphate of iron in Dr. Garnet's analysis, is partly owing to his giving his salts in a crystallized state ; 36-747 grains of anhydrous sulphate are equivalent to 67-2 grains of crystal- lized sulphate. As Dr. Garnet has neglected to state the specific gravity of this water, we have no means of judging whether it has become weaker since 1797. This water has been found of considerable ser- vice as an astringent in all cases where there is relaxation of the solids, and indeed in every dis- ease connected with general debility. The dose of it is more limited than that of most other mineral springs. It is proper to begin at first with a very small quantity, and it can scarcely ever be increased to more than an English wine- pint in the course of the day ; but this quantity may be continued for a considerable time, not only without injury, but with decided benefit. III. Strong Moffat Chalybeate. This new chalybeate seems to have been disco- vered about the year 1825. It is said to run down the face of the Hartfell mountain in considerable quantity. It has a red colour and a harsh astrin- gent taste. It reddens vegetable blues. Its spe- cific gravity, as determined by Dr. Thomson, is 1-00965. Of this water a specimen, amounting only to a wine-bottle full, was sent to Dr. Thomson of Glasgow in 1825, who subjected it to analysis. The saline contents of the imperial gallon, accord- ing to this analysis, are as follows :— Sesquisulphated peroxide of iron 591-025 grs. Sulphate of alumina...........112-726 Uncombined sulphuric acid...... 5-202 708-953 This water is much stronger than the preced- ing, and contains a notable quantity of sulphate of alumina. It is too strong to be administered internally without dilution, but as an external ap- plication it answers well in many cases as an astringent. IV. Vicar's Brig Chalybeate. This extraordinary chalybeate was discovered a few years ago. It occurs in Perthshire on the south side of the Ochil-hills, about two miles east from Dollor, and near Blarngone. It rises in a 3o* coal country, and doubtless originates from the decomposition of pyrites balls in the slate clay, which usually accompanies the coal beds. It was accidentally observed running in various little streams near the road. Specimens of it were sent to Dr. Thomson of Glasgow, who subjected it to a chemical analysis. There are different sources of this water, and the probability is that the com- position of the water varies in each, though all of them are uncommonly strong. The specimen sent to Dr. Thomson was trans- parent, but had a red colour and an exceedingly astringent and harsh taste. Its specific gravity was 1-0100. The saline constituents in the im- perial gallon of this water were found to be — Common salt................. 5-87 grs. Sulphate of soda.............. 170-99 Sulphate of alumina........... 953-18 Bisulphated peroxide of iron .... 1753-10 Sulphated peroxide of iron...... 141-55 Silica....................... 58-70 3083-39 Another specimen of water from Vicar's Brig was found by Mr. Connel to have a specific gra- vity of 1-04893. He subjected it to analysis, and found the saline contents of the imperial gallon to be — Sulphated protoxide and perox- v „.„„ R. ide of iron..............5 Sulphate of alumina........... 580-64 Sulphate of magnesia.......... 277-20 Sulphate of lime.............. 43-68 Common salt and chloride of ~i _ .„ potassium...............5 3941-76 It is obvious, both from the specific gravity and the saline constituents of these two specimens, that they must originate from different sources. Dr. Thomson examined the sample of the water sent to him, in order if possible to detect lime and magnesia in it, but he could discover none; while the sulphate of soda, which exists in a notable quantity in the mineral water examined by Dr. Thomson, is wanting in the water which was analysed by Mr. Connel. Vicar's Brig water is, perhaps, the strongest chalybeate in existence; at least it is the strongest which we ever met with. It is similar in its na- ture and properties to the strong Moffat chalybe- ate, but more than four times as strong. This water might be employed with advantage exter- nally, and indeed is in high reputation with the country people as a remedy for cuts, and even bruises. It could scarcely be taken into the sto- mach unless it were much diluted. In that way it might be employed for the same purposes as the weaker Moffat chalybeate. We are of opinion that when iron is used as a medicine, the best possible form is that of protox- ide. In this state it exists in all those chalybeates in which the iron is held in solution by carbonic acid. In the strong Moffat chalybeate, and in Vicar's Brig mineral water, the iron is in the state of peroxide. We have some reasons for believing that in the tincture of muriate of iron, which is so 678 WATERS, (MINERAL) powerful a remedy in ischuria, the iron is in the state of peroxide, or at least of perchloride, which may be considered as equivalent to the peroxide. It might therefore, perhaps, be worth while to try whether the strong Moffat chalybeate and Vicar's Brig water, if it were mixed with alcohol, might not be employed with advantage as a cure for ischuria. The chalybeates which we have now specified may be considered as exhibiting a pretty fair spe- cimen of all the different varieties of these waters which occur in such great abundance' in different parts of Great Britain; for, so far as we have ob- served, the iron in chalybeates is either in the state of protoxide or peroxide. When in the state of peroxide, we believe it is always held in solution by sulphuric acid ; but when in the state of prot- oxide, it may be held in solution either by car- bonic acid, as in the water of Tunbridge Wells, or by sulphuric acid, as in the Hartfell Spa at Moffat. There are some chalybeate waters on the continent which have acquired so much celebrity that we think it right to notice them. V. Spa Chalybeate. Spa is a village situated in that mountainous tract of Belgium which constitutes a part of the forest of Ardennes. It is about six leagues from Liege, and seventy-five from Paris. The town is situated in a kind of amphitheatre formed by two mountains. It is well built, and crowded annually with the best company in consequence of the ce- lebrity of its mineral waters. The wells are seven in number, and are all characterized by holding a quantity of protoxide of iron in solution. The solvent of the iron is carbonic acid gas, of which they contain so much that they might without impropriety be placed among the acidulous mineral waters. But as they probably owe much of their value to the iron which they contain, we have thought it better to describe them here. The fashionable time for visiting Spa is from May to October. The springs are very nume- rous ; but the most celebrated are the following seven:—the Pouhon, the Geronstere, the Sauve- niere, the Groesbeck, the two Tonnelets, and the Watroz. The Pouhon, which is the most celebrated and the most frequented, rises in the middle of the town from a rock of clay state. In cold dry weather it is transparent and colourless. When first taken out of the well, it scarcely sparkles ; but it emits air-bubbles when poured from one vessel to another. Its taste is acidulous and inky, and, like the water of Tunbridge Wells, it gra- dually lets fall its iron when left exposed to the air. Its specific gravity, according to Bergman, is 1-0010. In 1816 it was analysed by Dr. God- den Jones: according to his analysis, an imperial gallon of this spring contains :— Sulphate of soda............... 1-188 grs. Common salt.................. 1-392 Carbonate of soda.............. 2-700 Carbonate of lime..............11-848 Carbonate of magnesia.......... 1-260 Protoxide of iron............... 6-288 Silica......................... 2-712 Alumina......................... 0-348 27-736 Carbonic acid gas, 314-4 cubic inches. As the imperial gallon contains 277-274 cubic inches, it is evident that the Pouhon spring con- tains 1-13 its volume of carbonic acid. This is rather a larger quantity than water without artifi. cial pressure can dissolve; but the difference is easily accounted for by the quantity of carbonate of lime, carbonate of magnesia, and oxide of iron, which it holds in solution. The Geronstere is the most celebrated fountain at Spa after the Pouhon. It lies about a mile from the town, on the side of a mountain and in the middle of a wood. The water rises in a cir- cular pit about three feet in diameter, and very shallow.- The constituents of the imperial gallon of this water, according to the analysis of Jones, are as follows:— Sulphate of soda................0-744 grs. Common salt...................0-768 Carbonate of soda...............1-716 Carbonate of lime...............6-240 Carbonate of magnesia...........1-260 Protoxide of iron................1008 Silica..........................1-680 Alumina.......................0-228 13-644 Carbonic acid gas, 201-6 cubic inches. This water has been stated to contain a little sulphuretted hydrogen gas; but the presence of this gas has not been confirmed by the analysis of Jones. The Sauveniere is about a mile and a half from Spa, and springs from the side of the same moun- tain as the Geronstere. It is situated near the great road to Malmedy, in the midst of a wild thicket of trees. The constituents of an imperial gallon of this water, as determined by Jones, are as follows:— Sulphate of soda.................0.06 grs. Common salt....................0-30 Carbonate of soda................0-72 Carbonate of lime................4-20 Carbonate of magnesia............0-72 Protoxide of iron.................2-52 Silica..........................0-48 Alumina........................0-12 9-12 Carbonic acid gas, 289-2 cubic inches. Groesbeck bears considerable resemblance to the water of the Sauveniere. Its taste is sharp and agreeable, and it contains less iron than any of the preceding springs. The constituents of an imperial gallon of it, as determined by Jones, are as follows :— Sulphate of soda.................006 grs Common salt....................0-18 Carbonate of soda................0-36 Carbonate of lime...............2-88 Carbonate of magnesia............0-24 Protoxide of iron.................1-86 Silica..........................0-72 Alumina........................0-12 6-42 Carbonic acid gas, 318 cubic inches. WATERS, (MINERAL) 679 This spring contains more carbonic acid than any of the preceding, and being less impregnated with iron, it approaches more nearly to a simple saline spring. The fountains of Tonnelet are two in number. They both yield a great deal of water, and give out a slight smell of sulphuretted hydrogen gas. The taste of the water is sharp and agreeable, and less ferruginous than most of the other springs. The constituents of the imperial gallon of these two springs, according to the analysis of Godden Jones, are as follows:— 1. Tonnelet spring. Sulphate of soda.................0-07 grs. Common salt....................0-18 Carbonate of soda................0-24 Carbonate of lime................1-32 Carbonate of magnesia - ~...........0-36 Protoxide of iron.................3-34 Silica..........................0-72 Alumina, a trace. 6-13 Carbonic acid gas, 336 cubic inches. This is the spring which is most impregnated with carbonic acid of all those that occur at Spa. 2. Tonnelet spring. Sulphate of soda, trace. Common salt, trace. Carbonate of soda................0-12 grs. Carbonate of lime................1-08 Carbonate of magnesia............0-24 Protoxide of iron................1-80 Silica..........................0.78 Alumina, trace. ♦ 4-02 Carbonic acid gas, 314-4 cubic inches. The Watroz spring furnishes but little water ; its taste is decidedly chalybeate; its temperature is various, and it contains but little gas compared with the other springs. The constituents in the imperial gallon, as determined by Jones, are as follows:— Sulphate of soda, trace. Common salt....................0-24 grs. Carbonate of soda................0-12 Carbonate of lime................1-68 Carbonate of magnesia............2-28 Protoxide of iron.................3-12 Silica..........................1-08 Alumina........................0-72 9-24 The proportion of carbonic acid gas has not been determined, but it is small. The use of the Spa waters is said to produce some degree of vertigo, and a kind of intoxication, which continues about half an hour, and is very similar to that produced by spirituous liquors. This effect is doubtless owing to the carbonic acid gas with which these waters are impregnated. They have a decidedly stimulating property, and may probably promote all the secretions; but their most direct determination is to the kidneys and skin. They are observed to quench thirst better than common water, especially in slight feverish complaints. In short, all the remarks made upon Tunbridge Wells water apply to them in a greater degree, because they contain a greater quantity of iron, and the carbonic acid and carbonate of soda which they contain add both to their agreeable taste and their medicinal properties. VI. Passy Chalybeate. Passy is a village near Paris, on the right bank of the Seine, and celebrated for its beautiful situ- ation in the neighbourhood of the Bois de Bou- logne. There are different mineral springs, which have been divided into two sets, the old and the new. The old are formed of two springs, which rise very near each other. The new waters are at a small distance from the old, and consist of three springs, which are enclosed in a building. The old springs are limpid, and have a very weak ferruginous taste; the taste of the new is much more decidedly inky and astringent. When these waters are left exposed to the air in an open ves- sel, they deposit an ochreous sediment, showing that the iron in them is partly held in solution by carbonic acid. These waters have been often analysed. The imperial gallon of the new springs, according to the analysis of Deyeux, contains the following constituents:— Sulphate of lime...............200 grs. Sulphate of iron............... 79-84 Sulphate of magnesia...........104-63 Common salt.................. 30-55 Alum........................ 34-74 Carbonate of iron.......... 3-70 Bituminous matter, trace. 453-46 The carbonic acid gas amounted only to 1-955 cubic inch. This water approaches somewhat to that of the Hartfell spa, only its ferruginous impregnation is not so strong. It differs also by the sulphate of lime and sulphate of magnesia, the last of which may in some measure serve to counteract the astringent tendency of the sulphate of iron. The quantity of carbonate of iron is so small, that, considering the sulphate present, it cannot have great effect upon the patient. VII. Bourbon 1'Archambault Chalybeate. Bourbon 1'Archambault is a small town in the department of the Allier in France, about six leagues west from Moulins. It lies in a valley surrounded by four hills. The waters are hot, and appear to have been frequented during the time of the Romans. Gaston d'Orleans, brother of Louis XIII., improved the baths, and various ameliorations have been made since, which render these waters the most convenient as bathing-places of any in France. The waters rise in the middle of the town, and emit a noise resembling that of boiling. This noise is owing to the rapid disengagement of gas. These waters have a slight smell of sulphuretted hydrogen.^ The taste is slight and not easily de- scribed. The temperature of the water as it issues from the earth is 144°; but it cools as it flows. In the basin which serves for the common use of the inhabitants of the town the temperature is 131°. In the basin for the use of the poor it varies from 100° to 120°. It is said that this 680 WATERS, (MINERAL) water, notwithstanding its heat, is not the least disagreeable when taken into the mouth, nor does it injure the petals of the most delicate rose. The best analysis of these waters has been made by M. Faye. The saline constituents in the im- perial gallon, according to his determination, are as follows :— Chloride of calcium............12-336 grs. Chloride of magnesium........ 7-716 Common salt................. 28-550 Sulphate of soda.............. 10-026 Sulphate of magnesia..........14-290 Sulphate of lime..............10-803 Carbonate of iron.............. 14-290 Silica........................ 5031 103-042 Carbonic acid gas 158-50 cubic inches. Sulphuretted hydrogen gas, a trace. Vegetable soap, a trace. This mineral water contains a greater quantity of iron than either Spa or Tunbridge Wells water; but its impregnation of carbonic acid gas is inferior to that of the Spa Wells, though it greatly exceeds that of Tunbridge Wells. If to this we add the temperature of the waters of Bourbon 1'Archam- bault, we must admit that they constitute a very valuable medicine. When used as a bath, pro- bably they derive their chief value from their tem- perature. When taken into the stomach, doubt- less the carbonate of iron and the carbonic acid impregnation give them considerable efficacy as a chalybeate. VIII. Renncs Chalybeate. The mineral waters of Rennes (called formerly the waters of Montferrand) are attached to a small village called Les Bains, situated in a narrow val- ley about seven leagues south from Corcassons, in the south-west of France, not very far from the Pyrenees. As a watering-place, it appears to have been frequented in the time of the Romans. The mineral springs are five in number, three of which are hot and two cold: these are— 1. Bain de la Reine, the least hot of the warm springs, is situated on the left bank of the Salz, about 500 paces from the village. The waters rise directly from the rock, and are received into a large covered basin, from which they are conducted by pipes into the various baths, erected for the use of the invalids. The temperature of this water is 89° 5' of Fahrenheit. 2. Bain doux or les Ladres. The spring to which this name is given rises from the same level as the Allot. It is received into three large ba- sins ; one destined for women, and the two others for men. Very recently separate bathing-places have been established. The temperature of this spring is 90° 5'. 3. Bain Fort is situated in the middle of the village in an ancient inn, which has been lately restored by MM. de Fleury. The water rises from the level of the river Salz, and is received into a small basin. In this place a vapour-bath has been established. The temperature of the Bain Fort is about 106°. 4. Source du Cercle is situated about 300 yards above the Salz. It rises from below a huge rock, and winds its way into a reservoir, in which it does not remain. Both this spring and the fol- lowing one are cold, or have merely the mean temperature of that part of the earth where they rise. 5. Source du Pont lies about 100 yards north from the Bain de la Reine. It runs above the Salz and upon the left bank of that river. This i6 the spring most frequently used by the invalids who frequent the place. These five springs are transparent and colour- less, and never freeze. They are hottest during summer, and coldest during winter. The water of the Cercle has a strong ferruginous odour; the Bain doux exhales an hepatic smell, which is most sensible when the basins are emptied. The other three have no smell. The water of the Cercle, when exposed to the air, lets fall some carbonate of lime. They have all a slightly bit- ter taste. The saline constituents in the imperial gallon of each of these waters are, according to the ana- lysis of MM. Julier and Rebouhl, as follows:— 1. Bain de la Reine. ■ Chloride of magnesium..........53-707 grs. Chloride of calcium.............23-150 Common salt.........,........55-560 Sulphate of lime...............67-133 Carbonate of magnesia..........41-669 Carbonate of lime..............18-520 Carbonate of iron..............52-243 311-982 2. Bain doux. Chloride of calcium............106-49 grs. Chloride of magnesium.......... 46-30 Common salt........%.........37-04 Sulphate of lime............... 39-35 Carbonate of lime.............. 10-19 Carbonate of magnesia.......... 3-50 Carbonate of iron.............. 13-89 Silica........................ 0-93 Sulphuretted hydrogen gas, a trace. 257-69 3. Bain Fort. Chloride of magnesium..........123-15 grs. Chloride of calcium............. 23-15 Common salt.................. 11-57 Sulphate of lime............... 50-93 Carbonate of magnesia........... 43-98 Carbonate of lime.............. 37-97 Carbonate of iron.............. 20-83 311-58 Carbonic acid 364$ cubic inches. 4. Source du Cercle. Chloride of magnesium.......... 23-15 grs. Chloride of calcium............. 11-57 Common salt................... 32-41 Sulphate of magnesia........... 16-21 Sulphate of lime............... 20-83 Sulphated peroxide of iron........ 9-26 Carbonate of magnesium......... 13-89 Carbonate of lime............... 13-89 Carbonate of iron............... 13-89 155-10 WATERS, 5. Source du Pont. Chloride of calcium............. 24-54 grs Chloride of sodium............. 12-04 Sulphate of magnesia............ 18-52 Sulphate of soda............... 9-26 Carbonate of magnesia........... 18-52 Carbonate of lime............... 6-94 Carbonate of iron............... 11-57 101-39 The first of these mineral springs is used as a bath in nervous affections, in oedema following acute diseases, in glandular obstructions, chlorosis, and in calculous diseases when they have resisted the Bain Doux. It probably owes its value as a bath to its temperature. The Bain Doux has received its name from a kind of oily feeling which it communicates to those who are immersed in it. It is said to have the property of preserving the skin soft and flexi- ble. It is employed as a bath in herpetic erup- tions, and also in gout. Its efficacy in the former of these diseases is probably owing to the sulphu- retted hydrogen which it contains, and in the lat- ter to its temperature. The waters of the Bain Fort are used in chro- nic rheumatism, paralysis, and chronic ulcers. Undoubtedly its value as a bath in these diseases is owing to its temperature. The waters of the Cercle have some resem- blance to those of Spa, except that they are cold. They are chiefly used as a drink, and produce the effects of chalybeate waters in general. The waters of the Pont, besides being chaly- beates, are slightly purgative in consequence of the salts with which they are impregnated. Hence they are used in cases of indigestion. It is cus- tomary to drink this water for two or three days before beginning to use the waters of the Cercle. IX. Tongres Chalybeate. Tongres is a town situated on an eminence near the little river Geer, and about a league from Maestricht in the Low Countries. There are se- veral mineral springs in the neighbourhood of this town; but two of these are chiefly distinguished. The first, called the Fountain of St. Giles, and known to the inhabitants by the name of Foun- tain of Pliny, is situated in a valley surrounded on all sides by low sand-hills. The spring is co- pious, and is received into a basin composed of large limestones. It is limpid and colourless, has a chalybeate taste, and its temperature is 59°. It deposits on standing some ochre, showing that it contains carbonate of iron. The second fountain is about eight hundred yards distant from the first, just on the north side of the little hill of Fer. The water of this foun- tain is always muddy. There is an iridescent pellicle on the surface, and it has a stronger inky taste than the other fountain. Its temperature is 61|°. The saline constituents in the imperial gallon of these fountains, according to the analysis of M. Passe, are as follows:— First Fountain. Carbonate of iron............... 7-957 grs. Carbonate of magnesia..........11-991 19-948 Vol. IV. —86 (MINERAL) 681 Second Fountain. Carbonate of iron...............10-254 grs. Carbonate of magnesia...........10-624 20-878 The presence of iron in water is easily known by the inky taste and by the property which such water has of striking a purple colour with the infusion of nutgalls, or with an infusion of tea. Prussiate of potash strikes a blue, and sulpho- cyanate of potash strikes a red with peroxide of iron, but produces no sensible action on the prot- oxide. By means of this reagent we can easily determine whether the iron be in the state of protoxide, or whether the water does not also con- tain peroxide. If the whole iron precipitates when the water is exposed to the air, or when it is boiled, we may be sure that it is in the state of carbonate, and therefore all protoxide. If it only precipitates partially on exposure to the air, part of it is in the state of carbonate and part of it in the state of sulphate. To determine the quantity of iron in a chaly- beate, we may have recourse to various processes. One of the easiest is to mix a determinate quan- tity of the water (previously concentrated if ne- cessary) with sulphohydrate of ammonia. The iron precipitates in the state of sulphuret, and its quantity might be determined by drying and weighing that sulphuret. For the iron constitutes 7-llths of the weight of the sulphuret, supposing it pure. But it will be more accurate to dissolve the sulphuret in nitra-muriatic acid, and after neutralizing the solution, to throw down the iron by caustic ammonia; when washed and dried, it is in the state of peroxide. Let its weight be a. To reduce it to protoxide, multiply by 4-5 and divide by 5, or the weight of protoxide of iron is Ty*. If the mineral water contains no other consti- tuent which can be thrown down by caustic am- monia but iron, the easiest method of proceeding is to peroxidize the iron by heating a certain por- tion of the concentrated water with nitric acid. Let the liquid be then neutralized, and the per- oxide of iron precipitated by ammonia. Its quan- tity in the state of peroxide may be estimated as above. Should alumina be also present, as is the case with Moffat Strong Chalybeate and with Vicar Brig water, we must digest the recently precipitated peroxide of iron with a sufficient quantity of caustic potash ley to dissolve out the alumina. The residual peroxide of iron is to be separated, washed, and estimated as above directed. Saturate the potash ley with muriatic acid, and throw down the alumina by means of carbonate of ammonia. When washed, ignited, and weighed, if we deduct its weight from that of the mixture of peroxide of iron and alumina at first thrown down, we have the weight of the peroxide of iron which the given quantity of the mineral water contains. [The most celebrated chalybeates in the United States are Balston, Saratoga, Bedford, and Brandy wine. Anderson's spring, Bedford, has been found to 682 WATERS, (MINERAL) yield on analysis the following constituents in a wine gallon. Carbonic acid 74 cubic inches. Solid Contents. Sulphate of magnesia..............80 grs. Sulphate of lime .................14-5 Chloride of sodium ...............10 Chloride of calcium............... 3 Carbonate of iron................. 5 Carbonate of lime................ 8 120-5] III-—Of Sulphureous Mineral Waters. Sulphureous mineral waters have been so named from the sulphuretted hydrogen gas with which they are impregnated. They are easily distin- guished by the peculiar smell which they exhale, similar in some respects to the smell of rotten eggs ; by the property which they have of blacken- ing silver and of giving a dark-coloured precipitate when mixed with a solution of acetate of lead. The greater number of sulphureous waters have a kind of unctuous feel, and give a softness to the skin. They lose their peculiar smell and charac- teristic properties by exposure to the air, or by being heated in an open vessel. All the sulphure- ous mineral waters in Great Britain are cold; but the greater number of those that occur on the Continent are hot. Sulphureous mineral waters have been always highly esteemed on account of their medicinal pro- perties. When employed as a bath, they are particularly efficacious in herpetic eruptions on the skin. Indeed, in diseases of the skin in general, and in cases of old, callous, fistulous ulcers, which have resisted medical treatment, they have been frequently found of immense benefit. When taken internally, they are found to be stimulating. They have been often recommended as useful in cases of want of appetite and heart- burn. They have been considered as highly valuable in cases of amenorrhoea, and in diseases of the breast. They have been reckoned capable of even dissipating those tubercles in the lungs which are the usual forerunners of consump- tion, and many cases are upon record in which they have been of undoubted utility in the early stages of that deplorable disease. The use of sulphureous waters is considered as injurious to those who labour under plethora, or are affected with inflammatory fever. The most celebrated of the sulphureous waters in England is Harrowgate in Yorkshire. In Scot- land two of these waters have been resorted to by invalids for a considerable time; these are Moffat and Strathpeffer, the former in the south and the latter in the north of Scotland. A new sulphure- ous water has been lately discovered near Rothesay in the Isle of Bute. We shall, in the first place, give a short account of these four mineral waters, comprehending the principal sulphureous springs in Great Britain. We shall then notice a few of the most celebrated sulphureous waters on the continent. I. Harrowgate Water. Harrowgate lies in Yorkshire near the south-west extremity of an extensive plain, about twenty miles from York and fifteen from Leeds. It is situated on a bed of shale, which covers the mountain limestone, and is itself covered br magnesian limestone. It is from this shale that the mineral waters of Harrowgate all rise. It seems to be all the substitute which exists in this part of the country for the coal-beds, so abundant at the distance of fifteen or twenty miles. Harrowgateof late years has increased very much, chiefly on account of the celebrity of its wells. At present there are no fewer than fourteen dif- ferent wells at Harrowgate, all of which are more or less resorted to on account of their medicinal properties. The longest known among these is the Tewit Spa, so called from the lapwings which still frequent the spot. It was accidentally disco- vered in the year 1571 by William Slingsby, Esq. Having travelled in Germany and used the cele- brated chalybeate waters at Spa, he was struck with its great resemblance to the Sauvenier foun- tain. He was induced to use it, and to prefer it to the Spa waters as more agreeable and more valuable, and thus brought it into a certain degree of celebrity. This reputation has been ever since augmenting, and has no doubt been promoted by the gradual discovery of the other mineral wells which are now so numerous. Numerous books have appeared professing to give a medical and chemical account of these waters. The first was by Dr. Deane in 1626; Dr. Stanhope published a work on the subject in 1632; Dr. French gave another treatise on these waters to the public in 1651. The work of Dr. Neal of Leeds, though drawn up in 1656, was not published till 1734, when it was incorporated with the work of Dr. Short, of Sheffield, on Mineral Waters. Dr. Higgins gave an analysis of them in 1780 ; Dr. Garnet's treatise on them appeared in 1791. Sir Charles Scudamore in 1820 gave a chemical analysis of several of the Harrowgate wells, in his chemical and medical report of the proper- ties of various mineral waters. The last and most complete account of these springs was published by Dr. Adam Hunter, of Leeds, in 1830, under the title of A Treatise on the Mineral Waters of Harrowgate and its vicinity. The springs at Harrowgate are not all of the same class, though it will be most convenient to give an account of them all in this place. Six of them are impregnated with sulphuretted hydrogen gas, and therefore are entitled to the name of sulphureous springs. Five of them are pure chalybeates; one is a saline chalybeate ; and two may be considered as simple saline, since they contain little iron, and are destitute of sulphuretted hydrogen. Indeed, besides the fourteen springs which we mean to describe, many others might be added, for the neighbourhood of Harrowgate abounds in mineral impregnations. But the re- semblance of those left out to some one or other of those which we mean to introduce is so great, that were we to describe them all, we should be merely lengthening out the article by a needless repetition. Class I. Sulphureous Springs. 1. The old sulphur or drinking well issues from the base of a considerable ascent inclining to the south-west, and is encircled with rising grounds which are partly covered with buildings. The water rises into a circular stone basin, covered with a large leaded dome, supported by pillars. The WATERS, (MINERAL) 683 water is transparent and colourless, and very spark- ling : its temperature is 49°, which is doubtless the mean temperature of that part of Yorkshire. The smell is strongly hepatic, the taste saline, with an impression of sulphur: it loses its colour by standing or by boiling, and a white matter is de- posited : its specific gravity, as determined by Dr. Garnet, was 1-0064 ; Sir Charles Scudamore found it 10101 at 60°, and Dr. A. Hunter found it 1-0110 at 61°. The saline contents of the imperial gallon, ac- cording to the analysis of Dr. A. Hunter, are as follows:— Chloride of sodium................867 grs. Chloride of calcium............... 87 Chloride of magnesium............ 42-5 Bicarbonate of soda............... 20 1016-5 Sulphuretted hydrogen gas 15-64 cubic inches. Carbonic acid gas........ 2-72 Carburetted hydrogen..... 6-80 Azotic gas.............. 8.84 Total 34-00 2. Thackwray's Garden Spring or Crown Spa is about two hundred yards from the old sulphur well, nearly on a line with it, and in the lowest part of the valley, in the garden at the east end of the Crown hotel. It was discovered in 1810, and was long used as a bath. A small Chinese tem- ple has been placed over this spring, and the gar- den and some surrounding land has been con- verted into pleasure-ground. Its properties are so nearly similar to those of the old sulphur well, that a particular description is needless. Its spe- cific gravity at 58° was found by Dr. A. Hunter to be 1-0105. The saline constituents of the imperial gallon of this water, according to the analysis of the same gentleman, are as follows :— Chloride of sodium.............802 grs. Chloride of calcium............. 77-5 Chloride of magnesium.......... 38-6 Bicarbonate of soda............. 28-0 946-1 Sulphuretted hydrogen gas. .21-6 cubic inches. Carbonic acid gas.......4.32 Carburetted hydrogen...... 5-76 Azotic gas............... 4-32 36-00 3. The Crescent New Pump is situated in the garden immediately to the west of the promenade room, and about a hundred yards from the old well. It is more strongly impregnated with salts than any of the springs, except the preceding ones. Its specific gravity, according to Dr. A ■ Hunter, is 1-0051 at 59°: its constituents, by the analysis of the same gentleman, in the imperial gallon, are as follows:— Chloride of sodium..............462 grs. Sulphate of soda................ 14 Chloride of calcium.............. 47-2 Chloride of magnesium........... 21-8 Bicarbonate of soda.............. 11-0 5560 Sulphuretted hydrogen gas. 5-75 cubic inches. Carbonic acid gas......... 3-3o Carburetted hydrogen. ._. .. 4-80 Azotic gas...............10-10 2-400 4. The Crescent House Pump is placed in one of the back-rooms of the Crescent hotel, and had been almost confined to its use as a bath. It was first analysed by Dr. A. Hunter. Its specific gra- vity at 58° is 1-0029. The saline constituents in an imperial gallon of this water, according to the analysis of Dr. A. Hunter, are as follows :— Chloride of sodium.............280 grs. Chloride of calcium............. 23-25 Chloride of magnesium.......... 17.25 Bicarbonate of soda............. 4-00 324-5 Sulphuretted hydrogen gas.... 3 cubic inches. Carbonic acid gas........... 3 Carburetted hydrogen....... 2 Azotic gas................12 20 5. Knaresborough or Starbeck Spa, though the weakest, is, however, of considerable importance. It is the only sulphur spring not at or immediately adjoining Low Harrowgate. It is situated in the township of Knaresborough, and at nearly an equal distance from Knaresborough and Harrow- gate. It seems to have been the first sulphur well discovered at Harrowgate, but was gradually ne- glected as the others increased in celebrity. It was at last altogether destroyed, and the ground ploughed over; but it made its way again to the surface; and some individuals, finding it useful as a bath, formed a pond for leading away the water as occasion required. It then became a subject of dispute between Knaresborough and Harrow- gate. By the enclosure act, it was awarded to Knaresborough; and in 1822 it was enclosed by subscription in an elegant fabric. A neat cottage, with shrubberies and a garden, with hot and cold baths at a moderate price, together with a chaly- beate spring, complete the establishment of the Knaresborough Spa. It is an excellent pure light water, which sits easily on the stomach, and is less disagreeable to the palate than the stronger sulphur waters. It is peculiarly recommended as a bath in cutaneous diseases. Its specific gravity at 58° is 1-0026. The saline constituents in the imperial gallon of this water, according to the analysis of Dr. A. Hunter, are as follows:— Chloride of sodium.............122 grs. Sulphate of soda............... 2-5 Chloride of calcium............ 10 Chloride of magnesium.......... 8-25 Bicarbonate of soda............. 3 145-75 Sulphuretted hydrogen gas.. 5 cubic inches. Carbonic Acid.... •....... 8-3 Azotic gas...............11.7 25-0 6. The Hospital well is situated in the moss or 684 WATERS, ( bog from which, in the opinion of some, all the sulphureous springs in Harrowgate originate. It is one of the springs which supplies the hospital, built upon the edge of the bog. Its specific gra- vity at 58°, as determined by Dr. A. Hunter, is 1-0039. The saline constituents in the imperial gallon, according to the analysis of the same gen- tleman, are as follows : Chloride of sodium............. 329 grs. Sulphate of soda............... 6 Chloride of calcium............. 27-6 Chloride of magnesium.......... 16-8 Bicarbonate of soda............. 3-0 382-4 Sulphuretted hydrogen gas Carbonic acid gas........ Azotic................. 4-5 cubic inches. 5.4 8-1 18-0 Class II. Pure chalybeates. These springs are five in number. The follow- ing table shows the specific gravity of each ac- cording to the determination of Dr. A. Hunter:— 1. Oddy's pure chalybeate ... 1-0007 at 58° 2. Old spa................1-0003 at 56o 3. Tewit well.............1-0003 at 56° 4. St. George's well........1-0005 at 59° 5. Starbeck's chalybeate.....1-0005 at 57° Oddy's chalybeate was discovered in the year 1818. It was first subjected to analysis by Dr. A. Hunter, who found the saline contents of the imperial gallon as follows:— Protoxide of iron................ 1-8 grs. Common salt.....,............. 5-0 Sulphate of soda................ 3-5 Chloride of calcium.............. 6-0 Chloride of magnesium.......... 4-0 20-3 Carbonic acid gas.......... 5 cubic inches. Azotic gas................. 8 Oxygen gas............... 1 ^4 The Old spa or sweet spa was discovered by Dr. Michael Stanhope in 1631. It is situated on the common of High Harrowgate, near the Granby Hotel, and adjoining the Knaresborough road. For many years it has been the principal Harrow- gate chalybeate. The saline contents in the im- perial gallon of this water, as determined by Dr. A. Hunter, are the following : Protoxide of iron............... 2-5 grs. Carbonate of lime................ 7.5 10 Carbonic acid gas.........5-25 cubic inches. Azotic gas................6-0 Oxygen gas..........»... 0-5 11-75 The iron is kept in solution by carbonic acid. The Tewit well was the first mineral spring discovered in Harrowgate, and was much fre- quented almost three centuries ago. Many vo- MINERAL) lumes have been published on its medical virtual and the most exaggerated accounts have been given of the surprising cures which it performed To it Harrowgate is indebted for its rise and cele- brity ; yet this spring, though possessed of all the virtues which it ever had, is now almost entirely neglected, and even its situation unknown to many of the inhabitants of the place. It is «'tu. ated at the extreme eastern corner of the common near the Leeds and Harrowgate road, in a rough and swampy piece of ground. Dr. A. Hunter subjected it to an imperfect chemical analysis, From the imperial gallon of the Tewit spring he obtained— Protoxide of iron................... 2 grs, Earthy salts.......................g ~io Carbonic acid gas......... 5 cubic inches. Azotic gas............... 5-75 Oxygen gas.............. 0-75 11-5 Hence it would appear not to differ much from the Old spa. St. George's well is about fifty yards from Oddy's chalybeate, on the outside of the fence and close to the road. It is entirely neglected, and has not even a stone basin to receive the water, which is pure and light, though it contains less iron than any of the preceding chalybeates. The saline constituents in the imperial gallon are, according to Dr. A. Hunter, as follows :— Protoxide of iron....................1 gr, Earthy salts........................9 10 Carbonic acid ga3.............5-25 cub. in. Azotic gas...................5-5 Oxygen gas.................1 11-75 Starbeck chalybeate is very near the sulphu- reous spring of the same name. In its general properties it coincides with the other chalybeates; but it is kept with so much neatness, and is so bright and so clear when taken from the well, that it is generally preferred by the visitors, though the weakest of all the chalybeates. The saline con- stituents in the imperial gallon are, according to Dr. A. Hunter, as follows :— Protoxide of iron...............0-75 grs. Common salt, with some earthy salts 17-25 18-00 Carbonic acid gas...............3 cub. in. Azotic gas..................... 8 Oxygen gas....................1 12 Class III. Saline Chalybeates. To this class there belongs only one spring, namely, Oddy's saline chalybeate or Cheltenham spring, which is so important in its nature and effects, and differs so much from all the rest, that it is entitled to a place by itself. It is situated WATERS, (MINERAL) 685 about two hundred yards from the promenade- room, in a field adjoining the Leeds and Ripon road. It was discovered in 1818, while boring in search of sulphur water to supply the increasing demands for the baths. Water was found at the depth of eight yards in the lowest part of the narrow valley, and a few yards from the fence adjoining the road. The alluvial earth being re- moved, a layer of clay was found, beneath which was a bed of sand covering a dark bluish stratum of shale, from under which the water issued. A cistern was afterwards prepared for its reception, and when the value of the water became known, a neat pump-room was built and other suitable improvements effected. The specific gravity of this water, as determined by Sir Charles Scuda- more, is 10046 at 60°. Dr. A. Hunter found it 1-0076 at 59°. This last gentleman from the imperial gallon of this water obtained the follow- ing quantity of saline constituents:— Carbonate of iron............... 5-3 grs. Common salt...................576-5 Chloride of calcium............. 43-5 Chloride of magnesium.......... 9-65 634-95 Carbonic acid gas ............5-75 cub. in. Azotic gas..................7-75 13-5 This water is not only impregnated with a con- siderable proportion of carbonate of iron, but from the quantity of purging salts which it contains, counteracts the binding effect of the iron, and may therefore be persisted in without injury for a longer time than Tunbridge Wells or any pure chalybeate, unless the effects of the iron in these waters on the intestines be counteracted by the administration of purgatives. It may be taken, with proper management, either as a tonic, an alterative, or aperient. It is, therefore, a valuable medicine in derangement of the liver and debility of the stomach. Indeed it may be considered as in some measure uniting together the virtues of the spring at Tunbridge Wells, and some of those at Cheltenham. It is, therefore, a valuable water to Harrowgate, because it saves the invalid from the necessity of being obliged to repair to Chelten- ham or Leamington after having exhausted the virtues of the sulphur water. Class IV. Saline Springs. These waters contain more or less of purgative salts, but they are destitute of iron and of sul- phuretted hydrogen. There are two such at Har- rowgate, namely, Crescent old well and Knares- borough dropping well. The specific gravity of these two wells, as de- termined by Dr. A. Hunter, is as follows:— Crescent old well..........1-0033 at 52° Dropping well............1-0032 at 55° The Crescent old well is situated in the garden behind the Crescent Inn, and immediately adjoin- ing the promenade room. It was first analysed by Dr. Garnet, who bestowed very high encomi- ums on its virtues. But it would appear to have considerably deteriorated since his time. It seems at one time to have contained a notable quantity of sulphuretted hydrogen ; but in 1829 no trace 3h of that gas or of iron could be detected. The saline contents in the imperial gallon of this water are, according to the analysis of Dr. A. Hunter, as follows :— Common salt...................107 grs. Sulphate of soda................ 27 Chloride of calcium............. 10-1 Chloride of magnesia............ 7.4 Carbonate of lime............... 4-0 155-5 Carbonic acid gas..........•......6 cub. in. Azotic gas.....................8 14 Knaresborough dropping well has been long famous on account of its petrifying powers. It is mentioned in Leland's Itinerary, who, after de- scribing its properties, adds, " There was once a conduit of stone made to convey water from this well over Nid to the Priory of Knaresborough ; but this was decayed afore the dissolution of the house." The water of the dropping well rises in a deep narrow dell, about fifty yards from a rock, over the projecting ledge of which it trickles and falls from a height of ten feet, giving a good idea of a natural shower bath. It is over against the castle on the south side and near the edge of the river Nid. The saline constituents in the imperial gal- lon of this water, according to the analysis of Dr. A. Hunter, are as follows:— Carbonate of soda................ 6 grs. Sulphate of lime.................132 Sulphate of magnesia............. 11 Carbonate of lime................ 23 172 Carbonic acid gas...........7 cubic inches. Azotic gas................8 Oxygen gas...............1 16 II. Moffat Sulphureous Spring. This is the most celebrated sulphureous spring in the south of Scotland. The village of Moffat lies at the bottom of a range of transition moun- tains, which stretch with little interruption from St. Abb's Head, the south-eastern extremity of the frith of Forth, to the western coast of Scot- land, where they lose themselves in the sea on the north side of Loch Ryan, in Galloway. The situation is fine, owing chiefly to the contrast be- tween the bleak and green mountains constituting the back-ground, and the finely wooded little hills and fertile fields in the immediate vicinity of the village. There is an extensive view to the south, over the valley of Annandale, bounded only by the distant mountains of Cumberland and Gallo- way. The mountains behind Moffat are com- posed of gray-wacke, transition, greenstone, and transition slate : whether alum-slate be present is doubtful. The well is about a mile and a half from the village, and is said by Dr. Garnet to take its rise in a bog; but the writer of this article, after some pains in examining this spot, could not satisfy himself of the accuracy of this statement. 686 WATERS, (MINERAL) The sulphureous well at Moffat has been re- sorted to by invalids for many years. An analy- sis of it was published by Mr. Matthew Mackail, of Edinburgh, in 1659. Sir Robert Sibbald de- scribes it in his Nuncius Scoto-Britannus, pub- lished in 1683. A short treatise on it appeared in the first volume of the Edinburgh Medical Es- says in 1746, written by Mr. George Milligan, at that time a surgeon in Moffat. Dr. Johnston, who long practised medicine at Moffat, drew up an account of it, which was published by Dr. Garnet, in his tour through Scotland, about the end of the last century. Dr. Garnet spent a sum- mer at Moffat during the year 1797. He made an analysis of the water, and obtained from a wine gallon of it the following constituents:— Common salt..................36 grains. Sulphuretted hydrogen gas.......10 cub. in. Azotic gas.................... 4 Carbonic acid gas.............. 5 19 Dr. Thomson of Glasgow analysed it in the year 1823. He found its specific gravity 1-00255. The water as it issues from the pipe is transparent and colourless; but when kept for some time, it becomes opal-coloured, as is the case with water impregnated with sulphuretted hydrogen gas. It has the well-known odour of this gas, and a slightly sweetish taste. The constituents in the imperial gallon of this water, according to the analysis of Dr. Thomson, are as follows :— Common salt................ 176-569 grs. Sulphate of soda............. 16-562 Sulphate of lime .'............ 11-579 Sulphate of magnesia.......... 5-474 210-184 Sulphuretted hydrogen gas, 21-29 cub. in. The quantity of this gas was determined by a small quantity of sulphate of copper having been put into a bottle of the water upon the spot at the instant of filling it. The precipitate (sul- phuret of copper) was dissolved in nitric acid, and the sulphuric acid formed was precipitated by chloride of barium. 4-27ths of the precipitate gives the amount of the sulphur in the quantity of water employed. Two grains of sulphur are equivalent to 5-841 cubic inches of sulphuretted hydrogen gas. Hence, to find the quantity of this gas in cubic inches in the volume of water ana- lysed, multiply the weight of sulphur found by 2-92; the product will be the number of cubic inches required. This is a much more accurate method than extricating the gaseous contents of the water by boiling and analysing them by ab- sorption ; because sulphuretted hydrogen gas is so soluble in water, that a portion of it must always disappear during the process; whereas sulphate of copper throws down the whole sulphur present in the water, and this sulphur is wholly converted into sulphuric acid when the sulphuret is dissolved in nitric acid. Acetate of lead cannot be used, because the lead would be thrown down not only by the sulphur, but also by the sulphuric acid contained in the water. III. Strathpcffcr Sulphuretted Water, This mineral water is situated in the valley tj Strathpeffer, a few miles west from Dingwall, ife county-town of Ross-shire, in the north of Scot. land. The situation is romantic, and the neigh- bouring country fertile and exceedingly beaattftii, The wells seem to rise in the new red sandstone of which the country is composed, and are at do great distance from the lofty mountains of ]_.„ Nevis, so conspicuous in the north of Scotlui These wells had been long known as mediant! and an imperfect analysis of them was published by Dr. Donald Monro in the Philosophical Trans. actions for 1772. They were brought into con- siderable celebrity by Dr. Morris, an Aberdeen- shire gentleman, who built a pump-room, and wu enthusiastically attached to these waters, which he affirmed to be the strongest and most salubrious in Great Britain. This gentleman died in 1824, and thus the wells were deprived of his valuable patronage. There are two wells at a little distance from each other. Their temperature was found by Dr, Thomson, on the 24th of June, 1824, to be 39°-75', that of the air at the time being 60°. The day happened to be rainy. The specific gravity of these wells was found at the same time to be as follows:— Upper well...................1-00193 Lower well...................1.00031* It is the lower well which is supplied with a pump-room. It is obviously the weaker of the two. An imperial gallon of the lower spring, ac- cording to the analysis of Dr. Thomson of Glas- gow, contains the following constituents. Sulphate of soda...............52-710 grs, Sulphate of lime...............30-686 Common salt..................19-233 Sulphate of magnesia............4-855 107-484 Sulphuretted hydrogen gas, 13-659 cub. in. An imperial gallon of the upper spring was found to contain— Sulphate of soda................67-770 Sulphate of lime................39-454 Common salt..................24-728 Sulphate of magnesia............ 6-242 138-194 Sulphuretted hydrogen gas, 26-167 cub. in. IV. Rothsay Sulphuretted Water. This spring was discovered in 1831 by Mr. Richmond. It lies about half a mile east from Rothsay, the county town of Bute. The situation is magnificent. The town forms a kind of am- phitheatre, lining as it were a semicircular bay. From this bay the sea, divided by the point of Towart, the southernmost extremity of Cowal, forms what appears to the eye two magnificent rivers. The first of these, constituting the Kyles * The specific gravity of two other specimens was found in 1828 as follows:— Upper well.............................10022 Lower well............................10015 Hence tlieirstrength obviously varies with the weather. WATERS, (MINERAL) 687 "of Bute, about a mile wide, and gradually nar- rowing to little more than half a mile, separates the island of Bute from Argyleshire to the north- west of Rothsay. The other, about six miles wide, passes to the north, dividing the county of Argyle from Ayrshire and Renfrew, and gradually narrowing into the river Clyde. This division proceeds southwards, and after passing by Bute and Arran with its beautiful mountains, gradually widens to at least 80 miles. The banks on both sides of this frith are of the boldest and most ro- mantic description, and want nothing capable of constituting one of the most splendid pieces of sea scenery that Great Britain can anywhere exhibit. This water, as it rises from the sand, (for it is situated very near the shore,) is transparent and colourless. Its taste is disagreeably salt, and its smell that of sulphuretted hydrogen gas. Its specific gravity, as determined by Dr. Thomson, is 1-0228. This spring rose a few feet distant from an old , quarry-hole filled with stagnant water, which con- tained no sulphuretted hydrogen gas, and its spe- cific gravity was considerably less than that of the spring. The Marquis of Bute, to whom this part of the island belongs, employed a number of work- men, during the summer of 1831, to drain the quarry, in order to trace the source of this mine- ral spring; but before they had completed their object, a high tide made its way to the quarry- hole, and filling up the cavity with water, de- stroyed the undertaking, and it was not again renewed. In consequence of this injudicious at- tempt, the sulphureous spring ceased to flow; but it has again broken out a few feet nearer the sea, and probably were the quarry drained and deep- ened, and a wall built to keep off the sea, a regu- lar sulphur spring might be obtained, from which the sea-water would be excluded. The saline constituents in the imperial gallon of this water, as determined in the winter of 1830-1 by Dr. Thomson, are as follows .-— Common salt.................1860-73 grs. Sulphate of lime.............. 125-20 Sulphate of soda.............. 129-77 Chloride of magnesium......... 32-80 Silica........................ 14-39 216289 Sulphuretted hydrogen gas, 17-4 cub. in. From the nature of these constituents, we think there can be little doubt that the sulphur spring had been contaminated with sea-water. Indeed it was situated so near the sea that it must have been overflowed at high spring-tides. Of course, before the real nature of this water (with the exception of the sulphuretted hydrogen gas which it con- tains) could be accurately known, it would be nmvsary to exclude the sea completely, and then to analyse it again, after all the sea-water had been removed. V. Enghien Mineral Water* Enghien, or Montmorency, is a small town, not far from the right bank of the Seine, about four miles from St. Denis, and twelve miles from Paris. The mineral water of this place has been known for about a century, and has not been much frequented on account of the want of the requisite accommodations for visitors. Its taste is bitter and sulphureous. Its specific gravity is 1-00069; its temperature 59°, and it reddens paper rendered blue by litmus. When boiled, it lets sulphuretted hydrogen gas escape for a long time. It becomes first greenish, then milky, and deposits flocks of a vegeto-animal matter. Its constituents in the imperial gallon, as deter- mined by M. Henry, junior, are as follows:— Common salt................ 3-54 grs. Chloride of magnesium........ 7-08 Sulphate of magnesia......... 7-43 Sulphate of lime ............ 3-54 Subcarbonate of magnesia..... 2-69 Carbonate of lime............ 2-33 Silica....................... 0.28 Sulpho-hydrate of lime and mag- nesia ..................... 3-94 Vegeto-animal matter, trace. 30-83 Azotic gas.................. 3-88 cub. in. Carbonic acid gas............33-94 Sulphuretted hydrogen gas..... 5-00 From this it appears that Enghien water is very weak, so far as the impregnation of sulphu- retted hydrogen gas communicates medical virtue. VI. Bareges Sulphureous Water. Bareges lies in the department of the Hautes Pyrenees. It is situated in a small valley sur- rounded with high mountains. Formerly it was nearly inaccessible, but of late years a good road has been made to it. It is covered with snow during a considerable part of the year, and is only a pleasant residence during a few months in sum- mer. The mineral waters of Bareges were known to Cajsar and Sertorius. Marguerite, sister of Francis I. and queen of Navarre, in some measure restored them to the splendour which they exhi- bited in ancient times. Henry IV. frequented them a great deal during his youth. They were visited by Montaigne, and their celebrity was much increased in consequence of a visit paid them by Madame Maintenon in company with the Due de Maine. Louis XV. built a military hospital at Bareges, which became celebrated for the numerous cures which were wrought in it by the use of the waters. There are three springs: 1. the hot spring, which is very abundant; 2. the temperate spring, which is colder and not so copious ; 3. the luke- warm, which is still colder and more scanty than either of the other two. There are five baths. The waters are clear and limpid; they give out the smell of sulphuretted hydrogen : their taste is sweet and rather unpleasant. Their surface is covered with a pellicle, which.gives them an oily appearance. The temperature of these waters, according to Lomet, is as follows:__ First spring..........113 degrees. Second spring........100 Third spring......... 88| They are always colder in spring and summer than during winter. This is owing to the infil- tration of melted snow. The specific gravity of these waters has not been stated, but it exceeds 668 WATERS, (MINERAL) that of distilled water very little. Their saline contents are very small in quantity, not exceeding, acccording to Longchamp, l-3400th part of the weight of the water. They have been analysed by M. Poumier, who obtained from the imperial gallon of the royal spring, the oldest and most renowned, the following saline constituents :— Chloride of magnesium............ 2-26 grs. Common salt................... 2-46 Sulphate of magnesia............ 5-90 Sulphate of lime................. 9-52 Carbonate of lime............... 4-08 Sulphur.......................10-68 Silica.......................... 0-90 Vegeto-animal matter, trace. 25.80 Sulphuretted hydrogen gas 1-615 cubic inch. If this analysis be near the truth, the water of Bareges is one of the weakest of the whole class of sulphureous waters. We have an account of this water by M. Longchamp, who informs us that it leaves l-3400th of its weight of saline residue composed of the subcarbonate, muriate, sulphate and hyposulphate of soda, of a little subcarbonate of lime and magnesia, of a small quantity of silica, and of an animal matter to which he gives the name of barigin. He says that the sulphuretted hydrogen gas does not exceed 28-1000000 of the bulk of the water, which is a still smaller quan- tity than that deduced from the analysis of M. Poumier. VII. Aix. Aix is a small town, about twelve leagues from Geneva, and two and a half from Chambery. Its hot baths were frequented during the time of the Romans. They were repaired at the expense of the emperor Gratian; they are frequented from the month of May to the middle of September, when the season breaks up. The months of July and August are the most fashionable. There are two wells ; one called the alum well, or the well of St. Paul; the other called the sul- phur well. These two springs are distant from each other about one hundred paces. They pass into leaden pipes, and are conducted into very large receivers. The principal building encloses the sulphur spring. It is called Batiment Royal. It is divided into a series of baths of different kinds. | The temperature of these waters is the same all the year round, except during the melting of the snow and during the equinoxial rains, when it is slightly diminished. The usual heat is 113°; that of the air in the baths is about 83°.75. The water is transparent, has an unctuous feel and a strong smell of sulphuretted hydrogen, which is dissipated by exposure to the air. The taste is sweetish and earthy. The alum water has a slightly bitter styptic taste, which the sulphureous water wants. According to the analysis of M. Socquet, the imperial gallon of the sulphur spring contains the following saline ingredients:— Animal extract................. 0-135 grs. Sulphate of soda............... 2-24 Sulphate of magnesia............ 1.97 Sulphate of lime................ 4.88 Common salt.................. 0-6L Chloride of magnesium.......... 2-10 Carbonate of lime.............. 7-32 Carbonate of magnesia..........4-00 23-255 Sulphuretted hydrogen gas 2-22 cubic inches, Carbonic acid gas..........3-14 5-36 From this analysis it appears that the sulphu- reous spring at Aix is very slightly impregnated with sulphuretted hydrogen, and that it contains but an insignificant quantity of salts. The alum spring is stronger, though also very weak. It does not contain a particle of alum notwithstand- ing its name, but minute quantities of the follow- ing salts, according to the analysis of M. Socquet, —sulphate of soda, sulphate of lime, sulphate of magnesia, common salt, chloride of magnesium, carbonate of lime, carbonate of magnesia, and ani- mal matter. The sulphuretted hydrogen gas is about two-fifths of that contained in the sulphur well, while the carbonic acid is about one-and-a- half times as much. VIII. Aix-la-Chapelle. Aix-la-Chapelle is a considerable town about twelve leagues west from Cologne and seven from Spa. It is situated in a beautiful and fertile val- ley, surrounded by well-wooded hills, and has been long celebrated for the salubrity of its air, The hot springs which it possesses were frequented by the Romans, and after having been long aban- doned and forgotten, they were again restored by Charlemagne, who was so delighted with the baths of this place that he made it his residence, and was in the habit of holding his court in them. The fundamental rock in the neighbourhood of Aix-la-Chapelle is calcareous. Over this lies a bed of micaceous sandstone, seemingly connected with the coal-beds, being often replaced by coal 01 slate clay. Three principal springs have been observed. The first, called the great spring, is situated on the east side of the town-house. The second is placed in the principal street of the town, called the Grande Rue, where we find the foun- tain set apart for the drinkers. The third spring is situated south-east from the first. These springs, which are copious, unite together, and are en- closed in vaulted reservoirs; the waters run out of different aqueducts of stone, wood, or lead, in the houses where there are baths. These exist to the number of four in the old town, namely, the emperor's bath, the little bath, St. Quirinus's bath, and the new balh. There are six in the new town, namely, Charles's bath, the bath of St. Corneille, two large baths called bains del seigneurs, the bath of the rose, and the bath of the poor. The waters are clear and transparent; they have the smell of sulphuretted hydrogen gas, and an alkaline, saline, and hepatic taste. When allowed to cool, they lose their smell, taste, and transparency, and become milky. The tempera- ture of the emperor's bath is 135i°; but as it issues from the ground, it is as high as 144°. The heat of Quirinus's balh is 120° ; that of Corne- lius's bath 119°. The specific gravity, before WATERS, (MINERAL) 689 boiling, is 1-012; after boiling, it becomes as high as 1-016. The saline constituents of the imperial gallon of the water of the emperor's bath, according to the analysis of MM. Reumont and Monheim, are as follows:— Carbonate of soda............. 35-343 grs. Common salt.................210-520 Sulphate of soda.............. 18-691 Carbonate of lime............. 9-244 Carbonate of magnesia......... 3-119 Silica....................... 4-997 281-917 From the experiments of Monheim in 1812, it appears that 100 cubic inches of the gases disen- gaged from this water are composed of Azotic gas...............51-25 cubic inch. Carbonic acid gas.........28-26 Sulphuretted hydrogen gas .. 20-49 100-00 But he does not determine the absolute quantity of these gases, which is the most interesting point. If any confidence can be put in the analysis of Kortum, the imperial gallon contains about 133 cubic inches of sulphuretted hydrogen gas. It is therefore much more strongly impregnated with this gas than any of the other sulphuretted springs which we have hitherto noticed. The waters of Aix-la-Chapelle are more cele- brated in a medicinal point of view than any other sulphuretted water whatever. They act with con- siderable energy, and are particularly valuable in all chronic diseases of the skin, in scrofulous sores, and in chronic rheumatism and gout. They have been recommended also in diseases of the liver, in diseases of the bones, in colics from me- tallic poisons—in short, in diseases to which sul- phur or its compounds are considered applicable. When taken internally, the patient should drink them cautiously, and should scarcely take more than a couple of glasses at a time. When taken to the extent of a couple of quarts, they become purgative. They are at first disagreeable on ac- count of the smell; but the patient soon becomes reconciled to their use. As a bath, they are par- ticularly valuable in all cutaneous affections, and indeed in chronic ulcers in general. IX. Xioeche or Leuki Leuk is a small town in the Valais, six leagues distant from Sion, built upon the right bank of the Rhone, in a valley, the bottom of which has been channelled by torrents. The waters of Leuk are celebrated for the energy with which they act, and are not a little frequented, although the place does not afford all the conveniences to strangers that could be wished. These waters are known in the Valais by the name of Baden, (the baths). Within a circuit of about half a league there are eleven or twelve hot springs, most of which flow into the Dala. They issue from the bottom of a mountain covered at the summit with perpetual snow. The great spring issues from a place situ- ated between the inn and the buildings of the baths. It constitutes a considerable rivulet, and furnishes water to various baths. It is unneces- Vol. IV. —87 3h* sary to describe the particular situations of the other springs. The temperature of the great spring is 125}°, and that of the coldest of the whole is 115£°. About two hundred paces from the baths there rises a spring, which is always very cold, and which flows only from May to September. The water exhales a slight odour of sulphuretted hydrogen gas. It is perfectly limpid, and has no peculiar taste. Pieces of silver left in it for a few days acquire a yellow colour, which is perma- nent. We are not in possession of any recent analysis of this water; but from the analysis of Morell it follows that an imperial gallon of it con- tains the following saline constituents:— Common salt, with a little sulphate of magnesia............... 13-33 grs. Sulphate of lime...............175-00 Carbonate of magnesia.......... 13-88 Carbonic acid gas.............. 8-53 Protoxide of iron.........,..... 4-28 215-02 But no great confidence can be put in this analysis- [The warm sulphureo-saline waters in this country, are the White Sulphur, Red Sul- phur, Salt Sulphur, «fcc. of Virginia. The water of the White Sulphur was analysed by Prof. W. Rogers, of the University of Virginia. The wine gallon was found to contain the follow- ing ingredients:— Gaseous Contents. Sulphuretted hydrogen ... .2-5 cubic inches.. Carbonic acid...........2 Oxygen................1-448 Nitrogen...............3-552 9-5 Solid Contents in a Pint. Sulphate of magnesia............5-588 grs.. --------of lime . •...............7-744 Carbonate of lime...............1-150 Chloride of calcium.............. 0-204 ■--------of sodium..............0-180 Oxide of iron, a trace. Loss..............0-410 15-276] IV.—Or Acidulous Watehs. The mineral waters of this class are character- ized by the notable quantily of carbonic acid gas which they contain, and which gives them an acidulous and sharp taste, somewhat resembling that of brisk beer, which they lose when left for some time exposed to the atmosphere. Air-bubbles are continually rising through them and. breaking at the surface of the liquid, which gives it the ap- pearance of boiling. By exposure to the air or to a gentle heat, they lose the carbonic acid upon which their principal peculiarities depend. These acidulous waters are easily known by their taste and briskness and by the property which they have of reddening (slightly but sensibly) paper stained blue by litmus. When the litmus paper is exposed to the air, the red tinge is gradu- ally destroyed by the evaporation of the carbonic acid, and the original blue colour restored. Lime- water occasions a precipitate when mixed with a 690 WATERS, (MINERAL) portion of acidulous water; this precipitate is carbonate of lime. Should the quantity of carbonic acid present be great, and the quantity of lime- water used small, it might happen that the original precipitate produced by the addition of lime-water might be again dissolved. But should this take place, we have only to leave the mixture for some time exposed to the atmosphere, and the precipi- tate will again appear. These springs have always attracted a great deal of attention. The cold acidulous waters are much used in bilious affections, and in fevers, whether putrid or malignant, as an agreeable drink. Even in chronic cases they are not with- out utility. They are considered as having a peculiar action on the stomach and intestines. Probably their virtues depend in some measure on the mechanical action of the carbonic acid which they contain. When strongly impregnated with carbonic acid gas, they sometimes affect the head of those that use them too liberally, producing a species of temporary intoxication, similar to that occasioned by the use of brisk beer or champagne wine. It is obvious that they must be injurious to those who are troubled with habitual flatulence, indicating a bad tone of the stomach or an imper- fect digestion. In such cases considerable quanti- ties of carbonic acid are apt to be generated in the stomach, and the addition of liquids charged with that gas would be only increasing the quantity of e substance which is already producing inconveni- ence. [Most of them contain either carbonate of soda or iron, or both; and their efficacy is, of course, partly dependent upon the amount of these ingre- dients. The carbonic acid always, however, com- municates decided qualities to them. It gives them a piquant taste, their excitant agency upon the stomach, and their exhilarating effect upon the system. The Pyrmont water is said to be drunk by the country people, partly as a medicine, and partly on account of the kind of intoxication it induces. The Congress, and other waters of Saratoga, are mainly indebted for their agreeable qualities to the carbonic acid which they contain. It is the pleasant ingredient in the effervescing draught in soda powders, and in the soda water from the fountain ; and it is to it that these pre- parations owe their power of arresting vomiting, and that soda water and Seltzer water aid digestion, when taken during a repast.] The easiest method of determining the quantity of carbonic acid gas in a mineral water, is to put a certain portion of it into a flask, from the mouth of which there passes a glass tube which plunges into a Wolfe's bottle filled with lime-water, or, what is better, with barytes water. The Wolfe's bottle should be filled with the liquid in question, and a bent tube from one of the mouths of the phial passes into a pneumatic trough to collect the other gases which the water may contain. The carbonic acid gas is absorbed by the barytes or lime-water, arid precipitated in the state of carbo- nate of barytes or of lime. This carbonate, when the process is finished, is to be separated from the liquid, and after being carefully washed and dried, is to be weighed. 1-225 grains of carbonate of barytes indicate 2-75 grains of carbonic acid. Hence, if wc multiply the weight of carbonate of barytes obtained by 0-2245, the product will be the weight of carbonic acid gas contained in the volume of the acidulous water subjected to exami- nation. And as 100 cubic inches of carbonic acid gas under the mean pressure and temperature weigh 47.4691 grains, it is easy from the weight thus found to deduce the number of cubic inches of the gas. When we use lime-water, 6-25 grains of the precipitated carbonate of lime contain 2-75 grains of carbonic acid. Hence, if we multiply the weight of carbonate of lime which we get by 0-44, the product is the weight of carbonic acid gag in the portion of the water which we have subjected to examination. We have only one acidulous water in Greal Britain. On the continent there occur more than one variety of these waters, some of which have acquired considerable celebrity, On that account we shall notice a few of the most remarkable in this place. I. Ilkeston Water. This water, situated near the old market-town of Ilkeston, in Derbyshire, about eight miles from Nottingham, has lately acquired considerable cele- brity, and deserves on that account, and because it is the only acidulous water at present known to exist in Great Britain, to be noticed in this article, The history of its discovery, as it has been stated to us by a Nottingham gentleman, is as follows:— The Rutland colliery being very much annoyed by an immense body of water accumulated in the waste workings of the old Ilkeston coal-field, an engine was erected on one of the level pits of the latter, to assist in draining the works. Close to the engine was made a reservoir, partly to supply the boiler, and partly to be used as a warm-bath. The water had been observed to have the smell of sulphuretted hydrogen, and it irritated the hands of the workmen who put down the pumping appa- ratus and kept it in order. These circumstances led to the suspicion that it contained ingredients different from those in common water, and Ihe engineer was ordered, when he next emptied the boiler, to put it into a tub, from an expectation that the concentrated water might deposit its con- tents, and thus betray their nature. The conse- quence of this was the deposition of a crop of beautiful crystals, which were found to act as aperients. This discovery led to the extensive use of the water, both as a bath or external appli- cation, and as an internal remedy, both in its natural and concentrated state. The beds in this part of the country consist of the usual coal metals which dip to the north-east. The grand subterranean reservoir is formed by the excavations made in getting ihe bed of hard coal, and the water doubtless acquires its mineral im- pregnation as it soaks through the different coal metals from the surface. The Ilkeston water was analysed by Dr. Fyfe, of Edinburgh, Dr. Calvert, of Derby, and Mr. Greeves, of Nottingham. But we have not seen the results obtained by any of these gentlemen, except the last. He obtained from the wine pint of this water the following constituents:— WATERS, (MINERAL) 691 Carbonic acid.................0-4189 grs. Sulphuric acid.................1-3 Muriatic acid..................1-1678 Lime.........................1-3323 Magnesia.......•..............0-5700 Soda.........................0-5860 5-3750 These he considered as existing in the water under the form of the following crystallized salts: Carbonate of lime.............0-34375 grs. Carbonate of soda____<........2-0000 Muriate of lime...............4-8000 Sulphate of magnesia..........2-5900 Sulphate of soda..............0-5905 10-32425 Mr. Greeves informs us that he found also in the water a large quantity of uncombined carbonic acid gas, a considerable portion of sulphuretted hydrogen gas, and a little iron. If we abstract the water of crystallization from the preceding salts, they will be reduced to the following quan- tities :— Carbonate of lime.............0-34375 grs. Carbonate of soda .___.........0-7500 Muriate of lime...............2-2590 Sulphate of magnesia..........1-2630 Sulphate of soda..............0-2624 4-87815 Now, as'4-87815 grains is much less than 5-375 grains, the weight of the constituents stated by Mr. Greeves to have been extracted by him from a pint of the Ilkeston water, it is obvious that he has committed some mistake in his calcu- lations. In the month of November, 1832, a young Nottingham gentleman, a student of medicine in the college of Glasgow, brought to Dr. Thomson, professor of chemistry in that university, two wine bottles of the Ilkeston water, and a wine bottle of the concentrated water. It was subjected to a chemical examination, as minute as was consistent with the small quantity of water to be operated upon. We shall now relate the result of that ex- amination. The water was transparent and colourless, des- titute of smell, and without any sensible saline taste. Its specific gravity was 1-00049. It ren- dered cudbear paper violet, and therefore con- tained an alkali. 9726 grains of it being evapo- rated to dryness, with the requisite care to avoid loss, left a saline residue weighing 4-85 grains. From some previous trials on another portion of the water, it was found to contain sulphuric acid, chlorine, and carbonic acid, together with soda, lime, and> a little magnesia. It was the knowledge of these circumstances which regulated the analysis of the 4.85 grains of saline residue. Being digested in water, it left undissolved L65 grains of sulphate of lime. The portion dissolved yielded the following substances, when minutely analysed:— Sulphuric acid..................0-71 grs- Chlorine-.....................0-74 Lime .........................0-311 Magnesia......................0-035 Soda..........................Ml Silica........^.................0-059 The 1-65 grains of sulphate of lime were com- posed of, Sulphuric acid...................0-97 grs. Lime............................0-68 1-65 Hence, the whole sulphuric acid.....1-68 grs. Lime...........................0-991 A portion of the soda was in the state of car- bonate, and the carbonic acid with which this portion was united was found by calculation to be 0-207 grains. Thus the whole constituents ex- tracted from the 4-85 grains of saline residue were 4-763 grains. There was, therefore, a loss of 0-087 grains. There was found beside a trace of oxide of iron and a little silica. But both of these certainly did not exceed 0-02 grains. The loss, 0-067 grains, therefore, was probably owing to the presence of a minute quantity of something not discovered, for the analysis was so conducted that there could scarcely be any loss. These constitu- ents were probably combined in the mineral water so as to constitute the following salts:— Sulphate of lime................. 1-650 grs. Sulphate of magnesia.............0-105 Sulphate of soda.................1-280 Chloride of calcium..............0-722 Common salt...................0-568 Carbonate of soda...............0-4008 4-7258 Hence the imperial gallon must contain— Sulphate of lime................11-883 grs. Sulphate of soda................10-704 Sulphate of magnesia............ 0-756 Chloride of calcium............. 5-200 Common salt.................. 4091 Carbonate of soda.............. 3-355* Silica.......................... 0-455 36-444 The sulphuretted hydrogen and carbonic acid gas had made their escape during the conveyance of the water to Glasgow, and could not therefore be ascertained. The bottle marked concentrated Ilkeston water had a pretty deep reddish brown colour, a saline and bitter taste, and gave a deep violet colour to cudbear paper. When an acid was dropped into it, a pretty brisk effervescence took place, showing clearly the presence of an alkaline carbonate. The specific gravity was 1-04107. This liquid was not precipitated by oxalate of ammonia, nor did prussiate of potash produce any alteration in its colour. The colouring matter was found to be a vegetable substance; but it was present in too small quantity to permit its nature to be deter- mined. ♦This is made up by supposing the loss to have been carbonate of soda, as it undoubtedly was. 692 WATERS, (MINERAL) Five hundred grains of this water being evapo- rated to dryness, left 24-6 grains of saline residue in two different trials. These 24-6 grains being subjected to analysis, were found to consist of, Sulphate of soda................ 8-676 grs. Common salt.................. 2-483 Carbonate of soda..............13-855 25-014 Besides a trace of lime, oxide of iron, and oxide of copper. There is an excess in this analysis amounting to 0-414 grains. It is owing, we be- lieve, to the sulphate of soda, into which the whole salt was ultimately converted, not having been long enough heated to drive off every trace of moisture. The constituents of the imperial gallon, accord- ing to this analysis, are, Sulphate of soda...............1264-80 grs. Common salt.................. 361-96 Carbonate of soda..............2015-80 3642-56 The difference between the saline constituents of the concentrated and unconcentrated water is so great, that it cannot be explained on any other supposition than that various kinds of springs exist at Ilkeston, and that a very different water has been concentrated from that which was brought under the name of unconcentrated water. Even the supposition that carbonate of soda hud been added on purpose to the concentrated water, would not account for the anomaly, as the sulphuric acid and chlorine bear very different ratios to each other in the unconcentrated and concentrated water. II. Pyrmont Water. Pyrmont is situated near the river Weser, about four leagues from Hamelet, in Westphalia. The springs rise in a beautiful and fertile valley, and amount to about six. These are—1. The sacred fountain, which issues from the ground with a remarkable noise. It supplies the water which the patients drink. 2. The bathing spring, distin- guished by the name of the boiling fountain. 3. The augenbrunnen* (eyefountain,) which, like the preceding spring, contains carbonate of iron. 4. The new spring, only recently brought into notice, and situated about a mile from Pyrmont; the other two springs are called the salt well and the new salt well. The characters of these springs vary somewhat. The waters of the sacred fountain are limpid and colourless. They are covered as they issue from the ground with an atmosphere of carbonic acid gas, which is much more perceptible in winter than in summer. The temperature is always about 58J °. The specific gravity has been stated to be 1-0024. The boiling spring is not so clear and transparent as the preceding one, and it is con- stantly emitting numerous bubbles of carbonic acid gas. The new spring is remarkable for its agree- able flavour. It is the fashion to drink it mixed with wine. The augenbrunnen is weaker than the others, but possesses the same characters. We have no modern analysis of these springs; * So called because it is used as an application to the eyes. but Westrumb, who was remarkable for his ac- curacy, has left us an analysis of them all which is probably very nearly correct. According to him, an imperial gallon of the sacred fountain contains the following saline constituents:— Sulphate of soda................ 28-9 grs. Common salt................... 12-2 Sulphate of lime................ 83-4 Carbonate of lime............... 34-8 Sulphate of magnesia............ 54-7 Chloride of magnesium........... 13-4 Carbonate of magnesia............ 38-9 Resinous matter................. 0-9 Protoxide of iron................ 10-5 277-7 Carbonic acid gas 300 cubic inches. He states the saline contents of the imperial gallon of the boiling fountain as follows:— Sulphate of soda................ 37 grs. Common salt................... 17-5 Sulphate of lime................ 97-5 Carbonate of lime............... 68-0 Sulphate of magnesia............ 60-1 Chloride of magnesium........... 15-0 Carbonate of magnesia........... 12-5 Silica......................... 3-0 Resin......................... 1-0 Protoxide of iron................ 9-0 320-6 Carbonic acid gas 225 cubic inches. This fountain is richer in saline constituents than the former, but contains less carbonic acid gas. The constituents of the augenbrunnen are as follows:— Sulphate of soda................ 11 grs. Common salt................... 5-5 Sulphate of lime................ 61-2 Carbonate of lime............... 380 Sulphate of magnesia............ 180 Carbonate of magnesia........... 11-0 Resin......................... 10 Protoxide of iron................ 40 149-7 Carbonic acid gas 135 cubic inches. The saline contents of the imperial gallon of the new spring are as follows:— Common salt................. 76-36 grs. Carbonate of lime...............72-73 Sulphate of magnesia........... 33-63 Chloride of magnesium.......... 45-45 Carbonate of magnesia..........2363 Silica........................ 2-73 Resin and extractive............ 5-45 Sulphate of iron............... 8-18 Protoxide of iron............... 7-26 275-42 Carbonic acid gas 200 cubic inches. The saline contents of the imperial gallon of the salt spring are as follows:— Sulphate of soda................170 grs. Common salt...................704-4 WATERS, (MINERAL) 693 Sulphate of lime................ 69-6 Chloride of calcium.............. 28-4 Carbonate of lime................ 36-4 Chloride of magnesium........... 32-4 Carbonate of magnesia........... 59-2 Alumina ....,.................. 7-6 Resin.......................... 2-0 1110-0 Carbonic acid gas 236 cubic inches. We perceive that this well is much more im- pregnated with common salt than any of the pre- ceding. The saline contents of the imperial gallon of the new salt well, according to the analysis of the same chemist, is as follows:— Sulphate of soda................ 63 grs. Common salt...................532-4 Sulphate of lime................ 37-3 Carbonate of lime............... 64-8 Sulphate of magnesia............ 5-2 Chloride of magnesium ..........113-5 Carbonate of magnesia........... 3-0 Alumina ........................ 9-5 Resin......................... 8.0 836-7 Carbonic acid gas 230 cubic inches. It is rather weaker than the preceding, though it differs but little in the proportion of carbonic acid gas. III. Seltzer Water. Seltzer, (or, as the Germans write it, Selter,) is a small town on the Rhine, about ten miles from Frankfort and thirty-six from Coblentz. This part of the country has been long known for its beauty, and it abounds in mineral springs. Those of Seltzer issue out of the earth about two hundred paces from the town, in a long narrow valley. The place is frequented by visitors during the summer season, and the water is sent in stone bottles, closely corked and sealed, to different parts of Europe. Seltzer water is transparent and colourless, and sparkles much when poured into a glass. Its taste is slightly pungent, with a saline and decidedly alkaline flavour. If left exposed to the air, it soon loses its pungency, and its saline and alkaline taste becomes stronger. As a medicine, this water has been in high re- pute ever since the days of Hoffmann, who re- commended it as aperient and highly diuretic. It has been found useful in all those diseases for which acidulous waters are recommended, and at one time it was considered as almost a specific in calculous diseases, whether in the kidney or the bladder. The most accurate analysis is probably that of Westrumb, who found the saline constituents of the imperial gallon of this water as follows:— Common salt...................185-5 grs. Crystals of carbonate of soda......167-7* Carbonate of lime ............... 27-2 Carbonate of magnesia............ 15-7 * Equivalent to 62 88 grains of anhydrous carbonate oi soda. Carbonate of iron...............'• 1-2 Silica......................... 2'4 399-7 Carbonic acid gas 343-8 cubic inches. So that 100 cubic inches of this water contain 124 cubic inches of carbonic acid gas. It is ob- vious from this that it has been saturated with gas under a certain degree of pressure. It is the richest in carbonic acid of any mineral water with which we are acquainted, excepting the waters of Gmlenau, to be noticed afterwards. IV. Pougues. Pougues is a town situated on the great road from Paris to Lyons, distant about nine miles from Nevers. The country is fertile, and exhibits numerous little hills which add considerably to the beauty of the district. The principal mineral spring acquired great celebrity during the sixteenth century, having been visited by the prince of Mantua, Henry III. of France, Catharine de Medicis, Henry IV., Louis XIV. and many other eminent personages. The prince de Conti embel- lished the environs of the spring by planting trees around it. It lies in a limestone country, and is situated in a meadow about four hundred paces from the town and six hundred from the nearest limestone hill. The water is abundant at all sea- sons of the year. It is limpid and colourless. Its taste is pungent, and it is destitute of smell. When left in an open vessel, it deposits a small quantity of oxide of iron. We are not aware that any later analysis of this water has been made than that of Hessenfratz in 1789, at a time when chemists were not in pos- session of such accurate methods as at present. The saline constituents of the imperial gallon, according to his experiments, are as follows :— Carbonate of lime..............112-96 grs. Carbonate of soda.............. 96-30 Common salt.................. 20-37 Carbonate of magnesia.......... 11-11 Alumina...................... 3-24 Silica with protoxide of iron..... 29-63 273-63 Carbonic acid gas 325.9 cubic inches. If any confidence can be put in this analysis, the quantity of carbonic acid in the waters of Pougues does not fall short of that which exists in Seltzer water. It must answer all the purposes of Seltzer water, and be equally applicable to all the diseases for which that water is considered as a remedy. V. Mont d'Or. Auvergne, in which the small village of Mont d'Or is situated, abounds in acidulous waters. The hot mineral springs of Mont d'Or were known and frequented by the Romans, who have left monuments of their residence, several of which still remain. The village is situated in an elevated country about twenty-four miles from Clermont. The Monts d'Or, as they are called, are covered with snow during seven months of the year. It is only from May to September that they afford an agreeable residence. Indeed the accommoda- tions are not very good. The springs are four in number, which all rise 694 WATERS, (MINERAL) at the bottom of the mountain L'Angle. They are very near each other, and situated in a straight line, and traverse the village from north to south- west. The highest of these springs is distin- guished by the name of St. Marguerite. Its waters are received in an open basin composed of cut stones. Near this basin, and a little to the right of it, is another spring, whose waters are of the same nature as those of St. Marguerite. The noise which it makes in issuing out of the ground has induced the inhabitants to give it the name of the drum. The second spring is called Cxsar's bath or balneum cryptx. It is about fifty feet below St. Marguerite's spring. Its waters are enclosed in a very ancient edifice. There are two holes in the floor, through which the waters issue as if they were boiling. The third spring is called the great bath, or the bath of St. John, and is about twenty feet below the second. It is enclosed in a square gothic building. Within it is a rec- tangular basin divided into four parts, and three baths of tinned copper. The fourth spring, called the Magdeline fountain, is situated at the foot of Mount L'Angle: its waters flow into a square building in the centre of the Pantheon Place. The waters of these four springs possess dif- ferent properties. Those of the Magdeline are transparent and free from smell, and have an acidulous and saline taste. Their temperature is 107° 5. The surface is covered with a very thin iridescent pellicle. The specific gravity is 1-0015. The properties of Cxsar's bath are analogous ; but its temperature is 113°. It furnishes 2441 cubic inches of water per minute, which is not much less than nine imperial gallons. The waters of the great bath have a slight taste. The temperature is about 108°. The waters of St. Marguerite are clear and limpid, and let fall no deposite in their channel. Their taste is acidulous and slightly styptic. Their tempe- rature is about 40° or 42°. They are much used to dilute wine for drinking. For the best analysis of these waters we are indebted to M. Bertrand, who published an excel- lent treatise on them. According to him the saline contents of the imperial gallon of these waters are as follows :— Carbonate of soda..............33-07 grs. Sulphate of soda............... 9-97 Common salt..................25-37 Alumina......................10-85 Carbonate of lime..............20-30 Protoxide of iron............... 1-92 Carbonate of magnesia.......... 6-65 108-13 Carbonic acid gas____4-79 cubic inches. The waters of Cxsar's bath, according to M. Bertrand, are similar in their constitution to those of the Magdeline. The saline constituents in the imperial gallon of the waters of the great bath are, according to the same physician, as follows:— Carbonate of soda..............35-00 grs. Common salt..................25-72 Sulphate of soda............... 8-50 Carbonate of lime..............24-15 Carbonate of magnesia........... 8-22 Protoxide of iron............... 0-70 Alumina...................... 6-82 Silica........................ 5.25 114^36 Carbonic acid gas .... 23-95 cubic inches. These springs are considerably weaker in car- bonic acid than some of the preceding, owing probably, to their temperature. V. Tlchi. Vichi is a small and very old town on the right bank of the Allier, situated nearly in the centre of France, in what was formerly the Bourbon- nois. It lies in a valley from which the hills rise in an amphitheatre, and being covered with vine- yards and orchards present a rich and agreeable landscape. The town is but poorly built, and the streets are narrow and disagreeable; but the springs are detached from it, and there are several excellent hotels and walks in their immediate neighbourhood. These springs amount to seven. 1. The great grille, so called because it is sur- rounded by a railing of iron. 2. The little puit- carre, which is enclosed. 3. The great puitcarre. Both of these are used only to supply water for the baths. 4. The little boulet, distant about one hundred paces from the great grille. 5. Lucas's spring, situated very near the little boulet. 6. The great boulet, which is in the neighbourhood of the hospital. These three last springs are inclosed in a cylindrical reservoir and surrounded with a wall, through which passes a tube to allow the waste water to escape. The advantage of this is, that the drinkers get the water before any of its gaseous contents have escaped. 7. The fountain of the Celestines, or of the rock, is at the bottom of a hill situated at the end of the town, and its ap- proach is not very good. The waters of the great grille and of the puit- carre, as they issue out of the ground, give out great bubbles of gas, which break upon the surface and exhibit the appearance of ebullition. The taste of the six first springs is acidulous and alka- line. They have a slightly sulphureous taste, and the wafers of the great boulet and of Lucas's spring seem to be most impregnated with sulphu- retted hydrogen gas. The water of the Celestines is pungent, and its surface is covered with small bubbles of gas. These waters deposit a sediment consisting of carbonates of lime and magnesia and a little oxide of iron. Cattle are particularly fond of these waters, and after having drunk them once, they endeavour to get at them if possible, and even cross the river Allier to reach them. The temperature of these different springs is as follows:— Great grille......................91 i° Great puitcarre...................97 Little puitcarre...................97j Great boulet.....................86 Little boulet.....................73J Fduntain of the Celestines.........63$ For the most recent analysis of these waters we are indebted to M. Mossier. The following tables exhibit the saline contents of the imperial gallon of these waters, according to the analysis of this gentleman:— WATERS, (MINERAL) 695 1. Great Grille. Carbonate of lime.............. 14-91 grs. Carbonate of magnesia.......... 2-78 Carbonate of iron.............. 0-74 Carbonate of soda...............320-46 Sulphate of soda............... 51-57 Common salt.................. 21-17 411-63 Carbonic acid gas .. 132-84 cubic inches. 2. Great Puitcarre. Carbonate of lime.............. 15-74 grs. Carbonate of magnesia.......... 2-78 Carbonate of iron.............. 1-39 Carbonate of soda.............. 300-00 Sulphate of soda............... 63-98 Common salt.................. 35-93 419-82 3. Little Puitcarre. Carbonate of lime.............. 21-29 grs. Carbonate of magnesia.......... 2-78 Carbonate of iron, trace Carbonate of soda..............336-11 Sulphate of soda............... 65-28 Common salt.................. 24-44 449-90 4. Great Boulet. Carbonate of lime.............. 22-68 grs. Carbonate of magnesia.......... 2-50 Carbonate of iron.............. 3-33 Carbonate of soda..............310-37 Sulphate of soda____».......... 5805 Common salt.................. 10-18 407-11 5. Little Boulet. Carbonate of lime.............. 30-46 grs, Carbonate of magnesia.......... 3-24 Carbonate of iron ....'.......... 3-24 Carbonate of soda..............395-37 Sulphate of soda............... 28.12 • Common salt.................. 4-35 464-78 6. Fountain of Lucas. Carbonate of lime............. 31-57 grs. Carbonate of magnesia.......... 3-79 Carbonate of iron.............. 1-57 Carbonate of soda..............264-44 Sulphate of soda............... 60-09 Common salt.................. 67-68 429-14 VII. Geilenau. The village of Geilenau is situated in the grand duchy of Nassau, at no great distance from the city of Frankfort. Its waters are acidulous, and have been long and deservedly held in high esti- mation ; for they are perhaps the most strongly impregnated with that gas of any mineral waters in Europe. The water is clear and transparent, and sparkling. Its taste is pungent and acidulous, without any saline flavour. According to the analysis of Dr. Bischoff of Bonn, who published a treatise on the mineral waters of Germany and France in 1826, the saline contents of the impe- rial gallon of this water are as follows :— Carbonate of soda..............56 grs. Sulphate of soda................ 0.84 Phosphate of soda .............. 2-52 Common salt................... 2-7o Carbonate of lime...............18-10 Carbonate of magnesia...........20-37 Carbonate of iron............... L47 Silica......................... 0-98 10301 Carbonic acid gas.....452-51 cubic inches. Here the carbonic acid gas amounts to 1-6322 times its volume. The mineral spring of Fachungen lies likewise in the duchy of Nassau, and at no great distance from that of Geilenau. It has also been analysed by Bischoff, who found the saline constituents in the imperial gallon of this water as follows:— Carbonate of soda..............149-89 grs. Sulphate of soda............... 1-54 Phosphate of soda............. 0007 Common salt.................. 39-28 Carbonate of lime.............. 22-75 Carbonate of magnesia.......... 15-77 Carbonate of iron.............. 0-84 Silica........................ 0-77 230-847 Carbonic acid gas.....373-86 cubic inches. This water, though not so strongly impregnated with carbonic acid as the preceding, is yet well charged with it. It contains 1-3485 times its bulk of it. VIII. Eger. Egerland constitutes a wide valley at the western extremity of Bohemia, surrounded on all sides by eminences. It seems originally to have been a lake which burst its barriers between Culm and Konigsberg, and nothing of which remains but the river Eger, which flows through the val- ley, passes through a gorge between Culm and Konigsberg, and makes its way to the Elbe. The principal town in this district is Eger. In this valley there are several acidulous springs, which have acquired considerable celebrity. The spring which has been longest known, and which is most frequented, has received the name of Franzens- brunnen, from the name of one of the emperors of Austria, to whom it is indebted for much of the accommodations which it possesses. It was analysed, by Reuss in 1792, by Trommsdorf in 1820, and by Berzelius in 1825. According to this last chemist, the constituents in the imperial gallon are as follows : Sulphate of soda..............222-44 grs.. Common salt................. 84-15 Carbonate of soda............47-29 Carbonate of lithia............ 0-34 Carbonate of lime............. 16-41 Carbonate of strontian......... 0-028 Carbonate of magnesia......... 6-125 Carbonate of manganese........ 0-392 Carbonate of iron............. 2-142 Phosphate of lime............. 0-210- 696 WATERS, (MINERAL) Subphosphate of alumina....... 0-112 Silica....................... 4-312 383-931 According to Reuss, the imperial gallon of this water contains 446-17 cubic inches of carbonic acid gas. If this statement be correct, 100 cubic inches of the water must contain 160 cubic inches of this gas. Berzelius has given us the fixed constituents of three other mineral springs in this district. They are all acidulous ; but as the water which he analysed, was concentrated on the spot, and sent to a distance to be analysed, the gaseous contents could not be determined. It will be sufficient if we give, in the following table, the constituents obtained by Berzelius from the imperial gallon of each of these springs. Sulphate of soda......... Common salt............ Carbonate of soda....... Carbonate of litllia...... Carbonate of lime....... Carbonate of strontian .. Carbonate of magnesia .. Carbonate of manganese Carbonate of iron....... Phosphate of lime....... Subphosphate of alumina Silica................... Fluoric acid............. Iodine................... Salt Spring Grain 190154 79-933 47-467 0245 12-936 trace 7 273 0112 0-644 J 0-224 4 473 Ferdi- nand's Spring. Grains. 205-408 81-99* 55-874 0-616 36-5G1 0049 27-790 0-960 3-64(1 0049 6104 trace trace ? 349-401 419-049 603-288 The cross Spring. Grains. 347-410 123-627 65016 1043 35-861 0035 24-780 0-350 1003 0-028 3-535 trace Specific gravity of Franzensbrunn.....1-005387 " " salt springs........1-004883 That of the other two springs is not stated. IX. Ems. The celebrated mineral waters of Erns are situ- ated on the north bank of the river Lahn, not far from Darmstadt and Nassau Dietz, in the duchy of Nassau, and about two hours' journey from Coblentz on the Rhine. The mineral waters of this place have a temper- ature of 90°. Their taste is saline and bitter. They are considered by medical men as possessing virtues similar to those of Bath-water in England. They have been frequented for nearly three cen- turies, and employed both for bathing and internal use. Two springs have been set apart for baths, and two for drinking. We are not aware of any modern analysis of these springs. Many years ago, they were examined by Cartheuser, who de- tected in them soda, lime, and iron: but when he lived, the art of chemical analysis had made so little progress that it was not in his power to de- termine the weight of these constituents. [The Sweet Springs, of Monroe county, Vir- ginia, are the best specimen of simple carbonated waters in the United States. The temperature of the water is 73°.] V. Of Hot Sprixgs. This division, though not natural, is at least convenient. It is obvious, from the preceding part of this article, that both sulphureous and acidulous and chalybeate waters may be hot as well as cold ; for we have described several of each of these in the preceding sections. The saline springs are frequently hot also, as well as cold. We have reserved several of these for this section, The reason which induced us to give a separate section to the consideration of hot springs, is thai there are several of them in this country which are possessed of a high reputation, and which have been long celebrated for the numerous curei which they perform, and frequented accordingly, Thus Buxton enjoys a high reputation for curing chronic rheumatism, while Bristol hot-well ii equally celebrated for its salutary effects on con- sumptive patients. Now these waters contain to little saline matter, or indeed foreign matter of any kind, that we cannot avoid ascribing their medi- cinal properties chiefly at least to their tempera- ture. Hence, considered in a medicinal point of view, such waters ought not to be overlooked, ai they point out the particular temperature at which waters, when used as a bath, are most beneficial in removing certain complaints. [The simple thermal waters have the same effect upon the economy as warm water and hot water baths. (See Bathikg.) They have the great ad- vantage, however, in rheumatic and other diseases, that their temperature continues the same, what- ever may be the duration of the immersion.] I. Matlock Water. The situation of the village of Matlock is per- haps the finest in England. It lies in a moun- tainous part of Derbyshire, half-way down a pretty steep limestone hill, at the foot of which flows the clear and rapid stream of the Derwent, the steep banks of which are covered with a thick clothing of woods. The view is not extensive, but it is rich and picturesque in the highest degree. A number of springs issue from the limestone rock, all of them possessing the clearness and purity which characterize mountain streams. Many of them are of the mean temperature of that part of England, while there are others whose temperature is always steadily above that point. All the tepid springs arise from fifteen to thirty yards above the level of the Derwent, while those situated either above or below that level are cold. The supply oX tepid water is very copious, and the tempera- tTrre, as determined by Dr. Percival, is always very nearly 66°; according to Scudamore, 68°. In its sensible properties, this water scarcely differs from common good spring-water. It is beautifully clear, and has no peculiar taste or smell by which it can be distinguished. When it first issues from the ground, it is said to curdle soap, owing, probably, to its containing carbonate of lime in solution ; but this property it loses when left for a few days standing exposed to the air. Its specific gravity, as determined by Sir Charles Scu- damore, is 1-0003. This water has not been subjected to a regular analysis; but from the effects of tests upon it, we learn that it contains some carbonic acid gas and some carbonate of lime. There are present, also, sulphuric and muriatic acids in minute proportions. It contains also a little magnesia, and, probably, common salt; but from the specific gravity and sensible properties of this water, it is obvious that the saline constituents must be very minute in quantity. As an internal remedy, it may doubtless be used with advantage in all cases where water as a di- WATERS, (MINERAL) 697 luent is advantageous. On this account, its in- ternal use use may doubtless be advisable in dys- pepsia and gravel. But it is as a bath that it is chiefly useful. Its temperature being 66°, it occa- sions but little shock on immersion, and is there- fore peculiarly fitted for those delicate habits that cannot exert sufficient reaction to overcome the effects of the ordinary cold bath, and on which the benefits which it produces chiefly depend. II. Bristol Hot Well. This spring, formerly one of the most celebrated in England, is situate at the bottom and southern ex- tremity of St. Vincent rock, a lofty cliff on the banks of the Avon, on the Gloucestershire side, about a mile below the city of Bristol, and four from the Bristol Channel, where the Avon flows into the sea. The country is exceedingly beautiful, and this beauty is owing in a considerable degree to the bold banks of the Avon, the hilly nature of the country, and the rich clothing of wood with which it is adorned. St. Vincent rock is composed of limestone, employed both as a building stone, and to be converted into quicklime. The Hot well spring is a very fine clear water, discharging at the rate of about forty gallons in a minute. It has no smell, but is limpid and spark- ling, and gives out air-bubbles when poured into a glass. It is very agreeable to the palate, and is, in fact, without any peculiar taste, and so pure, that it is employed by the inhabitants in prefer- ence for making tea or coffee. Its specific gravity is 1-00077. Its average temperature is 74°. It is slightly affected by the spring tides, which rise 'to an immense height in the Severn and Avon. It becomes somewhat turbid, and during these periods it is not used till by two hours' pumping the water returns to its original purity. It .has been repeatedly analysed, though not by modern chemists. The latest analysis which we have seen is by Dr. Carrick, published in the year 1797. The saline constituents in the imperial gallon of this water, according to his analysis, are as follows:— Chloride of magnesium............. 8-7 grs. Common salt....................4-8 Sulphate of soda.................13-5 Sulphate of lime.................14-1 Carbonate of lime................16-2 57-3 Carbonic acid gas......36 cubic inches. Oxygen and azotic gases.. 3-6 39-6 These salts are purgative; but their quantity is so trifling, not exceeding six grains in the wine- pint, that they can scarcely be supposed to pro- duce any sensible effect. The carbonic acid gas rather exceeds one-ninth of the bulk. Its medi- cinal virtues, therefore, must be ascribed to its temperature chiefly. When taken warm and fresh from the spring, it is said to produce a gentle glow in the stomach, sometimes succeeded by slight headach and giddi- ness. A continued use of it usually produces an increased flow of urine, while the skin is kept moist and perspirable; and the appetite and gene- Vol.IV. —88 31 ral health are usually improved by a residence at the Hot wells. These effects, we doubt not, would be equally derived from the use of any otheT pure water raised to the same temperature. III. Buxton Water. The tepid springs of Buxton have been long known and resorted to; indeed, it is probable that they were frequented during the time of the Ro- mans. In the year 1572, a treatise on their vir- tues was written by Dr. Jones of Derby, from which we learn that at that time they were crowded with visitors from the neighbouring coun- ties. They were examined in 1784 by Dr Pear- son, and in 1820 they were subjected to a chemi- cal analysis by Sir Charles Scudamore and Mr. Garden. Buxton is situated at the north-western ex- tremity of the county of Derby, on the borders of Cheshire, in a narrow valley surrounded on all sides by hills. The whole of this part of Derby- shire is mountainous and thinly inhabited. The hills are composed of mountain limestone, a well- known rock lying immediately under the coal- beds. Some of the hills at a little distance, as Mam Tor, are composed of sandstone, perhaps belonging to the coal formation. The mountain limestone of this district is distinguished for the numerous caverns which it contains, the most re- markable of which are Pool's Hole and the Peak Cavern. The climate of this part of Derbyshire is cold and rainy ; but the soil is of so dry a nature, that the moisture immediately runs off. Hence it hap- pens that the shortest interval of good weather may be taken advantage of by the invalid. The high winds, though too often bleak and unplea- sant, yet obviate all the inconveniences which at- tend stagnation. Much has been done by the Duke of Devonshire to embellish the place. The crescent in particular has a grand effect, when we descend towards it from the neighbouring hills. The warm springs of Buxton rise into day through numerous small fissures in the limestone rock, and the supply of water is amply sufficient for the numerous baths and other purposes to which it is applied. The original and most an- cient fountain is St. Anne's well, which is enclosed in an elegant stone building. It is appropriated for drinking. The other springs are employed for the baths. Buxton water is clear and transparent, and does not sparkle. It has no smell and no taste by which it can be distinguished from common water of the same temperature. Its temperature as it issues from the earth is 82°, but in the basin its temperature is no higher than 77°. It gives out, soon after it issues to the day, no inconsidera- ble proportion of azotic gas, as was first ascer- tained by Dr. Pearson. Its specific gravity, when cooled down to 60° of Fahrenheit, is 1-0006. Dr. Pearson was the first who attempted to analyse this water. From a wine-gallon of it he extracted the following salts : Carbonate of lime...............H.5 grs. Sulphate of lime................ 2-5 Common salt................... 1.75 15-75 693 WATERS, (MINERAL) The analysis of Scudamore and Garden in 1820 gives us the following as the saline consti- tuents in the imperial gallon of Buxton water. Sulphate of soda................ 0-76 grs. Chloride of calcium.............. 0-62 Common salt................... 2-16 Chloride of magnesium........... 0-70 Carbonate of lime...............12-48 Extractive, &c................... 1-44 18-16 Carbonic acid gas .. .t 1-8 cubic inches. Azotic gas..........5-57 7-37 The existence of azotic gas in this water, with- out any trace of oxygen, is not easily accounted for. In general, the azotic gas contained in mine- ral waters is merely what is imbibed from the atmosphere. It is accordingly mixed with oxygen gas ; and as oxygen gas is more absorbable than azotic gas, the gas extricated from water by boil- ing is richer in oxygen gas than common air. When a water contains an impregnation of sul- phuretted hydrogen gas, all the oxygen gas which it may have absorbed is of necessity abstracted. Water in such a case may contain carbonic acid gas, and it may also contain azotic gas ; but here we have a water deprived of all its oxygen gas, without containing a trace of sulphuretted hydro- gen gas. The quantity of azotic gas present is precisely what ought to be contained in Buxton water, on the supposition that it was imbibed from the atmosphere. But what has become of the oxygen gas ? The imperial gallon should con- tain lg cubic inch of it. We suspect strongly that it would be found were the water properly examined. For example, if a drop or two of newly dissolved sulphate of iron were dropped into a glass of Buxton water, and afterwards a drop of caustic potash added, it would be easy to see whether the water contained oxygen gas. If it did, the iron would be precipitated yellow; if it did not, it would be thrown down of a dirty green, which would not alter its appearance. The great reputation of Buxton water depends upon its use as a bath. St. Anne's spring, how- ever, is taken internally by invalids while enjoying the benefit of the baths. When taken internally, it is said to be inconveniently stimulating to some persons of a sanguineous temperament and full habit of body. It is said to produce headach, giddiness, and flushing of the face. It is not easy to account for these effects from its saline consti- tuents. We are disposed to ascribe them, so far as they are not fanciful, to the temperature of the water. Nor have we any doubts that temperature enters as a most important ingredient in the effects which water produces when taken into the stomach. But it is as a bath that the value of Buxton water is to be chiefly appreciated. It is to per- sons labouring under chronic rheumatism that it is most useful. The baths are highly convenient, and provided with every thing requisite for the convenience ar/d accommodation of the bather. It is said in the first place to aggravate the symp- toms ; so that a patient is congratulated, when, upon first having recourse to it, his pains are aug- mented. Gouty patients are also benefited by the use of these baths ; but they arc considered as in- jurious to those who are labouring under a gouty paroxysm. The best time for bathing is before breakfast, and it is better to plunge in at once than to step slowly in. At the instant of immersion a slight sense of chilliness is perceived ; but this is speedily followed by a moderate degree of warmth and an agreeable sensation, which the patient compares to immersion in cream. At first he should not remain more than a few minutes in the bath. The proof that it agrees with the patient is that he de- rives an agreeable refreshment and a general in- crease of elasticity. It acts unfavourably when it occasions feelings of chilliness, lassitude, and a languid appetite. Besides the tepid springs, Buxton possesses also a chalybeate spring, which rises (according to Sir C. Scudamore) from a bed of shale, on the north side of the river, near the George Inn. It ii weakly impregnated with carbonate of iron, and contains very little saline matter. Its specific gravity is only 1-0003, and its temperature as de- termined by Scudamore is 54°. IV. Batli Waters. The city of Bath undoubtedly owes its exist- ence, as it does its name, to the use of the warm springs in which it abounds. From the remaini of Roman baths which have been discovered in it, we cannot doubt that these springs were noticed by the Romans, and employed by them to supply the luxury of a warm-bath. It continued to be more or less frequented during every period of English history ; but it was not till the reign of Charles II. that it became a fashionable resort to the gay and the idle, as well as the invalid. Bath is situated in a deep narrow valley in the county of Somerset, distant one hundred' and seven miles from London, and twelve from Bris- tol. It was originally confined to the valley, and occupied a space amounting to about fifty acres. But the celebrity which it acquired induced the inhabitants to extend it in all directions, and it has gradually creeped up the hills with which it was originally surrounded. The elegant magni- ficence of its circuses and crescents is too well known to be dwelt on here. The view is not ex- tensive, but it is rich and beautiful, while the city itself has no parallel for splendour in any part of England. It is situated in the great oolite form- ation, and the oolitic limestone of the neighbour- hood is used as a building-stone. It is this cir- cumstance chiefly which has given Bath such a superiority of appearance over the brick-built houses of the other towns of England. The climate is mild but rainy; and the new town from its exposed situation is open to the west and south-west winds, which are the most frequent and most violent. The hot springs in Bath are three in number, namely, the King's-bath, the Cross-bath, and the Hot-bath. These springs all rise at a short dis- tance from each other at the lower part of the town, and not far from the Avon, into which the hot water flows after having supplied the several baths. The water is so abundant that all the re- servoirs used for bathing are filled every evening with water fresh from the respective fountains.. WATERS, (MINERAL) 699 According to Mr. Phillips, the temperature of the lbre#3prings is us follows: Hot-bath........................117° King's-bath......................114° Cross-bath......................109°* Their specific gravities at 60°, as determined by Scudamore and Children, are as follows:— Hot-bath......................1-00245 King's-bath....................1-00238 Cross-bath.....................1-00231 The water when first drawn is quite clear and colourless, and not the least brisk or sparkling. When left for some hours exposed to the air, it becomes muddy and lets fall a pale yellow ochre. The taste of the water while hot is chalybeate without any flavour distinctly saline; but if it be allowed to cool, the chalybeate taste vanishes, and you can hardly distinguish Bath-water from any other common water. Bath-water has been frequently analysed. Dr. Lucas, Dr. Charlton, Dr. Falconer, and Dr. Gibbs, published experiments on it in succession ; but by far the best and most satisfactory analysis is that of Mr. Phillips, published in 1806. (Phil. Mag. vol. xxiv. p. 342.) According to his experiments, the saline contents of an imperial gallon of this water are as follows :— Sulphate of lime.................86-41 grs. Common salt...................31-68 Sulphate of soda................14-40 Carbonate of lime............... 7-68 Silica.......................... 1-92 Protoxide of iron................ 0-02 142-11 Carbonic acid gas............11-52 cub. in. Through the water in the King's-bath, bubbles of gas are perpetually rising in considerable numbers. Mr. Phillips collected a portion of this gas and examined it: he found it a mixture of 5 volumes carbonic acid gas 95 volumes azotic gas 100 We have here, therefore, the same phenomenon as at Buxton, namely, azotic gas escaping from the water without any mixture of oxygen gas whatever. Is this absence of oxygen gas to be ascribed to anything connected with the tempera- ture of the water? or is it connected with the small proportion of iron which it contains 1 When Bath-water is newly drawn from the spring, it strikes a purple with the infusion of nut-galls, and a blue with a solution of prussiate of potash; but after remaining sometime exposed to the air, neither of these re-agents is capable of indicating the presence of iron. Mr. Phillips has shown that this alteration is owing to the presence of carbonate of lime in the water, and to the con- version of the iron by the action of the air from protoxide to peroxide. Carbonate of lime pro- motes the action of these two reagents on solu- tions of protoxide of iron, but it almost destroys their action in peroxide of iron. * According to Dr. Falconer the temperature of the King's-bath is 116«> and that of the Cross-bath 1120. Sir Charles Scudamore made a set of experi- ments upon Bath-water in 1820. From these experiments compared with those of Mr. Phillips, he considers the saline constituents in the imperial gallon to be as follows:— Chloride of calcium..............11-52 grs. Chloride of magnesium...........15-36 Sulphate of lime................91-24 Sulphate of soda................ 8-64 Silica......................... 1-92 Protoxide of iron................ 0-02 128-70 The differences between these two results are owing chiefly to the mode of considering the con- stituents. Mr. Phillips evaporated the water to dryness and analysed the residue. Scudamore determined the weight of the constituents by pre- cipitation, and then supposed them combined so as to constitute the most soluble salts. Both of these modes of proceeding are liable to objections; but we have made some remarks on the subject in a previous part of this article. The presence of magnesia in Bath-water was discovered by Scuda- more. So much hasJpeen written upon the medical properties of the^Bath-water, that it may seem superfluous to touch upon the subject. As a bath, its value doubtless depends in a great measure on its temperature. It contains (if the last view of its saline constituents be taken) several salts which possess purgative qualities; and although the im- pregnation be not considerable, there can be no doubt that if a person continue the use of the water, they will at last produce a certain effect, especially the chlorides of calcium and magnesium, which act with considerable energy upon the liv- ing body. The proportion of iron is small, and it exists in the water in the state of carbonate. But iron is so active a medicine even when administered in small quantities, that the iron in Bath-water can- not be without its effect upon the system. Bath-water has been recommended by medical men as a remedy of no small efficacy in chlorosis, visceral obstruction, palsy, gout, rheumatism, co- lica pictonum, hypochondriasis, St. Vitus's dance, and lepra. These diseases are of so opposite a character, and require so very different treatment, that it is difficult to understand how Bath-water can be applicable to them all. As a bath, its tem- perature may render it valuable in gout, rheuma- tism, and lepra, and even in St. Vitus's dance. The ferruginous constituent might give it some value when taken internally as a remedy in chlo- rosis, while the saline constituents, joined to the temperature, might be conceived to give it some value as an internal medium in visceral obstruc- tions, hypochondriasis, colica pictonum, and even palsy. But if we consider the very small quan- tity of iron present, and even of purgative salts, we can scarcely doubt that the principal benefits derived from the use of this water arise from its temperature. The internal use of this water in cases of in- flammation has been interdicted by medical men ; and this prohibition is founded upon its stimulat- ing qualities. We cannot avoid thinking that 700 WATERS, (MINERAL) much of the benefit resulting from the use of mi- neral waters is owing to the mode of living with which the employment of such waters is accom- panied. If a person who has been in the habit of living fully, and indulging in the pleasures of the table without restraint, be suddenly removed from the centre of the metropolis, and placed in one of the parades or crescents of Bath, and if he be pre- vailed upon to enter upon a course of Bath-water, and to take the air and exercise with which such a course is accompanied, it is obvious that his general health will be greatly improved, and that improvement will be ascribed to the use of the waters, whereas in reality it is owing to the altera- tion in the mode of living — to the additional air and exercise, and the substitution, in part at least, of water for wine. In gout the greatest benefit is derived from Bath-water in those cases where it produces ano- malous affections of the head, stomach, and bow- els. The principal advantage here is to be able to bring by warmth that active local inflammation in any limb which relieves all the other trouble- some and dangerous symptoms. Hence it is commonly said that Bath-water produces the gout; by which is meant that when persons have a gouty affection shifting from g^ace to place, and thereby disordering the system, the use of Bath- water will soon bring on a general increase of action, indicated by a flushing of the face, fulness in the circulating vessels, and relief of the dys- peptic symptoms; and the whole disorder will terminate in a regular fit of the gout in the ex- tremities, which is the crisis always to be wished for. (Saunders on Mineral Waters, p. 187.) Scudamore considers their use as inadmissible when an active state of gouty diathesis is present, and likewise when the constitution is undermined by the long continuance of gout accompanied by irregularity of living. The reason of this restric- tion is too obvious to require any illustration. We refer the reader to Dr. Saunders's Treatise on Mineral Waters for some very judicious remarks on the use of Bath-waters. V. Carlsbad Waters. The village of Carlsbad (Bath of the Emperor Charles) lies at the south-west side of the king- dom of Bohemia in a narrow and dark valley, very near the hollow through which the river Eger runs. A brook, called the Tepel, flows through the middle of this small valley, and nu- merous hot springs rise on both sides of this brook at a little distance from each other. The number of these springs is very great; but five or six of them have been distinguished by names and chiefly used for the baths. These are the sprudel or furious spring, the muhlbrunnen or millspring, the neubrunnen or new spring, Theresienbrunnen or Theresa's spring, and Bernardsbrunnen or Ber- nard's spring. The springs rise through openings in a limestone-bed, over which conduits are erect- ed, up which the waters are forced a certain way by the internal pressure, so as to suit the purposes of the bathers. This limestone-bed has been de- posited by the waters themselves. It was broken through by the waters in 1713 and 1727, and the hot stream flowed directly into the Tepel. This induced the proprietors to pierce the limestone-bed in order to dicover the cause of this alteration and to prevent it from happening again. As soon at they made a hole in the upper bed, the Grater issued with violence, and various cavities of dif- ferent sizes were observed filled with the water. The bottom of these cavities consisted of another bed of limestone, which was also pierced, and below it other cavities were observed from which the water rushed with still greater force. The bottom of these cavities consisted of a third bed of limestone. This being also piercod, a great reservoir of water was discovered which received the name of sprudelkessel, or cauldron of the sprudel. The thickness of each of the beds of limestone thus pierced was between one and two feet, and consisted of a white stone with brown bands, to which the name of sprudelstein (sptu. del stone) has been given. These three beds are not concentric with each other. They constitute unequal spaces separated by partitions, as if hemi- spheric vases were placed reversed upon each other. The water in this reservoir was boiling with violence: its depth varied from three to four yards, and in one direction no bottom could be found with poles tied to each other to the length of thirty fathoms. It was from this place that the waters seemed to flow. This reservoir is of vast extent. We come upon the calcareous crust that covers it, if we dig down in almost any part of the village of Carlsbad, and when this crust is pierced, the hot-water rushes through it with vio- lence. Carbonic acid gas issues in such quantities from the crevices in this crust, that the cellars of the houses are filled with it, and from that part of the Tepel which is near the sprudel, we see bubbles of carbonic acid gas rise in great numbers. The opening thus artificially made was shut up with mason-work, the joints of which soon became covered with sprudelstein. Thus the water was kept in its basin and obliged to rite by the ordinary openings, and to flow out from their mouths. These openings are gradually filled with sprudelstein deposited from the water, and this deposition takes place so rapidly that they require to be cleared out four times a year. What is called the sprudel is an opening in the basin through which the water is driven out at intervals; for the water and gas rush out alter- nately. The upper parts of the basin become filled with carbonic acid disengaged from the hot- water, in consequence of the diminution of pres- sure as the water rises towards the surface of the earth. This gas, accumulating in the upper part of the basin, presses upon the surface of the water, and at last issues out instead of it at the opening. In this way the water and gas alternate about eighteen or nineteen times per minute. The quantity of hot-water is immense. Ac- cording to the measurements of Reuss, Fuhr- mann, Damm, and Mitterbacher, the sprudel alone gives 192§ millions of cubic feet of hot-water per day, All the springs at Carlsbad have the same spe- cific gravity, namely, 1-004975 at the temperature of 64£o. While under the earth they are all boiling hot; but their temperatures as they issue out of the ground are different, depending upon the degree that they have been cooled while pass- ing from the sprudelkessel to the surface. The WATERS, (MINERAL) 701 temperatures of the principal springs have been stated by Becher, a physician, who resided on the ■pot and paid particular attention to Carlsbad water, as follows :— Sprudel....................... 164°-75 Neubrunnen ..................144.5 Muhlbrunnen..................133-7 Theresienbrunnen..............133-7 Schlossbrunnen................122-6 It was analysed with much accuracy by Becher in 1771, who obtained from 1000 parts of the water 5-55 of saline constituents, consisting of the following salts:— Sulphate of soda..................2-52 Carbonate of soda.................1-54 Common salt......................0-87 Carbonate of lime.................0-56 Protoxide of iron..................0-06 5-55 He found that the water of the sprudel con- tained 0-39 of its volume of carbonic acid gas. Klaproth analysed it in 1789, and obtained nearly the same results as Becher. From a thousand parts of the water he extracted the fol- lowing constituents :— Sulphate of soda................2-431 grs. Carbonate of soda...............1-345 Common salt...................1-198 Carbonate of lime...............0-414 Silica..........................0-086 Protoxide of iron................0-004 5-478 Dr. Reuss examined them again in the year 1812. 1000 parts of the sprudel water contain, according to his analysis— Sulphate of soda................2-405 grs. Carbonate of soda...............1-302 Common salt...................1-163 Carbonate of lime...............0-447 Carbonate of iron..............0-004 Silica.......... ..............0-080 5-401 Berzelius subjected them to another examina- tion in 1822, and discovered in it some magnesia, which preceding chemists had overlooked. From 625-4 grammes (9651-8 grains) of the water he obtained— Sulphate of soda...........1-618 grammes. Carbonate of soda..........0-790 Common salt..............0-649 Carbonate of lime..........0-195 Magnesia.................0-054 Protoxide of iron ..........0004 Silica....................0-046 3-356 During his analysis of the water, he met with several substances in minute quantities which had not hitherto been discovered in mineral waters; but he was able to determine their nature by analysing the calcareous deposit from the water, which yielded these new substances in appreciable quantities. The following table exhibits the saline 3 i* constituents in the imperial gallon of Carlsbad water, according to his analysis :— Sulphate of soda..............18200 grs. Carbonate of soda............. 88-81 Common salt................. 7306 Carbonate of lime............. 21-71 Fluate of lime................ 0-225 Phosphate of lime............. 0-015 Carbonate of strontian......... 0-067 Magnesia.................... 12-540 Subphosphate of alumina....... 0-022 n Protoxide of iron.............. 0-254 Protoxide of manganese........ 0059 Silica....................... ' 5-286 384-048 The carbonic acid gas in the imperial gallon, according to Dr. Reuss, amounts to 124-06 cubic inches. Doubtless the waters, before they issue from the earth, contain their own volume of car- bonic acid at the temperature of 212°. The waters of Carlsbad were accidentally dis- covered in 1358 by the emperor Charles IV. while hunting. The country all around would appear to be of volcanic origin. This may, perhaps, in some measure account for the heat of the water. With respect to its saline impregnation it is not possible to form any rational conjecture. From Berzelius's examination, the gas which this water contains is mixed with about one per cent, in vo- lume of azotic gas without any trace of oxygen gas; so that we have the difficulty to account for the absence of this gas which occurred in the case of Buxton and Bath wat^. These waters, besides their high temperature, which fits them admirably for a bath when suffi- ciently cooled down, possess a notable quantity of purgative salts, sulphate of soda, carbonate of soda, common salt, and carbonate of magnesia. Hence they act upon the bowels when taken to a considerable extent. The secretions of urine, perspiration, and saliva, are also increased by the internal use of these waters. It is said to exhibit the effects of a general stimulant by increasing the pulse and heat, and even sometimes by inducing headach in plethoric and irritable habits. It is said also occasionally to bring on a kind of oedema in the feet, which continues for a day or two after using it as a bath. Some other symptoms are enumerated, rather proceeding from the too high temperature of the water than from any thing else. The diseases for which these celebrated hot springs have been recommended are of the most various and opposite kind. It has been found of great use in dyspepsia and other derangements of the healthy action of the stomach. It is no less noted for its services in obstructions of the abdo- minal viscera, not connected with great organic disease, and in defect or depravation of the biliary secretions. They have been long celebrated for their efficacy in those calculous diseases in which the patient is in the habit of passing gravel. No doubt the carbonate of soda is the ingredient which renders them useful in these cases, when there is an excess of uric acid, and a disposition to deposit it from the urine. The small quantity of carbonate of iron which 702 WATERS, (MINERAL) these waters contain, is probably the cause of their being recommended in derangements of the ute- rine system, and particularly in cases of sterility, which they are said to have a tendency to remove. In short these waters may be considered as in some measure combining the virtues of saline, chalybe- ate, acidulous, and hot springs. VI. Plombieres Hot Spring. The village of Plombieres lies in the department of the Vosges, in the ancient province of Lorrain. It is situated to the west of the Vosges mountains, in a deep valley, through which runs the small rivulet called Eau Gronne. The village is small, containing about 1200 inhabitants, but well-built, and the neighbourhood is beautiful and furnishes many delightful walks. The hot springs for which this village is cele- brated were known to the Romans, and for many years they have been frequented by invalids from different countries. The course prescribed to the patients is to continue the use of the waters for three weeks. If, at the end of this period, the patient is not cured, he gives up the use of the waters for a fortnight, and then begins another course, which continues as long as the first. The country is sandy and quite destitute of limestone. The baths are four in number, supplied by dif- ferent springs. 1. The great bath situated in the middle of the principal street, just behind the Ar- cades. It is divided into three parts, which are supplied from two different springs. 2. The new bath, supplied by three springs. 3. The bath of the Capuchins, immediately behind the new bath. 4. The ladies' bath, situated at the eastern ex- tremity of the principafltreet of Plombieres. The waters of Plombieres are limpid and colour- less, and have no peculiar taste. They emit an odour slightly fetid and sulphureous. Their spe- cific gravity, according to Vauquelin, does not differ from that of river water in general. The temperature of the different springs, as determined by M. Martinet, is as follows:— 1st spring of the great bath 144-° 5 2d spring of the great bath 131 Poor's bath............ 99- 5 New bath.............. 90- 5 Capuchins'bath......... 104- to 95° Ladies' bath............ 99- 5 to 95 Spring of the crucifix .... 122 The constituents of these waters were deter- mined by Vauquelin. From his analysis it ap- pears that the saline contents of the imperial gal- lon are as follows:— Carbonate of soda...............10-03 grs. Sulphate of soda................10-80 Common salt................... 5.79 Silica......................... 6.17 Carbonate of lime................ 2-31 Animal matter.................. 5.OI 40-11 The gaseous contents have not been determined. These waters contain so little saline matter that their efficacy in all probability depends upon their temperature. The carbonate of soda may give them some diuretic powers, and may render them useful in some cases of calculous diseases. VII. Wiesbaden. Wiesbaden is situated in Germany, about two leagues from Mayence and seven from Frankfort It lies in a hollow, surrounded on all sides with mountains, except to the north, where there is an opening through which the Sulzbach finds a pas- sage to the Rhine. The temperature, owing to the sheltered situation of the place, is very mild, Snow seldom lies, and even frost is, comparatively speaking, rare. This place has been long celebrated for its hot springs, and has been very much frequented bv the Germans for ages. It constitutes another of the numerous examples of mineral waters in the neighbourhood of Frankfort, which have been already given in this article. There are fourteen springs employed by those who frequent the place. Two of these are open to the day ; the rest are built over. These springs are of two kinds, namely, hot and cold. The hot are saline and acidulous; the cold contain sul- phuretted hydrogen gas. The temperature of the hot springs varies from 117° to 151° in different springs : that of the sulphureous spring, which it called Wielbach, is 65° 75. The constituents of the hot springs, according to the analysis made of them, are as follows, for the imperial gallon : Sulphate of soda............... 6-56 grs. Common salt..................441-51 Sulphate of lime............... 4-18 Chloride of calcium............. 49-31 Carbonate of lime.............. 11-40 Chloride of magnesium.......... 6-86 Carbonate of magnesia.......... 4-56 Alumina...................... 6-86 Extractive matter............... 23-43 Protoxide of iron............... 1-02 555-69 Carbonic acid gas 50-67 cubic inches. The saline constituents of the Weilbach spring, as determined by Dr. Creve, are as follows for the imperial gallon:— Carbonate of lime.............. 3200grs. Magnesia..................... 11-81 Carbonate of soda.............. 42-75 Chloride of magnesium.......... 889 Common salt.................. 7-13 Sulphate of soda............... 10-68 Sulphur resin.................. 3-56 116-89 Sulphuretted hydrogen gas 85-51 cubic inches. Carbonic acid gas........38-00 123-51 VIII. Baden in Switzerland. Baden lies on the banks of the Limmat, about twelve miles from Zurich in Switzerland, and is one of the most ancient towns in Switzerland. The hot springs are five in number, and rise in a plain to the north of the town. Three of these are employed in furnishing water to the public baths. The other two supply about thirty private baths with the requisite quantity of warm water. WATERS, (MINERAL) 703 The most abundant and interesting of these springs is called Sainte Verenne. It rises out of a reser- voir situated in the Place Publique. These baths wero used during the time of the Romans, and Tacitus informs us that it was to them that the town was indebted for its celebrity. These waters as they issue from the springs are nearly at the boiling temperature. The bath re- quires to be prepared seven or eight hours before it is used, that it may have time to cool sufficient- ly. When this water is put into a glass, it is transparent and colourless, but viewed in the re- servoir it appears opal. It has a slight smell of sulphuretted hydrogen, and a slightly disagreeable taste. According to the analysis of Morell, the Baline contents of the imperial gallon of this water are as follows :— Sulphate of soda............... 98-34 grs. Sulphate of magnesia............ 6-97 Sulphate of lime............... 90-27 Chloride of magnesium.......... 24-43 Carbonate of magnesia.......... 29-18 Carbonate of lime.............. 8-36 Protoxide of iron .............. 0-36 257-91 Carbonic acid gas 3257 cubic inches. Sulphuretted hydrogen gas, a small quantity. The reputation of the hot waters of Baden is so great, that they are had recourse to by the in- habitants of the country as a remedy for almost every kind of disease. It is chiefly upon their qualities as a hot bath that their real value de- pends. In chronic rheumatism, and in some other chronic diseases of an analogous nature, they are very useful. They are not much employed as an internal remedy. The principal salts which they contain are of the purgative kind ; but the impreg- nation is not strong. Their chalybeate ingredient is very small, though it considerably exceeds the iron in Bath water, which gets credit for perform- ing many remarkable cures. IX. St. Nectaire Hot Wells. St. Nectaire is a large village built upon a rock at the bottom of a barren glen, on the left bank of the Couze. It lies on the south side of the great plain which constitutes the boundary of Limagne on the west. It is situated in Auvergne, and is at the foot of the enormous volcanic mass called Mont D'Or. The whole of this country is primary, but covered in a great measure with ex- tinct volcanic rocks. The hot springs of St. Nec- taire were known to the ancients and employed by the Romans as baths. The remains of Roman baths have actually been found upon the spot; but after the destruction of the western empire, they had been covered over with rubbish and for- gotten, till they were accidentally discovered in 1812, while digging round a small spring in the neighbourhood. The neighbouring peasants re- paired thither and used the newly-discovered spring as a bath. This induced the French government to appoint a commission to repair to the place and examine the merits of the water. The report being favourable, Dr. Marcon was appointed as medical inspector of the waters. He applied himself to the examination of the different waters, carried M. Berthier to the spot, and prevailed on him to make an accurate analysis of them. Berthier found the specific gravity and saline contents of all the different springs the same. There are a great many springs at St. Nectaire, but six only of these deserve particular notice. These are, 1. The great spring or Gros Bouillon, which was discovered in 1812, while digging a cellar. It seems to have been obstructed by the calcareous deposits which it had gradually formed. Its tem- perature is 104°. A kind of basin has been dug in the calcareous deposits, which all those that frequent these waters use promiscuously as a bath. 2. The old spring, distant about ten paces from the preceding, and rising from the centre of a small basin which appears to be very old. Its temperature is 97i°. 3. The spring of the vault. It lies very near, but a little higher up than the old spring. It is covered by a small building open to all the world. Its temperature is only 74° 75. 4. The road spring was discovered by M. Mar- con during the formation of the great road to Mont D'Or. It is a few hundred yards from the great spring. Its temperature, like that of the preced- ing, is only 74° 75. 5. The border spring (source de la Cdte) is situated about half-way between the bath-house and the village of St. Nectaire, on the right bank of the rivulet. Its temperature is 92° 75. 6. The village spring lies at the bottom of the road which rises from St. Nectaire, a little way above the rivulet. Its temperature is scarcely above that of the cold springs in the neighbour- hood. It is very scanty in its supply. The saline contents of the imperial gallon of this water, according to the result of M. Berthier's analysis, are as follows:— Bicarbonate of soda ............198-30 grs. Common salt..................169-40 Sulphate of soda............... 10-91 Carbonate of lime.............. 30-80 Carbonate of magnesia.......... 16-80 Silica........................ 7-00 Protoxide of iron............... 0-98 434-19 Carbonic acid gas.......108-51 cubic inches. From the large quantity of the bicarbonate of soda contained in these waters, it is evident that they must act with considerable energy when taken into the stomach. To a certain extent they may be considered as analogous to soda water, and might doubtless be of considerable service in those calculous habits in which there is a tendency to deposit uric acid. If we reckon the soda in the state of carbonate instead of bicarbonate, as has been done with the carbonates of lime and magnesia, then the car- bonic acid gas in the imperial gallon of this water will amount to 229-43 cubic inches or 101-91 grains. Of this, the quantity required by the dif- ferent bases to bring them into the state of bicar- bonates, is as follows :— 704 WATERS, (MINERAL)—WORMS. Carbonate of soda...............57-4 grs. Carbonate of lime...............13-55 Carbonate of magnesia........... 8-80 Carbonate of iron............... 1-10 80-85 There is, therefore, an excess of 2806 grains of carbonic acid gas more than is requisite to keep the carbonates in solution. This amounts to 59-11 cubic inches. It would be easy to extend the list of hot springs almost indefinitely ; but those which we have de- scribed include almost every variety at present known to exist. Were we to continue our de- scriptions, we should be only repeating and apply- ing to other springs the remarks which have been already made. [The chief thermal springs of the United States are the Warm Springs and the Hot Springs of Virginia ; the temperatures of which are 97° and 107°, respectively ; the Warm Springs of Bun- combe county, North Carolina, (94° to 104°,) and the Hot Springs of Arkansas, (167° to 210).] Thomas Thomson. WORMS.—It seems to be a principle of nature, says a distinguished physiologist, that every situa- tion capable of supporting living organized bodies should be peopled with them. All animals seem destined to be preyed on by others, not only after their dissolution, but even during their life. The latter part of this assertion is exemplified, at least in a limited sense, in the relation which exists be- tween intestinal worms and many of the other classes of creation. The frequency of worms in the bodies of men, as well as of the lower animals; their obviousness to the senses ; their situation, in most instances, in those portions of the body opening externally, and permitting their occasional expulsion by the efforts of nature alone, and thus, as it were, forc- ing them on the observation, together with their very common connection with debilitated and morbid states of the animal economy, all tended to render them an object of interest from the re- motest periods. Yet, though so long and so fre- quently investigated, there is perhaps no subject in the whole range of medical science around which a greater number of errors, whether of ob- servation or theory, were till very lately accumu- lated ; and though within the last half century an immense progress has been made in the study of helminthology, this, it must be confessed, bears reference rather to the anatomy and physiology, or, in general, to the natural history of worms, than to those questions in human pathology and therapeutics to which they give rise. The history of helminthology, and that of the various opinions entertained of the influence of worms in the production of diseases and in the exasperation of their symptoms — opinions which maintained their ground even through the greater part of the seventeenth century, would require more space than could be assigned to them in the present article, consistently with a due attention to the more practical parts of the subject. There is scarcely any disease which has not at one time or another been attributed to worms; and any one who will take the trouble cautiously to weigh the opinions of some of the most distinguished prac- tical writers, or, what is better, to examine the various well-authenticated facts on record, cannot fail to be convinced that worms do occasionally induce most serious symptoms, and, in some case* extremely rare it is true, even fatal consequences. We proceed, however, without dwelling on this part of the subject at present, to the Classification of the Extozoa. The term entozoa (from the Greek evrot, within, and {wav, an animal) was introduced into the lan- guage of natural history by Rudolphi, now many years ago, and is already very generally adopted both by the French and German physiologists. It includes all those creatures which naturally and permanently inhabit the intestines or any other internal part of animal bodies. By this de- finition the larvae of insects, as they exist only ac- cidentally in the alimentary canal, or at most only for a limited period, and evidently originate in all cases from without, are excluded; as likewise those animalculae, or microscopic zoophytes, which have been detected in certain of the fluids of ani- mal bodies, and the structure of which is so simple or so minute, that no internal organization has yet been detected in them. The entozoa, on the contrary, though likewise occupying a very humble place in the scale of being, yet possess, in general, obvious vessels, serving for the purposes of nutri- tion and generation, and in many instances have also evident muscular fibres. The distinguished physiologist mentioned above, originally intro- duced into his definition of the entozoa the nega- tive character of wanting nerves; but as this is a disputed point, it is better omitted. These parasites are found in all classes of ani- mals, even in the invertebrate, and may exist either in the cavities of the body or in the paren- chymatous substance of the organs. Hence they have been divided by some naturalists into " ver- mes intestinales" and " vermes viscerales;" whilst others have, with greater propriety, preferred an arrangement founded on their external form, or on their internal structure: thus Bloch, from their form, divided them into the long and the broad; and on this division Lamarck, adopting the same principle, has since improved. Linnaeus, without separating them from other worms, arranged some of them under the head of animalia intestina, embracing the gordius, ascaris, and fasciola; and the remainder, hydatids and taenia, under zoophyta. Goeze was satisfied with dividing them into genera, as were likewise Miiller and Schrank. Zeder laid the first foundation of a good classification of these animals, dividing them into five classes, subse- quently called families, at Rudolphi's suggestion; and these were again subdivided into genera and species. Dumeril, separating them altogether from the class Vermes of other naturalists, which com- prised along with them those occurring on the earth and in the water, has made of them, under the title helminthes, a separate family or group of the class Zoophytes, and afterwards, somewhat after the manner of Lamarck, he divides them into the flat, the round, and the vesicular. Brera hai formed, out of the intestinal worms of man alone, five orders, which contain, in all, twelve genera and twenty-six species; just double the number WORMS, 705 recognised by Bremser as genuine intestinal worms. In the «Systeme des Animaux sans Vertobres" of Lamarck, the intestinal worms all fall under the fifth class, of which they constitute the two first orders, under the names of " vers molasses" and " vers rigidules;" the first of which are subdivided into the " vesiculates," « planu- laires," and " heteromorphes," and the second into interior worms (such as the strongle, ascaris, filaria, &c.) and the exterior (dragonneau or dra- cunculus, &c). In Cuvier's arrangement, these animals constitute the second class of zoophytes, and have many external species mixed up with them. Availing himself of a difference in their internal organization, Cuvier has divided them into the " cavitaires," or those which have an ab- dominal cavity and a distinct intestinal canal within it, and the " parenchymateux," or those in which no proper intestinal tube is traceable, and which, for the most part, consist throughout of an homogeneous structure. The former of these divi- sions is equivalent to the Nematoidea of Rudolphi, and includes filaria, hamularia, trichocephalus, oxyuris, ascaris, strongylus, &c.; and the latter coincides in extent with Rudolphi's four last orders, and includes taenia, ligula, hydatids, &c. Thi6 classification of Cuvier's is, however, any thing but a natural one, as worms the most dis- similar in their general appearance, round, flat, and globular, are here promiscuously congregated together. M. de Blainville, recognising in intes- tinal worms very dissimilar degrees of organization, has consequently located them in very different situations in his general system of zoology. Rudolphi doubts the possibility of ever reducing all the species of entozoa to absolutely natural and well-defined families ; but as Zeder's system (of which the first hint was furnished by Goeze) makes the nearest approximation to a perfect natural classification, he has adopted it as his own, with the substitution of classical names for the original German ones. According to this arrangement, the entozoa are divided into five orders or families, viz. the nematoidea, acanthocephala, trematoda, ces- toidca, and cystica. I. Nk.matotdea (vvp.a, a thread, and ttSo;,furm); vermes teretes ; rundwiirmer of Zeder. They con- stitute a very natural order, having a cylindrical and clastic body, a very complicated structure, a digestive apparatus with its two orifices, of which the mouth, by its varieties, affords generic charac- ters. The sexes are distinct; the females, which are longer than the males, being for the most part oviparous. This family is divided into eleven genera. 1. Genus Filaria .- of nearly an equal thickness throughout their whole length, mouth orbicular, male organ a single or double spicula, occurs not only in all parts of the vertebrata, (chiefly in the cellular membrane,) but even in insects and their larvtE. The filaria Medinensis occurs in the cel- lular membrane of man. 2. Trichosoma.- on its anterior extremity, which is very thin, is the mouth, resembling a minute point. It occurs only in the lower animals, mam- malia, birds, and amphibia, between the coats of the stomach, in the intestines, or urinary bladder. 3. Trichocephalus: capillary in front and swell- ing out suddenly behind, mouth orbicular, penis Vol. IV. —89 simple and contained in a sheath; occurs in the ccecum of the mammalia. Trichocephalus dispar in man ; trichocephalus depressiuscuhis in the dog. 4. Oxyuris.- subulate posteriorly, mouth orbi- cular, penis in a sheath. Oxyuris vermicularis, placed in Ascaris by Rudolphi; occurs in the large intestines of man. 5. Cucullanus.- attenuated posteriorly,head with an orbicular mouth and striated hood, penis simple; occurs in the intestines and abdomen of reptiles and fishes. 6. Spiroptera.- attenuated at each end, orbicular mouth, penis comes out between the lateral ahe of the spiral tail; occurs under the nictitating membrane of birds, in the cesophagus and in the stomach of fish, or in tubercles in this organ, in their intestines and swimming-bladder; said to have been also found in the urinary bladder of man. 7. Physaloptera: attenuated at both extremi- - ties, mouth orbicular; tail of the male bent down- wards, winged and furnished below with a sort of bladder, penis coming out of a tubercle ; occurs in the stomach of mammalia, birds, and reptiles. 8. Strongylus: attenuated at both ends, moulh orbicular or angular, the tail of the male terminates in what Rudolphi calls a bursa, and through this the penis passes out; it occurs frequently in the three first classes of vertebrate animals, in the tympanum, trachea, bronchi, cesophagus, lungs, heart, intestines, liver, kidneys, and in aneurismal tumours of the mesenteric and other great arteries. Strongylus gigas in the kidneys of man, the dog, horse, &c; strongylus filaria in the trachea and bronchia of sheep. 9. Ascaris.- attenuated at the extremities, mouth with three valves, penis double. The most nume- rous genus of the intestinal worms; occurs in almost every part of the bodies of vertebrate ani- mals, the cesophagus, bronchi, lungs, stomach, but especially in the intestines, in their membranes, and in tubercles therein; in the abdomen, liver, spleen, mesentery, &c. Eighty species have already been determined. Ascaris lumbrico'ides in the intestines of man and many of the mammiferffi. (Ascaris vermicularis, head with lateral floating processes or ahe, found in the large intestines of man, is placed in this genus by Rudolphi; with Bremser it forms a separate genus—oxyuris.) 10. Ophiostoma: attenuated at extremities, mouth with two lips, a superior and inferior; oc- curs in the intestines of mammalia and fishes. 11. Liorhynchus.- mouth at the end of a sort of erectile and polished tube; occurs in the stomach or intestines of some of the mammalia and of many fishes. II. Acanthocephala, (oKavda, a thorn, and KtfaXn, the head); vermes uncinanti; hakenwtir- mer of Zeder. This is also a natural order. The body is roundish, utricular, terminated anteriorly | by a retractile proboscis furnished with hooks, or I spiculse, arranged in rows ; no intestinal canal; they have distinct genital organs and a separation of sexes. There is but one genus—the echynor- j hynchus. 12. Echynorhynchus: generic definition same as that of the order. Numerous species ; occurs , in all classes of vertebrate animals, in the hog, 706 WORMS. various birds and fishes, &c, generally in the in- testinal canal infixed between its membranes, and occasionally found even in the peritoneal cavity; has also been found in the neck under the skin. III. TnKMATODA (rpnp.a, a foramen); vermes suctorii; saugwilrmer of Zeder. Body flattish, soft, of various forms, often tending to oval; one or more pores on its under surface, and these? fur- nish the grounds of their subdivision into genera. They have no intestinal canal, and the organs of generation of the two sexes coexist in the same individual. 13. Monostoma; a single anterior pore; it oc- curs in mammalia, birds, reptiles, and fishes, be- tween the muscles, in the thorax, the lungs, the intestines, and the abdomen. 14. Amphistomu: two pores, one.anterior and one posterior; found in the stomach, intestines, and abdomen, and in the hydatids of the viscera of mammalia, birds, and reptiles. 15. Distoma: two pores, an anterior and a ventral. Above one hundred and forty species known; occurs in mammalia, birds, fishes, &c. Distoma hepaticum in man; in several of the ro- Jentia; also in the horse, hog, and almost all ruminant animals. 16. Tristoma : three pores, the anterior simple, the posterior radiated ; found fixed in the gills of a species of fish. 17. Pentastoma.- the mouth between two pores Dn each side, through which a spicular process comes out; occurs in the frontal sinuses, lungs, and surface of the liver of the mammalia (dog, horse, wolf,) and in reptiles. 18. Polystoma: six anterior pores, besides a ventral and posterior one; occurs in the throat and. in the branchiae of fishes and bladder of frogs. Polystoma pinguicola found once attached to the ovary of a woman. IV. Cestoidea (kcotoc, a band, and etios,form); vermes leniaeformes; bandwiirmer of Zeder. Body elongated, soft, and flat like a riband; in some continuous, in others articulated ; has lateral or marginal pores and erectile papillse passing through them (lemnisci), supposed to be the male organ of generation. The head is generally marked by two or four depressions, or suckers ; but the head is so dissimilar in different genera, and their form varies so much, that they do not constitute a very natural family. There is no trace of intestinal canal, unless the vessels proceeding from the suck- ers be considered as such. In some, nutrient ves- sels and ovaries are to be seen (tenix). Like the third order, they are all androgynous; but the sexual organs are not well understood. 19. Caryophyllxus.- body flat, continuous, head dilated, divided into flattish processes, furnished with an upper and under lip; occurs in the intes- tines of fishes (carp, &c.) 20. Scolex.- body flat, continuous, head has four fossa: on it; occurs in the intestines and ab- j domen cf fishes, scpise, &c. 21. Gymnorhynchus: body flat, continuous, very long, with a globular receptacle at the neck ; head with two opposite fossa?, and four naked re- tractile probosces; occurs in the muscular substance of many fish. 22. Tetrarhynchus: body flat, continuous, head ' with four fossae and four retractile probosces, fur- J nished with recurvated spicular processes; occurs in reptiles, fishes, molluscse—in the muscles, bran- chiae, stomach and its membranes, the liver and peritoneum. 23. Ligula: in its first stage of development, body elongated with a longitudinal fissure, without any appearance of head or of organs of generation. In its perfect state, a simple fossa on each side of the head, the ovaries and processes (lemnisci) forming a single or double row along the median line; occurs very frequently in birds and fishes very rarely in the mammalia. 24. Trixnophorus.- body elongated, flat, sub- articulated, mouth bilibiate and furnished on each side with two tricuspid acicular processes; occurs in the intestines of fishes, in cysts of the mesen- tery and liver (perch, pike, salmon, &c.) 25. Bothriocephalus.- body long, flat, articu- lated, head subtetragonal and furnished with two or four opposite fossae ; occurs very frequently in fishes and birds, in the branchiae, cesophagus, py- loric appendices, intestines, and abdominal cavityj they occur also, but more rarely, in the mammalia. Bothriocephalus latus, vel txnia lata, in the in- testines of man in Switzerland, Russia, parts of j France, &c. ! 26. Txnia.- body flat, long, articulated, four [ suckers on the head; occurs in the intestines, i biliary ducts, gall-bladder, and liver of vertebrate | animals. Taenia solium vel cucurbitina, occurs in the human intestines in Great Britain, Ger- many, the north of Europe, Holland, part of France, and in Egypt, &c. V. Cystica (kvo-tic, a bladder),- vermes ve- siculates ; blasenwurmer of Zeder. Body flattish • or rounded, and terminating posteriorly in a trans- \ parent bladder-like cyst filled with a pellucid fluid, and appropriated in some genera to a single indi- j vidual, whilst in others it is the joint property of several. The head, which is retractile, exhibit? ; two or four fossae, or depressions, or four suckers with a coronet of humular processes, and four probosces. The organs of generation and nutri- tion are almost, or entirely unknown. The worms are in some instances,extremely small, and occupy the inner surface of the cyst or bladder, and in others again they float at large in the fluid in its interior. They are for the most part encysted in the organ in which they occur. This is not a natural order; thus the ecchinococcus, or granular hydatid, though referred to it, is not hollow. 27. Anthocephulus: body long, flat, terminated behind by a caudal vesicle, and in front by a head with two or four fossae and four probosces fur- nished with spicular processes. Each exists soli- tarily in a double bladder, of which the outer layer is hard and elastic, the inner more thin and delicate; it occurs in fish, in the liver, mesen- tery, and peritoneum, and within hydatids in the viscera. 28. Cysticercus.- body roundish or flat, termi- nated by a caudal vesicle, the head with four suckers and a rostrum furnished with recurved processes or hooks. Exists solitarily within a simple bladder; occurs between the muscles, in the fat, the brain, thorax, pleura;, heart, liver, mesentery, and peritoneum, in fishes. Cysticercus cellulosus in man, the monkey, hog, &c. 29. Ccenurus.- body elongated, flattish, wrin- WORMS. 707 kled, head furnished with a rostrum on which there arc hooks and suckers, adhering in greater or b ss number to the internal surface of a bladder tilled with fluid. Ccenurus cerebralis in the brain of sheep, oxen, &c. The above brief view of the orders and genera of intestinal worms, disposed according to the scientific arrangement at present mostrin repute, will suffice to enable the physician to refer any species he may chance to meet with in man to its true place in the system. For practical purposes it will be advantageous to follow a somewhat dif- ferent order ; dividing intestinal worms into those strictly so called, as occurring in the intestinal tube, and into those whose natural situation is in other parts of the body, and out of this canal: arranging them also somewhat in the order of the frequency with which they present themselves to us in practice, and prefixing those appellations which are as yet most familiar to the great body of the profession in this country. The order in which we mean to treat of them is adapted, with some very trifling variations, from Bremser, and is as follows :— WoEMS BELONGING TO THE INTESTINAL CaNAL. 1. Ascaris lumbricoides, or "common round worm" of the intestines, very generally, but im- properly, called the lumbricus,- a term appro- priated by Linnaeus and other naturalists to the earth-worm. 2. Ascaris vermicularis.- this species of worm is commonly called " the ascarides," " thread- worms," or " maw-worms." 3. Trichocephalus dispar, or «< the long thread- worm." 4. Txnia solium, or common tape-worm of these countries. 5. Txnia lata, or bothriocephalus of Bremser: broad tape-worm. Worms occurring in other parts of the body thax the intestinal canal. 6. Filaria Medinensis, or Guinea-worm. [61. Filaria oculi. [6*. Filaria bronchialis.] 7. Hamularia. 8. Strongylus gigas. 9. Distoma hepaticum, or liver-fluke. 10. Polystoma pinguiculum, or hexathrydium of Treutler and Brera. 11. Cysticercus cellulosx .- hydatid of the cel- lular membrane of the hog, &c. 12. Ecchinococcus hominis, or many-headed hydatid of the Germans. [13. Diplosoma crenata. 14. Spiroptera Hominis. 15. Daclylius aculeatus. 16. Trichina spiralis.] The Pseudo-Helminthes ok Spurious Worms. 1. Ditrachyceras rudis. 2. Ascaris stephanostoma. 3. Ascaris conosoma. 4. Cercosoma. 5." Hexathyridium venarum. 6. Diacanlhos polycephalus. 7. Larva? of insects in various animals intro- duced from without. 8. Fictitious worms of the teeth. 1. Ascaris Tjumbricoides. Syn. Lumbri- cus teres or "common round-worm of the intes- tines." Ascaride lumbricoide of the French. Rundwurm or Spulwurm of the Germans. Lorn- brico of the Italians. General character.—Body cylindrical, elastic, attenuated at both extremities : head trivalvular; the male orga/i a double spiculum. Specific character.—The head without alae or floating processes. The length of this worm is from five or six inches to about a foot, and its thickness about two lines; but young ones of about only one inch and a half long are occasionally met with. The colour is of a reddish brown with somewhat of a yellow tinge. A shallow groove or darkish line runs down along each side of the body, a white and smaller line being also visible all along the upper and under surface. The animal is moreover encompassed from the head to the tail with close-set transverse circular striae. The male is smaller and much rarer than the female, and is readily distinguishable by the end of the tail being somewhat more curved, as well as by the double penis occasionally seen project- ing. For some time after they are voided, they are sufficiently transparent to enable us to see the internal organs. The valves or tubercles about the mouth are visible to the naked eye. The lumbricoides, when examined anatomically, is found to consist of integuments, muscles, diges- tive apparatus, and genital organs, in addition to which some have thought they could discover traces of a nervous and circulatory system. The organs of digestion and generation are bathed in a kind of mucous fluid secreted by the interior of the great containing cavity, in which in the greater part of their extent they float free, or only very slightly supported by delicate cellular adhesions. In the upper third of its extent, however, the diges- tive tube is enveloped in a closer cellular, or some- what parenchymatous structure. On the lower portions a very delicate membrane analogous to the peritoneum is discoverable. The muscular system forms two layers of fibres ; the one circular or transverse, the other longitudinal and adhering closely to the integument. The digestive tube is straight, and from its contents generally of a green- ish brown colour. The upper orifice or mouth is triangular, surrounded by three tubercles, and lined internally with minute granulations, probably glands. The anterior part of the canal, or the cesophagus, is succeeded by a rather wider portion, which may be called the stomach, and this narrows slightly into the intestine, which, after running a straight course, terminates about a line from the tail in a transverse fissure or anus. From the external surface of the intestinal tube come off numerous filaments, which soon swell out into culs-de-sac, of which the use is not certainly known: in all probability they serve for the dis- tribution of the nutritive fluid elaborated in the alimentary canal. The genital apparatus fills a great part of the animal, especially in the female, and consists of an intricate interlacement of apparently innumerable whitish filaments, which are easily seen through the integuments, or escape on making an incision into the great abdominal cavity. In the male a 70S WORMS. penis, vas deferens, seminal reservoir, and a portion j lines on its upper surface. The lumbricoi'des has of the seminal tube, analogous to a testicle, are nothing corresponding to feet; the earth-worm has discoverable. The male organ, which is double, on each side a quadruple row of bristle-like pro- about a line in length and close to the anus, is , cesses on its under surface, serving apparently the occasionally found protruded. A canal leads from purposes of locomotion. The large and complex it to what is considered to be the testicle, namely, j stomach of the earth-worm consisting of two a tube of extreme tenuity, about three feet long, ' cavities, the sacculated intestines, the coexistence very flexuous, forming a set of entangled meshes, of the male and female organs of generation in and finally terminating in a cul-de-sac, which ■ the same individual, and the appearance of these floats unattached in the abdomen. The female ; organs, form additional marks of distinction; as organs commence externally by a fissure, at the ( do likewise its more decidedly red colour, the distance of about the third of the animal's length nature of its food, (for it seems to live upon earth,) from the head, where there is a slight contraction | its power of alternate elongation and contraction, of the worm, as if a string had been tied tightly j and finally, its mode of progression, in which the around it. The vagina leads to the uterus, which | motion is propagated continuously from ring to soon divides into two long horns, each of which ( ring; whereas the ascaris lumbricoi'des moves in a forms a convoluted canal of extreme delicacy and serpentine manner, the head being sent forward great length, which may be supposed to represent ! by the worm curling itself into circles, and then the ovary. This minute tube of each side is found, suddenly protruding it with considerable force to on being unravelled, to be continuous with its some distance. fellow of the opposite side, their combined length This worm has been supposed to feed on the being variously stated at from eight to twelve feet. ! chyle or mucus in the intestines, and the three tubercles around the mouth are thought to be muscular, and to serve in the suction of their food, or in their attempts to adhere to the intes- tines ; though of such adhesion, or at least of its frequency, the best writers express considerable ! doubts. Thus Bresmer has invariably found them involved in mucus, and unattached. M. Fortassin, however, is said to have once found one adhering so strongly to the inside of a phial, that its forcible detachment caused an audible noise. At all events they do not appear to possess any organs capable of doing injury to the tunics of the bowels, so that the stories of their perforating them are worthy of little credit, and are perhaps all attri- butable to the existence of ulceration or gangrene, and to these animals having subsequently made their escape through the apertures so caused. Their natural place of abode is the small in- testines. When they either ascend into the sto- mach, or descend into the great intestines, they The uterus and its two prolongations are usually found full of eggs, the worm being oviparous. M. Jules Cloquet supposes that the two whitish lines running, the one along the abdominal, and the other along the dorsal surface of the worm, consisting of knotted and variously interwoven filaments, are rudiments of a nervous system ; and he conceives, moreover, as well as Laennec, that the two lateral lines distinguishable by being somewhat coloured, are vessels in which the sanguineous fluid oscillates. The latter were by Hooper thought to be ligaments for the attachment of the transverse or circular muscles. For a fuller account of the anatomy of this worm, the reader is referred to the works of Werner and Rudolphi, Hooper, Laennec, and Jules Cloquet. The ascaris lumbricoides, if accurately examined, is found to differ very much from the common earth-worm or lumbricus, with which it was long confounded. Tyson pointed out, a century and a half ago, many remarkable grounds of distinction are for the most part speedily expelled. They between them; but his observations seem to have have been known to make their way into the been unknown to, or undervalued by, many subse- ' cesophagus, exciting cough, or to creep into the quent writers. Externally the lumbricoides, as ' posterior nares, or even into the larynx, trachea, mentioned by Dr. Bailey, is more pointed at both or bronchi. We have seen the biliary ducts of extremities ; its triangular and terminal mouth the liver stuffed full of them, and they are said to surrounded by three tubercles is very different have been found in the gall-bladder, pancreatic from that of the earth-worm, which consists of a ducts, appendix cceci, &c. Laennec says he once small longitudinal fissure, situated on the under found in a child, whose stomach contained a grfal surface of the small rounded head. Upon the number of lumbricoides, the biliary pores dis- under surface of the earth-worm there is a semi- tended and the tissue of the liver gnawed, as it lunar fold of skin, into which the head can be were, in several points by them. In such a case retracted, which is wanting in the intestinal worm. ' it is conceivable that the parietes of the biliary The anus of the lumbricoides opens upon the vessels may have been burst by the distension under surface of the worm nearest its extremity, produced by the worms, and that the soft hepatic by a transverse curved fissure; that of the earth- tissue thus denuded may have easily yielded to worm is an oval terminal aperture. The transverse the influence of their organs of suction, as the wrinkles in the integuments of the former are less narrator suggests. They have been known to strongly marked, and the broad yellowish elevated pass through ulcerated or fistulous openings into band generally seen to encircle the body of the the abdominal cavity, the bladder, or vagina, and earth-worm is wanting; whilst in place of it we to make their appearance through the parietes of have, on the contrary, a depressed one, as we I the abdomen, where an inflamed and grangrenous have already seen. • incarcerated hernia opened them a passage. The lumbricoi'des is marked by four parallel The number of these worms which may coexist longitudinal lines, the two lateral ones, as men- is very considerable. Dall' Olio tells us that he tioned above, being very obvious from their brown- threw up in the course of a fortnight four hundred ish colour. The earth-worm has three very faint j and fifty of them, and Mnrteau de Grandvillieri WORMS. knew a soldier of twenty-three years of age who passed three hundred and sixty-seven within six days. Dr. Hooper speaks of a girl of eight years old who voided upwards of two hundred in one week. Frank knew of a case where eighty of them rolled up into a mass were expelled in a fever, and alludes to another in which the whole intestinal tract, both great and small guts, was stuffed full of them. Guersent has found above fifty or sixty in one subject on dissection. Some- times, however, only one or two exist, so that even the passing of a lumbricoides is not by any means a demonstrative proof of the patient being still infested by worms. 2. Ascaris Vermicularis.— Syn. Oxyuris vermicularis of Lamarck and Bremser. Ascaride vermiculuire of Cuvier. Pfriemenschwanz, mast darnvmrm or maden-wurm of the Germans. The maw-worm, thread-worm, or ascarides. The body is round and elastic, the mouth orbi- cular, the male organ in a sheath. The anterior extremity is rather obtuse, with a bladder-like transparent membrane on both sides; the tail of the male spiral and obtuse; that of the female tubulate and straight. Bremser has separated them from the genus Ascaris, and placed them under Oxyuris, because they want the three tubercles around the mouth, and differ in other respects, which he has pointed out. The male is about a line and a half in length, very thin, and of a white colour. Its in- ternal structure bears a considerable resemblance to that of the A. lumbricoi'des. The female is much the larger of the two, being about half an inch long, and its tail is extremely attenuated. The body is sufficiently transparent to enable us to see the convoluted organs of generation. The vulva, according to Goeze, is found about one third of the length of the animal from the head. The author just named, as well as Hooper, thought them viviparous, but probably mistook the filiform j ovaries or the oscillatory motion of the ova for their young, as both Rudolphi and Bremser are, on the contrary, satisfied that they are oviparous. The minuteness of these worms has thrown a great difficulty in the way of examining their internal structure. Their head is in constant motion. From their restlessness and activity, they get their name (from aoKapi^uv, to leap). They are supposed to have been named maw worms from the uneasiness of stomach which they seem sometimes to occasion. Their abode is the large intestines, and especially the rectum, where they occur often in great quantities, particularly in young children, though they are not absolutely confined to any period of life. Bloch speaks of finding them in a cyst in the walls of the stomach, and Brera asserts that he met with them in con- j siderable number in the cesophagus of a woman who died of a slow nervous fever. They some- times make their way into the vagina, where they | cause intolerable itching; and Frank has found them in the urethra. In the intestines they often exist in very great numbers, thousands perhaps, and are sometimes expelled matted together in the form of balls. Lister says that he had seen this species of worm in a well; and Dr. Barry (Trans, of the King and Queen's ColL of Phys. in Ireland, vol. 3k ii.) has related a case where a whole family with their servants and guests became affected with them, and where, -upon examination, they were thought to have been traced to a well from which the inmates of the house, which was situate in the country, were supplied with water, as there was discovered therein an immense multitude of minute worms resembling ascarides in all but their colour, which was somewhat darkish. On changing their abode, the sufferers became in the lapse of a few years in some degree freed from their tor- mentors, though not entirely ; the observation is, however, we think, very far from being conclusive in regard to the identity of the worms, or the reality of their external origin, as it does not ap- pear that any very satisfactory microcospical ex- amination of their internal structure was made. 3. Tricnocephalus Dispar.— Trichuris of Roederer and Wagler, and of Lamarck. Ascaris trichuris of Werner. Trichocephale of most French writers, (from 9pIn the intestines. Bothriocephalus latus. .. [ Taenia solium......... Ditrachycaros rudis .... J Diplosoma crenata ....") Spiroptera hominis .... C In the urinary bladder. Dactylius aculeatus .... j Distoma hepaticum___. Gall-bladder. Strongylus gigas...... Kidney. Filaria oculi.......... Eye. Acephalocystis endogena Liver. r, , • , . . C Liver, spleen, and Lchinococcus hominis .. -t ' r (_ omentum. Poly stoma pinguicola.. . Ovary. Filaria bronchialis..... Bronchial glands. Trichina spiralis ......? Muscles. Cysticercus cellulosae ... 5 Acephalocystis multifida Brain. Filaria Medinensis..... Cellular texture.] Spurious Worms. The number of these must obviously be alto- gether indefinite, as innumerable objects belonging both to the animal and to the vegetable kingdom have at various times been mistaken for worms. Our limits will only permit us to notice the in- sects or their larvae, and other animals which have been accidentally introduced into the body. Individuals of the human species are very liable to 6uch fortuitous inmates. The larvae or ova of insects may be introduced into the nose or ears, or into the stomach and intestinal canal by the mouth, or, finally, may occur in the skin, especi- ally when wounds, ulcers, or cutaneous affections exist. M. Daquin has described what he calls a Vol. IV. —91 3l species of worm, though it was probably the larva of an insect, which came out of the ear. Kerk- ringius gives an account of certain animals found in the ears, which Rudolphi supposes were of the same nature; as also of others which came from the nose, and appear to have been the scolopendra electrica; and this seems also to have been the case with those mentioned by Honold. Ernst speaks of a worm which was blown from the nostril, its appearance being followed by a great hemorrhage. Razouz published a case in which a prodigious number of worms, as he calls them, (though there is reason to think they were the larvae of flies,) came from the same part. Martin Slabber, a Dutch writer, tells us of a man fifty- two years old, who had laboured under severe headachs from an early period of his life, which ceased immediately on his expelling, in the act of sneezing, a worm, called by him a lumbricus, and described as being above eight inches long. Lange, in the third volume of Blumenbach's Medicin. Bibliothek, gives the case of a peasant, from whose frontal sinus a worm of a similar ap- pearance came forth; and Blumenbach himself, in his anatomical treatise concerning the frontal sinuses, speaks of the scolopendra electrica' and other insects and worms being found in this part. Sandifort makes mention of a living earwig es- caping from the nose. Tengmalm, a Swedish writer, has recorded a very interesting case, in which,above two hundred larvss of the domestic fly, covered with mucus, were expelled from the nose of an infant of eight months old. In the eighth volume of the Edinburgh Medical Com- mentaries, is a case which occurred in Jamaica, of worms (larvae ?) in the nose, which caused very severe symptoms, till they were at length expelled by injecting a decoction of tobacco into the nostrils. In the history of the Academy of Sciences for the year 1708, there is an account of a woman who, at thirty-six years of age, began to suffer from a fixed pain in the forehead, on the right side, near the nose, and which gradually ex- tended towards the temple. This, by the end of two years, had become very violent, and almost constant, and was accompanied by convulsions, an almost perpetual insomnia, and temporary af- fection of the intellect. At the end of four years, after having tried a great variety of remedies in vain, she began to use snuff', in hopes of its assuaging her sufferings; when one morning, after a violent fit of sneezing, a worm, or, more properly speaking, an insect, gathered up into a lump, came away from her nose, and along with it a little blood. From that moment she was well. The animal, which was alive, measured, when stretched at full length, six inches, but only two when it folded itself into a zig-zag form,__a habit which it had acquired from its long confine- ment in the limited space of the frontal sinus, into which it had perhaps been introduced in the state of an ovum. It was two lines broad, and about one and a half thick in the middle of the body. It was of a clear coffee colour, convex above and fiat beneath, and covered with annular scales separated from each other by minute inter- vals, through which the feet came out, there being fifty-six of them on each side, about a line in length, and as thick as a hair. It seems, in short, 722 WORMS. from these particulars, as well as from the re- mainder of the description, to have been a species of centipede. It lived for many hours after its expulsion, and even for two or three after having been plunged into brandy. M. Littre, who relates the case, suggests that in similar ones, if injections of oil, infusion or smoke of tobacco, and other ordinary measures failed, a surgical operation on the frontal bone might be had. recourse to with safety and success, and would be fully justified if the symptoms were violent. Insects in the ears may be removed by frequent mild injections, especially of an oily nature; or if very obstinate, they may be first killed with sulphureous fumes, and then washed out. Such instances as those above alluded to may be supposed commonly to originate from insects depositing their ova in the auditory or olfactory passages, or creeping in unobserved, especially in individuals who are fast asleep or broken down by disease, and hence less attentive to external impressions, or not in full possession of their senses; and also in infants. Sometimes, perhaps, they may be drawn in, in the act of smelling strongly of flowers, or they may be swallowed with' fruits, cheese, flesh meat, or various other articles of food, or in impure water used for drink. Rudolphi discredits their entrance per anum, as well as that by the urethra. Of the cases in which worms have been said to be passed with the urine, almost all, except those which we have ilready spoken of when treating of the strongylus gigas, seem to have been instances of the larvae of insects (the oniscus asellus most frequently, ac- cording to the author just named) which had been introduced furtively, and with a wish to deceive, or casually and unobserved, into the containing ■vessel. The worms alleged to have been discovered in wounds a'nd ulcers, as in the case published by Stenevelt at Leyden, in the year 1697,— and in cutaneous diseases, as in a case of lepra, of which an account was published by Murray at Gottingen'in 1769, appear likewise to have been merely larvoe. M. Bosse, in the thirty-second volume of the " Journal de Medecine," gives a description of the larvae of flies found in pustules in the skin of a negress. Such seem also to have been the elcophagi of the old writers, or worms found in wounds and supposed to fee'd on the flesh. There is a case mentioned in the Lancet, for May 21, 1831, of a compound fracture of the humerus treated in one of the Parisian hospitals, in which, on the fifth day, intense itching was complained of, and was found to depend upon a multitude of worms in the wound and on its edges. Similar facts were frequently observed in Syria by Larrey, who thinks that the worms rather favoured the healing process by devouring the putrid matter and not touching the living flesh. Camphor- ated spirits and other antiseptics were found to bo quite adequate to prevent their immoderate increase. Worms resembling the lumbricus teres, but more of a white coltwr, have been seen, according to Lister, coming from an abscess in the ankle. What these were we cannot pretend to say. Of insects inhabiting the skin, the American species of acarus mentioned by Humboldt, and the acarus scabiei and louse are likewise examples. The latter is well known to be peculiar to man, and incapable of existing elsewhere. Their abun- dance seems to depend on the greater or less degree of cleanliness of the individual, und certain cutaneous affections seem greatly to favour (heir multiplication. The inunction of mercurial oint- ment is a certain mode of destroying them. It ij commonly believed by sailors that they die under the equator, being killed by the excessive heat; but the truth of this is not generally admitted. They seem, however, to flourish in cold situations, Thus Humboldt mentions that they are very abundant in the higher regions of the Andes; and in Greenland they exist in prodigious quantities, according to the late Sir Charles Girsecke, and are turned to account there as an article of diet. The pulex penetrans or chigoe is very trouble- some in sugar colonies in South America, pene- trating into the skin and lodging its eggs there, and causing malignant and often fatal sores. It is of a reddish-brown colour, and the proboscis is as long as the whole body. The abdomen of the female, when gravid, becomes swollen to a hun- dred times its natural size. "The chigoes," says Dr. Elliotson, in his lectures, " are a sort of large fleas which infest the inhabi- tants of the West-India islands; they get under the skin, and there form a bag, in which they lay about sixty eggs, which hatch there and produce a very bad sort of ulcer. The negro women are very expert at extracting this bag by means of a needle, without wounding it. If it is wounded, an acrid fluid which it contains escapes and pro- duces an ulcer, which is also troublesome to heal. The genus of the chigoe was formerly disputed, till a Capuchin friar, to settle the dispute, allowed one to breed in his great toe, and such mischief ensued that amputation was necessary." The mstus humanus, described by Linnius and more recently by Humboldt, occurs in the warmest regions of America. It deposits its ova on the skin, which the larvae soon after penetrate, remaining beneath it for about half a year, when they pass into small brown flies. If they be not interfered with, they make their appearance in due time, and the part quickly heals; but much deep-seated pain is induced by attempting their premature extraction. The cestrus boi'is, which also infests sheep and goats, deposits its eggs more especially on the back of the animal, where it forms a small tumour, in which the larva; remain from autumn to the commencement of the ensuing summer. The fly is said always to select the most vigorous and fattest animals. The torture which the reindeer experiences from a similar species of fly is well known. The xstrus ovis lays its eggs on the margin of the nostrils, whence the larvae make their way into the frontal sinuses, and remain there, often in very great numbers, from autumn till the end of spring. The astrus equi deposits its ova on the skin of the legs or sides of the horse, which on licking itself conveys them into the stomach : here they become convert- ed into larvae, and are at length passed along with the faeces, soon to undergo their final metamor- phosis. Another species, according to Bracey Clarke, deposits its ova in the lips of the horse. Bots, though often very numerous in the stomach, do not induce any inflammation. The larvae of WORMS. 723 the ccstri appear, from the experiments of Fischer, •to be very tenacious of life; even spirits and a strong solution of salt did not kill those of the sheep. Anointing their respiratory orifices with nil, and keeping them for several hours in this fluid, only produced a temporary languor. The fumes of burning sulphur, however, killed them in a very few minutes. Rudolphi believes that they do little injury to the horse and the other animals which they infest. If, however, we wish to destroy them, turpentine or Chabert's oil may be employed. Those in the frontal sinuses of sheep are expelled with difficulty; the frequent introduction of tobacco-smoke has been recom- mended. Larvae have been observed in the expec- toration when the vessel containing it has been kept in a warm place, of which an instance is to be found in the fourth volume of Hufeland's Jour- nal. These originated, doubtless, in ova deposited in the sputa subsequently to their excretion. The digestive organs, and especially the stomach, are by far the most frequent receptacle of these extraneous animals. Albrecht has recorded an interesting case where a boy passed a considerable number of what the narrator calls worms, though doubtless they were the larvae of flies, the origin of which was traced to some cakes which the child had been in the habit of eating; and similar ones were found to abound in the cupboard in which the cakes were kept. Odhelius mentions an in- stance where the larvae of the musca pendula were evacuated with the stools; and in the first volume of F. B. Osiander's " Denkwurdigkeiten," a still more remarkable one is to be found of a woman who passed, both upwards and downwards, a great variety of insects and worms, viz. millepedes, flies, rind their larvae, the curculio and staphylinus, spi- ders, earth-worms, ascaris lumbricoides, tricoce- phalus, &c. Rosenstein, moreover, has described a case in which numerous larvae, curculiones, sca- rabaei, elster, modella, &c, came away from a woman by stool; and Ariel has also given, in the " Scientific Transactions of Upsal," a somewhat similar but still more wonderful instance, where an immense number of such insects existed in the stomach for the long period of two years, when they were at length, after a great number of un- successful experiments, expelled by means of a mixture of turpentine and linseed oil : amongst them were observed staphylinus splendens, staphy- linus fuscipens, oxyporus subterraneus, paederus elongatus, carabus leucopthalmus (alive). Of the staphylini there were two hundred and sixty-three in all. The larvae were almost past counting, es- pecially those of the tenebris molitor and of the carabus. Such unnatural inmates, as Rudolphi remarks, give rise to very great distress by their restlessness, and perhaps also by gnawing at the coats of the stomach, (for it is chiefly in the stom- ach that they seem to take up their abode,) and they may-induce very violent spasmodic affections. It is in the debilitated, cachectic, ill-fed, and hys- terical, that they have chiefly been observed: a vigorous digestion and an active peristaltic motion would generally speedily effect their destruction and expulsion. Of all the marvellous cases of this kind on re- cord, one of the most so, and yet at the same time I one of the best authenticated, is that related by j Dr. Pickells, in the fourth and fifth volumes of the Transactions of the King and Queen's College of Physicians in Ireland. The person in whom it occurred was a young woman of a chlorotic. habit and melancholy disposition, who, from cer- tain superstitious notions, had been in the habit of drinking daily a mixture of water with the clay taken from the grave of two priests, who had main- tained during life a high character for sanctity, by which practice she in all probability acquired the ova of those insects which continued to be devel- oped at intervals for some years afterwards. It is also mentioned, that on one occasion she lay out the entire of a rainy winter's night, stretched across the grave of her mother; and moreover that she was addicted to eating chalk in incredibly large quantities. Of the larvae of the beetle evacuated per anum prior to the publication of his first paper, Dr. Pickells estimated the number at above one hundred, and supposed that above seven times that quantity had then been vomited : and in the next year and a half, the period comprised in his second account, terminating with June, 1825, above thir- teen hundred beetle Iarvre, all of which he himself reckoned, were discharged. Thus the whole num- ber during about three years and a quarter amount- ed to above two thousand, and mgst of these were alive. Both the larvae, pupae, and the perfect in- sects, were simultaneously observed. Many made their escape the instant they were vomited, and ran off into holes in the floor; and two large winged insects were so lively on their expulsion, that they immediately flew away and escaped. The relator of the case and several other credi- ble witnesses actually saw her vomit up many of the larvae. Amongst these is mentioned that of blaps mortisaga, which was an inch and a half long by four lines and a half in girth ;t also the tenebris molitor or meal-worm, and the larvae of two kinds of fly, one of which seems to have been the musca vomitoria or blue fly. By this case, says Dr. Pickells, «the interesting fact seems to be established,- that the different successive meta- morphoses of insects may take place in the human stomach during life." » The present," he conti- nues, <• is, as far as my inquiries have extended, the first well-authenticated case in which the larvae, pupae, and imago of the same insect have been discharged from the same individual." The train of symptoms to which they gave rise was most complicated and distressing—a gnawing and sense of something creeping at the pit of the stomach, haematemesis, amenorrhoea, hysteria, convulsions, perversion of the senses, and also at times a de- gree of mental derangement, with headach, reten- tion of urine, dropsy, &c. &c. Emetics and various other remedies were employed, but what seemed most effectual, and eventually appears to have cleared the stomach and intestines of these formi- dable inmates entirely, was turpentine given in enormous doses, being gradually carried so high as six ounces in a day. .When given, it generally induced an immediate flow of the menses, with giddiness of some days' continuance, and an her- petic eruption. During its employment, ascarides vermiculares were passed in considerable numbers, and were generally found, notwithstanding the largeness of the dose of turpentine, to be still alive. 724 WORMS. In the Transactions of the Royal Society of Gottingen, Klaerich has given a description of a convulsive affection caused, as he asserts, by the creeping of an insect in the srtomach, which ap- pears to have been a scolopendra electrica. Dr. Elliotson likewise has seen two centipedes which were said to have been vomited by a girl: he has also known two cases where a live caterpillar (the noctua proxuba) was discharged from the bowels; and a third is to be found in Duncan's Medical Commentaries. Their introduction into the sto- mach seems to be explained by a habit which the individuals had of eating raw cabbage-leaves, in which the ova were probably contained. Cases in which earth-worms, snails, lizards, spiders, bees, frogs, toads, leeches, and even serpents, have been thrown up from the stomach, are upon record; the great majority of these we may be justified in ascribing to deceit and imposture. Some of them, however, are supported by respectable evidence; and there is evidently no physical impossibility in such animals being swallowed under the influence of mental derangement, or with a view to excite wonder and gain profit; and from their great te- nacity of life they may doubtless continue for some time to exist even in the stomach, especially if this organ be in a debilitated state, and while there they may excite a train of very aggravated and inexplicable symptoms. Thus, Bremser mentions a case which fell within his own knowledge, of a hypochondriacal woman, who, upon one occasion, when out of her right mind, swallowed a young toad wrapped up in a morsel of the peritoneum of a cow or sheep, which she got of her butcher for the purpose. She conceived the toad to be poi- sonous, and was desirous in this way of getting rid of her existence. It remained in her stomach all day, but towards night great oppression and sickness coming on, it was thrown up, with its hind legs broken, along with the half-digested membrane. In his useful synopsis of intestinal worms, Mr. Rhind details a case, on what appears credible testimony, where the common grey snail (limax major), four inches long, was vomited by a farm-servant in Haddingtonshire, after suffering from various obstinate dyspeptic symptoms for above a year and a half; namely, inordinate appe- tite, vomiting of foetid slimy matter, sour eructa- tions, constipated bowels, swelling and tenderness of the epigastrium. Various treatment had been ineffectually employed, till at length, whilst mak- ing use of a strong solution of soda, and of pills of calomel, hyoscyamus, and gentian, the snail was expelled in one of his severe fits of vomiting, and lived five days in the possession of the medi- cal man who was attending him. All the distress- ing symptoms disappeared immediately after. The man was in the habit of drinking daily out of a muddy ditch, which may perhaps be thought to afford some explanation of its origin. The intro- duction of leeches into the stomach, where they are said to attain to an .enormous size, is a very dangerous occurrence, and may even prove fatal by the loss of blood occasioned. Large doses of salt constitute an obvious remedy. It is supposed that they have sometimes been swallowed when in a very minute state in a draught of turbid water. Larvae and most insects are very tenacious of life j togs coleoptera are known to live for weeks after they have been pierced through with ping; and Rudolphi has seen a species of curculio walk about as usual after part of the elytra and most of the abdomen had been eaten away by ants. The larvae of flies are very common in ordure, putrid flesh, &c. When tainted meat is eaten, the ova may thus get into the stomach and be developed there; and of the possibility of the propagation of the staphylini and other insects even in the interior of the body, as occurred perhaps in Acrel'a case, Rudolphi does not doubt, though in all pro- bability this is very rare. Larvae and insects are best got rid of by means of turpentine; and Cha- bert's oil has also been suggested as likely to prove a useful remedy. On the Orioix of Worms. There are but two conceivable modes in which the presence of intestinal worms can be accounted for ; they must either come from without, or they must originate within the body of the animal in which they are found. To the improbability of the external origin of the worms infesting the human body, we have already Tepeatedly alluded; and Rudolphi and Bremser, after a careful analysis of all the supposed instances of their introduction from without, whether in man or in the lower animals, are led to pronounce that this view of the question is utterly unsupported by any positive evidence, whilst at the same time the arguments against it are at once numerous and apparently insuperable. How very improbable does it seem that these animals, which are delicate and easily injured, should be capable of sustaining such a violent and sudden change of temperature, food, and all their habits, as this theory would imply. • It is unquestionable that the few instances in which they have been detected accidentally exist- ing externally, bear no kind of proportion to the frequency with which they are discovered in Ihe interior of animals; and the situation in which any creature is most usually met with, is, it may be presumed, its natural one. The rare exceptions as to situation just alluded to, may be safely at- tributed to the casual transplantation of these worms from their native region; and if tbey be found when so misplaced still in a living state, il only shows that they are capable for a limited pe- riod of resisting the hostile influences by which they are surrounded. Brera, who inclines to a belief in their external origin, notwithstanding all the difficulties with which it is accompanied, suggests that they may undergo such a complete metamorphosis in their new position within the body, as no longer to be- tray the source whence they were derived; but as they have never been detected in any intermediate condition or state of transition, this hypothesis may be dismissed without ceremony. The arguments for their internal origin are, as we have just stated, weighty, and many in num- ber. Thus their structure is altogether peculiar, being quite unlike that of worms and other ani- mals existing externally, whether on the land or in the water. Particular kinds of intestinal worms are, with a few exceptions, appropriated to differ- ent species of animals, and even to particular parta of the same animal, which could scarcely be ex- pected if they came promiscuously from without: they occur in all parts of the body, even in tbos* WORMS. 725 ^Kich have no communication with the external world, and have been met with in some well-at- tested cases in the fcetus both of man and of the lower animals: they not only multiply most abund- antly within the bodies they inhabit, but very soon die when removed from them, in which latter cir- cumstance they altogether differ from the larvae of insects : and, finally, their presence, even in very considerable numbers, is frequently unattended with any obvious inconvenience to the individuals in whom they have their abode, these being often found to be fat and in all respects healthy ; and if neither nervous nor previously debilitated, they are sometimes quite unconscious of their presence; whereas, with regard to larvae and other living things fortuitously and unnaturally located within ui, the case is quite otherwise, as they usually give rise, as we have already seen, to much suf- fering. Pallas and some other authors, who fully admit the internal origin of intestinal worms, are yet dis- posed to think that they do not in all, nor even in most instances, take their rise in the individual in which they happen to be found, but that they or their ova have commonly been transmitted to them from other animals, of the same or a different spe- cies, previously infested with them; and in sup- port of this view, Pallas, its chief advocate, brings forward the three following propositions, which are, however, very far from being conclusive. 1st. He asserts that worm-diseases are most common in great towns, where a want of personal cleanliness, and the use of water impregnated with various impurities, often of an animal origin, facili- tate the transmission of the ova. But both the tact and its explanation are liable to dispute. Were it even proved that they are more frequent in crowded cities, the debility of the digestive or- gans so common in such situations from the in- fluence of bad air, bad food, privations, or intem- perance, would much more satisfactorily account for it. The specific gravity of the ova seems in- compatible with their aerial transmission, and the cold of water at ordinary temperatures would in- evitably destroy their vitality. 2dly. The limitation of particular worms to particular animals, he thinks, may be explained on the principle of the ova becoming developed in those, and those only, which afford them a conge- nial nidus. The fact is admitted, but the explana- tion is not the only one, nor the most satisfactory. On the contrary, the appropriation of peculiar spe- cies is so general as to furnish a strong argument for their innate origin. 3dly. He adduces the fact of the occasional oc- currence of worms in the fcetus, as well as their remarkable frequency in certain families, as proofs of the possibility of their transmission. As to the latter fact, however, it seems to be merely one of , the examples of hereditary predisposition to a par- ticular disease.; and with regard to the former, we shall afterwards see how very improbable it is, if it be not altogether impossible, that a body of the dimensions of an ovum should be transmitted through the vessels of either parent to the embryo. To Pallas's assertion that the rodentia and ru- miuantia, which carefully comminute their food, are less liable to acquire worms than the carnivo- rous and predaceous tribes, or such as swallow 3i* their food hastily and voraciously, Bremser'e more extensive knowledge of the subject enables him to give an unqualified contradiction, and even to re- verse the proposition. In the case of hydatids, which are so common in herbivorous animals, the supposed transference seems quite inconceivable, for they have no known ova, and are besides com- pletely insulated by a cyst. An experiment made some years ago by M. Schreiber, the distinguished director of the mu- seum of Vienna, seems to prove that worms and their ova are not capable in ordinary circumstances of resisting the digestive powers of the stomach, and consequently that they cannot be introduced by this channel into the system. During six months he fed a polecat almost exclusively on various kinds of intestinal worms, and their eggs mixed up with milk; and on killing and examin- ing it at the end of this period, not a single worm of any kind was found in it. Yet it is not denied that, in some rare instances, the worms of one animal introduced into the stomach of another have lived there for some short time. Bremser himself mentions some examples of it. Thus a particular species of ligula, belonging to certain fishes, have been found in the stomach and intes- tines of aquatic birds, by which these fish were devoured ; but even in these cases they had already undergone manifest changes, if it was some time since they had been swallowed. Rosenstein thought he had once seen a ligula alive in a fish after it had been boiled and sent up to table ; but it is supposed, with some probabi- lity, that he may have mistaken the contractions produced by the change of temperature in placing them on a cold plate, for vital motions. Bremser states, moreover, that if we remove small worms out of spirits of wine into water, though long dead, they will appear to move in an extraordinary manner, till all the alcohol within them, or ad- herent to them, has become perfectly mixed with the water. Pallas inserted the ova of the taenia of one dog into the peritoneal cavity of another, and on open- ing the latter about a month afterwards found young taeniae, about an inch in length, in its ab- domen ;—an experiment which shows that if the ova of worms be only placed in a favourable con- dition, as far as regards heat and moisture, and are out of the reach of all injurious influences, such as we have seen that of digestion to be, their evolution, as in the parallel instance of the eggs of birds, readily takes place. It now only remains to consider whether worms or their ova are, strictly speaking, hereditary,— that is, whether they are communicable to the germ by one or other of the parents. Such a supposition, when considered in relation to their first origin, would imply that every kind of worm now found in a given species of animals, (and in man no less than twelve have been already recog- nised, and nearly as many in various other spe- cies,) must have coexisted in their first parents at the epoch of creation, and been transmitted in an uninterrupted line through their several descend- ants ; — a proposition for the truth of which no adequate evidence has been adduced, and in itself most improbable when we consider the incessant changes which the body is undergoing by the ab- 726 WORMS. sorption, excretion, and renovation of its compo- nent parts.' If the ova exist in all individuals, why are they not developed in the intestines of air; heat and moisture, as we have'seen by Pallas's experiment just related, being alone necessary 1— if they exist in the male semen, why are they not evolved even in the uterus after impregnation, where likewise these requisites are present ? Some species, as the strongylus and distoma, on the con- trary, are so infinitely rare in man that only a few examples of their occurrence are on record ; whilst others, such as the hamularia and polystoma, have as yet been found but once in our race. The ccenurus cerebralis, in the brain of the sheep, is alone decisive of this question; for, left to nature, it constitutes a fatal malady, and consequently, as it occurs chiefly in young Iambs, the whole race of the worm would have been extinguished with the first animal that suffered from it. This supposed communication by the father's side is inconceivable, for in many classes of the animal kingdom copulation does not take place. The quantity of semen requisite to fecundate the spawn of the frog is, as Spallanzani has shown, infinitely small; merely touching one of the ova with the point of a needle dipped in this secretion is sufficient, and three grains of it added to a pint of water impart the fecundating property to the whole of the fluid. Now it is not conceivable that the rudiments of all the worms to which this animal is liable should be contained in so inappre- ciably minute a quantity. That their communi- cation to the embryo should take place through the mother is equally incomprehensible. The ab- sorbents and exhalants by which, according to this hypothesis as well as the last, they must be taken up out of their natural situation and depo- sited again in the torrent of the circulation, and thus introduced into the system of the fcetus, are quite inadequate for the office assigned them, being of such a degree of tenuity as not to let even a globule of red blood, which, according to Rudol- phi's^ calculation, is .ten thousand times less than one of these ova, pass through them. Besides, these ova have never been detected by the micro- scope in the blood either of mother or fcetus. The influence of climate and locality, moreover, on the generation of worms, which, in consideration of the changes produced on the general health, is reconcilable enough with the theory of their in- nate production, is totally opposed to that of their origin by hereditary descent. The Guinea-worm is confined to particular regions; and in these the European becomes liable to it, though none of his progenitors ever suffered from it. The cysticercus cellulosae of the domesticated hog is never met with in the wild boar, which is the original stock. Nor can lactation be the medium of their intro- duction, as is evident from the minuteness of the extreme vessels already alluded to;—to say nothing of -the innumerable tribes, birds, fishes, &c. which never suckle their young: besides, children which are entirely spoon-fed are notoriously more liable to worms than those which are nourished exclu- sively by the mother's milk ; indeed, \t is a well- known fact, and one which is all but universal, that infants at the breast are not affected with these parasites. The improbability, not to say impossibility, of worms having an external origin being thus estdP lished, we are compelled to adopt the alternative, and to admit that they originate within us. Fur- ther than this we cannot go; and we believe that we must for ever rest content with this almost negative species of knowledge. The terms spon- taneous or equivocal generation explain nothing With the conception of creation in all its modes whether the object be a world or a worm, our limited faculties are altogether incommensurate. Causes.—It is singular that in a disease of such common occurrence as worms, so little should as yet have been ascertained in regard to their causes. Almost every generalization or rule which has been attempted to be made on this subject is very nearly counterbalanced by the exceptions. A feeble state of the general health, debility of the digestive organs, food either in excess or in too small quan- tity, or of unwholesome quality, sedentary habits, damp and ill-ventilated habitations, peculiarities of climate, together with the influence of season, sei, and age, have, separately or collectively, been ac- cused of favouring their appearance and encour- aging their multiplication. Their connection with a debilitated state of the constitution, and in many cases with a scrofulous habit, seems to be pretty well made out. The in- activity of the lacteal and absorbent vessels, and the consequent accumulation in the intestines of chyle and mucus, which form so congenial a food or so favourable a nidus for these animals, together with the generally weakened condition of the di- gestive organs in strumous patients, enable us In some degree to comprehend this cause. Yet it is indubitable that they are often also met with in the robust and healthy. Rush has even endea- voured to make it appear that they are indicative of, or almost requisite to, the possession of perfect health, in which opinion, however, he has but few followers. It would seem that whatever produces a redundancy and stagnation of nutritive or ani- malized fluids in the intestinal tube—whether it be too abundant a supply of food, too active a chylification, or too great a secretion of mucus,— is to be ranked amongst their causes. The peculiar prevalence of worms in certain localities may, ac- cording to Rudolphi, be explained by the unwhole- some influence of a moist atmosphere or bad food. If there be any epidemic disease in which they are generated in unusual numbers, (which, how- ever, the author just named is inclined to doubt, as fevers 6eem rather to exercise a destructive in- fluence over them,) it is to its debilitating tendency that it must be ascribed. When the tricocephalui was rediscovered by Roederer and Wagler, it was attributed, but erroneously, as we have seen, to the peculiar fever which happened to prevail at the time. That in several chronic diseases worms are often very numerous, is an unquestionable fact, however it may be explained; and it would seem that it was from falsely ascribing to.their presence the symptoms really produced by the affection which they complicate, that their importance has come to be so much overrated. Thus, in very • indolent cases of scrofula, accompanied by disorder of the digestive organs, if medicine, a change of climate, the approach of puberty, or other circum- stances happen to lead to an improvement of the general health, and to a coincident discharge of WORMS. 727 worms, the latter are immediately pronounced to have been the cause of all the previous ill symp- toms ; or if the glandular affection assume a more acute form, and is attended with well-marked hectic, and worms make their appearance, the fever is immediately laid to their charge, and called a worm-fever. That there is really no such disease, we have attempted to prove in a former part of this work, (see Infantile Remittent Fever ;) for though this disorder is vulgarly attributed to worms, yet, in the great majority of cases, none are either evacuated during life, or discovered after death on dissection. That the local irritation which they occasionally cause may, in some instances, give rise to a slight and passing feverishness, is not de- nied ; but this will have neither the progress, the duration, nor the general character of an ordinary fever, much less of an epidemic* Scrofula may with much more truth be said to be often the cause of worms, than these of such symptoms as we have just been speaking of. In the parallel case of glanders in the horse, which commences in a tubercular state of the Schneiderian membrane, the disease subsequently extending to the lungs and enfeebling the whole system, worms are known to be extremely common. Aliments of a peculiarly nutritious quality, such as fatty substances, milk and its various prepara- tions, cream, butter, and cheese, are very commonly supposed to produce a slimy state of the intestines and a prolific progeny of worms; and of this Holland and Switzerland have been adduced as proofs. An exclusive use of farinaceous foods has been frequently suspected to have a similar tend- ency. But when we recollect how rare these parasitic animals are in infants at the breast, and couple this with the fact that the fine peasantry of the Tyrol, who, as Mr. Inglis in his recently pub- lished tour remarks, live almost exclusively on Indian corn and milk, and are yet, as Bremser in- forms us, (unlike their neighbours, the Swiss,) little troubled with worms, we are forced to doubt the reality of some of these supposed causes, or, to speak more correctly, the universality of their influence: for it is highly probable, that in the case of individuals unaccustomed to their use, and leading a very sedentary life, they may, by lower- ing the tone of the digestive organs, and keeping them overloaded with a mass of ill-digested food, promote the production of these creatures. Guer- sent agrees with the common opinion as to their greater frequency in summer and autumn than in other parts of the year; and in alluding to their prevalence in Normandy, ascribes it to the almost constant use of milk, apples, and cider. He adds, that he has often known children who had been staying in the country, where they were fed chiefly on milk and fruit, discharge great numbers of worms on returning to town and being put on the use of a meat diet. To us, on the other hand, it Ins sometimes appeared that fruits, and especially * Fevers and most Of the other ill effects at various periods ascribed to worms, were believed to be produced in one of two ways, viz. either through the medium of local irritation, or by the absorption of a putrid matter whicli they were supposed to generate; the latter is, however, altogether hypothetical, as, in whatever abun- dance they may exif-t, they do not cause any peculiar fictor in the intestines, and even their maceration in water is not productive of any bad smell, as Rudolphi remarks, save that from the adherent foecal matter. unripe ones, have unjustly got the credit of causing worms, merely from their use being immediately followed by the appearance of these animals in the stools—a circumstance which should, we think, rather be ascribed to such food proving, from its acid and purgative qualities, actively anthelmintic. As to sugar and saccharine matters in general, there has been a great difference of opinion; many persons supposing that, opposed as they are in their nature to bitters, they must necessa- rily be productive of worms: whilst others attri- bute to them, with equal confidence, much vermi- fuge power. The truth seems to be, that when long used and just in sufficient quantity to enfeeble the tone of the digestive organs, they have, the former of these effects; and that, on the contrary, when very largely and only occasionally taken, they prove purgative, and may thus lead to the expulsion of some of these animals. Climate and locality have indubitably much influence in the production of worms. The cause of their frequency in Switzerland and Holland is to be found, perhaps in the humid atmosphere which both of these countries possess, rather than in any peculiarity of diet common to the two. It has been stated, we know not with what truth, that when the inhabitants of other countries con- tinue to reside for a 'length of time in Switzerland, they become, like the natives, very liable to the bothriocephalus. [It would seem that particular countries possess a species peculiar to themselves, and some even a distinct genus. The inhabitant of Switzerland, for example, whilst in his own country will suffer from the presence of the bothriocephalus latus; and if this have been got rid of, on changing his residence for Vienna, he may become infested by the taenia solium, which is another genus ; whilst the German, who emigrates to Russia, may expe- rience the development of the bothriocephalus latus, a species which rarely or never occurs in his own country. (Wawruch, Praktische Mono- graphic der Bandwurmkrankheit, u. s. w. Wien, 1844, cited in Brit, and For. Med. Rev. Oct. 1844, p. 321.)] In respect to Holland, the frequent use of fish has been accused, but unjustly, of the production of worms ; for as Miiller remarks, the Danes and other people who live on the sea-coast and partake largely of this kind of food are not particularly troubled with them : and some traveller, we think Hasselquist, has mentioned that, in Cairo, the very lowest classes, who from poverty are unable to procure fish, are much more infested with tape- worm than those in a more comfortable condition, into whose diet it enters pretty largely. In the fenny parts of England the ascarides vermiculaires are said to be a very frequent disease. If they really prevail there more than in other districts, the fact may be explained f>y the general impair- ment of the health, and the debility of the diges- tive organs in particular, which such situations almost invariably produce, without supposing the introduction of these animals or their ova into the body from without. Their greater frequency in autumn, mentioned by Hippocrates and many subsequent writers, is attributed by Hoffmann to the moisture and variability of the atmosphere at that season. In the lower animals, and especially 728 WORMS. sheep, certain species can be produced almost ad l libitum by wet pasturages and too watery food. I Dumereil mentions that rabbits and hares often j die in a swollen dropsical state, accompanied with ' hydatids, from the same cause; and Andral thinks j that the measles in swine may depend on the foul | and damp situations usually assigned to them, j The deprivation of solar light and of exercise are also powerful auxiliaries in the production of such ' diseases. j Hamilton, in his work on the diseases of women j and children, treats as a vulgar prejudice the as- cribing of worms to peculiar kinds of food. Ru- dolphi, on the contrary, is one of those who believe that they are peculiarly abundant in such children as eat voraciously of potatoes, or of coarse bread and other farinaceous foods. Where the climate is very relaxing, the effects of an injudicious diet are particularly felt. Thus amongst the Hindoos, who live almost entirely on rice, worms are, ac- cording to Annesley, amazingly frequent, having been passed in nine cases out of ten by the pa- tients in the native hospital, which was at one time under his charge; and even Europeans, if they fail in paying a sufficient degree of attention to the slate of the bowels and to the tone of the stomach, are said to acquire by long residence in India a similar tendency to generate these ani- mals. A low scale of diet, in which nothing more is eaten than can be perfectly digested and is abso- lutely requisite for the support of the system, seems, along with regular exercise, to be the best preventive of worms. The perfect absorption of the chyle is thus insured, and the quantity of mucus effused into the intestinal canal reduced to a healthy pitch. Bremser has observed, that in the fish which are kept up for the Vienna market in reservoirs off the Danube, where they are ill supplied with their ordinary nutriment, the intes- tinal mucus becomes scanty, and worms are ex- tremely rare. An inadequate supply of stimulants with our food appears to predispose to worms. In Hol- land those criminals who, according to an ancient law of the country, were fed on bread made with- out salt, are said to have been horribly infested with these animals,—an effect which, in prisoners cooped up in that moist climate, seems not alto- gether incredible, especially when coupled with the acknowledged efficacy of this condiment in preventing and curing worms in some of the lower animals as well as in the human species. They certainly make their appearance more frequently in women than in men,—a fact which has been ascribed by Rudolphi to the former making use of a more relaxing diet together with fewer stimu- lants, whilst at the same time their habits are, generally speaking, more indolent and sedentary, and their constitution* less robust. The moderate use of wine and spirituous liquors is thought by the same author to have somewhat of a preventive tendency. The very means sometimes employed for the expulsion of worms may in injudicious hands, by the debility which they are capable of inducing in the intestinal canal, favour their speedy re- appearance. After every due allowance has been made for the influence of external agents in their produc- tion, much remains which can only be explained: by tBe existence of a peculiar predispositioa. Thus, children are much more liable to the com. mon round-worm and to the thread-worm than adults, and the tendency to their formation often ceases spontaneously on the approach of puberty. In some instances the predisposition appears to be of an hereditary nature. Thus Rosenstein men- tions an instance where some of the individual of a family were affected with taenia for three suo cessive generations. Symptoms.—The symptoms caused by wormi in the alimentary canal may be divided into thow which are common to all of them, and those which are peculiar to each kind; and these may again be subdivided into the local and the general. Of local symptoms, taken in the strictest sense of the term, we know of none but pain in the ab- domen, especially about the navel, of a colicky character; swelling and hardness of the abdomen; an increased secretion of mucus giving rise to slimy stools, and the occasional appearance of worms in the evacuations; but if taken in a some- what wider sense, so as to embrace all the various signs of disorder in the digestive organs which are occasionally present, the list of local symptoms will be much extended. Thus, to commence with the parts seated next the upper extremity of the alimentary canal, we find the tongue often white and loaded; the secretion of saliva in- creased ; the breath heavy and fetid; a disagree- able or sweetish taste in the mouth ; occasionally thirst; the appetite extremely variable, sometimes remarkably deficient, and at others voracious, re- turning immediately after eating, and felt espe- cially at night. There is sometimes a sickish feel- ing, with mucous vomitings, flatulence of the sto- mach and intestines, and indications of irritation in some part of the mucous membrane, relief be- ing obtained by lying on the belly ; the bowels are irregular, successively constipated and re- laxed ; the 6tools, except when some worms hap- pen to be evacuated, presenting nothing in any degree characteristic, save an increased quantity of mucus and an occasional tinge of blood. The urine is often turbid or milky, and deposits a sedi- ment. There is frequently itchiness of the parts at each extremity of the digestive tube, namely, of the fundament and nose ; hence frequent pick- ing of the nose, which, as well as the upper lip, is often «wollen and red. Many patients complain of a feeling of some- thing creeping within them, or gnawing, piercing, or sucking at the stomach or intestines; but Brem- ser attributes no importance to such imaginary sensations, having even more frequently met with them in those persons in whom there was no rea- son to suspect the presence of worms, than in those who were known to be affected with them. It seems to be only when they approach to either extremity of the alimentary canal, as in the case of ascarides in the rectum, and the lumbricoide* in the stomach and cesophagus, that there is any distinct consciousness of their movements in the sensorium. It is very rare on disseetion to find them adhering to any part of the lining membrane of the intestines. The mucus in which they are enveloped, and which, according to Alibert, is the WORMS. 729 consequence and not the cause of worms, as com- monly supposed, must serve in a considerable de- gree as a protection to the raucous membrane, and tend greatly to diminish its irritation by their contact. But that they are capable of producing a certain degree of local excitement in irritable habits is evident from the general symptoms to which they sometimes give rise, the chief seat of which is the brain and nervous system. Thus there is occasionally disturbed sleep, with grind- ing of the teeth, and sudden awaking in a fright. There are at times headach or giddiness, ringing in the ears or even deafness, faintness arid syn- cope, convulsions, somnolence, indolence»of man- ner, and ill-temper. In some rare cases epilepsy and chorea, and even apoplectic and paralytic symptoms, and several of the signs of Hydrocepha- lus, and catalepsy, have appeared to be connected with worms. The respiratory functions likewise may suffer a certain degree of sympathetic de- rangement, as is indicated by the frequent exist- ence of a short dry cough, along with which there are in some rare cases haemoptysis and even pleu- ritic pains. From the intimate connection of some of the nerves of the thoracic organs with those of the in- testinal tube, such sympathetic affections are rea- dily explained. It is well known that even fla- tulence in the stomach or bowels occasionally gives rise to a pungent pain erroneously referred to the pleurae, and Morgagni asserts that he has known a stitch in the side cease immediately after the expulsion of worms. The circulatory system also not unfrequently participates in the general disturbance, as is obvious from the occasionally feeble and irregular'pulse, the occurrence of pal- pitations, and the appearance from time to time of an irregular pyrexia. Coldness of the extremi- ties and a sour smelling perspiration have also been enumerated amongst the symptoms. The nutritive functions are sometimes greatly impaired, as is evident from the degree of emaciation and debility induced. The countenance often under- goes considerable alteration, being generally pallid or sdllow, and somewhat bloated, and there is occasional flushing of one or both cheeks. The eyes are hollow and surrounded with a livid circle, and the pupils, as was first observed by Monro, are sometimes much dilated, and the vision im- paired. - We have thus attempted to arrange in a some- what more physiological order than they are usu- ally exhibited, the greater number of the symp- toms which by systematic writers are commonly ascribed to worm^, and more especially to the lumbricoides. Amongst them all, however, (aud many of them are of very rare occurrence,) there is not a single one, save the actual appearance of these animals in the evacuations, which is truly pathognomonic ; for any or all of the others may be present and yet no worms exist, and worms, on the other hand, may abound, and yet all these signs be absent. Even the occurrence of worms in the stools, when considered in regard to its practical indication, is open to cavil, for it affords us no certain proof that they were the cause of the coexistent symptoms, nor yet that any more of the race still remain behind. Even the relief which follows their expulsion mav depend on the Vol. IV. — 92 simultaneous evacuations which take place. The itching of the nose, with the incessant picking at it, and consequent hemorrhage, to which so much importance has been attributed, is nowise conclu- sive, for it may occur equally from any other cause of gastro-enteritic irritation, and as Guer- sent suggests, may not unfrequently depend merely on the presence of -hardened mucus in the nos- trils, to which children, as yet unable to blow the nose, are peculiarly liable. Most of the other symptoms enumerated are -merely indicative of dyspeptic derangement. Even the sudden and severe abdominal pain is not by any means cha- racteristic, for it may depend on flatulence or any other cause of spasmodic constriction in the in- testines. The shreddy substances occasionally observed in the slimy stools, and mistaken for the debris of worms, seem to be really the morbid se- cretions from the mucous membrane. The exist- ence of reddish particles in the evacuations, which GeischliLger, in the fifth volume of Hufeland's Journal, asserts to be a common and conclusive sign of the presence of the lumbricoides, has not been confirmed by other observers. The diagnosis of worms is in fine often extremely difficult, or even impossible ; and this has long been admitted. St. Clair, the professor of medicine of Edinburgh, observed, about a century ago, that all the symp- toms ordinarily ascribed to worms may coexist though none of these animals are present, and re- lates the case of a child of four years old who had pains in the stomach, itching of the nostrils, watchings and terrors in its sleep, after which it would start in a fright, and it was perpetually rubbing its nose whether asleep or awake; after some time convulsions came on, of which it died on the sixth day. Worms were in vain searched for in the intestinal canal: about two ounces of a gelatinous fluid were found in the jejunum near its commencement. Though there is no unequivocal sign of the pre- sence of worms, yet the existence of an atrophic state of body, a tumid abdomen and emaciated extremities, with swelling of the nose and upper lip, and other evidences of a scrofulous habit, in conjunction with frequent colicky pains, will often, as Rudolphi remarks, enable us to guess at their presence without much risk of being mistaken; for these animals form, as we have already seen, a very frequent complication in strumous diseases. With regard to the cases of aphonia supposed to be excited by worms, the greater number of those met with in authors appear to have been merely instances of extreme debility and conse- quent indisposition or inability to speak, occurring in the course of febrile disorders, in which the co- incident evacuation of worms was merely acci- dental. Yet that they have really in some rare instances induced a temporary dumbness, we have the evidence of Hoffmann, who asserts that he had himself seen cases where the voice, which had been lost for some time, was immediately re- covered upon the evacuation of worms. Their influence on the organ of vision, rendered evident by the occasional dilatation of the pupil and im- perfect amaurosis, as well as that over the organ of hearing, as manifested in some'very rare cases by temporary deafness, seems unquestionable. In the fourth volume of Hufeland's Journal, there is 730 WORMS. mention made of a man who saw all things yellow, though he was not affected with jaundice, and this singular symptom at once vanished on the expul- sion of worms. Bremser cured a child of nine years old of epilepsy, by medicines which de- stroyed a taenia with which she had been long affected; but he admits that the removal of this formidable complication may have depended as much on the direct and well-known influence of the turpentine employed over the epilepsy, as on the mere removal of the worm. Numerous cases of chorea have been said to have been cured by the expulsion of worms. But in these there was always room to doubt whether the system of pur- gation pursued, and the consequent removal of faecal accumulations and improvement in the in- testinal secretions, may. not have had a much more important share in subduing the disease. An instance is mentioned by Dr. Suck, of Wolmar, of a girl twelve years old, in whom a violent spas- modic affection of the eyes, followed by general con- vulsions and furious delirium, was induced by as- carides. After persisting for some time in the use of purgatives and vermifuges, a great number of these worms were passed, and the patient immediately recovered. Moennich cured a child of two or three years old of a sudden paralysis of the legs and strabismus of the left eye by the use of vermi- fuges, which caused the expulsion of eighteen worms and much slimy matter. Trismus and tetanus, satyryasis, nymphomania, and hysteria, have all in some very rare instances been appa- rently traced to worms. Various other singular states of the nervous system have been at times attributed to them ; thus a case is mentioned by Delisle, where a patient suffering from worms could not endure music; and another, on the con- trary, by Desarneaux, where the concomitant con- vulsions were always relieved by it. A's to catalepsy, we have included it amongst the sympathetic affections which have been known to arise from the same cause on the authority of Van Swieten, who says tha.t he had himself wit- nessed a case of it originating in this source. He had also known a violent vertigo cease imme- diately on the vomiting of worms. Hoffmann believed them capable of inducing temporary men- tal alienation. That cough may be excited by stomachic and intestinal irritation, is an indisput- able fact, however we may choose to explain it, whether by reference to the double functions of the pneumo-gastric nerve, or to the extensive dis- tribution of the great sympathetic. Thus, in the case of a soldier, who had an artificial anus in the tract of the colon, the consequence of a wound of the abdomen, Albinus mentions that coughing was instantly induced as often as the cool air was suffered to. come in contact with the mucous membrane, which occasionally protruded; and the cough did not cease until the intestine became again warm. Dr. Elliotson had a patient, an in- fant, which instantly lost a chronic cough upon discharging from the bowels several large larvae of the common fly. A child of eleven years old, which was in the habit of frequently passing morsefs of taenia, was affected with a dry cough, which ceased for two months on the expulsion of a very large fragment of the worm by means of vermifuge medicines. The same thing happened three or four times in succession ; and Bremser, by ridding the patient entirely of the tape-worm, succeeded in curing the cough permanently, fo the ninth volume of the Medico-Chirurgical Trao*.. actions, there is a paper by Mr. Rumscy, on the occasional connection of pulmonary and hemor- rhagic affections with worms. Both Abernethy and Cheyne have pointed out the occasional con- nection of epistaxis with disorder of the digestive organs, which probably takes place, as the former has suggested, through the medium of the excite- ment of the heart and arteries. The following passage from Dr. Anncsley's work ont the Diseases of India, exhibits the train of symptoms and disorders which occur in con- nection with worms in that country :—« Cases of asthenia, dyspepsia, colicky pains, diarrhoea, vo- miting, pains of the head, of the upper and lower extremities, pains of the back, slight fever, hemor- rhoids, rheumatism either with or without fever, epilepsy, hemeralopia, and marasmus, were most frequently observed as the consequences or con- comitants of worms in the large bowels, and of morbid accumulations in the same situation; the worms being in all these cases evidently the con- sequence of the morbid secretions formed upon the digestive mucous surface, and the disorders enu- merated above being symptomatic of this state, as well as of the irritation occasioned by the worms themselves." The symptoms caused by worms have in some instances given rise to an erroneous belief in the presence of hydrocephalus, as in both cases there may be pain in the head, convulsions, enlarged pupil, tendency to vomiting, and great depression of spirits. The mistake is, however, hardly ex- cusable, inasmuch as the symptoms are far less intense and less continuous in the former case than in the latter. But in forming our diagnosis, it must not be forgotten that worms and hydrocepha- lus may coexist. On the importance of Worms in a patho" logical point of view. "The evil effects attributed to worms," says Rudolphi, after a careful analysis of the symptoms commonly ascribed to them, " are only occasional and accidental, and when they do occur, depend as much or more on a debilitated, disordered, or over-irritable state of the body, and especially of the intestinal canal, as on the mere presence of these its natural inmates. In a very great majo- rity of cases they do not excite any inconvenience, and even with regard to taenia, the most dreaded of them all, the first suspicion of its existence is often awakened by the appearance of fragments of it in the evacuations. The ascaris lumbricoides and taenia, in such peculiar cases as those just alluded to, and in those only, are capable," con- tinues the same author, " of exciting convulsions and certain other spasmodic affections, and the ascaris vermicularis may produce itching of the anus and genitals; all the other evils ascribed to worms in the intestines of the human specie* are fictitious." Such is the opinion of one of the highest authorities on this subject;-and Dr. Parr expresses himself very much to th§ same effect. " Worms," says he, in his Medical Dictionary " seem to form a part of a healthy constitution. and are scarcely injurious but from accidental cir- WORMS. 731 cumstances." He admits, however, that when in great numbers they may excite irritation and lead to disease. " Their formation," he adds, " is as- sisted by the accumulation of mucus, and conse- quently in children, and sometimes in cachectic patients, they may become inconvenient, but are soon destroyed by any kind of fever." Agues in particular are said to determine their speedy ex- pulsion. Clarke thinks that they serve to keep away other diseases; but this is not very proba- ble. Healthy children, as Rudolphi remarks, do not stand in need of them; and to the delicate they are obviously injurious. Such hypotheses have arisen from the vanity or error of supposing that all animals were made in reference to man, and for his advantage alone, instead of primarily for their own sake and for their own enjoyment of existence. Bremser likewise rates their impor- tance in relation to pathology very low, insinuating that the chief reason for investigating the means of expelling them is to be found in the fancy which all patients in whom they are known to exist have to get rid of them ; and his testimony is the more disinterested as he seems to be very extensively employed in this department of prac- tice. The account, however, which M. Louis has given of the symptoms of taenia, drawn from cases which have fallen under his own immediate obser- vation, leads us to believe that several of the above distinguished physicians have made rather too light of the matter. M. Fortassin has run into the opposite extreme, ascribing all manner of evils toworms—affections of the brain and lungs, ophthalmia, dyspepsia, gangrene, paralysis, as well as various spasmodic and nervous affections. The only mtorbid appearance, as discovered by dissection, which worms seem capable of exciting in the intestines, is a slight injection of the mu- cous membrane, together with an unusual quantity of mucus. Whether they have ever, from their numbers being very great, caused obstruction and consequent inflammation and gangrene, is doubt- ful. In the human species we have rarely oppor- tunities of ascertaining by actual dissection the number of worms which may at once be present, or the state of the intestinal canal which coexists with them in healthy individuals. Comparative pathology, however, enables us to supply this de- ficiency. Rudolphi has found the intestines of horsrs and lambs, and of various birds, fishes, &c. stuffed full of worms, and yet no inflammation was induced. One animal he found filled up with them from the fauces to the cloaca. He does not, however, think they can ever produce absolute obstruction, as there will always be room for the passage of chyle and faeces. Their agglo- meration, occasionally detected in the human in- testines along with ileus, as in a case mentioned by Rahn, is probably the effect and not the cause of the obstruction. That such worms as are met with in the intes- tinal canal of man are altogether incapable of perforating the healthy tissues is the belief of Wickmann and Bianchi, Rudolphi, and Bremser, and was indeed long since advocated by Plater. And even in the case of the ecchinorhynchi, which by means of their proboscis armed with curved hooks do occasionally perforate the walls of the j intestines of fish, birds, and some of the mam- malia,—Rudolphi having himself seen not only the proboscis and part of the body thrust through the aperture, but even the whole animal in the abdominal cavity,—the process is so gradual, and the organs by which it is effected are so minute, that no inflammation is produced. The wound inflicted is extremely small, and heals up so rapidly that he never was able to discover an unoccupied apertuie. For the most part, however, only one of the intestinal tunics is penetrated by them. Bremser doubts whether the lumbricoides can even induce irritation of the intestines. In animals just killed, he has always found them insulated and enveloped in mucus, so that they were not even in contact with the internal membrane. Neither he nor Rudolphi ever found them adherent to this part by either extremity, though they do not absolutely deny the possibility of such an occurrence. Their smooth and taper surface will also tend to prevent their getting impacted. If they be ever capable of causing irritation, Brem- ser thinks it can be in those oases only where the intestines are independently in a morbid condition. The tape-worm, though it affixes itself so firmly as to break rather than to loose its hold, and to retain its position even when put up as a prepara- tion in alcohol, induces no local inflammation. All the reputed cases of perforation by worms seem to have originated either in ulceration of the intestines, or in strangulated hernia accompa- nied with inflammation, suppuration, or gangrene, the worms merely passing out through the lesion into the cavity, or to the surface of the abdomen. It has been supposed by Richter and otners that worms may themselves be the cause of strangula- tion of the intestines; and Widekmd has en- deavoured to show that they produce this effect either by producing'spasmodic contractions and consequent inflammation and incarceration of the portion of gut in the hernial sac, or else by me- chanical obstruction. But all this is rejected by Rudolphi, who believes that worms are totally incapable of producing such phlogosis or ob- struction whether in the free intestine or in the case of rupture; and Bremser's extensive expe- rience has never furnished him with a single instance of the kind. He quotes, however, two cases, one from Daquin, and the other from Cam- pedon, which were perhaps of this nature. There was violent colic in both. Daquin's patient, a child of ten years old, had obstinate vomiting, delirium, amaurosis, and eventually coma. The small intestines and caecum were found quite dis- tended with worms, as if they had been forcibly stuffed-into them. The head unfortunately was not examined. The other caseVvas that of a man who died after enduring excruciating pains for twenty-four hours, and on dissection the caecum and part of the colon were found filled up with worms, the number of which amounted to three hundred and sixty-seven. The intestines were inflamed and gangrenous. Of the Symptoms peculiar to each kind of Worm. Symptoms of the Ascaris lumbricoides.— In the preceding section nearly all the symptoms to which this species gives rise have been enumerated. The general description of worm-symptoms met 732 WORMS. with in'professed writers on the subject, who have for the most part merely copied their predecessors from the time of Andry down with great assiduity, have commonly been made in reference to this the most frequently observed of the whole race. The group which Dr. Baillie selects out of them as more particularly indicating the presence of the round worm is as follows, — "a swelled belly, emaciated extremities, an offensive breath, and a deranged appetite." "The appetite is often greater than in health, but sometimes it is much less. The stools are slimy, and the patient fre- quently picks his nose, and during sleep grinds his teeth." In Heberden a still fuller list is to be found, but in giving it we should only be repeating the enumeration already made at so much length. According to Laennec, the most frequent symp- toms are colics and other kinds of pain in differ- ent parts of the belly, alternation of anorexia and excessive appetite, nausea, hiccup, cardialgia, diarrhoea, and tension of the abdomen: and to these he annexes a long catalogue of general symptoms which do not differ materially from those to be found in a preceding page. Whether the lumbricoi'des is capable of causing pain even in a morbidly sensible mucous membrane, is one of those points which Rudolphi believes it impos- sible either to prove or to disprove. Similar pains occur where none of these animals exist; and even the cessation of suffering on their expulsion is not conclusive, for to the evacuation of faeces, flatus, &c. which takes place at the same moment, the amelioration may be equally ascribed. Where they leave their natural abode, the small intestines, and mount into the stomach or cesophagus, parts not destined for their reception, they may doubt- less produce very distressing symptoms, pain, nausea, vomiting, titillation of the throat, convul- sions, &c. The convulsions induced by them are not generally of a very formidable nature. Guer- sent never saw them prove fatal save in the single instance already alluded to, where they seemed to have suddenly introduced themselves into the biliary ducts. Symptoms of the ascarides vermiculares.—Itch- ing of the anus, coming on especially in the even- ing, and aggravated by the warmth of bed, violent exercise, or anything else which overheats the body, is, next to the actual detection of these worms in the stools, their most characteristic symptom. In the early part of the day the patient is often entirely free from this annoyance. There is occasionally an uneasy heavy feel or dull pain, more rarely a lancinating one, about the extremity of the rectum, where from the frequent rubbing of the part to relieve the pruritus, small tumours, like piles, form, and sometimes secrete a fluid from their surface, which concretes into thin scales. An oft-recurring inclination to go to stool is a frequent symptom, along with tenesmus, and slimy evacuations, which are at times tinged with blood. We have known a spasmodic state of the sphinc- ter ani also to exist along with other symptoms indicating a considerable degree of irritation in the mucous membrane, which, perhaps, in some in- stances, passes into subacute inflammation. Many additional symptoms have been ascribed to them by various writers. « Sickness, gripings, faintness, tremblings, indigestion, giddiness, pains of the head and stomach, too much or too little appetite, itching of the nose, unquiet sleep, coughs, offensive breath, have all," says Heberden, "beea found in different persons together with ascaridear, but experience teaches us that none of these symp. toms are necessarily connected with them, and therefore it is doubtful, whenever they have met, whether chance or the nature of the distemper have had the greatest share in bringing them to- gether. This sort of worm has continued for twenty or thirty years without doing any conaj. derable injury to the health." The general symptoms to which they have in some rare instances given rise in very irritable habits, and especially in young children, have been of an alarming nature. Thus, Hoffmann eivej the case of a boy of seven years old, who, being active and healthy previously, was suddenly seized with an acute pain in the head along with febrile heat and quickness of pulse. Shortly afterwards there supervened tormina about the navel, efforts to vomit, intolerable itching of the anus, and ob- struction of the bowels of three days' duration, succeeded by convulsive movements of the head and feet. On the cessation of these, he lay breath- ing heavily, with his eyes fixed, and deprived of sense and motion. Antispasmodics, anthelmin- tics, and purgatives were administered. Nume- rous stools were induced, and along with these above a thousand ascarides rolled up into a ball were passed, after which all the symptoms imme- diately ceased. The same writer assures us that he had in several other instances seen them induce violent nervous symptoms, not only in children, but also in cachectic females whose health had been impaired by a deranged state of the menstrual function. Restlessness, insomnia, and a very irritable and even wretched state of body and mind during those hours in which their motions are most felt, are not uncommon. Brera, and even Rudolphi, have con- jectured that their intolerable annoyance, in the worst cases, may depend on a deficiency of pro- tecting intestinal mucus; this cause, however, ap- pears very doubtful, being inconsistent with' the well-ascertained fact, that the severityof the symp- toms may be greatly reduced by such means as are known to diminish the quantity of this secre- tion, as by extreme temperance in eating and drinking, regular and active bodily exercise, &c. Their irritation often causes, or at least is ac- companied by, symptoms of indigestion, as an uneasy faintish feel at the pit of the stomach; a capricious or sometimes a depraved appetite mani- festing itself in a desire for indigestible substances; pains in the belly, itchiness and redness of the nose. In females they may induce, either by sym- pathy, or, as is much more frequently the case, by their actual presence in the vagina and orifice of the urethra, intolerable pruritus, leucorrhoeal discharges, or even irritation of the bladder, nym- phomania, and other evil consequences alluded to by Wichmann ; and in males, likewise, a tendency to excessive sexual indulgences has sometimes been attributed to the state of congestion and ex- citement induced by their proximity to the genital organs. Prolapsus ani has been supposed both by Plater and Van Phelsum to be sometimes in- duced by them, and a sensation compared to ■ WORMS. 733 drop of cold water falling in the rectum has been paid by the latter to be sometimes produced by them. If the falling down of the gut be ever really produced by them, it must be in an indirect man- ner, through the medium of the lorfg-continued and vain efforts made at stool. In many patients | most or even all of the above symptoms are absent though ascarides are found in the stools, which can only be explained either on the supposition of an unusually low degree of sensibility in the rectum, or on that of these animals occupying a higher situation than usual in the bowels. In forming our diagnosis we must bear in mind that the pruritus, and many of the other inconveniences enumerated above, may equally owe their origin to hemorrhoids. Symptoms peculiar to txnia.—The effects to which the presence of tape-worm gives rise in the animal economy ore represented in the most dis- similar lights by the different writers who have treated of it; for whilst to some it has appeared scarcely to merit the name of a disease, others speak of it as one of the most formidable affections to which humanity is liable. The taenia solium and taenia lata, says Rudolphi, are found in very healthy individuals, and are generally known to exist only in consequence of portions of thein being evacuated. They seem commonly to remain at rest,- and though patients sometimes speak of their producing an undulatory sensation, yet this is probably often the result of fancy ; for such a motion should no more be felt by healthy individuals than the peristalsis of the intestines. That the feeble and irritable, who have a mucous membrane possessed of a morbid degree of sensibility, should be capable of perceiv- ing such motions, is conceivable. The occasion on which they will be felt is most probably when the creature gathers its whole length into a ball in one spot of the intestine. Women of a very nervous habit complain of their causing disagree- able undulatory, creeping, or rotatory movements; but though these may sometimes really depend on the presence of taenia, they probably much more frequently originate in imagination or in globus hystericus. M. Hippolyte Cloquet, on the other hand, says that the symptoms of taenia, though often obscure and equivocal, are very numerous and varied, and are capable of similating any disease, however rare and extraordinary. Those which first ap- pear, according to this author, are swelling of the abdomen, pain, and borborygmi; the colour of the face is altered, being redder or paler than natural, of a leaden hue or mottled, and changing momen- tarily ; the eyes are fixed, watery, dull, and sur- rounded by a dark circle, and the pupils are greatly dilated; the eyelids yellowish and puffy; there is pruritus of the nostrils, and occasionally epistaxis; the tongue is whitish, speckled over with purplish points, (the prominent villi,) and j reddish or inflamed at the tip. At a later period como on headach and a sense of confusion, loss of sleep, severe pain in the orbits. The appetite is unnaturally increased or diminished, or each alternately, there being at one time excessive hun- ger, and at another disgust for food. The urine is turbid, milky, jumentosc; the perspiration of a fetid acid odour, and the extremities are cold. 3m There are ringing in the ears, much frothy saliva in the mouth, hiccup, nausea, sour eructations, fetid breath, desire for cold drinks, night-sweats, rigors, an uncomfortable feeling of weight in the abdomen, vomiting of a yellow or porraceous bile, a short dry cough, cardialgia, frequent lipothomy, respiration difficult and stertorous, or even panting in the sleep, which is broken and unquiet, som- nambulism, trembling of the limbs, vertigo, palpi- tations, hardness, frequency, and intermittence of the pulse, an obscure sensation of pricking or dragging in the abdomen, diarrhoea or obstinate constipation, tenesmus and extreme itching of the anus, an irregular anomalous fever, a fungous state of the gums, livid lips, and great emaciation, even when the appetite is great. There exists, moreover, a state of great anxiet^ depression of spirits, and debility. The uneasy feelings are for a time appeased by eating, but return as soon as digestion is finished. There is a disposition to lie on the abdomen, and a temporary feeling of ease after a draught of cold water. Out of this formi- dable host of symptoms, those which he selects as most characteristic, are dilatation of the pupils, itching of the alae nasi, a sour breath, lividity or paleness of the face, derangement of the digestive organs, emaciation and a sense of creeping or dragging within the abdomen, and ptyalism. The symptoms which were considered by Dr. Baillie as most indicative of its presence, are a gnawing uneasy feeling in the region of the sto- mach, diminished or removed by eating, an appe- tite commonly somewhat voracious, though occa- sionally less than natural, an itching of the nose, frequent nausea, colics and giddiness, in sonic cases a cough, and in others convulsions. The great majority of cases which have fallen under our own observation have been in middle- aged females in the poorer classes of life. The symptoms complained of were occasional pain in the stomach, vomiting of a watery fluid in the mornings, anorexia or craving appetite, thirst, swelling of the abdomen, itching of the anus and nose, a sense of general soreness all over the body, weakness of the limbs and of the back, great ten- dency to perspiration, heaviness of the head and a stupid confused feeling, dulness of sight, though the pupils were natural, and finally portions of the worm coming away, not only when at stool, but even while walking. Amongst the symptoms of impaired digestion, caused by these animals, Van Swieten mentions in particular borborygmi, which were so loud in one instance as to be audible at thirty paces dis- tance ; and a similar case is mentioned by a French author. In a well-marked case of tape-worm, detailed in one of Dr. Elliotson's clinical lectures, the subject of which was a man of twenty-seven years of age, the following were the symptoms present: — con- stant hunger, confusion of head, with heaviness and tension of the forehead; throbbing of the temples, and starting from sleep; pain in the re- gion of the heart, and palpitations; frequent and fruitless visits to the water-closet, and tenesmus ; itching of the nose, and nausea before breakfast; in addition to all of which, he had frequently passed large portions of the worm. The pains in the limbs, which occur in many cases of taenia, as 734 WORMS. Dr. Elliotson remarks, are not peculiar to worms, being met with in irritation of the stomach and bowels from various causes. In cholera, they are seen at their maximum of intensity. Examples of pains in distant parts of the body, neuralgia, cramps, &c, from derangement of the digestive organs, are daily presenting themselves to the medical practitioner. In bilious attacks, as they are popularly called, or in gastro-hepatic derange- ment, paki in and over the eye-balls is an almost constant symptom. In gastric fevers, and cases of subacute inflammation of the mucous mem- brane of the stomach and intestines, pains and a feeling of extreme fatigue, or of the parts having been bruised, are, as every one knows, extremely common. On the exhibition of medicines tending to procure fre" evacuations from the bowels, to reduce inflammation of the mucous membrane, and to restore the digestive organs to a healthy condition, all the symptoms which had been as- cribed to worms will often immediately cease, though none of these animals may have been passed. Of all the accounts of the symptoms of taenia, that by M. Louis, drawn from the careful observa- tion of ten cases in the hospital " La Charite," at Paris, a few years ago, is by far the most satisfac- tory. Three of the patients were females, and seven were males, the youngest being a boy of twelve years old, the son of one of the other pa- tients, and the oldest seventy-four years old. Most of them were in a very comfortable station of life, and all were habitually well fed. All, ex- cept two, were of a good constitution, and gene- rally healthy prior to the appearance of the tape- worm, the disagreeable symptoms all dating from the period when they had first perceived the joints of the worm in their evacuations. Their mode of life was generally active. Thus, as far as these ten cases go, there is no reason to attribute the disease either to bad food, to the influence of age, debility of constitution, previous maladies, or a sedentary mode of life; all that could be made out about the matter, was the existence of the worm, and of certain symptoms to which it gave rise. The greater number of the patients had been eyacuating fragments of taenia almost daily for several years, some even from their earliest youth up ; and the joints of the worm came from them even in the intervals of the stools, and were found in their clothes or in their beds. In one individual, however, the appearance of the articu- lations in the evacuations had been observed but twice, and each time after the exhibition of a pur- gative. In all except two the period of the origin of the symptoms, and that when the first traces of the worms were detected in the faeces, were coincident. Louis accounts for this by supposing, that until their attention was awakened to the subject, the patients had overlooked or forgotten the symptoms which may have long previously existed. But this absence of symptoms in the earlier periods of the affection, taken in conjunc- tion with their temporary subsidence after each expulsion of a large portion of the worms, seems to us rather to indicate that it is chiefly when it becomes so elongated as to get into the large in- testines that it is productive of serious annoyance. That the lower portion of the worm does occa- 4 mm °4 sionally extend so far down, is unqucstion Thus, in a case to be found in a recent numl of the ML-dico-Chirurgical Journal, it is nvntioi that a patient was in the habit of ridding himsefc of large fragments of tape-worm by introducin|: a stick into the rectum, and twisting the worji around it till it broke. In none of M. Louis' cam were the functions of the body in a state of perA integrity, though the degree of derangement vajB much in different individuals, being very irihmT siderable in some, and yet so annoying to otheri that they took every means within their power u get rid of the disease. The chief symptoms were colic and pain in abdomen of various kinds, itching about the ani and at the end of the nose, more or less derange. ment of the appetite and digestion, and pain it the epigastrium. Headach was rare, but pain and lassitude in the limbs very frequently existA' and that to so considerable a degree as often w interfere materially with the free exercise of their several trades. The most constant of the abo\s symptoms was pain in the abdomen, which existed in all the cases, though in very different degrees of intensity, being in some like a colic, and in others of a less marked kind, the nature of which they could not well explain. It was seated chiefly towards the flanks, intermittent and recurring it various intervals. The colicky pains were neither accompanied nor followed by diarrhoea except in one case, that of a female who had likewise been labouring under a menorrhagic affection for four years. Itching at. the margin of the anus was the symptom next in frequency, being present in seven-tenths of the cases. Itching at the end of the nose was much less frequent, being present only in four-tenths of the patients. But with the exception of a single case, pruritus existed in one or other of these situations in all; and the degree of it seemed to be often proportional to the num- ber of joints passed, which appears to prove that this symptom depends in a great degree on the local irritation of the rectum from the actual pre- sence of portions of the worm in it. The appe- tite in one case was sensibly increased; in four not notably altered; in the remainder it had fallen off or was subject to alternate increase or diminu- tion. In the case of the women especially, there frequently occurred a degree of hunger difficult to satisfy, and requiring the repeated ingestion of food at very short intervals; and in one individual nothing but animal food seemed capable of allay- ing this craving, which was accompanied with a distressing feeling of convulsive motions or spas- modic contractions within the abdomen. It was also chiefly the females who complained sf sharp pain at the epigastrium: in one case this seemed to have been induced by the violence of the reme- dies which had been imprudently employed, but in the others it was caused evidently by the taenia itself, as it ceased immediately after its expulsion. One woman complained of a sense of weight at the stomach after eating. In one case only was there any vomiting; and in this it was constantly induced by eating carrots, of which the patient, a young Swiss, was very fond. He was able to eat them without inconvenience, both before he be- came affected with taenia and after its expulsion. The same patient complained likewise of bor WORMS. 735 .>oryurmi and pains in the regions of the kidneys, and a sense of debjlity in the mornings without my known cause. All of these symptoms ceased after he got rid of the worm. Headach, as al- ready mentioned, was rare; in one instance where it existed, the patient was phthisical, and it may have depended on the violence of the coughing. Yet in two of the females pain in the head seemed to be connected with the presence of the tape- worm. Pains, lassitude, and even cramps in the extremities were very common, and from inter- fering with the patient's avocations, were, with many, the symptoms which chiefly urged them to seek a cure. Emaciation to a certain degree ex- isted in all,- it was not, however, very marked in any, and had not generally become obvious till one or more years after the fragments of taenia began to be passed. Singing in the ears was a symptom in the women's cases; in one only was there slight dimness of sight. The pupil was in its natural state in all; hence its dilatation cannot be considered an ordinary symptom of taenia, . though mentioned as such by many writers. The •intensity of the symptoms, as well as the number of fragments passed in two instances, increased notably in spring. From the above review of the symptoms, it ap- pears that their number and variety were greatest in the women, as in addition to those complained of by the men, they had singing in the ears, occa- sional imperfection of sight, pain at the epigastrium, and a considerable derangement of the appetite. M. Louis thinks that we may almost with certainty conclude that a worm of some kind or other is .present in the intestinal canal, when there exists the following combination of symptoms, viz. pain in the belly, colic of various degrees of frequency and intensity, but unaccompanied with diarrhoea ; and finally pruritus about the anus and the end of the nose. Other symptoms, such as pains in the limbs, lassitude, disinclination to work, and various nervous affections occasionally present, may also assist our diagnosis. To M. Darbon's reme- dy, by which the tape-worm was so speedily and safely expelled in the above cases, we shall after- wards allude. All the symptoms ceased within a few days af farthest after their expulsion; the appetite and digestion became natural; the colour, flesh, and strength returned ; and the patients all continued in perfect health four months, when the stability and completeness of the cure were tested by again exhibiting the anthelmintic medicine. Those who had previously been relieved by other modes of treatment had never enjoyed so long an interval of repose after their use. Diarrhoea, though excluded by Louis, seems, according to the experience of Dr. Darwall and various other practitioners, to be by no means a rare symptom in cases of taenia, though tenesmus seems to be a still more frequent one. The last- n;uned author, though he has treated some hundred cases of the disease, never once observed that temporary alleviation after eating, of which so many writers speak; on the contrary, the patient's sufferings were usually rather increased by it. Pains of a rheumatic character appeared to him to be very common, and were influenced in some degree by the weather, though they ceased entirely on the worm being destroyed. He confirms the observation made above, as to dilatation of'the pupil not being one of the ordinary symptoms of this affection, never having met with it except in cases of concomitant cerebral affection. Treatment.—In the treatment of worms we have a twofold indication to fulfil,—namely, first to expel those which are already present, along with their ova, and the superfluous mucus in which they exist; and, secondly, to prevent their repro- duction. The medicines by which these objects are at- tained are called anthelmintics, which, as stated in a former part of this work, are divisible into evacu- ants, which simply expel the worms, either by their mechanical, chemical, or purgative influence ; the specific, which act as a poison to the worms; and the corroborant, which tend to correct that state of the system on which their generation de- pends. (See Anthelmintics.) Though the first of the above-mentioned indications be that which commonly attracts most attention, yet in real im- portance it is infinitely inferior to the second. The worms themselves in many, perhaps in most in- stances, are productive of little inconvenience; whereas that impaired state of the digestive func- tions to which, as we have seen, they so often owe their existence, is incompatible with the perfect enjoyment of life. The number of reputed vermifuge medicines to be met with in authors, even limiting the term to such as are thought to have the power of killing or expelling worms, is very great; their mere enumeration would occupy several pages; but, as commonly happens, this apparent superfluity of means is deceptive, the invention of new remedies being generally the result of the inefficiency or of the dangerous nature of those previously in use. The following heterogeneous catalogue, though brief in comparison to some others that we could mention, contains, we believe, most of the anthel- mintics which enjoy any degree of credit in the present day, and certainly many more than the practical physician will almost ever find it neces- sary to have recourse to. Those which are most in use have already been noticed in the article Anthelmintics, with appropriate directions and cautions. Many which have in their day been zealously advocated are infinitely more to be dread- ed than the disorder they are intended to combat. 1. Mechanical Anthelmintics. — Metallic zinc, tin, or iron, in-a state of somewhat coarse subdivision; cowhage, [the short thick bristles surrounding the nut of Corylus rostrata or beaked hazel, (see the writer's New Remedies, 4th edit., p. 200, Philad. 1843,)] charcoal. 2. Specific Anthelmintics.—Various empy- reumatic and essential oils ; turpentine; Dippel's' animal oil; Chabert's oil * petroleum ; cajeput oil; essence of bergamot; oil of juniper; camphor ; pomegranate-root bark; the male fern root; ve- ratrum sabadilla; Geoffraea inermis and Surina- mensis; spigelia Marylandica and anthelmintica ; scabiosa Indica; colchicum; areca oleracea; ca- rica papaya ; helminthochorton ; chenopodium anthelminticum ; the hellebores ; savine ; rue; bastard dittany ; tobacco; prussic acid. Bitters.—Tansy ; artemisia Santonica and Ju- daica, (worm seed, semen contra); hiera picra; chamomile, &c. 736 WORMS. Acid*. Vegetable and mineral; fixed air, &c. Metallic Salts. Sulphate and carbonate of iron; nitrate of silver, &c. Common salt; sea water; sugar; sulphur; sulphuretted hydrogen; sulphuret of tin; muriate of ammonia; muriate of barytes; ether; alcohol; assa- foetida ; garlic ; onions; squills; valerian ; green shell of the walnut; juice of carrots; large draughts of cold water; mare's milk; electricity. 3. Purgatives used as Anthelmintics. The saline class of purgatives ; oily purgatives ; (castor oil, croton oil, olive and other bland oils in large quantities, &c); drastic and other purgatives; gamboge ; scammony; colocynth ; gratiola ; jalap; aloes; senna ; rhubarb; ipecacuanha ; mercurial medicines, especially calomel; antimony (tartar- emetic). Of the medicines enumerated above under the head of specifics, several are of a highly dangerous nature, and, we repeat it, quite disproportioned to the importance of the malady; and some of the rest have but a doubtful claim to the place which they here occupy. Thus it is very uncertain whether the salts of iron, as well as bitters and mineral acids, do not owe the whole of their bene- ficial influence, not to any direct or immediate impression on the worms, but to their gradual effect in improving the tone of the stomach and intestines. But however this may be, their utility in the treatment of worm cases is well established. 'Amongst the best accredited vermifuges, or sub- stances which seem really to exercise a specific influence over worms, are turpentine, Chabert's oil, the root of the pomegranate and of the male fern, Geoffrssa inermis, spigelia Marylandica, and Cevadilla. The use of the three last is, however, attended with a degree of risk which is scarcely counterbalanced by such efficacy as they possess; and we can the more easily dispense with them in consequence of the well-ascertained vermifuge power of those which precede them, and which are more manageable and more readily obtained here of an uniform strength. Even in the use of many of the purgatives employed against worms, considerable caution is requisite, as the debility which their untimely or excessive employment may induce is not only more detrimental to the patient's health and comfort than the worms usu- ally prove, but actually predisposes to the recur- rence and multiplication of these parasites. Where an inflammatory condition of the mucous mem- brane of the stomach or intestines happens to exist, the injurious effects to which drastics might give rise scarcely need to be pointed out; and, indeed, in most cases where a febrile state of the system connected with some acute or subacute 'local affection is present, the treatment of the coexisting worms may be safely postponed as altogether of secondary importance. These excep- tions being made, aperient medicines judiciously employed constitute, it must be confessed, one of the most useful and most generally applicable remedies against worms, and especially in the cases of children. They at once improve the secretions, tend to relieve the coexisting dyspeptic and nervous symptoms and to prevent any inordi- nate accumulation of these animals, and thus greatly alleviate the symptoms even where they do not altogether put an end to the affection. The mild influence of certain mineral waters often proves very beneficial in worm-cases, both immedi- ately, by keeping up a free slate of the bowels, and mediately, through the accession of energy which the digestive organs receive during their use. The water of Seidlitz, abounding in the muriate of magnesia, has long been celebrated in such cases; and sea-water, which owes its bitter- ness to the presence of the same salt, is likewise often found very useful. The presence of sulphu- retted hydrogen, in addition to the nbove-named and various other purgative salts, gives the Har- rowgate water a still higher claim to our confi- dence. The waters of Pyrmont, from containing iron in solution, were reckoned by Hoffmann and many other German physicians very beneficial in cases of taenia. The employment of such measures as strengthen the body constitutes by much the most important part of the treatment of worms, as it tends not only to prevent their formation, but also to remove the irritable state of the system so often present, and to add energy to the various functions on the imperfect performance of which much more than on the presence of these animals, the troublesome symptoms depend. A diet, consisting of food of easy digestion, and so restrained in quantity as to insure its perfect assimilation, along with a healthy habitation, a dry atmosphere, and regular exercise, will often, alone or with the aid of the mineral and vegetable tonics, prove perfectly sufficient to attain the desired end. If, however, they fail, and the evidence of the existence of worms and of their inducing irritation in the system continues strong, the employment of some of the best estab- lished and safest of the anthelmintic medicines mentioned above becomes justifiable. If a scrofu- lous diathesis, as is so often the case, coexists, all those means which are known to be useful in its management must be simultaneously brought into action. As to the nervous affections which form the great bulk of those fairly traceable to worms, we must endeavour to palliate them as they rise, by the use of a mild and demulcent diet, the tepid bath, and other ordinary antispasmodic reme- dies, until we can succeed in removing their cause by the means just alluded to. Some of the German practitioners are extremely partial to the use of Chabert's oil. " It is the only medicine," says Rudolphi, " which at once expels the worms, and by giving that degree of stimulus to the enfeebled body which is so requisite in scrofulous and hysterical cases, removes the tendency to their reproduction." It only remains to make a few remarks on the particular treatment more especially applicable to each of the three species of intestinal worm from which inconvenience may in this country be experienced. The treatment of the bothriocepha- lus is of little comparative interest here, and will, therefore, only be cursorily noticed when we come to speak of that of the common tape-worm. The trichocephalus, as already stated, does not appear to induce any disturbance in the economy, and is hence rarely if ever the object of medical treat- ment. Treatment of ascaris lumbricoides. — The means generally resorted to in this country for the removal of this species of worm, consist in the WORMS. 737 employment from time to time of active purga- tives ; whilst bitters and tonics, together with such mild aperients as suffice to keep the bowels in an open state, are administered in the intervals. A combination of calomel and jalap is the purgative most frequently employed ; from two to five grains of the former along with from four to fifteen of the latter, according to the age and strength of the individual. Larger doses than these might perhaps, sometimes be advantageously substituted, and have, in the case of adults at least, been re- commended by the best practitioners. Thus a formula employed by Dupuytren in worm cases contains thirty grains of jalap with six of rhubarb and two of calomel. Both Wepfer and Van Swieten, also, give jalap in half-drachm doses; and Pringle administered even in fevers a similar quantity of rhubarb with twelve grains of calo- mel. If the more moderate of the above-men- tioned doses be preferred, and the patient be of a tolerably strong constitution, they may be re- peated for a few days in succession, and their action aided either by castor oil, infusion of senna, or some of the saline aperients. Scammony, aloes, and rhubarb enter into the composition of several of the formulae employed in such cases; and the last-mentioned substance forms a useful addition to whatever purgative may be selected, as it tends, whilst producing an aperient effect, like- wise to support the tone of the mucous membrane. Bitters, quinine, or some of the preparations of iron, the carbonate, sulphate, or acetate, may be subsequently employed and continued for a con- siderable length of time, along with such mild aperients as will produce two, or at the very most three stools daily. For the latter purpose the in- fusion of rhubarb, combined with a bitter and an alkali, answers extremely well, or a combination of rhubarb and carbonate of iron with some bitter extract. Such preparations, whilst they prevent the accumulation of worms, serve likewise to give energy to the process of digestion, and if em- ployed in conjunction with a tonic and moderately stimulant system of diet, and healthful exercise, remov* that condition on which the production of worms so often depends. Calomel is thought by many practitioners to possess a power of de- stroying those animals greater than its purgative effects alone are capable of accounting for; and a perseverance in its use, where the constitution ad- mitted of it, has subdued some very obstinate cases. " Calomel, in order to be effectual," says Rush, " must be given in large doses. It is a safe and powerful anthelmintic." That mercury really exerts a poisonous influence over worms in cer- tain circumstances seems proved by an observa- tion of Laennec's, who says that he once procured their expulsion in a dead state by means of mer- curial frictions; whereas, after all the previously employed anthelmintics, they came away alive. Such an effect from mercury is, however, very far from being universal. Thus Scopoli observes that worms are in no persons more abundant than in those living near the great quicksilver mines of Idria, though their constitutions are often tho- roughly saturated with mercurial exhalations. Van Helmont, Hoffmann, Dionis, and others, had great faith in water in which quicksilver had been boiled as an anthelmintic ; yet there is no reason Vol. IV. —93 3m • to suppose that any portion of the metal is dis- solved if the water be pure. Van Helmont, in- deed, was aware of this, but fancifully believed that the water borrowed the property though not the substance of the mercury. Rush has great confidence in the carbonate of iron, taken daily in doses of from five grains up to half a drachm, a purgative being occasionally interposed to carry down the worms. The following combination of bitters and pur- gatives was much employed by Hoffmann, and, as he informs us, with great success. Assafoetida, extract of rhubarb, tansy, aloes, myrrh, and calo- mel, of each a drachm, together with four grains of extract of saffron and as much castor oil, were all well mixed together; and each scruple of the mass divided into fifteen pills, of which the dose was from five to eight, according to the age. Rosenstein's favourite anthelmintic powder con- sisted of four grains of sulphate of iron, with ten of semen Santonici, and twenty of jalap, very well rubbed up with an equal quantity of sugar to prevent its griping, and administered in a little honey at breakfast-time. When it began to ope- rate, a glass of cold water was to be taken after each stool. It was administered for three morn- ings running at the beginning and end of the wane of the moon, a part of the prescription to which much importance will not now be attached. He was also in the habit of giving repeated small doses of assafoetida (five grains every four hours) for two days, and then purging it off" on the third with rhubarb. Stork's vermifuge electuary, which still enjoys a high reputation, was composed of sal polychrest, jalap, and valerian, a drachm each, along with four ounces of the oxymel of squills, the dose for an adult being half an ounce four times a day; and for a child one or two drachms. " Most of the empirical remedies," says Under- wood, "consist either of bitter purgatives or mer- curials ; calomel, scammony, and jalap, have been said to be the active medicines in several of our worm lozenges and worm cakes. That their efficacy is often superior to that of the medicines used in similar cases by the regular practitioner, depends, therefore, rather on the greater size of the dose than on any peculiarity in the ingre- dients. Bremser's treatment consists in the administra- tion of a tea-spoonful of the following electuary, (called by him No. 1,) night and morning for three or four days, or till the bowels are well cleared out by it, increasing the dose if necessary, but taking care that it shall not be carried so far as to induce watery and debilitating evacuations. R. Semen Santonici et s. tanaceti rude,- oontus, a. gss.; pulv. valerian s. Jjii.; jalajjae, giss.-ii; sulphat. potass, jiss.-ii.; oxymel scillitic, q. s. ut fiat electuarium. As the taste is very disagree- able, the same ingredients may be given, as sug- gested by M. Grundler, in the form of pill, when children cannot be prevailed on to take it other- wise. Bremser attaches some importance to the two first ingredients being only slightly pounded, in order that, being in a state of coarse subdivi- sion, they may act in 6ome degree mechanically, or at least retain more of their peculiar virtue in their transit through the stomach, and thus carry part of it with them into the intestines. By being WORMS. long kept, they lose much of their efficacy. Va- lerian he considers to be at once an excellent ver- mifuge and antispasmodic, and jalap he conceives to be less apt than most other purgatives to weaken the bowels, and most proper to remove stagnant mucus and faeces; whilst the slow solubility of the sulphate of potass causing it to act more slowly and certainly renders it peculiarly suited to such cases. Should the diagnosis even have been erro- neous and no worms exist, such an electuary can- not fail of being beneficial to the health by re- moving those symptoms of intestinal derangement and inactivity which had given rise to the suspi- cion of their presence. He has rarely had occa- -sion to renew the prescription more than once. Where a more active purgative seems called for, .he suspends the use of the electuary for the fol- lowing preparation—(No. 2.) R. Pulv. rad. jalap, Qi.; fol. sennae. gss.; potass, sulphat. g\.; M.—to be divided into four parts, of which one is to be taken hourly (by an adult) till it operates. ■If the patient be of a lymphatic habit, he gives >*br some time after, by way of preventing a relapse, from ten to thirty drops of the following tonic tincture three or four times a day, in a glass of wine or water.—(No. 5.) R. Tinct. aloes comp. Ji.; tinct. martis pomat. (Ph. Austriacae,) ^i.; elixir vitrioli, gss. M. For the tincture of the jnelate of iron, that of the acetate of the Dublin Pharmacopoeia may be substituted. A decompo- sition ensues in the mixture, and the sulphate of iron is formed. During the whole duration of the treatment-Bremser prohibits the use of farinaceous stud greasy articles of diet, and even restricts the patient as to his allowance of bread. He has never found it necessary in this species of worm •to have recourse to any other remedies than the .above. The cowhage (stizolobium or dolichos pruriens) long employed against worms by the natives of !^e East and West Indies, and so highly recom- mended by Chamberlaine, Bancroft, and other •British practitioners, was much used in cases of lumbricoi'des a few years ago; a teaspoonful of the electuary being given for two successive mornings, and worked off on the third by an active purgative. Granulated tin, another mechanical anthelmintic, has likewise been employed with advantage, about half a drachm of it being given for four or five days, and then a purgative inter- s posed. For both of the last-mentioned remedies, .and for a more particular account of their mode of administration, see the article Anthelmintics. As for the spigelia and Geoffraea, they have already been alluded to ; and though it is against this species of worm that they have been found most effectual, we believe they need rarely be had recourse to, inasmuch as we are in possession of other means of equal efficacy and of much greater safety. The first is rejected by Bremser, and he docs not appear ever to have found it requisite to have recourse to the second. The account of the mode of employing them will be found under the head just referred to. The epithet Branvilliers, which the French have given to the spigelia, from a female celebrated in the annals of poisoning, alluded to by Madame de Sevigne in one of her letters, is not very inviting. Dr. Wenzel, in a work published in 1828 at Erlangen, strongly recommends croton oil as one of the most efficient remedies, in cases both of the ascarides lumbricoi'des and taenia. It has the great advantage, that in the case of children, who often vehemently refuse to swallow any medicine, its external application is almost equally effectual. A few drops rubbed on the abdomen will very often, he insists, lead to the expulsion of the worms. Camphor seems entitled to some consideration as a vermifuge. Rosenstein occasionally used it, and Moscati is very partial to its employment. He suspends half a drachm of it in half a pint of water by means of a drachm of gum-arabic, and administers it in divided doses. Turpentine is a very effectual means of expel- ling this kind of worm, and may be employed either in small and frequently-repeated doses, as described in the article Anthelmintics; or, if, as happens in some habits, it should excite urinary irritation in this form, it may be given in larger doses and unfrequently, either suspended by means of mucilage in milk, or combined with castor oil. The tartrate of antimony has been strongly recommended by Mellin as a vermifuge, especially where the worms exist in complication with fever; and Armstrong and others think it particularly applicable where epilepsy coexists. Both Ru- dolphi and Bremser countenance its employment where the primary and more important disease requires such an evacuant. In such fevers, how- ever, as are accompanied with gastro-enteric in- flammation, it would be obviously improper. The muriate of soda was a favourite remedy with Rush. " I have administered," says he, " many pounds of common salt coloured with cochineal, in doses of half a drachm, upon an empty stomach in the morning, with great success, in destroying worms." The use of common salt as an anthelmintic medicine is both ancient and universal. Celsus recommends it. In Ireland, it is a common practice to feed children who are afflicted by worms for a week or two upon a salt sea-weed ; and when the bowels are well charged with it, to give a purge of wort in order to carry off the worms after they are debilitated by the salt diet. It is probably from the acknowledged effi- cacy of salt when given alone that it has become so usual in Germany to recommend salt fish and pickled meats previous to or during the employ- ment of an anthelmintic course. The helmintho- chorton (mousse de Corse, corallina Corsicana, &c.) so much in use in France as a vermifuge, has been thought by Bremser to owe its influence to the salt which it contains; but this is probably a mistake, as the quantity of the muriate of soda discoverable in it is but small. Dumeril and others attributed its efficacy to the presence of iodine. The terms mousse de Corse and hel- minthochorton were formerly used synonymously; but M. de Candolle has shown that the substance met with in the shops under these names, and which is mostly obtained from submarine rocks on the coast of the island of Corsica, is of a very mixed nature, belonging partly to the vegetable, and partly to the animal kingdom ; not above one- third part of it consists of the fucus helmintho- chorton, its most active portion, the rest being made up of other fuci and confervae, as well as WORMS. 739 of corallines, sertulariae, &c. It has, according to Richard, a bitter nauseous taste, and a smell of sponge. It is given either in powder, in doses of from twenty grains to a drachm, in a little wine and water, or in some conserve; or else in the form of decoction, syrup, lozenges, &c. Its solu- tion, on cooling, forms a jelly, and in this state also it is sometimes administered. Gardien fancies it has some power of dissolving the worms, as they are rarely discoverable in the stools after its use. Externally, various applications have been made, either with a view to expelling the worms, or of affording temporary relief to the colics they are supposed to cause, but which probably, as has been already hinted, are most commonly merely of a flatulent nature. In cases of sudden abdo- minal pains, in conjunction with the exhibition of oily mixtures internally, and the use of the tepid bath, Rudolphi countenances the employment of frictions with petroleum and oil of cajeput; and in similar cases Rosenstein, with a view to de- taching the worms which he supposed to be en- gaged in the work of perforation, rubbed the surface with the former of these two substances, previously impregnated with garlic. Underwood recommends the application to the umbilical region of a plaster composed of a drachm of aloes with the same quantity of pow- dered chamomile flowers or rue, with a little Ve- nice turpentine; or frictions twice or thrice a week, with equal portions of aloes and ox-gall mixed up with any unctuous substance; either of these applications will often, he asserts, without the use of aperients by the mouth, keep the bowels open, and prove quite sufficient to carry down the worms; whilst a course of the rust of iron is simultaneously exhibited in the manner advised by Rush. Hoffmann speaks favourably of the use of epithems, or plasters made of absinth, aloes, colocynth, the lesser centuary, &c. Boerhaave likewise was an advocate for purgative and aro- matic ointment. The unguentum Agrippae, con- taining very strong purgatives, such as briony root, the juice of the wild cucumber, squills, &c. and the unguentum arthenitae or ointment of sow- bread, which, besides the roots of cyclament and the wild cucumber, contained colocynth, ox-gall, scammony, aloes, euphorbium, &c, were very fre- quent applications to the abdomen in worm cases, in the middle of the last century, in Germany; but from the nature of their ingredients, even the external use of such preparations demands much caution, as hypercatharsis and dysenteric symp- toms have followed their employment; and hence, as soon as they have induced a copious stool, the anointed parts should be immediately and carefully washed, in order to prevent any further absorption. Brera recommends a liniment of gall, Venice soap, and oil of tansy, as well as an ointment contain- ing aloes and colocynth, aethereal tincture of gar- lic and camphor, and a plaster of assafoetida, gal- banum, cerussa and yellow wax. In domestic practice, frictions with ointments of savine and rue are still a popular remedy. Epithems of tobacco-leaves moistened with vinegar have been recommended by Barton ; but even the external use of this plant is sometimes attended with dan- gerous consequences. All these external medica- tions participate in the common disadvantage, that we cannot well estimate beforehand the quantity of effect likely to be produced, nor gra- duate their influence. Purgative enemata are also occasionally employed, but much less frequently than against the following species of worms. Treatment of the ascarides vermiculares. — Many individuals are troubled with ascarides almost from their cradle to their grave. The most various remedies have been employed against them, often with no other effect than a temporary alleviation of the symptoms. They constitute, perhaps, the most obstinate of all the forms of worm disease ; and it must be confessed, that though the annoy- ance to which they give rise may be very materi- ally palliated, medicine alone rarely if ever pro- duces a perfect cure. Even where their expulsion in vast numbers has been effected, they are so amazingly prolific, that they are speedily replaced. Fortunately, however, these worms are attended for the most part with inconvenience alone ; and as life advances, and especially at the period of transition from childhood to puberty, they become often greatly reduced in their numbers, or are even altogether got rid of by the mere efforts of nature; and even if they persist after this epoch, or origin- ate subsequently to it, and maintain their ground up to a very advanced age, as is sometimes the case, the symptoms do not seem ordinarily to have any tendency to become aggravated in proportion to the duration of the affection. They are often, indeed, undergoing slight variations in intensity, induced either by fluctuations in the number of worms present, or by almost inappreciable changes in the health or habits of the individual at whose expense they subsist; yet, upon the whole, they produce a pretty equable degree of suffering ; or this tends, if any thing, rather to grow less than to increase, in proportion as habit and the dimin- ishing sensibility of advancing years reconcile the mind as well as the body to their presence. The amount of suffering at all times depends much upon the temperament of the patient; in the irri- table and impatient, it forms a kind of periodical martyrdom, recurring daily at a fixed hour, some- times with singular precision. Bianchi says that a friend of his own was for many years constantly troubled with itching from this cause, from nine till ten o'clock at night, during which time he was unable to do any business, though at all other times entirely free from this annoyance. If the pruritus can, by any effort of the will, be patiently endured for a few minutes, it soon reaches its acme, and then its intensity spontaneously de- clines ; whereas, if additional excitement and con- gestion of the hemorrhoidal vessels be brought on by giving way to the desire to rub the part, the suffering is very generally aggravated and pro- longed. The means by which the annoyance arising from ascarides may be reduced to the lowett possible point, consist in keeping the bowels con- stantly free, so that the patient shall have one or two stools daily, an appropriate diet, and medicine also, if necessary, being employed for the attain- ment of this desirable end. If at any time they happen to accumulate to an unusual degree, an active purgative or an aperient enema will gene- rally be found to give immediate though but tem- porary relief. Regular walking exercise, and great 740 WORMS. abstemiousness in eating and drinking, so as to prevent an excessive formation of mucus, or the heating and distension of the parts supplied by the hemorrhoidal vessels, are most important. Particular articles of diet, which can only be as- certained by individual experience, occasionally produce an immediate exasperation of the symp- toms. Thus we have known one case in which the use of strong tea or coffee, beverages which temporarily increase the sensibility of the body, was always followed within a few hours by a great increase of the pruritus; and small doses of opium, which of themselves so often produce an itchiness of the skin, had a similar effect. We have lately seen another patient in whom the dis- ease seemed to have been induced, or so much in- creased, as for the first time to attract his notice, by drinking very largely of hot beer for several weeks together. The following case, to be found in one of He- berden's papers in the first volume of the Trans- actions of the College of Physicians, contains a very full and clear account of the symptoms of this affection, and of the numerous measures which were put in practice with a view to its relief. Being acquainted with an experienced and intel- ligent physician, who from his infancy had been troubled with ascarides, Dr. Heberden desired to be informed by him what were the inconveniences which they had occasioned, and what was the success of the remedies which he had used; to which he replied, that « according to his experi- ence the peculiar symptoms of this species of worms are a great uneasiness in the rectum, and an almost intolerable itching of the anus. These symptoms usually come on in an evening, and prevent sleep for several hours ; they are attended with a heat which is sometimes so considerable as to produce a swelling in the rectum, both inter- nally and externally : and if these symptoms, be not soon relieved, a tenesmus is brought on, with a mucous dejection. Sometimes there is a grip- ing pain in the lower part of the abdomen a little above the os pubis. If this pain be very severe, there follows a bloody mucus, in which there are often found ascarides alive. They were some- times suspected of occasioning disturbed sleep and some degree of headach. Purging and irritating clysters were injected with very little success. One drachm and a half of tobacco was infused in six ounces of boiling water, and the strained liquor being given as a clyster, occasioned a violent' pain in the lower part of the abdomen, with faintness and a cold sweat. This injection, though retained only one minute, acted as a smart purge, but did little or no good. Lime-water was also used as a clyster, which brought on a costiveness, but had no good effect. Six grains of salt of steel were dissolved in six ounces of water, and injected. This clyster in a few minutes occasioned an ach- ing in the rectum, and griped a little without purging, and excited a tenesmus. Some few asca- rides were brought off with it, but all of them were alive. The uneasy sensation created by the clys- ter did not abate till some warm milk was thrown up. Whenever the tenesmus or mucous stools were thought worth the taking notice of, warm milk and oil generally gave immediate relief. If purging was necessary, the lenient purges, such as manna with oil, were in this particulat case made use of; rhubarb was found too stimulating. But in general the most useful purge, and which, therefore, was most usually taken, was cinnabar and rhubarb, each half a drachm: this powder seldom failed to bring away a mucus as transpa- rent as the white of an egg, and in this many ascarides were moving about. The cinnabar fre- quently adhered to this mucus, which did not come off in such large quantities when a purge was taken without the cinnabar. Calomel did no more than any other purge which operates briskly would have done ; that is, it brought away asca- rides with a great deal of mucus. Oil given as a clyster has sometimes brought off these animal- cules: the oil swam on the surface of the mucus, and the ascarides were alive, moving in the mucus, which probably hindered the oil from coming in contact with them and killing them. The same mucus may reasonably be supposed to preserve these worms unhurt, though surrounded with many other liquors the immediate touch of which would be fatal. If the ascarides be taken out of their mucus and exposed to the open air, they be- come motionless, and seem to die in a very few minutes. " The general health of this patient did not seem to have at all suffered from the long continu- ance of his disorder, nor the immediate inconveni- ence of the disorder itself to have increased. It is perhaps universally true that this kind of worm, though as difficult to be cured as any, is yet the least dangerous of all. They have been known to accompany a person through the whole of a long life without any reason to suspect that they have hastened its end. As in this example there was no remarkable sickness, indigestion, pain of the stomach, giddiness, nor itching of the nose, possibly these symptoms, where they have hap- pened to be joined with the ascarides, did not pro- perly belong to them, but arose from other causes. Purgatives which carry off mucus never fail to afford some relief, which may be attributed to their carrying away some of the worms, and enfeebling or causing the death of others through the want of a sufficient supply of their ordinary pabulum. Those purgatives," continues Heberden, "are beat which act briskly, and of which a frequent repe- tition can be easily borne : purging waters are of this kind, and jalap especially for children, two or more grains of which mixed with sugar are easily taken, and may be repeated daily." In another paper, which forms the pendant to the one which we have just been quoting, the same author has communicated a very striking instance furnished to him by Mr. Thomas, of the good effects of common salt when taken in very large quantities. The patient, Daniel Neal, of Doddle- stone, in Cheshire, had been complaining for four or five years of violent pains in the stomach. The other symptoms were, nausea, restlessness and anorexia, constipation, a hard retracted belly, loss of sleep, emaciation and debility, and milky urine with a whitish sediment. He was bowed down almost double by the pain in the abdomen. The symptoms had persisted in spite of various model of treatment recommended by different physicians in his neighbourhood. At length, at the advice of a friend who had seen similar pains of the belly WORMS. 741 tnd stomach cured by the use of salt and water, he swallowed within an hour two pounds of kitchen salt dissolved in two quarts of water; violent vomiting ensued, with ejection of half a pint of ascarides and other worms, somewhat like bots, only much smaller; five or six copious bloody and fetid stools followed, with a quantity of similar worms. He had previously been costive for a fortnight, for his excrements were never voided without the assistance of medicine, being hard, lumpy, and in small fragments, like those of the sheep. Being greatly fatigued, he went to bed, slept quietly two hours, all the while sweating pro- fusely. Instead of his usual pain, he now only complained of rawness in the cesophagus, stomach, and bowels, with an unquenchable thirst, which obliged him to drink abundantly. The urine was small in quantity, passed with difficulty, and ex- tremely saturated with salt. These symptoms gradually abated under the use of cold drinks, water, buttermilk, whey, &c. Three days after, he took another such dose of salt, with similar effects, voiding dead worms, with much mucus, and again suffering temporary inconvenience from thirst and dysury. After this he enjoyed a good state of health, but by way of precaution continued to take, a few days before the full and change of the moon, half a pound of salt in a pint of water. " If he had taken," adds the narrator, " smaller doses, he would have avoided much pain, and by degrees have gained the same point." In the treatment of ascarides, purgatives taken by the mouth are, generally speaking, insufficient, as they lose almost all their virtues, with the ex- ception perhaps of aloes, in their traject through the bowels, long before reaching the rectum, the seat of these worms; hence the necessity for ene- mata. The injections recommended by Macbride consisted of decoctions of wormwood and rue, or of oil with a small quantity of aloes dissolved in it; " or, what is still more effectual, blowing the smoke of tobacco, by a proper contrivance, into the rectum once or twice a day." (Practice of Medicine, ii. 290. Essay on Scurvy, &c, p. 162.) Darwin likewise praises the use of tobacco-smoke in these cases; Pallas, too, says he has seen it employed with success; and Turner, in his letter to Dr. Fothergill, in the second volume of the London Medical Observations, has given a very convincing example of its efficacy. It is a reme- dy, however, very troublesome in its application, and from its danger quite disproportioned to the trifling annoyance which it is intended to remove, to say nothing of the temporary nature of the relief which it is calculated to afford. Yet Dr. Mason Good has given his sanction to the employment of tobacco in injections, " in which form," says he, " it succeeds admirably against the small ascarides." A long course of Harrowgate water has been found very beneficial in ascarides, and its good effects may be increased by its simultaneous use from time to time in the form of clysters. Enemata of the sulphuret of potass have likewise been em- ployed with advantage. Hamilton recommends aloes suspended in milk to be employed in this way, or a strong decoction of chamomile-flowers along with castor oil and salt; and we have known the latter to afford very great and immediate relief. If the restlessness of the child renders the exhibi-1 tion of these remedies impossible, a large dose of powdered aloes, with a little calomel, administered every third or fourth night, has been found very effectual by the author last named. Turpentine enemata, or those of lime-water and olive-oil, may also be tried. Camphor and the essential oils, sus- pended by means of yolk of egg in water, ap- peared to Laennec to be often extremely useful; but he reminds us that the exhibition of medicines for the expulsion of these worms constitutes the least part of the requisite treatment, the great object being to re-establish the tone of the organs, and improve the health generally, if we would prevent their constant reproduction. In Martinet's Manual of Therapeutics, we find some very good directions as to the most essential mode of em- ploying enemata in this disease : it is there advised to throw up three of these, one after another, at short intervals; the first a common aperient, one to unload the intestines of their faecal contents : the second to kill and expel the ascarides; this may consist either of a strong solution of common salt, or of the chloruret of soda much diluted, or of vinegar and water, and should be injected cold, and retained as long as possible ;—the third and last consisting of three or four large spoonfuls of olive oil, or of a thick mucilaginous decoction of flax-seed or marsh-mallows ; the object of which is to mitigate any remaining uneasiness in the rectum, whether caused by the previous remedies or by a few straggling worms newly descended from the higher portions of the colon. " Another precaution," he continues, " which is in general by itself sufficient when the ascarides are few in number, and do not occasion great uneasiness, is to solicit the action of the bowels regularly every morning, and to resist any desire to go to stool in the afternoon; otherwise the pain and itching, which in general begin towards night, come on at an earlier hour, and with much greater severity." Of the advantage of following this last piece of advice, even where practicable, there is room for doubt. By Dr. Darwall, an enema composed of half an ounce of the tincture of the muriate of iron to half a pint of water, is strongly recommended. He regards it as the most useful kind of injection: " There are few cases so obstinate that this will not suffice to overcome. It will generally be use- ful," he continues, " to clear out the upper portion of the canal at the same time by an active pur- gative ;"—as by calomel and jalap, for instance; and for ten days after he continues to give a wine- glass-full of an infusion of chamomile thrice a day. Brera recommends the mechanical extraction of these worms by introducing into the rectum a piece of lard or candle, which, on being subse- quently drawn out, brings along with it the greater number of those situated in the lower portion of the rectum. The advice is not new: a similar plan was acted on in France above a century ago, as we find from the following passage in Andry:—"One thing which I prescribed with success to several patients was to put up into the fundament a little piece of lard tied to a string, leave it there for some time, and after that you shall draw it back full of worms." Rosenstein likewise mentions it, only substituting a piece of fresh pork; and a 6omewhat similar expedient was 742 WORMS, recommended not long since in our own country by Mr. Howship,—namely, the occasional intro- duction of the finger of the patient, previously well greased, high up into the rectum, which is then to be withdrawn in such a manner as to bring away all the worms within reach; and this will often, no doubt, prove a valuable palliative. Frequent ablution with cold water is in all cases proper as an effectual means of allaying irri- tation, at least for a time; and where the ascarides have made their way into the external organs of generation in the female, in addition to vaginal in- jections consisting of infusions of the bitter plants, or of vinegar and water used cold, local baths containing salt of sulphuretted hydrogen may be employed. Bremser's treatment of ascarides consists in the administration, night and morning, of a tea- spoonful of his electuary, the composition of which has been given above, to which he oc- casionally adds a little more jalap, in order to purge gently. He directs the patient, moreover, to take two small enemata daily, consisting of an infusion of absinth, tansy, and orange-peel along with valerian, and a spoonful of the empyreumatic oil of hartshorn; the fittest time for their adminis- tration being immediately after having had a stool, as they are then likely to be longer retained, and come more in contact with the worms, now no longer protected by the faeces. Where the patient is not of an irritable habit, he sometimes adds a spoonful of fresh ox-gall. These measures must be persevered in daily for many weeks, after which the patient will continue long free from all annoy- ance, or may even in some instances find himself radically cured. A small injection of olive-oil (two or three ounces) will sometimes, as has been remarked by Soemmerring, give immediate relief to the insufferable itching. Van Swieten advised injections of cold water. Bremser speaks of a young lady who cured her- self by drinking twice a-week half a cupful of olive-oil, with a clove of garlic chopped small through it. Dr. Vest finds sulphur useful if taken every morning fasting, in doses of from ten to fifteen grains, and persevered in for a considerable length of time: in the hands of others, however, it has disappointed the expectations. A couple of tea-spoonfuls of Chabert's oil, in a bitter or mucilaginous decoction, has been found a very effectual injection by Fechner, Rollet, &c. Brem- ser apprehends some risk from this mode of its administration; but wherefore does not appear, as he himself has given very large doses of it, even by the mouth, with impunity. He suggests its internal use in conjunction with the employment of lavements containing the infusion of bitter herbs above alluded to; but he did not seem to have tried it himself against this species of worm when his work was published. Treatment of txnia.—An almost incredible va- riety of remedies have at various times been em- ployed as well by regular practitioners as by em- pirics against the tape-worm. Of these the tere- binthinate and empyreumatic oils, tin granulated or in the state of filings, the rind of the pome- granate-root and the root of the male fern, and drastic purgatives in very large doses, are amongst the most conspicuous. It is with the taenia solium almost exclusively that we have to do in this country, and it is to this that the following re- marks chiefly apply. Authors who have described particular modes of treating the tape-worm have not always distinctly stated to which of the two kinds their remarks are applicable. The taenia lata or bothriocephalus is generally supposed to induce milder symptoms, and its expulsion is said to be effected with less difficulty than that of the taenia solium. The oil of turpentine, in large doses, has for some years past in this country almost displaced all other remedies in the treatment of taenia; a sufficient evidence of its efficacy. Dr. Fenwick of Durham generally gets the credit of having first made its value known to the public by a paper published in the Medico-Chirurgical Transactions in the year 1811. He had been made acquainted with the utility and safety of the practice by a non-professional person, who had employed it in several cases with success; and the latter, in his turn, had been instructed in its use by a seafaring man, who, having frequently freed himself from large portions of tape-worm by means of gin, was led by analogy to expect similar but still more marked effects from the spirits of turpentine; and on trial his expectations were not disappointed. The use of turpentine as an anthelmintic is no- ticed in Rudolphi's work published in 1808; and Underwood informs us that Dr. James Sims had given it, in two-drachm doses, in cases of worms, with success. The peculiarity of the plan pro- mulgated by Dr. Fenwick consisted, it may be said, in the largeness of the dose: even in this respect, however, the practice was not absolutely unprecedented, Mr. Maiden, in the Memoirs of the London Medical Society for 1792, having already shown the utility of turpentine so used in taenia; and in the Medico-Chirurgical Transactions for the year 1817 there is a letter of Dr. Walker's, claiming to have anticipated Dr. Fenwick in his knowledge of this remedy. It seems certain, how- ever, that it was the paper of the latter gentleman, accompanied as it was by the most satisfactory evidence of the beneficial effects of this plan of treatment, which first led to its general adoption. The dose employed by him was two ounces in the first instance, to be repeated in two hours if no stools had been yet produced, and even a third time if requisite. The worm was generally passed dead an hour or two after the administration of the turpentine. He admits that the cures were not in all cases permanent, the symptoms in a few instances recurring within a few months, or even weeks. He directs it to be taken in the morning fasting, little or no supper being allowed the night before, and no food being eaten till two or three stools have been procured. The remainder of the day diluent drinks are to be freely used, and all spirituous and fermented liquors carefully abstained from, as a violent diarrhoea was observed to occur in one case where a draught of beer had been taken soon after the turpentine. Dr. Elliotson, who makes much use of the oil of turpentine in the treatment of worms, both of the round and of the flat kind, has given even to a delicate female so much as from two to three ounces of it every second day for a fortnight; each dose being followed in two hours by castor oil, WORMS. 743 and commonly with no other effect than that of expelling the worms and purging rather briskly. He does not concur in the general opinion that freedom from urinary irritation may always be ensured by administering the medicine in a large dose, much less in the ordinary explanation of such immunity,—namely, that when so adminis- tered it always acts as a purgative, and passes off before there is time for absorption to take place. On the contrary, he remarks that he has often found the urine smell strongly of turpentine for several days after such great doses, proving that absorption had actually taken place, and to a large extent; and he has moreover frequently found it necessary to follow it up with castor oil, or no purgative operation ensued. He has seen urinary irritation succeed to the use of large as well as of small doses, and is inclined to ascribe it in both cases to some peculiar susceptibility to its influ- ence in the organs of the individual. The expe- rience of this distinguished practitioner is here, however, in direct opposition to that of the great body of the profession. He recommends us to commence its use in doses of half an ounce, which are to be gradually increased to two or even three ounces, being administered cither alone or in bar- ley-water, &c. " Persons should remain quiet," says he, " after its use ; and as it is not wished to irritate the stomach, and is very likely to produce vomiting, it is best given, not when the stomach is empty, but two or three hours after a meal. As it affects the head, producing vertigo and a feeling of intoxication, the fluid with which it is diluted should be given cold." "I may mention," he continues, " a curious circumstance which has oc- curred to others as well as myself; that when there were circumstances indicating the presence of intestinal worms, and oil of turpentine was given, no worms have been expelled, and yet all the symptoms have disappeared. This has been called helminthia spuria." According to Dr. Latham, turpentine, when given in doses of from one to two ounces, gene- rally passes off within two hours after it is taken. He recommends broths and mucilaginous decoc- tions to be taken during its operation, to preclude the occurrence of intestinal or urinary irritation. The sense of giddiness induced, he observes, will sometimes continue for several days after; a symp- tom which, however, gradually declines if the pa- tient remain quiet, and the bowels be kept gently open. The occasional use of aperient medicine should not be neglected as long as the violent smell of the urine and the headach exist. In one case, the stool which followed in about an hour after the exhibition of the turpentine, contained some gela- tinous-looking matter mixed up with it, apparently a portion of the taenia in a semi-digested state, as traces of the joints were still evident in it. The next day the patient, a female, complained of slight flatulence and frequency of making water, which, together with a little heat in the mouth, and a slight nausea and vomiting about an hour after the exhibition of the medicine, were the only in- conveniences it induced ; and in the great majority of cases, the annoyances from this remedy are even less, so that the apprehensions which some continental practitioners express as to the danger of this remedy seem entirely hypothetical and groundless. Dr. Latham admits that it does not always remove the tendency to the regeneration of the worm; thus, in one case, that of a fish- monger, the symptoms always recurred within a few weeks. The green portions of the common fir, of the savine, and all the terebinthinate class, powdered and taken in large quantities, would probably, as the writer just named suggests, prove as effectual in cases of worms in the human sub- ject, as they are known to be in those of the horse. The largest doses of turpentine which we have ever heard of being given, were those by Dr. Pickell, who, in the singular case already detailed, carried them gradually so high as six ounces, though, on its first employment, the system was not tolerant of it even in comparatively small doses, a cutaneous eruption and other inconveniences arising from its use. Raimann and several other German practitioners still seem averse to its employ- ment in the large quantities given in this country, and think that it would be even more efficacious as well as safer if exhibited in small and frequent doses and long continued. Bremser comprises, in the list of its occasional inconveniences, pains in the belly, nausea, vomiting, and a general uneasi- ness, a sense of confusion in the head, and heat in the rectum and urethra; but grounds his strong- est objection to its use on the very frequent re- currence of the disease requiring the repeated exhibition of the remedy. The dose for an infant, says Dr. Mason Good, is from half a drachm to a tea-spoonful in a little milk ; " a child of ten or eleven years old may take an ounce without any evil effect in ordinary cases; but in delicate habits a full dose sits uneasily on the stomach, and dis- quiets the system generally, though in different ways; for it sometimes produces a general chill and paleness, sometimes a tendency to sleep, and sometimes an alarming intoxication. It is in small doses alone, as half a drachm or a drachm to an adult, that it enters into the circulation, and proves an acrid irritant to the bladder, often exci- ting bloody urine." We have often given it in dispensary practice, where economy is an object of importance, in doses of half an ounce mixed with twice that quantity of olive-oil as an aperient, in cases where castor oil would ordinarily be given, and have usually found it, when employed in this manner, at least as mild in its operation, and nearly as certain as the latter medicine. It has been suggested by Dr. Good, that some of the other finer terebinthinate oils, as the Hungarian balsam, the oleum templinum, or krummhOlz-ohl, distilled from the green cones of a particular variety of the pinus silvestris, formerly sold at a high price and kept a secret by certain medicine-venders in Germany, might be less apt to disagree with the stomach and the system than the common turpentine, and yet prove equally deleterious tO' the worms. Chabert's empyreumatic oil, which is prepared. by mixing one part of the empyreumatic oil of hartshorn with three of oil of turpentine, letting: them stand for three days, and then distilling off in glass vessels by the heat of a sand-bath three- fourths of the mixture, had often been given to animals with the greatest success in expelling worms of all kinds, by the distinguished veterinary 744 WORMS. professor whose name it bears; the dose for a cow being about two or three drachms, that for a dog or sheep from half a drachm to a drachm. He once administered it also to a girl of twelve years of age, from whom it carried away numerous worms of the kind so rare in the human species, called flukes (distoma hepaticum). Goeze and Brera likewise proposed its employment in cases of worms in the human species ; and by Rudolphi it was considered the first of all vermifuges. Brem- ser, before giving it to any of his patients, put the safety of its administration to the test on his own person, and thus ascertained its dose. By the contact of air, it is blackened and rendered thicker and more disgusting to take ; it should, therefore, be kept in small phials well corked and covered with bladder. Chabert's oil, as used by Bremser, appears to be unquestionably one of the most powerful as well as permanent remedies hitherto employed in taenia. He has treated with it above five hundred individuals suffering from this affection, and amongst them two children about a year and a half old ; and of the whole number there were but four who found it necessary to take a second course of it. A fifth individual, after remaining free from the disease for two years, which may be considered equivalent to a cure, became again affected with it. The length of the interval indi- cates that the original taenia and its ova had been entirely destroyed, and that this ought to be con- sidered in the light of a perfectly new affection. After submitting a second time to the treatment, he had had no further return of the disease up to the period at which Bremser was writing. The remainder of the patients, at least as far as he knew of, continued free from any recurrence of the symptoms. He commences the treatment with his purgative electuary as already spoken of, and when the first portion of this is finished, he begins to give two tea-spoonsful of Chabert's empyreumatic oil in a little wate night and morning. Its very disa- greeable taste and smell may be got rid of by swallowing with a certain degree of force a few mouthfuls of water, rather than rinsing the mouth, which might introduce it into the posterior nerves and prolong the annoyance. Chewing a clove or a morsel of cinnamon is also recommended, but peppermint and such other things as might cause eructation should be avoided. The above dose is, according to Bremser, easily borne by persons of all ages. There are, however, he admits, some individuals in whom it causes considerable irrita- tion and even a slight confusion of the head, and here the quantity must be diminished till they become habituated to Its use. Some can take it without inconvenience fasting; but where it causes nausea, it had better be taken about an hour and a half after breakfast. If it should cause dysury or a sense of heat in the intestines, as is sometimes the case, barley-water and oily emulsions soon afford relief. When the patient has consumed from two and a half to three ounces of this oil, that is, in about ten or twelve days, a light purga- tive, such as the powder marked No. 3, of which we have already given the composition, is admin- istered, and the use of the oil is then immediately resumed, and persevered in till from four to six ounces shall have been taken in the whole course of the treatment. He admits that this is rather a tedious proceeding, but this disadvantage, he asserts, ! is fully counterbalanced by the certainty of the result, unattended as it is by danger, or even by any serious inconvenience. All those remedies for taenia which are perma- nent in their effect require, as well as this one, to be persevered in for 6ome weeks, in order to de- stroy all the ova as well as the worm itself. If there be a continuance of mucous stools after the disease itself has been cured, he gives the tonic tincture, (No. 5,) above described, for several weeks. The only rule which he lays down for the patient's diet during the treatment, is that he shall be moderate in the use of farinaceous food and fatty substances. He warns us not to expect large portions of the worm to be expelled visibly, as happens after many other vermifuge medicines, as this is rarely the case after the use of Chabert's oil, its efficacy being manifested sometimes solely by the disappearance of the symptoms, and of all evidence of its continued existence, as well as by the prevention of its return in almost every in- stance. It is probable that it is passed during the first few days of the treatment in a semi-digested state, and so much changed in appearance as hardly to be recognised. Nor does he give him- self any trouble in looking after the head of the animal, as the discovery of this, even when it can be made, is one of equivocal value, as two or more taenia may coexist. When the patient continues free from the worm for three months after the treatment, he looks upon it as a perfect cure. Its occasional recurrence many months or years after- wards must evidently be considered a new forma- tion or quite distinct affection. Such is the account given by Bremser himself of this his favourite medicine. In the hands of others it has been found, though fully as effica- cious as he represents it to be, yet not altogether exempt from considerable inconvenience in some cases ; and these are, perhaps, more frequent than he seems willing to admit. M. Grundler, the French translator of his work, has found that where there exists a weak state of the stomach and intestines, it soon produces considerable gene- ral uneasiness, followed by colic, nausea, and fre- quent eructations ; and hence he advises, by way of precaution, that we should in every case begin with a small dose, half a tea-spoonful, for example. He does not think that the small quantity of tur- pentine present can materially add to its anthel- mintic virtues. The addition of a little syrup of lemon is found by M. Page to be the best mode of disguising its disgusting flavour; or the same end may be in some degree attained by making it into small boluses, and immediately swallowing them, enveloped in a thin wafer-cake. In an over-dose it gives rise to considerable pain and danger. In the case of a cook who drank off, in opposition to the directions given him, a whole phial of the medicine in one night, severe colic ensued, but it was subdued in the course of the following day by an oily emulsion. Rudolphi, on one occasion, not having Chabert's oil at hand, employed Dippel's animal oil, in doses of from five to ten drops in a cup of broth thrice a day, and succeeded in expelling by it, not only several WORMS. 745 ascarides lumbricoi'des, but also some portions of taenia: it appeared to him, however, inferior in general efficacy to the more compound oil of the French professor. Another author, mentioned by Bremser, likewise employed Dippel's animal oil, in a case of tape-worm, for a considerable time and with good effect; and M. Grundler, by taking it in doses of from five to fifteen drops night and morning for six weeks, consecutively, got entirely rid of this disease, which he had had for two-and- twenty years. He had taken Nouff'er's remedy in childhood, perhaps upwards of twenty times, without success, but, on the contrary, with no other effect than the permanent impairment of his general health. As to the worm itself, it had never, at any period of his life, given him the slightest inconvenience. Rosenstein mentions the case of a lady with a tape-worm, who took from time to time, by his orders, ten or twelve drops of Dippel's oil, and a purgative the next morning; this was continued for two years, a part of the worm being always expelled after each repetition of the treatment; but at length the medicine be- came so nauseous to her, that she gave it up in disgust. "The animal oil of Dippel," says Dr. Turner, in a recent edition of his work on che- mistry, " is a product of the destructive distillation of animal matter, especially of albuminous and gelatinous substances. It was formerly much used in medicine, but is now no longer employed." The last assertion, as we have just seen, is not absolutely correct, at least in regard to German and French practice. It is, however, very seldom used, and its employment certainly requires much caution. In the Dictionnaire de Medecine it is described as being " a very energetic stimulant, which, when taken into the stomach, even in a very moderate dose, occasionally produces vomit- ing, diarrhoea, sweating, sometimes salivation, and enlargement of the glands of the neck and groin, with a certain degree of fever. It seems, in short, to be a very active poison: a person who took a Bpoonful of it by mistake, died instantly." " It is now," continues the same writer, " little employed in medicine in France, and not at all in England. Formerly, it had a great reputation in epilepsy, neuralgia, paralysis, &c. Internally, a few drops may be given in water or in an emulsion, and be gradually carried as high as thirty or forty drops, or even more, but we must never commence with so large doses." In Egypt, as we are informed by Hasselquist, petroleum is in great repute as an anthelmintic, being administered either alone or in conjunction with turpentine, in cases of taenia, with great effect. The dose is from twenty to thirty drops, which is repeated thrice a day for a few days, and then a purgative is given. The three last days of the moon is the favourite period for the use of this medicine: if it fail, it is repeated again the following month. The bark of the pomegranate root has lately attained to a very high degree of celebrity in the treatment of tape-worm. Though its efficacy was known to Celsus, and it is to be found in Andry's list of anthelmintics, and has long been employed in Indian practice, it is only within these few years that it has been prized, either in this country or France, according to its deserts. Vol. IV. — 94 3n It was recommended some years ago by Dr. Flem- ing, in his catalogue of the Indian medicinal plants and drugs. An account of some cases in which it was successfully employed was published in the eleventh volume of the Medico-Chirurgical Transactions, by Mr. Breton, which contributed much to bring it into general notice. In the first case he tried the fresh bark of the root, boiling two ounces of it in a pint and a half of water till the quantity of fluid was reduced to three-fourths of a pint, and when cold he administered a glass of it, or about two ounces, every half-hour, till four doses were taken. About an hour after the last dose, that is, in three hours after commencing the remedy, an entire taenia was voided alive, no other effect than a slight nausea having been ex- perienced by the patient. This dose is rather smaller than that usually recommended. In sub- sequent trials he found the bark which had been dried in the sun a still more potent remedy, its virtues being concentrated by the process, in which it loses near half its weight. Thus the same quantity of the dried bark made into a decoction as before, and similarly administered to a stout man forty years of age, after four doses had been taken, induced so much sickness at stomach, gid- diness, and uneasiness in the bowels, that he was deterred from giving a fifth. About three hours from the taking of the first dose, after complaining of faintness, and after vomiting a little, he voided an entire taenia alive, measuring nineteen feet two inches—the longest met with in the whole eight cases; the shortest of the taenia solium being under eight feet, and of the taenia lata four feet nine inches. Immediately after passing the worm he was affected with faintness and universal tre- mour, and continued to feel sick for several hours. From this it seems that the decoction made of two ounces of the dried bark in the manner al- ready described, " is rather too powerful, and that the exhibition of it may be attended with danger." To two boys of seven and ten years old he ad- ministered one ounce of a decoction of half the strength of that used in the preceding case, and repeated it every half-hour till six doses had been taken, without any other disagreeable conse- quences than a slight sickness of stomach and a little vomiting, which at length about this period occurred. The medicine, which in this as in all the other cases had been commenced early in the morning, was resumed again in the middle of the day in reduced doses of half an ounce each: gid- diness and faintness soon came on, and prevented its further repetition. About five o'clock in the evening, however, each of these patients passed a taenia solium, one of these being fifteen feet four inches in length, the other fourteen feet two inches. These cases prove that a temporary suspension and renewal of this medicine may be successfully adopted in certain cases. The powder of the bark was found by Mr. Breton equally efficacious, and milder in its operation. To a boy of nine years of age he gave a scruple of it in an ounce of cold water every hour till five doses were taken: forty minutes after the last dose, an entire taenia came away alive. The next case is inter- esting, as showing the possibility of taenia solium and taenia lata coexisting. «« A girl of ten years old took at eight a, m. the same quantity (a scru- 746 WORMS. pie) of the pulverized bark in an ounce of cold water, and repeated the dose every hour till noon. At twenty-four minutes past one p. m. a taenia lata was discharged alive, four feet nine inches long. The next morning, about nine a. m. an entire taenia solium was voided dead, and measuring nine feet ten inches. In these two instances a little nausea oniy was occasioned, and three or four copious motions in the course of the fore- noon." To two adults, two scruples, or double of the above dose of the powder, was given every hour or half-hour till the sixth dose, with similar success, and no other inconvenience than trivial nausea in one instance, and a little giddiness. On plunging living taeniae either into the decoction, or into the mixture of the pomegranate bark and water, they writhe and manifest great suffering. In plain water they will live in the temperature of India for several hours. As all the trials de- tailed above were made on natives of India, and as their constitutions are generally more delicate and more susceptible of the influence of medical agents than those of Europeans, there was every reason to expect that its cautious exhibition in our own country would be unattended with dan- ger ; and repeated trials have now confirmed the safety of the practice. The shortest period from the commencement of the treatment in which the worm was expelled in any of the above cases ap- pears to have been three hours, and the longest twenty-five hours. Dr. Annesley, in his work on the Diseases of India, speaks very favourably of the effects of this remedy, both in the form of decoction and in that of powder, but seems yet to consider it in some degree inferior to the oil of turpentine, which, given by the mouth and in the form of injection, he has found to be the most successful of all the remedies yet known against taenia. By Dr. El- liotson, also, the pomegranate-root bark is charac- terized as an excellent remedy in tape-worm, es- pecially the powder, which he considers still more effectual than the decoction. In the case of a female, detailed in his clinical lectures, he gave two scruples of the powder every half-hour till six doses had been taken, and the next day twelve similar doses in the same manner. Three days afterwards a drachm was given every half-hour to the sixth time, and all this with no other ill effect than an occasional slight giddiness and nausea, the bowels being opened two or three times daily, either spontaneously or with the aid of salts and senna. In another case, in addition to stupor and giddiness, it caused severe headach. After being exhibited thrice, at intervals of a few days, the symptoms of tape-worm gradually declined, and in six days after the last dose they had all entirely disappeared. M. H. Cloquet informs us that it is the medicine now most trusted to in France in cases of taenia, especially the decoction of the fresh root. Richard, who wrote the account of this substance in the Dictionnaire de Medecine only a year or two before, says that it had not then come much into use, but states the dose of the powder at from one to two drachms twice or three times a day, or else a decoction of half an ounce of the rind in a pint of water sweetened with syrup. Amongst the substances capable of effecting the expulsion of taenia, the bark of the punica grana- tum, says MaTtinet, merits the highest rank. '< The decoction of the root of this plant has recently acquired such a great reputation, that it would be wrong to employ any other remedy against the tape-worm till a trial has first been made of this. It is prepared by boiling two ounces of the bark in a pint of water. It should be taken in the morning fasting and succeeded by an ounce or an ounce and a half of castor oil to obtain a free evacuation from the bowels." This is the mode of its exhibition recommended by Dr. Deslandes. (Nouvelle Bibliotheque Medicale, t. ix. p. 76, An. 1825.) M. Martinet has several times em- ployed it in this manner, and never saw any ill effects follow its use. The patient should be put on a low diet the day the medicine is given. The potion of M. Darbon, of which the com- position is still, we believe, a secret, is very highly spoken of by M. Louis, in consequence of the in- variable success and safety which attended its ad- ministration in the cases at La Charite already alluded to. This nostrum, which, according to the report of the patients, had no very well-marked taste, was taken to the extent of eight or ten ounces in the morning fasting, and the cure was effected by this single dose. It produced little or no inconvenience beyond a very slight uneasiness at the epigastrium or a colicky feel, but this was even less in degree than that often induced by castor oil or other mild purgatives ; and as it was not left on the repetition of the dose four months after the cure, it should be ascribed rather to the motion of the worm through the intestines whilst in the progress of expulsion, than to the direct action of the medicine itself. It generally pro- duced a few stools containing portions of the taenia ; and if evacuations did not take place within a few hours, a simple lavement was given. The head of the taenia, which Louis describes as a small bulbous prominence marked with three dark spots arranged in the form of a triangle, was found in the evacuations in the greater number of the cases. In one instance the heads of no less than seven of these worms were expelled simultaneously. The expulsion of this part by most other modes of treatment appears from the testimony of authors to be rare, and hence, pro- bably, their frequent failure in regard to producing a radical cure. It is doubtful whether M. Dar- bon's remedy acts at once as a specific and as an aperient, or only in the latter of these qualities. The portions of the worm expelled in the cases alluded to, though immediately placed in tepid water by M. Louis, did not appear to move; but M. Darbon assured him he had sometimes seen them alive after their expulsion, from which it would appear that it did not invariably at least act as an effectual poison to the worm. Yet from its feeble purgative action, on the other hand, we are forced to refer much of its influence to a spe- cific power. It seems to have succeeded equally well in each species of taenia. The trial of the medicine was made in the presence of MM. I««f- minier, Fouquier, Chomel, &c. and the notes of the cases were taken by M. Louis himself, fto conjecture is offered as to the probable nature of its composition. Its speedy effect and the absence of any very strong flavour suggests the possibility of its containing some preparation of the pome- WORMS. 747 granate bark rather than any of the other hitherto promulgated remedies. Alston's method, which is praised by Pallas, Bloch, Brera, Alibert, and Cloquet, consisted in giving one ounce of the filings of zinc in four ounces of treacle, the patient having been pre- viously well purged with senna and salts. The filings were again administered, but only in half the quantity, the two following days; and, finally, a purgative was ordered to work all off. Pallas preferred the granulated zinc, which is less apt to irritate the intestines, to the filings, though the latter are much more efficient in their action on the worm. They act merely mechanically, being always employed in a pure state, free from all alloy of arsenic or lead. Analogous instances of the effect of hard and sharp particles in the de- struction of worms are seen in some of the lower animals. Thus Rudolphi has observed the taenia found in the intestines of birds to be often much lacerated by the rough husks of the grain they had swallowed ; and Bremser mentions that cer- tain birds are free from worms in such parts of the year as they take in sand and other hard sub- stances with their nourishment, though they are liable to them at other periods when their food is of a soft nature. Yet Alston's, like all other mechanical methods, is defective in regard to the great object, namely, that of destroying the ten- dency to the generation of these worms; and ac- cordingly Bremser always found that the patients whom he treated on this plan returned within three months after their expulsion, again complain- ing of the symptoms of taenia. In France, a modification of Alston's method is occasionally employed, the filings of tin in doses of from twelve grains to half an ounce being substituted for zinc; and in the only two cases in which Cloquet saw it tried it was permanently successful. By Brug- natelli, another preparation of tin, the sulphuret, in doses of from half a drachm to a drachm thrice a day, is considered as the most effectual vermi- fuge in taenia, if its use be continued for some days. The root of the male fern (polypodium, vel as- podium filix mas) forms a part of the several modes of treatment which have been recommended in tape-worm. Its vermifuge powers are men- tioned by Pliny, Galen, and Dioscorides, and by old Gerard ; and likewise by Andry and Marchant in the beginning of the last century, and have enjoyed from time to time, even down to our own days, a kind of intermittent celebrity. Its sensi- ble qualities are not very striking, as it possesses merely a glutinous and sweetish taste, combined with a barely perceptible degree of bitterness and a slight astringency. Hence doubts have often been raised as to its anthelmintic powers; but these have again speedily yielded to the test of experience. The good effects of M. Peschier's oil of fern, obtained by treating the root with ether, concerning which mention has been already made in the article Avthelmintics, shows that Pallas was in error in supposing it to act merely mecha- nically. Its efficacy in taenia lata (bothriocepha- lus) seems well established; but with regard to the taenia of this country, (taenia solium,) it rarely succeeds in effecting its perfect destruction. Brem- ser suggests its utility as a means of detecting taenia in doubtful cases, as its use is commonly followed by the expulsion of large fragments of the worms. He directs the upper or green por- tion of the root and its lowest and oldest part to be rejected as comparatively inert. The root should be ascertained to be in a healthy state, and be prepared just before it is going to be used, the bark being removed before pounding it. It is a nauseous medicine, requiring to be taken in very considerable doses; and unless, moreover, it be long continued, and strong purgatives be taken after it, it is very apt to disappoint us ; and with every precaution as to its mode of administration, it can very rarely be depended on in the ordinary cases of taenia of this country. Still, if very largely given and persevered in daily for some weeks, so as to keep the bowels constantly full of it, it will sometimes succeed even against this species, as in a case which occurred to Dr. Latham. In many instances, however, he found that the stomach could not bear it in sufficient quantities, and he substituted the powdered tin in very large doses, and generally, as he informs us, with success. After neither of these medicines is he anxious to procure stools by purgatives, believing that the efficacy of these and of most other anthelmintics depends on their extensive distribution through the bowels, so that they shall come in contact with every portion of the surface of the intestinal canal, as well as with all the parasitic animals which they are intended to remove. The ordi- nary dose of the fern-root is from two to four drachms taken in water. Gardien says it will be found less nauseous in the form of a bolus, which is to be wrapped up in a wafer-cake and swallowed at once, than in fluids, as commonly administered; a slice of lemon or orange, or a clove should after- wards be held in the mouth for a few minutes, or a cup of strong coffee, without milk, taken to ob- literate the taste. The method of a Swiss lady, Madame Nouffer, is the most celebrated of those in which the fern- root is used : being a secret, it was purchased by the king of France for about seven or eight hun- dred pounds of our money, and made public about the year 1776. On the evening preceding the exhibition of her medicines, she directs the patient to take, in place of his ordinary supper, a basin of thin panada, made with a little butter and enough salt to season it, and a goblet of white wine, or of water alone if not habituated to the use of wine ; and a simple lavement is to be ad- ministered if constipation exists. Early the next morning the specific, consisting of two or three drachms of the male fern-root, gathered in autumn, and reduced to a very fine powder, is to be taken in six or eight ounces of « eau de tilleul," or some other slightly aromatic distilled water. Two hours afterwards the patient should rise and take the purgative bolus, consisting of ten grains of calomel and as much scammony, along with six grains of gamboge, all carefully mixed together, and swallowed in a little conserve of hyacinth, one or two cupfuls of weak green tea being drunk after it. The patient should now walk about his chamber till the purgative effect of the medicine commences, which is to be promoted by taking a cup of tea from time to time till the worm has been passed; then, and not till then, some broth 748 WORMS. or soup is allowed and a very little dinner. If the bolus fails to purge sufficiently, a few drachms of Seidlitz or Ep3om salts are to be taken in hot water about eight hours after it. Should the worm not come away at once in a ball, but on the con- trary hang out from the bowels, no attempt should be made to pull it away : sometimes its exit may be accelerated by eating something, or by a lavement being injected. As for the heat and uneasiness which so violent a purgative is calcu- lated to excite, Madame Nouffer looked upon them as mere temporary inconveniences and of no im- portance ; and the French commissioners, to whom her treatment was submitted, never found it to do harm. The greasy panada taken on the preced- ing evening, and the free use of diluents, must no doubt have tended, in a very material degree, to protect the intestines; yet M. Odier, Vieusseux, and other later practitioners, have sometimes seen this very rough medicine induce considerable irri- tation of the intestines, as indicated by violent colics, pain in the praecordial region, vomiting, faintings, &c. In some cases it was found neces- sary to repeat the treatment on the following day, with the exception of the bolus, for which the aperient salts alone were substituted. It fails al- most constantly, as the French commissioners were from the first aware, in cases of the taenia solium, but is generally quite adequate to the expulsion of the bothriocephalus, or taenia lata. In Great Britain, therefore, as well as in Ger- many, it need never be put in practice, and in a great proportion of cases in France, likewise, it will prove inefficient. Bremser approves of the postponement of the purgatives, as directed by Mde. Nouffer, till after the specific shall have had time to take effect on the worm. The combina- tion and simultaneous exhibition of the two kinds of medicine is an injudicious practice. Sennert has made a similar remark with respect to specific anthelmintics generally. M. Odier's method very nearly coincides with that of Madame Nouffer, save that for the power- ful purgative bolus three ounces of castor-oil are substituted, a table-spoonful of it being taken every half-hour in a little thin soup. Rudolphi conceived that the castor oil was much more effectual if recently expressed than if some time kept; but we are not aware that this remark has been confirmed by the observation of others. [A similar plan of treatment is pursued by M. Wawruch (Op. cit.)] A variety of other methods of treatment bear- ing the names of the several persons by whom they were devised are given at full length in Bremser's work; but as they are admitted to be far inferior in efficacy, and many of them more dangerous than those already described, we shall not enter very minutely into their details here. Most of them consist of drastic medicines in ex- tremely large doses, together with calomel, fern root, &c. Thus Beck's treatment consists in the administration of a scruple of calomel, with ten grains of burnt hartshorn, and of cinnabar of antimony; the patient drinking two ounces of almond-oil some time after, a practice enjoined in several of the other plans of treatment, and which will tend to protect the mucous membrane from the violent agency of some of the medicines ex- hibited. The following morning a powder is to be taken containing amongst other ingredients ten grains of gamboge and the like of jalap, and this is directed to be repeated every two hours, if ne- cessary, till the third time. Clossius likewise gave large doses of calomel and gamboge. Dessault'i method consisted of mercurial frictions made over the abdomen, whilst calomel was at the same time largely taken internally. Hautesierck gave ten grains of gamboge with colocynth and bitter almonds and extract of absinth, the dose being repeated in eight days ; whilst pills of aloes and assafoetida, and an amalgam of tin and mercury, were taken daily in the intervals. Herrenschwand administered a drachm of fern root night and morning for two days, and then a powder con- taining twelve grains of gamboge and other minor ingredients; this was followed by castor oil and injections if requisite. IJufeland directs a decoc- tion of garlic in milk to be taken night and morning, and a table-spoonfur of castor oil mid- day and evening, and half an ounce of zinc filings in a little conserve of roses daily ; the abdomen to be rubbed with petroleum, and an enema of milk to be administered in the evening, the patient all along subsisting chiefly on salted and high- seasoned meats. AH this must be persisted in for several weeks, or till the worm be passed. Where this treatment fails, Hufeland recommends a course of the Pyrmont or Driburg waters. He seems, like Bremser, to have no faith in short or sudden cures. Lagene gives a powder consisting of a drachm of valerian and a scruple of powdered egg-shells for three mornings running, the patient observing a very low diet throughout. On the fourth day he administers a powerful purgative bolus containing ten grains of calomel and twelve of the diagrydium sulphuretum (a preparation of scammony), followed by the infusion of senna and enemata. When the patient is very robust, or the tongue very foul, with other symptoms of gastric derangement, he commences by a lavement of tartar-emetic. Lieutaud's process comprises diagrydium, fern root, savine, rue, calomel, a vinous infusion of the kernels of peaches, &c. Mathieu's method, purchased by the king of Prussia, com- prehends the use of tin filings, fern root, semen santonici, jalap, sal polychrest, scammony, and gamboge ; the exhibition of these medicines being preceded by a restricted system of diet for several days, salted foods, thin panada, &c. Rathier'a formula contains calomel, savine, rue, oil of tansy, syrup of peach-flowers, and a vinous infusion of peach-kernels, &c. and is, in short, very similar to Lieutaud's, save that the doses are larger. Schmucker's plan consisted in the long-continued use of cevadilla, a purgative of rhubarb being premised, and also occasionally interposed during the treatment. Weigel's method was to give a small dose of Glauber salt nightly, and a few drops of elixir of vitriol twice a day for several months together; but Rudolphi, with much reason, doubts the adequacy of these measures to the cure of tape-worm. Kortum gives a case in which mare s milk taken for a day or two at the recommenda- tion of a countrywoman, caused considerable colic and the expulsion of the worm. The use of an infusion of green flax continued for ten days, reported in one of the public journals not WORMS. 749 long since, is said to have proved curative in one case. Very cold or iced water, if taken in large quantities, seems to act injuriously on worms in the intestines,—such at least was the opinion of Rosenstein and of Pallas. As it must very quickly acquire the temperature of the body, its effects in the expulsion of these animals have been ascribed by Rudolphi in a great measure to the impression at first made on the stomach being propagated downwards to the intestines, a con- siderable degree of commotion taking place in them in consequence thereof. He supposes like- wise that the large quantity of water absorbed by the worms will over-distend them and facilitate their displacement. Perhaps also the well-known purgative effect of large draughts of water con- tributes not a little to this result; for the addition of the muriate of soda, as recommended by Goeze, Brera, and Tommasini, or of various other kinds of aperient salts, contributes not a little to its efficacy. Many delicate persons, however, are quite incapable of bearing the necessary quantity of cold water. Rosenstein says, that half a large glass of it must be swallowed every four or five minutes till a gallon or upwards has been taken ; the patient beginning to drink it just at the mo- ment that an aperient of jalap or salts previously administered is beginning to operate, and thus the water will pass off rapidly and without any risk of injuring the individual by its accumulation. The author whom we have last named mentions the case of a gentleman who cured himself of tape- worm by swallowing, three or four times a week, two or three cloves of garlic, chopped into small pieces, and washed down with water or tea, a purgative elixir being occasionally interposed ; and he alludes to several other instances where garlic proved useful, when persevered in for several months. It is a very old remedy against worms, having been used in this way by Hippocrates. Any of the bland oils in large quantities, it has been said, constitutes an effectual remedy in tape- worm. Thus, in the Bulletin de la Societe Me- dicale d'EmuIation, for October 1822, it is asserted that if a pint and a half of either almond or olive oil be taken at the rate of about two ounces every quarter of an hour till the whole is finished, they prove a certain remedy against the disorder. The repugnance to the oil may be in some degree di- minished by taking a little sugar after each dose. The patient should move about constantly, to facilitate the passing off of the oil by stool. Carbonic acid gas has been considered vermi- fuge by Hartmann, Ingenhouz, and others. Meier, in cases of taenia, used to give the carbonate of magnesia, and immediately after it the bitartrate of potass, which was followed by the disengage- ment of much gas: a tea-spoonful of each was taken hourly, and the practice was generally fol- lowed by the evacuation of portions of the worm. Seltzer water has likewise been recommended. Professor Dubois's mode of treating taenia, as given by Ratier, is as follows. In the evening the patient is to take some panada, and the following morning half an ounce of the powder of the male fern root in a cup of broth ; an hour afterwards he has a bolus composed of jalap, diagrydium, gam- boge, and scammony, two grains each, which is 3k* repeated every hour till the third time. A little broth is to be taken from time to time throughout the remainder of the day. M. Guilbcrt, as we likewise learn from Ratier, thinks it unnecessary in general to employ any remedies against tape-worm, having observed that it may exist for a length of time without exciting any disturbance in the economy, provided the pa- tient be plentifully supplied with nourishing food. In a great number of cases which have come under his notice, drastic purgatives seemed to have been the chief cause of any disagreeable symptoms which happened to be present. His general rule is, to leave the disease in most cases to nature, being persuaded that the worm will almost always event- ually disappear spontaneously. In the few cases, however, where it seems really to produce serious disturbance, he employs the treatment of M. Bour- dier, as practised at the Hotel Dieu of Paris, in preference to all others. This consists in giving in the evening a panada along with the yolk of an egg; and the following morning a drachm of sul- phuric ether in a glass of strong decoction of fern, which is to be succeeded in about five minutes by an injection composed of the same decoction with two drachms of ether. An hour after this a pur- gative potion is administered, consisting of two ounces of castor oil and one of the syrup of peach- blossoms, the action of which is to be promoted by drinking a few cupfuls of broth. This treat- ment is to be repeated for three days running. It is said to have proved successful in the hands not only of Bourdier and Guilbert, but also in those of Halle, Alibert, Fortassin, &c. If, by means of the remedies employed, a part of the worm makes its appearance and hangs out from the anus, the protruding portion should be received in tepid milk or water, by which means the exit of the remainder of the animal, provided it be still alive, is, according to Grundler, often greatly accelerated. " As soon," says Brera, " as a part of the worm has shown itself, one might suppose it easy to drag out the remainder. But observers are agreed that this is impossible; and I have had opportunity more than once, when attempting it, to satisfy myself that if we pull at it, however cautiously, the patient immediately is sensible of a sort of twisting or dragging in the intestines, which induces convulsions if we do not speedily desist, or cut the worm across. If, in place of cutting it, we tie a silk thread round the protruded portion, it will retreat several feet into the bowels, but some time after makes its appear- ance again at the anus. The moment the patient perceives the worm begin to come forth, he should place himself on the night-chair, and remain there until it is entirely evacuated. It is ordinarily ex- pelled rolled up in the form of a ball along with the faeces; but if it comes out with difficulty, whether from the head being firmly attached to the mucous membrane, or from an accumulation of mucus interfering with its expulsion, the pa- tient should still continue quietly seated, and drink frequently of an infusion of chamomile, or, what is better, of a solution of sulphate of magnesia, to quicken the peristaltic motion. If, after having taken the appropriate remedies, the worm is either not evacuated at all, or only in part, we must re- peat the treatment on the following day, or sub- 750 WORMS —YAWS. stitute a more powerful one. It sometimes hap- pens that the patient, when just about to expel the worm, experiences, after an abundant alvine evacuation, a sensation of heat, and a feeling of anxiety at the praecordial region, which terminates in vomiting. Such an occurrence should, how- ever, cause no alarm, as the disagreeable sensation speedily passes off, and is unattended with danger." W. B. Joy. * This writer pointed out the resemblance of the yaws to the disease described in the thirteenth chapter of Leviticus, as affecting: the Israelites in their passage through the wilderness, and Adams has expressed his belief of their identity. (Obs. on Morbid Poisons, p. 206.) Dr. Hillary supposes that Haly Abbas, who lived in the tenth century, refers to the yaws under the general term lepra, both kinds of the Arabian leprosy having been described in a preceding chapter under the name (as it is translated) elephantia. " Inquiry into the Means of improving Medical Knowledge, by W. Hillary, M.D." It appears that in general, if not always, the occurrence of the yaws is consequent to the applj. cation of its specific virus to an abraded surface of an individual in whom it has not previously existed, and this, although frequently by accident, not unfrequently by design,— in some instances with a view of obtaining exemption from labour but in many from a popular though erroneous notion amongst the negroes, that, like measlei, scarlatina, and small-pox, its invasion at some pe- riod or another (being common at all ages) it ■ fixed law of the animal economy. Observing also, as in these, that the constitution is Tendered insusceptible of a second attack,! and that child- hood is the most favourable period for its endur- ance, the parents are apt not only not to guard against the intercourse of their children with the infected, but even to contrive their exposure to it. The most usual circumstance, however, under which it is contracted, says Dr. Wright, are first, by sleeping in the same bed, and the ichor getting on the wounds or scratches of the uninfected; secondly, by handling the infected, and allowing the virus to touch scratches or excoriations; thirdly, by the use of the same bowl or basin in washing their sores which had been previously used for similar purposes by the infected negroes; fourthly, and most usually, by small flies, which, having gorged themselves with the virus of the diseased, alight on the ulcers of the hitherto uninfected, its propagation being as certain by the minutest quan- tity as if it were ever so considerable. (Memoirs of Dr. Wright, p. 408.) The accession of yaws may in many instances be suspected by pre-existing lesions of the cuta- neous surface assuming the appearance of its characteristic ulcerations ; and if with such sus- picious appearance the individual has frequented the company of the infected, and has for some weeks had pains in his joints and limbs, the dis- ease will sooner or later take place, according to the condition of the individual. In some cases the eruptive fever is pretty smart, but in others scarcely discernible; frequently, 6ays Dr. James Thomson, (Edin. Med. and Surg. Journal, vol. xv. p. 322,) prior to the eruption, the whole sur- face is covered with a white scurf, as if it were dusted with flour. The eruptions are at first about the size of a pin's head, and scarcely rise above the level of the skin, but soon increase and be- come protuberant like pimples. Some time after this the cuticle falls oft, leaving the parts covered with white sordes or sloughs; under these, small red fungi or excrescences spring up and increase daily, some resembling in appearance and size the wood-strawberry, others the raspberry, and others even mulberries, being granulated, as it were, like them. They appear in all parts of the body, but mostly on the face, in the axillae, on the groins, genitals, and perineum. The size of these fungi, as well as tho number, depend on the state of the patient's health and habit of body; a healthy strong person will have few, but of a large size, whilst those of a thin or reduced habit will have t Dr. Owen, who had considerable experience of the disease, saw only two instances of its second occurrence in the same individuals, and that after an interval of twenty years. Edin. Med. and Surg. Journal, vol. xviii. p. 36. YAWS.—A word which has its origin in the vernacular dialect of Guinea and other parts of Africa, where it has been used to designate the fruit of the rubus idxus (raspberry) ; and from an imagined resemblance between it and certain fun- goid excrescences from the dermoid tissue pecu- liarly characteristic of a disease indigenous in that territory, the latter has obtained the same denomi- nation. Yaws continues also to be its popular name in our own language, and in its translation into others its etymological signification has been retained. Thus, on the coast of America it is vulgarly called plan or epian, and by the French framboise, whence systematic writers generally have adopted the name frambcesia. By Mason Good, the more chaste and legitimate term rubula, the diminutive of rubus, (blackberry or raspberry,) has been substituted, and he has classed it under this name as one species of the genus Anthracia. The common distinctions into African and Ameri- can yaws, adopted by the last-mentioned nosolo- gist as they had been previously by Sauvages and Cullen, appear to be void of foundation. The yaws first became known to Europeans as an endemic disease in that part of Africa called Guinea, but from what period it had prevailed amongst its uncivilized inhabitants it is of course impossible to ascertain. With the commencement of the slave-trade in the sixteenth century, it is probable that it was imported into our West India islands and America, where it has since prevailed to a great extent amongst the negroes, and has been found occasionally, but with comparative rarity, to affect individuals of the white population. Dr. John Hume, formerly surgeon to the Naval Hospital in Jamaica, and a commissioner of the sick and hurt, was the earliest writer who drew the attention of British practitioners to the phe- nomena of this disease, in an account of it pub- lished in the sixth volume of the Edinburgh Medi- cal Essays in 1744.* It was next treated of by M. Virgile, who practised for several years in the island of St. Domingo; subsequently, by M. Des- portes, Peyrilhe, Dr. Hillary of Barbadoes, and Dr. James Grainger of St. Christopher's. To Drs. Winterbottom, Dancer, Moseley, Ludford, Thom- son, Thomas, and Wright, we are indebted also for the results of their immediate and extensive experience of it. The last-mentioned writer sup- plies us with much of the information (not other- wise acknowledged) in this paper. YAWS. 751 a vast number of small eruptions, scarcely exceed- ing the size of a millet. In healthy subjects the disorder will arrive at its height in a month's time; in those that are sickly the period will be three or four months. At length the fungi de- cline ; yellow scabs are formed, and the skin is left smooth and in general without cicatrices. One or two of these, however, larger than the rest, continue some time after the others have dis- appeared : these are called the master, mother, or mamma yaws, from the absurd idea that the others are supplied from them ; they leave scars resem- bling, says Thomson, those of the cow-pox, but are broader and more superficial. In the mean time the patient loses neither appe- tite, flesh, nor strength; he suffers no pain or un- easiness except from the nastiness of the disease, and a slight sense of soreness when the excres- cences are rubbed or pressed. It is stated by Dr. Hume, Dr. Hillary, and others, that the hair pro- ceeding from the spots where the peculiar fungi of the yaws have grown, changes gradually in colour until it becomes perfectly white; others have contradicted this assertion, and it has been suggested from this discrepancy, that it must have been mistaken for leprosy. It is much more pro- bable, however, that the occurrence is an occasional though by no means a constant one, amongst the phenomena of the disease. Such is the progress of the symptoms when left to nature, and neither retarded nor forwarded by medicine taken internally or used by applica- tion to the parts first infected; but if a yaw-sore, for example on the leg or foot, be treated as a common ulcer, or the patient continue to work or stand as in health, it soon assumes an unhealthy appearance, the neighbouring parts become in- flamed, its edges are ragged and turn back like those of cancerous ulcers; its surface looks foul and is covered with small specks and sloughs; the discharge is ichorous, black, and extremely offensive, and the patient's strength is wasted and worn out with pain. Under such circumstances, the eruption of the yaws is retarded, and, when it appears, is of long continuance, especially if mercurials have been employed too early. The fungous excrescences break out also in the soles of the feet and palms of the hands, where, from walking barefooted as the negroes commonly do, and from hard labour, the integuments are excessively thickened. Hence, the eruption of the yaws is very painful, and the excrescences are sometimes so large as to extend over a great part of the sole of the foot. In this situation they are called by the negroes in the West Indies, " tubba" or " crab yaws." These, unless skilfully treated, are apt to continue troublesome for a number of years. Like corns, they are frequently affected by different states of the atmosphere, but more particularly by rainy weather. When the yaws have been repelled by the too early use of mercury, or, as was frequently the practice in the ships employed in the slave-trade for the fraudu- lent purpose of enhancing the price of the damaged commodity, by various external applications, as the sulphate of copper and corrosive sublimate, the risk has been considerable to the life of the sufferer. If the eruption have been thus sus- pended for any length of time, it has subsequently recurred with redoubled violence. In some it has caused the most obstinate and ill-conditioned ul- cers, in others erosions of the nose and palate, bone-ach, and distortions of the limbs: occasion- ally the whole cellular substance has been infil- trated with serum or even purulent fluid, and the wretched sufferer has fallen a victim to the injudi- cious treatment; in many instances, it is to be feared, instigated by a murderous cupidity. A glossy smoothness of the skin where this peculiar eruption commonly makes its appearance is often an indication that the disease has been suspended only by the means already adverted to. It is a singular fact with regard to the manifestation of yaws, that if a person with a large ulcer be in- fected, he may pass through the disease without any eruption,—at a certain time the sore begins to acquire a new granulated appearance, and be- comes elevated, the edges assume their character- istic form, and a constant discharge is kept up. If an attempt be made to heal the sore and is successful, an eruption of yaws follows in the regular manner; otherwise it goes on and gene- rally remains as an ulcer for life. The practice always to be pursued is to endeavour to heal the sore as soon as infection is suspected. (Dr. Thom- son on Yaws, Edin. Med. and Surg. Journal, vol. xv. p. 325.) To some of the eruptive diseases of the infe- rior animals in the West Indies, the appellation yaws has been indiscriminately applied ; but com- parison has sufficiently disproved the identity of their nature, and repeated experiments have served to show the incapability of the disease in question being transferred by inoculation beyond the human species. Desportes asserts, and Alibert has taken it for granted in support of his idea of the de- pendence of yaws upon unwholesome nutriment, that he has seen it declare itself in some of the Gallinaceae of St. Domingo, especially Guinea fowls and turkeys, after feeding entirely on the seeds of the holcus spicatus. But although we know by sufficient experience that the exclusive use of similar and equally unwholesome food has been conducive to the eruption of lepra, pellagra, and other diseases of the skin, it is the peculiarity of yaws in the human species to be propagated only by contagion ; hence we are entitled to infer that the correspondence did not exist. The identity of many of the phenomena, as well as of the original signification of the names of the disease under our consideration, with sivvens or sibbens, (Sibbens in the Erse dialect signifies a raspberry,) a malady well known in the western parts of Scotland, renders it a matter of interest if not of importance that we should notice their characteristic distinctions. The sivvens, it is re- marked, at first seizes the throat and nose; the yaws never, until after a length of time or improper treatment. The eruptions in sivvens are watery, of a dirty hue, and of intolerable foetor; those of the yaws are at first as small as a pin's head, hard, and without any peculiar odour. In sivvens boils appear here and there, forming deep and ill- disposed ulcers, a character which does not belong to yaws. In sivvens itchy tetters break out in form of ringworms, and occasion either a dpep ulcer or a scabby large spot with inflammation; the yaws have no such appearances. The sivvens 752 YAWS. rarely affect the bones, the yaws always unless well managed. In the yaws the excrescences succeed the pimples as well on the face and body as on the axillae and pudenda; in sivvens the fungi appear on the groin and perineum in a very advanced stage of the disease. The sivvens is highly contagious without sensible inoculation, the only mode, as it appears, by which yaws is propagated. The sivvens may be cured early by mercurials, but mercurials in the yaws, at least in the early stage, are pernicious. In constitutions otherwise healthy the yaws will usually run a definite course, be spontaneously exhausted, and terminate in health even without medicine; but if speedy and effectual means be not used to counteract sivvens, it will almost certainly proceed to a fatal issue. The yaws and syphilis have frequently been considered as modifications of the same disease, but a comparison between the descriptions of the two will at once establish some important distinc- tions. It is true that the yaws will affect the bones, the cartilages of the nose, and the palate, like syphilis, and will admit of cure by similar means ; but in primary syphilis neither eruptions nor fungi appear as in the yaws, except on the pudenda, and then only in the form of warts. Syphilis will never cease spontaneously, like yaws, and, unlike yaws, it may be and is contracted re- peatedly. Persons who are suffering from the yaws may contract gonorrhoea, and even syphilis; and it is very remarkable that the former may be cured independently of the yaws, but that the latter cannot until the yaws have begun to decline. If the patient be a person of a previously healthy constitution, and be judiciously and carefully managed, even under the most formidable appear- ances of yaws, it is rarely attended with danger; but if otherwise, and there has been much pre- ceding debility, by whatever causes induced, if the eruptions have been repelled, or if mercury have been used in the early stages, it is liable to a tedi- ous if not dangerous protraction, and often proves fatal under the best-directed efforts. When there has been any tendency to hereditary disease, yaws will always excite it into action, and the probability of its issue will of course be materially influenced by the nature and effects of the former, whatever it may be. It has been imagined that the seeds, as it were, of yaws are implanted in the negro constitution, and that they must necessarily be developed at some future period without any obviously exciting cause. It need scarcely be observed that reasons are wanting in support of this hypothesis, and it has been denied by Dr. Wright and others that the habits and circumstances of negroes predispose them more than Europeans to receive the specific infection. Alibert has advocated the more popular belief, and accounts for a superior susceptibility of this and other cutaneous diseases in negroes by the circumstance of their dermoid tissue being endowed with a larger share of sensibility. He considers, also, in accordance with the commonly accredited assertion, that the diet of the negroes contributes in a great measure to the ready propa- gation of yaws amongst them, their food, particu- larly in Guinea, being of a nature little accommo- dated to the wants of the system, naturally untract- able by the organs of digestion, and scarcely rendered less so by the very imperfect modes of cookery to which it is subjected. It is obvionj that the circumstances of the climate, the customs, and domestic habits of this uncivilized race must very powerfully co-operate with the diet above noticed in inducing as well as in keeping updii- order of the cutaneous surface; but in the West Indies we are informed that the negroes, though well fed and healthy, are as readily affected by this morbid poison as the puny and debilitated; that the diseases of the former are often of the inflammatory kind, and are advantageously treated by repeated bleedings, the blood being generally firm and buffy ; whereas the diseases of white people in the same locality mostly partake of the remitting fever, in which, if the lancet is at all used, the greatest caution is requisite, and the blood is generally loose, discoloured and watery. Of the immediate operation of the virus of yaws on the animal economy, we know nothing more than the effects already detailed ; the progress of its operation, unlike that of small-pox, is very va- riable in different individuals ; but from the experi- ments of Dr. Thomson it may be inferred that from seven to ten weeks is the usual period which elapses between the insertion of the virus and the development of the eruption. In one instance, however, for which we have the authority of Dr. Adams, the interval appears to have been ten months. It has been remarked that the blood of yaw patients does not differ in appearance from that of healthy persons, and that, when used for inoculation, it fails to communicate the disease; moreover, that the infected are as liable to other diseases as persons in a healthy condition. (Edin, Med. and Surg. Journal, vol. xv.) Treatment.—The prevention of yaws may be, and is almost always, successfully accomplished by the simple observance of avoiding the sources of its contagion, principally by an entire and dis- tant separation from the infected, and by the strict- est care in not participating with them in the use of any articles of clothing or domestic utensils through the medium of which the virus might by any possibility be conveyed. The intervention of authority, however, is often absolutely neces- sary to enforce the requisite precautions on the negroes, who, reckless of the consequences, would rarely avoid even the most familiar intercourse with the infected. The adoption of the usual means for the maintenance of the general health, such as good clothing, wholesome food, and usage otherwise conducive to mental content and cheer- fulness, doubtless imparts considerable power to the constitution, if not of resisting the contami- nating influence of the virus, of very much miti- gating the consequent injury to the constitution, and shortening the duration of the disease. On well-grounded suspicion, or the earliest ap- pearance of yaws, its extension should be guarded against by the removal to a distance of the infected from the healthy, and by cutting off' entirely all intermediate communication. In the best regu- lated of the West India estates a house is provided in a convenient situation for the reception of the infected negroes. The planter selects for its ma- nagement a careful and discreet matron, who ii insusceptible of the contagion, by having experi- YAWS. 753 cnced the disease at some former period. He pro- vides them with plenty of good food and raiment, and takes care that they have easy work, as weed- ing and cleaning their own provision grounds, watching a cane-piece, or following sheep and cattle. Thus they are prevented from indulging, as they otherwise would do, in sloth and indo- lence, and their attention is diverted from brooding over the affliction they labour under. Their health also is improved by the same means. He further insists on the most strict attention to personal cleanliness and neatness of apparel. During the eruptive stage, according to Dr. Thomas, who had considerable experience of its management, (and such appears to have been the line of treatment generally recommended by the West India practitioners,) the efforts of the sys- tem should be assisted by some mild diaphoretic, and with this view precipitated sulphur, contra- yerva in powder or infusion, decoction of China- root, or infusion of sassafras, and vapour or warm baths have commonly been resorted to. When the eruptions begin to dry off, a course of the compound decoction of sarsaparilla is found to be of great service, and other tonics of the vege- table kingdom, such as contrayerva, sassafras, guaiacum, &c, are occasionally used. Towards the decline, says Dr. Wright, if the disease do not go off kindly, mild mercurials may then, and not till then, be given with safety and advantage, so as to act as alteratives, and not occasion a ptyal- ism. Minute doses of a solution of the oxymuri- ate of mercury, have generally been preferred, to- gether with the use of the compound decoction of sarsaparilla. When erosions of the cartilages of the nose and of the palate, obstinate foul ulcers, bone-achs, &c, have taken place, the most appro- priate counter-agents will be a generous diet, and a plentiful use of sarsaparilla, both in decoction and powder. With regard to ulcerations from the yaws, it is to be remarked that simply unctuous dressings and warm fomentations are rarely serviceable. Washing them with cold water and certain vege- table applications will often have a good effect. If the ulcers are small, it will be sufficient, says Dr. Wright, to cover them with a leaf of the cissus cicyeides or snake-wyth, commonly called the yaws-bush, or with a leaf of the iatropha curcas or English physic-nut If the ulcers are large, a poultice of these leaves beaten and mixed with a little sugar, or with the pulp of roasted Seville oranges and sugar, forms an antiseptic well adapt- ed to the purpose for which it is required. To the master yaw, which is apt to degenerate into a troublesome ulcer, the ung. hydr. nitrico-oxydi is often a good application. A combination of car- bonate of iron with citric acid and prepared lard is also much employed in the West Indies for the same purpose, and is said to be very efficacious. When the excrescences proceed from the soles of the feet, the thickness of the cuticle there occa- sions a resistance to the discharge, which leads to Vol. IV.—95 extensive ulceration, very difficult to heal, but best treated by a poultice of the fresh cassava-root, a plant possessed of a narcotic quality, and well known in every West India island. Hard swellings of a very painful nature, which do not suppurate, sometimes appear in the soles of the feet as a consequence of the yaws, and occasion lameness. To remove them the patient should bathe his feet in warm water until the swellings are softened; they should then be seared with a hot iron, which produces an eschar. The consequent sore is readily healed by dressing it with some mild escharotic. (Practice of Physic, by R. Thomas, M. D. 8vo. p. 645.) Under all the usual circumstances of yaws, and in every stage except the primary febrile one, it is necessary that the patient's strength should be supported by a generous diet, including a full allowance of animal food, with a due proportion of wine or of diluted spirits. The liability of persons in yaws to other exan- themata, as measles and small-pox, is a feature which has been taken advantage of for the pur- pose of expediting the cure of the first-named disease: by inoculating for the small-pox when the yaws are on the decline, the latter will entirely subside, or if perchance any of the excrescences should re-appear, their continuance will be of short duration.* It has been proposed also, as in small-pox, to inoculate the unaffected with the specific virus of the yaws, in order that the symptoms may be ren- dered milder in their nature, and quicker in their progress; but the inducements, if there be ground for the anticipation, which is very doubtful, are by no means equivalent to those of the analogous process in the former disease, as the latter is'infi- nitely more easily avoided, never proves fatal when judiciously treated, and even after the ope- ration, under the most favourable circumstances, is often many months in going through its regular course. In some instances it is to be remembered that after every* appearance of the yaws shall have passed away, even for months, and all possible care has been taken of the convalescent, the dis- ease will break out afresh. The separation, there- fore, of the diseased from the healthy should be continued for some time subsequent to the last appearance of an eruption or ulcer, be either ap- parently ever so unimportant. -yy rrv„„ * " All this is perfectly analogous to what has been traced in other morbid poisons. It is probable that the irritation from small-pox and measles being greater than that from yaws, may interrupt the latter at any time. But the laws of that poison requiring a certain course to be pursued, if the new irritation is induced before that course is completed, the disease must return as that new irritation ceases. If, on the contrary, that irritation has not been induced till the course of yaws is completed, and nothing remains of it but an habitual ulceration, the new irritation will not only supersede the old action, hut by breaking the habit, very much ex- pedite the cure."—Adams on Morbid Poisons, p. 212. GENERAL INDEX. Abdomen, exploration of the, i. 25 physical conditions of the, iv. 327 latent diseases within the, iii. 122 Abdominal aorta, nervous pulsation of, i. 134 dropsy, i. 182 tumour, feigned, see Feigned diseases, ii. 125 Abortion, i. 33 Abortives, iii. 477 Abscess, internal, i. 36 in particular tissues, i. 37 in the abdomen, i. 40 in the brain, i. 38 in the chest, i. 39, see also iii. 617 in the kidney, iii. 377 in the liver, iii. 150 Absorbent system, tuberculous matter in, iv. 479 Abstinence, i. 42 curative effects of, i. 43 as a cure for obesity, iii. 409 morbid effects of, i. 43 partial or total, ii. 126 Acarus folliculorum, i. 48 Acarus scabiei, iv. 64 Achor, i. 45 Acid, oxalic, treatment of poisoning by, iv. 420 Acids, disinfecting properties of, i. 691 sulphuric, nitric, and muriatic, as poisons, iv. 416 Acne, i. 46 simplex, i. 47 follicularis, and indurata, i. 49, 50 rosacea, i. 51 syphilitica, i. 53 Aconitum napellus, or monk's-hood, as a poison, iv. 453 Acrids, as poisons, iv. 439 Acrodynia, i. 54 Acupuncture, i. 54 in dropsy, i. 719 Adipose tissue, hypertrophy of, ii. 546 Adolescence, physical education in, i. 757 .fEgophony, ii. 253; iii. 30 ^Ethusa cynapium, a poison, iv. 453 Age, i. 57 changes effected by, i. 58 critical, iii. 34 Agheustia, iii. 458 Agrypnia, iv. 653 Ague, ii. 205 Air-bath, warm, i. 285 Air, change of, i. 67 in the cavity of the pleura, iii. 637 Alabama, climate of, i. 449 Albuminuria, iv. 587 Albuminous urine, iv. 587 Alcohol, as a poison, iv. 456 Aliments, classification of,-i. 647 Alkalies, as poisons, iv. 421 Alimentary canal, functional affections of the, iv. 324 Alopecia, i. 70; iii. 657 Alteratives, i. 74 Alveolo-dental membrane, inflammation of the, iv. 404 Amaurosis, i. 78 Amenorrhoea, i. 89 Amentia, iii. 44 Ammonia, as a poison, iv. 423 Amnion, dropsy of, iv. 604 Amygdalitis, iv. 385 Anaemia, i. 92, 94 of the liver, iii. 145 Anaesthesia, iii. 458 Anasarca, i. 95 Aneurism, dissecting, ii. 128 of the aorta, i. 126 of the heart, ii. 379 Angina gangraenosa, iv. 73 maligna, iv. 376 membranacea, iv. 376 Angina cedematosa, iii. 107 Angina pectoris, i. 103 Animal irritants, iv. 441 magnetism, iv. 203 matter, diseased or putrid, as a poison, iv. 443 Animals in the stomach, ii. 126 Animation, suspended, i. 117 Anodynes, i. 117 Anosmia, iii. 457 Anthelmintics, i. 119 Anthracion, i. 122 Anthrax, ii. 759 Antimony, as a poison, iv. 436 Antiphlogistic regimen, i. 122 Antiseptics, i. 689 Antispasmodics, i. 124 Aorta, aneurism of, i. 126 inflammation of the, i. 139 nervous pulsation of abdominal, i. 137 Aortic valves, induration of, ii. 421 Aortitis, i. 139 Aphonia, i. 139 Aphtha anginosa, iv. 376 Aphthae, i. 140 in phthisis, iv. 513 Apoplexy, cerebral, i. 142 hepatic, iii. 144 persons found dead from, i. 556 sanguineous, latent, iii. 118 pulmonary, i. 155 renal of the spleen, iv. 227 Appendix vermiformis caeci, ii. 54 Appendix vermiformis, inflammation of the, i. 163 Areola, in pregnancy,, iii. 664 Argol, as a poison, iv. 422 Arsenic, as a poison, iv. 426 Arteries, inflammation of, i. 163; ii. 767 Arteries, perforation of, iii. 494 mortification from obliteration of the, iii. 350 obliteration of, softening of-brain from, iv. 180 Arteritis, i. 163; ii. 768 Arthritis, i. 170 Artisans, diseases of, i. 170 Ascaris lumbricoides, iv. 707 Ascaris vermicularis, i. 182; iv. 709 Ascites, i. 182 (735) 756 GENERAL INDEX. Asphyxia, i. 188 of the newborn, i. 205 Assurance of life, iv. 233 Asthma, i. 206 application of the galvanic shock to, ii. 295 cardiac, ii. 422 Astringents, i. 229 Atlantic climate, i. 446 Atropa belladonna, as a poison, iv. 452 Atrophy, i. 234 of the liver, iii. 146 of the spleen, iv. 227 mesenteric, iv. 333 of the spinal marrow, iv. 220 of the stomach, iv. 269 Attitude, iv. 308 Auscultation, i. 236 in the foetus, i. 263; iii. 673 Australia, climate of, i. 449 Azores, or Western Islands, climate of, i. 447 Bahamas, climate of, i. 447 Baldness, i. 70 Ballottement, as a sign of pregnancy, iii. 672 Barbiers, i. 264 Barbadoes leg, i. 770 feigned, ii. 143 Barytes, as a poison, iv. 438 Bathing, i. 266 cold, i. 266 sea, i. 269 shower-bath, i. 271 affusion, i. 272 douche, i. 272 hip-bath, i. 272 warm, i. 275 tepid-bath, i. 282 hot-bath, i. 282 vapour-bath, i. 283 warm-air bath, i. 285 Belladonna, as a preventive of scarlatina, iv. 70 as a poison, iv. 452 Beriberi, i. 287 Bermudas, climate of, i. 447 Bile, diseased states of, iii. 152 Biliary calculi, composition of, i. 356 formation of, iii. 91 ducts, diseased states of, producing jaundice, iii. 93 dilatation and obliteration of, iii. 152 Births, premature, iv. 279 Bismuth, as a poison, iv. 438 Bitartrate of potassa, as a poison, iv. 422 Black tongue, ii. 101 Black-water, iii. 770 Bladder, catarrh of, i. 547 inflammation of, i. 545 paralysis of, iii. 252 perforation of, iii. 494 Blains, ii. 352. Bleb, iii. 482 Blebs, i. 352 Blindness, feigned, ii. 127 Blistering, i. 290, 531, 601 Blood, congestion of, i. 476 determination of, i. 290 expectoration of, ii. 362 loss of, morbid effects of, i. 298 morbid states of, i. 291 properties and uses of, ii. 701 state of, in pregnancy, iii. 679 transfusion of, iv. 468 tuberculous matter in, iv. 479 Bloodlessness, i. 9 Bloodletting, i. 296, iv. 151 Blood-vessels, changes effected in, by age, i. 60 within the chest, latent diseases of, iii. 122 pseudo-morbid appearances in, iii. 732 Bloody flux, i. 726 Blue disease, i. 301; i. 542 Boarding-schools, neglect of exercise in, i. 762 Bone, hypertrophy ofj ii. 549 inflammation of, ii. 773 Bones, hollow, perforation of, iii. 495 softening of, iv. 43 Bothriocephalus latus, iv. 714 Bouton malin, i. 122 Brain, hydatids in the, ii. 466 induration of the, i. 322; ii. 671 inflammation of, i. 301,317 softening of the, i. 317; iv. 178 congestion of the, i. 317 organic diseases of the, i. 322 hypertrophy of the, i. 323 latent inflammation of, iii. 119 Brain fever, ii. 158 Brain, membranes of, inflammation of, i. 302 latent, iii. 119 Brain, and spinal cord, inflammatory softening of, iv. 178 6 softening of, from obliteration of arteries, iv. 180 tuberculous matter in, iv. 479 Breathing, difficult or disordered, i. 732 Bright, disease of, i. 331 Brighton, climate of, i. 441 Bronchi, dilatation of, i. 331 perforation of, iii. 494 Bronchial glands, diseases of the, i. 331 Bronchitis, i. 331, 337 acute, i. 332 asthenic, i. 343 chronic, L 337 epidemic, acute, i. 332 summer, i. 332 effects of climate in, i. 451 latent, of fever, ii. 160 Bronchocele, i. 343; ii. 42; iv. 135 Bronchorrhcea, i. 352 Brucea, and strychnia, as poisons, iv. 454 Buffy coat, i. 294; ii. 714 Bullae, i. 352 Burning, persons found dead from, i. 567 Bute, Isle of, climate of, i. 442 Cachexia Africanorum, ii. 127 Cachexia, i. 353 Cachexia, tuberculous, iv. 491 feigned, ii. 127 Cacochyma, i. 353 Caecum, diseases of the, i. 354 inflammation of the, ii. 53 Calculi, chemical composition of, ii. 354 Calculous diseases, i. 365 deposits in the spleen, iv. 228 Calculus, (chemical composition,) i. 354 biliary, i. 356 gouty and intestinal, i. 357 of the prostate gland, i. 359 uripary, i. 359 Calculus, (pathology and treatment,) i. 365; i. 736 renal, i. 366 vesical, i. 368 urethral, i. 370 prostatic, i. 370 Calculi, excretion of, feigned, ii. 132 X. GENERAL INDEX. 757 Calculi in the veins, iv. 646 Caoaphor, as a poison, iv. 455 Canary Islands, climate of, i. 447 Cancer, i. 378; m «2 f Cancer aquaticus, iv. 382 Cancer, chimney-sweepers', i. 178 of the liver, iii. 151 of the pancreas, iii. 455 soft, or carcinoma spongiosum, ii. 280; iv. 84 of the stomach, iv. 254 Cancrum oris, iv. 382 Cantharides, as a poison, iv. 441 Cape of Good Hope, climate of, i. 449 Carbuncle, ii. 759 ; iii. 360 Carbonic oxide, as a poison, iv. 459 acid, as a poison, iv. 460 Carbuncled face, i. 51 Carcinoma, iv. 83 of the uterus, iv. 606 Cardia, scirrhus of, iv. 257 Cardiac asthma, ii. 422 Cardialgia, ii. 307 Carditis, i. 378; iii. 504 Carunculae myrtiformes, diseases of, iv. 616 Catalepsy, i. 378; i. 467 feigned, ii. 128 Cataleptic somnambulism, or ecstasis, iv. 199 Catamenia, i. 89, 382, 728 ; iii. 303, 308 Cataphora, see Coma, i. 466 Catarrh, epidemic, iii. 17 pulmonary, i. 382 pituitous, i. 382 see also, ii. 121 - dry, i. 383 of the bladder, i. 547 Cathartics, i. 385 Cauterizing counter-irritants, i. 534 Cellular tissue, dropsy of, iii. 411 hypertrophy of, ii. 546 inflammation of, iii. 754 mortification of, iii. 335 of new-born children, oedema of, ii. 673 Cephalaea, cephalalgia, ii. 371 Cephaloma, iv. 83 Ceramuria, iv. 586 Cerebral substance, induration of, ii. 671 Cerebritis, i. 308 Chest, contraction of, i. 391; iii. 574 exploration of, i. 391 inspection, i. 393 manual examination, i. 394 mensuration, i. 394 latent diseases of the great vessels of, iii. 122 compression of by stays, evils of, i. 756 water in the, ii. 538 Chicken-pox, i. 395 ; iv. 171, 636 Child-bed fever, ii. 231 Childhood, phthisis in, iv. 425 prevention of tuberculous diseases in, iv. 544 physical education in, i. 755 Chimney-sweepers' cancer, i. 178 Chloasma, i. 396 Chlorides as poisons, iv. 415, 463 Chlorine, a poison, iv. 415 Chlorosis, i. 396 Cholera, i. 3.49 common or sporadic, i. 399 epidemic or malignant, i. 402 infantum, i. 426 Choleric temperament, iv. 350 Cholcsterine, analysis ofj iii. 152 Chorea, i. 427 Choroid, inflammation of the, iii. 436 3o Chrome, a poison, iv. 439 Circulation, morbid affections of the, iv. 323 Cicuta virosa, as a poison, iv. 453 \ Circulation, disorders of, feigned, ii. 128 organs of, perforation of, iii. 494 tuberculous matter in, iv. 479 Cirrhosis, i. 440 of the liver, i. 440 of the lungs, i. 440 Clifton, climate of, i. 442 Climacteric disease, i. 65, 440 effect of climate in, i. 452 Climate, i. 440 English, i. 441 Foreign, i. 444 France, i. 444 Italy, i. 445 Mediterranean islands, Malta, Atlantic, Madeira, i. 446 Canary islands, Azores, Bermudas, Ba- hamas, i. 447 • United States, i. 449 Southern hemisphere, South America, Cape of Good Hope, Australia, &c. &c. i. 449 West Indies, i. 447 effects of in pulmonary consumption, i. 449 ; iv. 562 in chronic bronchitis, asthma, and rheu- matism, i. 451 in gout, scrofula, and dyspepsia, i. 451, in the climacteric disease, i. 452 on temperament, iv. 354 in producing or preventing scrofula, iv. 138 influence of in phthisis, iv. 532, 562 Clothing, in infancy, i. 752 in adolescence, i. 760 improper, a cause of tuberculous cachexia, iv. 489 Cobalt, iv. 431 Cobra di Capella, mortification from the bite of the, iii. 358 Cocculus Indicus, as a poison, iv. 455 Caecum, diseases of, i. 354 Colchicum autumnale, as a poison, iv. 454 Cold, morbid and remedial effects of, i. 453 mortification from, iii. 357 persons found dead from, i. 568 survivorship from, iv. 295 Cold in the head, i. 524 Colloid, iv. 93 Colic, i. 459 Colica pictonum, i. 463 stercorea, ii. 658 Colitis, colonitis, i. 720 Colon, diseases of, i. 354 inflammation of the, ii. 55 torpor of the, i. 466 Colonic dyspepsia, ii. 657 Coma, i. 466 vigil and somnolentum, i. 467 from exhaustion, i. 468 from concussion, compression, and intoxica- tion, i. 468 Combustibility, preternatural, i. 470 Combustion, spontaneous, human, i. 470 Condiments, i. 668 Congestion of blood, i. 476; ii. 718 Conium maculatum, as a poison, iv. 453 Conjunctiva, inflammation of, iii. 413 gonorrhceal, &c. iii. 212 Constipation, i. 477 758 ERAL INDEX. Constipation, from debility, i. 478 from vitiated or deficient secretiqn, i. 479 from the nature of the diet; from increased tone of the intestinal muscular fibres; from morbid states of the encephalon, i. 480 from increased secretion of other organs, i. 481 from obstruction to the passage of the faecal mass, 481 from hemorrhoids, i. 489 when dependent on relaxation and stric- ture of the rectum, i. 487 when accompanied with spasmodic af- fection of the sphincter ani,% 490 Constitution, tuberculous, iv. 481 Consumption, pulmonary, iv. 489 effects of climate in, i. 449; iv. 562 Contagion, i. 500 Contraction of the limbs, feigned, ii. 128 of the stomach, iv. 271 Convalescence, i. 505 , Contro-stimulus, theory of, iv. 153 Convulsions, i. 508 crowing, i. 522 infantile, i. 519 puerperal, i. 522 salaam, i. 522 Cookery, i. 651 Cophosis, iii. 457 Copper, as a poison, iv. 431 Cores, ii. 759 Cornea, inflammation of the, iii. 434 Corpulence, iii. 403 Corpus luteum, iii. 690 Corrosive sublimate, as a poison, iv. 423 Coryza, i. 524 Countenance, morbid appearances of the, iv. 302 Counter-irritants, various, i. 532 Counter-irritation, i. 526 Cove, climate of, iv. 302 Cow-pox, iv. 620 in the cow, iv. 623 Crasis, see Temperament, iv. 349 Cream of Tartar, as a poison, iv. 422 Cretinism, ii. 39 Crisis, Critical days, i. 686 of fever, ii. 170 Critical age, iii. 311 Croup, i. 534 cerebral, i. 522 primary, i. 541 secondary, i. 541 of the adult, i. 542 Cupping, i. 298 Curability of a disease, iii. 699 Curare, a poison, iv. 455 Cyanogen, as a poison, iv. 446 Cyanosis, i. 542 Cyanuret of potassium, as a poison, iv. 448 Cynanche, trachealis, iaryngea, stridula, i. 534 maligna, iv. 73, 379 parotidcea, iii. 475 tonsillaris, iv. 385 Cystitis, i. 545 Cytisus laburnum, iv. 455 Dactylius aculeatus, iv. 720 Dandriff of the head, iii. 538 Datura stramonium, as a poison, iv. 452 Dead persons found, i. 548 Deaf and dumb, number of, iv. 232 Deaf-dumbness, feigned, ii. 130 . feigned, ii. 129 Death, qu^s-lfoT>qfthe time that has elapsed Bince, iii. 457 from wounds, i. 570 • sudden, iii. 54§ from natural causes, i. 556 from violent causes, iii. 557 Debility, feigned, ii. 130 Defloration, iii. 773 Deliquium aniini, iv. 329 Delirium, i. 582; ii. 26 senile, ii. 31 tremens, i. 587 Delivery, signs ofj iii. 659 concealed or feigned, iii. 692 signs of recent, iii. 692 without consciousness, iii. 697 Dementia, iii. 44 senile, iii. 72 Dengue, i. 594 Dental membrane, inflammation of the, iv. 404 Dentition, disorders of, i. 595 first, i. 595. second, i. 601 Derbyshire neck, i. 343 Derivatibn, i. 601 Derivatives, i. 601 Dermalgia, rheumatic, iv. 43 Devonshire, climate of, i. 442 Devonshire colic, i. 463 Diabetes, i. 606 Diagnosis, i. 625; iv. 298 Diaphoretics, i. 626 Diarrhoea, i. 632 adipous, i. 642 chylous, i. 634 feculent, i. 633 bilious, mucous, serous, i. 633 feigned, ii. 130 Diathesis, scrofulous, iv. 492 Diet, see Education, physical, i. 752, &c. Dietetics, i. 642. materia alimentaria, i. 646 nutritiveness and digestibility of different kinds of food, i. 650 cookery, i. 651 articles of diet, i. 652 drinks or liquid aliments, i. 662 condiments, i. 668 the periods best adapted for meals, and the intervals which should elapse between each, i. 669 the quantity of food that ought to be taken at different meals, i. 672 the conduct to be pursued previous and sub- sequent to meals, and the relations of diet to the non-naturals, i. 672 Digestibility of different kinds of food, i. 660 Digestion, organs of, tuberculous matter in, iv. 478 Digitalis purpurea, as a poison, iv. 453 Diphtheritis, i. 541 Diplosoma crenata, iv. 720 Dirt-eating (pica Africanorum), feigned, ii. 127 Disease, i. 674 forms of, i. 678 theories of, i. 679 relations and conversions ofj i. 682 modification of, by temperament, i. 683 vis medicatrix, i. 684. periodicity and crises, i. 686 nosology, i. 688 GENERAL INDEX. 759 Disease, symptoms of, iv. 302 Diseases, latent, iii. 117 Disinfectant, i. 689 Disinfection, i. 690 Dissection, wounds in, ii. 743 Diuretics, i. 695 Dothinenteritis, ii. 55 Drastic cathartics, i. 386 Drinks, or liquid aliments, i. 662 Dropsy, i. 701 abdominal, see Ascites, i. 182 from disease of the heart, i. 704 see also ii. 502 of the lungs, i. 705 liver, i. 706 spleen and pancreas, i. 706 kidneys, i. 707 uterus and ovaries, i. 709 ovaria, iii. 445 pericardium, ii. 502 complicated with pregnancy, iii. 682 after scarlatina, iv. 75 of the spinal marrow, iv. 213 of the uterus, iv. 604 Drowning, asphyxia from, i. 195 persons found dead from, i. 557 survivorship from, iv. 293 Duodenal dyspepsia, ii. 639 Duodenitis, ii. 50 Dyscrasy, i. 353 Dysentery, i. 720 uncomplicated, of temperate climates, i. 720 tropical, i. 721 chronic, i. 722 feigned, ii. 130 Dysmcnorrhcea, i. 728 Dyspepsia, ii. 608 effect of climate in, i. 451 strumous, iv. 491 Dyephagia, i. 730 see also iv. 376, and iii. 468 Dyspnoea, i. 732 Dysuria, i. 734 Ear-ach, iii. 436 Ear, diseases of, feigned, ii. 130 inflammation of, iii. 436 perforation of, iii. 495. Ecstasis, or cataleptic somnambulism, iv. 199 Ecstasy, i. 378 see also i. 466 Ecthyma, i. 737 vulgare, i. 739 infantile, i. 740 luridum, i. 740 febrile, (cachecticum of Bateman,) i. 741 syphiliticum, i. 742 Eczema, i. 743 solare, i. 744 impetiginodes. i. 744 rubrum, i. 745 mercurial, i. 745 Education, physical, i. 750 in infancy, i. 752 clothing and food, i. 752 air, cleanliness, exercise, and moral ma- nagement, i. 753 in childhood, i. 755. in adolescence, i. 757 clothing and food, i. 760. exercise, i. 761 errors committed in that of girls, i. 758 Effusion, a termination of inflammation, ii. 780 Effusion, spinal, iv. 216 Electricity, i. 765; iy. 248 Electro-magnetism, ii. 297 Electro-puncturation, ii. 298 Elephantiasis Arabum, geographical distribution, persons liable to, symptoms, i. 770 organic changes, remote and exciting causes, ' i. 771 Graecorum, (tubercular,) i. 773 Elephant leg, i. 770 feigned, ii. 143 Emaciation, feigned, ii. 130 Emansio mensium, i. 89 Emetics, i. 776 direct, i. 780 indirect, i. 780 Emmenagogues, i. 784 direct, i. 786 indirect, i. 787 Emphysema, ii. 10 traumatic, ii. 10 idiopathic, or spontaneous, ii. 9 of the lungs, ii. 17 vesicular, or true, ii. 17 interlobular, ii. 21 Emprosthotonos, iv. 366 Empyema, ii. 21 Encephaloid, ii. 280; iv. 83, 93 Endemic diseases, ii. 39 intermittent fever, ii. 40 bronchocele, ii. 42 cretinism, ii. 43 plica, trichoma, plaited hair, ii. 43 guinea-worm, ii. 44 nostalgia, ii. 44 tarantismus, ii. 45 Endodontitis, iv. 404 English climate, i. 441 Enteritis, ii. 46 acute and chronic, of infants, ii. 47 the principal phenomenon in the weaning brash, infantile remittent, and tabes me- senterica, ii. 49 in the adult, ii. 50; duodenitis, 50; inflam- mation of the jejunum and ileum, 52 ; inflammation of the caecum, ii. 53 see also for inflammation of the colon, i. 720 Entero-mesenteric fever, ii. 53 Entozoa, classification of, iv. 707 Ephelis, ii. 63 lentigo, ii. 63; diffusa, 63 Ephemeral fever, ii. 155 Epidemics, ii. 64 Epilepsy, ii. 75 feigned, ii. 131 application of the galvanic shock to, ii. 295 Epistaxis, ii. 91 entonic or active, ii. 92 atonic or passive, ii. 93 Equinia, ii. 324 Erethismus mercurialis, ii. 96 ■ Ergot, or spurred rye, as a poison, iv. 456 Ergotism, convulsive, iii. 361 Eruptions, retrocession of, anasarca from, i 96 Erysipelas, ii. 96; simple, ii. 97s phlegmonous. cedematous, ii. 98 Erysipelas, epidemic, ii. 101 Erysipelatous fever, ii. 101 Erysipelatous peritonitis, iii. 513 Erythema, ii. 105 Erythema, aerodynia, i. 54 idiopathic, or local, ii. 106 symptomatic, ii. 108 7m GENERAL INDEX. Erythema fugax, ii. 108; laeve, marginatum, pa. pulatum, tuberculatum, nodosum, ii. 109 Essera, iv. 369 Eutrophic, ii. 111. Exanthemata, ii. 112. Excitants, iv. 239 Exercise, of infants, i. 754 in adolescence, i. 761 neglect of, in boarding-schools, i. 762 mental, as a means of health, i. 765 in atonic gastric dyspepsia, ii. 622 in atonic duodenal dyspepsia, ii. 643 deficient, a cause of tuberculous cachexia, iv. 538 see also iv. 402 Expectorants, ii. 112. Expectoration, ii. 119 Exploration of the abdomen, i. 25 of the chest, i. 391 Eye, perforation of the, iii. 495 Eyes, inflammation of, iii. 413 Eyelids, paralysis of, iii. 464 Face, paralysis of, iii. 465 Faeces, incontinence of, feigned, ii. 134 Fainting, iv. 329 Fallopian tubes, diseases of, iv. 598 Famine, effects of, i. 44 Farcy glanders, ii. 324 Fatness, iii. 403 Fatty and greasy degenerations of the heart, ii 391 liver, iii. 149 Fatuity, iii. 28 Fauces, tubercles of the, iv. 387 Favus, ii. 123; iii. 653 Feigned diseases, ii. 123 Feu Persique, i. 122 Fever, ii. 147 adynamic, ii. 162 ataxic, ii. 162 childbed, ii. 231 classification of, ii. 152 congestive of Armstrong, ii. 177 continued, ii. 153 simple, ii. 154 in inflammatory, ii. 155 gastric, ii. 156 see also ii. 201 complicated, ii. 157 cerebral, ii. 158 pulmonary, ii. 159 abdominal, ii. 160 typhoid, ii. 163 typhous, ii. 162 use of redBrigerants in, iv. 22 a cause of tuberculous disease- of the lungg, iv. 541 dengue, i. 594 ephemeral erysipelatous, ii. 101 inflammatory, epidemic gastrio, ii. 201 intermittent, ii. 205 complicated-, or malignant, ii. 157 masked, ii. 218 feigned, ii. 132 secondary, of small-pox, iv. 164 hectic, ii. 229 puerperal, ii. 231 peritonitis in, ii. 236 uterine inflammation in, ii. 237 remittent, ii. 219 Fever, infantile, ii. 224 remittent, malignant, ii. 223 milk, iii. 102 miliary, iii. 312 yellow, ii. 247 Fibrous tissue, hypertrophy of, ii. 549 inflammation of, ii. 771 mortification of, iii. 338 tumours of the uterus, iv. 605 Filiaria bronchialis, iv. 707 Filiaria oculi, iv. 717 Fire, Persian, i. 122 Fish, poisonous, iv. 442 urticaria from poison of, iv. 590 Fish-skin disease, ii. 589 Flatulence, ii. 618 Florida, climate of, i. 449 Fluctuation, in the chest, ii. 21 Fluor albus, iii. 134 Fly-powder, a poison, iv. 430 Fcetus, auscultation of the heart in the, i. 263 motions of, as a sign of pregnancy, iii. 661 Food, in infancy, i. 753 in adolescence, i. 761 most conducive to corpulency, iii. 405 putrid or diseased, effects of, iv. 443 see also i. 642 Fool's parsley, a poison, iv. 453 ; Foxglove, as a poison, iv. 453 Fracture, feigned, ii. 132 Frambcesia, iv. 750 France, climate ofy i. 444 Freckles, ii. 63 Friction, as a tonic, iv. 402 Fulness, iii. 553 Fumigation, i. 691; ii. 694; and iv. 651 Function, disorders of, i. 678 Fungi, poisonous, iv. 455 Fungus haematodes, ii. 280 ; iv. 84 Furuncle, ii. 759 Gall-bladder, diseased states of, producing jaun- dice, iii. 92 diseases of, iii. 152 perforation of, iii. 492 Gall-stone, iii. 92 Gall-stones, iii. 152 Galvanism, ii. 285 application of, to the treatment of diseases, ii. 293 Galvano-puncture, ii. 297 Gangraena oris, iv. 382 Gangrena senilis, iii. 351 Gangrene, iii. 332 see ii. 755 hospital, iii. 359 of the lungs, ii. 598; iii. 330 Gangrenous pemphigus, iii. 486 Gases, poisonous, 458 in the uterus, iv. 603 Gastralgia, ii. 307 Gastric acids, perforation of the etomaerr by the, iii. 490 dyspepsia, ii. 612 fever, ii. 156 fever, epidemic, ii. 201 Gastric juice, softening of the stomaeh from the action of, iii. 490 Gastritis, ii. 298 acute, ii. 293 chronic, ii. 302; Gastrodynia, ii. 307 Gastroenteric dyspepsia, ii. 664 GENERAL INDEX. 761 Gastro-enteritis, ii. 314 General system, morbid conditions of the, iv. 316 Generation, organs of, perforation of, iii. 493 Generative organs, malformations of, iv. 154 tuberculous matter in, iv. 479 Georgia, climate of, i. 449 Gestation, in women, natural period of, iv. 279 protracted, iv. 281 Glanders, ii. 323 Glandular organs of secretion, inflammation of, ii. 776 Globus hystericus, ii. 562 Glossitis, ii. 325 Glottis, oedema of, iii. 411 spasm of the, i. 522; ii. 329 Goitre, i. 343 Gold, as a poison, iv. 423 Gonorrhoea, spurious, in the male, iii. 777; in the female, iii. 777 dormientium, iv. 211 Gonorrhceal inflammation of the conjunctiva, iii. 426 Gout, ii. 332 ulceration of the throat, iv. 390 effects of climate in, i. 430 Gouty calculi, composition of, i. 357 Gras fondure, i. 642 Green-sickness, i. 396 Grippe, iii. 17 Gravel, iv. 585 > Gravedo, i. 574 Grease, molten, i. 642 in horses, identity of cow-pox with, iv. 628 Grubs, i. 49 Guinea-worm, ii. 44 see iv. 714 Gutta rosacea, i. 51 serena, i. 78 Haematemesis, ii. 357 feigned, ii. 123 Haematology, i. 295 Haematuria, iv. 588 Haemoptysis, ii. 362 Hair, falling off of the, i. 70 plaited, ii. 43; iii. 587 Hallucination, form of insanity attended with, iii. 34 Hanging, persons found dead from, i. 561 Hastings, climate of, i. 441 Head, pseudo-morbid appearances in, iii. 726 Headach, ii. 371 sick, ii. 618 Heart, aneurism of, ii. 391 auscultation of, i. 255 in the foetus, i. 263 dilatation of, ii. 379 disease of, feigned, ii. 128 diseases of the, ii. 377 displacement of the, ii. 385 dropsy from disease of, i. 704 fatty and greasy degenerations of, ii. 391 hypertrophy of, ii. 391 inflammation ofj hi. 495 malformations of, ii. 404 mortification of the inferior extremities from disease of, iii. 346 neuralgia of the, i. 103 ossification of, ii. 414 palpitation of the, iii. 449 polypus of the, ii. 409 perforation of the, iii. 494 rheumatic inflammation of, iii. 495 Vol. IV. — 96 3o» Heart, rupture of, ii. 410 valves of, diseases of, ii. 414 latent organic diseases of, iii- 121 Heartburn, ii. 307; ii. 618 Heat, excessive, survivorship from, iv? 295 Helleborus niger, as a poison, iv. 453 Hematemesis, ii. 357 feigned, ii. 133 Hemeralopia, iii. 403 Hematuria, iv. 588 feigned, ii. 133 Hemicrania, ii. 391 Hemiplegia, iii. 468 Hemlock, as a poison, iv. 453 • water, a poison, iv. 453 dropwort, a poison, iv. 453 Hemoptysis, ii. 362 in phthisis, iv. 510 feigned, ii. 133 Hemorrhage, internal, ii. 430 idiopathic and symptomatic, ii. 432 active and passive, ii. 435 constitutional, ii. 436 from the stomach, ii. 357 a consequence of inflammation, ii. 786"* Hemorrhcea petechialis, iii. 762 Hemorrhoids, i. 488; ii. 438 feigned, ii. 133 accompanying constipation, iv. 579 Hepatitis, iii. 159 acute, iii. 164 suppuration, iii. 166 chronic, iii. 170 feigned, ii. 133 Hepatization of the lung, iii. 596 Hereditary transmission of disease, ii. 443 Hermaphrodites, iv. 153 means of ascertaining the sex of, iv. 159 Hernia, feigned, ii. 134 Herpes, ii. 445 phlyctaenodes, ii. 446 zoster, ii. 446 circinnatus, and labialis, ii. 447 praeputialis, ii. 448 iris, ii. 449 Hiccup, ii. 450 Hip-bath, i. 272 Homoeopathy, i. 682 Hooping-cough, ii. 453 Hospital gangrene, iii. 359 Hospitals, deaths in, iv. 232 prejudicial influence of on children, iv. 232: ventilation of, iv. 652 Hot bath, i. 282 springs, iv. 696 Hunger, persons found dead from, iii. 569 or thirst, survivorship from, iv. 294 Hydatids, ii. 459 genera and species, ii. 461 in the brain, in the thorax, ii. 466 in the abdomen, ii. 468 in the liver, iii. 149 uterine, ii. 472 in the spleen, iv. 228 Hydrocele, feigned, ii. 134 Hydrocephalus, ii. 134; 476 chronic, ii. 134, 497 feigned, ii. 134 Hydrocyanic acid, as a poison, iv. 446 Hydrogen, as a poison, iv. 459 Hydrometra gravidarum, iv. 604 Hydropericardium, ii. 502 from organic disease, ii. 504 762 GENERAL INDEX. Hydrophobia, ii. 506 feigned, ii. 134 Hydrorachis, iv. 213 Hydrostatic test, ii. 680 Hydrothorax* ii. 538 Hydruria, iv. 584 Hyeres, climate of, i- 445 Hymen, iii. 684, 774; iv. 616 Hyoscyamus, as a poison, iv. 451 Hyperemia, i. 476; ii. 433, 718 df the liver, iii. 144 Hyperaesthesia, ii. 543 Hypertrophy, ii. 543 of the muscles, ii. 544 adipose and cellular tissue, ii. 546 mucous tissue, ii. 547 skin and vascular system, ii. 548 nervous tissue, ii. 548 fibrous tissue, bone, lungs, and liver, ii. 549 spleen, pancreas and kidney, lymphatic glands, thyroid, thymus, and man:. mary glands, ii. 551 of the heart, ii. 391 of the liver, iii. 145 of the spleen, iv. 226 of the spinal marrow, iv. 220 of the stomach, iv. 629 of the tonsils, iv. 386 Hypochondriasis, ii. 554 an accompaniment of inflammatory gasu-ic dyspepsia, ii. 622 Hysteria, ii. 562 Hysterical aphonia and paralysis, iii. 46$ Ichthyosis, ii. 589 Icterus, iii. 91 feigned, ii. 135 a plethora, ii. 644 infantum, iii. 191 Identity, personal, ii. 591 Idiocy, iii. 28 Ileum, inflammation of, ii. 52 Impetigo, simplex, ii. 594 erysipelatodes, ii. 596 i Impotence, ii. 597 in the male, ii. 597 and sterility, in the female, ii. 602 Incontinence of faeces, feigned, ii. 134 of urine, iv. 575 feigned, ii. 134 Incubus, ii. 606 Indigestion, ii. 608 gastric, ii. 612 atonic, ii. 612 acute, ii. 612 chronic, ii. 614 inflammatory, ii. 622 irritable, ii. 629 complication of irritable and inflamma- tory, ii. 631 follicular, ii. 636 duodenal, ii. 639 atonic, ii. 640 inflammatory, ii. 644 strumous, ii. 650 follicular, ii. 653 colonic, ii. 657 atonic, ii. 658 inflammatory, ii. 661 irritable, ii. 662 follicular, ii. 663 gastro-enteric, ii. 664 Indigestion, effects of climate in, i. 451 Indigo, sulphate of, a poison, iv. 420 Induration, general pathology of, ii. 666 of cerebral substance, ii. 671 of the cellular tissue of new-born children ii. 673 a termination of inflammation, ii. 786 of the liver, iii. 146 spleen, iv. 225 spinal marrow, iv. 219 valves of the heart, ii. 415 Infancy, physical education in, i. 752 Infanticide, ii. 677 hydrostatic test, ii. 683 static test, ii. 685 Infants, enteritis of, ii. 47 oedema of cellular tissue in, ii. 673 peritonitis of, iii. 506 Infection, ii. 693; i. 500; i. 690; iii. 174 see also iv. 651 Infiltration, purulent, of the lung, iii. 596 Inflammation, ii. 694 diffuse, ii. 762 latent, ii. 753 varieties of, ii. 750 mortification from, iii. 333 Inflammatory fever, ii. 155 Influenza, iii. 17 Inhalation, ii. 113. Inoculation, of rubeola, iv. 56 of variola, iv. 172 of cow-pox, iv. 621 of chicken-pox, iv. 430 Insanity, iii. 26 in relation to criminal and civil law, iii. 314 puerperal, iii. 67, 750 senile, iii. 72 feigned, ii. 135 Insomnia, iv. 653 Intestines, inflammation of, ii. 46 ulceration of, ii. 59 in phthisis, iv. 524 sphacelus of, iii. 349 perforation of, iii. 491 Intussusception, iii. 76 Iodine, and iodide of potassium, as poisons, iv.41l Iris, inflammation of the, iii. 4o5 * Irritant poisons, iv. 415 Irritants, vegetable, iv. 439 Irritation, iii. 76 puerperal, of the stomach -and iptestme* ef- fects of,- iii. 746 spinal, iv. 221 Ischuria renalis, iv. 578 Issues, i. 531 Italy, climate of, i. 445 Itch, iv. 59 Jactitation, periodical, i. 427 Jail fever, ii. 162 Jaundice, iii. 91; ii. 51, 644] of the infant, iii. 91 feigned, ii. 135 Jejunum, inflammation of, ii. 52 Joints, scrofulous affection of the, iv. 133 Kidneys, diseases of, iii. 96 dropsy from disease of, i. 707 hypertrophy of, ii. 551 inflammation of, ii. 777; iii. 377 mortification of, iii. 340 Kiestein, a sign of pregnancy, iii. 680 King's evil, iv. 125 GENERAL INDEX. 763 Labia, diseases of the, iv. 620 Labour, excessive, a cause of tuberculous ca- chexia, iv. 538 Lactation, iii. 99 as regards the prevention of tuberculous dis- eases, iv. 546 Lactuca virosa, and sativa, as poisons, iv. 451 Lagophthalmia, iii. 464 Lameness, feigned, ii. 128 Land's End, climate of, i. 442 Laryngeal phthisis, iii. 115 Laryngismus stridulus, i. 537; ii. 331 Laryngitis, iii. 104 chronic, iii. 115 cedematous, iii. 107 Larynx, muscles of the, paralysis of, iii. 468 oedema of the, iii. 107 ulceration of, in phthisis, iv. 521 syphilitic ulceration of the, iv. 389 and fauces, tubercles of the, iv. 387 Latent diseases, iii. 117 sanguineous apoplexy, inflammation of the membranes of the brain, iii. 118 inflammation of the cerebral substance, pleu- risy, iii. 120 peripneumony, organic diseases of the heart, iii. 120 pneumothorax, pulmonary tubercles, of the great vessels within the chest, of the abdomen, iii. 121 of the spine, iii. 122 evidence concerning, in medico-legal cases, iii. 123 8 peritonitis, iii. 514 scrofula, iv. 492 phthisis, iv. 503 Laxatives, i. 385 Lead, as a poison, iv. 433 Leaping ague, i. 436 Legitimacy, iv. 276 Leipothymia, iv. 329 Lepra, iii. 125 Lethargy, i. 466 Leucorrhcea, iii. 134 Lichen, iii. 138 Life-assurance, iv. 233 Lightning, persons found dead from, i. 570 Lima, climate of, i. 449 Limb, paralysis of a, iii. 467 Lime, as a poison, iv. 422 Literary men, diseases incidental to, i. 181 Lithuria, iv. 585 Lithic urine, iv. 585 Liver, diseases of, iii. 143 affecting the investing membrane, iii. 143 affecting the structure, iii. 144 anaemia, hypertrophy, iii. 145 atrophy, induration, softening, iii. 146 tubercles, iii. 146 erectile tumours, iii. 148 flaccid, fatty, phlebitis, cysts, hydatids, iii. 149 rupture, traumatic abscess, iii. 150 melanosis, cancer, iii. 151 ossification, diseases of the biliary ducts, gall- bladder, and bile, iii. 152 diseased states of, producing jaundice, iii. 95 dropsy from disease of, i. 706 hypertrophy of, ii. 549 inflammation of, ii. 777; iii. 159 abscess, iii. 161 acute, iii. 164 Liver, diseases of, suppuration, iii. 161 chronic, iii. 170 complicated with gastro-enteritis, ii. 321 mortification of, iii. 340 walls of, perforation of, iii. 492 disease of, in phthisis, iv. 524 Liver-fluke, iv. 719 Locked-jaw, iv. 364 Longevity, iv. 230 Louisiana, climate of, i. 449 Lumbago, iv. 41 feigned, ii. 141 Lumbrici, iv. 707 Lungs, abscess of, ii. 597 emphysema of, ii. 17 gangrene of, ii. 775; iii. 339; iii. 598 hypertrophy of, ii. 549 inflammation of, iii. 590 mortification of; iii. 339, 598 Lupus, iii. 385; iv. 125 Lymphatic glands, hypertrophy of, ii. 551 vessels, inflammation of, ii. 769 system, scrofulous affection of, iii. 129 Maculae, ii. 63 Madeira, climate of, i. 446 Madness, iii. 26 feigned, ii. 135 Magnetism, animal, iv. 203 Magrums, i. 436 Malacia, feigned, ii. 127 Malaria and miasma, iii. 174 Malformation, feigned, ii. 137 of the heart, ii. 404 Malingerers, ii. 124 Malleatio, i. 438 Malta, climate of, i. 446 Mal-vat, i. 122 Mammae, affections of, in pregnancy, iii. 663 Mammary glands, hypertrophy of, ii. 551 Mania, iii. 136 puerperal, iii. 67, 750 and monomania in relation to jurisprudence, iii. 315 Marasmus, iv. 333; ii. 650 Marseilles, climate of, i. 444 Materia alimentaria, i. 646 Maw-worm, iv. 709 Meals, periods best adapted for, i. 669 quantity of food to be taken at, i. 672 Measles, iv. 51 Medicine, history of, iii. 179 to the end of the 18th century, iii. 179 American before the revolution, iii. 231 of the 18trffcentury, iii. 242 practical, principles of, iii. 271 Mediterranean islands, climate of, i. 446 Medullary sarcoma, ii. 280; iv. 84 Megrim, ii. 377 Melaena, iii. 279 Melancholia, iii. 34 Melanosis, iii. 284 spurious, iii. 295 of the liver, iii. 151 of the spleen, iv. 228 Melituria, iv. 587 Membranes, false, tubercles in, iv. 480 Meningitis, i. 302 acute, i. 305 chronic, i. 307 spinal, iv. 215 tubercular, ii. 489 Menispermum cocculus, a poison, iv. 455 764 GENERAL INDEX. Menorrhagia, iii. 303 Menses, retention of, i. 89 suppression of, i. 91 as a sign of pregnancy, iii. 660 Menstruation, painful or difficult, i. 728 pathology of, iii. 306 vicarious, i. 92 morbidly profuse, iii. 303 after conception, iii. 660 Mentagra, iv. 296 Mentagrophyte, iv. 297 Mercurial erethism, ii. 96 Mercury, as a poison, iv. 423 Mesenteric disease, iv. 333 Mesmerism, iv. 203 Metallic tinjding, i. 251; iii. 648 Method, numerical, iv. 229 Miasma and malaria, iii. 174 Miliaria, miliary fever, iii. 312 Milk in the breasts, as a sign of pregnancy, iii, 666 fever, iii. ] 02 Milk-sickness, iii. 314 Milzbrandkarbunkel, i. 122; iii. 365 Mind, disorders of the, iii. 26 soundness and unsoundness of, iii. 314 Misery, effects of, iv. 230 Mobile, climate of, i. 449 Mollities ossium, iv. 47 Molten grease, i. 642 Molluscum, iii. 332 Monks-hood, a poison, iv. 453 Monomania, iii. 34 and mania, in relation to jurisprudence, iii. 314 Montpelier, climate of, i, 444 Morbid products, i. 679 Morbilli, iv. 51 Morbus niger, iii. 279 Morphia, as a poison, iv, 450 Mortality, iv. 230 Mortification, iii. 332 ; a termination of inflam- mation, ii. 784 Morve, ii. 324 Mouth, sloughing phagedaena of the, iv. 382 Motion, paralysis of, iii. 460 Moxas, i. 534 Mucous membranes, inflammation of, ii. 761 mortification of, iii. 337 softening of, iv. 187 tissue, hypertrophy of, ii. 547 Mumps, iii. 475 Muriatic acid, as a poison, iv. 416 gas, as a poison, iv. 463 Muscles, changes effected in by a%e, i. 62 hypertrophy of, ii. 544 paralysis of, iii. 460 inflammation of, ii. 770 mortification of, iii. 338 Myelitis, iii. 362 Mutilation, feigned, ii. 145 Naples, climate of, i. 445 Narcotico-acrid poisons, iv. 451 Narcotic poisons, iv. 444 Narcotics, iii. 362 Nausea and vomiting, ii. 618 as signs of pregnancy, iii. 663 Nauseants, iii. 376 Necropneumonia, iii. 339 Needles in the body, feigned, ii. 137 Nephralgia, iii. 377 Nephritis, iii. 377 Nervous diseases, proneness of scrofulous indivi- duals to, iv. 137 fever, ii. 163 palpitation of the heart, iii. 449 pulsation of the abdominal aorta, i. 137 tissue, hypertrophy of, ii. 548 inflammation.of, ii. 766 Nettle-rash, iv. 590 Neuralgia, iii. 381 Nice, climate of, i. 445 Night-blindness, iii. 398 Night-mare, ii. 606 Nipples, sore, iii. 101 state of, in pregnancy, iii. 663 Nitric acid, as a poison, iv. 416 oxide, and nitrous acid vapour, as poisons iv. 459 Nitrogen, as a poison, iv. 458 Nitrous oxide, as a poison, iv. 459 Noli Me Tangere, iii. 385 Nose, bleeding from the, ii. 91 Nostalgia, ii. 44 Numerical method, iv. 229 Nursing, Hi. 99 as regards the prevention of tuberculous dis- eases, iv. 538 Nutritiveness of different kinds of food, i. 650 Nux vomica, a poison, iv. 454 Nyctalopia, iii..398 Obesity, iii. 403 Observing, method of, iii, 411 Odontalgia, iv. 404 GEdema, iii. 411 glottidis, iii. 411 lacteum, iii. 529 of the cellular tissue of new-bom children, ii. 673 of the side, ii. 21 m phthisis, iv. 513 QEnanthe crocata, and aethusa cynapium, as poi- sons, iv. 453 (Estrus humanus, iv. 721 Ophthalmia, iii. 413 mild inflammation of the conjunctiva, iii. 414 severe inflammation of the conjunctiva, or purulent ophthalmia, iii. 416 gonorrhceal inflammation of the conjunctiva, iii. 426 granular, iii. 425 purulent, of infants, iiL 430 scrofulous, iii. 433 variolous, iii. 433 feigned, ii. 138 Opisthotonos, iv. 365 Opium, as a poison, iv. 448 Os uteri, cauliflower excrescence of, iy. 600 follicles of, inflammation of, iv. 605 Osseous system, tuberculous matter in, iv. 480 Ossification, iv. 466 of the spleen, iv. 225 Otalgia, iii. 436 Otitis, iii. 436 Otorrhoea purulenta, iii. 439 Ovaria, diseases of the, iii. 442 inflammation and its consequences, iii- 444 cysts and tumours of the, in. 445 malignant, iii. 448 structure and functions of, iii. 442 Ovaries and uterus, dropsy from disease ofj i.709 GENERAL INDEX. 765 Oxalic acid, treatment of poisoning by, iv. 420 Oxygen, as a poison, iv. 456 Pain, feigned, ii. 139 of stomach, ii. 307 as a symptom of inflammation, ii. 734 Painters' colic, i. 463 Palpitation, iii. 449 Pancreas, diseases of the, iii. 454 inflammation and scirrhus, iii. 455 cancer and calculous concretions of, iii. 455 dropsy from disease of, i. 706 hypertrophy of, ii. 551 Palsy, shaking, iii. 474 Paralysis, iii. 457 of sensation, anaesthesia, iii. 457 Bell's, iii. 456 of motion, iii. 460 of sensation, iii. 457 general, iii. 462 partial, iii. 464 hemiplegia, iii. 468 intermittent, iii. 470 paraplegia, iii. 472 agitans, iii. 474 congenital, iii. 470 feigned, ii. 140 Paraplegia, iii. 473 Parotid gland, inflammation of, iii. 475 Parotitis, iii. 475 Parturients, iii. 477 Pau, climate of, i. 444 Pearlash, as a poison, iv. 421 Pellagra, or pelagra, iii. 477 Pemphigus, iii. 482 acute, iii. 484 chronic, iii. 485 gangrenous, or infantile, iiL 486 Pensacola, climate of, i. 449 Percussion, i. 237 auscultatory, i. 255 of the chest, i. 239 direct, i. 239 mediate, i. 240 of the abdomen, i. 31 of other parts of the body, i. 242 Perforation of the hollow viscera, iii. 487 of the stomach, iii. 488 of the intestines, iii. 491 o£the gall-bladder, iii. 492 of the respiratory organs, iii. 493 of the organs of generation, iii. 493 of the urinary organs, iii. 494 of the organs of circulation, iii. 494 of hollow bones, and of the eye, and the ear, iii. 495 of the veins, iv. 649 Pericarditis, iii. 495 Pericardium, dropsy of, ii. 502 Periodicity and crises of disease, i. 686 Periodontitis, iv. 404 Peripneumonia, iii. 590 Peripneumony, latent, iii. 120 Peritonitis, iii. 505 acute, in the infant, iii. 506 in the adult, iii. 507 puerperal, iii. 511 chronic, iii. 515 from perforation of the serous membrane, iii. 522 in puerperal fever, ii. 236 Pervigilium, iv. 653 Perityphlitis, ii. 54 Persian fire, i. 122 Pertussis, ii. 453 Pestilence, ii. 64 Pestis, iii. 540 Petechiae, ii. 163; iii. 762 Phagedaena, sloughing, of the mouth, iv. 382 Pharyngitis, iv. 377 gangrenous, iv. 382 follicular, iv. 387 Phlebitis, iv. 640 crural, iii. 529 of the'liver, iii. 149 uterine, ii. 239 Phlebolites, iv. 646 Phlegmasia dolens, iii. 529 Phrenitis, i. 301,317 Phosphatio urine, iv. 586 Phosphorus, a poison, iv. 416 Phrenology, iv. 357 Phreno-mesmerism, iv. 209 Phthisis, laryngeal, iii. 115 pulmonalis, iv. 489 dyspeptic, iv. 544 feigned, ii. 140 Physical diagnosis, iv. 298 education, i. 750 Physiognomy, medical, iv. 300 Physometra, iv. 604 Pica Africanorum, dirt-eating, feigned, il. 127 Piles, i. 488; ii. 438 Pisa, climate of, i. 445 Pityriasis, iii. 538 Plague, iii. 540 Plethora, iii. 553 Pleura, perforation of the, iii. 493 inflammation of the, iii. 574 air in the cavity of, iii. 637 Pleurisy, iii. 574 acute, iii. 574 chronic, iii. 581 latent, iii. 120 Pleuropneumonia^ iii. 609 Pleurosthotonos, iv. 366 Plica Polonica, ii. 43; iii. 587 Plumber's colic, i. 463 Pneumatorachis, iv. 217 Pneumonia, iii. 590 latent, iii. 120 typhodes, iii. 612 Pneumothorax, iii. 637 latent, iii. 121 Poisoned wounds, ii. 743 Poisoning, iv. 407 Poisons, iv. 407 mortification from, iii. 358 irritant, iv. 415 narcotic, iv. 444 narcotico-acrid, iv. 451 paralysis from, iii. 474 Pollution, nocturnal, iv. 211 Polyaemia, iii. 553 Polypus of the nose, feigned, ii. 140 of the uterus, iv. 606 Polysarcia, iii. 403 Pompholyx, feigned, ii. 141 diutinus, iii. 485 Porcupine man, ii. 589 Porphururia, iv. 586 Porrigo, iii. 653 true, iii. 653 eczematous, anomalous, iii. 656 Potass as a poison, iv. 421 766 GENERAL INDEX. Potassa, binoxalate of, a poison, iv. 420 bitartrate of, a poison, iv. 422 sulphate of as a poison, iv. 422 Practical medicine, principles of, iii. 271 Pregnancy, diagnosis of, i. 263; iii. 659 feigned, ii. 141 and delivery, signs of, iii. 659 duration of, iv. 279 Prepuce, herpes of the, ii. 448 Prognosis, iii. 699 Prolapsus ani, feigned, ii. 141 Prostate gland, composition of calculi of, i. 370 Prostatic calculi, i. 370 Prurigo, iii. 720 Prussian blue as a poison, iv. 448 Prussic acid as a poison, iv. 446 Pseudo-membranous inflammation, ii. 763 Pseudo-morbid appearances, iii. 723 in the external integument and cellular tis- sue, iii. 725 in the head, iii. 726 in the thorax, iii. 727 in the abdomen, iii. 729 in the blood-vessels, iii. 732 Psoriasis, iii. 733 of the tongue, ii. 328 Ptosis, iii. 464 Ptyalism, iii. 738 spontaneous, iii. 738 mercurial, iii. 738 Puerperal convulsions, i. 522 diseases, iii. 740 inflammation within the abdomen, iii. 743 effects of stomachal and intestinal irrita- tion, iii. 746 effects of loss of blood in the puerperal state, iii. 748 mixed cases, mania, iii. 750 fever, ii. 231 insanity, iii. 67, 750 peritonitis, ii. 236; iii. 511 Pulmonary apoplexy, i. 155 catarrh, i. 382 gangrene, iii. 339 tissue, mortification of, iii. 339 tubercles, latent, iii. 121 Pulmonitis, iii. 590 Pulsation, nervous, of abdominal aorta, i. 137 Pulse, iii. 752 physiology of, iii. 756 pathology of, iii. 759 state of in pregnancy, iii. 679 venous, iv. 324 Pneumothorax, iii. 576 Purgatives, i. 386 Purpura, iii. 672 simplex and hemorrhagic, iii. 763 urticans, iii. 764 Purpuric urine, iv. 586 Purulent discharge in young females resembling gonorrhoea, iii. 777 infiltration of the lung, ii. 597 ophthalmia, iii. 417 of infants, iii. 430 Pus, iii. 770; iv. 284 collection of, within the sac of the pleura, ii. 22 * Pustula maligna, i. 122; iii. 360 Pustule, malignant, i. 122; iii. 360 maligne, i. 122; iii. 360 Pustular counter-irritants, i. 530 Putrid or diseased animal matter, a poison, iv.483 Pylorus, scirrhus of, iv. 254 Pyrosis, iii. 770; ii. 629 of infants, ii. 49 Quickening, as a sign of pregnancy, iii. 667 Quinsy, iv. 385 Rabies canina, ii. 506 Rachitis, iv. 53 Ramollissement, iv. 175; in fungus haematodes ii. 282 of the brain, i. 317; iv. 178 of the spinal marrow, iv. 218 Rape, iii. 773 Ratafia, poisoning by, iv. 448 Rectum, diseases of, i. 487 state of, in hemorrhoids, ii. 438 relaxation of the, i. 487 structure of the, i. 488 Recurrence of disease, liability to, iii. 711 Refrigerants, iv. 18 Regimen, antiphlogistic, i. 122 Relapses, liability to, iii. 711 Remedies, effects of, iv. 328 Remittent fever, ii. 219 infantile, ii. 224 Renal calculi, pathology and treatment of, i. 366 Resolution, a termination of inflammation, ii. 780 Resonance, metallic, i. 251 Respiration, auscultation of, i. 246 difficult or disordered, i. 732 morbid, iv. 320 Respiratory organs, perforation of the, iii. 493 tuberculous matter in, iv. 478 Rest, bodily, i. 123 Resuscitation, in cases of asphyxia, i. 202 of drowned persons, i. 204 Retina, inflammation of, amaurosis from, i. 82 inflammation of the, iii. 436 Revulsion, i. 601 Rachitis, iv. 43 Rheumatic dermalgia, iv. 42 Rheumatism, iv. 23 acute, iv. 24 capsular* iv. 35 chronic, iv. 36 effects of climate in, i. 451 feigned, ii. 141 Rhonchus, rhonchi, different kinds of, L 241 Rickets, iv. 43 of children, iv. 43 of adults, iii. 47 Ringworm, ii. 447;" iii. 656 Rome, climate of, i. 445 Rose, the, ii. 97 Roseola, iv. 50 Rotatio, i. 427 Rubefacients, i. 527 Rubeola, iv. 51 Rupia, iv. 58 Rye, spurred, effects of, iii. 361 Saint Anthony's fire, ii. 96 Saint Augustine, climate of, i. 449 St. Leonard's, climate of, i. 441 Salivation, as a sign of pregnancy, iii. 663 Sancti Viti chorea, i. 427 Sarcoma, medullary, ii. 280; iv. 84 Scabies, iv. 59 Scall, papulous, i. 737 Scarlatina, iv. 67 simplex, iv. 70 anginosa, iv. 71 GENERAL INDEX. 767 Scarlatina, maligna, iv. 73 faucium, iv. 74 Scarlet fever, iv. 67 Scelotyrbe, iv. 104 Sciatica, iv. 41 Scirrhoma, iv. 83 Scirrhus, iv. 82 carcinoma, specific divisions of, iv. 83 of the pancreas, iii. 455 stomach, iv. 254 uterus, iv. 606 Sclerotica, inflammation of the, iii. 434 Scorbutus, iv. 104 Scrofula, iv. 125 latent, iv. 492 mesenterica, iv. 353 effects of climate in, i. 451 Scrofulous diathesis, iv. 492 laryngitis, iii. 105 ophthalmia, iii. 433 Scurvy, iv. 104 Sea-bathing, i. 269 Secretions, changes effected in by age, i. 59 vitiated or deficient, constipation from, i. 479 Sedatives, iv. 145 Sedentary habits, diseases attendant on, i. 180 Semeiology, iv. 298 Semeiotics, iv. 298 Senile insanity, iii. 72 Sensation, loss of, iii. 458 Sensibility, changes effected in by age, i. 63 Serous membranes*; inflammation of, ii. 755 mortification of, iii. 337 surfaces, tubercles on, iv. 480 Serpents, poisonous, iv. 442 Setons, i. 531 Sex, doubtful, iv. 153 Sexual ambiguity, iv. 153 Shaking palsy, iii. 474 Shingles, ii. 446 Short sight, feigned, ii. 441 Shower-bath, i. 271 Sick stomach, iii. 314 Silver, nitrate of, as a poison, iv. 423 Simulated diseases, ii. 123 Singultus, ii. 450 Skin, discoloration of from nitrate of silver, iv.400 hypertrophy of, ii. 548 inflammation of, ii. 758 pseudo-morbid appearances in, iii. 725 Skulkers, ii. 124 Sleep-walking, iv. 194 Small-pox, iv. 159 natural, iv. 162 modified, iv. 171 inoculated, iv. 172 theory and practice of inoculation, iv. 174 phenomena of inoculation, iv. 174 occurrence of, after cow-pox, iv. 630 extermination of, iv. 636 and chicken-pox, common origin of, iv. 430 Smell, loss of, iii. 457 Smothering, persons found dead from, i. 565 Soda, as a poison, iv. 421 Softening of organs, iv. 175 from inflammation, iv. 177; ii. 786 of the brain and spinal cord, physical characters of, iv. 178 of the brain, from obliteration of the arte- ries, iv. 180 of the mucous membranes, iv. 187 of the stomach and intestines from in- flammation, iv. 188 Softening of the stomach and intestines by the gastric juice, iv. 189 of bones, iv. 43 of the liver, iii. 146 of the stomach, iv. 271 of the stomach in the gastritis of infants, ii. 302 a termination of inflammation, ii. 786 of tuberculous matter, iv. 477 Solanum nigrum, and dulcamara, as poisons, iv. 451 Somnambulism and animal magnetism, iv. 194 proper, iv. 194 cataleptic, or ecstasis, iv. 199 artificial;—history of animal magnetism, iv. 201 animal magnetism, phenomena of, mode of producing, iv. 205 theory of, iv. 206 pathology of, iv. 209 Somnolency, feigned, ii. 142 Sore throat, iv. 385 clergyman's, iii. 116; iv. 387 Sorrel, salt of, a poison, iv. 420 South America, climate of, i. 449 Spasm of the glottis, i. 522; ii. 329 Spermatorrhoea, iv. 24 Sphacelus and gangrene, general phenomena of, iii. 332 Sphincter ani, spasm of, i. 499 Spina bifida, iv. 213 Spinal marrow, diseases of, iv. 213 dropsy of the, and spina bifida, iv. 213 morbid states of the spinal meninges, iv.218 spinal effusions, iv. 216 morbid conditions of;—inflammation and its terminations, ramollissement, iv. 2ia * induration, suppuration, iv. 219 atrophy, hypertrophy, new formations, . iv. 220 irritation, iv. 221 tuberculous matter in, iv. 221, 479 Spinal marrow and brain, softening of, iv. 178 Spine, curvature of, i. 756 lateral, iv. 47 scrofulous affection of the, iv. 143 latent disease of, iii. 122 Spiroptera hominis, iv. 720 Spleen, diseases of, iv. 223 dislocation of the, iv. 229 inflammation, iv. 223; ii. 775 softening, induration, ossification, gan- grene, iv. 225 enlargement and hypertrophy, iv. 226 atrophy, hemorrhage or apoplexy, hy- datids, iv. 227 tubercles, melanosis, calculous deposits, rupture, iv. 228 dropsy from disease of, i. 706 tuberculous matter in the, iv. 479 Splenectopia, iv. 229 Spongoid inflammation, ii. 280 ; iv. 84 Spurred rye, a poison, iv. 456 Static test, ii. 684 Statistics, medical, iv. 229 vital, iv. 229 Stays, bad effects of, i. 759 Sterility, and impotence in females, ii. 602 Stethoscope, iv. 237 Stimulants, iv. 239 Stimuli, mortification from, iii. 357 Stomacace, iv. 382 768 GENERAL INDEX. Stomach and pylorus, diseases of, iv. 253 debility of, ii. 614 hemorrhage from, ii. 357 inflammation of, ii. 298 in infants, ii. 302 morbid conditions of, in phthisis, iv. 523 organic diseases of, iv. 253 cancer or scirrhus, iv. 254 ulceration, iv. 267 hypertrophy and atrophy, iv. 269 softening, iv. 271 enlargement, iv. 271 contraction, iv. 275 pain of, ii. 307 perforation of, iii. 488 softening of, from the action of the gastric juice, iv. 187 in the gastritis of infants, ii. 302 Stomatitis, iv. 275 aphthous, i. 141 follicular, i. 141 gangrenous, iv. 382 simple, iv. 275 diphtheritic, iv. 275 pseudo-membranous, iv. 275 Stone-pock, i. 50 Strangulation, asphyxia from, i. 196 persons found dead from, i. 561 Strangury, i. 734 Stricture of the rectum, i. 487 of the female urethra, iv. 618 Strophulus, iv. 276 Strychnia, as a poison, iv. 454 Sublimate, corrosive, a poison, iv. 423 Succession of inheritance—legitimacy, iv. 276 Succussion, i. 243 ; iii. 647 Sudorifics, i. 626 Suffocation, iv. 294 Suicide, i. 458 * Suicides, number of, iv, 233 Sulphate of indigo, a poison, iv. 420 Sulphate of potassa, a poison, iv. 422 Sulphur and the alkaline hydrosulphurets, a poisons, iv. 416 Sulphuretted hydrogen, as a poison, iv. 462 Sulphuric acid, as a poison, iv. 416 Sulphurous acid, as a poison, iv. 463 Supersensitiveness, ii. 543 Suppuration, i. 36; ii. 784 5 iv. 284 a termination of inflammation, ii. 784 of the brain, i. 318 of the liver, iii. 161 of the lung, ii. 597 of the spinal marrow, iv. 219 Surface, state of, in disease, iv. 313 Survivorship, iv. 290 Swallowing, difficulty or impossibility of, i. 730 Swelled leg, feigned, ii. 143 Swelling, as a symptom of inflammation, ii. 731 Sycosis, iv. 296 Symptomatology, iv. 298 of diseases, iv. 302 the 6ountenance, iv. 302 the attitude, iv. 308 the tongue, iv. 311 the general surface, iv. 313 the general system, iv. 316 the brain, iv. 318 the respiration, iv. 320 the circulation, iv. 323 the alimentary canal, iv. 325 the urinary organs, iv. 326 the uterine system, the abdomen, iv. 327 Symptomatology, the effects of remedies, iv. 328 Syncope, iv. 329 feigned, ii. 143 Synochus, ii. 153 Syphilitic laryngitis, iii. 107 ulceration of the throat, iv. 389 larynx, iv. 389 Tabes mesenterica, ii. 46; iv. 333 Taenia lata, or broad tape-worm, iv. 713 ■ solium, or tape-worm, iv. 710 Tampa Bay, climate of, i. 449 Tarantella, i. 427 Tarantismus, ii. 45 Tartar-emetic, as a poison, iv. 437 Tartar of the teeth, iv. 406 Taste, loss of, iii. 458 Teeth, neuralgia of the, iv. 406 exostosis of the, iv. 406 tartar of the, iv. 406 Temperament, iv. 349 modification of disease by, i. 683 Tenesmus, i. 720 a Bcyhalis, iL 658 Tetanies, iv. 363 Tests of poisons, iv. 411 Tetanus, iv. 364 Tetter, humid, ii. 594 scaly, iii. 733 ulcerated, i. 737 vesicular, ii. 445 Thorax, hydatids in the, ii. 466 pseudo-morbid appearances in, iii. 727 Thread-worm, iv, 709 Throat, diseases of the, iv. 376 gonorrhceal ulceration of the, iv. 390 inflammation, iv. 376 venereal affections of the, iv. 388 Thrush, i. 140 Thymus gland, hypertrophy of, ii. 551 Thyroid gland, enlargement of, i. 343 hypertrophy of, ii. 551 Tic douloureux, iii. 381 Ticunas, a poison, iv. 455 Tin, as a poison, iv. 439 Tinea, iii. 653 Tissues, accidental, iv. 390 tuberculous matter in, iv. 480 Tobacco, as a poison, iv. 452 Tongue, inflammation of, ii. 325 paralysis of, iii. 468 morbid appearances of the, iv. 311 Tonics, iv. 391 Tonsillitis, iv. 385 Tonsils, disease of follicles of, iv. 387 hypertrophy of, iv. 386 Toothache, iv. 404 nervous, iv. 406 Touch, loss of, iii- 458 Toxicology, iv. 407 Trachea, ulceration of, in phthisis, iv. 521 Transformations, iv. 464 cellular, vascular, iv. 465 erectile or muscular tissue, membranous, cutaneous, fibrous, iv. 465 cartilaginous, osseous, iv. 466 of teeth, iv. 467 Transfusion, iv. 468 Trembles, iii, 314 Trichina spiralis, iv. 721 Trichoma, plaited hair, ii. 43; iii. 587 Triocephalus dispar, or trichuris, iv. 709 Trismus, iv. 364 GENERAL INDEX. 769 Trismus nasce'ntium, iv. 368 Tubercle, iv. 489 subcutaneous, iii. 384 Tubercles, in the spleen, iv. 228 of the larynx and fauces, iv. 387 in the mesentery, iv. 333 pulmonary, latent, iii. 121 of the liver, iiL 146 Tubercular cachexy, ii. 350; iv. 491 ' meningitis, ii. 489 phthisis, iv. 489 duration of, iv. 496 varieties of, iv. 497 particular symptoms and diagnosis of, iv. 505 principal complications of, iv. 520 of certain occupations, iv. 528 of climate, iv. 532 causes determining tuberculous disease in the lungs, iv. 539 pathology of, and of tuberculous diseases, iv, 542 prevention of tuberculous diseases, iv. 544 remedial measures, iv. 551 Tuberculous cachexia, iv. 492 diseases in animals, iv. 534 Tumours, erectile, of the liver, iii. 148 ovarian, treatment of, iii. 445 uterine, iv. 605 Tympanites, iv. 570 of the uterus, iv. 603 Typhlitis, ii. 53 Typhlo-enteritis, ii. 53 Typhous fever, ii. 162 Typhus, ii. 162 Ulceration a termination of inflammation, ii. 786 gonorrhceal, of the throat, iv. 390 mercurial, of the throat, iv. 370 syphilitic, of the throat, iv. 388 larynx, iv. 389 of the epiglottis, larynx, and trachea, in phthisis, iv. 520 Ulcers, corroding or phagedenic of the uterus, iv. 605 feigned, ii. 143 Umbilicus, state of, as a sign of pregnancy, iii. 667 Undcrcliff, climate of, i. 441 Upas antiar, as a poison, iv. 455 Urethra, female, and meatus urinarius, diseases of, iv. 618 Urethral calculi, pathology and treatment of, i. 370 Urinary calculi, i. 359 organs, perforation of the, iii. 494 functional affections of the, iv. 326 tuberculous matter in, iv. 479 Urine, bloody, iv. 588 state of in pregnancy, iii. 679 healthy, iv. 581 morbid states of the, iv. 581, 584 aqueous, sub-aqueous, iv. 584 lithic, phosphatic, iv. 585, 586 purpuric, albuminous, iv. 586, 587 saccharine, iv. 587 difficulty in voiding, i. 734 incontinence of, iv. 575 feigned, ii. 134 retention of, iv. 580 suppression of, iv. 578 state of, in pregnancy, iii. 680 Urticaria, iv. 590 Uterine system, functional changes in the, iv. 327 Vol. IV. —97 3p Uterus and its appendages, pathology of the, iv. 59 6 inflammation of, iv. 600 dropsy of, iv. 604 tumours of, iv. 605 malignant or cancerous diseases of, iv. 606 states of, as signs of pregnancy, iii. 671, 685 and ovaries, dropsy from disease of, i. 709 inflammation of, in puerperal fever, ii. 237 inflammation of the veins of^ in puerperal fever, ii. 239 inflammation of the absorbent vessels of, in puerperal fever, ii. 238 and vagina, perforation of the, iii. 493 state of, as a sign of pregnancy, iii. 671 substances expelled from, as signs of preg- nancy, iii. 675 Vaccination, history of, iv. 621 phenomena off iv. 623 revaccination, and surgery of vaccination, iv. 626 theory of, iv. 628 protective influence of, iv. 629 constitutional inaptitude to, iv. 629 small-pox after, iv. 630 sources of failure of, iv. 631 remedies for the imperfections of, iv. 633 Vagina, state of, as a sign of pregnancy, iii. 670 and vulva, diseases of, iv. 616 purulent discharge from, resembling gonor- rhoea, iii. 773 Valves of the heart, diseases of, ii. 414 Vapour-VJath, i. 283 Varicella, iv. 636 lymphatica, iv. 637 Varicose veins, iv. 647 Variola, iv. 159 Varioloid, iv. 171 Variolous and vaccine poisons, identity of, iv. 628 Vascular system, hypertrophy of, ii. 548 state of, in mortification, iii. 341 Vascular system, inflammation of the, ii. 76 Vegetable poisons, iv. 439 Veins, diseases of the, iv. 639 phlebitis, iv. 640; ii. 768 obliteration of the cavities of, iv. 647 varicose, iv. 647 rupture and perforation of, iv. 649 of the uterus, inflammation of, ii. 239 iliac and femoral, inflammation of, iii. 529 Venereal affection of the throat, iv. 388 disease, pustular, i. 742 Ventilation, iv. 650 Veratrum album, as a poison, iv. 454 Vermes, iv. 704 Vertebrae, scrofulous affection of the, iv. 143 Vesicle, malignant, i. 122 Vesicula gangraenescens, i. 122 Vigilia, iv. 653 Villa Franca, climate" of, i. 445 Virginia, climate of, i. 449 Vis medicatrix, i. 684 Voice, privation or suppression of, i. 139 paralysis of muscles of, iii. 468 auscultation of the, i. 252 Vomiting, theory of, i. 776 as a sign of pregnancy, iii. 663 feigned, ii. 144 of blood, ii. 133, 357 Vulva, diseases of the, i v. 616 Wakefulness, iv. 653 770 GENERAL INDEX. Warm air-hath, i. 285 Warm-bathing, i. 295 Water-brash, iii. 770 Water-canker, iv. 382 Water in the chest, ii. 538 head, ii. 476 Waters, mineral, iv. 658 saline, iv. 661 aperient, iv. 666 thermal, iv. 666 alkaline, iv. 666 ioduretted, iv. 666 Cheltenham, iv. 666 Leamington, iv. 668 Scarborough, Spital, Pitkaithley, Air- threy, and Dunblane, iv. 671 Innerleithen, Sea-water, Seidlitz, iv. 673 Seydschutz, iv. 675 Balston Spa, iv. 675 Saratoga, iv. 675 chalybeate, iv. 675 Tunbridge, iv. 675 Hartfell, iv. 676 Moffat, Vicar's Brig, iv. 677 Spa, iv. 678 Passy, Bourbon 1'Archambault, iv. 679 Rennes, iv. 680 Tongres, iv. 681 Bedford, Balston, Saratoga and Bran- dy wine, iv. 681 sulphureous, iv. 682 Harrowgate, iv. 682 Moffat, Strathpeffer, iv. 686 Rothsay, Enghien, iv. 686 Bareges, Aix, iv. 687 Aix-la-Chapelle, iv. 688 Waters, mineral, Loechc or Leuk, iv. 689 acidulous, iv. 689 Ilkeston, iv. 690 Pyrmont, iv. 692 Seltzer, iv. 693 Pougues, Mont d'or, iv. 693 Vichi, iv. 694 Geileneau, Eger, iv. 695 Ems, iv. 696 Sweet Springs of Virginia, iv. 696 hot-springs, iv. 696 Matlock, Bristol, iv. 696, 697 Buxton, iv. 697 Bath, iv. 698 Carlsbad, iv. 700 Plombieres, Wiesbaden, iv. 702 Baden, St. Nectaire, iv, 702, 703 Warm and Hot Springs of Virginia, iv. 704 Weaning-brash, iii. 770 of infants, ii. 49 West Indies, climate of, i. 447 Wine, administration of, in fever, ii. 195 Woorara, a poison, iv. 455 Worms, iv. 704 classification of, iv. 707 spurious, iv. 721 Wounds, death from, i. 570 circumstances affecting the medico-legal character of, iv. 578 in dissection, ii. 743; iv. 443 feigned, ii. 144 Yaws, iv. 750 Zinc, as a poison, iv. 436 THE END. TO THE MEDICAL PROFESSION. LEA AND BLANCHARD present a condensed list of Books published and preparing for publication by them, and would refer to the other pages of their catalogue for a more detailed account. The prices, and all other information in relation to them, will be given on application, free of postage. Being extensively engaged in the publication of Medical and Scientific works, it Will be their effort to furnish them at prices lower than formerly, and as low as they can be afforded consistent with correct and well-executed editions. The latest editions will always be furnished; and, to their present extensive list, they will add, from time to tune, such other good works as the wants of the profession may call for. Their publications may be found at all the prin- cipal Bookstores throughout the Union. Anatomical Atlas, by Smith and Horner, imperial 8vo., nearly 650 figures. Arnott's Elements of Physics, new edition, in 1 vol. 8vo., 484 closely printed pages. 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WILLIAMS, M. D., Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of "Principles of Medicine," &c. &c. WITH NUMEROUS ADDITIONS AND NOTES. By MEREDITH CLYMER, M. D., Physician to the Philadelphia Hospital. In One neat Svo.. Volume, with Cuts. NOW READY, ANOTHER VOLUME OF THE SERIES OF SIR ASTLEY COOPER'S WORKS. ON THE STRUCTURE AND DISEASES OF THE TESTIS. ILLUSTRATED BY 120 FIGURES. From the Second London Edition By BRANSBY B. COOPER, Esq. "The rep-ublication of this splendid volume supplies a want that has been very severely felt front the ex- haustion of the first edition of it. . . . The extraordinary merits of this treatise have been so long and so univer- sally acknowledged, that it would be a work of supererogation to represent them in our pages. The practical surgeon who is not master of its contents, cannot be fully aware of the imperfection of his owu knowledge on tie subject of diseases of the testicle."—British and Foreign Medical Review. AND ON THE ANATOMY OF THE THYMUS GLAND, ILLUSTRATED BY 57 FIGURES, The two Works together in one beautiful imperial octavo volume, illus- trated in the best style of lithography, and printed and bound to match the author's great work on Hernia, lately published. BRICHAM ON MENTAL EXCITEMENT. REMARKS ON THE INFLUENCE OF. MENTAL CULTIVATION AND MENTAL EXCITEMENT UPON HEALTH. Third Edition. By A. BRIGHAM, M.D., Superintendent and Physician ofthe State Lunatic Asylum, Utica, N. Y. In One Vol. 12mo. This oooular little work has been reprinted in London, Edinburgh and GHsgow. In this third American Pdition the author has included all the Improvement* of the three British editors, and has also addee new BtttWi"which brings it up to the day, and renders it still more worthy ofthe favour it has so long enjoyed. 4 NOW READY, MEIGS'S TRANSLATION OF COLOMBAT DE L'ISERE ON THE DISEASES CF FEMALES. A TREATISE ON THE DISEASES OF FEMALES, AND ON THE SPECIAL HYGIENE OF THEIR SEX. WITH NUMEROUS WOOD-CUTS. BY COLOMBAT DE L'ISfcRE, M. D., Chevalier of the Legion of Honour; late Surgeon to the Hospilul ofthe Rue de Valois, devotid to the Diseases of Females, S;c c\c. TRANSLATED, WITH MANY NOTES AND ADDITIONS, Br C. D. MEIGS, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson MeaHcai College, $-c. $e. In One Volume, Svo. The notes and addenda of Professor Meigs are very extensive and valuable, bringing the whole up to the day of publication, and giving whatever maybe necessary with regard to American practice. It fauns a large octavo volume of near TOO pages, with numerous wood-cuts. LATELY PUBLISHED. A NEW EDITION OF WILSON'S HUMAN AUATOMT. MUCH IMPROVED. A SYSTEM OF liUMAN ANATOMY, GENERAL AND SPECIAL. By ERASMUS WILSON, M.D.T SECOND- AMERICAN EDITION. EDITED BY PAUL B. GODDARD, A.M., M.D., Lecturer on Anatomy, and Demonstrator in the University of Pennsylvania, 8f6. WITH OVER TWO HBNDltED ILLUSTRATION'S, Beautifully Printed from the Second London Edition. From the Preface lb the Second American Edition. "The very rapid sale of the first edition of this work, is evidence of its appreciation' by the profession arid is most gratifying to the author and American editor. In preparing the present edition1 no pains have been spared to render it as complete a maiiuai of Anatomy for the medical student as-possible. A ch'tfftter dri' Histology has therefore been prefixed, and a considerable number of new cuts added'. Amonj the 'latter, arc' 3orrte very fine onesof the nerves which were almost wholly omitted from the original workr. Gfeaf care ha> also been taken to haive this edition correct, and the cuts carefully and beautifully worked, and it is confidently believed that it will gjve satisfaction, offering a farther inducement to its general use as a Text Book in the various Colleges." LATELY PUBLISHED, A NEW AND MUCH IMPROVED EDITION OF D R UITT'SJ U R G S R IT, THE PRINCIPLES AND PRACTICE OF MGMRN SURGERY, By ROBERT DRUITT, Surgeon. FROM THE THIRD LONDON EDITION. ILLUSTRATED BY ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. WITH NOTES AND COMMENTS Br JOSHUA B. FLINT, M.M. & S. In One Volume,. 8vo. "An unsurpassable compendium not only of surgical but of medical pracv.ce.^-^London Medical Gazettt "It may be said with troth that the work of Mr. Druitt affords-a. complete, through brief and condensed view of the entire field of modern surgery. \V e know oi no work on the same subject, havin* the annear-inre of a manual, whieh inelude* so many topics of interest to. the surgeon; and the tesse mannef in which ear 1. h«« been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the nen Notwnhstanding various weedings and alterations, we find that there are nearly fifty pages of additional mat ter in the present volume, and evidently much has been done by both author and publishers to sustain the reputat;on aUready acqu.red The wood-em*have been greatly increased in number, and the pencil and eraver of William Bagg have added bnllumey to thi»portion of the book. * * * It is a useVul handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinon, it is admirably adapted to the wants of the student; and with congratulation, in the author and publishers—for the latter deserve much credit for the handsome appearance of the volume-on foe success of their undertaking, we leave the present edition as a piquant proportion of the ample stow of knowledge which it is thegood fortune ofthe rising youth in the profession tobe socbeaplv provided with in th* preseiitday."—Provincial Med Journal. svvueupi) proviuea wiuhii the 5 JUST ISSUED BY LEA & BLANCHARD. WILLIAMS AND CLYMER ON THE RESPIRATORY ORGANS, ETC. A TREATISE ON THE DISEASES OF THE RESPIRATORY ORGANS, INCLUDING THE TRACHEA, LARYNX, LUNGS, AND PLEURA. By CHARLES J. B. WILLIAMS, M. D., -Consulting Physician to the Hospital for Consumption and Diseases ofthe Chest; Author of " Principles of Medicine," &c. &c. WITH NUMEROUS ADDITIONS AND NOTES. Br MEREDITH CLYMER, M. D., Physician to the Philadelphia Hospital. In One neat Svo. Volume, with Cuts. NOW READY, ANOTHER VOLUME OF THE SERIES OF SIR ASTLEY COOPER'S WORKS. ON THE STRUCTURE AND DISEASES OF THE TESTIS, ILLUSTRATED BY 120 FIGURES. From the Second London Edition By BRANSBY B. COOPER, Esq. "The republication of this splendid volume supplies a want that has been very severely felt from the ex- haustion ofthe first edition of it. . . . The extraordinary merits of this treatise have been so long and so univer- sally acknowledged, that it would be a work of supererogation to represent them in our pages. The practical surgeon who is not master of its contents, cannot be fully aware of the imperfection of his own knowledge* the sulyect of diseases of the testicle."-—British and Foreign Medical Review. AND ON THE ANATOMY OF THE THYMUS GLAND, ILLUSTRATED BY 57 FIGURES, The two Works together in one beautiful imperial octavo volume, illus- trated in the besft style of lithography, and printed and bound to match the author's grealt work on Hernia, lately published. BRICHAM ON MENTAL EXCITEMENT. REMARKS ON THE INFLUENCE OF. MENTAL CULTIVATION AND MENTAL EXCITEMENT UPON HEALTH. Third Edition. By A. BRIGHAM, M.D., Superintendent and Physician ofthe State Lunatic Asylum, Utica, N. Y. In One Vol. 12mo. This popular little work has been reprinted in London, Edinburgh and Glasgow. In this third American Edition the author has included all the improvements of the three British editors, and has also added new matter which brings it up to the day, and renders it still more worthy ofthe favour it has so long enjoyed. 4 NOW READY, MEIGS'S TRANSLATION OF COLOMBAT DE L'ISERE ONJHE DISEASES OF FEMALES. A TREATISE ON THE DISEASES OF FEMALES, AND ON THE SPECIAL HYGIENE OF THEIR SEX. WITH NUMEROUS WOOD-CUTS. BY COLOMBAT DE L'lSfeRE, .M.D, Chevalier of the Legion of Honour; late Surgeon to the Hospitul of ihe Rue de Valois, devot.d to the Diseases of Females. his subject. Il was published in 18TC0, and met with but little approbation from the English public on account of the strong feeling which it manifests in favour ofthe colonies. Mr. Orahame continued revising and emendating it till his death in 1S42. shortly after wliich all his MSS. and papers were sent by his son to Harvard College. President Quincy, Judge Btory, Professor Jared Sparks, and other gentlemen connected with the Uuiversity have accordingly undertaken the task of revising an edition ofthe work to be presented to the American public in a style as nearly as possible resembling that of the English edition. TAYLOR'S MEDICAL JURISPRUDENCE may be had bound in Law Sheep for the legal profe§sion. See Advertisement at page 12. 16 MISCELLANEOUS BOOKS. Lea &. Blanchard publish, and have for sale," the following valuable works in various departments of Literature and Science. American Ornithology; by Prince Charles Buon- aparte. In 4 vols, folio, half-bound. 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A GOBLIN STORY OF SOME BELLS THAT RUNG AN OLD YEAR OUT AND A NEW-YEAR IN A CHEAP EDITION, IN PAPER COVERS, AND A FINE EDITION WITH PLATES. dj* See the List far a new edition of CampbeWs Poetical Works, by Wash. Irving and Lord Jeffreys. ' 19 WATSON'S PRACTICE OF MEDICINE, L. & B. HAVE LATELY PUBLISHED LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. DELIVERED AT KING'S COLLEGE, LONDON. Br THOMAS WATSON, M. D., Fellow ofthe Royal College of Physicians, Physician to the Middlesex Hospital, ice. Src. In One large Octavo Volume, of over nine hundred unusually large pages, strongly bound in leather, containing Ninety .Lectures. Offered to the public at a very low price. This volume, although so short a time before the medical public of this country, has met with almost unprece- dented approbation from all classes ofthe profession, teachers, practitioners and students, in every section ofthe country, and has been favourably noticed by all the medical journals. The publishers 6ubmit the following notice of its approval from the Professor of the University of Pennsylva- nia, and from some of the journals, foreign and domestic, which have borne testimony to its excellence. Phila., Sept. 21th, 1844. Watson's Practice of Physic, in my opinion, is among the most compre- hensive works on the subject extant, replete with curious and important matter, and written with great perspicuity and felicity of manner. As cal- culated to do much good, I cordially recommend it to that portion of the profession in this country who may be influenced by my judgment. N. Chapman, M.D., Professor of the Practice and Theory of Medicine in the University of Pennsylvania. " We know of no other work better calculated for application of therapeutics to diseases, we are free to being placed in the hands of the student, and for a text say has not appeared for very many years. The lec- book, and as such we are sure it will be very exien- turer proceeds through the whole classification of human sively adopted. On every important point, the author ills, a capite ad calcem, showing at every step anexten- seems to have posted up his knowledge to the day."— sive knowledge of his subject, with the ability of com- American Medical Journal. municating his precise ideas, in a style remarkable for "In the Lectures of Dr. Watson, now republished its clearness and simplicity."—N. Y. Journal of Medi- here in a large and closely printed volume, in small cine and Surgery. type, of nearly a thousand pages, we have a body of "The style is correct and pleasing, and the matter doctrine and practice of medicine well calculated, by worth the attention of all practitioners, young and old." its intrinsic soundness and correctness of style, to in- —Western Lancet. struct the student and younger practitioner, and improve "We are free to state that a careful examination of members of the profession of every age."—Bulletin of this volume has satisfied us that it merits all the commen- Medical Science. dation bestowed on it in this country and at home. It is "We know not, indeed, of any work of the same a work adapted to the wants of young practitioners. size that contains a greater amount of useful and in- combining, as it does, sound principles and substantial teresting matter. We are satisfied, indeed, that no phy- practice. It is not too much to say, that it is a represent- sician, well read and observing as he may be, can rise ativeof the actual state of medicine as taught and prac- from its perusal without having added largely to his lised by the most eminent physicians ofthe present day, stock ofvaluable information."—Medical Examiner. and as such we would advise every one about embark- " We regard these lectures as the best exposition of ing in the practice of physic to provide himself with a their subjects of any we remember to have read: The copy of it."— Western Journal of Med. and Surgery. author is assuredly master of his art. His has been a " The medical literature of this country has been en- life of observation and study, and in this work he has riched by a work of standard excellence, which we can given us the matured Tesults of these mental efforts."— proudly hold up to our brethren of other countries as a New Orleans Medical Journal. representative of the natural state of British medicine, "Open this huge, well-furnished volume where we as professed and practised by our most enlightened phy- may, the eye immediately rests on something that«ar- sicians. And, for our own parts, we are not only wil- ries value on its front. AVe are impressed at once with ling that our characters as scientific physicians and the strength and depth of the lecturer's views. He gai ns skilful practitioners may be deduced from the doctrines on our admiration in proportion to the extent of our ac- contained in this book, but- we hesitate not to declare quaintance with his profound researches. Whoever our belief, that for sound, trustworthy principles, and owns this book, will have an acknowledged treasure if substantial,good practice, it cannot be paralleled by any the combined wisdom of the highest authorities is appre- similar production in any other country. * * * * We ciated."—Boston Med. and Surg. Journal. would advise no one to set himself down in practice, un- " One of the most practically useful books that ever provided with a copy."—British and Foreign Medical was presented to the student—indeed, a more admirable Review. Bununary of general and special pathology, and of the 20 wonxs by psoraaaoR etjwglisoh. Lea & Blanchard publish and have for sale the following valuable Medical Works by Professor Robley Dunglison. in ir ax ii si EPia'ffQacDi&aDcsnr* WITH "UPWARDS OE THREE HUNDRED ILLUSTRATIONS, Bx ROBLEY DUNGLISON, M. D., PROFESSOR OP THE INSTITUTES OP MEDICINE, &C. IN JEFFERSON MEDICAL COLLEGE, PHILADA.; ATTENDING PHYSICIAN AND LECTURER ON CLINICAL MEDICINE AT THE PHILADA. MEDICAL HOSPITAL; SECRETARY TO THE AMERICAN PHILOSOPHICAL SOCIETY, &C. &C. FIFTH EDITION, BREATLY MODIFIED AND IMPROVED. IN TWO VOLUftEES, OF 1304 IiARGS OCTAVO PAGES. In presenting this new and much improved edition of Professor Dunglison's standard work on Physiology, the Publishers beg to state, that "although only a short time has elapsed since the publication of the fourth edition of this work, the labours of Physiologists have been so numerous, diversified, and important, as to demand ma- terial modifications and additions in the present edition, and that no little time and industry have been bestowed by the author to introduce these, and to digest the various materials contained in the exprofesso treatises, as well as the various Journals of this country and of-Europe. '• To this edition nearly ninety wood-cuts have been added to elucidate either topics that had been already treat- ed of in the previous editions, or such as are new in this; most of the old cuts have been retouchedj and many replaced by others that are superior. Altogether, the author has endeavoured to malce the work a just and im- partial record of Physiolog'eal science, and to render it worthy a continuance of that favour which has been so liberally extended to it." The size of the volumes has been materially increased, by, the addition of 'over eighty pages, and the illustrations are far superior to those of any former edition. THE PRACTICE OF MEDICINE, OR A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. BY ROBLEY DUNGLISON, M. D., CONTAINING THE DISEASES OF THE ALIMENTARY CANAL, THE DISEASES OF THE CIRCULATORY APPARATUS, DISEASES OF THE GLANDULAR ORGANS, DISEASES OF THE ORGANS OF THE SENSES, DISEASES OF THE RESPIRATORY ORGANS, DISEASES OF THE GLANDIFORM GANGLIONS, DISEASES OF THE NERVOUS SYSTEM, DISEASES OF THE ORGANS OF REPRODUCTION, DISEASES INVOLVING VARIOUS ORGANS, &c. &c. In Two Volumes, Octavo. This work has been introduced as a text-book in many of the Medical colleges, and the general favour with which it has been received, is a guarantee of its value to the practitioner and student. " In the volumes before us. Dr. Dunglison has proved that his acquaintance with the present facts and doc- trines, wheresoever originating, is most extensive and intimate, and the judgment, skill, and impartiality with which Ihe maicrialsof Ihe work have been collected, weighed, arranged, and exposed, are strikingly manifested iii every chapter. Great care is everywhere taken to indicate the source of information, and under the head of treatment, formula; of ihe mo3t appropriate remedies are everywhere introduced. In conclusion, we congratu- late the students and junior practitioners of America, on possessing in the present volumes, a work of standard merit, to which they may confidently refer in their doubl3 and difficulties."—British and Foreign Medical Reviexo for July, 1842. "Since the foregoing observations were written, we have received a second edition of Dunglison's work, a sufficient iiulicat/m of the high character it has already attained in America, and justly attained."—British and Foreign Medical Revuiofor October, 1S44. " We hail ihe appearance of this work, which has just been issued from the prolific press of Messrs. Lea & Blanchard, of. Ph'ladelph'n, with no ordinary degree of pleasure. Comprised in two large and closely printed volumes, it exhibits a more full, accurate, arid comprehensive digest of the existing slate of medicine than any other treatise with which we are acquainted in the English language. It discusses many topics—some of them of great practical importance, which itre entirely omitted in the writings of Eberle, Dewees, Kosaek, Graves, Stokes, Mcintosh, and Gregory; and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as it atfordshim ready access to information of which he stands in daily need in the exercise of his .profession. It has been the desire ofthe author, well known as one of the most abundant writers ofthe age, to render his work strictly practical: and to this end he has been induced, whenever opportunity offered, to incorporate the results of his own experience with that of his scientific brethren in America and Europe. To the formi-r. ample justice seems to have been done throughout. We believe this constitutes the seventh work which Professor Dunglison has published witliin the last ten years; and, when we reflect upon the large amount of labour and reflection which must have been necessary in iheir preparation, it is amazing how he could have accomplished so much in so sliort a time."—Louisville Journal, NEW REMEDIES, PHARMACEUTICALLY AND THERAPEUTICALLY CONSIDERED. By ROBLEY DUNGLISON, M.D., In One Volume, Octavo—over 600 pages, the Fourth Edition. 21 PROFESSOR DUNGLISON'S WORKS. A NEW EDITION OF THE STANTATtD MEDICAL EIOTIOITAR?. A DICTIONARY OF MEDICAL SCIENCE: CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS WITH THE FRENCH AND OTHER SYNONYMES, NOTICES OF CLIMATE AND OF CELEBRATED MINERAL WATERS, FORMULAE FOR VARIOUS OFFICI NAL AND EMPIRICAL PREPARATIONS, ETC. Fourth Edition, Extensively Modified and Improved. By ROBLEY DUNGLISON, M.D., In One Volume, Royal Octavo. "The present undertaking wa3 suggested by the frequent complaints made by the author's pupils, that ther were unable to meet with information on numerous topics of professional inquiry—especially of recent intra- duction—in the medical dictionaries accessible to them. " It may, indeed, be correctly affirmed, that we have no dictionary of medical subjects and terms which can be looked upon as adapted to the state of the science. In proof of this the author need but to remark, that the present edition will be found to contain at least two thousand subjects and terms not embraced in the last edition and to have experienced numerous modifications. ' " The author's object has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. s " To execute such a work requires great erudition, unwearied industry, and extensive research: and we know no one who could bring to the task higher qualifications of this description than Professor Dunglison."—Ameri- can Medical Journal. THERAPEUTICS AND MATERIA MEDICA, GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR A MEDICAL TEXT-BOOK. By ROBLEY DUNGLISON, M.D., In Two Volumes, Octavo'.. "The subject of Materia Medica has been handled by our author with more than usual judgment. The greater part of treatises on that subject are, in effect, expositions of the natural and chemical history of the substanres used in medicine, with very brief notices at all of the indications they are capable of fulfilling, and the general principles of Therapeutics. Dr. Dunglison, very wisely, in our opinion, has reversed all tins, and given hii principal attention to the articles of the Materia Medica as medicines.....In conclusion, we strongly recom- mend these volumes to our readers. No medical student on either side of the Atlantic should be without them." —Forbes' British and Foreign Medical Review. LATELY PUBLISHED, DTJITGLXSOIT OH HTJMAST HEALTH. HUMAN HEALTH; OR, THE INFLUENCE OF ATMOSPHERE AND LOCALITY, CHANGE OF AIR AND CLIMATE, SEASONS, FOOD, CLOTHING, BATHING AND MINERAL SPRINGS, EXERCISE, SLEEP, CORPOREAL AND INTELLECTUAL PURSUITS, &c. &c. ON HEALTHY MAN: CONSTITUTING ELEMENTS OF HYGIENE. By ROBLEY DUNGLISON, M. D., A NEW EDITION WITH MANY MODIFICATIONS AND ADDITIONS. In One Volume, Svo. " We have just received the new edition of this learned work on the ' Elemenls of Hygiene.' Dr. Dunglison is one ofthe most industrious and voluminous authors ofthe day. How he finds time 10 amass and arrange the immense amount of matter contained in his various works, is almost above the comprehens'onol'meii possessing but ordinary talents and industry. Such labour deserves immortality."—St. Louis Med. and Surg. Journal. A NEW EDITION OF THE MEDICAL STUDENT; OR, AIDS TO THE STUDY OF MEDICINE. A REVISED AND MODIFIED EDITION: BY ROBLEY DUNGLISON, M.D., In One neat 12mo. Volume. " In effect, the authors aim is to teach the tyro what he ought lo. and how he may study to the best advantage both before and after he has attained the dignity of a medrcal diploma; and while he gives him much good advice in an agreeable manner and enforced by happyi 1 lustrations, he endeavours to simplify his labours by presenting him with 'a glossary of the prefixes, suffixes and radicals of many of the terms legitimately compounded."ot medical technology, a vocabulary of terms used in prescribing andother useful information."—American Medical Journal. 22 THE CYCL0P/ED1A OF PRACTICAL MEDICINE, TO BE READY IN MARCH. Forming Four magnificent super-royal Octavo Volumes of about 3200 unusually large double-columned pages, printed on beautiful white paper, with a new and clear type, done up in strong sheep binding, or neat extra cloth; or, in Twenty- four Parts, at Fifty Cents each. LEA & BLANCHARD ARE NOW ISSUING THE CYCLOPEDIA OF PRACTICAL MEDICINE: COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, DISEASES OF WOMEN AND CHILDREN, MEDICAL JURISPRUDENCE, &c. &c. EDITED BY JOHN FORBES, M. D , F. R. S., ALEXANDER TWEEDIE, M. D , F. R. S, AND JOHN CONOLLY, M.D. REVISED, WITH ADDITIONS, Bv ROBLEY DUNGLISON, M.D. This work is printed on good paper with a new and clear type, and forms FOUR VERY LARGE SUPEK-ROYAL OCTAVO VOLUMES, with over three thousand unusually large pages, in double columns. This work lias now been in the course of publication for about ten months, and is nearly completed, twenty-two numbers having been issued, and the whole will be completed early in March. The parts already published contain the following valuable articles by distin- guished authors: CONTENTS OF PART I. CONTENTS OF PART III. Abdomen. Exploration of the, Dr. Forbes. Abortion. Dr. Lie. Abscess. Internal, Dr. Tweedie. Abstinence, Dr. Marshall Hall. Achor. Dr. Todd. Acne, Dr. Todd. Acrod) nia. Dr. Dunglison. Acupuncture. Dr. Elliotson. Aye, Dr. Roget. Air, Change of. Sir James Clarke- Alopecia, Dr. Todd. Alteratives, Dr. Conolly. Amaurosis. Dr. Jacob. Amenorrhea. Dr. Loeock. Anemia, Dr. Marshall Hall. Anasarca. Dr. Darwall. Angina Pectoris. Dr. Forbes. Anodynrs, Dr. Whiting. Anlhelm nties. Dr. A. T. Thomson. Anthracion. Dr. Dunglison. Antiphlogislic Regimen. Dr. Barlow. Antispasmodic*. Dr. A. T. Thomson. Aorta. Aneursinof, Dr. Hope. CONTEXTS OF PART II. Apoplexy. Cerebral. Dr. Clutterbuck. ** Pulmonary, Dr. Townsend. Arteritis. Dr. I lope. Ascites. Dr. Darwall. Artisans, Diseases of, Dr. Darwall. Asphvxia, Dr. Rogct. of ihe New Born, Dr. Dunglison. Asthma. Dr. Forbes. Astringents, Dr. A. T. Thomson. Atrophy, Dr. Townsend. Auscultation. Dr. Forbes. Karbiers, Dr. Scott. Bathing, Dr. Forbes. Bathing {continued), Dr. Forbes. Beriberi, Dr. Scott. Blood. Deternvnation of, Dr. Barlow. ■• ' Morbid States of. Dr. Marshall Hall. Blood-letting. Dr. Marshall Hall. Brain, Inflammation ofthe, Meningitis. Dr. Quain. Cerebntis, Dr. Adair Crawford. Bronchial Glands. Diseases ofthe, Dr. Dunglison. Bronchitis. Acute and Chronic, Dr. Williams. " Summer, Dr. Dunglison. Bronchocele, Dr. And. Crawford. Bullee, Dr. Todd. Cachexia. Dr. Dunglison. Calculi, Dr. T. Thomson. Calculous Diseases, Dr. Cumin. Catalepsy, Dr. Joy. Catarrh. Dr. Williams. Cathartics. Dr. A. T. Thomson. Chest, Exploration ofthe, Dr. Forbes. Chicken Pox. Dr. Gregory. Chlorosis. Dr. Marshall Hall. Cholera, Common and Epidemic, Dr. Brown. CONTENTS OF PART IV. Cholera, Epidemic, {continued,) Dr. Brown. " Infantum. Dr. Dunglison. Chorea. Dr. And. Crawford. Cirrhosis ofthe Lung, Dr. Dunglison. Climate, Dr. Clark. Cold. Dr. Whiting. Colie. Drs. Whiting and Tweedie. Colica Pictonum. Dr. Whiting. Colon, Torpor of the. Dr. Dunglison. Coma, Dr. Adair Crawford. Combustion, Spontaneous. Dr. Apjohn. Congestion of Blood. Dr. Barlow. Constipation, Drs. Hastings and Sweeten. S3 Contents of Cyclopedia of Practical Medicine. Contagion. Dr. firown. Convalescence, Dr. Tweedie. Convulsions, Dr. Adair Crawford. " Infantile, Dr. Loeock. " Puerperal, Dr.Locock. Coryza, Dr. Williams. Counter Irritation, Dr. Williams. Croup, Dr. Cheyne. CONTENTS OF PART V. Croap,{continued,) Dr. Cheyne. Cyanosis, Dr. Crampton. Cystitis. Dr. Cumin. Dead, Persons found. Dr. Beatty. Delirium, Dr. Pritchard. " Tremens, Drs. Carter and Dunglison. Dengue, Dr. Dunglison, Dentition, Disorders of, Dr. Joy. Derivation, Dr. Stokes. Diabetes, Dr. Bardsley. Diagnosis. Dr. Marshall Hall. Diaphoretics, Dr. A. T. Thomson. Diarrhcea, Drs. Crampton and Forbes. " Adipous, Dr. Dunglison. Dietetics, Dr. Paris. CONTENTS OF PART VI. Dietetics, (continued,)!)!. Paris. Disease, Dr. Conolly. Disinfectants, Dr. Dunglison. Disinfection, Dr. Brown. Diuretics, Dr. A. T. Thomson. Dropsy, Dr. Darwall. Dysentery, Dr. Brown. Dysmenorrhea. Dr. Loeock. Dysphagia, Dr. Stokes. Dyspnoea. Dr. Williams. Dysuria, Dr. Cumin. Ecthyma, Dr. Todd. Eczema, Dr. Joy. Education, Physical, Dr. Barlow. Electricity, Dr. Apjohn. Elephantiasis. Dr. Joy. Emetics, Dr. A. T. Thomson. Emmenagogues, Dr. A. T. Thomson. CONTENTS OF PART VII. Emphysema, Dr. R. Townsend. " of the Lungs, Dr. R. Townsend. Empyema, Dr. R. Townsend. Endemic diseases. Dr. Hancock. Enteritis, Drs. Stokes and Dunglison. Ephelis, Dr. Todd. Epidemics, Dr. Hancock. Epilepsy, Dr. Cheyne. Epistaxis, Dr. Kerr. Erethismus Mercurialis, Dr. Burder. Erysipelas, Dr. Tweedie. Erythema, Dr. Joy. Eutrophic, Dr. Dunglison. Exanthemata, Dr. Tweedie. Expectorants, Dr. A. T. Thomson. Expectoration. Dr. Williams. Fayus, Dr. A. T. Thomson. Feigned diseases, Drs. Scott, Forbes and Marshall. CONTENTS OF PART VIII. Feigned diseases, {continued,) Drs. Scolt, Forbes and Marshall. Fever, general doctrine of. Dr. Tweedie. '' Continued, and its modifications, Dr. Tweedie. Typhus, Dr. Tweedie. " Epidemic Gastric, Dr. Cheyne. " Intermittent, Dr. Brown. " Remittent, Dr. Brown. " Malignant Remitent, Dr. Dunglison. " Infantile, Dr. Joy. " Hectic, Dr. Brown. " Puerperal, Dr. Lee. " Yellow, Dr. Gillkrest. CONTENTS OF PART IX. Fever, Yellow, {continued.) Dr. Gillkrest. Fungus Haematodes, Dr. Kerr. Galvanism. Drs. Apjohn and Dunglison. Gastritis, Dr. Stokes. Gastrodynia, Dr. Barlow. Gastro-Enterilis, Dr. Stokes. Glanders, Dr. Dunglison. Glossitis, Dr. Kerr, 24 Glottis, Spasm ofthe, Dr. Joy. Gout, Dr. Barlow. Haematemesis. Dr. Goldie. Hcemoptysis. Dr. Law. Headache, Dr. Burder. Heart, Diseases ofthe, Dr. Hope. '• Dilatation ofthe, Dr Hope. " Displacement ofthe, Dr. Townsend. " Fatty and greasy degeneration of the, Dr. Hope. u Hype rtrophy of the, Dr. Hope. CONTENTS OF PART X. Heart, Hypertrophy of the,(continued,) Dr. Hope. " Malformations of ihe. Dr. Williams. " Polypus of the, Dr. Dunglison. " Rupture ofthe. Dr. Townsend. " Diseases ofthe Valves ofthe, Dr. Hope. Haemorrhage, Dr. Watson. Hemorrhoids, Dr. Buriie. Hereditary transmission of disease, Dr. Brown. Herpes, Dr. A. T. Thomson. Hiccup, Dr. Ash. Hooping Cough, Dr. Johnson. Hydatids, Dr. Kerr. Hydrocephalus, Dr. Joy. Hydropericardium. Dr. Darwall. Hydrophobia, Dr. Bardsley. CONTENTS OF PART XI. Hydrophobia, (continued.) Dr. Bardsley. Hydrothorax. Dr. Darwall. Hyperesthesia, Dr. Dunglison. Hypertrophy, Dr. Townsend. Hypoehondrias;s. Dr. Pritchard. Hysteria. Dr. Conolly, Ichthyosis. Dr. Thomson. Identity, Dr. Montgomery. Impetigo, Dr. A. T. Thomson. Impotence. Dr. Beatty. Incubus. Dr. Williams. Indigestion, Dr. Todd, CONTENTS OF PART XII. Indigestion, (continued.) Dr. Todd. Induration, Dr. Carswell. Infanticide. Dr. Arrowsmith. Infection. Dr. Brown. Inflammation, Drs. Adair Crawford and Tweedie. CONTENTS OF PART XIII. Influenza. Dr. Hancock. Insanity. Dr. Pritchard. Intussusception, Dr. Dunglison. Irritation, Dr. Williams. Jaundice, Dr. Burder. ■' of the Infant, Dr. Dunglison. Kidneys, diseases of, Dr. Carter. Lactation, Dr. Loeock. Laryngitis, Dr. Cheyne. '■ Chronic, Dr. Dunglison. Latent diseases. Dr. Christison. ' Lepra, Dr. Houghton. Leucorrhcea, Dr. Loeock. Lichen. Dr. Houghton. Liver, Diseases ofthe, Dr. Stokes. CONTENTS OF PART XIV. Liver, Diseases ofthe, (continued.) Dr. Venahles. " Inflammation ofthe. Dr. Stokes. Malaria and Miasma. Dr. Brown. Medicine, History of, Dr. Bostock. " American, before the Revolution, Dr. J. B. Beck. " State of in the 19th century, Dr. Alison. "' Practical, Principles of, Dr. Conolly. CONTENTS OF PART XV. Medicine. Practical, Principles of, Dr. Conolly. Melrena, Dr. Goldie. Melanosis, Dr. Carswell. Menorrhagia, Dr. loeock. Menstruation, Patliology of, Dr. Loeock. Miliaria, Dr. Tweedie. Milk Sickness, Dr. Dunglison. Mind, Soundness and Unsoundness of, Drs. Pritchard and Dunglison. Molluscum, Dr. Dunglison. Mortification, Dr. Carswell. Narcotics, Dr. A. T. Thomson. Contents of Cyclopvedia of Practical Medicine. Nauseants. Dr. Dunglison. Nephralgia and Nephritis, Dr. Carter. Neuralgia, Dr. Elliotson. Noii-Me-Tangere or Lupus, Dr. Houghton. Nyctalopia, Dr. Grant. CONTENTS OF PART XVL Nyctalopia, (continued,) Dr. Grant. 0; esity, Dr. Williams. IKdtma. Dr. Darwall. Ophthalmia, Drs Jacobs and Dunglison. Omalgia and Otitis, Dr. Burne. Ovaria, Diseases ofthe, Dr. Lee. Palpitation, Drs. Hope and Dunglison. Pancreas, diseases ofthe, Dr. Carter. Paralysis, Dr. Todd. Parotitis. Dr. Kerr. Parturients, Dr. Dunglison. Pellagra, Dr. Kerr. Pemphigus. Dr. Corrigan. .Perforation ofthe I loilpw Viscera, Dr.-Carswell. Pericarditis. Dr. Hope. Peritoiulis, Drs. Ale Adam and Stokes. CONTENTS OF PART XVII. Peritonitis, (continued,) Dr. Stokes. Phlegmasia Dolens, Dr, Lee. Pityriasis, Dr. Cumin. Plague, Dr. Brow u. Plethora. Dr. I'arlow. Pleurisy, Dr. I.aw. Plica Polonica, Dr. Corrigan. Pneumonia, Dr. Williams. Pneumothorax. Dr. Houghton. Porrigo, Dr. A. T. Thomson. CONTENTS OF PART XVIII. Porrigo, (continued.) Dr. A. T. Thomson. Pregnancy and Delivery, signs of, Dr. Montgomery. Prognosis, Dr. Ash. Prurigo, Dr. A. T. Thomson. Pseudo-Morbid Appearances, Dr. Todd. Psoriasis, Dr. Cumin. Ptyalisin. Dr. Dunglison. Puerperal Diseases, Dr. Marshall Hall. Pulse, Dr. b'ostock. Purpura, Dr. Goldie. Ptis, Dr. Tweedie. Pyrosis, Dr. Kerr. Rape, Dr. Beatty. CONTENTS OF PART XIX. Refrigerants, Dr. A. T. Thomson. Rheumatism, Drs. Barlow and Dunglison. Rickets, Dr. Cumin. _, Roseola, Dr. Tweedie. Rubeola, Dr. Montgomery. Rupia, Dr. Corrigan. Scabies, Dr. Houghton. Scarlatina, Dr. Tweedie. Scirrhus, Dr. Carswell. Scorbutus. Dr. Kerr. Scrofula, Dr. Cumin. CONTENTS OF PART XX. Scrofula, [continued.) Dr. Cumin. Sedatives. Drs. A. T. Thomson and Dunglison. Sex, Doubtful, Dr. Beatty. Small Pox, Dr. Gregory. Softening of Organs, Dr. Carswell. Somnambulism and Animal Magnetism, Dr. Pritchard. Spermatorrhoea, Dr. Dunglison. Spinal Marrow, Diseases ofthe, Dr. Todd. Spleen, Diseases ofthe, Drs. Bigsby and Dunglison. Statistics, Medical, Drs. Hawkins and Dunglison. Stethoscope. Dr. Williams. Stimulants. Dr. A. T. Thomson. Stomach, Organic Diseases of, Dr. Houghton. CONTENTS OF PART XXI. Stomach, Organic Diseases of, (continued,) Dr. Hough- ton, and Dunglison. Stomatitis, Dr.Dunglison. Strophulus. Dr. Dunglison. Succession of Inheritance, Legitimacy, Dr. Montgomery. Suppuration, Dr. Todd. Survivorship, Dr. Beatty. Sycosis, Dr. Cumin. Symtomatology, Dr. Marshall Hall. Syncope. Dr. Ash. Tabes Mesenterica, Dr. Joy. Temperament. Dr. Pritchard. Tetanies. Dr. Dunglison. Tetanus, Dr. Symonds. Throat, Diseases ofthe, Dr. Tweedie. Tissue Adventitious, Tonics, Dr. A.T. Thomson. CONTENTS OF PART XXII. Tonics, (continued.) Dr. A. T. Thomson. Toothache, Dr. Dunglison. Toxicology, Drs. Apjohn and Dunglison. Transformations, Dr. Duesbury. Transfusion, Dr. Kay. Tubercle, Dr. Carswell. • Tubercular Phthisis, Dr. Clark. " We rejoicethat this work is to be placed within the reach of the profession in this country, it being unques- tionably one of very great value to the practitioner. This estimate of it has not been formed from a hasty exami- nation, but after an intimate acquaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many ofthe most eminent professors and teachers of London, Edinburgh, Dublin and Glasgow. It is, indeed, the great merit of this work that the principal articles have been furnished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them,—and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority."—American Ifotlical Journal. v Do young physicians generally know what a treasure is offered to them in Dr. Dunglison's revised edition? Without wishing to be thought importunate, we cannot very well refrain from urging upon them the claims of this highly meritorious undertaking."—Boston Medical and Surgical Journal. "It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English Medicine is exhibited in the most advantageous light, and with adaptations to various tastes and expecta- tions. The Publishers can be safely relied on as both able and willing to carry thi3 undertaking through with all possible expedition."—Medical Examiner. " Such a work as this has long been wanting in this country. British medicine ought to have set itself forth in this way much sooner. We have often wondered that the medical profession and the enterprising publishers of Great Britain did not long ere this, enter upon such an undertaking as a Cyclopaedia of Practical Medicine."— London Medical Gazette. '"The Cyclopa-dia of Practical Medicine, a work which does honour to our country, and to which one is proud to see the names of so many provincial physicians attached."—Dr. Hastings'1 Address to Provincial Medical arid Surgical Association. "Of the medical publications ofthe past year, one may be more particularly noticed, as partaking, from its ex- tent and the number of contributors, somewhat ofthe nature of a national undertaking, namely, the 'Cyclopaedia of Practical Medicine.' It accomplishes what has been noticed as most desirable, by presenting, on several impor- tant topics of medical inquiry, full, comprehensive, and well-digested expositions, showing the present state of our knowledge on each. In ihis country, a work of this kind was much wanted: and that now supplied cannot but be deemed an important acquisition. The difficulties of the undertaking were not slight, and it required great energies to surmount them. These energies, however, were possessed by the able and distinguished editors, who, with diligence and labour such as few can know or appreciate, have succeeded in concentrating in a work of moderate size, a body of practical knowledge of great extent and usefulness.''—Br. Barlow's Address to the Med. and Sur. Association. 25 Cyclopaedia of Practical Medicine continued. "This Cyclopaedia is pronounced on all hands to be one of the most valuable medical publications of the day It is meant to be a library of Practical Medicine. As a work of reference it is invaluable. Among the contri.SuJ tors to its pages it numbers many of the most experienced and learned physicians of Ihe age, anil as a wiloli> it forms a compendium of medical science and practice from which practitioners and students may draw tke richest instruction."— Western Journ. of Med. and Surgery. "In pur last number we noticed the publication of this splendid work by I.ea and Blanchard. We have sinr* received three additional parts, ah examination of which has confirmed us in our first imjiression, that as a work of reference for the practitioner—as a cyclopaedia of practical medicine—it is admirably adapted lolhe wants of the American profession. In fact, it might advantageously find a place in the library of any gentleman, who has leisure and taste for looking somewhat into the nature, causes, and cure of diseuses."—Western Journal of HUd and Surgery. . "The favourable opinion which we expressed on former occasions from the specimens then before us, is in no degree lessened by a further acquaintance with its scope and execution."—Medical Ernmintr. "in conversation with practising physicians, we have been gratified to find that this work cornea fully op to the high expectations formed of it from the complimentary notices of the Journals, and that ns a work of reference it is regarded as superior to any thing hitherto published on Practical Medicine."— Western Journal of Med. and Surgery. *** In reply to the numerous inquiries made to them respect- ing Tweedie's Library of Practical Medicine, the Publishers be^ leave to state that its place is supplied, in a great measure, by the Cyclopaedia of Practical Medicine, a work much more extended in its plan and execution. The works are entirely distinct and "by different authors. The '.'Library" consists of essays on dis- eases, systematically arranged. The " Cyclopaedia" embraces these subjects treated in a more extended manner, together with numerous interesting essays on all important points of Medical Jurisprudence, Materia Medica and Therapeutics, Obstetrics, History of Medicine, &c, &c. by the first physicians of England, the whole arranged alphabetically for easier reference. JUST PUBLISHED, CHAPMAN ON FEVERS, ftc. LECTURES ON THE MORE IMPORTANT ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, AND ON GOUT AND RHEUMATISM, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M. D., Professor ofthe Theory and Practice of Medicine, &c. &c. In one neat octavo volume. This volume contains Lectures on the following subjects: EXANTHEMATOUS FEVERS. Variola, or Small Pox; Inoculated Small Pox; Varicella, or Chicken Pox; Variola Vaccinire, or Vaccinia, or Cow-pock; Varioloid Disease; Rubeola, Morbilli. or Measles; Scarlatina vel Febris Rubra—Scarlet Fever. HJEMOKKHAUbS. Haemoptysis. Spitting; of Blood; M.-pmorrhajr'a Narium. or Itermorrhajre from the Nose: Ftrmmomesis, or Vomit* ing of Blood; Hematuria, or Voiding of Bloody Urine; Ha>morrhagia Utcrina. or Uterine Hemorrhage; Hxroor- rhois or fcta;morrlioids; Cutaneous Haemorrhage; Purpura Itemorrhagica. DKOPS1ES. Ascites; Encysted Dropsy; Hydrothorax; Hydrops Pericardii; Hydrocephalus Internus. acute, subacute, and chronic: Anasarca; with a Disquisition on the Management ofthe whole. GOUT, RHhUtMATlsM &c &c. THEY HAVE ALSO FuR SALE LECTURE2 GN THE MORE IMPORTANT DISEASES OF THE THORACIC AND ABDOMINAL VISCERA, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. Br N. CHAPMAN, M.D. Professor ofthe Theory and Practice of Medicine, &c. In one volume, octavo. 26 LEA & BLANCHARD PUBLISH AND HAVE FOR SALE, HCRITER'S AITATOMY. SPECIAL ANATOMY AND HISTOLOGY. BY WILLIAM E. HOKNER, M. D., Professor of Anatomy in the University of Pennsylvania, Member of the Imperial Medico-Chirurgical Academ) of St. Petersburg, of the Am Philosophical Society, &c. &.C. Sixth edition, in two volumes, 8vo. " Another edition of this standard work of Professor Horner has made its appearance to which many additions have been made, and upon which mim|i labour has been bestowed by the author. The additions are chiefly in the department of Histology, or Elementary Anatomy, and so important are they that the Professor has added the term to the title ofh's work. Every part of this edition seems to have undergone the most careful revision," and its readers may rest assured of having the science of Anatomy fully brought up to the present day."—Am. Med, Journal._______________________________ GIAHAM'S CHEMISTRY, THE ELEMENTS GF CHEMISTRY, Including the application of the Science to the Arts. WITH NUMEROUS ILLUSTRATIONS. BY THOMAS GRAHAM, F.R.S., L. and E. D. Professor of Chemistry in University College, London, &c. &c. WITH NOTES AND ADDITIONS BY ROBERT BRIDGES, M. D., &c &c In One Vol. Octavo. The great advancement recently made in all branches of chemical investigation renders necessary a new text book which shall clearly elucidate the numerous discoveries, especially in the department connected with organic Chemistry and Physiology, in which such gigantic strides have been made during the last few years. The pre- sent treatise is considered by eminent judges to fulfil all these indications, and to be peculiarly adapted to the wants ofthe medical student and practitioner. In adapting it to the wants ofthe American profession, the editor has endeavoured to render his portion of the work worthy the exalted reputation ofthe first chemist of England. It is already introduced as a text book in many ofthe Colleges, and has universal approbation. "Professor Graham's work is one ofthe best, if not the best, of all English text books, and is of such recent date as to embrace all the latest discoveries. The appearance of a correct and amended American Edition, under the care of Dr. Bridges, will prove an acceptable thing to both teachers and students of Chemistry in thi3 country." —Sittiman's Journal. FEREIRA'S MATBRIaTmBDIGA. WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES. BY JONATHAN PEREIRA, M. D., F. R. S. and L. 8. From the Second London Edition, enlarged and improved. WITH NOTES AND ADDITIONS By JOSEPH CARSON, M D. In Two Vols. Octavo. The object of the author has been to supply the Medical Student with a Class Book on Materia Medica, containing a faithful outline of this Department of Medicine which should embrace a concise account ot the most important discoveries in Natural History,-Chemistry, Physiology and Therapeutics, in so far as they pertain to Pharmaco- logy, and treat the subjects in the order of their natural historical relations. This great Library or Cyclopaedia of Materia Medica has been fully revised by DR. JOSEPH CARSON, profes- sor of Materia Medica and Pharmacy in the " College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and closely-printed pages. It may be fully relied upon as a permanent and standard work for the country,—embodying, as it does, full references to the U. S. Pharmacopoeia and an account of the Medical Plants indigenous to the United States.________________________________________ FERGUSSON'S PRACTICAL SURGERY. A SYSTEM OF PRACTICAL SURGERY, BY WILLIAM FERGUSSON, F.R.S E., Professor of Surgery in King's College, London; Surgeon to King's College Hospital, &c. &c. WITH TWO HUNDRED AND FORTY-SIX ILLUSTRATIONS. Engraved by Gilbert, after drawings by Bagg. WITH NOTES AND ADDITIONAL ILLUSTRATIONS BY GEORGE W. NORRIS, M. D., In one volume octavo. The publishers commend this work to the attention ofthe Profession as combining cheapness and elegance with aclear, sound, and practical treatment of every subject in surgical science. No pains or expense have been spared to present it in a style equal, if not superior to the London edition, and to match the editions of " Wilson's Anatomy," "Churchill's System of Midwifery," and " Carpenter's Human Physiology." It is now extensively used as a text book. 27 LEA AND BLANCHARD ARE PREPARING FOR PUBLICATION A MANUAL OF ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. By GEORGE FOVVNES, PH. D. WITH NUMEROUS WOOD ENGRAVINGS, And Notes and Additions by ROBERT BRIDGES, M.D, Professor of Chemistry in the "Philadelphia Medical Association," &c. &c. In one vol. royal 12mo. HOBLTfTTSDICl^O^fARy. A DICTIONARY OF TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES, # FOR THE USE OF «I UDENTS. BY RICHARD D. HOBLYN, M. D., &c. From the Second London Edition, with numerous additions. BY ISAAC HAYS, M. D., &c In One Volume, royal 12mo. BUTHRIE ON THE ANATOMY OF THE BLADDER AND THE URETHRA, AND THE TREATMENT OF THE OBSTRUCTIONS TO WHICH THOSE PASSAGES ARE LIABLE. From the Third London Edition, In one volume, 8vo. ALSO, ~~' ANOTHER VOLUME OF THE SPLENDID SERIES OF THE WORKS OF SIR ASTLEY COOPER. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST. The whole to form one large and beautiful imperial octavo volume, with numerous plates in the best style of Lithography, and printed and bound to match the volumes on Hernia and the Testis already issued. L. & B. HAVE LATELY PUBLISHED CARPENTER'S PHYSIOLOGY. PRINCIPLES OF HUMAN PHYSIOLOGY. With their chief applications to Pathology, Hygiene, and Forensic Medicine. Especially designed for tiie use of Students. IFVf/i over One Hundred beaulifut Illustrations on Wood. BY WILLIAM B. CARPENTER, M. D., Lecturer on Physiolozy in the Bristol Medical School. FIRST AMERICAN EDITION, WITH NOTES BY THE AUTHOR, AND NOTES AND ADDITIONS BY MEREDITH CLYMER, M.D., In one volume, octavo. ICP This edition of Carpenter's Physiology has been most carefully prepared by Dr. Cly- mer, at the request of Professor Jackson, for his lectures at the University of Pennsylvania. ALISONS PATHOLOGY. A NEW WORK. OUTLINES OF PATHOLOGY AND PRACTICE OF MEDICINE. BY WILLIAM PULTENEY ALISON, M.D., Professor ofthe Practice of Medicine in the University of Edinburgh, &c. &c. In three Parts-Part 1 —Preliminary Observations- Part II.- Inflammatory and Febrile Diseases, and Part III., Chronic or Non-Febrile Diseases. In one volume octavo. For numerous other works not detailed, see tbe Two following Pages. 28 WORKS . IN THE VARIOUS DEPARTMENTS OP MEDICINE AND SURGERY: PUBLISHED BY LEA & BLANCHARD. ANATOMY. ANATOMICAL ATLAS, illustrative of the Structure of the Human Body; with over Six Hundred Illustrations; the most complete work of the kind ever issued,— beautifully executed, in One Volume Im- perial Octavo; by H. H. Smith, M.D., un- der the supervision of Professor W. E. Hor- ner. HORNER'S Special Anatomy and His- j tology; 6th edition, much improved. 2 vols. i 8vo., 1114 pages. WILSON'S Human Anatomy; anew '■ edition (the second) revised, with additions ; by Dr. Goddard: 207 beautiful cuts. 8vo., ; 60S pages. WILSON'S Dissector, or Practical and ; Surgical Anatomy; with additions by God- ; dard—106 cuts. Royal 12mo., 444 pages. PHYSIOLOO-Y. CARPENTER'S Human Physiology; with notes and additions by Meredith Cly- mer, and over 100 cuts—in 8vo., 618 pages. 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AMERICAN JOURNAL OF THE MEDICAL SCIENCES; edited by Dr. Isaac Hays, published Quarterly at Five Dollars a Year. CYCLOPEDIA OF PRACTICAL MEDICINE; comprising Treatises on the nature and treatment of Diseases, includ- ing those of Women and Children, Materia Medica, Therapeutics, Medical Jurispru- dence, &c, &c. Edited by Forbes, Twee- die, Conolly and Dunglison. 4 large Su- ; per-Royal Octavo Volumes. About 3000 ! pages in double columns. DUNGLISON'S Medical Dictionary; 14th edition, containing over 40,000 words land synonymes; large 8vo., of 772 pages, ; double columns. MEDICAL NEWS AND LIBRARY. Published Monthly at One Dollar a Year. SELECT MEDICAL ESSAYS; by Drs. Dunglison, Chapman and others.—2 vols. 8vo., 1150 pages. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. UEA fc BLANCHARD are the Publishers of the American Journal of the Medical Sciences, Edited by ISAAC KAYS, M. D., Surgeon to Wills' Hospital, Physician to the Philadelphia Orphan Asylum, Member of Ihe Am. Philos. Soc., *c. &c. 4.C.. assisted by numerous collaborators in every section of the Union. This Journal was commenced TWENTY-FIVE YEARS AGO. and it is therefore the oldest Medical Journal now existing in the United States, antl its permanency may be considered as established. It was originally .edited by Dr. Chapman, who has been a constant contributor to its pages; and, for the last .eighteen years, it has been under the editorial direction of Dr. Isaac Hays. The pages of this Journal contain the records of the experience of the most distinguished members of tho Profession in every part of the Union. CONTENTS OF THE NO. FOR JANUARY, 1S45. Memoirs and Cases.—Art. I. Cases of Strangulated Hernia, with some remarks principally intended to show the necessity of an early resort to the operation. By John C. Warren, M. D. II. On the Pathology of Remittent Fever. By John A. Swett, M. D. III. On the treatment of Yellow Fever. By F. Wurdemann, MD. IV. On the Pulse of the Insane, by Pliny Earle, M. D. V. Temporary Protrusion of the Eyeball, with loss of Vision, from rheumatic inflammation. By Isaac G. Porter, M. D. VI. On Obstetrical Auscultation. By L. S. Joynes. M. D. VII. Tumourof the Neck,of extraordinary size, successfully removed. ByP.C.Spen- cer, M. D. [With two wood cuts J VIII. Surgical Cases. By Edwin Hall, M. D. IX. Cases of Strangulated Hernia. By A. B. Shipman, M.'D. # Reviews.—X. Pouchet on the Fecundation of the Mammifera?. Raciborski on Puberty and the Critical Age in Women, and ofthe Periodical Discharge of Ova, &c. Bischoffon the Proof of 4he Periodical Ripening and Separation ofthe Ovaof Mammalia and Man. independent of Coitus. XI. Chadwick on Interment in Towns. Bibliographical Notices.—XII. 1. The Twentieth Annual Report of the Officers of the Retreat for the Insane at Hartford. 2. Eighth Annual Report of the Physician and Superintendent of the Vermont Asylum for the Insane. 3. Report of the Superintendent of the Boston Lunatic Hospital, and Physician of the Public Institutions of South Boston.—XIII. 1. Reports of the state of the Kent County Lunatic Asylum. 2. State- ments of the Visiting Committee of the County Lunatic Asylum, near Gloucester. 3. The Report of the Committee of Visitors of the Lunatic Asylum for the County of Leicester. 4. Thirty-third Annual Report of Ihe General Lunatic Asylum, near Nottingham. 5. Reports of the Medical Officers of the Lunatic Asylum for the County of Lancaster. 6. Fifty-ninth, sixty-fourth and Sixty-Eighth Reports of the Visiting Justices of the County Lunatic Asylum at Hanwell. XIV. Zeis on the Plastic Surgery of Celsus: on Organic Adhesions: and on Inverted Toe-Nail. XV. Wattman on Means of Preventing the Rapid Occurrence of Fatal Symp- toms in the Accidental Introduction of Air into the Veins. XVI. Hennemann on a New Series of Subcuta- neous Operations. XVII. Hufeland's Enchiridion Medicum. XVIII. Summary of the Transactions of the College of Physicians of Philadelphia. March to October, 1S44. XIX. Chapman on the more important Eruptive Fevers, Haemorrhages and Dropsies, and on Gont and Rheumatism. SUMMARY OF THE IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. Anatomy and Physiology.—1. Scherer on the Coloration of the Blood. 2. Jobert de Lamballe on the Struc- ture of the Uterus. 3. Mulder on the products of the oxidation of Protein in the Animal Organism. 4. Moreau on the causes which determine the Sex in Generation. 5. Magendie on the Influence of Heat and of Stoves on Animal Life. 6. Bernard and Barreswil on Alimentary Substances. 7. Schvian on the importance of Bile in the Living Animal Organism. 8. Bluquiere on Gunshot Wound of the Anterior Cerebral Lobes. 9. Boudet on the Chemical Composition of the Pulmonary Parenchyma and of Tubercles. Materia Medica and Pharmacy.—10. Seidlitz on Cotton as a Dressing to Blisters. 11. Devay on the mode of preparing the Valerianate of Zinc. 12. Bouchardat on Croton Oil Plaster. 13. Millot on the Lithontriptic action of the Gastric Juice. 14. Gumprecht on Cortex Frangulae. 15. Scheidemandel on the mode of preparing some Narcotic Extracts in small quantities. 16. Burton on a new method of making Medicated Tinctures. 17. Hoffman on Caroub of Judea in Asthmatic Affections. Medical Pathology and Therapeutics and Practical Medicine.—IP. Lossnte on Smalt-pox in persons who had been Vaccinated. 19. Bertini and Bellingiere on Nitrate of Silver in Chronic Diarrhoea. 20. Bellin- giere on Balsam of Copaiba in Chronic Bronchitis. 21. Druitt on the uses of Pure Tannin. 22. Fourcault on the causes of Albuminuria. 23. Meyer's Researches on Albuminuria. 24. Rees on the Pathology and Treat- ment of the Morbus Brightii, and various forms of Anaemia. 25. Gregory on Deaths from Small-pox after Vaccination, in London. 26. Devay on Valerianate of Zinc in Nervous Affections. 27. Perini on a singular case of Encephalitis. 28. Salvagnoli on Analysis of the Blood of Persons Exposed to Malaria. 29. (Esterlen on the Passage of Metallic Mercury into the Blood and Solid Tissues. 30. Lamothe on Epilepsy caused by a Foreign Body in the Ear, and cured by its removal. 31. Symptoms of Acute Pleurisy, caused by Intestinal Worms. 32. J. and J. H. Smith on Sulphate of Iron combined with an Alkaline Carbonate,.an Antidote for Prussic Acid. 33. Mac Donnel on the Diagnosis of Empyema. 34. Mondiere on a Taenia evacuated through an opening in the Abdominal Parietes. 35. Trousseau on the Signs of Auscultation in Young Children. Surgical Pathology and Thehapeutics and Operative Surgery.—36. Syme on treatment of Obstinate Stricture of the Urethra. 37. Reybard on Suture of the Intestine. 39. Bodinier on the Nature and Source ofthe Liquid which flows from the Ear producing OZdema of the Scalp. 39. Danville on Gunshot Wound, where the charge passed from the Navel to the Back without fatal consequences. 40. Sandham on mode of Reducing Partial Displacement of the Semi-lunar Cartilages of the Knee-joint. 41. Porter on Operation for the Radical Cure of Hydrocele. 42. Two cases of Luxation of the Iliac Bone upon the Sacrum. 43. Singular cause of Error in Diagnosis of Affections ofthe Knee. 44. Daniell on Warty Excrescences near the Verge of the Anus. 45. Daniell on Enormous Steatoma removed from the Shoulder. 46. Jtaffreson on Operations for Removal of Ovarian»Tumours. 47. Bird on Removal of a Diseased Ovary. 48. Wiase^ on Ununited Fracture Successfully Treated by Acupuncture. 49. Monin on Luxation of the Forearm forwards without fracture of the Olecranon. 50. Segalas on Influence of Traumatic Lesions of the Spinal Cord on Diseases of the Urinary Passages. 51. Wildebrand op the Treatment of Syphilis by Tartar-emetic. 52. Barbiere's case of Recovery from Wound with Hernia of the Lung. . 53. Syme on Popliteal Aneurism in a Child. 54. Rognetta on Epidemic Erysipelas. 55. Inman on Mortality attending the operation of Tying the Large Arteries. 56. Vanzetli on Fibrous Tumour of the Parotid. 57. Vidal on New Operation for Varicocele. 58. Inman on Mortality attending the Operation for Hernia. 59. Laugier on Immovable Bandages of Starched Papej for the Treatment of FractuTes of the Limbs. . 60. Cox on Gunshot Wound of the Chest—evacuation of the ball per anum. 61. Wilde on Discharges from the Ears. 62. Syme on Bursal Swelling of the Wrist and Palm of the Hann. Ophthalmology.—63. Morant on Epidemic Ophthalmia. 64. Bernard's Method of Curing Lachrymal Fistula? and Chronic I.uchrymations reputed incurable. 65. Dalrympleon Cyst attached to the Anterior Surface of the-Iris. Midwifery.—66. Praelon Caesarian operation performed with success both for the mother and child; rupture of the uterus and of the abdominal parietes thirteen months subsequently, during a second pregnancy; delivery of the fcetus through this spontaneous opening; complete recovery of the mother. 67. Fischer's case of Grnvid Uterus passing into the Sac of an old Inguinal Hernia.—Caesarian Section. OS. Aubinais on Polypus of the Uterus adherent lo the Placenta Successfully Removed. 69- Ginestet on the Juice of the Urtica Urens ill Uterine Hemorrhage. 70. Darbey on Prolapsed Uterus— Pregnancy. 71. Lee on Dropsy of the Amnion 72. Lee on the Causes and Treatment of Uterine Hemorrhage, in the latter months of pregnancy. 73. Lee on Retained Pla- centa. 74. Lisfranc on Diagnosis of Inverted Uterus and Polypus. 75. Murphy's Statistics of Obstetric Practice. Medical Jurisprudence and Toxicology.—76. Olivier on Arsenic in the Earth of Cemeteries. 77. Ramsay on Aconitum Napellus. 78. Jacob on Poisoning by Euphorbia Lathyris, 79. Rupture of the Omentum. 80. Lis- franc's opinion on some Disputed Points in Obstetrical..Medical Jurisprudence. 81. Hereditary Insanity,how far, in cases of alleged unsoundness of mind, it may be pleaded. P2. Simpson on Relative Weight and Size of the Male and Female at Birth. 83. Copper Tanks at St. Uelena. 84. Trial for Murder. 85. Case of Suicide. 86. Recent English Law Cases. 87. Obituary of Dr. Abercrombie. American Intelligence.—Original Communications.—Horner on the Preservation of the Human Body for Anatomical Purposes. Proceedings ofthe Association of Medical Superintendents of American Institutions for the Insane. Perkins's Cases of Congestive Fever. Domestic Summary.—Fourgcaud on Mortality among Children in St. Louis. Le Conte on Extraordinary Effects of a Stroke of Lightning. Bowles on Removal of a Diseased Ovarium. Herrieh on Rupture of the Spleen. Marthens on Fracture during Pregnancy. Buck and Watson on Opium a Hazardous Remedy in Stran- gulated Hernia. Yellow Fever at Woodville, Miss. Davis on Colon Strangulated by the Meso-colon. Clark on Discharge of a Lumbricus from the Male Urethra. M'DoweU's cases of Extirpation of Diseased Ovaria New Works. Death of Dr. Forty. 31 AMERICAN MEDICAL JOURNAL PUBLISHERS' "NOTICE. In presenting the first number for the year of The American Journal Of thp Medical Sciences, the Publishers must offer their thanks to the profession for the increased favour extended to this long-established periodical, now the oldest Medi- cal Journal in the Union. As an evidence of this patronage it may be stated, that notwithstanding an enlarged edition was printed for last year, at the present time not a single copy of the January or October numbers can be supplied. It is intended to continue the work as heretofore, with about 264 large pages quarterly, with sudi cuts and plates as are essential to illustrate the different papers' and particular attention is invited to that portion embracing ' THE RETROSPECT FOR THE QUARTER, Presenting, as it does, the most copious Summary ofthe Improvements and Dis- coveries in Medicine and Surgery, from all the various Journals published abroad and at home. With a view of extending the circulation rjfthe Journal, the publishers are now furnishing, with it— A MONTHLY PERIODICAL,, FREE OF CHARGE, to such subscribers as remit Five Dollars in advance. Attention is solicited to the following terms:— Those persons who remit Five Dollars by the first of March, will receive not only The Medical Journal for 1845, but the Medical News and Library for 1845 free from any further charge. For Ten Dollars they will furnish the Journal for 1845 and 1846, and the News for 1844, 1845 and 1846 free from any further charge. Subscribers who have not yet paid for the year 1844, are particularly requested to remit at once, and are informed that if Ten Dollars are remitted at once it will be placed to their credit for the Journal for 1844 and 1845, and the News for the same years sent free of charge. No such terms can be made except to subscribers who remit in advance, free of postage, and direct to the Publishers. Agents can furnish the News gratis to be sent by mail, only in cases where the subscription, Five Dollars, for the Journal, is paid in advance: under no other cir- cumstances will they send The News gratis. Early orders are solicited, as very few more copies ofthe Journal willbe printed than are actually subscribed for, and subscribers may be disappointed in obtaining the early Numbers of the year, as was the case in the last volume. The Medical News and Library for 1845 will contain, in addition to the News ofthe month, ™ rnTD1S SS?GICAl MURES OP SIR BENJAMIN RRODIE; I hus following Watson's Practice of Physic, (which occupied the Library portion ofthe News for 1843 and 1844,) with a work On Surgery of great practical value, and by one ofthe first and most authoritative surgeons of the day. The pages ofthe Lectures will be so arranged that, when complete, they can be bound in a volume. I he News and Library will be issued monthly, and contain 32 pages, and go by mail as a newspaper. Price One Dollar a year, payable in advance, and in current funds, free of postage. Postmasters are at liberty to frank remittances in payment for subscriptions. 1 he Publishers beg to present the Contents of the Journal for January 1845, which will be found on the preceding page. B^~ This paper may be delivered to any physician if declined by the person to whom it is addressed or if they have removed—and Postmasters and others will particularly oblige the publishers by furnishing a list of the Physicians and Law- yers of their county or neighbourhood. In addition to the business it may bring to the office, a copy of " The Complete Florist," or such other volume, will be sent by mail gratis for any ten or more names furnished free of cost. Philadelphia} January. 1845. 32 ff ? r(* ^ tVN ^m01«IOm„M IVNOUVN 1N.3.03W JO A.V.,1, IVNOUVN 3NI3.03W JO A.V..M, "N 3NI3IQ3W JO UV11I, IVNOUVN IN DIQJN JO AIVIII1 IVNOUVN 3 N I 3 I 0 3 W J 0 A IV >g 11 1 VNC INE NATIONAL LIBRARY OF MEDICINE NATION AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MIDICl INE NATIONAL LIBRARY OF ME DI C I NE N A T I O N A L 11 B R A R Y O F M E D I C I N E N A T I O N A I 11 B R A R Y OF MIDII 5 ' I^V i VN 3N 13 IQ3W JO ABVaail TVNOU VN 3 N I 3 I d 3 W J O A « V B a I 1 1 V N O 11 V N 3 N I 3 I 0 3 W J O A I V « I 11 1VN0I1' t-INt NATIONA INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEI 'N 3NI3I03W jo Aavaan ivnouvn indiqiw jo Aavaan ivnouvn 3Ni3ia3w jo Aavaan ivn > I < ki j r , <£zxu \ ij,jyp.'^iL^T national library of NLn 01001571 M NLM010015714