• . PRIi^CIPlES &PRACTICE f-^OF PHYSIC ? WATSON ABRIDGED: A SYNOPSIS OF THE LECTURES ON THE PPJNCIPLES AND PRACTICE OF PHYSIC DELIVERED AT KING'S COLLEGE, LONDON, THOMAS WATSON, M.D." fellow of the royal college of physicians j late physician to the middlesex hospital; and formerly fellow of st. John's college, Cambridge. (ABRIDGED FEOM THE LAST ENGLISH EDITION.) WITH A CONCISE BUT COMPLETE ACCOUNT OF THE PROPERTIES, USES, PREPARATIONS, DOSES, &C, ( TAKEN FROM THE U. S. DISPENSATORY,) OF ALL THE MEDICINES MENTIONED IN THESE LECTURES, AND WITn OTHER VALUABLE ADDITIONS, J. J. MEYLOR, A. M., M. D. ,? "£r£C33*/ PHILADELPHIA: PUBLISHED BY THE AUTHOR. 1*67. m& W342w Entered, according to the Act pf Congress, in the years 1860 and 1866, By JOHN J. MEYLOR, M. D., In the Clerk's Office of the District Court of the United States for the Eastern Distrii of Louisiana. King & Baird, Printers, 607 Sansom Street, Philadelphia. SIR THOMAS WATSON, M. D.; Bart.; Pres. R. C. P. THIS ABRIDGMENT OF HIS MOST VALUABLE LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC, |s Post llespedfarg ^ebitalrb, AS A TESTIMONIAL OF HIGH APPRECIATION OF HIS TRANSCENDENT PROFESSIONAL TALENTS, AND AS A GRATEFUL ACKNOWLEDGMENT OF HIS KINDNESS IN APPROVING OF THIS WORK OF HIS SINCERE ADMIRER, THE AUTHOR. PREFACE. In presenting to the medical public this Abridgment of so important and well-known a work as Watson's Lectures on the Principles and Practice of Physic, it is due to the Profession to state what were the objects had in view in its preparation, and what are the merits claimed for it. The principal object that induced the making of this Abridgment was to afford young practitioners, who are often at a loss what to do on their first "sick call," and country and other physicians, whom numerous professional duties prevent from consulting more extended works, a convenient and expeditious means of reference in their daily rounds. Another, but no less important, object was to supply medical students, during lecture seasons, with a ready means of reading over, in a few minutes, the various subjects treated of in his daily lecture by the Professor on Practice. The merits of this Abridgment and the advantages claimed for it are: 1, that it is of pocket-size; 2, that it contains every thing of importance to be found in the large work; 3, that the lectures, being short, can be read in a few minutes ; 4, that the matter of each lecture is divided, according to the subject, into parts, by such side-heads as Symptoms, Treatment, Causes, Diagnosis, Prognosis, &c, thus rendering it easy to obtain, at a glance, any required information ; 5, that, being numbered as in the large work, the lectures can readily be compared with the original • (v) VI PREFACE. 6, that, in addition to the various tables, and the List of Poisons, their Symptoms and Treatment, it contains a short account of the Uses, Preparations, Doses (taken from the United States Dispensatory) of the many medicines mentioned in the work. It may be supposed, with regard to some of the lectures, that they are too short to contain all the substance of the original. A careful comparison of the two, however, will show this supposition to be totally groundless; for great pains have been taken, and much anxiety felt, to make this little work what it claims to be, a faithful Abridgment of Watson's Lectures. Should any of the first few lectures appear disconnected in their parts, or rather short, it must be remembered that they treat of general principles which often have no close connection with each other, and that many of these princi- ples often form the subject of a single lecture. The rest of the lectures, however, which treat of particular diseases, are intimately connected throughout all their parts; so that the reader obtains clear and connected ideas of the matter of each as he progresses. Those lectures that treat of one or two subjects are gen- erally of moderate length ; but those that treat of many or very important ones, are necessarily longer. With these remarks, this little work is given to the public, it being hoped that the profession will read before passing judgment on it, and that they will not be too severe « in their condemnation, if it fall short of what they think it should be. To the many eminent physicians throughout all parts of the country, who, by approving of the Author's efforts and plan in preparing this Abridgment, have greatly encour- aged him in his labors, he takes this means of tendering his most cordial thanks. J. J. M. A Letter from Sir T. Watson, M. JD., Bart. The Author takes great pleasure in laying before the medical public the following letter, received by him from Dr. T. Watson: 16 Henrietta Street, Cavendish Square, W., June 7, 1866. Dear Sir : I take great shame to myself for having suf- fered your very flattering letter to remain so long without a reply. I assure you that I am very proud of the favor with which my Lectures have been received in America, and I must offer to yourself in particular my best thanks for the honor you have done them and me in condensing them into a more portable and convenient form. I only regret that I have not been able to find time—and perhaps I never may be able—to revise them for a new edition. Our common profession is making such large advances every year, that a work on the Practice of Physic must very soon become stale and defective. Should I ever accomplish tho, revision I desire to make, one of the first persons to whom I should wish to transmit a copy across the Atlantic will be yourself; and I shall receive with pleasure and grat- itude the copy of " Watson Abridged" which you have been kind enough to promise me. It is always a great gratification to me to see any of my American brethren of the profession, and ***** Believe me, dear sir, to be, with much regard, Very truly yours, THOS. WATSON. Dr.'Meylor. (vii) WATSON'S PRINCIPLES AND PRACTICE OF PHYSIC. ABRIDGED. INTRODUCTORY LECTTJKE. Diseases are local or general; local, when they affect a definite portion only of the body; general, when they affect similarly the whole of some one system that pervades the entire body. The principles of medicine are those general truths and doctrines which have been ascertained and estab- lished. LECTUEE II. Pathology is morbid anatomy and something more. It comprehends a knowledge—1st, of the changes to which the several parts of the living body are subject; 2d, of the processes which work these changes ; 3d, of the causes of these processes; 4th, of the consequences of the same changes or of their symptoms. Pathology is special or general. Special contem- plates particular diseases ; general treats of the morbid conditions common to the entire-system, or to the whole of each of the several tissues compos- ing the system. The solid parts of the body may be altered by disease, in bulk in form, in consistence, in their intimate texture, and in situation. Tlie fluids may be'altered in quantity, in quality, and in place. The alterations in bulk without change of texture, are increase or hypertrophy, and diminu- tion or atrophy. Hypertrophy.—In hypertrophy nutrition preponderates over re-absorp- tion Hypertrophy, in most cases, is a compensatory and conservative condition, and morbid only insomuch as it is an effect of disease. Hyper- trophy of the voluntary muscles is generally harmless ; of the involuntary, e-enerally connected with disease. It affects the glandular and other sys- tems. It may affect one only of the component tissues of an organ. There may'be hypertrophy without enlargement: 1st, in hollow organs, where the increase is centrical; 2d, in any organ, wheve it is confined to one or more tissues, the others at the same time wasting; 3d, where the compo- (25) 26 ATROPHY—TRANSFORMATION OF TISSUES. nent particles are multiplied, the size, shape, &c, remaining unaltered. There may be enlargement without change of structure, and yet no hyper- trophy, as in congestion of the liver and spleen. The conditions which give rise to hypertrophy are: 1st, increased healthy action in the part; 2d, an increase in the blood of the particular materials which a part appro- priates in its nutrition or secretion; 3d, an increased afflux of healthy blood. Increased function produces increased nutrition; but of the con- verse of this proposition there is no certainty. Hypertrophy may be produced: 1st, by the influence of certain localities, as in bronchocele; 2d, by congenital or acquired conditions of the body, as the enlarged upper lip in the strumous diathesis; 3d, by certain habits of life, as full diet with bodily inactivity, which increase the adipose tissue; 4th, by removal of certain parts, as the testicles and ovaries, which causes increase of fat. The bulk of organs may be augmented by an undue quan- tity of their natural contents, or by foreign matter: in either case the func- tion of the part itself, or of neighboring or distant parts, may be disturbed or suspended. Atrophy is the decrease of the natural size of a part without alteration of texture. It depends upon diminution or defect of nutrition, or of supply of healthy arterial blood, as in inaction, compression, chronic inflammation, and the various diseases which, affecting the digestive organs, or causing some unnatural drain on the system, produce general atrophy or emaciation. Certain parts, having answered their temporary purposes, become atro- phied, as the thymus gland, supra-renal capsules, ovaries, &c. Atrophy may be limited to one or more of the component tissues of a part. It may exist without decrease of absolute size, as in the heart sometimes, and in the bones. The consistence of parts may be changed; 1st, by induration, when they become harder and firmer; 2d, by softening or ramollissement. Solid and hollow organs may be indurated without change of tissue; the solid by fulness of blood-vessels; the hollow, by accumulation of fluid. Induration may depend upon expression of fluid, or compression of parts, as when the lung is compressed by fluid in the pleura. It may also depend upon fluids or solids in the tissues, as in hepatization of the lung and in pulmonary apoplexy. The fluids may concrete within their proper vessels and produce induration ; as in the veins, biliary and urinary passages. Morbid masses, s tubercles, cancer, &c., may likewise cause induration. LECTURE III. Softening.—There is scarcely any tissue of the body in which softening may not take place. It affects the brain or spinal cord, the areolar tissue, muscles, mucous membrane and bones ; as in mollifies ossium. Softening may proceed from inflammation, insufficient sustenance, impoverished blood, or (like atrophy) from defective nutrition. Transformation of Tissues.—In the proper place of one natural tissue we sometimes find another, which last is thus unnatural in regard to its situation, but natural in all other respects. Either the original tissue has been converted into the new, or having disappeared, the new tissue has taken its place. This last is perhaps always the case. Muscular tissue is never changed into areolar, nor is areolar ever changed into muscular. In false joints the muscular tissue is not converted into fibrous or ligament- ous tissue, but the muscular disappears and the fibrous takes its place. In PLETHORA—AN.EMIA—CONGESTION. 27 the change of cartilage into hone there is simply an increase of the phos- phate of lime. Accumulations of fat are morbid changes and not conver- sion of tissues. The mucous membrane, lining sinusses, fistulous openings and tubes, is not conversion of tissue. Many of these changes are restora- tive in their tendency, thus proving the vis medicatrix natures. The inti- mate texture of parts may be further altered by an absolute disappearance, or confusion of all regular structure ; as in the effusion of fluids which become solid, or iu the growth of solids which do not belong to the body. These alterations of solids depend upon lesion of nutrition, the seat of the nutritive process being in the capillary system. The solids maybe changed in situation, as is often the case with the ' viscera of the chest, abdomen and pelvis. LECTURE IV. Morbid Alterations of the Blood, &c—The animal fluids are the blood, the fluids that enter the blood, and those that proceed from the blood. The fluids that enter the blood are intended for its renewal or en- richment, as the chyle; or are to be carried out of the body, as bile, &c. The fluids that leave the blood are expended in the growth and mainte- nance of parts, or aid some definite function, as saliva, gastric juice, &c.; or are intended to be excreted. The blood is subject to remarkable morbid variations; 1st, in quantity; 2d, in the proportion between its proximate constituents, as in watery blood; 3d, in its chemical composition, as in scurvy and purpura. Plethora, Anaemia. — The blood may exist in too great quantity throughout the body, as in persons of full living and sedentary life; or it may be in too great abundance in certain parts only. These conditions are called general and partial plethora or general and local congestion, deter- mination, hyperemia. Congestion and redness of one or more parts are generally attended with paleness and decrease of temperature of other parts. General plethora does not cause a proneness to inflammatory com- plaints, although the fibrin and red particles are richly abundant. This unnatural and unsafe condition is redressed by removal of a part of the superfluous blood, low diet, and active exercise. Poverty of Blood, Anemia, which consists in decrease of fibrin and deficiency of red particles, may be produced by disease, defective nutrition, the large or habitual loss of blood; as in piles, hemorrhage, &c. Pathology teaches that the red particles require more time for their restoration than the other constituents of the blood. Congestion.—There may he a deficiency of the whole mass of blood circulating in the body, and a deficiency of its nutritive materials, and yet often be local congestion. This is owing to the defective supply of blood sent to the brain and nerves, which are thus disordered in their functions, and in turn derange the balance of the circulation. Local congestion may also be produced, upon the surface of the body at least, by friction, by high temperature, by stimulants, mechanical or chemical. This is active congestion, otherwise called sthenic or active hypercemia. The capillary vessels are the seat of the changes which are wrought when there is something more than mere local plethora. Active congestion, as such, does not last long; it either passes into inflammation, or soon ceases. Active congestion sometimes causes hemorrhage, by which it is relieved. This congestion is relieved by the abstraction of blood from 28 CONDITIONS OF LIFE—DEATH BY ANEMIA. the part,—this, however, is not always sufficient; it is even sometimea hurtful. Mechanical congestion is that morbid fulness of the capillary vessels pro- duced by some mechanical obstacle to the return of the blood to the heart; as in disease of the liver, Ac. Passive congestion, also called passive or asthenic hyperemia, is a'loaded condition of the capillaries, depending upon the loss of their natural elasticity and propelling power. This state may be removed by friction or stimulants. In the production of active congestion the arteries are principally con- cerned ; in mechanical, the veins ; in passive, the capillaries. Internal organs also are liable to passive congestion ; as is often the case in the lungs. Active and passive congestion are apt to recur, and in those parts which have previously suffered from them. Mechanical congestion is often the prolific source of hemorrhage, and the almost constant pre- cursor and immediate cause of dropsical accumulations. The blood may be excessive in quantity, yet poor in materials, 6erous, deficient in globules and fibrin and color; in this condition of the blood also are dropsies apt to arise. 0------♦------- . LECTURE V. Modes of Dying.—Life is inseparably connected with the continued circulation of the blood. The different modes of dying, therefore, depend upon the different ways in which that circulation may be brought to a stand. For carrying on and maintaining this essential function, there are the heart and other blood-vessel's, the lungs, and lastly, the motor and regulating power of these two, the nervous system. Each of these systems must continue in action, or the circulation will stop and life come to an end : therefore their functions are called vital functions, and the heart, the lungs, and the brain are called vital organs. The phenomena of dying vary remarkably according as the interruption begins in one or other of these organs. That the heart may continue to propel the blood, there must be in it—1st, the power or faculty of contracting; 2d, sufficient blood to be moved and also to stimulate it to contract. There are, there- fore, two ways in which death begins at the heart. The sole purpose of the respiratory apparatus is to submit the blood to the chemical action of the atmosphere. For this purpose circumfused air must enter and depart at short intervals, and the chest must have alternating movements to cause its entrance and exit. These movements are essentially involuntary, de- pending upon the medulla oblongata, and, therefore, upon the nervous system. The action of the heart is not directly or necessarily dependent on nervous influence (witness anacephalous foetus) further than as it is necessary to respiration and the introduction of nutriment, yet very sudden and extensive injury or shock to the nervous system may instantly paralyze the heart and stop its action. There are two forms of death beginning at the head, in one of which the brain and nerves do not directly affect the heart, in the other they do. In the former case the lungs and respiration are first affected and then the heart. Death, in disease, is usually complicated, many parts and functions being affected at once. Death, beginning at the Heart.—One form of death, beginning at the heart, is death by anosmia, caused by deficiency of blood in the heart; as in flooding, &c. The phenomena are, paleness of lips and face, cold sweats, DEATH BY ASTHENIA, APNEA, COMA. 29 dimness of vision, dilated pupils, vertigo, a slow, weak, irregular pulse, speedy insensibility, often nausea, even vomiting, restlessness, tossing of limbs, transient delirium, breathing irregular, sighing and at last gaspiDg, and convulsions generally. After death the heart is found empty, or nearly so, and contracted. Another form of death, beginning at the heart, is death by astlienia, caused by a failure of the contractile power of the heart; as from the use of some poisons. After death by asthenia each chamber of the heart is found filled with its proper kind of blood. Syncope is the state of sus- pended animation, common to both these forms of dying. In anaemia the nervous functions fail from lack of blood sent from the heart to the brain ; in asthenia the heart fails for want of the nervous influence; as in death from grief, joy, terror, concussion of the brain, blows on the epigastrium, lightning and electricity, certain kinds of apoplexy, &c. In death by asthenia, occurring in disease slowly, the pulse becomes very feeble and frequent, muscular debility extreme; but the senses remain perfect, the hearing sometimes painfully acute, and the intellect is clear to the last; as often, in acute peritonitis, malignant cholera, and extensive mortifica- tion. Akin to this form of dying is that produced by lingering and wast- ing disorder, as phthisis. Here there is a deficiency of the natural stimu- lus to the heart. Death by Apnea, by Coma.—Death caused by sudden deprivation of air to the lungs, as in smothering, immobility of the chest and abdomen, rigid spasm or paralysis of the respiratory muscles, &c, is called asphyxia, suffo- cation, apnea. Death, caused by the insensibility of the respiratory muscles, is called death by coma. The phenomena of sudden and complete priva- tion of air are, strong but vain contractions of the respiratory muscles in breathing, distress extreme but transient, followed soon by not unpleasant sensation of vertigo, then by unconsciousness and convulsions; finally, irregular twitchings of the limbs alone perhaps remain, the muscles relax, the sphincters yield; but the heart and pulse beat for a short time after apparent death, so that, even after the heart has ceased to act, artificial respi- ration may save life. The above symptoms of apnea occupy only two or three minutes, the face being first flushed and turgid, then livid and pur- plish, the cervical veins and those of the head swollen, the eyeballs pro- truded ; at length the heart stops and life is extinct. The convulsions and insensibility and the other symptoms are caused by venous blood cir- culating in the arteries of the brain and rest of the body. The circulation fails mainly because venous blood circulates and finally stagnates in the capillaries of the lungs. Death begins in the lungs. Anatomical Characters of Death by Apnea.—The left side of the heart contains some dark blood ; the right side, lungs, the cavse and the whole venous system is gorged with dark blood. After sudden death blood seldom coagulates, so that if accumulated in any part by rapid apnea it may subside before the body is examined. Incomplete privation of air (or the division of the par vagum of both sides) causes the air tubes and cells to fill with serum and thus impede the respiration. Death by apnea may be produced by any thing which nar- rows the chink of the glottis, by warts, laryngeal oedema or inflammatory swelling, false membrane; by disease of the lunsrs or of their mucous membrane, effusion into the pleura preventing sufficient air from entering the lungs ; by disease of the heart and great thoracic blood-vessels affect- ing the quantity of blood in the lungs; by abdominal swellings thrusting up the diaphragm. In death by coma, certain morbid states of the brain produce more or less stupor, insensibility, sometimes sudden, sometimes gradual, the respiration becomes slow, irregular, stertorous, and finally 30 CAUSES OF DISEASE. fails. In death by apnea the chemical functions of the lungs cease first, then venous blood circulates through the arteries, suspending the sensi- bility ; in death by coma the sensibility ceases first, then the functions of the lungs. When death threatens by way of coma artificial respirations may sustain organic life till the insensibility passes away. The essential anatomical characters of death by coma are the same as those by apnea. All these modes of dying are apt to take place in fevers ; that by coma happens principally when the brain is much affected, as by headache, delirium, stupor; that by suffocation or apnea happens when the lungs are seriously affected ; that by syncope happens sometimes in fever, when the bowels are principally affected, as when there are much diarrhea and ulceration of the intestinal glands. LECTURE VI. Causes of Disease.—The causes of disease are predisposing, exciting, and proximate. The proximate cause is nothing else than the disease itself. A predisposing cause is any thing which has had such a previous influence upon the body as to have rendered it unusually susceptible to the exciting cause of the particular disease. An exciting cause is that which produces the disease. The sources of disease are sometimes atmospherical, as extreme heat and cold, sudden variations of temperature, excessive moisture or dryness, electric conditions, differences of pressure, as shown by the barometer, deficiency of light; malaria, contagious and noxious gases ; other sources are, bad and hurtful food, insufficiency of healthy food and excess in eating and drinking ; poisons ; various trades and avocations ; deficiency of exercise ; too much sleep or too long-continued want of repose ; excessive intellectual toil, violent passions, strong mental emotions; vicious and exhausting indulgences; above all, protracted anxiety and distress of mind. Diseases may likewise be hereditary or congenital. Heat.—Life is compatible with a very great range of temperature. It may be sustained, for a short time, at very high degrees of temperature (240°, 2G(P) without detriment. The most intense cold that occurs naturally on the surface of the globe is perhaps the lowest compatible with life. Under the action of the above very high temperatures the animal heat and respiration are little affected, but the pulse is very much quickened. Heat stimulates the organic functions, but when applied for some time it has a sedative or depressing influence upon the animal func- tions, i. e., upon the nervous system, causing languor, lassitude, &c. High temperature, when long-continued, stimulates the liver, increasing the quantity of biie and altering its sensible qualities, and often causing hepatitis. This morbid bile causes vomiting, diarrhea. In tropical cli- mates heat causes violent disorders of the stomach and intestines, with the evacuation of large quantities of vitiated and acrid bile, and also acute hepatitis, suppuration and abscesses, and yellow complexion. The hot atmosphere is the predisposing, and exposure to cold the exciting cause, of hepatitis. Heat is sometimes an exciting cause, as in sunstroke, inso- lation. Some regard this as a sort of apoplexy by way of coma, but the remedies of apoplexy have failed to cure it. The natives of India pour cold water upon the head. Stimulants, as rum and water, often answer well. Insolation is akin to concussion. Great heat produces cutaneous diseases, as prickly heat. CAUSES OF DISEASE. 31 Cold.—The continued application of cold acts as a sedative upon the organic functions, as shown by the cutis anserina. The heart and the whole arterial system becomes weak. Cold air in motion, or-moist, is more potent than in the opposite condition. Cold, especially when combined with exercise and fatigue, causes, generally, but not always, an overpowering tendency todrowsiness. Often, before torpor comes on, the sensations are blunted, the intellect confused, and the person affected appears intoxicated. If persons in this state are suffered to sleep, the cold still continuing, they soon die. LECTURE VII. Causes of Diseases — Continued.—Cold, Heat.—Cold, when not too intense, or too long applied, or when counteracted by exercise and clothing, becomes a tonic. The axiom, that sudden vicissitudes of temperature are dangerous, is not universally true; witness the Russian mode of bathing. If the power of evolving heat be entire, active and persistent, no peril need attend even violent alterations of external temperature. Heat, if steady and permanent, counteracts the applied cold; as in fevers. Cold is also counteracted by exercise and by any thing producing heat, provided the cause of the heat remains steady in action, that there is no local dis- ease, and that the body is not fatigued and fast losing its heat. This principle obtains whether the cold be applied externally or internally. When life is in jeopardy from draughts of cold water, apply warmth to the epigastrium, and give laudanum in free doses. If death does not speedily follow the application of cold, inflammation is very apt to arise. Heat, accumulated by exercise, is speedily dissipated by profuse perspira- tion and a state of rest. Any thing which weakens the system, heightens the effect of cold ; as fasting, evacuations, &c. The faculty of evolving heat is very feeble in the old and in the newly-born. The bad effects of cold depend upon the intensity of the sensation produced, but still more upon the duration of that sensation. Even slight chilliness, long con- tinued, is hurtful. The effects of cold are often counteracted by passions, or conditions which engage a close attention to one object; as spasmodic asthma ; by that state of the body, in which sensibility is greatly dimin- ished, as mania ; and by the power of habit. Sleep diminishes the power of resisting cold ; in it we are conscious of unusual sensations produced by cold. The experiment of hardening should never he tried on any child or per- son ailing, or unsound, or showing signs of present or future disease, especially scrofulous. Sufficient clothing and exercise should be used during the experiment. An abiding sense of chilliness must never be per- mitted. The best mode of fortifying the body against cold is the cold bath, especially the shower bath, and then used in the morning. If its use is followed by warmth it is good, but if by headache, chilliness, lan- guor, &c, it is hazardous. Catarrhs and pectoral complaints belong to the winter and spring; bowel complaints to the summer and autumn. The mucous membranes of the air passages sympathize with the skin under the agency of external cold ; those of the stomach and intestines under that of atmospheric heat. The mortality of winter is greater than that of summer, especially among the very old and very young ; malaria or epidemics may change this order. The number of deaths by palsy and apoplexy is greatest in winter; because 32 SYMPTOMS. then the cold drives the blood from the surface into the head and other internal parts, and, besides, the pectoral complaints, dyspnea, coughs, &c, which prevail in winter, embarrass the respiration and greatly impede the return of the venous blood from the head, producing cerebral congestion and its consequences, especially when the arteries of the brain are dis- eased. A severe cold season destroys a number of persons rapidly, and in others occasions diseases which prove fatal in four or six weeks. Gener- ally in continued fever the pectoral symptoms are most troublesome in the spring, the abdominal in the autumn. It is said that, in continued fever, the head affections are more frequent and severe in winter. Impure air (not air with specific poison) is a powerful predisposing cause of dis- ease,,but never an exciting cause", except perhaps of scrofula. In some persons, especially those hereditarily so inclined, small causes produce disease; in others, on the contrary, no amount of exciting causes will have any injurious effect. Hereditary disease may skip over a gener- ation or two, and thus a parent may transmit a disease which he himself does not possess. When one parent only bears the transmissible tendency, the disease'appears to be most apt to break out in the children who most resemble that parent in their physical conformation and appearance. Whether acquired peculiarities can be transmitted or not is perhaps yet uncertain. When both parents have a tendency to any complaint, there will be a double probability of a diseased offspring. Intermarrying in the same family is therefore often very objectionable. LECTURE VIII. Symptoms in Disease.—A symptom, in disease, is anything or circum- stance happening in the body of a sick person, and capable of being per- ceived by himself or others, which tends to point out the seat or nature of the disease, (diagnosis,) its probable course and termination, (prognosis,) or its treatment. Those symptoms or combinations of symptoms, which dis- close the place and nature of the disease, are called signs of disease; those which teach us what to do are called indications of treatment. There are also prognostic signs—symptoms and signs are not synonymous words. Signs are deduced from symptoms by arranging and comparing them, and noticing the circumstances under which they occur. Signs are symptoms interpreted. Pathognomonic symptoms are those which infallibly settle the nature of the disease. By commemorative circumstances is meant a knowledge of the previous history and condition of the patient. Symptoms are direct or indirect; direct when they relate to the very part affected ; indirect when they de- clare themselves through the medium of some other part, or through the constitution at large. Negative symptoms are derived from the regular functions compared with disease. The symptoms which consist of morbid changes are, 1st, uneasy, unnat- ural or impaired sensations; 2d, disordered or impeded J'unctions; 3d, alteration of sensible qualities, i. e., of structure or appearance. These last are called physical signs, when they come under the direct cognizance of our senses. Pain, one of the changes of sensation, varies in kind and de- gree according to the part affected, and to the morbid action. Pain is said to be sharp, shooting, dull, gnawing, burning, tearing, &c. Tenderness is pain on pressure. Pain often takes place in a part, distant from that really affected, (indirect or sympathetic pain,) as the pain of the right SYMPTOMS. 33 shoulder in inflammation of the liver or diaphragm. Other uneasy sensa- tions are itching, prurigo, tingling and pricking, nausea, giddiness or dizziness, technically vertigo, sinking, sensation of weight, of tightness and fulness, drowsiness, tenesmus, strangury, heartburn, excessive hunger, or thirst, or depraved appetite. Nausea may be a direct sign of stomach disease, or an indirect sign of disease in some distant part, as the brain or kidney ; the same may be said of vertigo. When, with pain or deranged sensation, we find functional derangement also of apart, there is additional reason for concluding that the part is the seat of disease. The functions of the brain and nerves may be affected, causing numbness, anaesthesia, dimness of sight or blindness, amaurosis. The hearing may be disordered, becoming obtuse or preternaturally acute—this last is a bad symptom. Tinnitus aurium sometimes depends on the strong throbbing of the arteries, and is often a symptom of diseased cerebral arteries and a precursor of apoplexy or palsy. The intellect may also be affected, and, as this is a species of first de- gree of delirium, it should be watched. The delirum of fever is always most marked at night. Voluntary motion may be excessive, or deficient, or perverted. Excess is not common nor very important; deficiency of it, or muscular debility, is very common, being an essential part of fever, not however necessarily implying any great danger. Debility late in disease shows a tendency to death by asthenia and points to a strengthening and supporting treatment. It is sometimes the principal symptom, as in hemiplegia, &c, and often indicates serious disease. Spasm, which is an irregular and violent con- traction of the muscular parts, is another disorder of voluntary motion; as in cramps, tetanus, &c. Tremor is near akin to spasm. Spasms, con- vulsions and tremors sometimes bode great danger, sometimes none at all. Dtspnea.—The respiratory apparatus may be affected. Dyspnea, diffi- culty of respiration, depends on various causes ; as inflammation of the lungs, pleurae, etc. It is almost always most troublesome when the patient lies on his back, for then the diaphragm is pushed up by the viscera. Up- right breathing is called orthopnea. Dyspnea sometimes comes on in par- oxysms ; as in asthma. Cough is a violent spasmodic action, consisting in a full inspiration, then of a firmly closed state of the glottis, and finally of a sudden and forced expiration of air; the object appears to be to expel substances from the lungs. There are several varieties of cough, some denoting dangerous complaints, as in phthisis, &c.; some not. Some are diagnostic. Sneezing is sometimes a symptom, as in catarrh ; sometimes a primary disorder. Sneezing combined with cough affords a presumption that the cough is not phthisical. Pulse.—The qualities to be attended to in the pulse are its frequency, regularity, fulness, and force. The average number of pulsations in a healthy adult is from 70 to 75, but it may reach 80 or 90, or even be as low as 60. In early life the pulse is more frequent, in old age more slow, than the standard. Its beats are more numerous in the standing, less in the sitting, and still less in the recumbent posture. There are variations and fluctuations of the pulse in respect to frequency; as in hydrocephalus. Ir- regularity of pulse is natural to some persons. There are two varieties of irregular pulse; in one the motions of the arteries are unequal in number and force, a few beats being occasionally more rapid and feeble than the rest; in the other variety a pulsation is from time to time left out—the pulse is said to intermit. A hard pulse is one which can hardly be abol- ished by pressure, the blood forcing its way beneath the finger. A full or large pulse is one which is felt to strike a large portion of the finger; a 34 INFLAMMATION—SYMPTOMS. small pulse strikes a narrow portion of the finger; a wiry pulse is one which is small and hard. Physical Signs.—Changes of sensible qualities are exemplified in the variations of the temperature of the body ; the color of the surface, espe- cially the face ; diminution or increase of bulk; the latter when general is called corpulence; when partial, swelling; and. in various other symp- toms, especially those which are detected" by auscultation. Wasting or emaciation sometimes occurs in complaints not commonly dangerous, as dyspepsia; sometimes in fatal maladies, as phthisis. LECTURE IX. Inflammation.—Inflammation affects all parts furnished with blood- vessels. It possesses healing tendencies, as in the curing of wounds, «&c. It is an instrument of cure, as in obliterating the cavity of the tunica vagin- alis in hydrocele, &c. Symptoms.—The symptoms of inflammation in external parts are pain, prv'.rrnalural redness, preternatural heat, and swelling. Phlegmonous inflammation is that violent kind in which the part seems on Are. When the inflammation becomes somewhat intense, other symptoms occur, as chilliness and feebleness at first, then soon heat of the whole surface, hot and dry skin, pulse more than usually full and hard, lassitude with head- ache and wandering pains in the limbs. The patient is unable or unwilling to exert himself, is unapt for mental exertion, gets confused and restless and sleeps ill, loses his appetite, tongue becomes white, mouth parched, thirst very great, and the secretions are deranged and diminished. This is injlummatory fever, also called sympathetic fever, symptomatic fever. This inflammatory state may terminate in resolution, be resolved ; i. e., the various symptoms may gradually disappear and the part return to its natural eondition. Or the symptoms may become aggravated, the swelling pointing, looking white in the centre and becoming softer; the pain being of a throbbing kind ; a pulsative sensation, beating with the heart, being felt in the part, and often a feeling occurring of something giving way within it; the cuticle finally breaking and a yellow cream-like fluid, called pus, being poured out; and then, generally, the local symptoms abating speedily. This is suppuration. Meanwhile, especially if the discharge of pus be long-continued or pro- fuse, slight but frequent sbiverings or feelings of chilliness take place, followed by flushes of heat, ending in perspiration. This is hectic fever. It mortification result from the violence of the inflammation, the vivid red color alters to a purplish, or livid, or black, or greenish black, the tension of the part exists no longer, the cuticle is raised by sanious fluid, the paiu ceases, the part loses all sensation—is dead and putrid and emits a peculiar and offensive odor. When the injury has been extensive, the constitution is disturbed, the patient grows more and more feeble and delirious, has involuntary startings of the tendons of the voluntary muscles, his pulse is weak and very frequent, his tongue becomes dry, brown, and tremulous his lips are biack with accumulated sordes, his countenance is shrunk' haggard, damp, and ghastly, his stools and urine escape unawares. These are features of an advanced stage of typhus fever. The dead part may slough oft". During the inflammation, blood drawn from a vein shows the huffy coat; i. e., yellowish or buff-colored fibrin on the surface of the coagulum. INFLAMMATION —PAIN—HEAT—REDNESS, ETC. 35 Pain, Heat, Redness, and Swelling.—The pain varies much in degree and kind according to the kind of inflammation and part affected. It results from the stretching of the vessels and textures of the part and the implication of the nerves. The pain of inflammation of external parts and serous membranes is generally greater than that of the substance of the viscera or mucous membrane. The pain of inflammation, especially of internal parts, sometimes precedes any other apparent change. The pain is sometimes continued, but irregular in severity, sometimes intermittent and even periodic. It is uncertain whether the state of the blood-vessels is determined by that of the nerves or the reverse. Inflammatory pain is usually aggravated by pressure ; other pains usually are not. Gradual pres- sure, applied uniformly, steadily, and gently to the whole organ or part affected, sometimes relieves the pain, as in orchitis. Stupor or coma may abolish all sense of pain. The heat of inflammation does not rise above the maximum heat of the blood in the centre of the body. The natural heat of the blood is about 98^ to 100O. The increased heat depends on the increased influx of arterial blood, and therefore of oxygen, to the part. Animal heat is caused by the mutual action between oxygen and the elements of the tissues, carbon and hydrogen. The heat is sometimes not perceived. The redness depends on the quantity of blood in the vessels of the part, or an extravasation of the coloring matter of the blood. The tint of the redness depends on the kind and degree of the inflammation and the part affected. Sometimes it is bright and vivid, as, generally, in the acuter forms and earlier stages ; sometimes it is dark or livid or purplish, as in some chronic cases, and when there is a tendency to gangrene; sometimes it is in patches; sometimes in a general blush. Redness exists in inflam- mation of internal parts. Inflammation may sometimes exist and yet the redness not be perceived. The swelling depends early in the disease in part on the distension of the blood-vessels, but especially on matter poured out into the parts, as blood, serum, albuminous fluid or coagulable lymph, and pus ; these are the products of inflammation. The presence of pus points to inflammation somewhere ; coagulable lymph in a part points to inflamma- tion of that part. The degree of the swelling depends on the intensity of the inflammation and on the nature and texture of the part. Inflammation may exist without any appreciable swelling ; as in sclerotitis. The blood consists of red particles or globules, and of a transparent colorless fluid called liquor sanguinis. The liquor sanguinis consists of serum and fibrin. The clot in coagulated blood consists of fibrin and red particles. The period of incubation is the time from the application of the exciting cause to the lighting up of the- inflammation. The fibrin, which, in inflammation transudes the blood-vessels, concretes, filling up tissues, or forming false membranes on surfaces. There are colorless corpuscles in the liquor sanguinis. Most of the events of inflammation are traceable to the changes which stagnant blood undergoes. Coloring and adipose matters are absorbed from the inflamed part. Coagulable lymph often becomes organized. Whether in inflammation the action of the small vessels is increased or diminished, is undecided. Arterial trunks leading to inflamed parts often pulsate more strongly, and, when opened, project blood further than natural. Veins leading from inflamed parts discharge blood faster and more copiously than natural. The circulation around the inflamed part is greatly increased, but in the part it may be stagnant or nearly so. In inflammation there is an increased afflux of blood to the parts inflamed. 3G INFLAMMATION—BUFFY COAT OF THE BLOOD. LECTURE X. Inflammation— Continued.—The buffy coat is sometimes flat and wide, often contracted and concave, cupped. Inflammation may exist without the buffy coat, and this without the former. The buffy coat is pure fibrin mixed with serum, and is identical with coagulable lymph. The venous blood of inflammation, when drawn, coagulates sooner than in health. A peculiar bluish tint on the surface of blood just drawn, shows that it is about to buff. That the buffy coat depends upon some vital change in the blood appears probable, as it is shown in some, but not in other por- tions of blood drawn at the same bleeding. The buffy coat may be thick, tough, contracted and cupped, the red portion being round, contracted, firm and detached from the sides of the vessel. This is usually the case in violent inflammation, occurring in strong constitutions, or in certain tissues, especially in fibrous or serous. Or the buffy coat may be thin, flat and easily broken, the coagulum being large. This is the case in slight or partial inflammation. Or the blood may be sizy; i. e., the butty coat is thick and abundant, but flat, soft and flabby, the coagulum often sticking to the vessel. In this case the local inflammation is accompanied by some other cause of general disorder, as continued fever, &c. Blood, drawn by leeches, never buffs ; that by cups, seldom. Arterial blood is liable to buff. Blood is more likely to buff when it flows in a full stream, or into a deep and narrow vessel. It is less likely to do so when it trickles from a small opening, or into a large, flat vessel. The buffy coat may be prevented, it is said, by a solution of caustic potass, by agita- tion, by receiving it in a very cold vessel, by its falling from the height of three or four feet. Generally a day or two elapses from the beginning of the inflammation, before the buffy coat appears. Generally, the more intense the inflammation, especially of fibrous or serous tissues, the more marked is the buffy coat. The blood in general plethora and in pregnancy is often buffed without any inflammation. The danger in disease is not in proportion to the buffy coat. It may exist after further bleeding becomes dangerous. In acute inflammation there is a remarkable increase in the fibrin of the blood. Events of Inflammation.—1st. Resohition.—Delitescence is sudden and rapid resolution. Metastasis is the sudden disappearance from one part, and appearance in another-, of the symptoms of inflammation. Counter irritation, derivation or revulsion, is stimulating distant parts to effect a cure. 2d. Serous Effusion.— (Edema is serous effusion into areolar tissue. Anasarca is oedema on a large scale, produced by impediment to the venous circulation. Immense quantities of serum are often poured out in a short time, giving rise often to perilous conditions; as in pleurisy sometimes. A small amount may have the same effect, as in infiltration of the sub- mucous tissue of the glottis, &c. Serous effusion often exists independ- ent of inflammation. Hemorrhage sometimes occurs as an event of in- flammation. 3d. Effusion of Coagulable Lymph.—This often forms false or adventitious membranes, or clogs up parts. Union by the first inten- tion is that by which the lymph unites the edges of cut wounds. Adhesive inflammation is that attended by exudation of lymph. Sometimes the coloring matter of the blood is also poured out, oftener, serum. Coagu- lable lymph often has a conservative tendency, preventing worse events. Lymph effused on inflamed surfaces readily becomes organized and comes EVENTS OF INFLAMMATION. 31 to look like areolar tissue condensed, or assumes the character of other tissues. The lymph is often effused and organized early, sometimes not for days. It is probable that the serous fluid permeates through the veins, but the fibrinous from the capillaries. 4th.-Suppuration.—Healthy, laud- able pus is an opaque, smooth, yellow, cream-like fluid, with no smell. Inflammatory lymph is fibrinous or corpuscular ; the former is the coagu- lable, organizable, adhesive lymph already spoken of; the latter does not coagulate or organize, but its corpuscles undergo degeneration, often into pus-corpuscles. Ichm-ous pus is that in which the globules are few in proportion to the watery part; sanious is that tinged with blood. Mucus or an alkali in the pus, makes it viscid and slimy, or flaky and curdled. Sometimes when cold, it is horribly fetid. Healthy pus and healthy mucus are easily distinguished. Turiform mucus is known from pus by the microscope. Pus poured into a natural cavity is called purulent effusion; pus in a closed, unnatural cavity, formed by lymph and con- densed tissue, is an abscess. The formation of pus is one step beyond the adhesive stage. This is often caused by the admission of air. Upon cut surfaces, open to air, pus is often formed. When suppuration takes place, the pain ceases or abates, except when the pus keeps up tension. Pus tends to soften and break down textures; lymph, to harden them. Pus is sometimes formed in a few hours, sometimes not for weeks. The duration of the suppurative process is not in proportion to the intensity of the inflammation. 5th. Ulceration is the absorption of lymph and of the surrounding tissues. Three things generally are going on at the same time in an ulcerated surface: 1st, effusion of plastic lymph, which forms granulations, these consisting of organized lymph; 2d, suppuration ; 3d, absorption or removal of parts. Suppuration may not be apparent; as in ulceration of the cornea. When absorption predominates and the ulcer- ation rapidly extends, it is phagedenic; when the texture perishes and drops off in sensible masses, it is a sloughing ulcer ; when the process is slow, the lymph effused at the base and round the edge of the ulcer is hardened and the granulations deficient, the ulcer is callous or indolent. When the granulations are larger, softer, and more flabby than usual, and require to be repressed before the ulcer will heal, it is a fungous ulcer, and the granulations proud flesh. LECTURE XL Inflammation— Continued.—The sixth event of inflammation is mortifi- cation, gangrene, sphacelus. The part dies, becomes cold, loses its circula- tion and sensation, and, when external, it becomes mottled, purplish, green, or black, decomposes, vesications appear filled with dark liquids, and a'ir is extricated. It there is much fluid in the part, there may be tension ; but usually it is flaccid and boggy ; it emits a cadaverous smell. Internal parts are often, when mortified, yellow, or of the color of the parts from which they have imbibed fluids. Mortification sometimes spreads and gets confounded with living and inflamed parts. In more favorable cases the dead part is separated from the living by a barrier of lymph, and amputated by a furrow of ulceration, lymph plugging up the divided vessels. Mortification is frequent in areolar tissue, in mucous and sub- mucous tissues of the alimentary canal, in the throat, in the glandular parts of the intestines in fever; but not in the other mucous systems, nor 38 CONSTITUTIONAL SYMPTOMS—HECTIC FEVER. in the substance of the lungs, nor in serous and fibrous tissues. It is com- mon in bones, producing exfoliation, when slight and superficial; necrosis, when the entire shaft of a bone dies. Besides intense inflammation, mortification is also promoted by weakness of the circulation in the inflamed part, or in the system at large ; as in the bed sores of fever in palsied and dropsical patients. These sloughing sores are probably promoted by unhealthy blood. Inflammation of the stomach and intestines is strongly disposed to run into gangrene. Other causes than inflammation produce mortification, such as cutting oft" the supply of arterial blood, as in gangrena senilis, or preventing the return of venous blood. The continued use of diseased grain, especially spurred rye, also produces chronic and dry gangrene. Constitutional Symptoms.—These are all-important in detecting and treating internal inflammation. The most noted of these is pyrexia, in- flammatory fever, which is denoted by debility and chilliness, followed by, or alternating with, increased heat of skin, frequent, forcible, and often hard pulse, with deranged functions, commonly with headache, confusion of thought, languor, thirst, loss of appetite, and a furred or white tongue. The chilliness marks the date of the febrile disturbance. Rigors more commonly attend the commencement of spontaneous inflammation, than of that caused by external injury. Inflammatory fever is perhaps owing to the circulation of altered blood through the body. Generally, the febrile state follows the local inflammation, but sometimes it precedes it, as in erysipelas and the febrile exanthemeta, &c.; sometimes the two are simul- taneous. Inflammatory fever is not always proportioned in violence to the size or importance of the part inflamed. It commonly runs higher in the young, plethoric, and those of sanguine temperament. It may be modified by the part; witness the depressing effect upon the action of the heart, produced by inflammation of the stomach and bowels and some other abdominal parts, the amount of reaction being lessened, or its dura- tion abridged, the quality of the pulse, especially, being affected, and there being a strong tendency to death by asthenia. Previous habits modify the character of inflammatory fever. In the habitually intemperate, and in those subject to long-continued nervous excitement, the fever is of the typhoid form from the beginning; the febrile reaction being weakened, and the functions of animal life more deeply involved. Stupor and delirium are apt to occur, with extreme debility and irregular movements of the voluntary muscles. These symptoms are more conspicuous in some cases • of inflamed veins, and in inflammation from animal poisons. The inflam- matory fever may continue a few days after the local signs have disap- peared, especially in irritable persons. These cases should be carefully watched and protected from relapse. Sometimes the local changes con- tinue, or even increase for a time after the abatement of the febrile svmn- toms. Still this augurs well. Hectic Fever.—The commencement of suppuration is often marked by rmors ; its continuance, by hectic fever. Rigors are by no means necessarily connected with suppuration, for they usher in most forms of fever. Some- - times there is one fit, sometimes many; usually they recur irregularly sometimes periodically. The symptoms of hectic fever often creep on insidiously, there being a slight emaciation, a pulse a little quicker than ordinary, with a small increase of heat, especially after meals. The patient feels chilly towards night, then the skin gets hot and dry, especially in the palms of the hands and soles of the feet, and the pulse more frequent and less hard and in the middle of the night or towards morning, perspiration often profuse, breaks out, but with no relief. The paroxysms are irregular' sometimes two or three or more in twenty-four hours. Any of the°three INFLAMMATION OF DIFFERENT TISSUES. 39 phenomena of the series may be wanting. During the fever chilliness sometimes returns ; or, after the perspiration, all the signs of fever. In hectic fever the appetite returns, thirst abates, the tongue, instead of being white, becomes clean and moist, and, towards the end, very red, or speckled with apthas; there is no headache or confusion of thought. The face is usually pale, but, during the exacerbation, flushed and often with the red spot on the cheek; the skin, when not perspiring, is harsh and scurfy, branny scales may be rubbed off; the finger-nails become adunque, the sclerotic pearly white, and oedema of the ankles comes on finally. Hectic may occur independently of suppuration, as in mothers suckling too much, in newly-married husbands, &c. ; and when there is a drain on the body. In mortification, as an event of inflammation, the fever is apt to assume the typhus-like form, to be characterized by a sinking pulse, shrunken features, cold and clammy skin, dry and black tongue, low muttering de- lirium or stupor, tremors of the voluntary muscles with spasmodic startings of their tendons, involuntary stools and urine. This is owing likely to animal poison in the blood : this poison may have come from the mortified part, or may have existed previously and helped to cause the mortification. The typhus-like symptoms are no necessary or constant concomitant of mortification. In typhus the tendency is to death by coma ; in gangrene, by asthenia. Sometimes, when mortification of internal parts takes place, the pain suddenly ceases. Inflammation of Different Tissues.—Diffused inflammation of the areolar tissue, accompanied by sloughing, is called diffused inflammation of the cellular membrane; if the skin is also implicated, it is called erysipelas phlegmonoides. This often comes from animal poisons, and inflammation of veins and absorbents. The larger glands and solid viscera are affected similarly to areolar tissue. Acute inflammation tends to form abscesses. Abscesses and gangrene are rare in the lungs; the last is unknown in the liver and very rare in the kidney. In the kidney, pus often follows in- flammation. Inflammation of the viscera is generally attended with little pain. Areolar tissue in all parts is rendered thick and hardy by chronic inflammation. Inflammation of serous membrane is characterized by sharp, severe pain, hard pulse, buffy blood, a tendency to spread, bythe effusion of serous fluid and coagulable lymph, and sometimes, in violent inflammation, or when air is admitted, by the effusion of pus. Adhesive inflammation belongs especially to this tissue. Ulceration and mortifica- tion, commencing in this tissue, are very uncommon. Chronic inflamma-- tion of serous surfaces thickens, hardens, and puckers them. Synovial membrane is strongly analogous to serous, but it is less liable to inflamma- tion, and rarely throws out lymph. Joints are anchylosed, not by aggluti- nation, but by granulations arising on their ulcerated surfaces. Pus seldom forms in synovial sacs, unless air be admitted. Inflammation of the synovial membrane speedily leads to serous effusion. Superficial inflammation of the skin is denoted often by a diffused, red blush, which disappears on pressure, and terminating by resolution, is followed by desquimation : this is erythema. The inflammation when more intense causes serous effusion aud vesication, or purulent effusion. Mucous membranes are indisposed to adhesive inflammation, though they sometimes pour out an adventitious membrane like, but which is not, coagulable lymph. This membrane is soft, never organized, and appears to be inspissated mucus, altered and containing much albumen. Mucous membranes pour out serous fluid, or viscid mucus, or pus, or blood. In- flammation of these membranes sometimes spreads, sometimes is confined to one place, and tends to penetrate the subjacent parts and cause ulcers 40 INFLAMMATION—TUBERCLES. and sloughing. The spreading kind is oftcnest met with in the air pas- sages ; the other in the alimentary canal. There are less pain, less tevei, less tendency to buffy coat in inflammation of mucous than of serous sui- faces, unless at the openings, as the mouth, rectum, &c. # Muscular tissue is not inclined to inflame, but when it does it is apt to lose its contractile properties. Its vessels seldom pour out any 01 the products of inflammation; when these are present, they are likely the products of the areolar tissue. -,-, ■ a__ a Arteries seldom suppurate or mortify ; they do not readily inflame, and when they do, lymph and stagnation of the blood are the consequences. The veins often inflame and become entirely or partially blocked up, giving rise to new symptoms. The part from which the venous trunk receives its tributary branches becomes dropsical, as in phlegmasia dolens. Suppuration may result and pus be deposited in different parts of the body; causing great constitutional disturbances and like fever of a typhus type. The membranes of the brain often inflame; and its substance also. The ordinary events of the latter are softening and suppuration, some- times in abscesses, sometimes diffused. Mortification is rare in nervous matter. LECTURE XII. Kinds of Inflammation.—Acute or active inflammation and chronic or passive do not differ in kind, but only in degree. The former runs its course rapidly and is attended with much general and local disturbance; the latter runs its course slowly and is attended with less violent, local, and constitutional symptoms. The former is more influenced by medi- eine ; the latter is obstinate and tends to thicken and indurate in the m- terior of organs, but to effuse pus on membranes and surfaces. Sub-acute inflammation lies between the acute and chronic. Chronic is offen dangerous. Acute inflammation may subside into chronic, and chronic may rise into acute. Latent inflammation i6 that which runs its course unperceived, being often masked by other disorders, or by a dull and languid condition of the vital powers; as in the aged, intemperate, &c. Specific inflammation is that produced by specific poison, as in small pox, measels, &c.; it never, or almost never, recurs, but common inflam- mation does. Scrofulous or strumous inflammation is slow and chronic, attended with little pain, or heat, or, for a time, change of color ; the redness, when any, is often livid or purplish. Suppuration at length occurs and lasts long ; but the pus is not homogeneous or smooth, but thin, serous, whey- like, with curd-like fragments. The ulcers are indolent. This inflamma- tion is generally little influenced by remedies. Tubercles.—These belong to scrofula; they are unorganized matter of various shapes and sizes, which may soften and suppurate, the pus having the characters of scrofulous pus. Tubercular matter is deposited from the blood, whether as a foreign matter or a malelaboration of it is un- certain. If it is fluid at first, the watery part is absorbed and there re- mains a pale yellow, or yellowish grey, opaque, unorganized substance. Its shape depends on the part it occupies. Its favorite 6eat is the/ree sur- SCROFULOUS DIATHESIS. 41 face of mucous membrane, but it is often also found on serous surfaces. It grows larger by accretion. No alteration takes place in tubercles except through the agency of parts in contact with them, so that when they be- come crowded, as in the lungs, they, by pressure, cause inflammation of the intervening areolar and other tissues, which suppurate and thus soften and break down the tubercular matter. There are often found among the tubercles, grey semi-transparent corpuscles. The tubercular matter may soften and be expelled, or it may become hard, cretaceous matter, as sometimes happens in tabes mesenterica, and the patient get well. In childhood and youth the lymphatic glands, especially the mesenteric and cervical, are very prone to scrofulous inflammation. In adults, tuber- cles are most frequent in the lungs, especially in the superior and pos- terior parts of the upper lobe; here also they begin to suppurate. When scrofulous ulceration occurs in the larynx and trachea, it is usually the concomitant of the lung affection. Tubercular disease is very com- mon in the digestive organs, in the mucous follicles of the small intestines and coecum. Tubercles are very seldom found in the adult liver, oftener in that of children. They are also found oftener in the spleen of chil- dren than in that of adults. They are likewise found in the uterus, tes- ticle, prostate gland, on the surface of the peritoneum, in the nervous system, especially the brain, in bones, especially the bodies of the verti- brae, and spongy extremities of long bones. They generally occur in more than one organ at a time. They are rare in the organs of circulation. They are not always or necessarily preceded by inflammation. Tubercles, by pressure, and probably by other ways, cause inflammation; and in- flammation often determines the development of tubercles. In the stru- mous, common inflammation may take on the scrofulous form, become chronic, suppurate tardily and produce unhealthy pus. Scrofulous Diathesis.—This is denoted during childhood by a pale and pasty complexion, large head, narrow chest, protuberant belly, soft and flabby muscles, and languid circulation. It very often exists in the sanguine temperament, and is indicated by light, or red hair, grey or blue eyes, large and sluggish pupils, long, silky lashes, fair, transparent skin and rosy cheeks. Cold changes the red color to purplish or livid ; the skin is thin and readily irritated; the sclerotic is often of a pearly lustre, and the extremities are subject to chilblains. Such children are often very clever, quick, susceptible, &c. It is also frequent in the melancholic or bilious temperament, in persons of a dark muddy complexion, harsh skin, and of dull bodily and mental energies. It may occur in others. Other marks of this diathesis are chronic lippitudo, or blear eyes, chronic con- junctivitis with extreme impatience of light, and a tendency to form little pustules at the edge of the cornea, tumid and chapped upper lip, red and swollen coluinnae nasi and lower parts of the nostrils, white swelling, rickets, moist eruptions behind the ears, chronic enlargement of the glands of the neck and lupus. This diathesis is hereditary. The exciting cause is any thing that pro- duces debility ; as insufficient nutriment, exposure to wet and cold, impure air, want of exercise, and mental disquietude. Infants at the breast sel- dom show scrofula. It may be prevented often from becoming developed by moderate exercise in pure air and in open daylight, with good nourish- ment and clothing, and attention to the bowels. 42 CANCER—TREATMENT OF INFLAMMATION. LECTURE XIII. Cancers—Treatment of Inflammation.—Cancers are called malig- nant. They are not changes in the natural texture of the body, but ad- ditions to them, assuming usually the shape of tumors, and called can- cerous growths. Some other tumors, as fatty, fibrous, and osseous, not necessarily implying danger to contiguous parts, or to life, or to the gen- eral health, are innocent. Those resembling natural textures, as the above, are styled analogous or homologous, while cancer and tubercle are styled heterologous. Cancers are hard or soft. There are three species : scirrhus, encephaloid, or brain-like, and colloid or gum-like. The first is as hard as cartilage and creaks when cutting; the cut surface is white or grey, or bluishwhite and satiny, with opaque, fibrous intersecting bands, and giving out thin juice on pressure. The second is brain-like, soft, white, opaque, with thin traversing and circumscribing fibrous septa. The third looks like cells of greenish-yellow transparent gum or jelly; it is sometimes called alveolar. Two or three species may exist in the same or different organs at the same time ; they are prone to multiply in vari- ous parts, and when one kind is cut out another may spring up in its place. Cancers, commonly during a part at least of their progress, are severely painful, incontrollable, augment sometimes very rapidly, sometimes slowly, eat away parts, break out into foul ulcers, corrupt the blood and destroy life. All parts are subject to cancers, especially the female mamma', uterus, the stomach, liver and testicle. The lymphatics, but especially the blood, carry the germs of cancer to all parts. The primary tumor should be completely extirpated as early as possible. Cancer is transferable from one person to another. The chimney-sweeper's cancer, affecting chiefly the scrotum, is produced by long handling common soot. Mortality from cancer increases as life advances. Women are more sub- ject to it than men. The secondary formations are generally encephaloid; this kind is much more vascular, grows faster and larger than scirrhus, and generally occupies several organs at once; but scirrhus is slow, and sometimes solitary. Fungus hcematodes are ragged red, bleeding growths on ulcerated surfaces of cancers. Alveolar cancer occurs principally in the pyloric end of the stomach and in the omentum, sometimes in bones, in the breast and testicles. It is sometimes alone and in one organ only, sometimes it is found with the other species; it is seldom met except in adults. Treatment of Inflammation.—Obtain resolution if possible; if not, then, in external inflammation, good suppuration is generally best; and in inter- nal, sometimes suppuration, sometimes adhesion. Remove the cause if possible, and prevent its re-application. Follow the antiphlogistic regimen; i. e., avoid all internal, external, or mental stimulants, as animal food, strong drinks, noise, &c. The temperature should be about 62 -, the apart- ment well ventilated, the body should be placed in the best condition for the free circulation of the blood, and the affected organ should be kept quiet. When suppuration or gangrene has supervened, the antiphlogistic regimen must generally be modified or abandoned. Bleeding is one of the best remedies in inflammation. Phlebotomy, arte- riotomy, called general bleeding, lessen the force of the heart's action ; scarrifieation, cupping, leeches, called local or topical, empty the loaded TREATMENT OF INFLAMMATION—BLOOD-LETTING. 43 capillaries. The general effects of bleeding are proportionate to the quan- tity of blood drawn in a given time. Venesection is the most effectual mode of bleeding, especially bleeding from the cephalic or basilic veins at the bend of the arm ; but if, from any cause, these are inconvenient, some other vein or artery will do, or cups or leeches may answer. Pyrexia of itself is not a sufficient reason for bleed- ing. The best warrant for it is a hard pulse, whether large or small, slow or frequent. This hard pulse must not be trusted to alone, for it is habitual in some persons, and exists in certain chronic heart diseases and probably in some unnatural state of the circulation. Frequency of pulse is less im- portant than hardness. The inflammatory pulse ranges generally from, 90 to 120, or more in the young, the nervous, and those previously suffering chronic and wasting complaints. If the organ inflamed be, or is supposed to be, a vital one, we should, other indications concurring, bleed. Bleed in the upright position, and as early as possible ; bleed freely from a sufficiently large orifice and pleno rivo, and produce a decided impression as soon as can be. The bleeding has been carried far enough when the inflammatory fever subsides, or changes its character, when the pulse be- comes soft or undergoes some marked change, when symptoms of syn- cope or of suppuration appear. When inflammation supervenes on chronic disease, or comes on in idio- pathic fever, or when there is specific poison in the body, or when suppu- ration is certain or probable, bleeding if necessary must be employed cau- tiously. The very young, the old, the feeble and cachectic, do not bear well the loss of much blood, but still bleed them carefully in dangerous inflamma- tion. Note the character of the reigning epidemic, for some require, others do not permit of bleeding. Pain, respiration, stupor and delirium are relieved by bleeding. Bleeding in the upright position causes defective supply of blood to the head and thus favors syncope. Syncope is relieved by a hori- zontal position. In inflammation more, blood must be drawn to produce syncope, than in health. Generally, the amount of bleeding required to cause syncope is in proportion to the exigencies of the case. Whether or not the case is one of inflammation is often settled by observing the quan- tity of blood which, taken in the upright position, produces incipient syn- cope. If, at the first bleeding, much blood flowed before syncope threat- ened, the bleeding will probably require to be early repeated. Generally 16 or 20 to 30 ounces is enough blood to draw. Sometimes two, three, or more such bleedings may be necessary. Topical bleeding is most appropriate in chronic cases, and when the general bleeding does not relieve the local symptoms, except when further loss of blood would be hazardous. These local bleedings for chronic in- flammation usually require to be often repeated. Bleed topically as near the inflamed part as possible; over the temples, or behind the ears, or just below the occiput in inflammation of the head; over the chest and precordia, when the lungs or heart are affected ; over the abdomen when the liver, or stomach, or intestines are inflamed. General and local bleeding combined are often highly useful. Blood- letting must be proportioned to the rate of progress and duration of the disease; that is, in chronic cases, use bleeding chronically. Bleeding may be demanded though the pulse be small, as, often, in inflammation in the abdomen. If, in this case, the pulse expands and rises, an impression has been made on the system and the bleeding must be stopped, or death by syncope may result. Repeat if necessary. Distant topical bleeding, (revulsion,) especially from veins returning to 44 TREATMENT OF INFLAMMATION—MERCURY. the inflamed part, does good. Arteriotomy is difficult to manage, and aneurismal tumors may result from it. Opening the external jugular vein is very hazardous;- for air may get into the heart and cause death ; besides it is often very difficult to manage, and any compression, necessary to stop the bleeding, might injure the cerebral circulation. Which has the most effect in restraining inflammation, arteriotomy or phlebotomy, is uncertain. LECTURE XIV. Inflammation—Continued.— Treatment — Continued. — Purging. — In acute cases purge actively. It frees the stomach and intestines of irritating matters, faeces, &c, and depletes by causing serous discharges. Purging is particularly good in inflammation, internal or external, of the head. It is also beneficial in inflammation within the thorax, but less so than in that in the head. It is beneficial in inflamed liver. Inflamed stomachs or bowels should be simply unloaded and then left alone. Mercury is next to bleeding, and better than purging, especially in acute, phlegmonous, adhesive inflammation. In health it causes increased watery evacuations from the bowels, or increased flow of bile, or of saliva. It seems to cure by equalizing the circulation, thus relieving congested parts. If pushed in health, it produces inflammation, the gums becoming tender, red and swollen, at length ulcerating, and sometimes, especially in children, the cheeks, throat and fauces sloughing. This inflammation is superficial, spreading, erysipelatous, and, in the enlarging ulcers, absorption predominates, and the patient gets thin and emaciated. Mercury, as an auxiliary to bleeding, when bleeding is indicated, but not as a substitute for it, is the remedy for stopping, controlling or entirely preventing the effusion of coagulable lymph, for bridling adhesive inflamma- tion. But it will likely be hurtful, when, in any disease, the morbid action approximates to its own; as in erysipelatous inflammation, disposed to gangrene ; in scrofulous diseases, in inflammatory complaints, with general debility and an irritable nervous condition, or a manifest tendency to take on the typhus-like form. In acute inflammation, after bleeding, bring the system as speedily as possible under the influence of mercury. When this specific influence has been obtained, the gums grow red, spongy and sore, there is a metallic copper taste in the mouth, and an unpleasant fsetor from the breath. This effect is best obtained by mercury, in equal and repeated doses by the mouth ; as calomel, grs., 2 to 3, every four or six hours for about thirty-six or forty-eight hours. If this purges and thus the specific effect is postponed, combine opium, as gr. {, to calomel grs. 2, or gr. ]/,, with grs. 3 to 4. A speedier effect is obtained by larger doses, as grs. 5 to 10, every three or even two hours; or mercurial inunc- tion may be combined. Blue pill or hydrargyrum cum creta, in larger doses, is sometimes preferable; or calomel and blue pill combined. Pre- vious bleeding renders the body more susceptible of the influence of mer- cury. In some persons mercury is unmanageable, in others, inert. To ease the distress of salivation, alum gargles, or gargles of chloride of soda or a dilute solution of chlorine in water, or open air, or sulphur or iodine are recommended. If there be much external swelling, eight or ten leeches may be applied beneath the edge of the jaw-bones, and a soft poultice wrapped round the neck, into which the leech bites may bleed. Pure tannin, moistened and smeared on the spongy gums, is good. One part ANTIMONY---COUNTER IRRITATION. 45 of brandy to four or five of water, as a gargle, often helps the saliva and the sore gums. In chronic inflammation, mercury must be introduced slowly into the system, and when the specific influence is obtained, it must be kept up for a considerable length of time. In scrofulous diathesis, if mercury is neces- Bary, use it, but very carefully. * Antimony, another very valuable remedy, subdues the action of the heart and arteries, and produces nausea, paleness and sinking of the pulse, and often great relief to the local symptoms. Repeated bleeding may perma- nently and dangerously debilitate the patient, but antimony is not followed by such weakness. Antimony is peculiarly beneficial in inflammation of the mucous membrane of the air-passages. It is often useful when mer- cury is not. The best form in which to use it is that of freshly dissolved tartar emetic. The antimonial powder is of very uncertain strength, and antimonial wine contains too rimch spirit to be used freely. After two or three doses, tolerance (as far as the vomiting and purging are concerned) of antimony is usually established, when the same quantity is persevered with. To obtain its full influence in a short time, dissolve gr. i of tartar emetic in f § ii of hot water, and give one-fourth every half hour. Pause when paleness and sickness come on, but repeat it when inflammatory symptoms appear. If it purge too much, add a few drops of laudanum. Digitate, though it retards the circulation, is not to be depended upon in acute inflammation, for it acts at uncertain periods, and, if used in large doses, it may produce deadly faintness, syncope and even death. Colchicum is very good in some kinds of specific inflammation, but less so in the common kind. Opium allays the nervous irritability, which arises from bleeding, and thus prevents the rekindling of the inflammation ; it is best adapted to nervous patients, and to cases of much local pain. In cranial and pectoral inflammation, or when there is a tendency to death by coma, or apnea, it is very ticklish, for it is hard to say how much of the stupor is produced by the disease, or how much by the drug. It should not be used if any duskiness of the face, or purplishness of the red lip, exists. Opium is most serviceable in tendency to death by asthenia; as after bleed- ing, in peritonitis and enteritis. Local Treatment.—Cold applications are very useful, especially in inflammation within the cranium, often allaying delirium. If the patient like them continue them, if not stop them. Cold applications to the chest and abdomen are perhaps injurious. External warmth, hot fomentation, is very good in some internal inflammations, especially of the abdominal organs; it determines to the surface, promotes perspiration, mitigates pain, and encourages sleep. In external inflammation, sometimes cold, sometimes warm applications do good; consult the sensation of the patient. In erysipelas use warm fomentation. Warm fomentations often forward suppuration and sometimes resolution. Counter Irritation, by blisters, sinapisms, irritating ointments, setons, issues, or moxas, is often very beneflcial, especially in chronic inflamma- tion, towards the decline of acute, and more particularly in scrofulous affections. In the height of inflammatory fever it is not admissible, nor in local inflammation should it be used very near the part. Blisters upon the head or neck, in the early stage of acute inflammation in the cranium, are not proper, though on the lower extremities they may do good. Blisters may with benefit be applied to the chest in thoracic inflammation and to the belly in abdominal. 46 CAPILLARY AND IDIOPATHIC HEMORRHAGE. LECTURE XV. Capillary Hemorrhage.—This is the most common kind. In nine cases out often, if there be any rupture at all, it is of the capillaries only. Rupture of arteries or veins is rare, except in cerebral hemorrhage, when it is common. It is likely that the blood oozes out through the apertures, through which the natural fluids of the parts are poured, for often a flow of mucus precedes hemorrhage from mucous membranes. Habitual hemorrhages are those which recur again and again, commonly at regular intervals, without any noticeable detriment to the health, or any obvious cause, but which depend on some necessity of the system. They occur most usually in the rectum and nares,*but also in the lungs, stomach, and skin, and are often hereditary. They resemble the catamenia in the time of life they come on and disappear, in their being often periodic, continuing on each occasion for the same length of time, with the same loss of blood, and being preceded by general indisposition, and often some fever. Their interruption, or metastasis to other parts, is generally from derangement of the health ; when profuse they become diseases. They are vicarious of each other and of the catamenia. Idiopathic Hemorrhage. — Idiopathic hemorrhage is that which is not habitual, nor connected with any appreciable previous local disease. It is active or passive. Active is preceded by active congestion ; passive, often, by no apparent congestion. The latter may depend on some change, very likely on rupture of, or debility in, the vessels or apertures of exhala- tion ; or perhaps more likely on some alteration in the consistence or com- position of the blood itself. In the first case, astringents are the remedies ; in the latter, reparation of the blood. Active hemorrhage occurs princi- pally in the young and robust, and those having a tendency to plethora. Sometimes it is caused by heat, strong mental emotions, or violent bodily effort; oftener there is no apparent cause. Symptoms of Hemorrhage.—The symptoms which often usher in hemorrhage are a general indisposition, wandering and obscure pains, which settle in the future seat of the hemorrhage ; a sensation of weight or tension, or heat and tingling ; sometimes slight redness andturgescence and fulness of the larger veins of the part; paleness, chilliness, and shrink- ings of distant parts, especially the feet and hands ; followed often by general increase of heat and a frequent, full, and bounding pulse, (hemor- rhagic pulse.) The blood commonly escapes rapidly, and from a single organ, is florid, and readily coagulates. The hemorrhage is followed by the disappearance of all the symptoms. Passive hemorrhage occurs in the feeble and in those debilitated by disease, fatigue, &c.; in it there generally are no precursory symptoms nor any reaction ; the effused blood is dark, serous, indisposed to coagulate, and often poured from several parts at once, causing, if at all considerable, a pale face and loss of heat. Symptomatic hemorrhage is that which is the result of previous disease in the part itself, or in other parts functionally connected with it. It is preceded by congestion, sometimes active, but generally mechanical, and especially of the veins. Thus we have hemorrhage from the bronchi in consequence of crude tubercles filling up a part of the lungs and obstruct- ing the circulation. In the same manner does disease of the heart cause hemorrhage of the lungs, and disease of the liver hemorrhage of the stom- ach and bowels. Seat of the Hemorrhage.—The mucous membrane is the most subject SEAT OF THE HEMORRHAGE—TREATMENT. 41 to hemorrhage, giving rise to epistaxis\ hcemoptysis, hamatemesis, melaena, hcemorrhois, hematuria, menorrhagia. Capillary hemorrhage occurs more rarely from serous membranes, and from the skin. Hemorrhage into serous sacs is, in most cases, an effect of inflammation or of the opening of a considerable vessel. Hemorrhage from the nose is most common in children; that from the lungs and bronchi, in youth; that from the rectum, uterus, and urinary organs, in the middle and decline of life. Hemorrhage often occurs from laying open larger vessels, as by ulceration, &c. In the brain, blood sometimes oozes from the capillaries of the brain or its membranes, but generally from the giving way of a diseased artery. The importance of the hemorrhage depends on the organ, the amount poured out, the time the bleeding continues, the pressure of the extravasated blood on internal parts, &c. Fatal hemorrhage may occur and yet no blood reach the outside, or, if reaching the outside, it may be doubtful whence it comes. It is generally more fluid and brighter the greater in quantity and the nearer the surface it is effused; but more in clots and darker the smaller in quantity and the longer it takes to reach the surface. Indirect symptoms of Internal Hemorrhage are, paleness of face, feebleness of pulse, coldness of extremities, and tendency to syncope ; alarm at the sight of the blood may occasionally produce these symptoms. Treatment.—Habitual hemorrhages should be let alone if they do not injure the health, or the structure or functions of the part. If they go by metastasis to more important organs, recall them if possible, for these changes are seldom for the better. Habitual hemorrhages, as hsemorrhois in plethoric persons, are often safety-valves and should not be stopped. But get rid of the plethora and piles, lest metastasis to the head cause apoplexy, or cerebral hemorrhage ; besides, the piles may bleed excessively, or, by exercise, inflame. In active idiopathic hemorrhages, unless there be danger from too great loss of blood, seldom use direct means to stop the bleeding, for they generally cure themselves. In these cases the treat- ment of inflammation may be requisite. With these exceptions, use both direct and indirect measures to arrest the hemorrhage as speedily as may be. Follow the antiphlogistic regimen ; as cool air ; absolute quiet, mental and bodily; the avoidance of any thing that hastens the circulation, as stimulating food, drink, &c. ; placing in that position which protects the part most from the afflux of blood. Bleeding, purging, and mercury in inward bleeding to slightly pytalize are remedies. Next to venesection and mercury come astringents, especially cold. Apply the cold to the bleeding surface by iced or cold drinks or enemata, or otherwise; or apply it as near, on the outside, to the organ affected as possible ; as to the chest, to the epigastrium, to the perineum, &c. Cold often acts on distant parts by shrinking them. Internal Remedies.—Acetate of lead, and many vegetable remedies, which seem to owe their astringency to gallic acid, as rhatany root, uva ursi, bistort, tormentil, pomegranate, kino, catechu, preparations of gall nuts and the nostrum Ruspini's styptic. It is better, in appropriate cases, to give the gallic acid itself. Some recommend nitre in large doses, min- eral acids, muriated tincture of iron, alum, oil of turpentine, secale cornu- tum, matico leaf, &c. 48 DROPSIES, CHRONIC AND ACUTE. LECTURE XVI. Dropsies.—These are collections of serous liquid in one or more shut cavities of the body, or in the areolar tissue, or both, independent of in- flammation. These are rather symptoms of, than real, diseases, but must often be treated as if real diseases. In dropsy depending on organic disease, there are two sets of symptoms, one depending on the primary disease, which is often permanent, the other on the collected fluid, which 'is often got rid of. Dropsy itself is often curable ; so also is, sometimes, the cause. Dropsy of the ventricles of the brain is called hydrocephalus; of the pleurae, hydrothorax; of the pericardium, hydropericardium; of the cavity of the peritoneum, ascites ; there are also oedema, anasarca, and gen- eral dropsy, this last being anasarca with dropsy of one or more serous cavities. Dropsies are caused by an augmented exhalation, or defective absorption, or both, of the serous fluid which naturally moistens all parts. It is probable that the lymphatics take up and carry effete matter into the blood and out of the body, and that the veins absorb the serous fluid. The entrance of fluid into partially filled veins, or the exit of it from full ones, depends on the physical principles of endosmose or exosmose. Chronic and Acdte Dropsies, Pathology, causes, &c.—Chronic, or passive, or cardiac dropsy is occasioned by defective absorption ; this de- fect is caused partly and chiefly, and sometimes entirely, by an unduly loaded state of the veins, which depends almost always on some impedi- ment to the return of the blood to the heart. The larger the vein and the nearer to the heart is the impediment, the more extensive will be the dropsy. Obstacles situated anywhere in the right or left side of the heart, or in the lungs, may produce secondary changes in the parts behind them. Passive dropsy is especially associated with disease ; primary or second- ary of the right heart. When a vein has been obliterated and no dropsy resulted, the vein was not a principal one of the part, or dropsy did exist at some time, or the collateral circulation prevented dropsy. Anasarca may occur without any obliteration of veins, or organic disease in the heart. A weak, debili- tated state of that involuntary muscle, the heart, may cause it, by not being able to propel the blood, which is thus retarded in the veins ; as in chlorotic girls, &c. Steel, good food, opened bowels and cold shower- baths in the morning, cure these, but bleeding makes them worse. Cardiac dropsies are those that have their origin in the heart; renal, those depending on disease of the kidney. Active, or acute dropsy depends on excessive exhalation, probably through the arteries or the capillaries near the arteries, and comes on sud- denly, and sometimes can scarcely be distinguished from inflammation with serous effusion. Between the surfaces of the shut cavities, the lungs, bowels, kidneys, and skin, there exists a compensating relation, by which, when any of them pours out more or less liquid than usual, some other one pours out an in- verse quantity. Should this compensating process fail, dropsy of some kind is apt to arise. Watery collections sometimes disappear suddenly from one part and rapidly appear elsewhere. If the fluid is discharged from a free surface we have a flux. Intercepted perspiration tends strongly to escape from free surfaces. Active dropsies are said to belong to the left side of the heart; passive, to the right. The water of dropsy is liable to change its location, subject to SYMPTOMS OF CATARRHAL OPHTHALMIA. 49 the force of gravity, and collects most where the areolar tissue is loose and plentiful, as in the eyelids, scrotum, &c. Active dropsies may sometimes be inflammatory, and may be 60 con- sidered if any pus, or flakes of lymph, or if the ordinary symptoms of in- ternal inflammation, exist. Active dropsy, with much disturbance of the whole system, might be called febrile. Prognosis.—Anasarca, in chlorosis, is the least perilous and the most hopeful. Febrile or active dropsies are more obedient to treatment and oftener entirely curable than chronic. Local dropsies are hopeful if the impediment which causes them can be removed or a compensatory cir- culation be established. In chronic cases, cardiac dropsies are more readily dispersed for a time, but Sooner return than renal. The immediate danger from the collected fluid depends on its location. Treatment.—1. Get rid of the accumulated fluid. 2. Prevent its re- turn ; in other words remedy the diseased condition which caused the dropsy. In active or febrile anasarca venesection often draws off the fluid, by relieving congestion, dimiuishiug the heart's action and promot- ing absorption. But as it also diminishes the fibrin and red particles of the blood, and makes it more watery, and weakens the heart, it should be used cautiously. The fluid may sometimes be got rid of through the ali- mentary canal, or kidneys, or skin. In chronic dropsies alleviate symp- toms and trust to time. Paracentesis, Acupuncture.—See Lecture LXVII. LECTURE XVII. Ophthalmia is inflammation of the eye generally. The mild form of in- flammation of the conjunctiva and meibomian follicles is caused by vicis- situdes of temperature, or certain conditions, or sudden variations, of the atmosphere, especially by cold, and is called catarrhal ophthalmia. Symptoms of Catarrhal Ophthalmia.—The leading symptoms are, red- ness, some pain and uneasiness in the eye, and increased discharge, and a sticking together of the eye-lashes and lids. The redness is superficial, bright, scarlet and usually irregular or in pcJcJies. In intense inflammation the whole surface, except the cornea, is scarlet red. The vessels are large, tortuous, and anastomosed into a network, which can be moved about by the finger. Extravasated blood in this net- work is called "blood shot," or ecchymosis. The conjunctiva of the lids is first inflamed, and afterwards that of the eyeballs. In sclerotitis the red- ness being seen through the conjunctiva, is pink, sometimes slightly violet, the vessels are small and fine, like hairs, and straight and point to the cornea, like radii, and cannot be moved by the finger. The pain in catarrhal ophthalmia is slight. At first there is intolerance of light; but not when the disease is fully developed. There is a sensa- tion of stiffness and dryness, as of some foreign substance, as sand, be- tween the globe and lids. In sclerotitis the pain is more severe, of a dull aching kind with a feeling of tightuess, the sclerotic being denser than the conjunctiva ; it is also often throbbing and felt in the brow, temples and head ; it increases in violence from evening till after midnight, and then abates and is nearly absent during the day. This is rheumatic ophthal- mia, and is produced by the same causes as catarrhal. 50 PURULENT OPHTHALMIA. The discharge from the eye in catarrhal ophthalmia is not generally abundant; it is altered mucus, at first thin, then thick and often puri- form, sometimes transparent, and viscid and gummy. The little" swelling, which sometimes exists, is caused by the serous fluid under the conjunc- tiva. Inflammation of the mucous membrane only, under favorable circum- stances, runs a certain course and subsides; but otherwise it may continue troublesome for weeks and injure the cornea. Treatment of Catarrhal Ophthalmia.—Antiphlogistic regimen; avoid drafts of air, and exposure to cold and moisture. Active and gen- eral remedies are seldom necessary. In the outset purge with calomel and jalap, or calomel followed by a black dose, (infus. senna;.) If the system sympathize with the local disease and the" inflammation is severe, or.if the disease was mismanaged or neglected, it may be necessary to bleed from the arm, or apply leeches. Purge well once or twice, and give moderate sudorifics, as warm dilu- ent drinks ; Dover's powder grs. v, and warm foot-baths at bedtime; and, during the day, saline draughts, containing liq. ammonia acet. 3 ii-iii. Local stimulating or astringent applications are the best remedies ; as distilled water § i, with argenti nitras grs. iv ; put a large drop in the eye once, twice or three times per day ; there is smarting pain at-first, followed in ten or twenty minutes by much ease of the sensation of sand in the eye, and abatement of the inflammation. Continue this as often as the symp- toms return. Acetas plumbi and zinci sulphas are also used in collyria, but are much inferior to argenti nitras. Prevent the gluing of the lids, by smearing them at bedtime with any mild ointment, as spermaceti ointmeut or lard. Pvri'lent Ophthalmia.—This is another disease of the conjunctiva, so called from the profuse discharge of altered munus, which cannot be dis- tinguished from pus, and which runs over and excoriates the cheek. It differs greatly from catarrhal ophthalmia in the degree of the inflammation and symptoms, in the danger to the sight, and in the exciting causes. Varieties of Purulent Ophthalmia.—There are three varieties: 1, purulent ophthalmia of adults, or Egyptian ophthalmia, or contagious ; 2, gonorrheal; 3, that of newly-born children. The two first are so essen- tially the same, in adults, in symptoms, course, and consequence, that one description will answer both. Purulent Ophthalmia of Adults, Egyptian, Contagious Gonorr- heal Ophthalmia.—The effusion beneath the conjunctiva bulges it out around the coruea like a ring, burying the cornea ; or it pushes the livid red eyelids forward and hides the eye entirely, the upper lid becoming hard and stiff and completely overhanging the lower. This pale red swelling with sometimes patches of extravasated blood, is called ihrmosis. If the inflammation is confined to the lining of the lids, it is not danger- ous, but it is prone to extend to the whole anterior surface and produce ulceration and sloughing of the cornea. Often, interstitial deposits he- tween the laminae of the cornea destroy vision. The conjunctiva, lining the lids, is often left chronically inflamed, thick, granular, hard, thus per- petually irritating the cornea and causing haziness, opacity, with some vascularity of it. If the inflammation penetrate to the deep-seated textures, there is much pain, which is pulsating, circumorbital, sometimes sharp and lancinating, sometimes dull and aching, sometimes intermittent, or, if constant, paroxysms come on at night and abate towards morning. This circum- orbital pain is characteristic of inflammation of the sclerotica, cornea, choroid and iris. It is when the pain is severe, throbbing and paroxysmal TREATMENT OF PURULENT, EGYPTIAN OPHTHALMIA. 51 that the cornea generally gives way. The giving way is sometimes followed by relief to the pain, and sometimes it is not. There is seldom much intolerance of light. When the local symptoms increase in severitv, the constitution sympa- thizes, the pulse becomes frequent, tti3 tongue"white, but there is seldom much fever or thirst, and generally the blood is not buffy. Children suffer more constitutional disturbance than adults. Purulent ophthalmia is con- tagious, and, for a short distance, likely infections, even though origin- ally it might have arisen from some ordinary cause and independent of contagion. LECTURE XVIII. Purulent Ophthalmia—Continued.—Gonorrheal is severer than Egyp- tian ophthalmia, and runs a more rapid course. It is said, that in the latter the lids are the parts first inflamed ; but in the former, the whole conjunctiva ; in the former, also, one eye only is generally affected. These and the history of the case may help the diagnosis. Purulent ophthalmia is produced by contact of the gonorrheal matter of the urethra with the eye. Whether or not it occurs by metastasis is uncertain. It does not, most likely, supervene as a part of gonorrhea, independent of inoculation and metastasis. Treatment of Purulent, Egyptian, Gonorrheal Ophthalmia.— Bleeding early and freely from the arm in the upright position till fainting is about to ensue, or the pulse begins to falter, may, in the young and robust, help the local remedies in Egyptian ophthalmia. Bleeding is also indicated by the throbbing, circumorbital and nocturnal pain. Bleeding, however, is not always satisfactory, on account of the inflamed part being a mucous membrane, and there being so little constitutional sympathy. When the patient rallies from the faintness produced by the general bleed- ing, twelve to twenty-four leeches around the eye, not upon the tumid lids, often do good. Local stimulants and astringents are generally best. Some use undiluted liquor plumbi acetatis; some introduce a very minute quantity of the oil of turpentine between the lids. The nitrate of silver solution, grs. iv to § i of distilled water, is much the best. Increase the strength of this solution in proportion to the intensity of the disorder. A very good plan is : wash away any discharge with a solution of alum, (3 i, to water, O i,) then insert beneath the lids the ten grain ointment, (nitrate of silver, in impal- pable powder grs. x to 3 i of hog's lard,) and move them freely ; or turn them out and rub on the ointment—if this does good the su face will turn white. The pain, caused by this application, and which lasts for a half hour, or an hour, or more, may be relieved by warm narcotic fomentations, and pain may be allayed and sleep obtained by opium. A mild ointment applied at night to the edges of the lids prevents their sticking. The next morning clean out the eye again, and again apply the ointment. Clean out the eyes occasionally. Mercury is useless or mischievous, for the disease is too rapid, and, besides, it is not adapted to this kind of inflammation. Scarification is preferable to non-scarification of the conjunctiva in chemosis, for it lets out the fluid, which, by pressure, injures the cornea, even to sloughing. Blisters on the nape of the necks, temples, or behind the ears during 52 PURULENT OPHTHALMIA OF NEWLY-BORN CHILDREN. the active stage, are of no use, but in the more advanced and chronic periods they are. In gonorrheal ophthalmia no benefit is obtained by reproducing the urethral discharge ; in fact it is generally not suppressed. Purges are proper and necessary. Purulent Ophthalmia of Newly-born Children, Neonatorum.— This is very common, very serious if neglected, but very easily managed if treated in time. Symptoms.—It comes on usually about the third day, but sometimes later, and is at first confined to the conjunctiva of the lids, but afterwards extends to the eyeball; there is intolerance of light; at length the lids 6well, sometimes enormously, and a copious discharge of pus takes place, which is often hot; the mucous surface of the lids is often villous and shaggy and bright scarlet; and at last the cornea may slough, or become opaque or protrude, (staphyloma,) or the iris may prolapse, or the coats of the organ may shrink. So long as the transparent parts are uninjured, which is sometimes for eight or ten days, the eye, with proper treatment, is safe. Causes.—The disease generally results from inoculation by the un- healthy fluids of the mother, whilst the child is being born, and is itself highly contagious. It is also probably brought on by bad management, by cold air, by hot, bright fires, by soap, and such irritants. Treatment of Ophthalmia Neonatorum.—In severe cases, if the lids be very much swelled and red externally, place a leech (in this case) upon the centre of the tumid upper lid, and watch its effect, as the bleed- ing may be hard to stop, or it may be sometimes too much for the infant. Empty the bowels with a little castor oil, and apply to the inflamed eye a lotion of plumbi acetatis grs. ii to water § i. In less severe cases, keep the bowels open with magnesia, apply a little lard along the edges of the lids, and inject carefully into the eye a solution of alum, grs. iv to water § i. If the eye become insensible to the alum, use a solution of nitrate of silver, grs. i to iv m water ^ i- Pustular, or Phlyctenular or Strumous Ophthalmia.—This is a disorder of children, occurring between the time of weaning and the eighth year, but sometimes much later. Sore eyes in children at the breast are, in nineteen-twentieths of the cases, puruleut, but after wean- ing, strumous. Symptoms of Pustular Ophthalmia.—The leading symptoms are slight and partial redness, sometimes confined to the lining of the lids, great intolerance of light, little prominences or pustules on the conjunc- tiva, sometimes on the cornea, but generally at the junction of the sclerotic and cornea. Sometimes one eye only is affected ; oftener both, and then generally one worse than the other. In scrofulous childrtn, catarrhal ophthalmia is apt to become strumous. A few vessels, collected into bun- dles, evidently superficial, often prominent, proceed from the circumference of the eye, especially the angles to the edge of the cornea, and sometimes encroach on it. At the end of these vessels are situated the pustules. These may be absorbed and leave a temporary white spot, or they may form little ulcers, which, if on the cornea, may penetrate it, and letting out the aqueous humor, cause prolapsus, iridis, &c.; or they may heal and leave a permanent white, opaque speck (leucoma) which interferes with vision. Intolerance of light is sometimes the only symptom noticeable, and be- gets a peculiar expression of countenance, which, when once seen is easily recognized afterwards. ' Often, the profuse discharge of scalding tears inflames and excoriates the skin and causes pustules which produce a discharge that crusts over TREATMENT OF STRUMOUS OPHTHALMIA. 53 the cheek, forehead, &c. This is crusta lactea or parrigo larvalis, and is very characteristic cf the scrofulous habit; it occasionally spreads over the whole body. Though there is extreme intolerance of light (called photo- phobia scrofulosa) the retina is not inflamed, nor in danger. Other evidences of scrofulous disease usually accompany the ophthal- mia, and sometimes alternate in severity with it, getting better as they get worse, and vice versa. These evidences are swelled and red alse nasi and upper lip ; enlarged cervical glands ; eruptions on the head ; sore ears ; a large and hard belly ; disordered bowels ; offensive breath ; grind- ing of the teeth ; and general debility. LECTURE XIX. Strumous Ophthalmia—Continued.—Pannus, which sometimes exists in strumous ophthalmia, is a patchy and vascular condition of the corneal surface, formed by anastomosing vessels. Strumous ophthalmia is very obstinate, and, as long as the scrofulous habit exists, very apt to recur during the period already mentioned. Treatment of Strumous Ophthalmia.—This should be general. Cor- rect the unnatural condition of the digestive organs by purging at the out- set, and occasionally, by a mercurial purge, and regulate them afterwards by laxatives, as rhubarb, or confectio senna?, or castor oil. Order warm clothing, frequent ablution of the body, nourishing but plain food, pure air, change of air, and regular exercise. Administer tonics, as the prepara- tions of iron, or the dilute mineral acids ; the best tonic is sulphas quinince. To a child give grain doses, three times a day, dissolved in water, with a drop of dilute sulphuric acid, and 6ome syrup of orange-peal. Leeches round the eye are seldom requisite, except when there are more pain and redness than common, and white tongue and hot skin. Intolerance of light is no fit indication for the use of leeches, for abstraction of blood rather aggravates that symptom. Warm fomentations are agreeable, and, when the system is somewhat rectified, local stimulants and astringents do good ; as vinum opii, and the lunar caustic solution: this last, if long and repeatedly used, is apt to stain the conjunctiva of an indelible olive color. These two preparations diminish the irritability of the eye and promote the healing of the ulcers. The red precipitate ointment, and the citrine ointment, diluted, are bene- ficial. Counter irritation is very useful; as blisters behind the ear, or at the back of the neck, or issues in the arms, or a ring of silk in the pierced lobe of the ear; a strong thread, smeared with emplastrum cantharidis, and firmly tied behind the ear at the angle of reflection, causes vesication. Ulcers on.the cornea may be checked by being touched, once in two or three days, with a sharp-pointed piece of lunar caustic. When the hot tears have ceased, get rid of the crusta lactea by a light poultice or warm water, and then from time to time bathe the part with a lotion of zinei oxyde 3 i and water, or rose water § iv. Iritis.—The lining membrane of the anterior chambers of the eye is a shut serous sac, and inflammation of it is of the adhesive kind. The in- flammation is sometimes confined to the iws, sometimes it is not. Symptoms.—The objective symptoms of iritis are redness of the sclerotic ; deposition of lymph ; change of color, of brilliancy and appearance of the iris from the presence of lymph ; irregularity and sometimes immobility of 54 IRITIS. the pupil from adhesion to neighboring parts. The subjective symptoms are impaired sight pain in and around the eye. The redness of iritis is the same as that of sclerotitis, and the fine hair- like vessels dip down at or about the edge of the cornea and go to the iris. The vascular zone becomes fainter from before backwards. Sometimes the red, inflamed vessels of the conjunctiva confuse the redness of iritis. The zone continues and disappears with the inflammation. The lymph is visible on the iris, resembling rust spots, or yellowish, or reddish brown drops towards the pupillary edge. Suppuration sometimes takes place in violent cases. Vision is always impaired, partly because the posterior tunics are perhaps implicated, partly because lymph fills the pupil more or less or prevents the iris from moving freely, and partly because the cornea is hazy. There are intolerance of litrht,, and pain in the eyeball, in the brow and temples, most severe at niirht. The pain is sometimes constant and severe, with nocturnal paroxysms, but occasionally very trifling. In most cases, particularly acute cases, there are much fever and headache, a full and hard pulse, and white tongue. If the inflammation reaches the retina, blindness usually results, and the pain and fever in- crease. Pure iritis is always manageable. Treatment.—Antiphlogistic regimen ; purgatives ; bleeding, local and general—these are useful, but they do not cure iritis. The intensity of the local symptoms, especially the pain, the degree of the fever, the hardness of the pulse, and the strength of the patient, offer the best measure of the necessity of the bleeding, and of its amount. Venesection till some decided impression is made on the circulation, cupping from the temples, or both together or in succession, may often be required. Active purgatives should be exhibited. Mercury is the remedy; use it, after such bleeding as may be necessary, to affect the gums as soon as possible, as calomel grs. ii, iii, or iv, with opium gr. 4, \ or \, given every four, or six, or eight hours; or calomel gr. i. with opium gr. Mo or \ every hour. Equal doses at equal intervals. If necessary, the mercurial friction may be added or used alone, or hy- drargyrum cum creta in doses of grs. v to x. It removes the lymph and all unfavorable symptoms, unless the lymph has become organized, or has glued the parts together; even in cases of some standing it does good. Belladonna should be used at the same time with mercury; its benefit consists in its power of dilating the pupil and thus preventing adhesion, or of stretching and breaking already existing adhesions ; Henbane, stramo- nium and cherry laurel also possess this virtue. When the eye is painful or much inflamed, smear the surrounding skin-with the extract of bella- donna, made semi-fluid with water, and wash off after an hour; but for dilating the pupil it is better to drop two or three drops of the solution (ext. 3 i to distilled water § i, filtered through linen) into the eye. In slow cases keep up the influence of mercury till the redness, lymph, &c, disappear; this may take a month or two. Nocturnal pains round and over the eye may be eased by rubbing well into the temples, before the pain comes on, an ointment of grs. x of strong mercurial ointment, and grs. ii of opium. Causes.—Surgical operations may cause violent iritis ; straining the eye, &c, often bring on iritis insidiously aDd slowly, and cause injury to-the retina. In this last case mercury, gradually introduced into the system, often does good. Iritis is often combined with syphilis or rheumatism. It is one of the earliest, and sometimes the only secondary symptom of syphilis. The pain RHEUMATIC IRITIS. 55 of syphilitic iritis is severe and chiefly nocturnal. This form of iritis can- not well be distinguished from other acute forms of iritis, from mere in- spection. It is never attended with abscess of the iris and hypopyon, the lymph is usually deposited in distinct masses, the pupil becomes angular, often towards the ncse ; these, and the periodic nightly pain, and the exist- ence of other secondary syphilitic symptoms, as eruption, nodes, pain in the limbs and ulceration of the throat, and the information obtained from the patient, show the iritis to be syphilitic. Syphilis in childhood very seldom affects the iris. Mercury is very beneficial in syphilitic iritis. It never causes it. LECTURE XX. Arthritic, or Rheumatic Iritis.—This is associated with gout or rheumatism ; like them it is apt to return again and again, and this return- ing makes it dangerous. Lymph is poured out at each attack, thus con- tracting and sometimes plugging up the pupil. Ten or more attacks may occur before any injury results to the vision. Symptoms of Arthritic Iritis and Rheumatic Ophthalmia.—These are some of the local symptoms characteristic of arthritic iritis ; the lymph is seldom deposited in distinct masses ; the contracted pupil keeps its cen- tral position ; the adhesions of lymph are whiter than usual; the zone of vessels is somewhat livid, or slightly purplish, with a perfect or sometimes partial ring of white between them and the cornea ; the larger conjunctival vessels, at the back of the eye, are apt to be tortuous and varicose. Rheu- matic iritis is ofteu combined with rheumatic ophthalmia. Rheumatic ophthalmia is inflammation of the fibrous coat of the eye, the sclerotic. The local symptoms of it are not, generally, violent, and seldom lead to permanent alteration of structure, it is associated with rheumatism ; there is some intolerance of light; the sclerotic is livid, red, mottled, dull, dirty looking; the vessels are partially distended and terminate short of the cornea, leaving a white ring round it. Treatment of Simple Rheumatic Ophthalmia.—Moderate topical bleeding and counter irritation; improve the health by change of air; try the remedies for rheumatism, as colchicum, bark, sarsaparilla, iodide of potassium. When the conjunctiva also is implicated it is called catarrho-rheumatic ophthalmia. Arthritic iritis almost always occurs in asthenic forms of gout and rheumatism, when repeated attacks have produced mental depression, indigestion, languor, and in those of intemperate habits. Dr. Mackenzie generally met with the disease in those over fifty, very often in tobacco smokers and whisky drinkers, who have often suffered rheumatism, who are teased by headache, acidity of the stomach, bad gums and teeth, and lowness of spirits. Treatment qv Rheumatic Iritis.— Free bleeding, or mercury to salivate is injurious. If there be any fever, and a hard pulse, a white tongue, bleed and purge; then give 111 xx to 3 ss of the wine of colchicum, two or three times a day. When the symptoms are less active, correct the digestive organ-, and the bad habits of the patient; give small doses of mercury (as grs. v of Plummer's pill) three or four times a week; excite counter irrita- tion by blisters, or croton oil liniment. After bleeding or leeching, aud regulation of the bowels, give tonics, as iron, sulphate quinae. In iritis, especially syphilitic, when mercury is forbidden, oil of turpentine, in drachm 56 AMAUROSIS. doses three times a day, often dispels pain, redness, sed. Sometimes they remain separated and empty, or contain a soft, orange-colored, spongy tissue, with vessels or a gelatinous or serous liquid ; or they are traversed by a few threads of areolar tissue. The coagulum of blood may be absorbed in five months, or not for three years. Cicatrization is perhaps slower when the effused blood crosses and tears the fibres than when it does not. The extravasated blood sometimes becomes "solid and organized. The clot may provoke suppura- tive inflammation; or the tearing of the nervous substance may cause spontaneous suppuration. After death white softenina is often found. It is caused by defective nutrition, owing to disease of the cerebral arteries, 74 APOPLEXY. or by the plugging or compression of one or more arteries and consequent on cutting off of the supply of blood to the brain. Softening of the brain may be caused by inflammation. It and effusion of blood often coexist. With the softening paralysis occurs, without loss of consciousness, for there is no necessary pressure. The hemorrhage is much more frequent in or near the corpora striata and optic thalmi, because these are softer and contain more and larger vessels than other parts. These are the seats most often of atrophic softening. Arteries at the base of the brain are subject to aneurisms, which may burst and cause hemorrhage. LECTURE XXX. Apoplexy— Continued.—The general and perhaps universal rule in par- tial palsy is, that hemorrhage on one side of the cerebrum or cerebellum is attended with palsy of the opposite side of the body. This is owing to the fibres of the anterior pyramids decussating and passing to opposite sides at the junction of the medulla oblongata and medulla spinalis. These decussating fibres strike into the centres of the opposite valves of the cord, and implicate the sentient and motor portions of it. The fact of the muscles of the face and tongue on the same side with the palsied limbs being also palsied, though receiving their nerves from above the place of decussation, is owing perhaps to the decussated fibres, as they pass, interlacing with the upward fibres, which bend towards the origin of the ninth and seventh, and of the eighth and fifth nerves. The affected cerebellum causes palsy of the opposite side, owing to its fibres aud those of the pyramids interlacing in the pons varolii. When blood is effused into one side of the cerebrum and into the other side of the cerebellum, palsy of the side opposite to the cerebral hemorrhage only occurs. These are likely anomalous cases. Predisposing Causes, &c.—©ne apoplectic fit is apt to be followed by others. The tendency to apoplexy is hereditary. It is most prone to attack those with large heads and red faces, short, thick necks, short, stout, squat build. It may, however, attack others also. It is more fre- quent in advanced life. A strong predisposition to apoplexy is engen- dered by Bright's disease, by disease of the cerebral vessels or of the chest, both of which interfere with the circulation ; by the cessation of habitual discharges, as piles, &c.; by intemperance. Causes.—The causes of apoplexy are any thing that hurries the circula- tion and increases the force of the heart's action, as strong bodily exercise, &c.; any sudden obstruction to the return of the blood from the head, as in certain thoracic diseases, holding the breath, straining, laughing, play- ing on wind instruments, loud and long talking, violent emotions, crowded rooms, the sun's heat, warm baths, drunkenness, venereal' excitement, stooping, different tight ligatures around the neck, exposure to cold, which drives the blood inwards from the surface, and also aggravates chest affec- tions, &c. External cold and, perhaps, certain barometric conditions of x the atmosphere, help to explain the existence of apoplexy as an epidemic. Hypertrophy of the left ventricle of the heart and cerebral hemorrhage sometimes exist as effects of disease in the arterial trunk ; but disease of the right chamber, impeding the circulation, may sometimes be the cause. Moreover, ossification of the cerebral arteries, or a similar condition or dilatation of the commencement of tlve aorta, impedes the flow of arterial blood ; so that hypertrophy is produced often by, and compensates for, tho APOPLEXY. 75 disease of the mouth of the aorta, aud the cerebral hemorrhage is the effect often of disease of the cerebral arteries. Prognosis.—If, after suitable remedies, coma persists for many hours, the prognosis, already, perhaps, precarious and uncertain, becomes worse. In those cases which begin with pain of the head, faintness, nausea, and which pass on to coma, the prognosis is positively bad, for it is pretty certain that blood has been extravasated. In paralytic cases, if coma supervene, the prognosis is gloomy, if not it is favorable. The symptoms of the apoplectic state which are more especially of evil omen relate, almost all of them, to the automatic functions of the cranio-spinal axis ; as the open, fixed, unwinking eye ; the explosive flapping of the cheek in expiration ; the inability to swallow ; the slow, sighing, interrupted breath- ing ; the loosened sphincters ; also, perhaps, the profuse sweat—symptoms of these kinds may be expected to arise from hemorrhage in or near the medulla oblongata, or from injury in the brain, causing pressure on the medulla oblongata. Treatment.—Obviate the tendency to death. If it be by coma, the blood- letting and evacuating plan is required ; if by syncope, stimulants and restoratives are necessarj'. If the pulse be full, or hard, or thrilling, or if there be external signs of plethora capitis, bleed. After one sufficient bleeding, cupping the nape of the neck or temples gives further relief. If the pulse warrant it, bleed, though the patient be pale; and if the head and face be turgid, bleed, though the pulse be small, for the small pulse may depend on organic heart disease. "Cupping and leeching the head are peculiarly adapted to cases where the arterial action is feeble, but the veins turgid and the capillaries of the head and face loaded. If the skin be pale and cold, pulse feeble and flickering, cautiously apply warmth to the surface, and cautiously administer diffusible stimuli, especially the preparations of ammonia; sesqui-carbonate grs. v, or sal volatile, 3 ss, mixed with camphor julep are ordinary doses. Watch for symptoms of reaction. Loosen any tight part of the dress, and bleed, when necessary, to produce a decided impression on the circulation. Repeat the venesection if the symptoms require, which is seldom the case unless the first bleeding was mismanaged. Even though blood be poured out upon the brain, bleeding largely and at once will do good ; by diminishing the stress on the arteries, and so tending to stop the hemorrhage; by lessening the danger of inflammation; and by favoring the rapid absorption of the extravasated blood. Bleed not too much, for it may cause convulsions, or syncope, or fatally weaken the old. In hemiplegia without loss of con- sciousness, venesection is justifiable only when there is also early rigidity of the palsied muscles, betokening irritation and threatening inflammation of the brain. In ambiguous cases, wait the effects of purgatives. These are of signal service. If the patient can swallow, give 3 ss of calomel and follow it up by a black dose ; if he cannot, put two or three drops of croton oil as far back on the tongue as possible. Without waiting for the medicine, given by the mouth, to act, administer strong purgative and stimulating enemata; as 3 iv or vi of turpentine, suspended by the yolk of an egg in gruel or warm water. In combination with blood-letting and purgatives, cold lotions to the head are often useful, especially if its sur- face is hot. Blisters near or upon the head are often serviceable, after due bleeding, in rousing the patient from coma. Emetics are safe only in cases where the coma appears to depend wholly or in part on a loaded 6tomach. After-Treatment.—When the immediate danger has passed and palsy remains, be not too busy, but trust to time. To the young and strong give small and repeated doses of mercury ; in all cases keep the bowels freely 76 SPINAL HEMORRHAGE—PARAPLEGIA. open once or twice a d ly by aperients; enjoin perfect quiet; and very short commo'is. Diuretics are proper when the urine is not plentiful. Moat, drink, and tonics, electricity, or warm baths, are certainly not per- missible in the earlier stages of palsy after apoplexy. If, after some time when all febrile action has ceased, the palsy seems stationary, cautiously try to stimulate the torpid nerves, and to accelerate the acquirement of power by the mind over the muscles. Electricity or galvanism are most relied on. In palsy of long standing, try to awaken the dormant powers of the muscles by stimulating friction. The preparations of iron, cautiously used, do good. LECTURE XXXI. Spinal Hemorrhage, Paraplegia.—The term apoplexy, applied to effusion of blood in any other organ than the brain, is a perversion of language. Spinal hemorrhage occurs occasionally, but the symptoms are not distinctive; they are, pain in some part of the spine, convulsions, palsy; being the same symptoms as are produced by inflammation, softening, mechanical injuries and other disorders of the same part. Spinal is much more rare than cerebral hemorrhage. Its symptoms arc often sudden. Paraplegia. — Causes.—The cause of paraplegia is sometimes obvious ; sometimes not. Effused blood, softening, the traces of inflammation, tumors, pressure in the spiual cord or its membranes, may produce it. Softening is the commonest condition found. Often, the palsy creeps on insidiously with no particular pain, or any morbid condition of the ver- tebrae. The legs get weak, heavy, and drag after the patient; the toes tingle or are numb, and feel as if ants were crawling on the skin, (formi- cation.) The lower limbs get weaker, the palsy creeps to the bladder and rectum, then to the arms, and fi lally death follows; taint traces or none at all may be found in the brain or spine. The separate existence of a "true spinal marrow," distinct from the brain and its prolongation into the spinal canal, and performing functions indepeudent of sensation, con- sciousness, and will, is shown in many cases by the paralytic limb, when pinched, springing up, of its own accord. Bed-clothes, flatus in the intestines, the passage of urine, &c, may cause this springing. The palsied limbs are more readily excited when the influence of the serebrum is excluded by disease of the cord ; the excitable parts lie beyond the seat of the injury. This fact may point out the part of the cord'injured. Iu hemiplegia these reflex movements do sometimes, but not often, exist, for the sensorial influence is not entirely cut off. Emotions may sometimes thus affect the limbs. When no involuntary movement can be excited, the spinal disease is, at least as low as the upper lumbar vertebrae. With t'iel)ss of power there is usually more or less anaesthesia. Paraplegia may depend on some primary morbid 6tate of the nerves of the cord. I.xposure to cold may injure the functions of the afferent, nerves; and disorder of the efferent perhaps causes palsy. Coexisting kidney diseases and enteritis, perhaps, paralyze the lower limbs. In most cases of para- plegia the urine, at length, becomes ropy, alkaline and stinking, and the bladder presents the appearances of chronic inflammation, the surface being rough aud red, and its coats thick. It is likely that the bladder is first affected, and pours out unhealthy mucus which changes the urine. Paraplegia is sometimes functional, and may be produced by cold intern- FACIAL PALSY AND ANAESTHESIA. 77 perance in drink, excessive sexual intercourse, but, especially, by self- abuse. It may also result from serous effusion into the spinal canal originally, or descending from the cranium. In most of these obscure casts there are some giddiness, transient confusion of thought, loss of memory. These cases are common ; they are usually slow and tedious. Treatment.—Attend to the bladder. Try friction along the spine; bis- ters to the loins or sacrum, frequently repeated; issues, an 1 electricity. Sometimes strychnia may be proper, which, in sufficunt doses, causes tetanic spasms, usually of the palsied limbs only, with \ery little or no affection of the sensorium. Use it cautiously; it does no good, but harm, unless the cord be free from organic disease. Begin with no stronger dose of strychnia, or sulphate or acetate of strychnia, than gr. one twelfth every six hours; cautiously and gradually increased until twitchings of the limbs, or some obvious effect follows, then continue the same dose as long as required. The tincture of cantharules in 3 ss doses, as a diuretic, is sometimes good. It also excites the functions of the paralyzed sphincter vesicce, thus counteract:ng incontinence of urine. Paralysis being a loss of the function of motion in muscular parts, it is incorrect to speak of palsy tf the kidney or nerve. Facial Pai sv and Anesthesia.—Sy/npt- ms, Physiology, <£v\— These are sometimes indications of extreme clanger, !>ut often they are only inconvenient, disfiguring, but not dangerous. Facial palsy affects one side of the face. On that side all power of expression is g. no, the features are blank and still, the eyelids m< tionless; the other side is natural, except that the angle of the mouth may be a 1 ttie awry. Gener- ally, sensation is perfect. Sometimes sensibility is lest, but the power of motion is perfect. Inability to close the eyelids is pathognomonic of facial palsy. The palsy results from suspension of function of the portio dura of the sevmth pair of nerves; the anaesthesia from a similar condition of the fifth pair, the former being the motor nerve of the facial muscles, the latter the sentient of the same. The masseter and temporal muscles may not be paralyzed with the other muscles, as they receive their motor nerves from the fifth pair. The portio dura may be affected by sudden injury done to its trunk, or by disease, or by pressure. If the-nerve is affected in the skull, other portions of nervous matter and other muscles are most generally involved. When the facial muscles alone are paralyzed, the portio dura within the bone, or the part of it in front of the ear, is, in most cases, affected; hence this form of paralysis is not generally dangerous. Causes.—The causes may be mechanical violence, external or internal disease, a stream of cold air; these last are the most obedient to remedies; or the cause may not he obvious. Sometimes, but rarely, the muscles, supplied by the portio dura, are alone paralyzed when the brain itself is involved. When deafness occurs it marks an affection of both the por- tions of the seventh nerve, and therefore points to a probable internal cause. The same remarks apply to anaesthesia which have been made of palsy. The anaesthesia may or may not portend danger, according as the fifth nerve is affected or not near its origin. Treatment. -When the complaint is recent, and has an obvious cause, the remedies will readily suggest themselves. When the cause is ise and visitors; blood-letting, if advisable, should be done c irly and sufficiently ; bleeding, cupping or leeches should ujt be repeated, unless plainly required; the bowels should be cleaned out HYDROPHOBIA. cl in the outset and then let alone ; the nerve should be promptly divided in severe traumatic cases; and, nothing to the contrary, give wine in large doses, and nutriment. If the tendency to mortal asthenia can be staved off, the disturbance of the excito-motory apparatus, on which the tetanus depends, may perhaps pass away. Trismus Nascentium, the "Jaw-fall," or "ATinth-day" Disease.— Treat- ment.—This usually conies on in the second week after birth. Some refer it to irritation of the meconium in the intestines; others, to irritation of the wound of the navel. A dose of purgative medicine is the best remedy. Pure air assists recovery. Tetanic symptoms, occurring in ague, should be treated as severe ague. Tetanus in hysteria should receive the treat- ment of hysteria, especially oil of turpentine by the mouth or rectum, aud the cold affusion. Hydrophobia.—This is essentially a spasmodic disease belonging to the nervous svstem. Symptoms, &c—The symptoms are excessive nervous irritability and ap- prehension ; spasms of the muscles of the fauces, excited by various causes, even the most trivial, as a gust of wind, insects crawling on the skin, &c, but especially by the sight or sound of liquids, and by attempts to swallow them ; and extreme difficulty or impossibility of drinking. The bitten part acts as any other sores, and gradually heals. After the period of incuba- tion, which lies usually between six weeks and eighteen months, the patient feels pain or uneasiness in the bite; if healed, the cicatrix tingles or aches, or feels cold or numb or stiff; sometimes it becomes red, swelled, or livid ; sometimes it opens afresh and discharges a peculiar ichor ; the pain or un- easiness extends towards the centre of the body. This is the period of re- crudescence. Within a few hours, or certainly a few days after these local symptoms and during which the patient feels ill, the specific constitutional symptoms come on ; the patient is hurried and irritable ; speaks of pain and stiffness perhaps about his neck and throat; cannot swallow fluids ; chokes and sobs when he tries to do so ; and after two or three days of this state dies exhausted by way of asthenia. Generally, when the disease has shown the peculiar hydrophobic symptoms, it runs a short and fierce course, and is perhaps always fatal. The patient is generally suspicious and A-ery irritable; in most cases there is mania, or delirium and garrulity, and sometimes paralysis of the lower extremities. In tetanus the mind is clear and the patient serene to the last. The spasms of hydrophobia are clonic ; those of tetanus, tonic. In the former there are thirst and an accumula- tion of tough and stringy mucus in the fauces and about, the angles of the mouth; in tetanus there is no thirst, and seldom stringy mucus in the mouth. Vomiting is probably always present in hydrophobia, rarely in tetanus. The pulse, though it may be hard and strong at the outset, soon becomes frequent and feeble, and the strength declines rapidly. Death occurs from one to five, sometimes seven, eight or nine days after the com- mencement of the specific symptoms, most commonly IIYDROPIIOI A. Cam's.—It is just possible that hydrophobia may be spontaneous. It may be commuuieatid 1o man by the fox, wolf, jickal, cat, badger, horse, human being, and perhaps by others. All animals may t ike the disorder from the dog; it is important to know whether these in turn can always impart it to others. Mr. Youatt does not think that the disorder can he imparted by the saliva, unless the cuticle is broken; he ho'ds that it is com- municable by mere contact with the mucous membrane. The mere scratch or" the rabid cat does not likely produce the disease. .Nor docs the bite of the healthy, though angry dog or cat, likely cause it. LECTURE XXXIV. Hydrophobia- Continued.—Period of Incnbation, l'cptics pre- serve their faculties to old age. Causes.—1 he cause of the lit may be centric or eccentric. Thcpnroxvsirs are possibly caused by a disturbance of the balance of the arterial and venous circulation in tie head, or by a temporary pressure, or by an in- crease or diminution of blood in the head. The tendency to epilepsy is hereditary. It often attends on unnatural forms of the head, as sugar-loaf, and other unsymmctrical shapes. It often attends chronic hydrocephalus. The scrofulous diathesis strongly predisposes to it. Whether the sex has any influence is unknown. Anatomical Characters.—After death, in epileptics whose intellect and locomotion were not permanently injured, often no alteration of the hraui or spinal cord is found. Sometimes organic disease in the head exists; a scrofulous tubercle, a spiculum of bone projecting from the skull. When the above persons die in the fit, there is always a strong injection of the vessels of the encephalon. This congestion is not the cause of the fit. After death, in those whose mental faculties were permanently injured, or who suffered some paralysis, were found induration, with sometimes a general injection of the whole white matter of the brain, and mostly dilata- tion of the vesse's; sometimes softening of the whole white matter, the gray matter being irregular on its surface, marbled, or rose-co'ored in its substance, and sometimes altered in consistence. Often the membranes adhere to the convolutions. The changes which predispose to 'epilepsy oftener affect the surface than the dec.]) parts of the brain, as tumors, alterations in the membranes or the cranium or spinal cord. Other morbid conditions, often found, are diseased liver, bi.iary concretions, granular kidney, renal calculi, stones'in the bladder, worms in the alimen- tary canal, diseases of the uterus or various parts. LECTURE XXXVI. Epilepsy— Continued.—Predisposing and Exciting .Causes.—Commonly, the fits are more severe the less frequent they are. Debauchery of all kinds, the habitual use of intoxicating liquors, above all, masterbation, tend to aggravate or create a disposition to epilepsy. The exciting causes are fright, any strong mental emotion in those already subject to it, bodily pain, and any great disturbance of almost any principal bodily function. Sometimes the cause is unknown. The niqhtly attacks Dr. Bright attributes to the "congestion" of sleep; the monthly ones, in women, to nervous irritation in sympathy with the uterus ; those occurring at long intervals, to some excess or neglect of the bowels. By observing what muscles or set of them are first affected by the spasms, and where the aura arises we may perhaps find the irritated organ or part, and thus know the nature and cure of the complaint. Other exciting causes are, repulsion of eruptions, especially about the head, when no proper artificial evacuations are obtained at the same time; the cessation of habitual discharges- profuse and unnatural discharges ; and the sight of a person in a fit. The fits of impostors become at last, from habit, involuntary and really epileptic. _ Diagnosis bttween True and Feigwd Epilepsy.—Impostors perforin where it most answers their purposes, as in frequented places, and where there is no danger of being hurt by falling ; true epileptics are ofteu seriously hurt by their falls. In epilepsy, the muscular strength is so great that it takes four or five per ons to hold the epileptic ; the impostor's strength is only EPILEPSY. 87 natural. Real fits, if long, are seldom violent; impostors make theirs long and v.olent. In true epilepsy, the eyes are usually partly open, with the eyeballs rolling and distorted; in the feigned, the eves are shut, but opened occasionally to notice the bystanders. In the true, the dilated pupils do not contract when stimulated bv light; in the false the puod is natural. In the true, the pulse is frequent and o'ten irregular, and the skin is commonly cold ; in the false, the skin is hot and covered with sweat from the exertion. Impostors do not bite their tongue ; epileptics often do, aud, besides, they void their excrement and urine and are insensible to external impressions. To try the impostor, press your thumb nail violently under ,11s, or propose, m his hearing, to pour boiling water on Irs le«'s, and then pour eld water on them. ° Distinguishing Symptoms bit men Epilepsy and Ilyteria.—In epilepsy, there is perfect unconsciousness ; in hvsteria, not. In epilepsy, there "is no globus hystericus, no alternations of laughing and crying. A solitary cry ushers in the former; repeated screams belong to the latter. The former is succeeded by a heavy, comatose sleep; the latter is not. Com- monly these do not hurt themselves, do not bite their tongues nor foam at the mouth. In the former, the expiratory efforts suffuse the countenance- in the latter, the respiration is rapid and sobbing. Attacks of convulsions with insensibility, independent of epilepsv, are apt to follow sudden injury to the brain, stunn:ng blows on the head, fractures of the skull, eruption of blood in sanguineous apoplexy, overwhelming mental emotions, and likely urea retained in the blood. They happen also in parturition, lead poison, hydrocephalus, hypertrophy of the brain, and in some eruptive fevers. Prognosis.—This is seldom favorable. If the disease is centric, the nervous centres being organically injured, it is bad, especially if scrofulous disease or diathesis exist, or if the patient's ancestors have had it. It is bad in those having slanting foreheads or misshapen skulls. It is worse the longer the disorder has lasted, and the oftener the fits have been re- peated. When the memory is permanently enfeebled or fatuity has come on, or there is any paralysis, perfect cure is hopeless. When the disease is eccentric, the prognosis is better, especially when the cause is knowu and removable. Many writers say children outgrow even habitual attacks of epilepsy, especially about puberty. Habitual epilepsy, though seldom curable, may most always, by treatment, be relieved as to its frequency and violence. Treatment.—During the fit, keep the patient from injury, and, if possible, mitigate the violence aud shorten the duration of the fit. Loosen all liga- tures on the body; keep the head elevated somewhat. A piece of cork or soft wood, placed between the teeth, may keep the tongue from being bitten and the teeth from being broken. If the head be congested and hot, apply cold wet cloths to it, and if the extremities be cold, restore warmth to them—cramming salt into the mouth is said to shorten the paroxysm. Immersing children, especially if the extremities be cold, into warm water is often of much benefit. Bleeding during the fit is seldom proper, uuless there be cerebral plethora, and then take only a moderate quantity by cups from the neck or temples, Excessive bleeding is very injurious. Abstrac- tion of blood does not probably shorten the convulsions or sopor. During the intervals get rid of the predisposition and avoid the exciting causes, if possible." Redress any tendency to general plethora, by regimen and exer- cise, by abstaining from stimulating food and drink, and, if necessary, by depletion. If there be a tendency to emptiness and asthenia, which per- haps is more common, use a tonic treatment. The object in both these cases is to give firmness to the nervous system. Do not carry the loweriu >• 88 EPILEPSY. or tonic plan too far. When the patient is young and full of blood, when he has a hard pulse, or any feverishness, when some customary discharge was previously suspended, when the disease has not become habitual; in any of these cases it will often be proper to take blood, always right to purge actively and order an abstinent regimen. . When former paroxysms were preceded by signs of plethora capitis, headache, throbbing of the temporal arteries, distension of the superficial veins, a flushed countenance, the lancet or cups may sometimes avert an impending attack. If the patient is pale and weak or nervous, or if he has had many fits, active de- pletion is injurious; but invigorating means are required, as the cold shower bath, other cold baths being unsafe. A general and pleasant glow after the bath shows it to be a good tonic. Of the mineral tonics, the salts of silver, zinc, copper, and iron are chiefly praised. The nitrate of silver is objectionable, for it is apt to cause a lead color of the skin if used too long, as it must be to do good, and it will probably do no good even then. Begin with gr. ss in a pill three times a day; grs. xv have been given as a dose. Large doses purge. The oxide or sulphate of zinc, or cuprum ammoniatum, but especially zinc or iron, as vinum ferri, Ac, do good. Liquor arsenicalis is thought good ; use it cautiously. These have been tried : valerian, assafoetida, wormwood, the mistletoe of the oak, the cardamine pratensis, rue, cotyledon umbilicus, the sedum acre, indigo; narcotic vegetable preparatious, stramonium, belladonna, hemlock, lettuce ; animal sub;rtances, musk, castor, ox-gall. Epileptics are apt to improve under every plan of treatment, for a time. They should be temperate in all things ; their food and drink should be simple, nutritive, unstimulating. They should rise early, take regular exercise in the open air, keep their heads cool, and extremities warm. All excitement, bodily or mental, should be avoided. In fits from moral contagion or irritation, avoid the cause, fortify the nerves, and calm the mind. If the fits likely depend on syphilitic affection of the bones of the skull, give mercury a full trial, but preceded by the iodide of potassium. When organic disease of the brain is suspected, follow a gentle and long- continued course of mercury, carefully watching the effects. It is proper to try counter-irritation ; blisters, a seton in the neck, or croton oil lini- ment. Dr. Pritchard divides the integument of the head to the bone in the direction of the sagital suture, and keeps it discharging for some time by issue-peas. In eccentric cases remove the cause. Sometimes there are symptoms of diseased liver; slight yellowness of the skin, uneasiness and tenderness in the right bypochondrium, and low spirits. Rectify the liver. Oil of turpentine is very good, in ordinary cases, in small and frequent doses ; as 3 ss to 1, every six hours. Oil of turpentine has done good as an anthelmintic. It sometimes produces strangury. If the bowels are costive, equal parts of oil of turpentine and castor oil go well together. Prevention, &c.—Interrupting the precursory symptoms sometimes pre- vents a coming fit. So may dashing cold water on the face, using snuff, smelling salts, perhaps a strong mental effort, arousing the dull, inter- cepting the aura, &c. The patient should be watched at all times, and kept from injury, from cold, from all danger of falling, from crowded places, &c. He should have about him a diffusible stimulus, as a potion of camphor mixture and ether, which may prevent the lit. CHOREA. 89 LECTURE XXXVII. Chorea—St. Vnrs's Dance.—This is a spasmodic disease belonging to the nervous system, very likely to the excito-motory part. Symptoms.—The prominent symptom is an irregular and involuntary clonic contraction of s' me voluntary muscles, which, however, are not wholly withdrawn from the government of the will. Consciousness .and volition are perfect. The movements are rendered imperfect and per- verted by, it would seem, some wanton and perverse power. These absurd movements are not paroxysmal, but continue all day or for weeks, but usually cease during sleep. There is no fever. Chorea usually begins with slight twitches of a few muscles of the face or of one of the upper extremity, by degrees the spasms become more decided and general. All the. voluntary muscles are liable to be affected. Sometimes the lower extremitii s are not affected, never exclusively so. Those of the face seldom escape. Generally it is more severe and difficult to cure in proportion to the extent. The features are twisted into all kinds of ridiculous forms; then succeeds a vacant look, and then again the convulsion. Chorea is more common in girls than in others. The patient, when asked to put out her toi gue, makes sundry attempts to do so ; then suddenly thrusts it out. and as suddenly withdraws it and snaps the jaws together. She writhes aud contorts her shoulders; cannot keep her hand or arm still half a minute ; cannot guide her hand, without many efforts, to her mouth at meals. When sitting or standing, her feet shuffle on the floor, or one is thrown over the other; her walking is most uncertain, she halts and drags her legs, and advances in a jumping manner by fits and starts. Articulation is impeded. The fantastic and capricious, movements of chorea are usually more marked and general on one side, or are sometimes confined to one side. Sleep is obtained with difficulty, and in the waking state there is no calm. The loins, hips aud elbows are chafed by friction with the bed-clothes ; the limbs, in their perpetual contortions are bruised; the bitten lips bleed ; the countenance looks piteous ; occasionally there is an involuntary cry or squeak ; at length come exhaustion and death. Who Attacked—Period of Attack.— Those most subject to chorea are the "nervous." If only the affected limb be held, another part takes on the convulsion. The irregular motions can often be.controlled by the will or, for some seconds, by a long, deep inspiration. Chorea is propagable by imitation. It is very common between the eighth and sixteenth year, especially among th< se of dark hair and eyes ; sometimes it occurs earlier ; sometimes in adults and old age. The imbecility of mind, fatuity and focdish expression of countenance, which usually occur in strongly-marked and long-standing cases, pass off and return more than once. Prognosis.—Chorea is rarely fatal; it is cured, and recovered from. Pathology.—The few fatal cases have thrown no light on its pathology; any organic diseases, which have been found accompanying it, were rather predisposing causes. Some affirm that the cerebellum regulates locomotion and, therefore, is the seat of the change which produces chorea. The irregular movements are not the effect of imperfect paralysis, nor of con- vulsions, properly speaking, but of want of harmony between the muscles. Causes.—Duration.— The cause may be centric or eccentric. In most c.ises there is no pain ; sometimes there is pain in the head, and even only on the side opposite the agitated limbs. Cupping or leeches cure this pain. Sometimes the patient is we'd, except there are irregular move- 90 CHOREA. ments ; but generally the bowels and stomach are out of order during or before the complaint; there are a capricious appetite, costiveness, tumid belly, offensive breath; and a foul tongue or irregular menstruation. Chorea is sometimes complicated with hysteria, acute rheumatism, rheu- matic carditis, and certain skiu affections owing likely to the circulation of bad blood. Any thing may cause chorea which makes a forcible impres- sion on the nervous system, especially fright. Irritation of the stomach and bowels, improper diet, accumulated feces, worms, or difficult men- struation, or second dentition, may cause it. Chorea may last from a week or two to some months. It often terminates at puberty, especially in females. It seems to be rare as we approach the equator, it is almost unknown in the tropics. Treatment.—Most cases would get well without physic. 1. Give sta- bility to the nervous centres. 2. Remove any cause of excitement of the incident nerves. Genuine chorea is seldom dependent on organic inflam- matory disease. Do not bleed, except locally for pain in the head. Purge. Begin by clearing out the bowels with calomel and jalap, or some active aperient. Let there be at least one full evacuation daily. Give tonics, especially the cold shower-bath every morning, or every other morning, on getting out of bed. If the patient be feeble, make the water tepid at first, then gradually cold. One of the best tonics is iron. Begin with half-drachm doses of ferri carbonas ; increase to one, one and a half, or two drachms ; give it three or four times a day. It may be given with twice its weight of treacle to form an electuary. Ferri carbonas cum saccharo may be used without treacle. When this does no good, give grs. ii or iii of sulphate of iron as a dose, or 3 ss of the citrate; or ^ iss of Griffith's mixture, (mist, ferri comp.,) or IT] xx or xxx of the tinctura ferri muriatis. Iron may form hard, large, masses in the bowels. Sulphate of zinc, increased gradually in severe cases to ten grains, given three times a day, is often good when the carbonate of iron fails. Beyond this the zinc is emetic. Arsenic is good, but hazardous. Dr. Bigbie never failed with arsenic. He gives gutt. v of liquor potassa arsenitis twice daily, an hour after meals, adding one drop every third day till he observes its specific effects ; he then withdraws it for a while. Its earliest effects are itching and swelling of the eyelids, redness of the conjunctiva, nausea, uneasiness at the pit of the stomach, and particularly a peculiar white silvery appearance of the tongue, seldom accompanied with tenderness. Mix equal quantities of oil of turpentine and castor oil, and give 3 ii or § ss of the mixture every morning, or every other morning, according to its effects upon the bowels; if they be very sluggish, or the stools unnatural, give calomel grs. ii, twice or thrice a week at bed-time. The diet should be plain and simple, but nourishing and even generous. Exercise should be taken in the open air in dry weather; strong emotions should be restrained. Chronic Chorea is an affection which very much resembles the genuine form, but the movements are confined to the same part, especially the limbs, neck, or face, almost always for life, are attended with good health, and are not dangerous. It consists of awkward tricks, as knitting the brow, shrugging the shoulder, &c, &c. Medicine has no effect over this. Varieties.—There is a sort of chorea, or morbid nervous condition, characterized by movements, not spasmodic, but depending on an irre- sistible propensity to muscular action, and increased, often to a mania, by irritation or music, volition being morbid and perverse. The move- ments are often regular and surprisingly rapid, consisting of dancing drumming on objects, (malleation,) circumvolutions, turning the head. MERCURIAL TREMORS. 91 moving in a straight line, &c. The patient is conscious and is generally a female, in whom menstruation is suspended or irregular. The Leaping Agpe is a spasmodic affection, resembling chorea on one hand and epilepsy on the other, and is propagable by imitation. It is seen among religious enthusiasts, whose actions, at first wilful, are soon performed from necessity. Treatment.—As the cause is~moral, let the treatment be the same. In the solitary cases, correct the bowels; attend to the uterine functions; strengthen the system. Cold sousing might do good. LECTURE XXXVIII. Paralysis Agitans—Siiakino Palsy.—Mr. Parkinson defines this thus : "Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported ; with a propensity to bend the trunk forward, and to pass from a walking to a running pace; the senses and intellect being uninjured." The latter symptoms are sometimes wanting. Its approach is insidious and slow; at first there is trembling of some part, of the head, oftener of the hands or arms. This becomes more decided and spreads to other parts; the patient has not perfect con- trol of his legs, he stoops and often steps quicker to avoid falling, Orleans on an attendant; after some time he cannot feed himself, his speech and deglutition fail, saliva dribbles away, he cannot retain his urine and faeces, and finally dies. The exact pathology of this disease, or its cure, is unknown. Treatment.—Treat the symptoms. Set right all wrong functions; reg- ulate the bowels; procure sleep; nourish and uphold, but do not stim- ulate, the patient. Mercurial Tremors—Trembles, is produced by the fumes of mercury, and is a convulsive agitation of the voluntary muscles, which occurs only when they are brought into action. It comes on sometimes suddenly, sometimes slowly; the tremors gradually increase till they get violent, and locomotion, mastication, and deglutition, &c, are impaired ; finally, if the cause continue, wakefulness, delirium, loss of memory, uncon- sciousness supervene. The digestive organs become disordered, appetite fails, nausea is felt, the tongue becomes furred, gas collects in the intes- tines, the patient becomes brown, the teeth turn black, the pulse is gener- ally full and slow. These effects are produced in from two to twenty-five years. The complaint may last two or three months, or more; sometimes it is never perfectly recovered from. It is not fatal. The nerves are at fault; the will has not perfect control over the muscles. Mental emo- tions, alarm, &c., aggravate the tremors. Treatment.—Remove from the cause ; order good diet, fresh air, regular exercise ; give tonics, as steel or quinine; very small doses of strychnia are useful. Iron is preferable. Prevent the disease by avoiding the fumes, ventilating the rooms, cleanliness, and by using a respirator. Iodide of potassium removes the imbibed poison from the body ; but as it sets the poison afloat into the circulation, it may happen that acute poisoning may result. Begin with small doses of the iodide, and gradually feel your way. Hysteria.—This mimics various other diseases, and is almost exclusively confined to women, especially the feeble. The various forms of it may be reduced to two. Species.—Symptoms.—1. This resembles an epileptic fit. The trunk and 92 HYSTERIA. limbs are strongly convulsed, the patient struggles violently, rises into a Bitting posture and then throws herself back again, forcibly retracts and extends her legs and twists her body; often it takes two, three, or four persons to hold a slight girl; the head is generally thrown back, and the throat projects ; the face" is flushed ; the eyelids closed and tremulous ; the nostrils dilated ; the jaws ofteu firmly shut, but with no distortion of coun- tenance ; the cheeks are at rest, uuless during the screams or exclamath ns ; the patieut strikes her breast often and quickly if uot restrained, or carries her fingers to her throat as if to remove some oppression ; she sometimes tears her hair or clothes, or tries to bite others ; her breathing is deep, laboring, irregular, and her heart palpitates. After a short time the violent agitation ceases, the. patient lies panting and trembling and starting at the slightest noises or touch, or sometimes remains motionless with a fixed eye; suddenly the convulsive movements return again, and then again quiet; this alternation of spasm and quiet go on for a variable time. 1 he whole often terminates in an explosion of tears and sobs and convulsive laughter. A vari'ty of this form is when the patient suddenly sinks down insensible, and without convulsions, with slow and interrupted breatlrng, a turgid neck and flushed cheeks, rnd recovers depressed in spirits, fatigued, and crying. The above symptoms belong to the nervous system, and Indicate great derangement of the functions of ;.nlmal life. 2. In this form, the principal marks or' disturbance refer to some of the viscera. The p.itient fee's a s< n-e of uneasiness in some part of the abdomen, often towards the left flank ; a ball appears to roll about, rising first to the stomach and then to the throat, where there is a choking sensa- tion ; the act of swallowing is often repeated ; the abdomen becomes dis- tended with wind ; loud rumb'ings and sudibn eructations take place; the heart palpitates much ; the patient is sad and prone lo tears. After, nnd sometimes during, the tit, much limpid pale urine is voided. This form often occurs alone ; it often, also, precedes the first, or convulsive form. Diagnosis of Epilei>sy and Hysteria.—Then< n-convulsive form of epilepsy is characterized by vertigo and a suspension, even brief, of the mental powers ; in the non-convulsive form of hysteria, the phenomena consist in derangement of the organic functions of the thorax and abdomen, the ganglionic nervous system seeming cliiefly affected. In the epileptic fit there is entire loss of consciousness, and no recollection after, of what occurred during, the tit; this is very seldom the case during the hysterical fit, and never at its outset, for the patient know s what happens during the fit. In the former, the face is usually livid, and frothy or bloody foam escapes from the mouth; in the latter, these symptoms do not exist. In the former, the convulsions are often more marked on one side of the body than ou the other, and less irregular, and rapidly repeated, and there is a strangling rattle in the breathing ; in the latter, the flexion and extension of the limbs and contortions of the trunk are more sudden and capricious, respiration is deep, sighing, mixed with cries and sobs, and often with laughter. In epilepsy, the eyelids are half open, the balls rolling or dull, projecting, with the pupil usually dilated, the mouth drawn to one side, the teeth grind.ng, the gums exposed, the tongue protruded and bleeding, the complexion leaden ; in hysteria, the cheeks are red but at rest, the eyelids closed and trembling, the eye, which is covered by the lids, is fixed, perhaps, but bright. When the:e are a sudden loss of co sciousness, with couvulr sive movements, a livid face, frothy saliva and convulsions more on one side than on the other, the disease is epilepsy. Dr. M. Hall says, that in hysteria the larynx is never closed ; in epilepsy it is. In the first, the in- spiration is heaving, sighing;-in the second, there are violent, ineffectual efforts at expiration. HYSTERIA. 93 Duration of the Fit, &c— The hysterical fit may last only a quarter of an hour or less, or several hours or days In a vast majority of cases there is some marked derangement of menstruation, the uterus or ovaries acting on the muscles through the medium of the nervous system. When the menstrual function is disordered without hysteria, it is perhaps because there is no predisposition to it, nor that nervous irritability which con- duces to it. The hysterical are often pale, have cold hands and feet, eat but little, dislike meat, have depraved appetites, eating chalk, pencils, &c, do not generally emaciate, but are plump, even ruddy sometimes. In these persons various parts of the nervous system are apt, even without cause, to fall into a disordered state, more or less resembling that caused by inflammation or organic disease in the same part. This should be kept in view. Diseases mimicked by Hysteria.—Hysteria may mimic peritonitis. This may be known from the uterine condition and the history of the pa- tient ; besides, the pain of the abdomen, in hysteria, is excessive, and felt as much on the slightest touch as on firm pressure, and is felt also in other parts, as the neck, &c. In this case, purge well and give an assafoetida enema. Hysteria mimics stitches and pain in the hypochondria, especially the left. It mimics palsy, perfect hemiplegia, or- paraplegia. In hyster- ical cases the piralysis is apt to come and go suddenly, without any affec- tion of the face or tongue or other symptoms of palsy. It mimics aphonia, larj/7igitis, dysphagia. There is the "hysterical breast," the mamma being tender, painful, and perhaps somewhat enlarged. Make light of this to the patient, and treat the general system. There is the hysterical cough, which is loud, harsh, dry, like a bark, sometimes incessant, sometimes paroxysmal. There are hysterical hiccough, eructation, vomiting, haemate- mesis, sanguineous expectoration, the blood coming from the mouth or fauces and hysterical joint affection and spine diseases. In the last, the patient is unable to stand, because she thinks she is. There is hysterical paralysis of the muscular fibres of the bladder, or spasm of its sphincter. Watch in these and similar cas's that the patient does not impose on you by feigning these conditions. There is the clavus hystericus, a pain occu- pying one spot in the head, often above the eyebrow, and causing a sensa- tion as of a nail driven into the part; and sometimes com'ng on everyday at the same hour. The hysterical pain, which mimics inflammation, is in- creased on the slightest touch, and is felt in other parts than that affected; moreover, the symptoms, which resemble those of inflammation, are ir- regular and contradictory, rising and subsiding rapidly aud attacking va- rious organs in succession. In doubt, pause, or treat on the most jmfavorable supposition. Real disease may be mixed with hysterical symptoms. Hysteria, with its symp- toms, may occur in males. Treatment.—Prevent the patient from injuring herself; loosen her dress ; admit cool air. Stop the fit by giving, if she can swallow, mistura assa- foetida § ii; or ether 3 ss, with laudanum ifl xv to xx, in camphor julep; or a draught containing 3 i of the a mmoniated tincture of valerian. When she cannot swallow, put stimulating volatile substances to the nostrils. Good is done by fetid or stimulating enemata, as assafoetida 3 ii, mixed with water O ss by means of the yolk of an egg ; or turpentine § ss, mixed in the same way ; or the same quantity of ice-cold water as an enema or applied to the pudenda. Sprinkle cold water freely or dash it on the face and chest. Purge actively, for the bowels are costive or unnatural. When other diseases are mimicked, especially in cases of bent and immovable limbs, use the cold affusion. As hysteria is propagnble by moral conta- gioD, prevent its spreading by threatening the cold affusion. Between the 94 CATALEPSY—ECSTASY—NEURALGIA. paroxysms, restore stability to the nervous system, and set the uterine functions right. Regulate the bowels by aloetic aperients; give steel, shower baths; order regular exercise; prohibit hot rooms, late hours of going to and rising from bed, strong mental emotions, novel-reading, &c. Marriage sometimes cures. Young girls should not be confined too much, nor spend too much time in studies ; they should take plenty of exercise in the open air. LECTURE XXXIX. Catalepsy, Ecstasy.—Symptoms.—These are nervous disorders, happen- ing mostly in persons subject to such complaints, and appearing often to be produced by similar causes. They are seldom dangerous; their pathol- ogy is obscure. Their treatment, for cure and prevention, is the same as that of hysteria. A fit of catalepsy implies a sudden suspension of thought, sensibility and voluntary motion, the patient remaining in the position, however fatiguing, in which she may be when attacked, or in which she may afterwards be placed, and the organic functions not being much af- fected. These attacks occur in paroxysms, alternating sometimes with hysteria, or occurring in connection with insanity. A minor form of this is, when the patient cannot speak or move, but is conscious of what is going on around. Ecstasy is a state in which the patient is lost to all ex- ternal impressions, but wrapt in some object of the imagination, the mus- cles being sometimes relaxed, sometimes slightly rigid, and the loss of voluntary power being not complete; for the patient often speaks and sings. Mesmerism may produce this state. Neuralgia.—By this are meant diseases which consist of pain only, there being often no inflammation, no change of structure in the painful part, no fever. Cause.—Situation.—The pain is owing to some morbid condition or irri- tation of a nerve. The cause of the pain may be placed in the painful spot, or in the brain, or in the spinal cord, or in the trunk of the nerve that supplies the affected part, or in one of its branches which is distributed to another part, (witness the pain of the thigh and testicle from irritation of the kidney, &c.,) or in some distant part which is connected with the pain- ful part through the nervous centres only; or, finally, no cause may be known. The pain occurs in all parts, oftenest in the head; next, probably, in the abdomen. Tic douloureux hemicrania, certain forms of angina pec- toris and of gastrodynia and sciatica, are neuralgic affections. The pain does not commonly follow the track of the nerve; but inflammation of it or its investments generally causes such pain. Character of the Pain.—Truly nervous pains are characterized by their coming on suddenly, and sometimes going off suddenly; by their often in- termitting 5 by their often, but not always, returning at regular intervals ; by the total absence, generally, of heat and swelling, and often of tender- ness too when they are external, and of febrile symptoms when internal; by their apparent dependence often on sudden changes of weather • by their occurring in the nervous and feeble; by their often abating under tonic treatment; and by their often being suspended during sleep. Long con- tinued aud intense neuralgic pain may give rise to even a moderate decree of inflammation of the part, which becomes tender to the touch, vascular aud a little swollen. The neuralgic attack may recur at intervals of a few seconds only, or daily, or every other day, or at much longer intervals re- TIC DOULOUREUX. 95 gularly or irregularly. Sometimes the pain is continual, but wonderfully aggravated by fits. It is sharp, sudden, twinging, momentary. Sometimes there is a feeling of cramp, but no spasm. Tic Douloureux.—Symptoms.—This is neuralgic pain situated in the facial branches of the fifth pair of nerves, nerves of sensation. Usually one only, sometimes two, sometimes the three branches are implicated. In the severe forms, the middle one, the infra-orbitary, is the most com- monly affected. The torture is excessive. When the uppermost branch is affected, the pain generally shoots from the superciliary hole, whence the nerve issues, and involves the parts on which the nerve distributes its fibrils, the forehead, brow, upper lid, and the eyeball, sometimes. During the paroxysm, the eye is usually closed, the skin of the forehead on that side is corrugated, and the neighboring arteries throb, and there is a co- pious gush of tears. Sometimes, at each attack, the eye becomes blood- shot ; after frequent attacks it becomes permanently infected. When the pain comes from affection of the middle branch, it sometimes comes on suddenly, sometimes slowly, being preceded by a pricking sensation of the cheek, and twitching of the lower lid ; pain at the infra-ortitary foramen soon follows, spreading in flashes over the cheek, lower lid, ala nasi and upper lip, often stopping at the mesial line of the face. Sometimes it ex- tends to the teeth, antrum, hard and soft palate, base of the tongue, and induces spasm of the neighboring muscles. When the pain is referable to the inferior, or maxillary branch, it darts from the mental foramen to the lips, alveolary processes, teeth, chin and side of the tongue, stopping often at the symphysis of the chin. Often it extends to the whole cheek and ear. Spasmodic action of the muscles is apt to disfigure the features and hold the jaw fixed. Causes.— Trivial causes may bring on a paroxysm, a slight touch, a cur- rent of air, eating, &c.; pressure often gives relief. This disease occurs most commonly in debilitated systems, and is often attendant on disorders of the digestive organs. Sometimes it is connected, and alternates with rheumatism. It may be caused by exposure to cold and moisture; by malaria, and is then intermittent and periodical, and often yields to the remedies of ague. It is sometimes dependent on some general state of the system, or on exostosis, or diseased bones. Treatment—li the disease depends on debility, give carbonate of iron, as in Lecture XXXVII. Attend to the digestive organs, the unhealthy state of which is shown by the furred tongue, loss of appetite, costive bowels, or by pain only. Some carbonate of soda in water may counteract acid in the stomach. The following has cured: mix oleum tiglii gut. i or n with compound extract of colocynth 3 i; give grs. v of this mass with grs. x of compound gallanum pill at bed-time. In rheumatic cases, try guaiacum ; colchicum; calomel and opium ; iodide of potassium. If a tumor or foreign body press upon the nerves, removing it with the knife might cure. If this cannot be done, or if the nerve be altered in structure, it is a question whether the nerve should be divided, or even the limb amputated. Remove or lessen any exciting cause. Violent bodily exercise has done good. As local means, belladonna or opium relieves pain. Acomtine gr. 1, mixed with cerate 3 i, aud about one-third of this smeared along the nerve two or three times a day, does much good. A saturated solution of iodine in a strong tincture of aconite is good. Another application, but not so good, is iodide of mercury 9 ii to lard I i, and rubbed into or placed on the part till some irritation is produced. Much may be hoped for from chloroform. There is a kind offaceache, which is not neuralgia, for the pain does not occur in short, stabbing paroxysms, nor is it acute; it occupies the lower part of the face, the jaw principally. The muriate of ammonia often cureB 96 SCIATICA—HEMICRANIA. this; give 3 ss in water three or four times a day. Stop it after four doses, if the pain continues. The iodide of potassium iu doses of grs. v or vi may cure. Sciatica, i. e., pain radiating from the sciatic notch, and following the course of the sciatic nerve, if inflammatory, must be treated as such by bleeding and blistering; if rheumatic, use calomel and opium, or colchi- cum ; if it result from irritation within the pelvis, caused by disorder of the kidney, the oil of turpentine may do good ; when neuralgic, try the treatment of facial neuralgia. Sciatica has been cured by sprinkling gr. ss or i of powdered morphine 0:1 the surface denuded by a blister the size of half a crown, put ou the spot where the nerve emerges. When there is no fever, success may follow from swathing the limb, night and day, with flannel, thickly sprinkled with precipitated sulphur, and covering the flannel with oiled silk, or thin gutta-percha. Hemicrania, Mi-iraiu", Megrim, is headache of one side, generally of the brow and forehead, sometimes of exactly o le-half of the head. There is o'ten sickness ; it is often periodicil. Sometimes it occurs in connection with hysteria, sometimes in women who suckle too long; sometimes malaria is a cause; sometimes the cause is unknown. Treatment.—When there is amemia, prescribe steel and the shower-bath ; if the complaint is periodical, give qu'ma. Arsenic, as liquor arseuicalis gutt. iv or vi, given three or four times a day, with attention to the bowels, cures in nine cases out of ten. LECTURE XL. Intermittent Fever—Ague.—Of this there are three stages, the cold, the hot, aud the sweating. Symptoms.—When the ague is coming on, the patient feels a sensation of debility and distress about the epigastrium ; becomes weak, languid, and listless, bodily and mentally; sighs, yawns and stretches; feels chilly, particularly along the sp ne ; the blood deserts the surface ; he grows pale ; his features shrink ; his skin gets dry and rough (cutisanxerina.) Presently the patient feels cold; trembles and shivers all over; his teeth chatter; Ids knees knock together; the hair of the scalp bristles, (harripilatio;) his face, lips, ears and nails turn blue; the respiration is quick and anxious; the pulse, frequent sometimes, but feeble; there is pain in the head, back, and loins ; the secretions are usually diminished ; the urine is scanty and pale; the bowels confined ; the tongue dry and white. After a time, flushes of heat are felt, commencing usually about the neck and face ; gradually the cold ceases entirely; the skin, features and extremities again return to their natural condition, but only for a while; the face becomes red and turgid ; the surface hot, pungent and dry ; the temples throb ; a new kind of headache comes on; the pulse becomes full, strong and rapid ; the breathing deep, but oppressed; the urine scanty and now high-colored; the patient is restless. After a time again, the skin recovers its natural Boftness; the forehead and face become moist; soon a copious, universal sweat breaks out, with great relief to the patient; thirst ceases; the tongue becomes moist; the urine plentiful, but turbid; the pulse natural; p*ain departs; after a while the sweat ceases, and the patient is again well. The earlier symptoms are those of debility and nervous depression. Varieties.—The cold stage may be absent; 60 may the hot; or, both being present, there may be no proportion between them. The paroxysms are INTERMITTENT FEVER. 9t periodical; but it is not known tvhy. The time between the termination of one paroxysm and the commencement of the next is the intermission; that between the beginning of one paroxysm and the beginning of the next is the interval. VVhen the intermissions are perfect, the feyer is intermittent; when they are not perfect, but the patient remains ill and feverish, it is remittent 'fever. Quotidian ague is that which occurs at the same hour every day ; tertian, every other day ; quartan, every third day. The interval of the first is twenty-four hours ; of the second, forty-eight; of the third, seventy-two. The paroxysms of the first begin in the moruing; of the second, at noon; of the third, in the afternoon. These are the rules, to which there may be exceptions. Sometimes quotidian paroxysms, occur- ring at noon or night, may be symptoms of local disease or of hectic fever. When the disease is about yielding, the paroxysms often occur later each time ; this is postponing; when they occur earlier, it is anticipating, and de- notes that the disease is getting more severe. The paroxysms of the quo- tidian last about ten or twelve hours ; those of the tertian, six or eight; those of the quartan, four or six. The quartan has the longest cold stage ; the quotidian the shortest. Quintans and sextans may occur; perhaps they are quartans postponing. Double tertian is when the paroxysms are daily, but the alternate ones only resemble each other. When two fits occur on the same day, as in the morning and evening, and this happens every other day, it is tertiana duplicata. Double quartan is explained muta- tis mutandis, in the same manner as the double tertian, there being ague on two successive days, but never on the third. Quartana duplicata is, with the same explanation, similar to the tertiana duplicata. Triple quartan is that which occurs daily, but only those paroxysms of every third day re- semble each other. There are other complications. Incomplete ague is shorn of one or more stages ; of tho rigors, of the heat, or of both of these. This often happens when the disease is leaving, though it happens at other times. Sometimes there is no distinct stage, the patient feeling frequently and irregularly chilly, languid, and uneasy; this is dumb ague. Tho quotidian often changes to tertian ; tertian, to quartan ; quartan to either of these. Erratic ague is that which has no definite type. Complications, Duration, &c—Occasionally ague is attended by violent delirium, especially in the hot stage. Sometimes there are convulsions, or syncope, or tetanic rigidity, or. petechise, which disappear after the fit. The deviations may depend on constitutional predisposition; moreover, malaria may impart a periodic character to other diseases. Ague may last one day only, or a few days, or for years. It is much more common in spring and autumn than at any other season ; autumnal ague is the more severe and .dangerous. Quotidian ague is most common in spring; quartan, in autumn ; tertian happens at both seasons. , All are liable to ague, but especially those of middle life, and men, for they are most exposed to the cause. Causes.—Debility is a powerful predisposing cause; but the most power- ful is the occurrence of the disease itself, for this renders the person liable to it under circumstances in which he would not otherwise be affected by it When ague has occurred once, the east wind and exposure to cold are common re-exciting causes. Malaria, not simple bad air, but invisible effluvia, (gaseous or aeriform probably,) from the surface of the earth, is the onlv primary exciting cause of intermittent and remittent fevers. The impure air of cities is prejudicial to health, but does not generate intermit- tent or continued fever. Its physical and chemical qualities are unknown. It is not peculiar to marshes. A certain and continuous heat, probably hie-her than 6(P Fahr., and a certain quantity of moisture, are requisite to produce the specific poison of malaria. Earth is also essential, for it does 98 INTERMITTENT FEVER. not prevail at sea. Vegetable decomposition is an accidental, frequent, but not, by any means, an essential condition of its evolution. Vegetable decomposition or animal putrifaction may go on and not produce malaria. To produce malaria, it appears to be requisite that there should be a sur- face capable of absorbing moisture, aud that this surface should be flooded and soaked with water and then dried; the higher the temperature, and the quicker the drying process, the more plentiful and virulent is the poison evolved. Ihe "edges of swamps, rivers, &c., therefore, may be sickly. The "hotter and drier the summer, the more frequent and fatal are the autumnal fevers. The disease may be latent for a long or short time, (period of incubation,) and break out after removal from the mala- rious locality. Though natives and residents of malarious places are not so liable, as strangers are, to the violent forms of the fever, still they seem to be affected by the atmosphere; for they are puny, sickly, sallow, feeble in body and spiritless in mind, have swelled bellies, wasted limbs, are subject to dropsies and fluxes, are phlegmonous, melancholy and short-lived. Negroes appear to be proof against malaria. Loose, porous, sandy soil, appears highly favorable to the formation of miasmata; so does clayey soil, which retains moisture. Peat-bog or peat-moss is not productive of malaria. LECTURE XLL Ague— Continued.—Its Periodicity.—Malaria in low and hot situations may cause a disease not distinguishable from yellow fever; and as the locality becomes higher and cooler, the fever attends to assume, first the remittent, then the intermittent type. Various explanations have been given of the regular periodic recurrence of the ague fits. Willis ascribes it to a periodic development of the fer- mentable matter in the blood. The question then is, why is this develop- ment periodic ? Reil referred it to some general law of the universe, meaning, likely, the alternations of light and heat of the seasons, the ebbing and flowing of the tides, the states of sleeping and waking, &c. This is unsatisfactory. Mr. Bailey attributes it to the modifications induced in the system, especially in the circulation, by the changes from the upright to the recumbent, and from the recumbent to the upright position in the twenty-four hours. But this is not the explanation, for animals which do not undergo these changes suffer ague. Besides this theory does not account for continued fever. Mr. Roche says the causes of ague are periodic ; in spring and autumn, when ague chiefly prevail, the difference of temperature and humidity of the atmosphere by day and night is great; the emanations from putrifying vegetable matter are greatest during the hottest part of the day, are taken up into the air, and are deposited at night on the body, in the air-passages and perhaps in the digestive organs, thus causing ague and giving rise to the habit of suffering attacks of ague. To this it may be said, that for months the patient may be exposed to malaria before the disease appears. Moreover, this theory does not account for the different types of intermittent. Cullen is perhaps partly right when he ascribes it to some law of the animal economy, whereby it is subiect in many respects to a diurnal revolution. This explanation may do for quotidian, but not for tertian or quartan fever ; for there is no two-dav or three-day habit. As to the habit, it may be asked how did the second third, &c, attacks periodically fecur to begin the habit ? Besides, quotidian INTERMITTENT FEVER—MALARIA. 99 ague occurs in the morning, when there is least effect from diurnal habit. The solution of this subject is still to be sought for. Habits of Malaria.—Its Properties.—Malarious districts are much more dangerous at night, especially during sleep, perhaps because there is then more of the poison, or it is more condensed, or the body is then more susceptible. Leaving the house early in the morning is therefore hazard- ous. Malariai loves the ground; it tends downwards, probably because it gets entangled with fog. Lying down, therefore, to sleep in the open air at night is very perilous. Lower rooms of houses may contain the nox- ious effluvia, while the upper are free from it. Malaria is movable by the wind, being often blown into healthy places, and even up and across hills, especially if the wind blows for a long time from the same quarter. The wind may sometimes clear the poison from other places. In hot climates, especially where the' trade-winds prevail, the lee side of swamps and rivers should be avoided in founding towns. Malaria loses its noxious property by passing over even a small surface of water. Drinking marsh water appears to cause the fever. On land, the malaria may be carried over a considerable distance. Malaria is attracted towards, and adheres to, the foliage of lofty umbrageous trees, so that in malarious places it is very dangerous to go under large, thick trees, and still more so to sleep under them. Persons, therefore, who live to theleeward of trees are pro- tected from the malaria of the opposite side. In proportion as cultivation and population increase, so does the power of malaria decrease; and in proportion as the former decrease, so does the latter increase. In large towns ague is less common than in small ones, because, probably, of the many fires burned in the former. Effects of Malaria.—Anatomical Characters.—If ague patients continue exposed to malaria, especially if their food, clothing, and shelter be bad, the disease is apt to become very dangerous, leading to disorder of the sensorium and of the abdominal viscera, even in the intermissions ; sick- ness, diarrhea, dysentery, diseases of the liver. After death are found hepatic alterations, inflammation and ulceration of the mucous mem- brane of the alimentary canal; and, in long continued agues, the enlargement of the spleen (ague cake) is such as to be felt, and even its outlines seen. This state of the spleen is caused by repeated congestions of the internal vessels and viscera of the abdomen, a part of the blood coagulating, or slow inflammation being set up in the stretched covering of the organ. An attack of ague is not salutiferous. Prognosis.—This, in cold countries, is almost always favorable; but if the patient were previously the subject of serious organic visceral disease, or if very old or infirm, ague may destroy him. In warm countries, ague is much more dangerous, and sometimes rapidly fatal. In these countries it is often accompanied by severe affections of the head, stupor, delirium, convulsions; and of the alimentary canal, diarrhea, sickness, and often black vomit. It is also prone to run into remittent or continued fever. In all countries, quartans are harder to cure than tertians or quotidians. The longer intermittents have lasted, the harder are they to cure, and the more danger is there of visceral disease. In cold countries, the cure would likely be spontaneous, if the patient were removed from the malaria, and protected from wet and cold and suitably nourished. Treatment.—Give a calomel purge at bed-time ; as calomel, grs. iii with rhubarb, grs. vi or viii, and quina next morning. Dr. Baillie says that, in obstinate cases, where a grain of calomel was given every night for eight or ten nights, bark cured in a few days. In the fit, cover the patient in bed, apply warmth to his feet, and give hot drinks during the rigors ; order a cooler regimen during the hot stage; wipe the skin dry if thero is much sweating. / 100 INTERMITTENT FEVER. LECTURE XLII. Treatment op Intermittent Fever.—In hot climates, where the dis- order is apt to be violent and serious, the time for interference is in the first assault or paroxysm. During the paroxysm, the object is to alleviate the uneasy sensations of the patient, abridge the fit, avert the dangers arising from intense, long-continued, internal congestion, or from severe symptoms. Cold Stage.—In this stage, diluent drinks have been recommended ; also cordials, external warmth, opium, emetics, and bleeding. Diluent drinks are proper ; let the patient have his choice of them ; they are decoctum hordei comp., simple barley water, toast and water, weak gruel, tea, &c. These should be taken warm, and, if the patient is very feeble, make them gently cordial; weak negus, for example, or white wine whey may be giveu. External warmth is beneficial and helps to shorten the cold stage, as the pediluvium, or bags of hot salt or bran to the epigastrium, and a hot bottle or brick, wrapped in flannel, to the feet, or eventhe warm bath, or perhaps, best of all, the hot air bath. This bath is given by placing a cradle of wicker-work, covered with blankets, over the patient, and then introducing beneath the blankets one end of a curved iron tube, and at the other end, which is expanded into a bell and looks downwards, applying a spirit lamp, which heats the air beneath the blankets. Friction with stimulating liniments along the spine often affords comfort and shortens the cold stage. Rubbing the spine of children with an embroca- tion of equal parts of soap liniment and laudanum, at the approach of the cold stage, often prevents the paroxysm. Opium has helped to cut short the cold stage and dispel the unpleasant symptoms. At the first approach, a dose of laudanum (never less than thirty drops) has been given ; if, in ten or fifteen minutes, warmth did not come on, twelve to twenty drops more have been given. Repeat, if the next paroxysm threatens. Emetics are good only when there are signs of a loaded stomach, as nausea, ill- taste, a coated tongue, and a foul breath. Ipecacuanha, 3 i, is enough. Do not give antimony. Nausea and vomiting, and irritability of stomach, which is apt to arise, especially in hot climates, are sometimes hard to stop. Bleeding in the cold stage has been found very serviceable by some. One, sometimes two, seldom more, bleedings they say are required. They let the blood flow till some relief is felt, as, usually, liberation from pain of the head and loins, freedom of respiration, departure of the coldness, tremors and debility. Bleeding is not advisable in the cold stage, for it is not required by the symptoms^and it produces debility. In the very outset, however, of the severe malarious fevers of hot climates, on account of the internal congestion and disturbance, blood-letting may, very probably, be the most important part of the treatment. Hot and Sweating Stages.—In the hot stage, bleeding is only necessary when there is danger of internal inflammation. The best remedy of the hot stage is opium. Promote sweating by hot gruel or hot chicken broth ; but when the patient's uneasy feelings pass away, cautiously and gradually stop it by wiping him dry, changing his linen, and getting him out of bed. Be not, however, over busy. Intermission.—The most important part of the practice is that to be used during the intermission. The general remedies are bleeding, emetics, and purgatives. Bleeding may be used only when there is a tendency to local inflammation or severe topical congestion, especially in the young and robust. Emetics may be used if the stomach is loaded and foul. Always INTERMITTENT FEVER. 101 purge at the outset, as by calomel, grs. ii or iii; with rhubarb, grs. viii or x, at bed-time ; and the next clay begin with the specific remedies. The most certain and important are bark and arsenic. Give every four or six hours sulphate of quina, grs. ii or iii, in the infusion of roses, or with twice as many drops of dilute sulphuric acid, and with 3 i of tincture of orange peel and 3 i of the syrup of the same, completing the draught with water. This speedily stops ague. But sometimes larger doses are necessary. This salt may be given in a pill, but the best is the solution. It appears better to give repeated doses during the intermission, than one large one a short time before the fit. Some quartans, however, seem to require large doses of the .sulphate of quina before the fit comes on. In warm climates larger doses are required ; and it takes a larger quantity, on the whole, to cure ague. The medium dose, in many parts of America, seems to be eight grains. If the patient will not swallow the quina, or if the irritable stom- ach rejects it, give it by the rectum. The menstruum should not exceed twro or three ounces. A few drops of laudanum sometimes prevent the expulsion of the enema. It is said that the bark in substance sometimes cures when the quina fails. In obstinate cases, give the quina in the de- coction of the bark. Continue the quina for ten days or a fortnight after the patient seems cured, gradually diminishing, after the first week, the amount and frequency of the doses. Buzzing in the ear is a sign that the quina has had its constitutional effect; then it should not be pushed further. Sometimes it diminishes remarkably the force and frequency of the pulse. Our American brethren have taught us that quina may be given during the paroxysm with perfect safety and much advantage ; and that in the severer remittent fevers, the real hazard lies in abstaining from its use until a com- paratively apyrectic period arrives. If the quina be stopped too soon, relapse may take place on the eighth day in quotidian fever, on the four- teenth or fifteenth in the tertian or double tertian, on the twenty-first or twenty-second in quartan. Arsenic has unquestionable power over ague ; besides, it is tasteless and, therefore, adapted to children and irritable stomachs. But as it is an active poison and one over-dose may be fatal, or many minute doses may permanently injure the health, it should be used cautiously. If required, however, use it. Ten minims of liquor potassa? arsenitis, (which contain one-twelfth of a grain,) two or three times a day, are a full dose for an adult. It is better to begin with five minims. Do not give this corrosive on an empty stomach. The poisonous effects of arsenic are loss of appe- tite, nausea; sometimes vomiting, griping pain of the stomach and bowels, and diarrhea, and often, if continued, fainting. Other less con- stant and less important symptoms are painful and hot tumefaction and stiffness and itching of the face and eyelids, with a red conjunctiva, or a tingling eruption like nettle-rash. Control these effects by a few drops of laudanum to each dose; or better, stop the arsenic, and give mild laxa- tives, followed by opiates. If bark fails, stop the ague with arsenic, and then use quina to prevent a relapse. Other remedies are willow-bark in substance or decoction and its alkaloid, salicine; holly-leaves and their alkaloid, illicine ; the iveb of tJie black spider, as two pills, each of live grains of the cobweb every two hours, beginning six hours before the paroxysm ; this removes not only the ague, but also pain, delirium, vomiting, and griping in ague and continued fever, when there is no inflammation ; charcoal, especially when there are nausea, flatulence, hiccough, diarrhea, or dysentery, give grains x or xx in arrow root or with a lew grains of rhubarb, till 3 ii of it are taken, when the ague is said generally to be cured : the snuff of candles; piperine, the salt of pepper, in six or eight grain doses; a popular form is a teaspoonful of 102 EPISTAXIS. pepper in a glass of gin ; chamomile flowers; preparations of irbn and of zinc, as sulphate of zinc grs. v to x several times a day, or oxyde of zinc grs. iii every three hours. Ague has been cured by strong mental emotion, anger, joy,"etc. As the continuance of ague may depend on habit, it one fit be cured the disease mav cease. Prophylaxis.—The patient should remove from the malaria, if possi- ble ; if not, he should avoid exhaustion of all kinds, sudden exposure to cold or heat, wet clothes, night air; he should sleep in upper apartments, and before going out into the early morning air something should be eaten, or some stimulous or spirits taken. In aguish countries, generous diet and fermented liquor are proper. Moderate doses of quina may be a safe-guard. Warm stomachic laxatives should be used, and not the neutral salts. Protection may be afforded by the orinasal respirator, or by a gauze veil over the head, or by a handkerchief to the mouth, when exposed to the malaria. LECTURE XLIIL Epistaxis.—This is a simple and, commonly, harmless hemorrhage from the nose. Sometimes it is a remedy, sometimes a warning, sometimes a disease. A slight blow, sneezing, &c., may sometimes cause it. In child- hood and early youth it is idiopathic, dependent upon active congestion, probably arterial. In old age it is symptomatic, the result of passive con- gestion, probably venous. When habitual, its suspension betokens disease or danger. It is sometimes vicarious of menstruation or hemorrhois. It may result from disease of the nares, or form part of a more general hemor- rhagic disorder, as purpura. Usually the blood flows gutlatim, drop by drop; sometimes, in a small stream; sometimes a few drops only fall; sometimes several pints. A moderate flow generally gives relief; a large flow may cause pallor, faintness, exhaustion^ even death. Treatment.—Active idiopathic epistaxis in children, being almost always salutary, may be let alone. If excessive, however, stop it by applying cold water to the forehead and bridge of the nose, and by applying cold sub- stances to distant parts, or sprinkling them with cold water. Besides, give cooling laxatives, and, if necessary, some astringent internal remedy, espe- cially gallic acid and acetate of lead. Powdered matico leaf snuffed often stops the bleeding. In profuse epistaxis, Dr. Latham, by salivating rapidly, stops profuse and frequent hemorrhage, when moderate blood-letting or purgatives fail. In habitual or oft-recurring cases without any excess of vascular action, or any other apparent ailment in the constitution at large, he salivates gradually aud moderately, and continues it for a few weeks. Dr. Southey considers mercury as almost a specific for obstinate hemor- rhage, under similar circumstances, from any organ. When epistaxis begins in advanced life, it indicates congestion of the veins of the head, and therefore should be attended to. Look for heart disease or threatenings of apoplexy, and act accordingly. The hemorrhage may be a safety valve for the vessels of the pituitary membrane, which in- directly iuosculate with the veins and sinuses of the skull and with the jugular veins. When habitual epistaxis stops, look for and obviate ten- dency to plethora capitis. When the epistaxis is a part of a general hemor- rhagic disorder, as purpura, treat accordingly. If the excessive epistaxis resists ordinary remedies, it becomes a disease. Then plug the bleeding nostril with a dossil of lint wetted with a saturated solution of alum. The BRONCHOCELE. 103 bleeding may be stopped by raising one or both arms above the head for a time. Bronchocele ; Goitre ; Derbyshire Neck.—This is hypertrophy of the thyroid gland, the texture of it becoming coarser, the blood-vessels larger and more nnmerous, the cells magnified and filled with a thick viscid se- cretion. It is usually a soft, smooth, elastic tumor, neither painful, tender, nor discolored. Sometimes all the parts are regularly increased, sometimes irregularly. The right lobe is perhaps oftener enlarged than the left. A goitrous tumor may be diagnosed from an enlarged lymphatic gland or an encysted tumor, or a collection of pus, and it may be shown to be uncon- nected with the larynx, which these are not, by placing the head and neck in different positions, and by its following the up-and-down movements of the larynx during deglutition. Inflammation, acute or chronic, of this gland, and which probably takes place spontaneously in scrofulous persons only, may enlarge it, making it hard, tender and painful. This gland is rarely the seat of cancer; sometimes it is the seat of cartilaginous or ossific deposits. Bronchocele is not painful, nor does it taint the system. Effects-—By its weight and pressure bronchocele often causes great dis- tress, even death. Its injurious effects are generally in proportion to its bulk. Sometimes there is only a slight fulness of the throat; at other times the tumor may rise to the ear or reach the chest. Sometimes the swelling is rapid, but ordinarily it is slow. The tumor may remain for years without being inconvenient, and then suddenly increase. The worst effect is its interfering with the circulation and respiration, causing headache, giddi- ness, noises in the ears, confusion of thought, and a turgid state of the head and face ; or hoarseness, wheezing, and dyspnea. It may impede de- glutition. The effects are more serious when it is bound down by muscles which impede its expanding anteriorly. It is much more common in females than in males. In child-bed and at the menstrual period, it may temporarily enlarge. Time of Occurrence, Causes, &c.—It seldom occurs before the age of eight or ten. It may be congenital, or probably hereditary ; it is acquired. It is endemic, prevalent in certain localities and scarcely occurring elsewhere. Goitre was supposed to depend on some morbid quality of the air. It abounds in the hollows of many mountainous districts, and in damp, low spots where there is little breeze and a hot sun. Cretinism is a sort of idiocy, accompanied by, and doubtless dependent upon, deformity of body, as blindness, deafness, dwarfish stature, large head, crooked limbs, &c. Humboldt shows that goitre does not depend on any particular configuration of the surface of the earth, nor on any peculiar condition of the atmosphere. It is not caused by drinking snow water. It is pretty certain that goitre is caused by drinking water impreg- nated with calcareous salts. If the salt be sulphate of lime, the remedy is to mix the carbonate of an alkali with the water ; if the carbonate of lime, Bimply boil the water. Where cretinism exists, there is, bronchocele ; but this may prevail without the former. With four exceptions, cretins are goitrous ; but many goitrous persons are not cretins. Cretinism is most common in mountainous places. It is probable that the exciting cause of goitre and cretinism is the same ; and that the want of circulation of air, the direct rays of the sun, reflected from the mountain rocks, marsh effluvia, filth, humid situations, are only predisposing causes. Treatment of Bronchocele.—Advise removal "from the infected locality. Iodine is the remedy. The tincture of it is dangerous to use, for the iodine, which is an active irritant poison, subsides to the bottom in aqueous men- strua, and thus no iodine is given at one time and too much at another. Iodide of potassium holds iodine in solution when they are mixed. An 1C4 CYNANCHE PAROTIDEA. ounce of the liquor potassii iodidi compositus (iodine, grs. v; iodide of potas- sium, grs. x ; distilled water, OiUsa safe dose ; but begin with 3 11, and increase gradually if need be. Use simple friction, or friction with an ointment containing iodine when its internal use is contra-indicated, or in addition to it. Rub a small portion of the unguentum iodinii compositum on the tumor, or paint it with the compound tincture of iodine night and morning. In anemic females, whose eyes are also sometimes prominent, cure the anemia with iron, &c., and if the gland still remain tumid, cau- tiously use iodine. Watch for the specific ill-effects of the iodine ; headache, giddiness, sick stomach, languor, acceleration of the pulse, palpitation, dry cough, watchfulness, marasmus, sometimes swelled legs, tremors, painful hardness of the bronchocele, diminution of the breast, great increase of appetite. When these occur, suspend or reduce the dose of this medicine. Correct any disordered function, and improve the general health. Surgical Treatment.—There should be no surgical operation as long as the circulation, respiration, or deglutition is not interfered with and there is no serious discomfort. The surgical operations are three. First, extirpa- tion of the whole organ. This should not be done when the tumor is small; and when it is large, there is great danger of perilous hemorrhage and injury of important nerves. Surgeons have abandoned this operation. Second, passing a seton through the tumor and breaking it down by sup- puration. Avoid the large vessels by not going too near the thyreoid cartilage. This has been more successful. Third, tying the arteries which supply the gland. This has been attended with varied success. If there be an enlarged cell or distinct cyst, containing a quantity of fluid, puncture it and let the fluid out. Burnt sponge, containing iodine, is useful. Cover the neck with flannel. LECTURE XLIV. Cynanche Parotidea.—Greek writers apply the term cynanche to in- flammatory affections about the throat, and interfering with respiration and deglutition : the Latin term angina has nearly the same meaning. Cynanche parotidea, mumps, branks, is an inflammatory affection of the salivary glands, particularly the parotid. It is also called parotitis, though it is not mere inflammation of the parotid arising from any cause whatever. Symptoms, &c.—The parotid beneath the ear swells; the submaxillary and sublingual glands at the outset, or soon after it, are also swelled in most instances ; the swelling then extends towards the chin and is hot, pain- ful, and very tender when touched. Sometimes only one side is affected ; sometimes both at once ; but most commonly, first one and then the other. There is slight fever; the motion of the lower jaw is impeded by the swell- ing. The inflammation most always terminates in a few days in resolution, under the antiphlogistic regimen and the application of external warmth. After reaching its height about the fourth day, it declines, its whole dura- tion averaging eight or ten days. It often prevails epidemically, affecting first one or more and then a whole school or family. It chiefly attacks children and the young ; it is contagious; it seldom attacks the same per- son more than once. Often when the swelling of the neck and throat sub- sides, especially when it subsides quickly, the testicles in the male and the mammae in the female, become swollen and tender: this is the case it is Baid, with the testicle or breast of the same side with the inflamed parotid. APIITIIiE. 105 Not usually the testicle wastes after the swelling recedes. Generally, the inflammation subsides the same way in both glands, the swelling being neither painful nor long-continued. A more serious but rarer metastasis is to the brain ; this takes place sometimes from the parotid, but much oft- ener from the testicle or mammae. Sometimes it oscillates two or three times between the.testicle and parotid. Treatment.—Observe the antiphlogistic regimen ; mild diaphoretics; laxa- tives, if the head aches or the bowels are costive; warm fomentations or dry warm flannel to the neck and throat. Do not use active measures to check or subdue the inflammation, lest metastasis to more important organs take place. Do not bleed or purge violently, nor apply cold to the swelling. If suppuration ensue, (which is unusual and unlucky,) use poultices in- stead of fomentations. When the testicles are attacked, order warm ap- plications and rest in the horizontal posture, or suspend the testicle by a bandage or bag-truss. If the testicle or mammae be very violently inflamed, apply leeches and afterwards poultices. If there be metastasis to the brain, treat for phrenitis, and try to reproduce the inflammation in the parotid or testicle or mammae by irritants, as mustard poultices. Mercurial Parotitis.—Treatment.—Severe parotitis, induced by mer- cury, may be treated by leeches, for there is no metastasis of it. There is usually a profuse salivary discharge and also sponginess and swelling of the gums. Probably when there is no ptyalism, the parenchyma and areo- lar tissue of the gland are principally affected ; but when there is, the lining membrane of the ducts, secretory and excretory, are implicated. Idiopathic Salivation.—Treatment.—Idiopathic, or spontaneous saliva- tion sometimes occurs, the salivary glands being tender and swelled, the flow of saliva copious, and there being the same fetor as that produced by mercury, or a fetor which cannot be distinguished from it. Occasionally also the saliva is increased by the preparations of gold, copper, antimony, arsenic, castor oil, digitalis, iodide of potassium, opium, by pregnancy, bad teeth, and by certain states of the constitution. Treatment.—There is none specific. Astringent washes may do good ; a solution of alum, or the infusion of catechu, or a few drops of creasote suspended by mucilage in water. Sometimes the cause may lie in the teeth or a disorder of some important function, which must be treated ac- cordingly. Aphthae.—Symptoms.—Aphthae consist in small, irregular, usually roundish, elevated, white specks or patches over the tongue, cavity of the mouth, and fauces, the angles of the lips, cheeks, palate, pendulous velum, tonsils, pharvnx, and contain a serous or gelatinous fluid. The epidermis falls off, leaving a reddish and raw-looking or a foul and ash- colored surface. Successive crops may form. This, in children, is thrush. It perhaps never occurs after lactation. The mouth is hot and tender, and pains when the child sucks. Other symptoms in children are drowsiness, sickness, diarrhea, and feverishness. The aphthae do not exist in the whole alimentary canal, though probably some morbid condition does. Improper diet or bad breast milk may cause it. It generally lasts eiuht or ten days. There is not much danger, unless the separation of the crusts leaves the surface brown or bluish ; for in such cases the local affection is apt to run into gangrenous ulceration, and the discharge from the bowels becomes slimy and shreddy. Treatment of Thrush.—Correct bad diet; and correct acidity of the sto- mach, which mostly exists in children, by antacids. For diarrhea, give pulvis sodce cum hydrarg., grs. iii to v, thrice daily, (pulvis cretae comp., parts ii; dried carb. sodae, parts ii; hydrarg. cum creta, part i.) Paint the mel boracis on the aphthous parts with a camel's hair pencil. 5* 106 CYNANCHE TONSILLARIS. Aphthae in adults, in the course of other diseases, are often harbingers of dissolution ; they denote great debility. Treatment.—Give winej bark, and nourishment to sustain the strength. Apply to the parts a mixture of equal parts of mel boracis and syrup of poppies. Use the following mixture as a gargle: borax, 3 ii, melrosae, j i, decoction of quince seed, § iii, water, % vi. Aphthae sometimes de- pend on a bad stomach, produced by food. Cynanche Tonsillaris ; Tonsilitis ; Amygdalitis ; Quinsy ; Com- mon Inflammatory Sore Throat.—The severity of this depends on its extent. It generally spreads from the tonsils to the uvula, velum palati, salivary glands, pharynx, root of the tongue, &c. When superficial, it produces no great distress though it be diffused. When it penetrates the mucous membrane, it is apt to cause suppuration ; the tonsils swell enor- mously, and at length contain deep abscesses. The disease is worst when the back part of the tongue or its surrounding muscular and areolar tissue is implicated. If it reach the larynx it is very perilous. Symptoms.—Ordinarily, there are at first slight uneasiness and dys- phagia, constant dryness and sense of constriction and of a foreign body in the fauces. The tonsils are both red and swell at once or in succession ■ the uvula is commonly elongated and drags on the parts below, causing painful acts of deglutition ; oftener it adheres to the more swollen tonsil boon the dryness gives way to a copious secretion of transparent, frothv and viscid mucus, which is hard to be hawked up. Early in the disease opaque white spots of exudations, which are not ulcers, appear on the red tonsil. In violent cases the submaxillary and parotid glands sometimes swell and are tender on pressure; occasionally there is profuse ptvalism, the salivary glands becoming implicated. When deglutition is painful and difficult, and the cause is out of sight, it is cynanche pharyngea; this does not need any further consideration. The pain of tonsilitis is felt almost solely during deglutition and is very severe. The swelled glands often push forward the anterior pillars of the velum paliti; they project and approach each other, or they may touch and, by pressure, mutually cause ulceration The tumid velum paliti is apt to drive liquids through Sn«tn.°n8iiIn?eE Utlil°-n' .In severe cases, pain shoots to the ear along the Eustachian tube; this, in most cases, points to suppuration. Tinnitus aurium and partial deafness sometimes exist from stoppage, by Sing or inflammation, of the same tube. When the root of the tongue & involved, the mouth can be opened only very little, and the tongue Ts mo- lonless. Breathing is scarcely affected, even in severe casef, but the ^ » "*"*» lateral, inarticulate. The voice is often d agnostic. When the swelled tonsils injure the breathing, then, almost only is there danger. In cynanche tonsillaris there commonly Is/from the verV 5ut«