"•TZrtsrsSi^r: SS;.iiT' ^*-r; .'!';. ■ HfcM.i kI'.'•■ • Wt'T* •'"'v.i' ,'. WLj :, iJ. ■ ,<■ ( 9K,l P^;; _ r *>•'' f ^ - ',"■ -■V3;::- £ ae- LECTURES THEORY AND PRACTICE PHYSIC. BY JOHN J£ELL, M.D., Fellow of the College of Physicians of Philadelphia; Corresponding Secretary of the Philadelphia Medical College; Member of the American Philosophical Society, and of the Georgofili Society of Florence, etc., etc. AND BY WILLIAM STOKES, M.D., Lecturer at the Medical School, Panc'Street, Dublin; Physician to the Meath Hospital, etc., etc THIRD EDITION, ENLARGED AND IMPROVED. IN TWO VOLUMES. apJiflaTrclpUfa: ED. BARRINGTON & GEO. D. HASWELL. 1845. [Ehtirib, according to act of Congress, in the year 1842, by Barringtok and Haswsli., in the clerk's office of the district court for the eastern district of Penn- sylvania.] V,l PREFACE TO THE THIRD EDITION. The call for a new edition of these Lectures within two years after the issue of the last, which was a large one, is a direct and pleasing evidence of public approval, that might well elicit strong expressions of gratified pride on the part of their authors. To the subscriber the most appropriate manifestation of this feeling seemed to be, to render, by careful revision and numerous additions, the present series still more acceptable than the last. When preparing these Lectures for publication, two years ago, portions of the treatise of Dr. Stokes on the Diagnosis and Treat- ment of Diseases of the Chest, which was then out of print, were incorporated in them, due credit being given, at the time, to the author. Now, however, that a new edition of this work has been brought out, it seemed proper to replace these portions by matter prepared expressly by the subscriber, with a hope, on his part, that what is lost in originality will be made up by more varied details for practical purposes. In addition to these and other interstitial changes by removal and replacement, large accretions have been made, in the present series, by subjects not included in the preceding one, viz., on the Diseases of the Organs ofGeneration, in both sexes; several diseases of the Respiratory Apparatus, omitted before; Tubercular Meningitis, Epidemic Meningitis ; Scrofula ; Syphilis; the Exanthemata, greatly enlarged ; Rheumatism, and Gout. The new matter added in these ways is fully equal, it is believed, to three hundred pages. No separate divisions have been made of Dropsies and Hemor- rhages; but the different diseases coming under these denominations have been described and their treatment laid down with more or less fulness,in their proper connections. Dropsy is almost always a symptom and an effect of antecedent disease, congestion or phlogosis, of some viscus or tissue, and finds its appropriate place when these lesions are brought under notice. Hemorrhage, as one of the morbid modes and manifestations of an organ, is treated of at the same time with the several diseases of this organ ; and in this way its true iv PREFACE. pathological characters and relations can be better understood than in the common but arbitrary classification. In these lectures, pains have been taken to turn to profitable ac- count, for the guidance of the student and practitioner, the large ac- cumulations made of late years on the pathology and modified treat- ment of the Diseases of Children. Distinct reference will be found to the various sources of knowledge on this head; but, as will be readily seen by the attentive reader, the admirable work of MM. Barthez and Rilliet has furnished the largest supply. Before dismissing these lectures from his own immediate charge, and sending them forth, with his kindly greetings, to their future readers, the subscriber will proffer a few, very few, words of apology and justification for the delay in their appearance beyond the time anti- cipated both by himself and the publishers. He did not overrate his laborious industry nor zealous devotedness to the task: but more time was, of necessity, required for its due performance, owing to the larger space procured by his own retrenchments and the larger margin ultimately allowed him by the liberality of the publishers than he had anticipated, or could well have anticipated up to the date of the com- pletion of the work. JOHN BELL. CONTENTS OF VOL. I. LECTURE I. General Observations ...... *age 13 LECTURE II. General Remarks on Local Diseases.—Fixed rules for the guidance of students.— Great importance of diagnosis.—Existence of pure fever rare.—Doctrine of the Humoralists and of the Brownists.—Pathology of the digestive system . 24 LECTURE III. DR. BELL. Diseases of the Mouth and Pharvnx. — Connexion in structure and function be- tween them and diseases of the stomach and bowels.— Stomatitis — Its dif- ferent species — Simple erythematic stomatitis—Its nature, causes, and treatment — Follicular or aphthous stomatitis — Its varieties, complications; pathology; analogous to follicular gastritis and enteritis — Connexion with dyspepsy in adults, and in children with cholera and diarrhoea — Remedies, general and local — Importance of hygienic measures—Ulcerous stomatitis . . .33 "LECTURE IV. DR. BELL. Pultaceous Stomatitis, or Muguet — Its Pathology — Treatment. — Pseudo- membranous Stomatitis. — Its complications with visceral disease — insidi- ous approach—Pathology — sometimes prevails epidemically—Treatment, modified by the state of the digestive system and degree of local excitement — Local applications — Means of properly applying mineral acids and lunar caustic — Sulphate of copper—Iodine, topically and internally — Warm bath . 41 LECTURE V. DR. BELL. Gangrenous Stomatitis — As a result of other kinds of stomatitis, and as a sepa- rate disease— Different opinions as to its violence and danger — Two states of gangrene of the mouth — Its Pathology — Common origin in the gums — Treat- ment, general and local — Emetics, tonics, and the warm bath and frictions — Iodine—Topical remedies—numerous—The chief one is sulphate of copper. 48 LECTURE VI. DR. BELL. Glossitis — Its varieties and causes — Symptoms — Termination— Diagnosis— Treatment — Importance of scarifications — Symptomatic or secondary glossitis — Treatment modified by the nature of the primary disease. — Parotitis — Pri- mary— Supposed contagion of—Terminations — Metastasis to other organs — Treatment — Secondary or symptomatic parotitis — That caused by mercury, — its treatment . . . . . . • .54 LECTURE VII. DR. BELL. Diseases of Dentition — Predisposition to numerous diseases in early infancy. — Causes besides dentition — The susceptibility of the organs of the child, and peculiar exposure to external agents—Sympathies of the dental apparatus — Direct and remote — Treatment during dentition — hygienic and medicinal — The measures chiefly demanded . . . . • .26 VOL. I. — B vi QONTENTS. LECTURE VIII. DR. BELL. Diseases of the Throat. — Their various origins and complications.—Retro-pha- ryngeal Phlegmon —Difficulty of diagnosis, and danger of this inflammation- Cases. — Angina Simplex — Its causes, symptoms, and treatment — Sometimes associated with typhoid fever. — Chronic angina— Inflammation sometimes lo- cated in the uvula, sometimes in the palate — Treatment of the same . p. 69 LECTURE IX. DR. BELL. Tonsillitis—Most common in young subjects—Symptoms, duration, treatment.— Importance of bloodletting—Purging—Gargles. —Chronic Tonsillitis—Incon- venience and even danger in this disease—An indirect cause of spinal curvature —Treatment, local and general; by caustics and inunction, and internal reme- dies—Diseased follicles of the tonsils—Morbid secretion,—how distinguished from tuberculous matter.—Morbid states of hearing and deafness caused by en- larged tonsils, and diseased mucous membrane of the throat.—Voice and speech modified from similar cause—Change of voice after extirpation of tonsil . 77 LECTURE X. DR. BELL. Angina Membranacea — Its varieties.—The simple and the malignant — Symp- toms and treatment of AnginaSimplex — Malignant Angina orDiphtheritis — Earlier notices of it — Causes — Connexion with scarlatina — Persons most liable —Epidemical and endemical, and sometimes sporadic — Symptoms—Diagnosis — Its anatomical characters. — Membranous exudation — Is sometimes ulcerous and gangrenous — Prognosis— Age, temperament, particular exposure and lodg- ing modify result .... . . .86 LECTURE XI. DR. BELL. Angina Membranacea Maligna—(Continued).—Treatment — Bloodletting some- times admissible — Emetics — Revulsives — Stimulants — Calomel—Blisters__ under what indications required — Topical treatment—Stress laid on it in malignant angina—Chief articles employed. — Summary of treatment in some of the worst cases marked by suddenness of invasion and prostration of the powers of life. — Angina vel Pharyngitis Gangrenosa — Two varieties — The circumscribed and the diffused— Circumscribed gangrenous angina described — Its defined limits —Diffused variety.— Its anatomical characters, seat, symptoms, diagnosis, prognosis, causes, and treatment . . . . .93 LECTURE XII. Pathology and Treatment of Diseases of the Digestive System — Different forms of gastritis—Pathology of this disease imperfectly understood by the an- cients—Gastritis and enteritis not always found in connection—Phenomena cha- racterising acute gastritis—Symptoms and sympathetic relations—Diagnosis —Gastritis simulating other diseases . . , , ° jqq LECTURE XIII. Gastritis—No one symptom decidedly indicative of the particular condition of any organ—Sympathetic irritation liable to terminate in organic disease—Sym- pathetic relations as connected with the viscera of the thorax— Treatment of simple acute gastritis—Antiphlogistic remedies—Purgative medicines injurious —Enemas and injections—Use of ice beneficial—Effervescing medicine hurt- ful......•... 113 CONTENTS. Vll LECTURE XIV. Pathology and Treatment of Gastritis—Application of blisters —Emetics can be seldom used in acute gastritis— Hematemesis and delirium tremens compli- cated with gastritis— Treatment of these affections — Dyspepsia, or chronic gastritis —Hypochondriasis—-Termination of chronic gastritis . p. 122 LECTURE XV. Treatment of Chronic Gsatritis.— Frequent excitement of the vascular syBtem necessary to the performance of the functions of the stomach— Local bleeding —Regimen—Counter-irritation over the stomach — Treatment of Broussais— Use of Vegetable tonics —Oxide of bismuth — Acetate of morphia —Friction with croton oil —Attention to diet during convalescence — Oragnic disease of the stomach—Principles of treatment—-Diet and attention to the bowels . 130 LECTURE XVI. DR. BELL. Dyspepsia.— Temperaments and Constitutions most liable to the disease — Habits of life inducing it — Concomitant diseases— of brain, liver, skin, lungs, uterus, and kidney — These are sometimes causes, sometimes effects of dyspepsia — A complex disease, sometimes caused by, sometimes causing spinal irritation — Modification of treatment required — Andral's case and reflexions — Dr. Chap- man's notice of chief causes — Tobacco, its injurious tendency and effects — High excitement of brain in England and United States. — Dyspepsia with Morbid Gastric Secretion — Pyrosis or Water-brash— Its causes and treat- ment. — Cardialgia, its mixed nature and treatment — Mercury — Ipecacuanha — Sulphuret of potassa — Gunpowder ..... 141 LECTURE XVII. DR. BELL. Gastrodynia, or Gastralgia—Its symptoms—Diagnosis—Causes—Treatment. —Hygienic means the first to be attended to—Alleviation of pain—Caution re- specting stimulants—Draughts of hot water—Blending of gastritis and gastralgia —Hydrocyanic acid—colchicum—emetic tartar in small doses—oil of turpentine —subnitrate of bismuth—oxide of zinc—subcarbonate of iron—carbonated chaly- beate waters—nitrate of silver__Periodical gastrodynia requires sulphate of quinia—Danger of alcoholic stimulants—Superiority of. water as a drink—Atten- tion to the lower bowels—The kind of food proper—Regulation of the cutaneous functions—Mental habits to be studied—Change of scene and travel . . 154 LECTURE XVIII. DR. BELL. Gastro-Duodenal Dyspepsia.—Relations of the duodenum—Varieties of duodenal disease—the acute and the chronic or atonic—General characters—Particular symptoms—direct and sympathetic—'Causes—common in the United States— Necessity of a better pathology of diseases called bilious and hepatic— Treatment—depletion if acute disease be present—Counter-irritation—Emetic tartar—castor oil—nitrate of potassa—mercury—taraxacum—mineral acids.—In the atonic variety, purging—suitable food—exercise—laxatives—tonics, and alteratives.—Follicular duodenal dyspepsia—Its symptoms, progress, and treat- ment. —Strumous dyspepsia—Its course, complications, and treatment—General directions ......... 163 LECTURE XIX. Duodenitis—Inflammation of the Jejunum.—Ileitis—complication and nature of—Dothinenteritis—Ulceration of the mucous membrane — Symptoms and diagnosis of ileitis___Diseases of the small intestines—Symptoms of ileitis— Occurrence of diarrhoea with fever symptomatic of this form of inflammation— Frequency and symptoms of the disease in children.—Tabes mesenterica,— Treatment of ........ 177 viii CONTENTS. LECTURE XX. Treatment of Ileitis—Ad vantage of leeching—Stimuli sometimes beneficial In- fantile remittent fever—Inflammation of the mucous membrane—Enteritis with diarrhoea—Effects of opium in inflammation of serous and mucous membranes Pathology and treatment of diarrhoea and dysentery—Perforation of the intes- tine—Diseases of the large intestine . . • • • p* LECTURE XXI. Diseases of the Large Intestines— Treatment of diarrhoea —Apyrexial period of diarrhoea —Danger in suddenly arresting the discharge —Purging in Phthisis — Dysentery — Epidemic dysentery ..... 199 LECTURE XXII. Sporadic Dysentery — Nature ofthisdisease— Treatment; mercurial, stimulating, antiphlogistic —Recommendation of Dr. Elliotson — Success of Dr. O'Beirne in the use of tobacco injections — Tympanites, or Meteorism — Windy Colic, remedies for the cure of ...••• • 207 LECTURE XXIII. DR. BELL. Dysentery.—The anatomical lesions in dysentery,—same in all parts of the world —Dr. Cheyne's experience in Dublin; Mr. Twining's in Calcutta; Dr. Cornuel's in the West Indies.—Stomach, small intestines, and liver, sometimes inflamed concurrently with the colon.—Causes of dysentery—crude ingesta—atmospherical vicissitudes—damp and impure air—particular seasons and climates,—Malaria nota cause—The disease nolcontagious—Duration—Terminations—Prognosis— Treatment—venesection—leeching—mercurials — ipecacuanha—diaphoretics.— Rectal inflammation — its treatment.—Hepatic Flux — its symptoms and treatment . . . . . - . . .214 LECTURE XXIV. DR. BELL. Enterorrhosa—Includes both diarrhoea mucosa and d. serosa.—Gastrorrhoea.— Pathology of enterorrhcea—Two varieties of the disease.—Acute and chronic stages—Connexion between dentition and development of the intestinal mucous follicles—Treatment of enterorrhcea based upon subduing intestinal irritation— diet, and sudorifics and opiates, sometimes astringents—In lymphatic subjects and in epidemic visitations, emetics and purgatives proper. Importance of diet for the cure of diarrhoea in all its forms—Kind of diet most beneficial—Ente- rorrhcea with Membranous Formations—Pellicular exudation on intestines of very young children—Associated sometimes with stomatitis—Later in life with dysentery—Probably the result of morbid follicular secretion, with or without inflammation—May appear and recur frequently,—sometimes without much general disorder — in duodenal dyspepsia— Causes and seat not known — Treatment ....... 232 LECTURE XXV. DR. BELL. Colonic Dyspepsia—The colon—its extent, situation, and functions.—Atonic co Ionic dyspepsia—Constipation—its general character, symptoms, causes and vari" ous terminations—Spinal irritation connected with dyspepsia—Treatment of the" colonic disease—Importance of a suitable diet . . o., LECTURE XXVI. DR. BELL. Inflammatory Colonic Dyspepsia—Connexion with chronic colitis—Causes and treatment.—Irritable colonic dyspepsia—jGn/era/g-j'a—Peculiar temperament of CONTENTS. IX persons suffering from this disease—Treatment; to be simple and mild—Follicu- lar colonic dyspepsia—its analogy to follicular duodenal dyspepsia — Treat. ment • ' • . . . . . . P. 249 LECTURE XXVII. DR. BELL. Diseases of the Caecum.—Peculiarities of position, structure, and function of th caecum—Its liability to be disordered—Symptoms of fecal accumulations in it— Treatment—Importance of enemata—Best means of employing them—Suspicion of hernia being present—Liniments and friction—Attention to diet.—Inflamma- tion of the cxcum—Its varieties.—Stercoral Csecitis—Symptoms and treatment 255 LECTURE XXVIII. DR. BELL. Acute Cfficms.—Symptoms and treatment. — Chronic inflammation of the cxcum — Its causes, complications, and cure. — Inflammation of the peri-csecal tissue. — Perforative ulceration of the caecum and of the appendix vermiformis— Causes —Symptoms—Prognosis—Treatment . . . .261 LECTURE XXIX. DR. BELL. Diseases of the Rectum.—The structure and sympathies of the rectum—Chief diseases of the rectum, viz., hemorrhoids, ulceration, stricture, and cancer.—Dan- ger from neglect of proper knowledge of rectal diseases.—Hemorrhoids—Defi- nition—Disease, both hemorrhage and tumours—Varieties of hemorrhoids or piles.— The anatomical characters of the three principal ones,—varicose, erectile, and cystic or spongy (mariscae)—Hemorrhoidal Flux or Discharges—Their sources —Quantity and colour of blood discharged.—Mucous or Sero-Mucous hemorrhoid dal discharge—Causes—Constipation and drastic purgatives overrated as causes of hemorrhoids.—Consequences and complications of hemorrhoids . . 269 LECTURE XXX. DR. BELL. Treatment of Hemorrhoids.—Relief afforded by hemorrhagic discharge.—Disad- vantage of this natural method.—Measures, medicinal and hygienic, required in a first attack of hemorrhoids.—Treatment of the fixed disease.—Difference be- tween arresting and curing a disease.—Attention to the general system, and to the removal of plethora and visceral disease.—Sometimes active measures— v.s., leeching, calomel, &c, required—To vary the treatment, according to preceding or accompanying disease.—'Chronic Variety—'Balsams, turpentine, and cubebs, useful.—Periodical hemorrhoids—treatment of—Precautions to avoid an attack of the disease.—Hemorrhoids with anemia.—Extirpation of tumours prac- tised sometimes with advantage—Danger—Constitutional measures more pru- dent.—Necessity of preparing the system for the operation of removal.—Re- stricted regimen afterwards ....... 279 LECTURE XXXI. DR. BELL. External Hemorrhoids. — Topical applications — washes, ointments, injections, pads to cause pressure.—Remarkable case of M. Guyot.—Reasons for enlarging on the subject of hemorrhoids.—Ulceration of the rectum—Two varieties—treat- ment of.—Prolapsus of the rectum—its peculiarities and treatment.—Stricture of the rectum.—Mistakes and malpractice respecting this disease—Stricture commonly the result of inflammation ..... 288 LECTURE XXXII. DR. BELL. Treatment1 of Stricture of the Rectum.—Spasmodic stricture—Fissures—Card- B2 X CONTENTS. noma of the rectum—Treatment, palliative.—Neuralgia—Preternatural PouC^ or sacs.—Blenorrhagia—Pruritus Jlni . . . . • p" LECTURE XXXIII. DR. BELL. Colic—Its chief divisions-Community of causes, and of many symptoms and other pathological features of these varieties—Inference to guide us in the treat- ment—Simple Colic—Its seat and diagnostic symptoms—Varieties of simple colic—Treatment—Preliminary inquiries to be made—Remedies according to the cause of colic—from cold, indigestible matters, or stercoraceous accumula- tions — Carminatives — Enemata — Purgatives —Venesection—Cupping—Lini- ments of narcotic substances—Oil of turpentine—Croton oil—Infantile colic— Two varieties of—the stercoraceous and that from indigestible matters—Modi- fications of treatment in consequence—Importance of attention to the diet and health of the mother—Danger from habit of giving opium to children—Periodical infantile colic .... ... 303 LECTURE XXXIV. DR. BELL. Bilious Colic—Time of its attacks—Causes and Symptoms—Anatomical lesions— Treatment—Venesection—Opiates—The warm bath or fomentations—Purgatives —Enemata—Means of acting on the bowels—Calomel—Caution against too early. excitement of any kind—Recourse at times again to bloodletting—Dover's pow- der—Blisters—Practice by others—Sydenham's directions—Emetics sometimes used.—Dry Bellyache—Analogous to bilious colic—Does not arise from lead— Common formerly in the West Indies and in America—Description by Hillary— Paralysis of limbs—Metastasis.—Colic of Madrid—Closely resembles the pre- ceding—Causes of—Symptoms—Anatomical lesions—Devonshire colic—Causes. — Vegetable colic,, similar to the preceding—Treatment of this kind of colic, in- cluding the preceding varieties ...... 312 LECTURE XXXV. DR. BELL. Ileus—Affinity between ileus and colic—Symptoms of ileus — Causes—Anato- mical characters—Volvulus, or intussusception,—Invagination of intestine__How formed ; its varieties and termination—Diagnosis of intus-susception__Treat- ment—Preliminary inquiry into the existence of hernia—Localization of intus- susception—For this last, bloodletting, opium and tartar emetic, and enemata— Venesection generally called' for in ileus—Blisters—Turpentine epithem—Dry cupping—Purgatives—Stimulants in last stage—Other remedies—cold—tobacco injection—Other narcotics externally and internally—Injections of linseed oil__ Crude mercury in quantity—Operation of gastrotomy—its doubtful propriety and dangerous consequences . . . . t . 393 LECTURE XXXVI. Painters' Colic—Effect of metallic poisons on the nervous system—Symptoms of painters'colic—Pathology of neuroses-Action of lead on the system—Abdo minal and cerebral symptoms—Species of painters' colic—Dr. Thomson's re searches on lead—Effects of, in animals— Effects of, on the generative system 333 LECTURE XXXVIL Pathology of Painters* Colic -Researches on the state of the nervous an J di- gestive systems-lreatment-Use of narcotics, purgatives, tobacco, &c, &c~ rreatment of paralyse from- lead-Efficacy of strychnia and brucia-lc0lic from copper-Poisonous effects of mercury-RemarkaWe case-Affection of thp respiratory musclea . , , 'uie • • . 343 CONTENTS. xi LECTURE XXXVIII. DR. BELL. Cholura Morbus — Definition — S)'denham's description — Divisions of cholera.— Sporadic or Common Cholera— Symptoms — Not a very fatal disease— Propor- tion of cases and deaths in the British troops in different regions— Greater pro- portionate mortality in northern than in southern latitudes —Often exceptions to this. — Causes — Mutations of temperature from heat to cold, and errors in regi- men — Seat of the disease — Not often depending on inflammation. — Diagnosis.__ Treatment — Diluents — External irritation — Emetics— Opium — Venesection occasionally — Calomel — Calomel and opium —Laxatives — Occurrence of gastro-enteritis— its appropriate treatment — venesection or leeching__laxa- tives, diluents, mild diaphoretics, and the warm bath.—Convalescence from cholera.........P# 353 LECTURE XXXIX. DR. BELL. Epidemic Cholera.—A counterpart to the pestilences of olden times—The great pestilence in the fourteenth century—Less mortality with advanced civilization. —First appearance of the epidemic cholera in India—Its progress in that country and in Eastern and Western Asia and the islands—in Russia ; Poland ; Hun- gary; Austria—Its appearance in England, Scotland, and Ireland; United States; Mexico; Havana; Southern Europe ; Algiers—Order of succession of the attacks of cholera.—No regular rate of progress or rule of transmission— Quarantine restrictions useless—Singular limitations of its range by the smallest change of locality . . . . . . .361 LECTURE XL. DR. BELL. Causes of Epidemic Cholera—Connexion between cholera and other diseases — Influenza—Influenza and cholera in 1780 and 1781—Both have pursued a similar course, including divergencies from the main line—Prevalence of bowel affections in cholera seasons—Increased mortality at this time from other diseases—Scarlet fever with cholera.—The special cause unknown—Predisposing and modifying causes, in weather and season; low situations; poverty, destitution, and vice of the inhabitants ; bad food ; watery fruits-and vegetables ; intoxicating drinks ; sudden debility of the nervous system; fear; great and unusual exposure to atmospherical extremes and changes—atmospheric and other phenomena anterior to and contemporaneous with cholera*— Attacks of the disease mainly in the sum- mer-half of the year—Prevalent winds—Sickness and mortality among animals coincident with cholera in different countries—Cholera not transmissible by contagion ......... 369 LECTURE XLL DR. BELL. Symptoms of Epidemic Cholera—To be described under the head of diarrheal ttage, or cholerine ; confirmed cholera, collapse and reaction-^-Importance of atten- tion to the first, or diarrhreal stage—Time of attack of.—Confirmed cholera— Disorder of the stomach and bowels; of the circulation ; of animal heat—Vomiting and purging vary in extent—Collapse without evacuations—Mind undisturbed —Symptoms of disordered innervation—Spasms and cramps—Symptoms of collapse, or blue stage—Sinking of the circulation the most constant and alarm- ing symptom of cholera—Thirst, and sense of heat in the stomach—Respiration, how affected—Symptoms connected with the blood and circulation—Sameness of cholera in all parts of the world—Stage of reaction, or consecutive fever— Urea in the blood, an alleged cause of the consecutive fever—Analogy between cholera and pernicious or malignant interin-ittents—Torti cited—The lecturer's ease of comatose intermittent ...... 380 xii CONTENTS. LECTURE XLII. DR. BELL. Prosnosis of Epidemic Cholera.—Common and individual signs—Modification byarre, sex, occupation, and race-Promptness of recovery—Congestions witn slower convalescence-Immediate causes of death-Remoter causes, in the con- stitution and habits of the individual-Misleading signs in the consecutive fever. —Post-mortem Appearances.• — 1. The adventitious, though common; 2. 1 he peculiar, and in a measure pathognomonic-Automatic movements-Increase of temperature—Textural and visceral changes in the digestive canal, lungs, and liver, and sometimes brain . • • • • • p> LECTURE XLIII. DR. BELL. Distinctive Post-mortem Appearances in subjects dead of cholera--Change in the blood—emptiness and contraction of the bladder—whitish fluid in the intes- tines—exudation on intestinal mucous surface—development and other changes in the follicular glands—psorenterie—Dr. Horner's observations—a vesicular eruption on the entire surface of the digestive tube—exfoliation of epidermic and venous lining of the tube—Great number of the gastro-intestinal mucous follicles—Changes in the fluids,—\n the blood,—in the secretions from the bowels—Special pathology of cholera—Analogy to poisoning—Two orders of functions affected—Experiments by injection of poisons into the veins—Dr. Namias's experiments with cholera blood—Organs and tissues simultaneously affected—respiratory, digestive mucous, and cutaneous—Mortality from cholera— In India—Russia—Poland—Hungary—France—Great Britain and Ireland— Berlin—Naples—Geneva—Leghorn—Sunderland—Glasgow — Quebec — Mon- treal—New York—Philadelphia—Cincinnati—Law of Recoveries and Mortality in cholera ......... 400 LECTURE XLIV. DR. BELL. Treatment of Cholera.—Study previously of its mortality, and comparison with that in other diseases—Almost certainty of death, unless medicine be given— The sedative class of remedies most useful in cholera.—Evidences of increased innervation—Increased glandular secretion—Indications of cure—Treatment of the Diarrheal Stage.—Necessity of prompt attention to the first symptoms of irregular digestion—Mild purgatives, sometimes an emetic ; laudanum ; diluents ; rest; moderate warmth—Case—Selection of purgatives—Treatment of Marked Cholera.—An emetic—Bloodletting—Sedative or contra-stimulant remedies— Calomel; its primary and sedative effect; is to be given in large doses, some- times alone, often with a full dose of laudanum—Opium . . .411 LECTURE XLV. DR. BULL. Treatment of Cholera (Continued).—Other Sedative Remedies.—Tartar emetio— Ipecacuanha—Magnesia—Sub-aeerate of lead -Sub-nitrate of bismuth—External sedatives—Warm, tepid, and cold baihs.—Enemata—Laudanum__Sub-acetate of lead—Stimulants—Alcohol injurious—Carbonate of ammonia—Spirits of turpen- tine— Campho —Capsicum.—Aqua amrooniae- Camphorated ether—External 6timulants—Blister—Cauterisation of skin—Irritating liniments to spine—Dry vapour to skin—Advantages of dry friction—The hot bath . 403 LECTURE XLVI. DR. BULL. Treatment of the Stage of Collapse.—Difficulty—Stimulants and sedatives often alike fail—External remedies; friction, ammoniacal liniment; friction with ice; the cold dash—Sudden collapse treated sometimes by venesection__ CONTENTS. X1I1 Arteriotomy useless and cruel—Cups to the abdomen—Astringent injections— Stimulant injections—Astringents—Special stimulants; oil of turpentine and capsicum—Ice grateful and serviceable—Cold water treatment—Dr. Shute's views in directing it—Tobacco enemata—The saline treatment—General expe- rience not in its favour—Saline injections into the veins—Delicacy and difficulty of the operation—Treatment of the Stage of Reaction.—This and the diarrhceal stage less common in India—Convalescence.—Prophylaxis.—Chief means are temper- ance, cleanliness, and equable temperature of the body—Importance of early atten- tion to the very first symptoms of the disease .... p. 429 LECTURE XLVII. DR. BELL. Cholera Infantum.—Is endemial in the United States—Scarcely noticed by the English and French writers—Dr. Cheyne's atrophia ablactatorum resembles it__ Symptoms—Ushered in generally by diarrhcea—state of the circulation—skin— discharges from the bowels—thirst—nervous symptoms—state of the brain— expression of the countenance.—Prognosis.—Causes—High heat of summer— Irritation of teething—Errors of regimen—Predisposition—Anatomical lesions— chiefly disease of the mucous follicles of the intestines—softening of the gastro- intestinal mucous membrane—Dillard's case—Entero-mesenteiio fever of Serres and Petit,—dothinenteritis of Bretonneau ..... 441 LECTURE XLVIII. DR. BELL. Cholera Infantum (Continued).—Farther dissections exhibiting inflammation of the small intestines and follicles—Dr. Horner's opinion of the nature of cholera infantum—M. Billard's view of the cause of follicular development applied to the pathology of infantile cholera.—Resemblance between this disease and epi- demic cholera—Hepatic pathology of cholera infantum not sustained by autopsie examinations—Mode in which heat causes hepatic derangement—Contents of intestinal canal.—Treatment—Indications to guide us—To reduce excessive sensibility and to remove irritations—Modification depending on temperament and constitution—Treatment of first stage—Demulcents, chalk mixtures,—an opiate, if the teeth irritate—Calomel in minute doses—Oil of turpentine—Cold affusions and cold water injections—Sugar of lead . . . .451 LECTURE XLIX. DR. BELL. Cholera Infantum (Concluded).—Caution not to irritate the stomach by needless repetition of either food or medicine—Danger of relapse during hot weather— Remedies for the diarrhoea after vomiting has ceased-Nitrate of silver —alumina —Dr. Diirr's cases, illustrative of German practice—Astringents,—of secondary value—Treatment when the disease remits—Renovation by fresh air—Treatment in the state of collapse with diseased brain—Proper food for the patient— Drinks,- great importance of selecting them and regulating their use—Removal of irritation from teething—Paramount importance of pure air, day and night— Bathing—Continued watchfulness on the part of the mother to withhold all irri- tating ingesta—Preservation of equable temperature of the skin—Prophylaxis,— cool air, cool bathing, cool drinks, and proper food at stated intervals . 459 LECTURE L. Gastritis, with Delirium Tremens—Varieties of intestinal worms—Organization and origin of—Occurrence in the foetuses of various animals—Formation—Patho- logy of—Perforation of the intestines by—Worms in tumours and abscesses 468 LECTURE LI. Symptoms of Intestinal Worms—Sympathetic irritations—Affections of the ner- vous and respiratory systems—Various diseases mistaken for worms—Exciting XIV CONTENTS. causes of worms—Farinaceous and milk diet—Verminous fever—-Treatm^ worms—Specific and mechanical purgatives; calomel, turpentine, &c., • Remedies for each species of worms—Preventive measures . • p* SUPPLEMENT TO LECTURE LI. DR. BELL. Double Indication in the Treatment of Worms.—Iron with purgatives; with calomel, followed by purgatives—Bark of pomegranate root—SpigeliaManlan- dica—Chenopodium anthelmintica—Pride of China—Common salt.— Ireatment of ascarides—Purgatives occasionally—Injections ; chiefly of turpentine, aloes, &c—Mixed treatment of worms; by bitter, saline, and sulphurous waters 484 LECTURE LII. DISEASES OF THE BILIARY APPARATUS. Pathology of Jaundice.—Its co-existence with a flow of bile—Case of aneurism of the hepatic artery—The disease, independent of mechanical obstruction- Colouring of the various parts—Effects on the milk, and humours of the eye- Jaundice with preservation of health—Icterus infantum . . .488 LECTURE LIU. Jaundice from Gastro-Duodenitis—Researches of Broussais and Marsh on— Jaundice without hepatic inflammation—Nervous symptoms—Treatment—Tel- low fever—its occurrence in this country—Predominance of gastric irritation in warm climates—Typhus icterodes—Jaundice from biliary calculi—Different situations in which biliary calculi may be found .... 495 LECTURE LIV. Diagnosis of Jaundice from Biliary Calculi—Proof of the passage of the^jal- culus—Indications of treatment—Rupture of the gall-bladder after the use of emetics—Spasmodic jaundice—Treatment of spasmodic jaundice—Discharges of fatty matter—Researches of Drs. Bright and Elliotson—Connection with malignant diseases examined—Source of fatty matter . . .505 LECTURE LV. Acute and Chronic Hepatitis—Pathological differences—Effect of climate— General and local symptoms—Character of fever—Pain of shoulder—Use of pleximeter—Complication with jaundice—Resolution—Abscess—Various open- ings of the latter—Cicatrization ..... .513 LECTURE LVI. Diagnosis of the Rupture of Hepatic Abscess — Pulmonary openings— Case of double opening — Puncture of the gall-bladder — Gangrene of the liver — Its con- nection with hepatic apoplexy— Diagnosis of distended gall-bladder — Its causes — inflammation of the parietes over the liver Sympathy of the integuments 523 LECTURE LVII. Aneurism of the Hepatic Artery—Distension of the liver with bile - Treatmen of hepatitis—Employment of mercury—Symptoms of Suppuration—Dr. Graves's operation for giving exit to matter in hepatic absce-s—Rupture into the perito- neum—Chronic hepatitis—Complication with disease of the heart—Embryonary state of the liver . . . . . 532 LECTURE LVIII. Treatment of Chronic Hepatitis.—Neuralgia of the liver succeeding hepatitis—! Connection of hepatic with gastro-intestinal disease—Modes of transmission of disease from the mucous surface of the liver—Phlebitis of the vena porta—Ob. struction of this vein—Case of pulmonary, hepatic, and intestinal fistulee—Hepa* tic neuralgia ....... 541" CONTENTS. XV LECTURE LIX. DR. BELL. DISEASES OF THE PANCREAS AND SPLEEN — CHLOROSIS. Pancreas—Its pathological states not well appreciated — Symptoms of inflamma- tion of the pancreas — Few positively diagnostic ones — Post-mortem appear- ances of the organ — its morbid secretions — Connection of these with pyrosis— Diagnosis.— Treatment — Moderately depleting remedies, with opiates and nar- cotics, and counter-irritants. — Diseases of the Spleen. Connection between the spleen and the liver, and stomach, and bowels — Community of affection with these organs in paludal fevers — Organic lesions of the spleen and their sympathetic disturbances — Exploration of the spleen—Its situation and size.— Splenitis. Obscurity of its symptoms — Enlargement — Characters of the tumour— Structural changes. — Chronic Splenitis. Symptoms equivocal — Ter- minations of inflamed spleen — suppuration — softening — congestion—; Sympa- thetic disorders from splenitis . . . . . .p. 551 LECTURE LX. DR. BELL. Treatment of Diseases of the Spleen.—Remedies for acute splenitis the same as for other phlegmasia?—Mercury in general inadmissible—Avoidance of extreme views and practice—Sedative narcotics useful—Free purging in enlargements of the spleen, or chronic splenitis ; to be followed or alternated with chalybeates— Mr. Twining's plan of treatment—Spleen mixture—Addition of sulphate ofquinia —Venesection and cupping, or leeches, occasionally directed before the use of chalybeates—Salutary crisis by hemorrhages—Native (Bengalese) remedies for diseased spleen ; chiefly aloes and iron, with occasionally castor oil—Acupunc- ture—Enlarged spleen with intermittent and remittent fevers, requires sulphate ofquinia—Great utility of this medicine—Iron in other varieties of tumid spleen —Connexion between spleen cachexia and chlorosis, scurvy, and anemia.— Chlorosis—Its real nature—Depending on impoverished blood—Changes in the blood at this time—Causes—Symptoms—Means of renovation—Iron, the chief medical agent—Hygienic restoratives—Hemorrhages do not always contraindi- cate the use of iron ........ 561 .DISEASES OF THE URINARY APPARATUS. LECTURE LXI. DR. BELL. Accumulation of Knowledge of Urinary Diseases of Late Years.—Importance of the function of the kidneys—Their office as depurators—Immediate seat of uri- nary secretion—Influence of the nervesonthisfunction—Ingredients of human urine —The chief ones noticed—Water—Urea—Lithic or uric acid ; its combinations— Sulphuric and phosphoric acids, and their combinations—Albumen ; its tests in urine—Xanlhic acid—Cystic oxide—Sugar—Oxalic acid—Bile—Secretion of the prostate gland—Pus—Semeiological Relations of the urine.—Diseased struc- ture of the kidney—Healthy size and weight of the organ—Exploration . 569 LECTURE LXII. DR. BELL. Nephritis.—Its species—Hyperemia common to them all in the beginning.— Symptoms .- organic and functional; remote or sympathetic—May be confounded with organic disease of stomach and bowels—Attention to state of the urine.— Causes,- traumatic and constitutional.—Anatomical lesions.—Chronic nephritis; its symptoms, lesions, and causes.—Nephralgia.—Treatment of nephritis in gene- ral—The acute form requires active antiphlogistics—Nephritis in fevers.— Suppuration of the Kidney—Directions taken by the abscess—Most frequent cause, formation of calculi—Not incompatible with even long life.—Pyelitis, its xvi CONTENTS. varieties, its tendency to end in suppuration and in nephritis-Its anatomical lesions.—Treatment ..••••• LECTURE LXIII. DR. BELL. Bright's Disease, or Granular Degeneration of the Kidney.—Renal dropsy—lis organic seat, common accompaniments and constant symptoms.—Symptoms.— History of the disease—Acute form of the disease; is short, and not often seen —Anasarca soon appears—Acute affection a sequence of scarlatina—Albumi- nous urine, how far a characteristic symptom—Properties of the urine in this disease—Tests of albumen in the urine—Blood ; its appearance and composition. —Secondary diseases—Anasarca most common ; next, ascites—Morbid state of the heart—Albuminous urine from diseased heart alone—Phthisis—Diarrhoea very common—Cerebral disease and meningeal inflammation with effusion— Pregnancy developing Bright's disease—Exanthemata—particularly scarlatina giving origin to it—Anatomical lesions—Summary by different observers—Precise state of the'kidney ; congestion with inflammation—Mr. Robinson's experiments— Mr. Rayer's opinion—Dr. Burbridge's views . . • .v. 586 LECTURE LXIV. DR. BELL. Causes and Treatment of Bright's Disease, or Renal Dropsy.—Predisposition by particular constitution, and especially intemperance—Exciting causes—cold and dampness.—Origin of dropsies—Antiphlogistic remedies—Appearance of the blood—After venesection, free purging—Mercurials not inadmissible in all cases —Salivation to be especially avoided—Diaphoretics of great value, and, also, all the aids for securing their effects—Warm bath—Diuretics to be sparingly used— Complication of renal dropsy with bronchitis—Treatment of—Other secondary disorders to be relieved—Employment of tartar emetic—Contributions to the treatment of dropsy, which is but a symptom of spme organic disease—Dr. Os- borne's practice in ascites—Measures useful in the more ad vanced stages of renal dropsy—Alteratives—Great importance of equable temperature of the skin and of regular diet ......... 597 LECTURE LXV. DR. BELL. Functional Diseases of the Kidney.—Suppression of Urine—Ischuria or Anuria— an effect rather than a primary disease—Sudden in its attacks—Sympathetic dis- turbances—Coma—Pyretic ischuria.—Anatomical lesions, not constant—Prognosis is unfavourable— Treatment—Antiphlogistic.—Morbid secretions—Circumstances under which they occur.—Excessive diuresis or hydruria— Not always productive of disease—Most troublesome in old persons.— Treatment, dietetic and medi- cinal—Diabetes insipidus, or anazoturia,—Symptoms—Treatment—Diabetes insi- pidus with azoturia—Diabetes mellitm, or melituria—Its definition,—qualities of the urine, symptoms, terminations, causes, post-mortem appearances__Treat- ment—Diet and regimen of most importance .... 605 LECTURE LXVI. DR. BELL. Various other Diatheses of Renal Secretion.—Renal calculi,__Lithic acid or Uthuria—amorphous and crystallised—Red gravel—Causes—Treatment.__Phos- phatic Salts and Deposits—Triple phosphates—White gravel—Phosphate of lime—Mixed phosphates—Treatment.—Cystic oxide—Oxalic acid or ox'aluria— Lactic acid—Calculi—renal and vesical—Diseases of the Bladder— Vesical cal- culi—Hemztum—Cystitis, its varieties—The most important is inflammation of mucous cozX.—Cystirrhcea, or Catarrhus vesicae—Symptoms and Treatment — Ischuria vesicalis.—Proportion of cases of urinary diseases . . 517 CONTENTS xvii DISEASES OF THE ORGANS OF GENERATION. LECTURE LXVII. DR. BELL. Connection between Diseases of the Genital and of the Urinary Organs.— The former not adequately studied or described by English physicians—In- fluence of the genital organs on the moral nature of man,—his sentiments and emotions.—Diseases of the Male Organs of Generation.—The organic are, I. Urethritis and its consequences ; II. Balanitis and Posthitis ,■ III. Orchitis and its consequences; IV. Neuralgia of the Urethra and Testicle,■ V. Prostatitis— Urethritis defined—Causes—Various kinds of irritants—First seat of the disease —Period of incubation—Symptoms.—New sensations in the urethra, discharge, thickening and hardness of the canal, occasionally hemorrhage—Sympathetic and consecutive inflammation of other parts—Appearances of "the urethral dis- charge—Chordee—Terminations and consequences of gonorrhceal urethritis.__ Pathology—Inoculation the true test of gonorrhceal and chancrous virus—Matter of gonorrhoea does not produce chancre—Syphilis not a consequence of gonor- rhoea—Gonorrhoea essentially an inflammation of the mucous membrane of the urethra.— Treatment—Too often empirical—Systematic division into the preven- tive, aborting and curative—Chief preventive means—Aborting remedies—Go- norrhoea to be treated like other inflammations—Hunter's remarks—Comparison with coryza and incipient catarrh—Remedies following antiphlogistic course__ stimulants and astringents . .... p. 629 LECTURE LXVIII. DR. BELL. Treatment of Gonorrheal Urethritis (Continued).—Selection of remedies— Chief ones employed—Copaiba balsam preferred to all others—Loses after a while its effects—Alternation of remedies—Necessity of inspecting tfie urethra— Local obstructions to be removed—Doses of copaiba and forms of^administerino- it—Use by enema; by injections into the urethra—Whether its virtues are greatest by purging— Copaiba sometimes injurious to the general health ; causes skin diseases—Cubebs ; its doses and preparations—Oils of cubebs and copaiba preferable—Extract of cubebs—Adulteration of the balsam of copaiba and of the cubebs—Instances of failure in the latter—Iodine; particularly the iodide and the ioduretted iodide of potassium—Mercurials ; when useful—Cantharides__ Astringents; tannin and iodide of iron the chief ones—Topical remedies in gonorrhoea—Injections; Hunter's remarks on their use—Emollient and sedative injections and warm fomentations—Enemata of the same nature—Stimulating and astringent injections—Sometimes curative at the inception of the disease__ Recourse had again to them in chronic cases, conjoined with internal remedies__ Use of medicines to be continued for a while after apparent cure—In cases of morbid sensibility, caustic to urethra—M. Ricord's plan of keeping sides of urethra apart—Compression of the urethra . . . 638 LECTURE LXIX. DR. BELL. Effects of Gonorrhceal Urethitis—Bubo—Chordee—Various remedies for hemorrhage from urethra—Treatment—Irritable and inflamed bladder—Stric- ture of the urethra.—Too exclusive use of surgical or instrumental means—Simu- lated stricture—Connexion between local and general disordei—Irritable ure- thra—Disease of prostatic urethra—Sympathetic pains of the urinary oro-ans —Difficulty of diagnosis between spasmodic and permanent stricture—Treatment of stricture—Caution against loo free use of bougies—Retention of urine—.its terminations—Termination of stricture in ulceration—Causes of disease of kid neya — Disease of prostate gland,and swelled testicle — to be afterwards de- scribed . . ...... 619 VOL. I. — C xviii CONTENTS. LECTURE LXX. DR. BELL. Effectsof GonorrhcealUrethritis (Continued).—Gonorrheal Ophthalmia.—A consequence of gonorrhoea or of inoculation with gonorrheal matter.—Theories to explain its attack—Three forms of gonorrhoeal inflammation—Chief and most violent—Symptoms and immediate effects—Diagnosis—Prognosis—Treatment.— Fearful rapidity of the disease—Antiphlogislics ; cauterisation, and excision and incision of the conjunctiva—Mild gonorrhoeal ophthalmia—Gonorrhoeal inflam- mation of the external tunics and iris—Its analogy to rheumatic ophthalmia- Simultaneous occurrence of rheumatism with gonorrhoea and gonorrhoeal oph- thalmia . . . • • • • . p. 656 LECTURE LXXI. DR. BELL. Balanitis and Posthitis—Slight difference between the two—Chief cause 0I" balanitis in gonorrhoea—External gonorrhoea—Symptoms—Treatment—Phi- mosis—Description of—Causes—Suspicion of chancres—Treatment—Paraphi- mosis—Symptoms—Danger of gangrene in—Treatment—Indication, to restore the displaced parts—Taxis—Incision—Subsequent treatment.—Orchitis—Two forms, acute and chronic—Is primary and consecutive—Causes of primary acute orchitis—Consecutive inflammation; chief cause, gonorrhoeal urethritis —Hernia humoralis—Epididymitis—Explanation of the mode of consecutive or- chitis—Continuous inflammation from urethra to testicle by mucous surface— Consecutive orchitis, or mumps—Wasting of testicle a rare effect of this disease —Symptoms—Progress in the consecutive disease from the vas deferens to the testicle—Sympathetic form—Varieties in the symptoms—Duration of orchitis— Right testicle most liable to orchitis—Diagnosis—Difference from hernia ; be- tween primary and secondary orchitis—Epididymis always affected in gonorrhoeal orchitis —Treatment—Venesection and active antiphlogistic remedies__Local treatment—Compression ; its advantages ; mode of applying it—Modification of treatment in irritable habits ..... 661 LECTURE LXXII. DR. BELL. Chronic Orchitis—Its origin; and chief anatomical characters and seat—Yellow matter—Glandular matter—Hernia testis—Is often indolent for years—Misap- plication of the term scirrhous to indurated and enlarged testicle—Causes—Symp- toms—Result generally favourable—Occasional termination in ulceration of the tunics and teguments, and in hernia testis—Treatment—Blue pill, and opium__ Sometimes iodide of potassium and sarsaparilla, or corrosive sublimate and some narcotic extract—Local applications—Treatment of hernia testis__preferably by cauterisation—Syphilitic Orchitis.—Symptoms and treatment analogous to those of chronic orchitis—-Mischief sometimes from persisting in the use of mercury —Other organic diseases of the testicle not treated of—Neuralgia of the Ure- thra and Testicle.—Symptoms of irritable urethra—Cause often obscure__Con- nection with constipation and deranged bowels—M. Civiale's and Sir Charles Bell's experience—Treatment—Various—First to use catheter or bougie__Disor- der of digestive organs to be rectified—Remedies often had recourse to same as for neuralgia in general—Neuralgia of the Testicle—Causes not well known— Symptoms—Treatment—Irritable Testis—Symptoms—Treatment 672 LECTURE LXXIII. DR. BELL. Prostatitis—Why considered in the present connection—Necessity of inspec- tion of parts on the dead body—Substitutes—Appearance of the prostate aland —Acute Prostatitis— Causes—Symptoms—.Extension of disease—Mode of examina- tion for—Reduction of disease—Resolution—Discharge of blood—Terminations in suppuration and abscess—To give early discharge to matter of abscess—Treat- CONTENTS. XIX ment—Decidedly antiphlogistic—Catheter for retention of urine—Cau9e of ob- struction to catheter at the neck of the bladder—Danger in trusting to the patient's account of himself—Chronic Prostatitis—A common, a troublesome, and often incurable disease—Old men very liable to it—Hunter's directions—Brodie's description— Symptoms—Secondary affections—Case of— Treatment—Chiefly palliative—Instrumental and therapeutical.—Functional Diseases of thb Male Organs of Generation—Satyriasis—Degenerates into monomania—Dis- eases with which connected—Caused by cantharides—An effect of prior disease —Treatment — Masturbation.—Occasional causes — Symptoms—Spermator- rhoea—Causes of—Predisposition to—Immediate cause and anatomical seat— Two varieties ; daily pollution and nocturnal pollution—Symptoms—Treatment— Local and general—Sedatives and tonics — M. Lallemand's method by cau- terisation—Testimony in its favour—Mode of applying the caustic—Adverse opinions—Regimen—Exercise—Change of air—Clothing . . p. 680 LECTURE LXXIV. DR. BELL. Diseases of the Female Organs of Generation.—Organs included in the genital apparatus of the female—Selection of the more important diseases—Anatomy does not indicate the vital actions and sympathies of the uterine system—Phy- siologically considered, the changes under functional exercise are diversified and marvellous—Three functions or stages of function of the uterus—What general anatomy points out—Genito-urinary system of mucous membranes—Connection between the uterus and vagina and other contiguous organs—Importance of cer- vix uteri and os tinea.—Knowledge of these things aids a comprehension of uterine diseases, and suggests better treatment—Examples—Attention not to be fixed on the uterus alone in studying any of its diseases—Diseases of the genital apparatus of three kinds ; neuralgia, textural or organic, and functional—Means of better diagnosis; by the touch and with the aid of the speculum—Both these indispensable in every fixed disease of the uterus.—Hysteralgia.—Symptoms— Coincident neuralgia of the vagina—Accompanying phenomena—Anatomical character and causes—Diagnosis—Treatment—Result uncertain—Occasionally if congestion be present, local bloodletting—Nitrate of silver to the cervix— Simple neuralgia to be treated by chalybeates and narcotics—also nitrate of silver, with some narcotic—Ergot—Use of the pessary—Remedies when dys- menorrhcea is present—Rest and recumbent posture, all important in hyster- algia—Neuralgia of the Ovaries.— Amenorrhea—Two forms, that of retention and that of suppression.—Amenorrhcea after puberty—Treatment depending on presence of plethora or anemia; in the first, depletion and revulsion; in the latter, chalybeates and other tonics, as in chlorosis—Suppression of the Menses—Acute or recent and chronic—Causes of acute suppression—Effects serious and alarming—Treatment by free depletion, in some subjects of a full habit—Purgatives and antispasmodics in spare and delicate women—Chronic Sup- pression.—To study the functions generally—It may be either cause or effect of constitutional disorders—Symptoms—Treatment—Sometimes purgatives, or blue- pill, chalybeates and purgatives—Sulphate of potass and aloes or rhubarb— Emmenagogues so called—The best are preparations of iron and of iodine, and of mercury and ergot—Various stimulants to vagina and uterus—Vaginal injec- tions—Travel, and mineral springs—Dysmenorrhea—Difficult or painful men- struation—Definition—Appears in different temperaments—Its gravity—Symp- toms—Varieties—Neuralgic, plethoric and congestive—Diagnosis—Difference between membrane expelled and the decidua—Prognosis—Treatment—Membra- branous not proof of prior inflammation — Sometimes local bloodletting in derivation from the arm—Treatment resolves itself into that during the pains and that in the interval—Anodynes and narcotics, ergot, acetate of ammonia, volatile tincture of guaiacum, warm hip-bath in the first period—Mercurials, chalybeates, and other tonics, and cold bathing in the second—Dysmenorrhcea from mechanical obstruction treated by metallic bougies introduced into the canal of the cervix—Dr. Mackintosh's success—Dr. Churchill's admission. XX CONTENTS. LECTURE LXXV. DR. BELL. Menorrhagia—Divisions into active acute and passive, the latter including the congestive — Acute menorrhagia — Symptoms—Causes — Diagnosis—Similarity of menstrual to common blood—Treatment—Passive menorrhagia—Risk of organic cause—Necessity of examination by the vagina—Leucorrhcea—Whe- ther a disease of the vagina or uterus—Sometimes is a metro-vaginitis—More commonly is vaginitis—Definition of leucorrhcea—Acute vaginitis—Symptoms— Subsidence of symptoms—Alternations of disease and suspension—State of the cervix uteri—Chronic or g/eety vaginitis—Symptoms—Causes of vaginal and ute- rine leucorrhcea—Diagnosis—That between leucorrhcea and gonorrhoea cannot be made—Treatment—To withhold astringents and special medication during the first stage—Antiphlogistic remedies—In chronic or advanced, purgatives and tonics, then astringents—Cold bath or cold sponging—Injections—At first sedative and anodyne, then stimulating and astringent—Special remedies— Regimen — Exercise—Baths—Clothing—Gonorrheal Vaginitis—Gonorrhcea in Women—Symptoms and tre? ment; same as in leucorrhcea with some few modi- fications—Ovaritis following gonorrhcea—Its treatment—Vaginal abscesses—. Early use of injections of nitrate of silver—Lint introduced into vagina—Ulcer- ation in cavity of uterus—Injection of nitrate of mercury and nitrate of silvar into its cavity—Organic Diseases of the Uterus.—Metritis, acute and chronic —Symptoms and treatment—Necessity of ascertaining the state of the cervix uteri—Prolapsus Uteri—Symptoms—Use of the pessary—Writers on diseases of females ........ p. 713 LECTURES OX THB THEORY AND PRACTICE OF PHYSIC. LECTURE I. GENERAL OBSERVATIONS. Gentlemen:—You may have often heard that the approaches to science are rugged and uninteresting, and some of you have perhaps experienced the truth of the remark. Hence the custom of delivering an introductory lecture, in order to lay before the young mind, when first entering on each path of knowledge, the objects, the results, the attained good, and the hoped-for glory of the pursuit. These are to be displayed with clearness and with truth, yet it is obvious that much of the effect of such a lecture must depend on the nature of the subject and the judgment of the speaker; and it is well when the exalted nature of the one is attain- able by the capabilities of the other. Such a lecture, then, should be an earnest lesson on the objects, the pleasures, and the advantages of that science, of which the course is destined to treat; its history, its true mode of study, its interest, actual state, and future pros- pects, may all form legitimate subjects, and when thus rightly viewed, an introductory lecture, so far from being a mere ornamental appendage, may become a most important part of the course. With these views let us approach our subject, the theory and prac- tice of medicine. Let us contemplate that study and that profession, which, venerable by all antiquity, yet in itself is "ever new." Even in its infancy, when the world was in darkness, was medicine a glo- rious science when compared wilh its contemporaries, and its first professors were ennobled and exalted by its influence. As their mantles descended through a long line of illustrious successors, we see medicine progressively expanding, and even when the night of barbarism hung gloomily over the earth, we see its genius triumph- ing over the surrounding darkness, and shining in the east as a beacon to the shipwrecked mind of man : and I trust that I shall be able to prove to you, that, in our own time, when the human mind vol. i.—2 14 GENERAL OBSERVATIONS. has made such astonishing advances, medicine has kept pace with her sister sciences, and it is a gratifying reflection to think, that among the most distinguished promoters of the collateral sciences, physicians have ever held a commanding rank, thus proving them- selves foremost in knowledge, as they have ever been in philan- thropy, in private and public charity, and in all good will to man. It is scarcely necessary to allude to the title of this course of lec- tures, further than to remark, that, however different they may be in name, it is yet impossible to draw the line of distinction between the theory and the practice of medicine. If medicine were merely the knowledge of a number of empirical remedies for particular symp- toms, given without our inquiring into their mode of action, or any acquaintance with the dependence of one function, or one viscus, on another, of any knowledge, in short, of physiology in the healthy or diseased state, then we might have a practice of medicine indepen- dent of what is called its theory. But medicine now holds a higher place, and much of its improvement is traceable to our advances in physiological and pathological science. Thus to treat, or teach, the treatment of a disease, we must know the healthy function of the organ or organs, the history of development, the influence of other organic systems, the changes produced by disease, and, as far as possible, the action of all external or internal agents on the viscera. But this is the theory of medicine. For example, let us suppose that we are called either to treat or to teach the treatment of a case of enlarged liver. Let me here remark, that in selecting this case I do not wish you to suppose that I am one of what might be called the hepatic school of medicine, in which the existence of almost every organ, except the liver, seems to be for- gotten, and of which the creed seems to be, that there is but one viscus, the liver, one source of disease, biliary derangement, and one cure, mercury ;'a creed which, though not enforced and defended by the sword, has lost perhaps as much of human life as others whose history is written in letters of blood.* But no one can doubt the importance of the organ, and I have taken it to illustrate the connec- tion between the theory and the practice of medicine. You detect an enlarged liver; you are called to cure the dis- ease : — 1st. You must be aware of the healthy state of the organ, and of its healthy functions, as shown by the volume, sensibility, influence on digestion, and the healthy state of the secretion. You must know all these, as it is by the departure from these conditions that von re- cognise this disease at all. — But this is the theory of medicine. 2dly. You must know the history of its development, because there is a period of life when the natural state of the liver is in a greatly * [I wish it could be said that we, in the United States are not amenable to this censure. But alas ! the spoonful doses of'calomel and pills, with calomel for their basis, by the dozens, are, or have been, prescriptions which have cast a stigma on too many American practitioners, who see but one disease, —that of the liver, and one remedy, — calomel. — B.] TWOFOLD OBJECTS OF MEDICINE. 15 enlarged condition, and this may continue even to adult life, and pro- duce an enlarged liver, not the result of disease but the arrest of de- velopment, and the question will arise as to whether the case be- fore you is an example of this, or of recent and actual disease. The whole treatment turns on this.— Yet this is the theory of medicine. 3dly. You must know the influence of other organic systems. An enlarged liver may be produced mechanically by obstructions in the lungs or in the heart ; it may be produced from the sympathetic irritation of a duodenitis, or be the result of original disease in its own structure. All these circumstances must be known and taken into account. If it be merely obstruction in the venae cavae hepaticae the ordinary treatment will not answer : if there be duodenitis we must modify our treatment, and so on. We must know these things: we must know how to recognise these diseases before we can pre- scribe or practise successfully. All this is that part of the theory of medicine called pathology, or the physiology of the diseased body. 4thly. You must know the effects of disease on the liver itself. Some of these are removable by art, others are totally incurable. You must know these in order to determine on the probability of their existence. 5thly, and lastly. You must know the influence of remedial agents on the liver and the adjacent organs. You must be familiar with the effects of stimulation of the mucous surfaces of the stomach and duo- denum. Then, indeed, and not till then, will you be qualified to treat the case with judgment and success. The same remarks, I need scarcely add, will be found applicable to the diseases of each viscus in the body. The objects of medicine, gentlemen, are twofold ; first to cure dis- ease, no matter where seated or how produced; and secondly, to re- lieve bodily suffering in cases where a cure is impossible. Its great end is to prolong life, and to diminish the bodily evils which result from the infirmities of our nature and other circumstances. Some of you may ask, where then is the distinction between medicine and surgery? In truth, there is no distinction in reality,and there should be none in theory. The human constitution is one ; — there is no division of it into a medical and surgical domain ; the same laws and the same principles of treatment apply to the cure of a fractured bone and the cicatrization of an internal ulcer. Unlike the corporations of medicine and surgery, the supposed purely medical and purely surgical parts of the body live in excellent harmony. Here, then, there is no division, no jealousy, no separation of interests. I am by no means prepared to deny that advantages may arise from a practitioner devoting himself to this or that branch of his pro- fession; but if he seeks for eminence, he will first educate himself generally. Let him attain extended views of pathological medicine ; let him make himself master of the actual state of the science, and then he will find that there is not a single fact or law with which he has become acquainted that will not have its bearing on his par- ticular pursuit. It is in the education of medical men that the ruinous effects of the division of the professions of medicine and surgery are most perceived: and I feel convinced, that of the two, the surgical 16 GENERAL OBSERVATIONS. student is the greatest sufferer, because his views of pathology are injured. All the great laws in pathology are drawn from the con- sideration of visceral disease ; vet the attention of the surgical stu- dent is diverted from this, and directed to what, I will say, can never elevate him in the ranks of science. He is taught anatomy, and what is called surgical disease, but is kept ignorant, by this wretched sys- tem, of the great part of his profession, until he comes to practise, when, if he has a mind fitted for observation, he will find, that ior one dislocation there will be hundreds of visceral diseases ; and he will discover what was concealed from him during his pupilage, that many, many more die of what are called medical than sur- gical diseases. During the late war, more men in the British navy died of fever than of all other causes —including the sword. But, I rejoice to say, in Dublin the exclusive system of education is fass wearing away, and one of the many excellences of our national school of medicine is the instruction in general pathology. There are few schools of medicine where now a more enlarged and liberal spirit of education exists. In the study of your profession, gentlemen, let me warn you not to allow yourselves to be misled by the idea that surgery and medi- cine are different in their nature. The mere surgeon, or the mere physician, only knows half of his profession. Reckless of human life, he may practise the healing art as a trade, but he never can know it as a science. But, as there are infinitely more cases of what are termed medical than surgical disease, it is plain, that the surgeon, ignorant of medicine, will far exceed the physician ignorant of sur- gery,in the extent of his malpractice. 1 have long observed the ruinous system which has been pursued by teachers, as connected with this subject. The pupil was taught to consider, that if he was a skilful anatomist, if he understood the routine surgery of an hos- pital, and had carefully studied certain works on surgery, and some obsolete books of pathology, he was thereby prepared, in the lan- guage of the schools, to go fonh to teach and practise the art and mystery of medicine in general. Now, all this was wrong. You may be profound anatomists and be bad surgeons, and worse phy- sicians; you may have by heart the writings of Pott and Dessault, of Hunter and Thompson, and be totally incapable of treating a sim- ple or complicated fever, or a case of visceral disease. But it is not necessary to say more. Society demands that the old system of a division in education should be abolished ; and ere long, I even trust to see a fusion of the profession, when much of the pre- sent evils must cease, when medical men shall have a common centre, from which they shall receive a common impulse ; when their efforts shall be solely directed to the increase of medical science, and the political and moral exaltation of their profession ; and last' yet not least, when the ingenious pupil shall not be led astray ; when we shall not be told by one teacher to despise this, and by another to neglect that part of his profession ; but, having the whole of the noble science of medicine thrown open to him, his mind unwarned by prejudice, unfettered by fear, shall be permitted to take that rioht view of his pursuit, that alone can lead him, and assuredly will lead A GENERAL AND LIBERAL SYSTEM. 17 him, to the honours and success which truth bestows on all its votaries. I have said, that the exclusive system of education had singularly diminished in Dublin. Indeed, our national school has earned great reputation for general pathology ; and, from a long and cordial in- tercourse with the class of Dublin, I will affirm, that there are few places where we can see such zeal, talent, and thirst for knowledge among the students. As an Irishman, addressing my own country- men, let me congratulate you on the fame the Dublin School of Medicine and Surgery has now acquired, and is every day acquir- ing ; and when the strength of Irish talent, aided by the proper work- ing of our unrivalled institutions, is brought into play, may we not anticipate a still more glorious result? This reflection has often cheered me, that within the last few years there has been a greater stimulus infused into the science and literature of this country. ' Amid the ungenial influences of political excitement, and the ani- mosities of party, how gladly should we contemplate the advance of what will prove an honour to our national character, and an ad- vantage to mankind. It is like the growth of the coral into rocks and fertile islands, though surrounded by the strife and waste of waters. Our scientific societies have multiplied; our periodical literature, the want of which furnished so fruitful a theme for cavil, has been extended'so as to afford a wholesome and vigorous supply in the varied departments of literature and science : and our monthly and quarterly publications are taking their proper places among thr ranks of British journals. When we turn to works of a more per- manent kind, we also see cause for satisfaction. Many most import- ant works in anatomy, surgical pathology, physiological medicine, and midwifery, have lately issued from the Irish press : and the Irish contributions to the Cyclopaedia of Practical Medicine are allowed on all hands to give to that work no mean portion of its value. There are few more wholesome exercises for the mind, few so ne- cessary and so useful as the comparison of the actual state of any science with its advance and character at a former period ; and it is in this, most chiefly, that the value of what is called the history of medicine consists. We study it then, not as a matter of antiquarian research, of learned curiosity, but as the picture of the human mind, now on the right path, now misled by error, yet still struggling on- ward ; as the record of a dear-bought experience, and a beacon to warn us of the*rocks and shoals that beset its future progress unto truth. To analyse the actual state of medical science, to show you all that has been done within a little time, to display all old preten- sions to the character of a true and thrice noble science, would far exhaust my capabilities and your patience. Let it suffice to contem- plate the improvement considered generally, and the means by which that improvement has been attained. It is an error too generally received, that medicine owes all its advances to the researches of modern times. Far be it from me to undervalue these, but I believe that the opinion I have alluded to is wrong, and is perhaps kept alive by our own vanity; for by a spe- cious deception we often take to ourselves the honours and distinc- O it 18 GENERAL OBSERVATIONS. tions of the time we live in. The truth is, that medicine, like many other of the sister sciences, has been long steadily advancing, and the flippant every-day remarks that the inductive system (that is, the observation of facts and the embodying of those conclusions that legi- timately flow from them) has only been introduced into medicine in our time ; and that our predecessors in medicine put theory first and fact second in their medical philosophy, are " as false as dicers' oaths." Have the authors and teachers who are so fond of decrying the medicine of a former day, at a time when they are (perhaps inno- cently) making use of its facts and observations — have they read the writings of the father of medicine ? Have they studied that " aureum opus," so well called from its lustre, its purity, and its surpassing value? Was Avicenna a mere theorist ? Did Morgagni observe no facts, nor truly record them, even at the expense of his medical reputation ? Is there no induction in Baglivi. Was Haller unacquainted with the method of experiment and induction ? Or is the discoverer of the circulation of the blood, the good, the great, the injured, the immortal Harvey, forgotten ? Where do they place Boerhaave ? and shall the name of Sydenham go down with his ashes to oblivion. The true state of the case is, that medicine, in its present advanced state, only represents the improvement in other branches of human knowledge, all of which are so intimately linked together, that al- though their extremes be far removed, there is a point where all are reciprocally cause and effect ; so that if we take any one of them, it is easy to show its intimate bearings with,and importance to, all the rest. We have been long advancing in medicine; though 1 admit most fully the vast strides which have been made, still I must here declare my firm conviction, that the study of the older authors is too much neglected, and that in them you will find a treasury of knowledge, much of which you may think to be the production of modern times. If the writings of the ancient authors only contained a small por- tion of the information with which they abound, it would be a suffi- cient stimulus to their study ; to reflect that it is in them, in the medi- cal writings of the ancients, that the germs of the inductive philosophy are first to be found. It is, then, in the old regions of medicine that we find the fountains of that mighty river, which, for two thousand years, has fertilized the earth, and made man its lord. Had the pro- gress of man not been retarded by the ignorance which is the child and servant of barbaric despotism, an earlier Newton might have en- lightened the earth, an earlier Laplace have measured the heavens or a Cuvier declared the glories of a past and present creation. The mind of man would have burst its chains, and ages ago have formed that holy alliance with knowledge and her first born, liberty, which now is its safeguard and its glory. I repeat it : in the wri'tings of Hippocrates you will find the principles of the inductive philosophy A physician showed Bacon the road to immortality. We find that there is in the mind of man a tendency to reverse the true mode of reasoning, and to seek for a principle before it has observed facts, and this was the cause of the retardation of medicine MODERN SYSTEM OF INVESTIGATION. 19 as well as of all other sciences. Hence the various schools, from Py- thagoras to Cullen or Brown, in our day. But a slow, though sure, revolution was long going forward ; and I believe that Cullen and Brown were even behind {he actual state of medicine in their time. Physicians turned disgusted from the war of words and doubt, to seek in tangible objects the certainty which these only can produce; in a word, they began to follow the Baconian system more generally. They reverted to the instructions of Hippocrates, and from that period our modern improvement may date. They turned their atten- tion to the examination of those changes which disease produces on the human body, and connected these with the symptoms observed during life. And what has been the result of this? 1st. The accumulation of an enormous number of facts, relative to the changes of organs produced by disease. 2d. The connection of a vast number of these changes with par- ticular symptoms, and hence the advance in diagnosis. 3d. The establishment of the true value of symptomatology, and the verification of that all-important fact, that opposite states and organs may produce similar symptoms. 4th. The knowledge of the vast class of latent diseases ; in other words, diseases which exist without influencing the phenomena of animal life, or, in some cases, the phenomena of both animal and or- ganic life. Diseases, either without symptoms at all, or only with such as previously were not supposed capable of leading to their de- tection. You know that the phenomena of life are divided into two classes, viz., those of organic or vegetable life, such as nutrition, cir- culation, absorption, respiration, secretion. While those of animal life, or the life of relation (so called from its being the source of our connection with surrounding bodies), are the senses, the phenomena of mind, and muscular motion. The one life seems more under the influence of the ganglionic, and the other under that of the cerebro- spinal system of nerves. As some of the junior part of the class may not have accurate ideas as to the meaning of symptoms, I may state that disease is recognised by signs and symptoms. By signs, we mean those mechanical alterations produced by dis- ease, in the conditions of parts, which are recognisable to the external senses of touch, sight, and hearing ; changes in appearances, volume, shape, resistance, peculiarities of feel, and the production of sounds. We may make a diagnosis by signs alone. Take, for example, a case of tympanitis. The abdomen is prominent, enlarged, circular, elastic, and sounding like a drum when struck. Thus we learn that the belly is distended by air. Now, symptoms are totally different; they consist in certain changes produced in functions; and these functional changes are to be considered in a threefold manner : — 1st. Changes in the functions of the part itself. 2d. Changes in the phenomena of organic life. 3d. Changes in the phenomena of animal life. Let us take, for example, a case of inflammation of the stomach. We have, first, changes in its own functions — morbid sensibility, 20 GENERAL OBSERVATIONS. vomiting, thirst, anorexia. In the next place, we have changes in the functions of organic life — fever, from the action on the circula- ting system ; hurried respiration, and cough, and hiccup, from the ac- tion on the respiratory system ; jaundice, from its action on the biliary system ; suppression of the secretion of the skin, kidneys, &c. All these", you observe, are lesions of the functions of organic life. But we may have other symptoms; prostration, headache, delirium, convulsions ; these are lesions of the life of relation, or animal life. Now, in many cases, we have to combine these sources of know- ledge to form a correct diagnosis. Take, for example, a case of hepatitis. The patient has had pains in the hepatic region, fever, jaundice, hurried breathing, tenderness. After some time he has a tumour; the side dilated ; the hypochondrium dull on percussion. Well, the signs point out an enlargement of the liver; the symptoms, that the cause of that enlargement was an acute hepatitis. In general, we may state, that signs only declare the actually ex- isting mechanical condition, while symptoms, either present or past, point out the cause of the change, whatever it may be. Both must be studied together ; but you will learn more from symptoms without signs, than from signs without symptoms. But to return to the re- sults of the improved method of investigation. Great light was thrown on fever in general; and it is, I believe, quite true, that, all the advances which we have made in the know- ledge of fever, are due to the prosecution of pathological anatomy. Almost all of what we may call our general knowledge of fever, is due to Hippocrates ; but anatomy has revealed its effects, its com- plications; and the all-important fact that the cause of its fatality is often local inflammation. This knowledge, however, is not so new as is taught by some modern systematists. Galen (De Affect. Intern. c. xli.) taught, that in continual fevers bleeding and cold drinks were the powerful remedies. Sydenham declares, that the ignorance of the inflammations in malignant fevers has been more fatal to the human race than the invention of gunpowder. Baglivi, that malig- nant fevers often depend on a visceral inflammation, and Van Swie- ten knew the frequency of intestinal ulcerations in typhus. Among the direct results of pathological anatomy, it is shown that disease is seldom confined to one organ, or even one system, and thus it has utterly shaken the nosological system of Cullen and his predecessors, which, you know, consisted in classifying disease by symptoms, which were supposed to point out a certain and single disease. For example, the nosologists class phthisis as an affection of the lung; but pathological anatomy has shown, that in many cases it is the result of a disease invading many organs and systems and that the pulmonary disease is but a link in the chain of morbid actions. Pathological anatomy, also, has demonstrated the inflam- matory nature of a vast number of diseases, and has thus given us a key to treatment, to prevention, and to palliation, when the disease is incurable. The last grand result of pathological anatomy is the discovery that a vast number of affections, supposed to be merely lesions of BENEFITS FROM PATHOLOGICAL ANATOMY. 21 functions, are more or less connected also with alteration of structure. Thus, many of the dyspepsias of the nosologists are proved to be ex- amples of gastritis, or of other organic diseases; cases of asthma turn out to be chronic inflammation with emphysema ; cases of palpita- tions may depend on organic disease which has sprung from a car- ditis, and so on. I need not now dilate on the vast importance of such facts to practical medicine. But let us now come to an all-important inquiry. Is pathological anatomy to be considered as the basis of medicine ? or is it, even when combined with clinical observations, the foundation of all medi- cal knowledge ? This inquiry, you will at once perceive, involves the question as to whether Hippocrates and his followers have done anything for the science, or whether medicine is wholly new, an in- fant, and consequently a weak and imperfect science. Are we to despise the works of the ancients, to be ignorant of them, and to allow medicine to be in its infancy ? In fact, if we review the his- tory of medicine from the Hippocratic era to the absurdities of Hahnemann, we find that there have been two orders of men, one constituting what we may term the school founders, who made a theory, and sought to square facts to meet that theory ; these have only brought disgrace on medicine. The other class consists of the Hip- pocratic observers ; that is, of men who sought for facts, who col- lected and pondered on these facts, in other words, who were Baco- nian philosophers. It is the labour of these that has really advanced medicine. Asclepiades, who lived in the first century of the Chris- tian era, declared that the medicine of Hippocrates was a cold medi- tation of death. The celebrated Thessalus, who lived under Nero, in writing to the emperor, makes use of the following words: — " I have founded a new sect, which is the only true one. I have been forced to this, because none of the physicians who have pre- ceded me have discovered anything useful, either for the preserva- tion of health, or for the cure of diseases, and because Hippocrates himself has put forward many dangerous maxims. And what was this new doctrine ? That nature in each case pointed out to the patient what was the most fit for him, and that hence he should be diligently supplied with everything that he fancied. We have next Paracelsus. He commenced his course of lectures at Basle, in the year 1526, by publicly burning the writings of Galen and Avicenna, and assured his auditors that a single hair of his head contained more knowledge than Hippocrates and his success- sors. He taught the cabalistic medicine, the intimate connection between the planets and the viscera : he was a vitalist, but embodied his vitalism under the shape of a demon, who resided within the sys- tem, and which he called Archaeus. Diagnosis was to repose on the examinations of the stars, and not on symptoms. He invented the doctrine of tartar, which is the cause of all diseases of accumula- tion, obstruction, and concretion ; '; and I call it tartar," says he, because it contains the oil, the spirit, and the salt, which burn the patient as hell docs." Hahnemann, the founder of the homoeopathic doctrine, may be 22 GENERAL OBSERVATIONS. quoted next as an example of these school founders ; and he, like his predecessors, expresses himself with all that arrogance, which ignorance, when it pretends to learning, invariably assumes. Speak- ing of the Hippocratic medicine, he says — " Since this art only consists in a gross imitation of a dangerous and insufficient process, it must be admitted that the true medicine was not discovered until by me. It is the infallible oracle of the art of curing; it is the sole mode of really curing disease, because it reposes on an eternal and infallible law of nature." And what is this mode and doctrine? We have it in four pro- positions, and it is hard to say which of them is most revolting to common sense. We are told that it is absurd to seek for the cause of symptoms in order to remove them ; that we must cure diseases by the exhibition of substances which would otherwise produce them ; that the dose is to be inconceivably small ; and that there are three original diseases from which spring all the maladies which afflict mankind — syphilis,-sycosis, and the itch. These are the fruit- ful causes of all diseases, — epidemic, sporadic, idiopathic, and symptomatic. Like his predecessor in quackery and deceit, he, too, has his syphilis, sycosis, and itch, the oil, the spirit, and the salt which burn the patient as hell does. Like Paracelsus, too, he maintains the curability of diseases, and is a disciple to animal magnetism. Let us next see how Broussais announced his doctrine to an ad- miring world. " Jlfter so many vacillations in its march, medicine at length fol- lows the only path which can conduct it to truth — the observation of the relations of man, with external modifications and the rela- tions of the organs of man, one to the other." This is the phy- siological method, because it cannot be followed without studying life, I am more anxious to draw your attention to this doctrine, as Broussais may be considered as the source of the anatomical school, which, of late, was so completely the fashion — if I may use such a term ; and it is a striking instance of the danger that attends the idea of our having made a discovery, to see a man like Broussais, than whom few have really added so much to medicine, falling into the same fault of arrogance and contempt towards his predecessors. At this moment, the medical world, particularly on the continent, is divided into two great sects. One may be called that of the pat ho- logicoanatomists, the other the Hippocratists. The first declares that diseases are primitively local in all cases; that the symptoms — say in a case of fever —are only the results of sympathetic irritation from some local disease, which is to be attacked ivith vigour ; that pathological anatomy is to be the foundation of all prac- tice; that there is nothing approaching to a specific in medicine ; and that nature makes little or no attempt to cure. Their favourite maxim is that saying of Bichat's — « What is observation, if we are ignorant of the seat of disease?" J This is the sentiment of an anatomist, but not of a physician • and we must regret that it once escaped the author of the « Researches on Life and Death," a book of such interest and such beauty as to HIPPOCRATIC OBSERVATION. 23 captivate even the non-medical reader, and make the very name of Bichat be hallowed in our memory. Many are the diseases of which we know not the seat: yet in which observation — Hippocratic ob- servation — is of the greatest utility. We know not the seat of fever, let the followers of Broussais say what they may to the contrary ; yet is observation of symptoms of no avail in fever? Are the effects of contagion, the history and nature of epidemics, the termination by crisis, the results of treatment, of symptoms as connected with prognosis — is the observation of these useless or unnecessary ? Sydenham knew not the seat of variola; yet he declared the true principles of its treatment. There are very many diseases on which pathological anatomy throws but a negative light — if I may use such a term—particularly affections of the fluids, and the neuroses. So much for the doctrine of the anatomical school. I beg of you not to misunderstand me as undervaluing pathological anatomy; I only wish to show you its true value. I believe there could hardly be adduced a single fact in pathological anatomy that has not its dis- tinct bearing on practical medicine. And it is true that the diseases whose treatment is best understood are those whose pathological nature are best known. Even in fever, the actual nature of which has not been revealed, great advantage has been derived from anatomical researches; for all the advance in our knowledge of this Protein dis- ease consists in ascertaining the number, nature, and seat, of the local inflammations which accompany or rise in the course, and complicate the disease. Let us, lastly, revert to the opinion of the Hippocratists. They admit that vast advantage has arisen from pathological anatomy ; but they see that its light is limited within certain bounds. They believe that great advantage is to be derived from the careful study of symptoms, even in cases whose pathological nature is not revealed by the knife. They believe that there are many diseases whose local origin cannot be demonstrated; for instance,fever. They deny that pathological anatomy is always to be our guide ; but admit a rational empiricism, and the use of remedies which may be called specifics; and, lastly, they hold that nature, in many cases, makes an attempt to cure ; and that the physician, in the words of Hippocrates, is to be the minister and interpreter of nature, rather than her master. Let us, then, combine the precepts of the founder of medicine with the lights of modern science. Let us take observation, and that ob- servation rendered fruitful by study, for our guide ; and let the ob- servation equally embrace the phenomena of the living as well as the dead. Let us be Hippocratists in the dissecting-room as well as at the bedside. By comparing the practice of these two schools, we get more accurate ideas as to their doctrine. The anatomists, holding that all diseases are local, direct their whole attention to the discovery of the lesion, and its connection with symptoms. This, with their doctrine that almost all diseases are inflammatory, leads them to a strict general and local antiphlogistic treatment. Fever is to them symptomatic, and the supposed source is to be vigorously attacked in the commencement. Diathesis, the nature of the epidemic, and 24 GENERAL OBSERVATIONS. the powers of nature to effect a cure, are comparatively neglected. They inhibit purgatives for fear of increasing the local inflammation, andlosema.iypatlentsforwantofatimelysupportofthepowersofhfe. They deny specificisin in diseases as well as in medicine, and are sorely puzzled to explain the extraordinary powers of bark and mer- cury, and sulphur,and iodine. They despise the experience of the past. The true Hippocratist, on the other hand, believing that we have not yet arrived at the knowledge of the local origin of all diseases, and particularly fevers, grounds his practice accordingly. He draws his experience from the recorded knowledge of the past, and his own unbiassed observation. When he recognises a local inflammation, he meets it with judgment, taking into account the habits, diathesis, epidemic, constitution, and tendency to crisis. He trusts much to nature, and watches her operations, particularly in fever. He is not afraid of moderate evacuations ; the phantom of a local inflamma- tion does not always haunt, him ; and even where he recognises its existence, that does not prevent him from using a stimulating and sup- porting treatment, if the general state of the patient requires it. He treats particular diseases by particular remedies, the utility of which has been proved by experience — such as syphilis, scrofula, inter- mittent fever, and so on. He uses the expectant medicine, which is not inactive treatment, but founded on the observations of the powers of nature— " Natura morborum medicatrix ;" but he never loses the opportunity of doing good, when such presents itself, re- membering the first aphorism of his great master: — " Occasio prseceps." I have great hopes for medicine, for I see men's minds turning to the true path ; and I trust that all whom I now address will deem themselves as labourers in the great work. Think what a noble science you profess ! the only one relating to earth-born things, which, while it ennobles the mind of man, yet softens and expands his heart; whose source is all science, whose end is good to man. Above all tilings follow truth ; nature can never deceive — see that you be her faithful interpreter. The great evil is, that there has as yet been adopted no means by which the experience of the past can be brought fully to bear on the actual teaching and practice of medi- cine. Too often has the physician to create his own instruments. But when all the scattered facts of medicine are collected, whether they be the observations on the living or the dead body, as old as history, or as young as to-day : when these votive tablets are hung up in the temple of truth, and their facts verified, compared, and classified, then, and not till then, will you see medicine in all her glory. LECTURE II. General remarks on local diseases—Fixed rules for the guidance of students — Great importance of diagnosis.—Kxistence of pure fever rare.-Doctrine of the Humorahsts and of the Brownists.—Pathology of the digestive system. I commence the course by entering at once on the subject of particular diseases. I am aware that the common practice is to REMARKS ON LOCAL DISEASES. 25 JL occupy the early part of a course on the theory and practice of medi- cine with preliminary discussions on general pathological subjects. To this I have strong objections. Every man who assumes to him- self the office of teacher, no matter what the fact may be, should presume that his auditors are ignorant of the subject he is about to teach; if he does not, he must be unjust to his class. Some of the class must be ignorant of the information he wishes to convey, and he should take it for granted that all are so. To commence with the consideration of general disease would argue that the whole class was acquainted with the subject in all its bearings, and capa- ble of understanding its principles without any previous illustra- tion. I think this is beginning at the wrong end. My plan is first to teach the facts, and then the general principles and conclusions to which these facts lead. It is of the deepest importance in the study of medicine to be able to form a collection of laws or fixed principles. In your professional career, nothing will give you so much satisfaction as having in your minds a number of established facts and fixed rules to bear on every case which comes under your cognizance. We commonly hear of the uncertainty of medicine and the instability of its practice; it is said to have as many phases as the moon, and as many changes as the tide; but, after all, I think this expression is more general among those who know little than among those who know much. Those who have successfully laboured in treasuring up a store of deep and extensive knowledge are firmly convinced, that, though some cases are involved in doubt and obscurity, the general certainty of medicine is at present in- creased far beyond what it was in former times. No man, except one in full and extensive practice, earned by industry and capacity, can be aware of the vast improvements of modern practical medi- cine, and of the number of lives which are saved by the judicious treatment which the rapidly progressive improvement of medical science has introduced. Medicine is much more certain how than it was in past times. There are two reasons for this; one of which is, that at the present period diagnosis, the guide and master-key to sound treatment,is more certain. Here, gentlemen,is a great source of certainty in the practice of medicine. You will find, in the course of a few years, that the old saying of •' doctors differ," will become less frequently applicable, because, as the education and acquirements of medical men become more extended, diagnosis will be reduced to fixed rules, and difference of opinion will be very seldom observed. A vast number of local diseases, formerly wrapt in obscurity, are now detected with the most unerring certainty, and this certainty of diagnosis must bear on fixed principles of treatment and similarity of practice. Another vast source of increased certainty is the fact, now extensively established, that the element of a great number of dis- eases is the same. This is an important law, because the deduction from it is, that the principle of treatment are the same in these cases. The principles of treatment in a case of hydrocephalus and in a case of vomiting from gastritis may be, and often are, completely identical, because, in many cases, both are reducible to a common action. . In the one case we have to deal with inflammatory action in the sto- vol. i.—3 26 REMARKS ON LOCAL DISEASES. mach, in the other we have to treat an inflammation of the mem- branes of the brain. The principle in both cases is to deplete the suffering organ, and to diminish or remove everything that keeps up irritation. Pathological anatomy, too, has effected a vast deal for medicine by the improvements in diagnosis which it has introduced, and by reducing to one class a vast number of affections formerly sup- posed to be unanalogous and distinct. Before I commence entering on the consideration of the pathology and treatment of diseases of the digestive system, it is necessary that I should mention another peculiarity of the mode of teaching the theory and practice of medicine adopted in this school. The ordinary way of lecturing medicine in the schools is this: the teacher begins by going over, at great length, the whole subject of fevers, and then pro- ceeds to the consideration of the signs, symptoms, and treatment of local diseases. We reverse this mode here ; we begin by teaching the pathology and treatment of local diseases, or affections of particu- lar organs; and having studied these with care and attention, we then proceed to the consideration of fevers. In point of fact, we are thoroughly impressed with the truth of this splendid conclusion in medicine, that local diseases may be considered, as it were, the alphabet of fevers,and that to have a distinct and accurate conception of the whole subject of fever, it is essentially necessary that we should be acquainted with all kinds of local disease. To commence with a class which the teacher presumes, or should presume, to be ignorant of the phenomena of local diseases, unacquainted with the rules on which their diagnosis depends, and unacquainted with the principles which should regulate their treatment — to begin with such a class by entering at once on the subject of fever, would, in my opinion, be extremely wrong. You will read in books and hear teachers speak of bilious fevers, of nervous fevers, of catarrhal fevers, of gastric fevers, and of simple fevers. These expressions are founded on the fact of the complication or non-complication of fever with local disease in various parts of the system. If simple fever was the rule, and its complication the exception, then, indeed, there would be some reason for pursuing the ordinary track of medical instruction, and we might commence by teaching the subject of fever, independent of local inflammation. But the truth is, that fever, in the simple form, is the exception, and its complication the rule, and that to have a correct idea of fever, in the general acceptation of the term, we must previously possess an intimate knowledge of the affections of particular organs. The progress of medicine has esta- blished, by the most unquestionable evidence, that simple fever is a matter of extremely rare occurrence ; so rare, in fact, that you might pass through the practice of fever hospital for years without meeting with a single case which you could say was, through its whole course, a case of pure essential fever. Sooner or later its character is changed and the complication with visceral disease comes on ; you may take this with you as a well-proved fact. You will havej at some period, a complication with local disease in the head, or local disease in the chest, or in the belly, or in the circulating system or perhaps all the great viscera in the body will be simultaneously FEVER WITH VJSCEKAL DISEASE. 27 affected. My experience on this point, after having attended the fever wards of the Meath Hospital many years, is this, that among all the cases which were admitted under such circumstances, there were very few indeed in which I could not say that the patient had some- thing more than fever. Many were admitted who presented no in- dication of disease in the head, chest, or digestive tube ; all that could be said of them, at the period of their admission, was, that they had fever ; but my experience of them is, that, in a vast majority, there was, during their progress, unequivocal evidence of the superven- tion of visceral disease. I do not go as far as the disciples of Brous- sais have gone,nor do I mean to say that all fevers are symptomatic ; all I assert is, that, at some period, most fevers are complicated with local disease. I admit that there is a vast number of symptomatic fevers, but I believe there are two which are essentially simple, typhus and intermittent. The progress of medicine has shown that these may exist in the simple form, and that their complications maybe secondary; this I believe to be the fact,but the almost inva- riable liability to complication is a point of the highest importance. We scarcely ever see typhus accompanied by symptoms of local dis- ease ; and, with respect to intermittent, in ninety-nine cases out of a hundred, visceral disease of the head, or chest, or belly, may, and will, supervene. Another great fact bearing on this subject, and which pathological anatomy has established beyond the possibility of a doubt, is,.that in the great majority of cases having a fatal termination, death is caused by disease of some particular organ or organs. The old notion of the eause of death was, that the patient died of debility or exhaustion. In cholera, in tetanus, in hydrophobia, we cannot, to be sure, demonstrate any appreciable lesion of structure, and we may say, if we like, that the patient died of debility; but this does not hold good in cases of fever, for on dissection you will generally find disease sufficient to account for death, even though there had been no fever at all. From these circumstances it follows that, in the management of fevers, the attention of the physician must be directed to the local affections, or, at all events, that to understand fever well, and to treat it successfully, he must be acquainted with the nature and treatment of every form of visceral disease. It will be sufficient for me to call your attention to this fact, that there is not a single acute local disease which may not occur during the progress of a fever. This is a broad and general proposition. If you look to the nervous system you will find, in patients who have died of fever, traces of lesion in almost every part of it, inflammation or conges- tion in the cerebrum, in the cerebellum, and in the spinal cord. If you go to the respiratory system, you will see all kinds of shades and varieties of inflammatory action, thickening and ulceration of the bronchial membrane, hepatisation, congestion, and destruction of the parenchymatous tissue, effusions of lymph, serum, or pus, into the pleural cavities. As you proceed in your examination you will discover new lesions; you may see the whole lung filled with(lately formed tubercular matter ; you will meet with the destructive ravages of phthisis. You will find the pulmonary tissue converted into a 28 REMARKS ON LOCAL DISEASES. dark and fetid mass by gangrene. You may see carditis, hypertrophy, inflammation of the external or internal coverings of the heart, inflam- mation of the lining membrane of the arteries, phlebitis (a common oc- currence in typhous fever); and passing on to the lymphatic system, you will often find evidenttraces of inflammation in itsglandsond ves- sels, an occurrence which I shall be able to demonstrate to you when treating on the subject of gastric fever. If we go to the digestive sys- tem we find that disease has here taken a wider range; congestions and ulcerations of the stomach and intestines, morbid states of the liver, congestion and inflammation of the spleen or kidneys, evidence the fatal extent of local inflammation. I think I might safely challenge any one to point out any one single organ which may not become diseased during the progress of a typhous fever. I do not wish you to suppose that typhus is a symptomatic affection. I think we may define it, in general terms, as a diseased state of the whole system, in which various local diseases arise, modify the character of the ori- ginal complaint, give it an additional intensity, and are generally the cause of death. Go round the wards of an hospital during the pre- valence of an epidemic fever, examine every patient in succession, and bring this principle to the test. You will see one labouring under the morbid excitement of high delirium; his face injected, his eyes sparkling, his carotids throbbing with intensity. Come next day, and you wili find him in a state of profound coma, perfectly in- sensible to every thing around him : — two or three days afterwards he is dead. You follow his body to the dissecting room, and open his brain; unequivocal marks of excessive congestion, inflammation of the substance of the brain, or of its membranes, sufficiently indi- cate the cause of the fatal termination. Here is a case of inflamma- tion of the brain. You find another with cold skin, his face of a dirty hue, faintly tinged with red, his breathing quick and hurried, and the spitting-vessel by his bedside filled with adhesive mucus tinged with blood ; you percuss his chest, and find dulness over the whole surface of one lung; you apply the stethoscope, and discover intense bronchitis, hepatization, or suppurative pneumonia. Farther on you see another in a state of deep prostration, with a sunken countenance, constant hiccup, and low delirium. Take down his bed-clothes, and you find his belly swelled, tympanitic, and tender on pressure ; then his tongue, lips, and gums, are parched and en- crusted with dusky sordes; his thirst is insatiable; he vomits, and has an emaciating diarrhoea. After death you find traces of an ex- tensive and fatal gastro-enteritis; in others you will find exemplified the very climax of inflammation, and all the three great cavities are simultaneously affected. But these, you will say, are cases in which the complications are evident, and where an ordinary knowledge of the phenomena of local disease will be quite a sufficient guide. Well, here is another case. You will meet with instances of fever without any apparent local symptoms, where the patient lies in what you would consider a quiet state, and free from danger ; nothing seems to be the matter with him, except that he is very weak ; he perhaps does not sleep at night, and his tongue is a little foul ; he complains, in fact of no thing but weakness and some thirst, and you think his fever is going NEGLECT OF MORBID ANATOMY. 29 on very well. Some morning or other, on coming to the hospital, you are astonished to see the change which has been wrought in him since the day before ; his countenance is altered, his pulse can hardly be felt, and life is fast ebbing away. You ask the nurse about him, and she tells you that, during the night, he suddenly complained of violent pain in his belly. On examining him, you find distinct evi- dence of intense peritonitis, and, after death, dissection reveals the existence of a perforating ulcer of the intestines, of which there was apparently no sign during life, except fever and the unexpected oc- currence of peritonitis. The frequency of the complication of local disease with fever, its insidious latency, and the fact, that death, in the majority of fever cases, is caused by visceral inflammations, all clearly point out the necessity of being intimately acquainted with every modification of local disease before you proceed to the study of fevers. Diseases of the Digestive System. — I commence with the digestive system. I am anxious to do this for several reasons, but for none more than this — that, to the improvements made in the pathology of the digestive system we owe much of the rapid advance- ment of modern practical medicine. Before our time the pathology of the digestive system was very little known, and if not quite a terra incognita in medicine, there existed respecting it a great deal of misconception. The schools were deeply tinctured with the doc- trines of the Humoralists and the Brownists ; and this had the effect of giving rise to irrational theories and false notions of the true state of the system in disease. The humoral pathologists, who sought for disease in an alteration of the fluids alone, neglected the study of visceral lesions; and when they turned their attention to the diges- tive system, they only considered it, its secretions, and not its actual condition, or the state of its sympathies. The liver, with them, was an organ of the highest importance, and the secretion of bile claimed a vast share of their attention. To it they gave a paramount influence, and to an alteration in its quantity and quality they attributed most of the changes which occur, not only in the digestive tube, but also in the whole system ; and hence the great object of their practice was to attempt to restore its healthy condition, convinced that if this were once accomplished every thing would go on favourably. From this, too, arose the purgative plan of treatment in various forms of intestinal disease, a plan too often rashly pursued, even where there was unequivocal proof of inflammation in the digestive tube.* Their sole purpose was to evacuate sordes, to produce a flow of healthy bile, and to eliminate depraved secretions : and they did this without possessing any knowledge of local inflammation, or of the effects of disease of the digestive system on other organs. The followers o£ Brown, on the other hand, only admitted disease of the digestive system in a state of intense, manifest violence, as, for instance, ileus or violent enteritis; but in the great majority of cases, they did not recognise intestinal inflammations, because their prominent symptom * [Our medical brethren of the south and west will see, if not re- proof, at least a salutary hint, in those remarks of the lecturer. — B, ] 3* 30 DISEASES OF THE DIGESTIVE SYSTEM. was prostration, or, to use their own terms, an asthenic condition of the whole system. They saw nothing but prostration : they pre- scribed for nothing but debility: they gave wine instead of iced water; ordered baVk instead of'local depletion. They exasperated the disease by stimulants ; and then, thinking they had not gone far enough, they heightened the stimulant and doubled the debility. Another cause of the low state of pathology in former times was the general neglect of dissection. The fact is, that in fever there were no post-mortem examinations made, until very lately. Mor- gagni, who did so much for pathological anatomy on almost every other subject, did little for fever, because he was afraid to dissect the bodies of persons who had died of a contagions disease. This was the idea which prevailed among the older pathologists ; and hence this source of knowledge was avoided, and for many successive cen- turies the state of the viscera in fever was a matter of speculation, doubt, and uncertainty. Even at the present day it is only done by the ardent pathologist, who cares not about filth and stench, and who had rather encounter the miasm of contagion than remain in the mists of error. Nothing is more common, I regret to say, even at the present time, than this:—A person says he has dissected cases of fever, and when asked whether he had examined the intes- tinal canal, he says that the intestines appeared healthy, but he did not make any particular inspection of them ; he only opened the belly, and, finding no trace of inflammation in the peritoneum, he went no farther. Now, nothing can be more useless than such an examination. If we compare the information afforded by an inspec- tion of the serous membranes of the three great cavities, we shall find that the least is given by an examination of that of the abdo- men. Disease of the substance of the brain is rare without affec- tions of its investing membrane ; disease of the substance of the lung is exceedingly rare without the occurrence of disease of the pleura; but you may have most extensive and fatal disease of the intestinal canal, without the slightest lesion of the peritoneum. In this point, therefore, it differs from the pleura, and from the arachnoid mem- brane. The fact of the rarity of disease of the peritoneum in cases of disease affecting the parts beneath, was noticed by Dr. Graves and myself, in our report of the Meath Hospital, and also by Mr. An- nesley, in his account of the diseases of India. You will see cases of hepatic abscess, which present a distinct tumour externally, and where you can detect a perceptible fluctuation ; and yet, if you exa- mine these cases, after death, you may not find any adhesions of the peritoneum, even in the situation of the abscess. You will find the mucous and muscular coats of the colon extensively destroyed, you will see the stomach all but perforated, you will meet with 'cases where the whole ileum is one extensive sheet of ulcerations with no disease in the adjacent peritoneum. ' In entering on the consideration of diseases of the digestive sys- tem, we shall begin first with the mucous expansion of the stomach and intestines, and then proceed to the affections of the solid viscera connected with them. The mucous surface of the stomach and in- testines is of enormous extent andextraordinarv sensibility, possessed LOCAL AND REMOTE PHENOMENA. 31 of innumerable and powerful sympathies ; its influence is felt by almost every organ in the body, formed for receiving and elaborating everything destined for nutrition ; its conditions, both in health and disease, are entitled to the deepest and most attentive consideration. To facilitate the study of its affections, and for the sake of some prac- tical arrangement, we shall divide its diseases into five classes, be- ginning with the oesophagus, or that portion of the digestive tube which is above the diaphragm, and then proceeding to the stomach, duodenum, ileum, colon, and rectum. But, in order to give you a clear idea of diseases of the intestinal canal, I shall commence with diseases of the stomach; because, if you consider the whole range of animal life, you will find that its functions are the most import- ant, the stomach constituting, as it were, the source and fountain of life, which is nutrition, and giving by its existence a character to all the upper classes of animals. No organ possesses such remarkable sympathies as the stomach, whether we look upon them as sympa- thies of organic or of animal life, none possesses such remarkable power and influence in modifying the condition of every part of the system. But, putting aside physiological reasons, let us come to practical matters. The success of almost every form of medical treatment, all the advantages to be derived from the administration of internal medicine depend upon the stomach ; in fact, in whatever point of view we consider it, we must look upon a knowledge of the state of the stomach as the great key to sound and successful practice. It is a most useful reflection to consider the extraordinary fre- quency of disease in some portion of the digestive tube. It is now admitted by every person possessed of experience in the causes of mortality, that more human beings die with acute or chronic dis- eases of the digestive tube than with diseases of any other part of the system. This has been established by numerous investigations, and is admitted by the best pathologists ; and, indeed, I think it can be easily accounted for, when we call to mind how many persons die of some form of fever or other, when we look to the ravages of remittent and yellow fever, to the hundreds of thousands who annually perish by the various classes of fevers. Now, in almost every one of these cases, disease of the digestive system forms one of the most promi- nent pathological characters. Recollect, besides, all that die of dysen- tery, whether sporadic or simple, and here is inflammation of the colon ; see, too, how many die with diarrhoea— here, too, there is intestinal disease ; remember how many die of the malignant inter- mittent of the West Indies, in which unequivocal proofs of disease of the stomach and intestines have been found. Observe what a close connection there is between tabes mesenterica and inflamma- tion of the mucous membrane and surface of the intestines; think what a vast number of persons fall victims to the harassing effects of constipation and dyspepsia ; and recollect that there is a host of dis- eases in which the train of morbid phenomena commences in the digestive system, and then exhibits itself by functional alteration or organic disease of other parts. We recognise the presence of disease in the digestive tube, first, by the local phenomena and the lesion of the digestive function, and 32 DISEASES OF THE DIGESTIVE SYSTEM. next by the sympathetic relations of other parts, by the sympathies of the respiratory system, of the circulation of the skin, and of the nervous system. I shall enumerate the local phenomena and func- tional lesions; vomiting, anorexia, thirst, jaundice, pain, tenderness on pressure, tympanitis, changes in the character and quality of the discharges, constipation. Here are a set of functional lesions and local phenomena; let us now consider the sympathetic relations; these are fever, heat of skin, suppression of the cutaneous secretion, suppression of the secretion of urine, morbid states of the tongue and pulse, pains in the chest and cough, hurried breathing, and palpita- tions of the heart. In the next place, we may have prostration of strength, delirium, coma, convulsions, tetanic spasms, and other symptoms of functional disease of the brain; these are all sympa- thies of relation. Now, in the first place, I have to remark, that there is a great deal of variety in the combination of these symptoms. On what does this depend? on a variety of circumstances ; some- times on the intensity or extent of the inflammation : sometimes on the situation of the disease : sometimes on the complication of the affection ; sometimes on the various modes and degrees of suscepti- bility of the individual. All these causes tend to produce a great variety in the disease, and an extensive modification of the sympa- thetic relations. For instance, in some cases inflammation of the stomach and intestines is so slight that the patient is not prevented from going about and pursuing his ordinary avocations; in others, on the contrary, the patients are struck down at once by the violence of the disease, and are carried off by the fever which accompanies it before the inflammation is completely developed. It varies also according to situation; there is a difference between gastritis and dysentery : in the former we have an inactive state of the great in- testine, and consequent constipation ; in the latter, the colon is thrown into violent action, and there are frequent dejections. Disease of the duodenum is attended with a very remarkable peculiarity, being very frequently complicated with jaundice ; here is a modification produced by situation. Again, inflammation of the ileum is attended with a very curious peculiarity, namely, the absence of pain. The patient states, that he feels unwell, he has obscure symptoms of in- testinal disease, but it is neither dysentery nor gastritis ; you investi- gate it with care, and find that the ileum is in a state of inflamma- tion. Yet the patient does not complain of any pain; and this is another peculiarity depending on situation.* But in considering the differences which depend upon intensity, extent, and situation of disease of the intestinal canal, we must not omit those which depend upon tissue. If disease be confined to the mucous membrane of the intestines alone, we may have an ex- tremely diffused and extensive inflammation, sufficient to destroy * [The physiological explanation consists in the fact, of the ner- vous supply to the ileum coming from the sympathetic ; a fact of some importance in making our prognosis of typhoid fever. The absence of pain might induce belief that there was no organic lesion. — B.j DISEASES OF THE MOUTH AND PHARYNX. 33 life, without any pain being complained of by the patient ; it is a painless though fatal disease. Recollect this, — extensive and fatal inflammation without pain. Informer times the ideas of pain and inflammation were inseparable. Thanks to the light which patho- logy has shed upon modern medical science, we are now acquainted with this seeming anomaly, and can conceive the existence of exten- sive disease of mucous surfaces unaccompanied by pain. But let the inflammation seize on the muscular tissue, the character of the disease is instantly changed, and the pain is dreadful. Here is a case in which difference of tissue is to be taken into consideration.* The phenomena and sympathetic relations of intestinal disease may vary also according to its complication, and here we come to investigate one of the most beauiiful laws of the human economy, namely, that the more complicated a disease is, the more latent will be any local lesion. This is a point that should never be forgotten. For instance, enteritis by itself is much more easily recognised than when complicated with pneumonia, or with irritation of the brain, and gastritis is but loo often completely masked by being combined with irritation of the bronchial mucous membrane. Lastly, we have the varieties which depend on different degrees of susceptibility. In one person we may have only slight cerebral irritation, in another high excitement, in a third delirium and extraordinary convulsions. The variety, then, in the modifications of diseases, and the combina- tion of sympathies, is very great, and is referable to the extent and the intensity of the inflammation, difference of situation, complication of disease, difference of tissue, and different degrees of susceptibility. LECTURE III. DR. BELL. Diseases of the Mouth and Pharynx. — Connexion in structure and function be- tween them and diseases of the stomach and bowels.— Stomatitis — Its dif- ferent species — Simple erythematic stomatitis—Its nature, causes, and treatment — Follicular or aphthous stomatitis — Its varieties, complications ; pathology, analogous to follicular gastritis and enteritis — Connexion with dyspepsy in adults, and in children with cholera and diarrhoea — Remedies, general and local — Importance of hygienic measures—Ulcerous stomatitis. Doctor Stokes passes directly from a general view of the patho- logy of the digestive system to a consideration of gastritis, its patho- logy and treatment. But before taking up this subject, it will be well to describe to yon some of the chief morbid alterations in the upper portion of the alimentary canal, or the buccal and pharyngeal legions. This proceeding is in conformity with an affinity between * [The position is, perhaps, rather too broadly laid down in the text. The sensations of the patient will depend very much on the portion of intestine affected; whether duodenum, for example, or jejunum, and whether even the upper or the lower part of the ileum. The first and last portions of the intestinal canal receive branches of the cerebro-spinal nerves, — the middle is supplied almost entirely by the sympathetic---B.] 34 DISEASES OF THE DIGESTIVE SYSTEM. * these regions and the stomach, which is manifested both by a con- tinuity and general resemblance of tissue (the mucous), and by a re- semblance and sympathy between them in their morbid states. In fact, just as we look at the tongue for an index to the state of the stomach, so may we expect to see often in the diseases of the mu- cous membrane of the mouth and pharynx a reflexion of those of the gastric mucous membrane. I do not by any means assert, that there is uniformity in this respect; but that there is so frequent a connexion between the inflammation and irritation of the stomach and the upper cavities already mentioned, that we shall be not a little remiss in our diagnosis, and needlessly conjectural in our pro- gnosis, of the diseases of the digestive system, if we do not, with a knowledge of the frequency of this connexion, institute a careful inquiry into the state of both regions, even when our attention is in- voked solely for one of them. In practice, we shall be much more successful by taking this enlarged view, than if we restrict ourselves to an investigation of either alone, and fail to see more than a mere local disease in the morbid alterations of the mucous membrane of the mouth ; or are aware that a chronic affection of the stomach assumes a much more serious, not to say alarming aspect, when ac- companied with some degree of pharyngitis, and still more with aphtha3 and ulcers of the mouth and palate. Stomatitis. — The morbid states of the buccal mucous membrane have been variously designated, not only in reference to their varie- ties, but to each of these separately. They have engaged the atten- tion of medical men more when they appear in the infantile subject than in the adult; on account of their greater frequency of occur- rence in the former than in the latter. The general and popular term for designating the sore mouth of infants is thrush; the techni- cal one, aphthae. Of late years a new title is given to the whole class of diseases of the mucous membrane of the mouth, which, as far as its radicle is concerned, is perfectly appropriate, but as in all cases implying inflammation, is not so accurate. The title is Stoma- titis, from e-To/ua, mouth ; and this is the generic name which is now adopted by the French and some English and American writers for diseases of the lining membrane of the mouth. The specific titles are more or less numerous with different authors. Those of M. An- dral (Cours de Pathologie Interne) seem to me to designate with sufficient distinctness the several morbid states of this region, and I shall therefore adopt them, with the addition of the ulcerous species. They are—1. Simple Stomatitis ; 2. Aphthous (Follicular) Sto- matitis ; 3. Ulcerous Stomatitis; 4. Pultaceous Stomatitis; 5. Pseudo-membranous, or Pellicular ; and 6. Gangrenous Stomatitis. 1. Simple or Erythematic Stomatitis. — This species is common, but in a mild degree, in newly-born children, who are predisposed to it by the congested state of the mucous membrane of the mouth at birth. It is usually marked by redness, heat, and some degree of dryness of the mouth and tongue. Sometimes, as M. Billard de- scribes it, the inflammation is confined to one part of the buccal sur- face, at others it covers the whole and spreads to the lips, which tumefy, excoriate, crack, and frequently become the seat of herpes FOLLICULAR OR APHTHOUS STOMATITIS. 35 labialis. Often it accompanies inflammation of the stomach or bowels, but rarely causes fever in very young infants, whereas this is a common addition in children from seven to nine years of age. The functions of the mouth, or those in which it participates, such as mastication, deglutition, and speech, are performed with difficulty and pain ; and sometimes there is a copious ptyalism. The duration of the disease is from three to eight days; and the termination is commonly by resolution. This description is applicable to infantile stomatitis, but when the erylheniatic variety occurs, as it every now and then does, in adults, associated with dyspepsia, and is aggra- vated by the use of tobacco, and particularly smoking this poisonous weed, the prognosis is not by any means so clear. Nor must we expect, even in children, always to find this kind of inflammation of the mouth retain its simple erythematic character; for, sometimes, it is followed by ulcerations and even gangrene; and it is not uncom- mon, says M. Andral, for us to see after this disease an induration of the sub-mucous tissue of the mouth. Causes. —Of the causes of simple stomatitis, dentition is the first and most common one; others are enumerated, such as very hot drinks taken into the mouth : acrid, caustic, and poisonous substances of various kinds; contusions, operations on the teeth, and the accu- mulation of tartar. Sometimes, as already intimated, it is sympto- matic of inflammation of the digestive canal. Treatment. — The cure of simple stomatitis is generally trusted to mild means, such as simplicity of regimen, mucilaginous drinks, consisting of gum water, or a decoction of slippery-elm or sassafras pith, alone, or mixed with milk. If the inflammation run higher, and fever be present, a few leeches should be applied at the base of the jaw, or even to the gums themselves, provided the child be not of a scorbutic habit, or badly nourished and with little habitual ac- tivity of capillary circulation. In this latter case, counter-irritation by moderately stimulating liniments is to be practised on the skin of the base of the jaw and mouth, extending back to the angles of the former. Saline or slightly acidulated gargles will be of service, and in nearly all cases of any intensity the bowels should be excited to increased exoneration by castor oil, magnesia and rhubarb, or, with reserve adapted to the temperament of the child, a small dose or two of calomel. This medicine will be most serviceable in the sanguine or nervoso-sanguine; but much less so, if allowable at all, in the decidedly lymphatic with much sluggishness of the functions gene- ally. The warm bath is a useful adjunct to the treatment in this as it is in most of the diseases of children, and in many cases it will, with a little change of air, and a simple, and even reduced milk diet, suffice for the cure. 2. Follicular or Aphthous Stomatitis — Aphthae—Thrush.— This is the most common kind of sore mouth in children ; and it is that which is a frequent accompaniment of chronic diseases of the gastro-intestinal mucous surface in subjects of all ages, as of gastritis, gastro-enteritis, cholera infantum, and dysentery; also of typhous fever, and diseases of the lungs, and particularly of pulmonary phthisis in its third stage. 36 DISEASES OF THE DIGESTIVE SYSTEM. Three varieties are described of aphthous stomatitis, viz.— 1, papular ; 2, vesicular ; 3, pustular. These are often met with con- stituting successive stages rather than separate varieties of the diseasp. Whatever may be the form under which it exhibits itself, it more especially attacks the parts in which the epithelium is the most ap- parent, 'it usually appears first in the angles of the lips, and then on the tongue and the lining membrane of the lips and cheeks, and on the velumpalati, in the form of little papular, vesicular, or pus- tular white specks, which some writers have denominated ulcers ; but this term is not applicable until the specks burst,—a termination which usually occurs between the second and third day. The eruption may be either discreet or confluent. The former is happily the most common ; but sometimes the other, or confluent variety, is met with, and it may prevail epidemically. It is no un- common thing to meet with it, in persons, and particularly children, who have long suffered from bowel disease, an increase in the num- ber and size of the specks, which run together and compose a thin white crust, that at length lines the whole inside of the mouth, from the lips even to the oesophagus. In this stage there is fever, head- ache, and often vomiting and other disorder of gastric function. But when this kind of sore mouth, or thrush, is a primary disease, there is not, says Underwood {Treatise on the Diseases of Children: with Additions, by Drs. Merriman, Hall, and Bell, rfmer. Edit.), in nine out of ten cases, the least fever, though the mouth is often so much heated as to excoriate the nipples of the nurse, and so tender that the child is often observed to suck with reluctance and caution. It is a popular opinion that the eruption and ulceration of thrush are continued down the oesophagus, and thence into the stomach, and along the entire course of the intestinal canal, showing itself in a redness about the anus. No doubt there is often coincident and sometimes preceding disease of the stomach and other parts of the digestive tube in stomatitis; but the continuity as above described seldom exists. Nothing is more common than this redness and ery- thematic inflammation about the anus in diseases of the digestive system of children ; and it is worthy of remark, that certain poisons will spend their whole force, as far as this system is implicated, on the stomach, pharynx, and rectum, leaving the-intermediate regions intact, or but slightly affected. The duration of this disease in its milder or simpler forms will vary from three or four days to as many weeks; sometimes returning at different intervals. Underwood states, that he has seen this so very often the case, that when he found a child to have the complaint very slightly, and that it did not increase after two or three days, he ventured to pronounce it likely to continue a long time, but that it will be of no consequence. Pathology. — It would be an erroneous notion respecting aphthee, if we regarded them as an ulcerative termination of common inflam- mation. Callisen has described them as small tumours, from a change of the muciparous glands. Billard, with more probability, considers them to be a morbid development of these bodies, or folli- cles of the mouth, sometimes in a state of simple tumefaction, at FOLLICULAR OR APHTHOUS STOMATITIS. 37 other times in a state of ulceration. "The muciparous follicles of the mucous membrane of the mouth are invisible in their ordinary state, and remain hidden in the thickness of the membrane, and com- pensate by their infinite number for the smallness of their size ; but when they begin to inflame and tumefy, they appear on the internal surface of the lips and cheeks, on the pillars of the velum and the palatine arch, on the inferior surface and lateral parts of the base of the tongue, under the form of small white points, sometimes exhibit- ing a coloured spot in their centre, slightly prominent, and often sur- rounded by a slight inflammatory circle. These follicles are either isolated, and few in number, or multiplied and spread over every part of the mouth. Sometimes they may be felt with the finger, when they are not sufficiently distinct to be seen. They often do not stop at the mouth, but spread to the oesophagus, stomach, and in- testinal tube." (Billard — Treatise on the Diseases of Infants, Dr. Steivart's Translation.) — The follicular points enlarge, preserving still their primitive circular form; and from their central aperture there soon issues a white matter, which, being squeezed by the sur- rounding epithelium, itself soon beginning to ulcerate, there is an exu- dation of white puriform matter over all the parts. Numerous aphthae and their proximity soon allow of the spread- ing of the excreted curdy matter so as to form a continuous coat of greater or less thickness, as already mentioned. In this state the aph- thous is often confounded with the pultaceous stomatitis, or muguet, hereafter to be described ; but they may be distinguished by inspec- tion of the inflamed follicles, and a solution of continuity, which is not met with in the latter disease. This is most common within the month ; aphtha? during dentition. Aphthae do not always exhibit the same characters in different spots. Sometimes, when the follicles are about to ulcerate, the edges of the ulcers, instead of being covered with a slight curdy excretion, exhale a small quantity of blood, which concretes under the form of a slight brown scab, mistaken, says Billard, by some authors, for a gangrenous eschar. The causes of follicular or aphthous stomatitis are predisposing and exciting; and of these the first is the most important and the least controllable, because consisting in an excess of the white tissues, or a predominance of the lymphatic temperament. This may be greatly increased by bad or defective food and impure air, under the influence of slight causes, such as indigestion, common bowel complaint, or changes in the milk or other food. As evincive of predisposition in certain subjects over others, the practitioner must doubtless be able, from his own observation, to confirm the remarks of Underwood, that "the thrush is sometimes found to seize every infant in certain families, in whatever way the children may be managed." Illus- trating the effect of dietetic regimen, is the additional observation of this experienced physician, though inelegant writer, that want of a proper attention to the state of the alimentary canal will bring on the disease, as "where the mother happening to be ill, the whole attention of the family has been thereby engaged; or where one in- vol. i.—4 38 DISEASES OF THE DIGESTIVE SYSTEM. fant has been put to nurse, while all the rest of the children have been carefully brought up at home." Aphthous stomatitis is mainly induced and kept up by disordered digestion and impeded nutrition; and hence its common occur- rence in those children who are brought up by the hand, and espe- cially in those who, in addition to the loss of their mother's or nurse's milk, are cooped up together in hospitals, and deprived of fresh air, and of the means for preserving a clean and fresh state of the skin. " The fact is, the thrush is a disease of debility, and therefore attacks very young and very old subjects, especially if otherwise weakened." Whoever has watched the progress of pro- tracted cases of cholera infantum, and seen the spread and severity of aphtha?, increasing as the disease advanced, and the little patient become weaker and more emaciated, will confirm the accuracy of this remark. Reference has been before made to some of the symptoms accom- panying aphthae. The most marked ones are produced by the mor- bid state of digestion, such as eructations of an acid smell, sometimes vomiting and irregular action of the bowels; heat of skin and fever; but you have been already told that this last is by no means a com- mon complication of simple or discreet aphthae. On this point, however, we must remember that the excitement of the heart and bloodvessel system is relatively low in subjects of a lymphatic tem- perament, and hence we are not to lay stress on this as the only measure of inflammation or febrile action in them. If we were to judge from the cries, wakefulness and restlessness of children affected with aphthae, we should infer that they experience pain. When the disease extends to the pharynx and produces a swelling of the glands and inflammation of the trachea, which is among its alleged effects, the cry of the child is sensibly altered, and it manifests pain, but more by a harsh or hissing cry than by its tears. (Gardien, Traite Complet d?Jlccouchemens.) Treatment. — We cannot judiciously apply our remedies in aph- thous stomatitis, without a due knowledge and consideration of its precursory and concomitant disorders. Thus, if it exists with den- tition, and there be much tumefaction and redness of the gums, with irritative fever at the same time, the treatment will be directed to the relief of this morbid state, and nearly all the medicines used for the aphthae will be of a topical kind, and these the most simple, such as a linctus made of mucilage of gum arabic and syrup, with a little acetic acid ; or if the heat and irritation of the mucous membrane be considerable, a weak solution of sugar of lead may be lightly applied to the parts by means of a fine brush or a piece of lint tied to the end of a small, rounded stick. The sub-lingual, or the sub-maxil- lary glands, taking on secondary disease by the irritation transmitted from the mucous membrane of the mouth, may require the applica- tion to them of a few leeches, followed by a poultice and camphor- ated spirituous lotions so applied as to produce evaporation. Patches of aphtha? or scattered ones in the regions already men- tioned, without apparent complication of pain or fever, may be treated by, at first, mild mucilaginous linctusappiied cold, and the administra- FOLLICULAR OR APHTHOUS STOMATITIS. 39 tion of a dose of castor oil, or rhubarb and magnesia, to procure a moderate but yet tolerably complete evacuation of the bowels. The disease still persisting, recourse will be had to a somewhat stimulating substance, such as borax, or alum ; the former in a linctus with sugar and mucilage, or with honey and water; the latter dissolved in sweetened barley water, in the proportion often grains to the ounce. The preparation of borax which I prefer myself, after frequent trials of its efficacy, is a solution with sugar in water and alcohol, to which sometimes a little laudanum isadded,as follows :— R. Sodse sub-borat. 3i.; Aquae fluvialis, fgij.; Alcohol, fgss.; Sacchar. albi, ij. M. ft. Solutio. As there is great difference in the common, as well as the morbid, sensibility of the parts, the quantity of borax will be in- creased or diminished accordingly. If it be thought advisable to circumscribe more accurately, and to retain the substance longer on the part to which it is applied than can be done by a simple solution, gum arabic may be mixed in adequate quantity. But of the pre- parations which combine power with mildness, I know none equal to a solution of chloride of soda, as it is sold in the shops, and diluted with water, to be applied as a gargle ; in the proportion of one drachm to an ounce. In place of this, the chloride of lime in solution may be used. The fetor is removed, and the sores cleansed and excited to heal by these chlorides. I need not enlarge on the use of other topical remedies in this disease, as I shall have occasion to recur to this kind of medication, when treating of pultaceous and pseudo- membranous stomatites. But, whenever we are called to a case of aphthous stomatitis which has lasted more than a few days in a child of very lymphatic tem- perament, and whose regimen has been faulty, we must regard all local remedies, indeed all treatment purely medicinal, as of secon- dary importance ; and direct our measures to a change in the food, the air, and the applicata, both as regards clothing and bathing. If a child has been weaned, we ought to restore it to the breast; or, if this cannot be done, to give it nutriment nearly analogous to that derived from the maternal bosom. Sometimes, indeed, we are com- pelled to prescribe the substitute in preference to the original supply, as where the mother is pregnant, and her milk evidently disagrees with and disorders the child. Cow's milk, fresh, and with a little farinaceous matter, as ground rice, pounded crackers, arrow root, or barley flour, mixed with it, and sweetened, is the best succedaneum for the mother's milk, and will, when given at proper intervals, in quantity not too great at a time, nourish, and correct, at the same time control, previous looseness and concomitant disturbance of the bowels. Fresh air is to be admitted to the little patient in the room, if circumstances prevent its being taken out; but the latter course is still better, and will alone exert a beneficially controlling power over the disease. Frequent changes of body clothes, which must be of a suitable warmth, but not oppressive by their weight and thickness, — and the daily, or twice daily, use of the warm bath, at from 90° to 94° F., according to the temperature of the skin and activity of circulation, will greatly contribute to the cure. During the time in which the appropriate regimen is employed attention is to be paid 40 DISEASES OF THE DIGESTIVE SYSTEM. to the state of the bowels. Sometimes they should be acted on by castor oil, or rhubarb and magnesia; sometimes with chalk mixture, and at other times again with minute or fractional doses of calomel, mixed with gum arabic, or still farther reduced in strength by mixture with chalk. For the most part you will discover complications of visceral dis- order with aphtha? of sufficient moment to prompt you to the reme- dies just indicated ; and it is on this account that I enlarge the more on the treatment of the disease of which aphtha? are but a part, perhaps only a symptom, as in gastritis, or in gastro-enteritis of chil- dren, constituting what is generally called cholera infantum, or it may be to analogous irritation in the digestive tube, kept up by teething. If I insist on the paramount importance of regimen in aphthous stomatitis, and dwell on the wants of nutrition, as indicated by the causes, and precursory as well as associated phenomena, I would wish to be understood as recommending renovation, but not that kind of excitement procured by stimulating remedies; and hence the pre- ference I give of regiminal over medicinal means. I would now, in harmony with this view of the nature of the disease, add that, after the therapeutic treatment, which I have stated to you, has been tried, and the febricula which may have been present removed, or so much abated as to excite no uneasiness in your mind, you may then administer with advantage a mild tonic. Of this class, a simple cold watery infusion of chamomile flower, or of wild cherry tree bark, or if the skin be cold and circulation feeble, sulphate of quinia, are to be preferred. Stress has been laid by some on preparations of iron, and I have myself used, the tincture of the chloride with advan- tage in that feebleness of frame, in which prostration and derange- ment of digestion and aphtha? were the predominant disorders. 3. Ulcerous Stomatitis. — This may be readily confounded with the former kind, but it differs from it in its not being restricted to the follicles. The ulcers occupy indifferently evey part of the buccal cavity, viz., the frenum of the tongue, its base, the internal surface of the cheeks, and the palatine areh. Under this head we may properly introduce mercurial stomatitis, the existence of which is not always announced nor accompanied by the characteristic mercurial fetor. I have seen ulcers of the mouth and gums following the use of calomel in large doses in young chil- dren, at a time when they who administered them thought that the medicine produced no effect. The treatment of ulcerous stomatitis requires nothing of a specific character, — at any rate different from that of follicular stomatitis. The same attention should be given, as in this latter disease, to the state of the general health, and the means recommended for renovating the digestion and quickening nutrition, concurrently with topical ap- plications, used in the one, as were thought advisable in the other. Pustular Stomatitis is a name given by M. Billard to the inflam- mation developed during the course of small-pox, and is analogous to the circumscribed pustular ulceration of the skin, and identical pre- cisely with that variolous ulceration which attacks all parts of the PULTACEOUS STOMATITIS. 41 mucous surface (pharyngeal and tracheo-bronchial) that are reached by the atmospheric air. Nor do the aphtha? which accompany scarlet fever or measles require any specific notice in this place, constituting as they do a part of these formidable diseases, and to be noticed with the other symptoms and the treatment hereafter. LECTURE IV. DR. BELL. Pultaceous Stomatitis, or Muguet —Its Pathology —Treatment. — Pseudo- membranous Stomatitis. — Its complications with visceral disease — insidi- ous approach—Pathology — sometimes prevails epidemically—Treatment, modified by the state of the digestive system and degree of local excitement — Local applications — Means of properly applying mineral acids and lunar caustic — Sulphate of copper— Iodine, topically and internally — Warm bath. I continue a description of stomatitis by speaking of Pultaceous or Curdy Stomatitis, or Stomatitis with altered Secretion — Muguet __White Thrush. — This species has a greater affinity to the first described one, or the erythematic, than any other. It is peculiarly a disease which attacks, in preference, infants soon after birth, and those still at the breast. " It is characterized by a concretion of mucus on the surface of inflamed mucous membrane, whether this be an epithelium or not. This concretion may be observed in the mouth, oesophagus, stomach, and small or large intestines." {Bil- lard.) Pultaceous stomatitis begins with small specks on the surface of the inflamed membranes ; they are seen on the inside of the lips and at the tip of the tongue. Gradually they are increased, enlarge, and unite together as irregular, thin lamina?, which sometimes remain separate, then exfoliate, and are replaced by others in successive se- ries. Sometimes, on the other hand, they become thicker and more diffused, so as to run into one another and form a continuous mem- brane, which lines the cavity of the mouth and covers the surface of the tongue, extending even over the pharynx and oesophagus, and, as M. Billard asserts, continued into the stomach and the whole intesti- nal canal. In the first or simpler form the disease is called discreet, in the latter confluent. Pathology. — Pultaceous stomatitis consists in an inflammation of the buccal mucous membrane, which soon produces a morbid secre- tion of mucus, of a white or curd-like appearance, that afterwards concretes and covers a surface of more or less extent. This pelli- cular or curdy production takes the place of the mucus which moistens and lubricates the mouth. Concretion in laminar shape, external to the epithelium and unaccompanied by ulceration, and its repeated removal and reproduction until the inflammation is ex- hausted, distinguish this kind of stomatitis, the true muguet of French writers, from the aphthous or ulcerous species. The causes of this disease, as laid down by M. Billard, are, " the first period of infancy — bad nutrition — the assemblage of a great number of children in the same place— debility — inflammation of 4* 42 DISEASES OF THE DIGESTIVE SYSTEM. the buccal membrane, — and lastly, the disposition which the mucous membrane exhibits in young children to be covered, when they are inflamed, with thick, curdy, and membraniform concretions." " As to general symptoms, they scarcely exist in very young in- fants; fever is hardly ever manifested. I counted," says M. Billard, " the pulse and the beatings of the heart in forty children, aged from one to twenty days, affected with it, and found fifty, sixty, sixty-five, eighty, and, in one instance, one hundred pulsations in a minute. With the exception of the last case, the number of pulsations did not differ from the natural state of the pulse." M. Billard, you ought to be apprised, does not believe that there is greater frequency of pulse in infants than in adults ; but in this opinion he is not sus- tained by the experimental observations of other physicians. The skin is usually hot and dry. When the membraniform concretions spread to the tonsils, and cover the pillars of the velum palati, the cry is husky. Sometimes, and the fact merits your attention, pulta- ceous stomatitis is complicated with other phlegmasia?., In fifty cases, fatal either from the disease or its complications, there was disease of the digestive apparatus in thirty-two. Season is said not to exert any marked modifying influence in causing muguet. It prevailed, according to M. Billard, with almost equal intensity, and at all times, at the Hospice des Enfans Trouvh (Foundling Hospital). But the statement which he gives is not in unison with this assertion. In the quarter ending in March, 1826, out of two hundred and ninety patients, there were thirty-four cases of this disease. In the quarter ending in June, out of two hundred and thirty-five patients, there were thirty4ive cases; in the three months ending in September, out of two hundred and thirteen sick, there were one hundred and one cases; and forty-eight cases in the quarter ending in December among one hundred and eighty-nine patients. Thus we see that the actual numbers in each quarter were respectively, 34, 35, 101 and 48, showing nearly three times as many in the third or summer quarter, as in the winter and spring,and more than twice as many as in the autumn. The proportion of the sick with muguet to other diseases in the Hospital, were as 1 to Si in the winter ; 1 to not quite 7 in the spring; 1 to a little more than 2 in the summer, and 1 to not quite 4 in the autumn. The contagiousness of this kind of stomatitis, believed by many, is denied by M. Billard, who refers to, while confirming, the expe- rience of M. Baron. This gentleman has often seen children drink from the cup used by those who have been affected without their contracting the disease. Treatment. — The remedies for this kind of sore mouth are nearly the same as those recommended in other kinds of stomatitis. In sim- ple or discreet muguet, it will be sufficient to cleanse the mouth with a little piece of sponge, or of lint, tied to the end of a quill or small round stick, after dipping it either in a simple mucilage, or in one slightly quickened with vegetable acid; and to alter somewhat the intestinal secretions by a mild laxative. But in confluent or diffused pultaceous stomatitis, or muguet, we should apply fomentations or cataplasms to the neck, and cooling saline gargles to the mouth, and PSEUDO-MEMBRANOUS STOMATITIS. 43 purge with a small dose of calomel, followed by castor oil and mag- nesia. The farther treatment will be regulated by the state of the stomach, accession of fever, and the appearance of the mouth. Minute doses of the alkalies, — carbonates of potassa and of soda, in solution with ipecacuanha wine; or ipecacuanha and chalk, the warm bath, and mildly astringent or stimulating washes or linctus to the mouth and fauces, will be brought into requisition, in the more violent cases of the kind of stomatitis now under notice. Of gargles, my preference is still in favour of a solution of the chloride of lime, or the fluid chloride of soda, to which, on occasions, in this, as well as in aphthous stomatitis, may be added tincture of myrrh, as in the fol- lowing prescription: — B. Liq. chlorid. soda?, Tinct. myrrhae, aa. f^ss.; Aqua? flu vial is, fgvi.; Aqua? Rosar. f§i. M. This gargle to be applied at intervals, as may be deemed necessary. In my observations on the different kinds of sore mouth, with inflammation, I have next to speak of the one which is charac- terized by a membranous or pellicular secretion, somewhat resem- bling that in croup, and identical with that which lines the fauces and pharynx in certain varieties of angina. After this, your atten- tion will be directed to the gangrenous sore mouth, the most vio- lent and unmanageable of all the species of stomatitis. Let me again impress on your minds the necessity of constantly being aware of the dependence of the local disease on the state of the general system, and especially on interrupted and perverted nutri- tion ; and the impossibility of removing the former unless the latter be corrected, and the permanent stimulants of pure air, wholesome food, and some exercise, be brought into operation on the frame of the little sufferer. 5. Pseudo-Membranous Stomatitis — Buccal Diphtheritis.— This is the most dangerous of all the stomatites. It occurs not only alone but in connexion with inflammation and a similar exudation on the pharynx, tonsils, or soft palate of children. Its seat is com- monly on the gums, where it first shows itself, the angles of the lips, and on their inner surface, and the lining of the cheeks, or the tip and sides of the tongue. It is more usually seen on one side only: at first appearing as small patches of a grayish-white or yellow, and irre- gularly rounded, it afterwards extends by the running of these toge- ther, and their becoming gray, dark, and livid; they appear de- pressed, owing to the projection on their margin of the surrounding mucous membrane. Laminae of the false membrane are, after a while, detached, to be replaced by others, leaving the mucous mem- brane beneath slightly eroded. At this epoch of the disease, the mem- branous formation extends over a part of the tongue, the gums, and the internal surface of the cheeks. During some days it is nearly stationary, after which there is a change, either by resolution or gan- grene. In the first contingency the patches at their centres, or their borders, begin to be absorbed, and there only remains a simple whi- tish streak, which gradually disappears, leaving no trace of disease. But when gangrene supervenes, we see some points on which absorp- tion takes place, whilst the rest of the tissue is completely mortified. This kind of stomatitis is complicated at times with bronchitis, 44 DISEASES OP THE DIGESTIVE SYSTEM. pneumonia, or inflammation of the digestive canal. Regarded as a pellicular inflammation, or one attended with exudation, for such is the etymological signification of diphtherite, this disease is not com- mon, but occasionally, as Drs. Evanson and Maunsell observes {A Practical Treatise on the Management and Diseases of Children), " we have seen and removed from the velum or back of the pharynx a thick pellicle of lymph; the mucous membrane beneath being in- flamed, but free from ulcer or slough. On the contrary, we have found from the first the inflamed surface beneath converted wholly into an ash-coloured slough or studded with patches of such." Happily this form of diphtherite is not so common as might be sup- posed from the remarks of some writers who apply this term to any spreading ulceration at the back part of the throat. It is always dangerous, and often the more so from the insidiousness of its ap- proach, and its having made extensive progress without any uneasi- ness in the throat, pain in swallowing, or other symptom to indicate the real nature of the disease. Sloughing in gangrene may be the result of any of the morbid conditions of the mouth or fauces of which we have spoken; but it is most liable to occur in affections of the tonsils, soft palate, or back of the throat; perhaps more particu- larly when attended by false membranes. " When inflammation of the tonsils or pharynx is very intense, ac- companied by false membranes, or occurring during scarlatina or any livid-coloured eruption, we may apprehend gangrene, particu- larly if the child be very delicate, badly nourished, or exposed to contagion (as when gangrenous sore throat prevails), or if gangrene of other parts of the body be present. We judge of the approach of gangrene by the local appearances and general symptoms, as when much or sudden prostration attends, or is induced by a dispropor- tionate degree of depletion ; while the colour of the inflamed part changes from a lively red to pale, or appears from the first of a livid or dusky red hue." {Op. citat.) When the isthmus of the fauces is affected the appearance of the parts betrays this state, accompa- nied by a sense of suffocation, and difficulty of deglutition ; which last becomes impossible, if the gangrene has extended to the oeso- phagus ; and when it has passed into the air tubes, there is a re- markable alteration in the cry or voice, which becomes hoarse or inaudible, with a peculiar cough, or wheezing respiration. Symptoms. — In the beginning of this disease, increased heat of the mouth is felt and complained of, and also pain, aggravated by the contact of any foreign body. The breath is fetid, and the sub- maxillary glands are engorged and painful. After a while the lips and gums are tumid and bleed, and a sanious saliva flows copiously from the half open mouth; the breath becomes more and more of- fensive, the face red and swelled, and the fever more or less intense ; there are, also, headache, restlessness, and vigilance. Gradually, when absorption has begun, these symptoms abate, and the conva- lescence sets in. Causes. — Membranous stomatitis attacks persons of all ages, but more frequently children from five to ten years of age than adults ; and of the former more boys than girls. (Taupin — Journ. des Conn. PSEUDO-MEMBRANOUS STOMATITIS. 45 Med. Chir., 1S39.) It. is most apt to occur in cold and damp wea- ther, and where attention has not been paid to cleanliness and ven- tilation, as where a number of children are crowded together in hos- pital wards, or small and close rooms. Sometimes this kind of sto- matitis prevails epidemically, but it does not appear to be contagious, although M. Taupin, who has paid great attentionto the disease, is of a- different opinion. It has been known to follow mercurial ptyalism, and it has been observed in fevers called by some continental wri- ters mucous, and at the termination of certain chronic maladies. It may, in fine, supervene on any of the diseases of infancy. Treatment. — The remedial measures to which we have recourse in pseudo-membranous stomatitis are nearly the same with those in aphthous stomatitis. The same prompt attention is required to re- move the external and other causes by which nutrition is deterio- rated, viz., impure air, bad and insufficient food, and personal filth ; and to substitute in their stead wholesome and appropriate aliment, pure air, bathing, and clean and frequently changed body linen. The condition of the digestive system must be ameliorated, it cannot all at once be relieved of disease, by mild laxatives, with the first dose of which we may combine a grain or two of calomel; and after- wards simple bitters, or a weak solution of sulphate of quinia. Concurrently with these means we attempt an abatement of the local malady, by leeches beneath the chin or under the jaw, if the glands be sympathetically swollen and inflamed. But, if good is expected from even local depletion, it must be in the first stage of the disease, and ere the system becomes prostrated, as if under the influence of a poison. In a more advanced stage, when the skin is cold and the circulation feeble, we may place considerable reliance on the effects of oil of turpentine, given at first in a dose of ji. with castor oil jij. to 3ss., according to the age of the child, and afterwards alone in a dose of 5ss. three times in the twenty-four hours, mixed with sugar and gum, — or, in extreme cases, with carbonate of ammonia. At this time a stimulating liniment, with turpentine oil as its basis, will be usefully applied, by rubbing, and by means of a piece of flannel dipped in the same to the throat and lower jaw. More stress is laid upon early recourse to local applications, and especially to those of a stimulant nature to the mouth, in this, than in the other kinds of stomatitis ; and above all, if the subject of it has been exposed to the deleterious influences so prevalent in hospitals and crowded and illy ventilated rooms. In the selection of these it is most prudent to begin with the milder ones, such as vinegar and water, fluid chloride of soda and water, tincture of myrrh, or a solu- tion of borax, or even of common salt, which last is a very good de- tergent ; and afterwards, if the excitement is feeble or rapidly dimi- nishing, we use those of a more potential character. Chloride of lime sprinkled over the diseased surface, is a favourable remedy of MM. Barthez and Rilliet. {Traite Clinique et Pratique des Mala- dies des En fans, torn, i., p. 266 — 26S.) The remedy must be re- peated so long as false membrane or exudation forms. Foremost in the good opinion of many, are the mineral acids, and of these the preferred one is the hydrochloric or muriatic acid. It may be used 46 DISEASES OF THE DIGESTIVE SYSTEA1. either as a common detersive gargle, sufficiently diluted or mixed with honey, in the proportion of one drachm of the acid to an ounce of the vehicle, or used as an escharotic undiluted, in which case it may be applied by a glass capillary tube, which, when immersed in the acid, takes up two or three drops, and afterwards put on the dis- eased surface, allows of their escape. In the common method of applying the acid with a sponge or dossil of lint tied to a quill, or a small rod of ivory or other stick, the acid is apt to be diffused over a greater surface than was originally intended. At all times, with- out great care, the teeth may suffer from this acid. On this account, as well as owing to its comparatively less stimulating nature, and a belief that the mode of action which it induces approaches nearer to the healthy one of the mucous tissue, lunar caustic is preferred by some judicious practitioners. It is recommended in solution — from a scruple to half a drachm, to the ounce of water — as a gargle or rather collutory. Preferably, however, to this, is rubbing quickly and lightly the diseased surface with a pencil of lunar caustic. There is one great advantage attending this latter method,—that it must be done by the physician himself, and hence that it will be properly done : whereas gargles left to be used by the mother or nurse are seldom applied as they ought to be, either through ignorance and timidity, or a false tenderness and fear of hurting the child. In dis- creet aphtha? it is also employed in substance; but pains are taken to touch each separate aphtha, in place of rubbing it over the whole diseased surface as is done in diphtheritis, and also in confluent aphtha?, particularly when the back part of the throat is the seat of either of these diseases. A still more favourite remedy with several who have written on this subject, and also tested its efficacy, is sulphate of copper, in solu- tion or as a linctus, in which ten grains, or even twenty and thirty, of this salt are added to an ounce of water or of honey ; or this salt alone may be employed in many obstinate cases. Testimony in favour of this practice is borne by Drs. Maunsell and Evanson, in the following terms: " From no other application have we derived equal benefit in the treatment of aphthae, muguet, cancrum oris, ulcer- ated sore throat, &c, &c. According to its strength, the solution of copper acts as a stimulant or escharotic, while its astringent power is of a higher order. Hence its applicability to a great variety of cases; while it is remarkable that under its use the surrounding in- flammation is lessened, as well as the ulceration improved." Powdered alum, blown into the back part of the throat, has been recommended by Bretonneau, when diphtheritis has extended that far : — " When sloughing has actually taken place, the most decided escharotics may be required to destroy the sloughing parts, and arrest the progress of the disease. For this purpose the muriate, or butter of antimony, is perhaps the most effectual and manageable of the escharotics, as its action does not extend beyond the part to which it is applied, nor is its use attended by inflammation of the surround- ing parts." There is yet another article of considerable activity, not hitherto mentioned by writers in this disease, but one in which I am disposed PSEUDO-MEMBRANOUS STOMATITIS. 47 to put no little confidence. I refer now to iodine, and particularly to the tincture and the compound solution of the iodide of potassium, -—the first prepared by dissolving two scruplesof iodine in an ounce of rectified spirit; the latter by dissolving a drachm of iodine with two drachms of iodide of potassium (hydriodale of potassa) in one ounce of water. With either of these the diseased surface may be painted over with a brush dipped in it; repeating the application after the lapse of twelve hours, — in less urgent cases in twenty-four hours. The tincture or the compound solution may be reduced in strength by dilution, — of the first with rectified spirit, and of the second with water, — in cases in which the pellicular exudation is not very thick, or the vitality of the mucous membrane is yet active, or where the stronger preparation has been found to be too severe. The advantages of the iodine used in this way are, that the morbid exudation is absorbed : sloughs, if they have taken place, are thrown off, and healthy granulations formed. At the same time that we use the iodine topically, we should, with no small reliance in its therapeutical virtues, direct its administration internally. With this view we give a simple solution of the iodide of potassium in a watery infusion of a bitter, at intervals of from four to six hours. The dose of the iodide will be from a sixth of a grain to half a grain, for young children. Its effects will, of course, be carefully watched, and if it prove irritating to the stomach, or cause any oppression of breathing, or restlessness and vigilance, for all these are occasional and unwelcome effects of this medicine, we must either suspend its employment or greatly reduce the dose. Carbonate of ammonia in full doses, of from five to ten grains, is also highly spoken of in this disease. Reference has been already made to bathing as a preliminary or incipient part of the treatment of this disease, in order to cleanse the skin of impurities, and to restore, in a measure at least, its function, suspended by accumulation of perspirable matter and want of com- mon ablution, as is the case under circumstances already explained. In the progress of the disease the warm bath ought to constitute a part of the regular treatment, and be used twice a-day, for about ten minutes at a time. In extreme cases and stages of the disease, sti- mulating pediluvia should be frequently had recourse to, as answer- ing all the purposes of counter-irritation, without the annoyance and troublesome sores, even of a gangrenous nature, which sometimes ensue on the application of blisters and even sinapisms to the extre- mities of subjects in whom capillary circulation is feeble, and the tissues prone to disorganization, owing to their lax temperament and imperfect and depraved nutrition. 48 DISEASES OF THE DIGESTIVE SYSTEM. LECTURE V. DR. BELL. Gangrenous Stomatitis — As a result of other kinds of stomatitis, and as a sepa- rate disease—Different opinions as to its violence and danger — Two states of gangrene of the mouth — Its Pathology — Common origin in the gums — Treat- ment, general and local— Emetics, tonics, and the warm bath and frictions — Iodine — Topical remedies —numerous —The chief one is sulphate of copper. I conclude my lectures on sore mouth with a notice of Gangre- nous Stomatitis. — This kind of stomatitis corresponds more nearly with gangrenous aphtha? than with gangrenous erosion of the cheek, or gangrene of the mouth ; names, these two last, given to a formida- ble and generally fatal disease. Gangrenous stomatitis may be the consequence or termination of any of the kinds of sore mouth already mentioned.and is frequently spoken of and described in this light; as, for example, by Andral {Cours de Pathologie Interne). Aphtha? are liable to degenerate into deep chancrous and eating ulcers, which soon become sphace- lated in subjects whose vital energy from defective nutrition is feeble. The supervention of this state in common aphtha?, or other kinds of stomatitis, requires a change of treatment, and a suspension of the liberal use of stimulating and caustic applications which may have been used before. Emollients, such as mucilaginous and slightly warm fluids, are to be applied to the parts; and not until gangrene is fairly begun ought we to attempt to aid them to throw off the now foreign and dead matter by stimulating substances, already mentioned. The other and more important, and unfortunately still less manage- able variety of gangrenous sore mouth, is that which spends much of its force on the cheek, and hence one of its names, gangrenous erosion of the cheek. It is also peculiar in being preceded by very slight inflammation ; indeed the chief and almost the sole evidence of this morbid state of the capillaries of the part is oedema and con- gestion, which soon yields to disorganization of the tissue. In this respect it- is analogous to anthrax or carbuncle. Antecedently, how- ever, to these changes in the substance of the cheek, are others in the mucous tissue lining this part, and also in the gums, which are designated under the title of cancrum oris—canker of the mouth. Owing to the different degrees of intensity of this last mentioned disease depending on the difference in constitution and circumstances of the patients, writers are not at all agreed in their opinion of its violence and danger. " The common canker," Underwood tells us, "is rarely troublesome to cure." It sometimes, he continues, makes its appearance in the month: at others, about the time of teething ; and frequently at the age of six or seven years, when children are shedding their first teeth, and the second are making their way through the gums, which are covered with little foul sores, exteud'- ing sometimes to the inside of the lips and cheeks. The worst va- riety of this disease which he saw was during the second period of dentition, when a child has been shedding a number of teeth to^e- GANGRENOUS STOMATITIS. 49 ther, leaving the rotten stumps behind, which have been neglected to be drawn out. The whole gums will then become spongy, or be the seat of foul spreading ulcers; and small apertures will be formed, communicating from one part to another, accompanied with an oozing of a fetid and some purulent discharge. Gangrene of the Mouth. — Very different from this is the gan- grene of the mouth, properly so called, in which, with M. Baron, we recognise two well-marked stages of the disease: — 1. An cedema- tous circumscribed swelling, characterized by a shining, and, as it were, oily appearance of the skin, and by a central body of more or less hardness, in which there is sometimes an obscure red spot, either on the internal or external surface of the buccal parietes. In this first, stage in young infants we do not meet with fever, or any symptom of reaction. 2. This central part presents an eschar which usually forms from within; the mucous membrane becomes disor- ganized, the bones are laid bare, all the soft parts, even to the perios- teum, mortify and separate in shreds, at the same time that the mucous or bloody matter, mixed with the remains of the gums or sMes of the mouth, flows out, exhaling an infectious odour. (M. Billard, op. cit.) Pathology. —Dr. B. II. Coates (N. Amer. Med. and Surg. Journ., vol. ii.), in a valuable paper on the " Gangrenous Sore Mouth of Children," says, coincidently with M. Billard, that its access was fre- quently preceded by no marks of visible disease, or at least none that attracted attention. The little subjects were, apparently, in merely a drooping or enfeebled state. Those met with in the Doc- tor's clinic, at the Asylum for Children below the city, in a low and unhealthy situation, were generally of feeble and anemic habit, that which is one of the chief, if not the chief predisposing cause of the disease. Sometimes the ulceration followed a common remittent or intermittent fever, insomuch that, at one time, whenever a child was brought to the asylum it was expected, as a matter of course, that its mouth would become sore. Dr. Hall {Edinb. Med. and Surg. Journ., vol. xv.) states that, in all the cases which have come to his know- ledge, this affection had been preceded by fever, acute disorder of the digestive organs, typhus, inflammation of the lungs, variola, rubeola, or scarlatina. The coincidence between gangrene of the mouth and pneumonia has been noticed very emphatically by different French writers {Taupin, Baudelocque, Barthez and Rilliet), and next in order of frequency of organs affected, after the lungs, is the intestinal canal,which is attacked either with acute entero-colitis or with soft- ening. A frequent concomitant, relatively considered, is gangrene of the lung, as I have elsewhere pointed out. {Stokes on Diseases of the Chest, 2d edition, Philadelphia, 1844, note, p. 325.) In illus- tration of the effects of debilitating causes, may be mentioned the great proportion, at times,of children congregated in an asylum who were attacked with this disease. Thus, out of 240 at one time in the institution, Dr. Coates tells us that 70 were more or less affected with the ulceration in question. The ulceration may begin in many parts of the mouth, but Dr. Coates tells us that, in by far the greater number of cases, it com. vol. i.—5 50 DISEASES OF THE DIGESTIVE SYSTEM. mences immediately at the edges of the gums in contact with the necks of the teeth, and most generally of the two incisors. The spread of the disease is, he thinks, uniformly from the gums to the cheek. MM. Barthez and Rilliet {op. cit.) tell us, that it occupies, in prefer- ence, the cheek and lips ; and that of the latter, the lower one is most frequently affected. When gangrene is formed, a fever of irritation is generally developed. It is aggravated by loss of rest, want of nourishment, and probably putrid matter finding its way to the sto- mach. To this latter cause, Dr. Coates refers a diarrhoea which almost uniformly comes on towards the close. We must not, however, forget the probability of a morbid state of the intestinal mucous fol- licles and membrane being coincident with that of the same tissue in the mouth, as has been already adverted to, when speaking of follicular stomatitis. Dr. Cuming {Dublin Hospital Reports, vol. iv.), in his " Obser- vations on an Affection of the Mouth in Children," as it occurred in the Dublin Institution for the Diseases of Children, says, that, in most instances, the ulceration, commencing in the gums, extends by con- tinuity of surface to the lips and cheek, but sometimes it commences in the lining membrane of the lips or cheek, and extends from thence to the gums. This disease is most liable to attack during the period of the first dentition. It is, however, he adds, frequently met with in children between three and seven years of age. The greater num- ber of cases under Dr. Coates's observation occurred between two and five years of age, but some as late as eight or ten. The period first mentioned is that which corresponds with Barthez and Rilliet's experience. Dr. Cuming has frequently seen it when the child had only six or eight teeth; and he constantly observed, that when it occurs thus early it is always the upper gum that is first and princi- pally attacked. This he conceives to be the mildest and most ma- nageable form of the disease. The most formidable variety, in his experience, is that which occurs in children between twenty months and seven years of age. Thickness and hardness have always occurred in the other situa- tions, besides the cheek, where this gangrene has approached the external cellular masses of the face. After reaching this stage a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly, and has always, in Dr. Coates's experience, been the immediate harbinger of death. I have seen the skin of the cheek and chin all black, or of a brownish hue, hard like tanned leather, in a fatal case of this kind of gangrene shortly before death. Billard directs attention to the coexistence of the affections of the teeth, the congestions of the gums, and the cedematous swelling of the face on the diseased side ; and he adds, this agreement establishes the existence of some connexion between the diseases of the gums and of the teeth, and gangrene of the mouth ; and he expresses his belief, that this latter disease may follow swelling and disorganiza- tion in the gums. If it should occur in a child in whom the second dentition had commenced, the consequences would be very serious, and might result in the loss of the teeth for the remainder of life. There is, in this disease, an increased flow of saliva from the mouth, GANGRENOUS STOMATITIS. 51 accompanied by great fever: the breath is sometimes fetid, without any perceptible lesion in the mouth. Treatment. — Before prescribing, we ought to be aware that the prognosis in gangrene of the mouth is unfavourable ; as we might suppose from the class of subjects who are chiefly affected, and the gravity of the disease itself as well as of its complications. Out of 29 cases collected by MM. Barthez and Rilliet, there were only 3 cured. If fully apprised, as we ought to be, of the antecedents of this disease, intermittent or remittent fever, or bowel disease, we must address ourselves earnestly and early to all the means adapted to alter this morbid condition ; and whilst doing so, to modify at once the functions of nutrition. With this view, a mild emetic of ipeca- cuanha will often be of service, followed at once by tonics, and among these the sulphate ofquinia, infusion of bark, calumba or of quassia, are to be preferred. Alternating with the quinia, and admi- nistered conjointly with the simple bitter, should be minute doses of iodine in its state of iodide of potassium, at intervals of four to six hours. Carbonate of ammonia is also to be used. Warm salt water bath, twice or thrice daily for a few minutes each time, followed by assiduous frictions, will contribute to the restorative effects of the preceding treatment. On purgatives we must not lay stress, after an evacuation of the bowels has been obtained by castor oil with oil of turpentine, in the proporlions already indicated. Mercury finds advocates in this form of gangrene as well as in aphthous stoma- titis, but we cannot rely on its local action to the exclusion of the interference by its impression on the general system with nutrition. The same remark applies, with still more force, to arsenic, which is directly adverse to nutrition, and on all occasions like that now under consideration we cannot afford an hour for vitality to retrograde, as would be the case by the diminished activity of nutritive life. Some may object, that iodine also attacks nutrition; but it is only in large doses that it acts in this way, and it does not produce that morbid impression on the nutritive centre, the digestive system, that arsenic does, and even, not unfrequently, mercury also. In small or moder- ate doses iodine quickens digestion and nutritive absorption, and increases, instead of diminishing, the bulk of the tissues and of the frame generally. Much and not unmerited stress is laid upon the local treatment in gangrenous sore mouth; but if we hope for more than temporary relief from this means, it must be when fully aided and sustained by the general remedies just indicated. Dr. Stewart {Practical Treatise on the Diseases of Children) very properly advises, in the forming stage of infiltration, the application of stimulating frictions to excite the absorbent vessels. Liniment of hartshorn may be used for this purpose, or a solution of muriate of ammonia, applied to the cheek by means of pledgets saturated with the solution. The disease being farther advanced, various substances, of a more or less stimulant and escharotic nature, are recommended ; such as lunar caustic, butter of antimony, the chlorides, as already mentioned in the treatment of other kinds of stomatitis ; also caustic potassa, and the actual cautery ; the last a favourite remedy with some of the French practitioners. In the use of these powerful 52 DISEASES OF THE DIGESTIVE SYSTEM. agents we ought, however, to be regulated by the extent of action of the tissues around the gangrened spot: if they be inflamed, and indicate a readiness to separate themselves from the mortified matter, we ought not to be too prodigal of astringents and stimulants, or escharotics; but rather use mild applications, such as the carrot or yeast poultice, or the slightly stimulating wash of a solution of com- mon salt, or powdered borax, on the part. There is one remedy which latterly unites more suffrages in its favour than any other, as a local stimulant and detergent, in gan- grenous sore mouth : it is sulphate of copper, the eulogy on which, by Drs. Evanson and JVlaunsell, in the worst and aphthous forms of sore mouth, I have already placed before you. I shall now add the unequivocally expressed testimony of Dr. Coates, who is also joined in opinion by some recent French writers, probably as a result, in a measure, of his experience, which was recorded some eighteen years ago {N. A. Med. and Surg. Jour., 1826). Dr. Coates's formula is as follows : — R. Sulph. cupri, 3'J- Pulv. cinchonas, ^ss. Aquae, %v. M. " To be applied twice a-day, very carefully, to the full extent of the ulcerations and excoriations. The cinchona here is not absolutely necessary, but operates by retaining the sulphate longer in contact with the edges of the gums." Sulphate of zinc, in solution with tincture of myrrh, was useful ; also, a simple solution of this salt, 5i- to an ounce of water. Extraction of the diseased teeth, or of the teeth of the diseased gums, early, is an important part of the cure. For the reasons already assigned we might, with some confidence, use topically the compound solution of iodine, as a suitable stimulant to the parts. There is yet a kind of sore mouth which,as far as our present know- ledge extends, is seen only in women during lactation, and hence I shall call it Stomatitis Nutricum. — The first notice of this disease which has met my eye is in a short communication from Dr. Backus, of Roches- ter, New York {American Journal of the Medical Sciences, Jan. 1841). But a more detailed description had been previously given by Dr. E. Hale (1830), in the Medical Communications of the Massa- chusetts Medical Society, vol. v.; also Am. Journ., April, 1842. The disease commonly begins with a hard pimple upon the edge of the tongue, generally at a little distance from the tip, which is very red and extremely painful. After a few returns, and not unfrequently after a first attack of this nature, the central spot ulcerates. The ulcer is deep, with hard elevated edges surrounded by an inflamed circle, and is still exquisitely painful. The location of these ulcers is generally the same as in the stomatitis of children, viz.. on the tongue and inside of the cheeks, but rarely if ever, upon the gums or the palate. The inflammation, however, extends to the fauces, and as we have seen in the case of muguet or pellicular stomatitis, is con- tinued on the oesophagus, stomach, and intestines ; and it is then ac- companied with diarrhoea. The ulcerations increase in depth, though STOMATITIS N7JTRICUM. 53 their extent of surface is not great. Dr. Hale has seen a considerable loss of substance in the edge of the tongue, which was only partially supplied when the ulcer healed, leaving the part jagged and uneven. The accession of the disease is represented by Dr. Backus to be very sudden ; " in three hours' time after seeing your patient in health, you may find her with a scalded tongue and fauces, and unable to con- verse or to take food." The appetite is good throughout the whole course of the disease, but the pain from taking food is so great that nothing but the mildest liquids can be borne. Although the patient becomes greatly emaciated, and her strength wastes rapidly, the secretion of milk is little if at all diminished, and the child continues vigorous and healthy. The subjects of this disease are, as before stated, women during the period of lactation. Sometimes, indeed, Dr. Hale has seen it during pregnancy ; but never in the first pregnancy, nor in a sub- sequent one, unless the woman had previously suffered from it while nursing; and even when it appeared at this time it readily yielded to remedies without any considerable constitutional irritation. Dr. Backus also admits that it sometimes appears during the latter months of pregnancy. Its attacks are not confined to any particular constitution or temperament; but are made at times on the most robust who have always enjoyed good health. Dr. Backus is in- clined, however, to believe " that females of a leucophlegmatic tem- perament and of dyspeptic habits, with habitually slow bowels, are perhaps more liable to its attacks than others." A woman who has once had this disease is always liable to a recurrence of it in every subsequent period of nursing. The prognosis is generally favourable, if too long a period be not allowed to pass after symptoms of debility and exhaustion have been manifested : and it is chiefly where there is a predisposition to phthi- sis pulmonalis that such appearances should excite solicitude, lest the constitution should be fatally undermined. Of course, under these circumstances we must be more urgent in our recommendation that the mother or nurse should wean the child, or hand it over to another and healthier person. Treatment. — This last mentioned measure is the most certain and speedy means of cure of this kind of stomatitis, and in some instances it is indispensable. The symptoms which require that the nursing should be suspended, are the violence of the diarrhoea and general exhaustion, more than the increased soreness of the mouth. As the stomach is sometimes disordered, an emetic of ipecacuanha will be of service. But this, although an occasionally useful pre- liminary to other parts of the treatment, is not indispensably neces- sary. Dr. Hale rests the cure chiefly'on tonics, such as the lime-water infusion of bark, given in the dose of a wine-glassful two or three times a day. Carbonic acid, as in bottled beer and porter and the effervescing salts, was found to be serviceable. When a laxative is proper, it is best given with some effervescing mixture, as, for example, powdered rhubarb mixed in water with the bicarbonate of potassa, o which a little lemon-juice or vinegar is added at the moment of aking it. When the porter has stimulated too much, and the effer- 54 DISEASES OF THE DIGESTIVE SYSTEM. vescing salts were agreeable to the patient, Dr. Hale gave a fermented solution of tartaric acid and sugar, as follows : An ounce of tartaric acid is put into about three gallons of water, with white sugar in quantity to please the taste : to this add two or three spoonfuls of good yeast, and stir it well when first mixed, and again after two or three hours; at which time, if necessary, add more yeast: let it stand quietly in a cool cellar about twenty-four hours; then draw it off and carefully bottle it. Sulphate of quinia is well adapted to some cases, and more particularly to those in which the debility is consi- derable. All stimulating tonics are injurious, and tinctures of all kinds are inadmissible. Dr. H. found it necessary to direct a discontinuance in the use of wine, a prohibition which ought to be the rule with mothers while nursing their children ; and the use of wine or of any fermented liquors the exception during this same period. Coincident with this view of the treatment of sore mouth of nurses is that of Dr. Backus, who places his chief reliance in chalybeates, combined with rhubarb and aloes, as in the following prescription : — R. Carb. ferri, grs. lxv.; Pulv. rhei et Gum aloes, aa. grs. xv. M. ft. mass., in pil 50 dividend. " Two of these pills should be taken twice or three times a day, or often enough to keep the bowels very open." Little value is attached to local remedies by Dr. Hale. When they are had recourse to, some of those heretofore mentioned, such as the chlorides, or a weak solution of the nitrate of silver, may be used. LECTURE VI. DR. BELL. Glossitis — Its varieties and causes — Symptoms — Termination —Diagnosis — Treatment—Importance of scarifications — Symptomatic or secondary glossitis ;— Treatment modified by the nature of the primary disease. — Parotitis — Pri- mary— Supposed contagion of—Terminations — Metastasis to other organs — Treatrnent — Secondary or symptomatic parotitis — That caused by mercury,— its treatment. In the description of the various species of stomatitis in the last two lectures, you have learned that the tongue is frequently affected, and, indeed, that the disease sometimes first manifests itself by aphthous or pellicular inflammation of its mucous membrane. But, in addition to these affections, which it has in common with other parts of the mouth, the tongue every now and then becomes the sole seat of in- flammation. This morbid state of the organ is termed glossitis, from >^a>!T3-*5 the tongue. Glossitis, though a term strictly applicable to partial inflammation of the tongue, induced by bruises from foreign bodies, or compression between the teeth, as in convulsions, or by irritants or corrosives taken into the mouth, or to symptomatic disease, as in violent ptya- lism, small-pox, scarlatina, &c, yet we seldom think of applying it formally, or carrying out a specially devised plan of treatment for it, except in eases of idiopathic or primary phlogosis of the organ. GLOSSITIS. 55 Before speaking of the probable causes and phenomena of this dis- ease, I will just repeat the paragraph in which Schill in his Semeio- logy* describes the circumstances under which it becomes enlarged, and the prognosis in consequence. " 454. Enlargement of the tongue maybe occasioned by hypertrophy, inflammation, or congestion. Inflammatory swelling of the tongue, if it occur in other acute diseases, as angina, pulmonary inflammation, measles, plague, or variola,yieids an unfavourable prognosis. Even non-inflammatory swelling of the tongue is a dangerous phenomenon, in acute diseases, especially in cerebral diseases which are combined with coma. If it be the consequence of mercury, of the abuse of spirituous drinks, of gastric inflammation, of chlorosis, of syphilis, or if it occur in hysteria and epilepsy, the prognosis is not dangerous; but the disease is always more tedious where the tongue swells, than where it does not. It is enlarged also by degenerescence and cancer." p. 169. Sanguine temperament and plethora, kept up by excessive and stimulating aliment, are spoken of as among the predisposing causes of glossitis,— the exciting ones being suppressed perspiration or other natural or accustomed discharges, and the immoderate use of spirituous liquors. But there must be some other circumstance which escapes our observation, and on which the occurrence of this disease depends; for we find, happily, no proportion between the combined operation of all the assigned causes and the frequency of the disease. Idiopathic inflammation of the tongue is a rare disease, and, I must add, as formidable as it is rare. The situation and connexions of this organ are such that, apart from the morbid changes in its own tissues consequent on its phlogosis, its enlargement exerts a pernicious in- fluence on respiration and deglutition, by the impediments which it offers to these two functions; and especially to the former. Glossitis has been divided into superficial and deep-seated ; the first attacking the mucous membrane and tissue immediately subjacent; the second extending to the substance of the tongue. - The first is the least dangerous. It is ushered in by the common symptoms of in- flammation, accompanied with some difficulty of deglutition; the tongue is painful, and the patient is sensible of its enlargement, which is evident on inspection. The pain is not great; the surface is dry and red, and after a while becomes coated with a thick tenacious mucus, sometimes mixed with blood, except at its tip and borders. There is an abundant flow of saliva, which, mixed with the mucus of the mouth, dribbles out continually from the angles of the mouth. Sometimes the sides of the tongue are studded with small ulcers, of a grayish colour, and excessively painful, which, in some cases, are quite deep, and exhibit schirrous margins. If the glossitis persist, or become deep-seated, the swelling in- creases rapidly ; speech, and the natural movements, are more and more impeded ; the tongue assumes a bluish hue, and its size is such, that it throws back the velum of the palate, presses upon the glottis * Published in one volume, with Aretaaus on iEtiology, in the Select Medical Library. 56 DISEASES OF THE DIGESTIVE SYSTEM. and larynx, and hence causes a troublesome cough, and, becoming too large for the mouth, protrudes externally. The mechanical im- pediment thus existing to a free return of blood from the head, causes a lividness of complexion, a protrusion of the eyeballs, and in fact most of the phenomena of strangulation, which are rendered the more obvious and alarming by the imminence of asphyxia, owing to the impeded respiration. In addition to some disorder of the senses,— vertigo, pain in the ears, indistinct vision, — complaint is often made of pain in the tract of the spinal cord and parts adjacent, from the cervix downwards. The constitutional symptoms are such as might be inferred from the violence of the local ones; the pulse is frequent, full and hard, but smaller, as the respiration becomes more difficult; the skin, which in the early stage is dry and burning, is at length bathed in a cold sweat; the thirst is excessive, and the urine deposits a lateritious sediment. Among the occasional effects of inflammation of the mucous membrane of the tongue, and, in a measure, a symptom of the disease, is a membranous exudation like that in buccal or pha- ryngeal diphtheritis, and in croup. The termination of glossitis is by resolution, suppuration, or gan- grene. The first of these is sometimes manifested as early as the second or third day, but seldom before the fifth or sixth : that in sup- puration is announced by diminished excitement of the system, with an accession of coldness over the surface of the body, or by a com- plete rigor, some diminution of pain if the abscess be superficial, an increase of swelling in some particular part, and finally a pointing which indicates more distinctly the place and the termination of the malady. Different is the case when the pus is deeply imbedded in the substance of the tongue, the muscular fibres of which, although forced apart, as by a wedge, do not yield as they would do if the supply of cellular tissue were more abundant; and hence the relief by suppuration is small in such a case. The termination of glossitis in gangrene is fortunately rare, and has happened only in constitu- tions extremely debilitated by intemperance or prior disease. Between idiopathic or primary glossitis and symptomatic or secon- dary, the diagnosis is made with tolerable ease. When occurring from acrid substances or poisons, the cause is obvious; and when following, or associated with pharyngitis, gastritis, variola, or ty- phous fever, the sequence and connexion indicate its source: the same may be said of metastasis of gout or rheumatism to the tongue, the inflammation of which follows the subsidence of irritation in other parts, and promptly disappears with its return to, or reappear- ance in, these or analogous parts. In all these cases we can have little solicitude respecting the swelling and inflammation of the tongue, which, as a symptom, is readily palliated and seldom is of itself dangerous. Treatment. — In primary glossitis of the profound kind, on the other hand, our prognosis willbe guarded,even if it is not unfavour- able. The remedies must be active and promptly used, and not desisted from until a marked impression is produced, by some abate- ment, at least, of the violence of the disease. Foremost of these GLOSSITIS. 57 is venesection, either from the arm or from the external jugular, to such an extent as to produce faintness; and to be repeated in four or six hours afterwards if the violence of the inflammation is not manifestly abated. Aiding the effects produced by the use of the lancet, is the application of leeches to the tongue itself, at the under surface : the oozing of blood from their bites should be encouraged by warm water held in the mouth, or, if this cannot be done, by warm moist cloths, or a sponge saturated with warm water frequently ap- plied to the bleeding surface. If any difficulty be experienced on the application of leeches to the organ itself, they should be put on the skin between the border of the lower jaw and the cricoid carti- lage, meeting at the median line just under the chin. Derivation is to be procured, as well as evacuations to diminish vascular excite- ment, by active purgatives, such as calomel and jalap, infusion of senna with salts, and stimulating enemata,—so as to cause the bowels to be freely and repeatedly evacuated. In a ease of extreme difficulty of deglutition, a drop or two of croton oil placed on the back of the tongue will often be carried down with the saliva and produce its wonted purgative effect. It would be a waste of time to rely on the common routine of diaphoretics; but recourse ought to be had at once, after venesection and leeching, to the potassio- tartrate of antimony or emetic tartar, in such doses and so repeated as to cause a powerfully sedative or depressing effect. With it we may conjoin either tincture of digitalis or of colchicum in adequate doses, to be repeated every hour until their peculiar and full impression is produced, or the disease is mitigated by their administration. For the purpose of counter-irritation hot pediluvia, or if there be a ten- dency to perspiration the warm bath, will be good adjuvants to the preceding remedies; but we must not regard them in any other light than as aids to more active means. In the early stage of glossitis, before congestion is so established as to threaten gangrene, ice to the tongue is sometimes serviceable — after bloodletting and leeching. But if the swelling remains unabated, and the parts assume a more livid hue, indicating what some have termed apoplectic congestion, and the respiration continues violently impeded, then must we have recourse to free and deep scarification of the tongue, in the direction of its length, from the base to its apex, and penetrating to its very centre. Several cases are on record, in which the danger was great, and death imminent, until this operation was performed. Its first and obvious effect is a free discharge of blood, which is sometimes followed at once by a lessened bulk of the tongue. But to insure the full efficiency of scarifications, they ought to be employed early, at least so soon as we find that no decided impression is made on the inflammation by the means already indicated. Delay subjects the patient to peril, by laborious and impeded respiration, and also to oppression and engorgement of the brain, which may go so far as to destroy life even after the partial abatement of the primary cause, the local disease. And, besides, the organ becomes so fixedly en- gorged, that the blood seems to form an integral part of its tissue, and after incision escapes by drops without any abatement of .its in- duration. There is a risk also, of acute inflammation supervening 58 DISEASES OF THE DIGESTIVE SYSTEM. on this state of congestion, and of the tongue being struck with gan- grene. In making the incisions, the only danger is of wounding the arteriae raninae. ~\i has been noticed, that large and deep as the scarifications may be, the retraction of parts, by the tongue resuming its natural size, is such, that they leave only scratches or imperfect traces of a wound. In cases in which suppuration has taken place in the centre of the tongue, but yet in which, although certain symptoms, as already enu- merated, indicate this occurrence, there is hardly any fluctuation or pointing, we must not stop short of very deep incisions to give vent to theconfined pus. As illustrativeof the advantages of perseverance in this part of the treatment, I shall repeat what Dr. Kerr, in a well written article on Glossitis,\n the Cyclopaedia of Practical Medicine, tells us on this point, when quoting from the Glasgow Medical Journal. The case occurred to Mr. Orgill. The patient, a farmer, fifty years of age, had suffered for some days from glossitis, and, besides other treatment, had undergone local bleeding by cupping at\d leeches, as well as incisions, half an inch deep, from as far as the scalpel could be made to reach to the tip of the tongue. The incised wounds bled freely, and the swelling was a good deal re- duced, but in the evening of the same day it became as great as ever; it was scarified still more deeply, and a castor oil enema prescribed ; this also gave great relief; but next morning the swelling had re- turned, with a peculiar lividity at the tip of the diseased half of the organ. An incision an inch deep was made with a scalpel, which gave exit to a gush of pus in a very offensive state ; and in eight days the patient was well. The sensibility of the organ on the affected side remained imperfect for a year afterwards, but was at length re- stored. ^ ' Few, if anyvwashes or gargles other than simple or slightly acidu- lated water'are required to aid the healing of the wounds caused by the incisions or of the canity from which the pus had escaped. There are cases in which the tongue is much swollen and inflamed in consequence of the constitutional and extreme effects of mercury ending in violent, ptyalism. An antiphlogistic treatment will gene- rally suffice for the cure ; but it may be necessary to have recourse to incisions in the manner already mentioned. Ice applied to the tongue has been before spoken of as one of the means of abating the violence of the inflammation after v.s. and leeching. In symptomatic glossitis the treatment will readily suggest itself with, and indeed as forming a part of, that of the original disease. Gangrene, and particularly where it assumes the appearance of carbuncle, is to be promptly met by free incisions, followed by the actual cautery and stimulating washes, such as solutions of the chlo- rides spoken of in my last lectures, and a solution of nitrate of silver. All the customary means are to be employed for supporting without exciting the general system. With this view, sulphate of quinia, wine whey, and light nourishing food will be administered. Parotitis — Cynanche Parotidcea — Mumps. — The term paro- titis, designating inflammation of the parotid gland, is derived from irzfwrio-, the Greek name of this gland. There are two varieties of PAROTITIS. 59 this disease, primary or idiopathic ; or, as called by some, specific, and the other accidental or secondary and symptomatic. To the first only the English term mumps is applicable. It is most apt to attack young persons, especially those of the male sex, just before the approach to puberty: but it seldom appears after the age of 25 or 30 years. It rarely attacks the same person more than once in his life ; and on this account, as well as its sometimes appearing about the same time, or in quick succession in several persons, it is commonly alleged to be contagious. As yet no morbific matter of a peculiar nature, and capable of causing the disease in another and healthy person, has been secreted by, or at least has been detected on, a patient with parotitis. There are also abundance of cases in which no trace of contagion could be ascertained, but which originated from exposure to cold or analogous causes. Sometimes it has prevailed epidemically. Parotitis is ushered in, generally, by the symptoms common to in- flammation, such as rigors, lassitude, acceleration of pulse, and hot and dry skin. To this succeeds a feeling of uneasiness, and then shooting pain in the parotid gland, some swelling under the ear, and impediment in mastication. More commonly, the swelling is on both sides, and increases to the third or fourth day, accompanied with hard and frequent pulse, thirst, headache, loss of appetite, and at times a great heaviness. When the inflammation, or at least tumefaction, is participated in by the sub-maxillary glands, velum palati, tonsils and pharynx, deglutition becomes excessively painful, and for a period impossible. In other cases, again, the swelling is more cedematous than inflammatory, and the constitutional symptoms are very slight. The most usual termination of mumps is by resolution, which occurs in most subjects on the fourth or fifth day from the beginning of the swelling. The accompanying, or as some might regard it, critical evacuation, is by sweat over the region of the gland and ad- joining portion of the neck and head, and sometimes over the whole body. Suppuration is a termination of rare occurrence in primary parotitis ; when it does occur, it is announced by the customary symptoms, — prominence of the swelling at a particular point, and softness and fluctuation, with a bluish hue and sluggish circulation of the skin above the tumour. More generally, however, as I have just said, resolution takes place, and there is a prompt diminution and almost disappearance of the swelling. But, at the same time, another and remote organ, the testicle in males, and the mamma or external parts of generation, and at times the ovaries, in females, and more rarely the brain, become, by metastasis, the seat of inflammation. When the disease is con- fined to one parotid, the testicle or mamma of the same side is affected. Sometimes the disease is retransferred from the genital organ to the gland, a change which may be followed by a second metastasis from this latter to the former. Cases are related, in which subsidence of inflammation of the testicle has been followed by wast- ing away of this organ. Treatment. — The remedial means in parotitis are, in general, quite simple. A saline laxative, reduced regimen for a few days, 60 DISEASES OF THE DIGESTIVE SYSTEM. and an avoidance of dampness and cold, will suffice in most cases. If the fever should, however, be high, and the pain and difficulty of deglutition considerable, a small bleeding from the arm, or a few leeches over the gland, followed by a cathartic of calomel and jalap, and antimonials, will meet the requirements of the case. Metastasis to the testicle will be treated by cooling applications to this part, and a suspensory bandage if the patient should be up and move about ; and also by a stimulating liniment rubbed over the parotid gland, or a sinapism of mustard applied to this part, with a view of re- storing the inflammation to its original seat. Fever accompanying the metastasis will be obviated by the same remedies as are adapted to the original disease. If arachnitis by metastasis ensue, an active antiphlogistic treatment should be at once instituted for its removal. Secondary or Symptomatic Parotitis requires little else than topical remedies, such as cataplasms in the first stage, and detergent washes if suppuration is declared, — other than the treatment adapted to the particular disease in which the parotitis manifests itself. In- flammation and abscess of the parotid are occasionally met with in fevers, such as typhus and plague, and in the eruptive ones, as in scarlatina and measles. I have seen the gland entirely exposed by the breaking of an abscess and loss of the teguments, in the case of a child with scarlatina. My little patient recovered notwithstand- ing, and the opening gradually closed without much disfiguration. The chief dressing was of lint and solution of chloride of lime. Mercurial Parotitis. — A variety of parotitis once quite common, in connection with similar inflammation of the other salivary glands, from the excessive use of mercury, is now, happily, of rare occur- rence. The salivation in these cases, which was merely a symptom or an effect of the morbid excitement of the salivary glands, was spoken of as the disease, against which the remedies were chiefly directed. But if we fix our attention on the parts really diseased, viz., the buccal mucous membrane, and the glands connected with it by their excretory ducts, we shall have little difficulty in devising a treatment adapted to the exigency. Fever, if high and accompa- nied by parotitis, stomatitis, and even sometimes glossitis, will be removed by venesection or leeches over the parotid and sub-maxil lary glands, to be followed by fomentations to these parts ; or, if the state of the patient, owing to the nature of the antecedent disease for which the mercury had been given, forbid the detraction of blood, we have recourse to purging by saline medicines, and to potassio- tartrate of antimony, at first conjoined with nitre, or, in dilution with purgative salts, and afterwards with opium. The extremes of cold or of heat should be avoided, and the feelings of the patient be the guide as to the amount of clothing, fire in the room,&c. : but the ad- mission of cool air, so as not to blow on the patient, will be service- able. The warm bath daily is one of the best means of keeping up a moderate action of the skin, by which the cure will be greatly ac- celerated. Of the various gargles recommended on these occasions, the milder or mucilaginous are the best in the acute stage, and after- wards an infusion of green tea, or a weak solution of sugar of lead. The last is apt to cause a temporary discoloration of the teeth. If GLOSSITIS. 61 there be mercurial ulceration of the mouth, hydrochloric acid, or the nitrate of silver may be employed in the manner recommended in a preceding lecture. In the treatment of a case of mercuria salivation, we cannot pro- pose to ourselves, nor promise our patient, that it will be arrested at once by any kind of treatment. On the contrary, like all kinds of poisoning, of which this is one, time is required both for an elimi- nation of the deleterious agent from the system and for a subsidence of the morbid phenomena, such as depraved secretions, and per- verted innervation to which it had given rise. Symptomatic and oilier varieties of salivation not mercurial. — We sometimes meet with salivation either occurring spontaneously or from other medicines than mercury. In these cases the salivary glands, though excited, and in some cases even paler than natural, are not inflamed. Spontaneous salivation is also called idiopathic. Occa- sionally, this variety is accompanied by all the symptoms, even to fetor, which are supposed to be diagnostic of mercurial ptyalism. More frequently the increased and continued flow of saliva is symp- tomatic of disease of some other organs. We must regard as proofs of continuous sympathy the salivation that accompanies the chew- ing of various substances, and some diseases, such as tonsillitis and certain varieties of angina; and, also, diseased tooth, or irritation of the gums, as in infantile ptyalism. Not dissimilar, although the original irritation be somewhat more remote, is the ptyalism often met with in dyspepsia, and particularly in pyrosis, the immediate source of the latter of which may be regarded as an excess of sali- vary secretion. Gastric derangement, the result of intoxication, frequently causes temporary salivation ; a torpid state of the bowels has given rise to the same result. Abundant salivation has been seen in consequence of deranged or excited states of the nervous system, as in nervous and hypochondriacal subjects, and in those who had imagined that they had taken mercury. Manifest sympa- thy is noticeable between the salivary glands and the uterus. Under these circumstances we must not be in haste to check the flow of saliva, as dangerous effects have followed attempts of this nature. Critical salivation forms an important part of the study of semeio- logy. I can only advert to it just now ; and dismiss it with mention- ing that it occurs in some fevers, small-pox, gout, phthisis, angina, glossitis, mania, and some other cerebral diseases, and dropsy. Various medicines, besides mercury, act as remote sialogogues. Of these we may mention iodine and its salts, chlorine and bromine, and some of their compounds, digitalis, arsenic, the salts of anti- mony and lead, the terchloride of gold, prussic and nitric acids, mix vomica, watery infusion of hemlock, when injected into the veins of a horse. For numerous interesting particulars relating to the phy- siology and pathology of the saliva, I would refer you to an elabo- rate paper by Dr. Wright, in successive numbers of the London Lan- cet for 1842. vox., t.—6 62 DISEASES OF THE DIGESTIVE SYSTEM. LECTURE VII. DR. BELL. Diseases of Dentition — Predisposition to numerous diseases in early infancy — Causes besides dentition —The susceptibility of the organs of the child, and peculiar exposure to external agents—Sympathies of the dental apparatus — Direct and remote —Treatment during dentition— hygienic and medicinal — The measures chiefly demanded. Diseases of Dextition. —There must, almost of necessity, be some vagueness in the ideas associated with the expression Diseases of Dentition. They are often confounded with the diseases of the period of dentition, and particularly of that which elapses from six months after birth to the appearance of the deciduous teeth. This is the period of the greatest mortality, of course, that in which the pro- bability of life is less than in the years immediately succeeding it. Dentition is one of the contributing causes ; but it is only one, and even though it were the chief, there would remain many diseases, the origin of which must be traced to other sources. The exces- sive activity of the organs of nutrition, and impressibility of the ner- vous system in early infancy, and the excitement, so apt to become morbid in consequence of the change of food from that of the mother's breast to various articles of a more stimulating and hetero- geneous nature, throw the system of the young being open, in a peculiar degree, to irritation of any kind, and a fortiori to that from teething. If, to these we add the extremes of heat and cold, to which, from the ignorance of parents and the carelessness of nurses, infants are so much exposed, we can have some idea of the strain upon the tender organization and naturally great susceptibility of the child during the period of first dentition. You need hardly be told of the great vascular and nervous supply to the dental apparatus, and the excitement of both the nerves and bloodvessels during the growth of the teeth. The direct sympa- thies, by means of the great and important sensitive nerves of the fifth pair, between the dental arches and all the senses, and the readiness with which febrile action must occur under the excitement of these parts during their nutritive erethism, are inferences which, irrespective of positive experience, might almost be drawn d, priori, from a survey of the anatomical relations between the teeth and ad- joining organs of the face and head. The indirect and reflex sympa- thies by which, through the irritation of the brain consequent upon morbid excitement of the dental apparatus, remote organs suffer, is also explicable though not so immediately obvious. In this way the stomach and digestive apparatus generally, the respiratory and secretory organs, including under this latter the s%in, are so often affected during painful and laborious digestion. It may be made a question, whether the functions of these organs are deranged in consequence of the primary excitement transmitted by the dental apparatus, or are predisposed to be morbidly excited by other and common agenis, such as cold and moisture giving rise to catarrh, bronchitis and pneumonia, great heat to gastric and intestinal dis- DISEASES OF DENTITION. 63 eases, wrong food to similar affections, and diseases of the skin, &c. On a review of all the premises, we should lean to the latter of these two opinions, while we cannot deny that at times dentition seems to be the direct exciting cause, since the disease is developed with- out any notable or sometimes any obvious or appreciable change in the qualities of the ingesta or sensible states of the atmosphere. Your physiology will have taught you the obedience of the muscular to the nervous system, and that any undue excitement of the latter is immediately followed by violent and irregular action, spasmodic or convulsive, of the former. Now, with an irritation of large branches of the fifth nerve continued for many months, acting on a susceptible brain, we cannot be surprised that at any moment of this period a slight exacerbation of the irritation should cause a re- flex action on the muscles, manifested by convulsions. Not seldom, during this period, the cerebral irritation and its reflexion on the muscles are the consequences of morbid impressions transmitted from an excitable stomach or intestine, and caused by food irritating either by its indigestibility or its excess. With this view of the subject we cannot be either ignorant of the nature of the morbid phenomenon as they present themselves during dentition, or negligent of the appropriate means of relief. Topical irritation is manifested by increased heat and swelling of the gums, and its extension to the salivary glands causing an increased flow of saliva, one of the most common and generally accredited symptoms of teething. There are great differences among children as to the time when this process begins, as well as the ease with which it is accomplished. Dr. Ashburne {Med. Gaz., 1833-4) gives the follow- ing table, as exhibiting the average order of the appearance of the teeth of the first dentition : — Periods. Teeth. Seven month from birth . . Two central lower incisors. Eighth „ „ „ . . Two central upper incisors. Ninth „ „ „ . . Two lateral lower incisors. About ninth or tenth . . Two lateral upper incisors. „ twelfth or fourteenth . Four first molars. „ seventeenth, eighteenth ~> Twq ^.^ nineteenth or twentieth 3 ri Twenty-third to thirtieth . . Four last molars. There are many examples of children born with some of their teeth cut; and some of those who had not any till they were twenty months old : Duges {Diet, de Med. et de Chir. Pract.) states his having seen a young person who did not cut the m until she had reached the eleventh year of her age; and Smellie cites a case in which they were not even visible until the twenty-first year. The child experiences a troublesome itching of the gums prior to the eruption of the teeth, which prompts to rubbing them with its own, and to willingly submit to this being done by others' fingers, or by hard bodies, such as coral, &c. Morbid heat of the gums and mouth also makes the application of cold bodies to them, or mouth- 64 DISEASES OF THE DIGESTIVE SYSTEM. fuls of cold water, grateful to the child. The irritation at this time is often transmitted to the nose, and by the Eustachian tube to the ear, causing symptoms of coryza and pain in the ear, and a frequent turning and tossing of the head, and also to the eyes, as manifested by their watering. Starting in the sleep, and occasional twitches of the muscles of the face or contraction of the hands, are not uncom- mon during this period. Alternations of drowsiness and morbid vigilance succeed each other. Sympathetic disorder of the digestive canal is indicated by occasional ejection of the contents of the sto- mach, and sour and bilious discharges from the bowels. The skin is often hot and the pulse frequent, constituting a state of things ap- proaching to the febrile, — the more evident if the heat and redness of the gums be increased and salivation suspended. The urinary secretion is very irregular ; more commonly less, sometimes more copious than natural. There is often a circumscribed redness of the cheeks, and blotches or papular erythemas on this part of the face, and on the thighs, hips, &c, and eruptions on the scalp. " A symp- tom less common than any of the foregoing, and appearing in certain habits, is," as Underwood apprises Us, " a swelling of the tops of the feet and hands: it is seldom, however, of much importance, and goes away upon the appearance of the teeth." Where this symp- tom persists with aggravation, dentition is slow and painful; and there is a greater call for purgative medicines to remove the fre- quently accompanying costiveness. Another occasional effect of, or at least associated disease with, dentition, is laryngismus stridulus, or spasm of the glottis, on which I shall have occasion to address you more fully hereafter. Bronchitis is at times developed appa- rently under the direct excitation of teething ; but more frequently the bronchia and pulmonary mucous membrane acquire a morbid irritability from this cause, which renders them peculiarly sensible to atmospheric changes. Lancing' the Gums. — The treatment of the disease of dentition mtLst of course be modified by the organ or the apparatus which suffers most and the degree of morbid excitement. As in the case of all symptomatic fever of irritation, we attempt a removal, or if this is impossible, a mitigation of the force of the local and exciting cause. On the present occasion, we direct our attention first to the gums, and if we find them redder than natural, swelled, and painful or spongy, we can have little hesitation in lancing them, either with the shoulders of a common lancet or with a gum lancet. In perform- ing the operation we cut down direct on the tooth, and do not stop until we feel the edge of the instrument grating on it: nor can we be content with one incision, but must make another intersecting the first, at an angle more or less approaching a right one. In cutting down on the tooth, the incision should be not entirely on the summit of the gum, but also somewhat on the anterior face of this latter,__ very much as the swelling points and the tooth is seen to protrude, when it does rise from the gum. The fears entertained by some that, if the tooth does not soon appear after scarifications of the gum, the cicatrix will be an additional obstacle to its progress out- wards, are groundless ; for this, like all newly formed parts, is more DISEASES OF DENTITION. 65 readily absorbed than the original structure. Ulcerations of the gum, spoken of as a sequence of lancing it, are thought by expe- rienced writers, such as Underwood and Hamilton, to be more fre- quent in cases in which this operation had never been performed, than in those in which recourse has been had to it. There are cases in which, even though the gums be not swelled or protruded by the tooth, it will be advisable to cut down on this latter. The resistance to the passage of the tooth, as where denti- tion is backward, may be greater from a hard and not inflamed, than from a prominent and inflamed gum, and there may be greater necessity for removing this resistance, and removing the irritation by pressure, which the confined tooth produces in the subjacent nerve. Hence, when we are called to a child from eight months to twenty months old, and are required to prescribe for the relief of some vio- lent disorder, such as vomiting and purging, or high fever, or great restlessness, spasms, and general convulsions, it will be prudent, on inspection of the mouth, to lance the elevated gum when this pre- sents ; or if it does not, to make our incisions in that part corre- sponding with or covering the expected tooth or teeth. Even if we have not thought it necessary to begin the treatment in this way, it will be highly advisable to have recourse to it, when we find that the disease for which our assistance was invited does not yield soon to the common and generally recognised appropriate remedies. Not unfrequently, no other treatment is required for convulsions of vio- lent and frequent recurrence before we are called, than free lancing. of the gums and a warm bath. The persistence of heat, and flushing of the face and preternatural excitement about the head in dentition, will justify, in addition to scarifying the glims, the application of a few leeches under the an- gles of the lower jaw or behind the ear, and the administration of laxative medicines, and cooling drinks and a restricted regimen; and also warm pediluvia. Convulsions when violent, and recurring after the gums are lanced, will require venesection, the warm bath and opium. This last, after we are assured that the stomach and bowels are cleared of any indigestible or other irritating matter to them, is essentially required for preventing the return of convulsions, by allaying the exquisitely morbid irritability in some children of a nervoso-lymphatic temperament, when vascular and local determi- nation to any important organ are not evident. With the same view tonics, such as the sulphate ofquinia and the simple bitters, are useful; they should be given early iu the day,—and the warm bath or a mild opiate, such as a portion of Dover's powder, in the evening. Diseases of the stomach and bowels, manifested by vomiting and purging, and depraved secretions, will be met by the treatment adapted to them in other cases. But both in these, and in the affec- tions of the thoracic viscera during the period of dentition, we can- not expect a reduction of the morbid excitement by the same direct and frank treatment as we would iu subjects more advanced-in life, and in whom the nervous system is not so continually excited. The predominance of nervous symptoms, or rather the greater share 6* 66 DISEASES OF THE DIGESTIVE SYSTEM. which the nervous has than the vascular in the diseases of dentition, require of us to address our remedies more to the first than the second. In our hygienic as well as therapeutical treatment, we should constantly bear this fact in mind ; and accordingly we shall avoid expos- ing the child either to extreme cold or high heat, both of which are inimical to the nervous system; and endeavour to give it tone by tepid bathing and fresh air. In its dietetic regimen, care must be taken not to confound nutritive with diffusible stimulants. The former are tonic; the latter, whilst they excite fever, also tend to provoke and keep up nervous disturbances of various kinds. Among the most troublesome diseases of dentition are, eruptions on the face and scalp, sores of the ears, &c. These are really less alarming than other internal diseases, but they often excite more solicitude on the part of the mother, — by the disfiguration of fea- tures which they cause to her little favourite, — mixed with anxiety and impatience to have them removed. Now, if it be ever required of us to avoid the charge of nimia medicina, or an impertinent in- terference with nature at the risk of the patient's life, it is in these cutaneous affections of children. Not that we are forbidden to use remedies on the occasion ; but these must be directed to an improve- ment of the digestive and nutritive systems by general treatment, rather than any specific one, to carry off the eruption or dry up sores. I shall not pretend to particularise the different eruptions which harass infants during dentition, but proceed to the more important part of my subject, an indication of the best measures to be pursued for their treatment. If we bear in mind the fact, that the remote irritation which keeps up those diseases of the skin being that of dentition, must last for a considerable period, we shall be less tempted to urge the use of heroical or violent remedies; but rather content ourselves with moderating its intensity, and calling off the secondary irritation of the skin by revulsion to the bowels and increasing the natural secretions, than have recourse to repellent remedies of any description. The warm or tepid bath, according to the degree of excitement and the powers of reaction in the little patient, with mucilaginous applications to the skin,occasionally laxatives to maintain a regular state of the bowels, the use of small doses of calomel with chalk, and the chalk mixture or chalk powder, alternating with small doses of bitters and iron, will constitute the outline of the therapeutical treat- ment. The hygienic will consist in taking the patient out in the fresh air, giving it good cow's milk diluted with water, and in which some farinaceous powder has been mixed, in addition to, or in place of the breast of the mother, according to the period of lactation. But if, in addition to the cutaneous disorder, the child be puny, with- out suffering from fever or phlogosis, and its teething slow and painful, we may every now and then with advantage direct a some- what more nutritive and varied diet, — such as animal jellies and broths ; and counter-irritation to the skin on parts remote from that which is the seat of the eruption. In the preceding remarks, you will see that no attempt is made to ay down a specific plan of treatment for children during the period DISEASES OF DENTITION. 67 of dentition. This must vary with the constitution of the child and the particular disease, as well as the stage of disease under which it may be suffering. Your intercourse will often be with those who are overfed, and in whom a plethoric state is induced by this means, which throws them open to inflammation of the brain and convul- sions, or to gastric and intestinal disorder, and troublesome pustular eruptions. The mother will sometimes boast of the quantity of milk, in addition to that furnished from her own breast, which her child takes daily, as if the measure of capacity for liquid aliment were in fact the measure of strength. It will be difficult to persuade her, in advance, that she is doing wrong to her offspring ; and even when disease, such as bowel complaint, comes on, she will be prone to give broths in addition to milk, and condiments to flour in order to strengthen the digestion of the little sufferer, whose bowels she sup- poses to be disordered because they are weak. All that is neces- sary often in such a case, is a reduction to a third of the original quan- tity of food, and an increase of exercise, or of airing at least, in order to restore health and obviate many impending and alarming maladies. Dr. John Clarke, in his Commentaries on the Diseases of Children, is disposed to attribute most of the diseases of dentition to over- feeding and consequent plethora, and to improper kinds of food which produce irritation. To these he adds another cause, too often overlooked by experienced medical men in their attendance on sick children, but which is undoubtedly one of a serious nature. It is keeping the head too warm. I have had frequent occasion, as indeed almost every observing practitioner must have had, to notice the sores and eruptions on the scalp and behind the ears kept up by the unnatural and unreasonable and cruel fashion of wearing caps, and these often worked and embroidered so as to render them still more rough and irritating to the tender heads of infants. There are few instances of more expressive natural language, than that of the little being in its desire to tear off its cap under the annoyance of itching, heat, and other irritation caused by this covering, or in its pleasure when freed for a while from this incumbrance. I have found it, in some cases, impossible to cure sores and scalding of the ears so long as a cap was worn ; but in a few days after it was laid aside the dis- ease was almost, entirely well, without there having been scarcely aiiy thing applied, to quicken the curative process. Contrasted with the practice of keeping the head too warm, by giving it a covering in the house which it does not require, since, independently of its natural covering of hair, the abundant supply of blood to this region and its great vascularity insure a continued evo- lution of animal heat, is that of leaving the limbs, and particularly the lower ones, without adequate protection by clothing. Vitality in this part is relatively feeble, and extrinsic aid is required by fric- tion, bathing, and warm covering for the feet and legs, the latter of which are, commonly, exposed when the child is in the nurse's or mother's arms. After the little being is old enough to run about, the circulation is rendered more active in the lower limbs, and there is then less call for the precautious just stated, which are indispensably necessary before this time. Of one elementary principle of physiology 68 DISEASES OF THE DIGESTIVE SYSTEM. there is very general ignorance among the community, and oversight by too many physicians. 1 refer now to the established fact, that animal heat requires for its evolution a certain degree of energy of function of the nervous as well as the vascularsystems, and that one of the best means of excitation of these two systems for such evolu- tion is external heat and retention of animal heat itself by warm clothing. In the young of all animals there is less activity of calori- fication than in older and adult ones; and hence the necessity of additional means of protecting the former from the depressing in- fluence of external cold, and of fostering by external aids the gene- ration of animal heat. The young of birds are covered in a close nest by their mother's body and wings, until they have acquired their own natural covering and protection, their down and feathers, against atmospheric extremes, and especially that of cold and moist- ure. Provision is made by the parent for imparting some of its own warmth to its young, in the case of the mammalia which are not born with a hairy covering adequate to their wants in this particular. It is only in the young of our own speoies that in- stinct does not meet the exigency of the case, and false reasoning fails to supply the omission. During the night the child is covered in excess with body and other clothes, in a warm and often close and illy-ventilated room: during the day it is imperfectly clad,— its legs and arms, and breast and shoulders, are bare, and exposed part of the time to cross currents of air. Catarrhs, croup, bronchitis and pneumonia are common effects of this unequal and inconsistent ex- posure, which is as adverse to plain and well-ascertained physiological principles as it is to medical experience. Children require more ex- ternal covering, more warmth than adults : they have less energy of calorification and less ability to take sustained and regular muscu- lar exercise, by which the nervous and vascular systems are excited and animal heat is evolved. Even when acute disease is not pro- duced by this exposure of some of the most sensitive parts of the body to cold and moisture, there is a deterioration of the functions of nutritive life, and impediment to regular and easy dentition, with additional probability, if not the direct occurrence, of scrofulous tumours, and even of tubercles. The plain hygienic precept for avoiding many of the evils which I have just sketched, is, to protect the child by suitable clothing, and with this view to cover all parts of the skin which in after life are kept covered. The breast and shoulders and arms ought to be clothed, as they are among the most susceptible parts of the body to atmospherical vicissitudes and extremes. The common and hacknied but-ill founded excuse of a wish to harden the child; is not applica- ble to the practice of leaving naked and exposed these portions of the body; for, it is not meant that they should remain so after the child leaves the nursery, nor ever be so subsequently in any period of after life; at any rate in the male sex. In the texture of the gar- ments we shall be guided by the season; as to fashion, they ought to be always loose. It may perhaps be said that these considerations and details belong to the nursery, and are beneath the consideration of a Professor of DISEASES OF THE THROAT. 6S the Theory and Practice of Physic. But a little reflexion will soon convince you, without any argument from me, that the theory of medicine involves, in fact imperatively requires, a study of all the probable causes of disease, and of the circumstances which give them additional activity, or in any way modify them. As the highest and noblest aim of ethical philosophy is premonition and preven- tion, so in medical philosophy it is both more humane and more in- tellectual to devise means to guard against disease, than to display skill, learning and research in trials to cure, uncertain as we must be of a successful result, and knowing often that our best-devised efforts, in some cases, will almost certainly fail. LECTURE VIII. DR. BELL. Diseases of the Throat. — Their various origins and complications.—Retro-pha- ryngeal Phlegmon— Difficulty of diagnosis, and d an ire r of this inflammation — Cases. — Angina Simplex —Its causes, symptoms, and treatment — Sometimes associated with typhoid fever. — Chronic angina— Inflammation sometimes lo- cated in ihe uvula, sometimes in the palate — Treatment of the same. Continuing my notice of the diseases of the mouth and throat, I shall next direct your attention to those which consist in an inflam- mation of the mucous membrane lining the palate and pharynx and covering the tonsils. To these the generic designation of angina or strangulation has been applied, from angere, to suffocate or strangle, or rather from the radical term ayx00, J strangle; this being regarded as the sensation or symptom of the greatest moment and danger. Cynanche is also a generic term for the same class of affections : it having the same root, with the prefix cy, the real meaning of which we may, with Dr. Good, regard as doubtful, and hardly justifying at any rate the common explanation of its being from *»»», a dog, under the idea either that dogs suffered much from this kind of disease, or that the noise they occasionally made when thus afflicted suggested the recollection of that made by the human subject, when suffering under throat affections. The name used by Hippocrates of pari- sthimia, or throat affection, morbus faucium, is sufficiently plain and general; and its equivalent has been given by the older writers in our own language, under the title of quinsy, or rather squinsy or squinancy. The French corresponding term is esquinancie. I would apologise for thus occupying your attention with philology in place of medical description and narrative, were I not desirous of showing you that there is no real meaning concealed under these terms of learned sound, and that critical refinements of language are no substitute for pathological and therapeutical knowledge. Of late years more precise ideas are conveyed of the seat of affections of the throat, by referring them to their anatomical seat; and hence, al- though some writers still retain the generic title of angina or cynan- che, the specific and true designation is that of palatitis, tonsillitis, pharyngitis ; and for affections of the air-passages, glottilis, laryn- gitis, tracheitis, and bronchitis. 70 DISEASES OF THE DIGESTIVE SYSTEM. It may readily be supposed, however, from a very slight inspec- tion of the mucous membrane, continuous as it is from the mouth to the oesophagus, and analogous as the several portions of it are in this space, both in texture and organic function, that its morbid state is seldom restricted entirely to any one of these portions, although the subjacent muscular and other tissues perform somewhat dif- ferent offices. On this account it is occasionally convenient to use a term which shall serve to designate the inflammatory condition of the mucous membrane of the palate, isthmus of the fauces, tonsils. and pharynx, even although its use be arbitrary, and its acquired meaning different from its original and radical one. Angina and anginose, therefore, to a certain extent, hold their places in the me- dical descriptions of the present day, but in a very subordinate rela- tion to that which they once had. A physician is not now afraid of being thought illiterate, even though he should talk in English of diseases of the throat, instead of using Greek terms: but then it will be expected that he shall be able to show, when occasion requires, the anatomical seat and characters of these several diseases. Throat affections differ not only in the seat and extent of mucous surface inflamed, but also in their intensity, origin, and complications with other organic diseases. Often slight and of small moment, they are also often violent and alarming : sometimes very painful without corresponding danger ; and, again, with little complaint on the part of the patient, they prove suddenly fatal. They are either acute or chronic, primary or symptomatic; but wheneverthey appear in the lat- ter relation, they complicate the disease and add to its danger. Thus, in scarlatina, small-pox and measles, angina, particularly in the two first of these diseases, is of common occurrence ; and we measure often their danger by its persistence and violence It is met with in some of the worst forms of acute gastritis, and when established in chronic gastritis makes us less confident of a cure, — at any rate, of a speedy one. The same remark applies to certain forms of enteric disease. Sometimes angina accompanies fatal affections of the heart, and it is the only symptom of any note which arrests the at- tention of the physician, when it appears some hours before sudden and unlooked-for death. Common and pellicular or membranous inflammation, and ulceration of the fauces and pharynx, are fre- quently associated with, and aggravate not a little, disease of the air- passages, and particularly of the larynx and trachea. This compli- cation is most generally met with in an epidemic form. It is very obvious, therefore, from these considerations, that our prognosis in diseases of the throat should generally be guarded, and espe- cially so if we cannot detect after a careful inspection adequate cor- respondence between the local inflammation or other organic change, and the i mpediment of function of the part, and remote or sympa- thetic disturbance. Retro-Pharyngeal Phlegmon. — In some cases of an obscure nature, an abscess forms in the sub-mucous cellular tissue of the posterior pharynx, which, by pressing on the glottis, produces great distress,'and in some instances has caused death, without the physician being able to form a correct diagnosis of the disease. On this point RETRO-PHARYNGEAL PHLEGMON. 71 I would refer to Porter on the Pathology of the Larynx and Trachea. An interesting case of this description was quite recently related by Dr. Caspar Morris, and is recorded in the first Quarterly Summary of the College of Physicians of Philadelphia, 1842. The patient, a female near her term of utero-gestation, was seized with a severe chill, slight cough, and much greater difficulty of swallowing than could be attributed to the apparent condition of the throat, which was examined with great care, the tongue being depressed and the mouth well open. She could not lie down from a dread of strangu- lation. On the third day from the attack, she drank with tolerable ease, but was unable to swallow liquids or to lie down : she was unable to raise the natural tones of her voice ; the uvula was slightly swollen, and there was some small deposits of lymph upon it. There was little cough. On the fourth day there was entire aphonia, slight cough, and utter inability to swallow. " Gargles were applied with a syringe, and always with some relief; and frequently she was able to swallow small portions immediately after their use.'7 Dr. Morris " examined the fauces and neck at each visit, but without being able to ascertain any cause for the urgency of the symptoms." About 11 o'clock in the evening the labour commenced. In the intervals be- tween the pain she spoke freely with her natural tones of voice. Under the care of Dr. Hodge she was delivered on the following (Thursday) morning, at 7 a.m., being the fifth of her anomalous dis- ease. A few hours afterwards she was able to sit up so as to allow of a weak solution of sulphate of copperto be injected into her throat, " which she threw again from her mouth, but could not swallow. Her voice was hoarse, but there was but little cou^i, and no difficulty of respiration." At 11 o'clock on Friday morning she expired; having been visited frequently from the preceding afternoon up to this time by Drs. Hodge and Meigs in conjunction with Dr. Morris. The treatment consisted in free bloodletting on the second and third days of the disease, and leeching the throat a few hours after the first venesection ; and in the administration of morphia, and towards the last of stimulating and nutritious enemata. I shall give the con- clusion of this narrative in Dr. Morris's own words. " The interesting points in this case are the intensity of the arterial excitement, the dysphagia and aphonia, without a corresponding difficulty of respiration, or sufficient swelling and inflammation in those parts of the throat within sight and commonly affected, to ac- count for these symptoms. It was not laryngitis, nor bronchitis, nor pharyngitis, nor tonsillitis. The examination of the body re- vealed the whole mystery. Upon opening the trachea and larynx, the traces of inflammation were so slight as hardly to be recognised ; and we were disposed at one time to seek the causes of death in the brain, or some other organ. It was, however, determined to re- move entirely the pharynx, together with the base of the tongue, in order to look at them carefully from behind; in doing this an abscess was opened, situated between the oesophagus and the vertebra, containing about half an ounce of purulent matter, and so immediately behind the glottis as to account most satisfactorily for the difficulty of swallowing, and dread of strangulation expressed by 72 DISEASES OF THE DIGESTIVE SYSTEM. the patient, from the time the disease first assumed a serious charac- ter. There were also minute depositions of pus between the aryte- noid and cricoid cartilages, showing the cause of difficulty of speak- ing." p. 17. Dr. Ballot, physician to the Hospital of Gien, reports {Archiv. Gin. de Med., Oct. 1811) a case analogous to that of Dr. Morris, the chief feature of which I have just detailed to you. The subject was forty years of age, in robust health but for the deterioration caused by excess in drinking : he was in his calling much exposed to atmo- spherical vicissitudes. He had suffered for some days from an affec- tion of the throat when he entered the Hospital of Gien on the 27th of September, 1S37. Dr. Ballot found,on examination of the patient, that there was redness and dryness of the pharynx, but without appreciable swelling of any visible part of the throat : the pulse was full, and beat 100 in a minute: there was some difficulty in deglutition and respiration ; the latter of which was somewhat hissing, especially during inspiration : the voice was muffled. The patient complained of a feeling of uneasiness in the larynx, as if there was something which interfered with freedom of swallowing and breathing, particularly when he inspired. Dr. B., in carrying his finger far down into the pharynx, detected in a line with the upper part of the larynx a resisting yet elastic tumour, which seemed to be lost in the borders of the glottis, and which sensibly obstructed the opening of this latter. From time to time there was short, dry, and wheezing cough. The patient, though a man of fortitude and energy, is sad and restless; his face is pale, and expressive of anxiety. Sept. 21th, moiling, — The treatment was begun by venesection to the amount of sixteen ounces (500 grammes) in the morning. No relief following this evacuation, the same quantity of blood was taken away in the evening ; and a mucilaginous gargle, veal water for sole food, and mustard pediluvia prescribed. On the following day, thirty leeches were applied to the sides and front of the neck ; pediluvia in the evening, and a large blister to the nucha. On the 29th the re- spiration was very laborious, and the patient sometimes had fits of suffocation. Deglutition was not more affected than on his entrance into the hospital; an emetico-cathartic potion was given, which caused abundant evacuations both upwards and downwards. A new exploration of the pharynx did not indicate any change in the sup- posed laryngeal tumour. — 30th. Twenty leeches on the front of the neck; purgative draught; mustard pediluvia. On the four follow- ing days large doses of emetic tartar were given, and this seemed to prevent the increase of the symptoms, by prolonging the inter- vals between the fits of suffocation, during which the inspiration was always made with extreme difficulty,— incompletely, and with an evident hissing sound : but this slight amelioration was temporary only, and on the 6th and 7th of October, Dr. Ballot applied a large moxa on each side of the larynx. Notwithstanding these measures, the entire closing of the glottis was more and more imminent; and suffocation being threatened, the operation of laryngotomy was re- solved on, after consultation with a colleague who examined the state of the pharynx and larynx, and agreed with Dr. Ballot in opinion respecting the affection of this latter organ. RETROPHARYNGEAL PHLEGMON. 73 There was this peculiarity attending the operation, that, although the crico-thyroidean membrane was largely opened, the breathing was imperfectly restored ; and it was only until the canula was in- troduced, through which the air passed freely, that he felt himself better. Unfortunately it was difficult to prevent frequent displace- ments of the instrument; and notwithstanding the care taken by Dr. B., and his injunctions to be watchful, it was partially displaced during the night, and the patient expired from suffocation. Twenty-four hours after death, a post-mortem examination was made. On opening the larynx in front, through its entire length, the mucous membrane and the cartilages were observed to be per- fectly healllwy, and there was no oedema of the rimae glottidis ; but the opening itself was almost completely closed by a fluctuating tumour, of the size of a hazel-nut, which projected at the upper part. This tumour extended downwards to the cricoidean cartilage, and encroached on the cavity of the larynx: it was a continuation of a collection of white and well-concocted pus, in contact with the ante- rior face of the vertebral column and on the posterior coat of the oesophagus : thence the purulent fluid had diffused itself along the sides of the larynx, so that, on the left side, it was only separated by a few lines from the upper angle of the incision made in the middle of tlfle crico-thyroidean space. Here is found an explanation of the projection met with by the finger, on introducing it into the pharynx, and wlric.h was attributed to the swelling of the borders of the glottis, and also of the difficulty of the air passing through the opening made in the cnco-thyroidean membrane, as well as of the continual tendency of the canula to slip out from the opening. Dr. Ballot was prevented by special engagements from completing in detail the post-mortem examination, but he ascertained the state of the lungs, and that the posterior part exhibited a hypostatic conges- tion, and was emphysematic over almost its entire surface. The above case, as Dr. Ballot remarks, although not really cedema- tous laryngitis, serves to confirm the accuracy of the advice given by Bayle, to have recourse early to the procuring of artificial respiration in this disease. Even if we commit an error in diagnosis similar to that which Dr. B. made, the operation may still be most serviceable to the patient: only in place of having recourse to laryngotomy, as recommended by Bayle, a preference ought to be given to tracheo- tomy. The editors of the Archives refer to analogous cases recorded by different writers. In some, the purulent collections are formed be- hind the deep cervical aponeuroses, and spreading more towards the thorax, offer but little impediment to deglutition and respiration. An instance of this kind is given by M. Meandre-Dassit. (Theses de Montpelier, 1836, No. 78.) In other cases, the tumour being more superficial, or in the cellular tissue, between the vertebral column and the pharynx or oesophagus, may acquire so great a size as to induce suffocation. Many examples of this nature, under the name of retro-pharyngeal or retro-cesophageal abscess, have been furnished, such as that by M. Prion, recorded in the Bulletins de I'./cadcmie de Mcdecine, 1S30, and Archiv., 1K Series, t. xxii., vol. i.—7 74 DISEASES OF THE DIGESTIVE SYSTEM. p. 413, Mars, 1830. In this case, puncture of the abscess gave issue to half a pint of pus of good quality ; a second opening was followed by the discharge of the same quantity, of the colour of wine lees, and the patient was cured in a short time. Dr. Ballot's case was analogous to those in which the chief seat of the abscess was between the vertebral column and the upper part of the oesophagus; but in consequence of sinuses formed in the sides of the latter, and of their prolongation towards the trachea and upper portion of the larynx, it bears some resemblance to the abscesses mentioned by Dessault {(Euvres Chirurgicales, par X. Bichat, 2e partie, 1798, p. 256). M. Vernois records a case similar to that which has been detailed, in its nature and fatal terminatiQn, although the progress was slower {Traite de la Phthisie Laryngke, par Trousseau and Belloc, p. 73). Dr. Carmichael has likewise pub- lished a case of the same kind {Edinb. Med. Trans., 1820). A wo- man was seized with pain in the throat, dysphagia and dyspnoea, threatening suffocation. Tracheotomy was performed, but it did not prevent a fatal issue. The abscess was opposite to the seventh cervical vertebra, compressed the oesophagus and upper part of the trachea, and opened by a narrow orifice near the summit of the larynx. In the case reported by Dr. Ballot, the editors of the Archives, whose bibliographical notices I have just been repeating, think that if it had been possible to discover the real cause of the disease, and that tracheotomy had been practised in place of laryngotomy, the success would probably have been more durable and complete. Our diagnosis is the more difficult in cases of dysphagia and apho- nia, as these affections are sometimes the results of a temporarily depraved condition of the nervous system, and pass off without leaving any organic trace ; although at the time they are not a little alarming. I have thought it right to prepare you by these views and cases for appreciating better the details under the head of each separate disease of the throat; to which I now proceed to direct your atten- tion. Angina Simplex vel Diffusa, called also guttural angina. Some writers speak of this disease under the name of Erythematic Pha- ryngitis; but they attach to this latter a more extensive meaning than would be inferred from it anatomically. All agree in speaking of it as a simple inflammation of the mucous membrane of the throat, commonly affecting that part which covers the isthmus fau- cium, the velum palati, uvula and tonsils, and to a certain extent the pharynx; or the disease may be almost exclusively seated in the latter, and only a slight redness and irritation manifested in the other parts. Of itself, simple and diffused angina has little gra- vity. The symptoms are dryness of the throat, with frequent and painful attempts to swallow ; the inflamed membrane is at first red, dry, shining, and tumid, except at the uvula, which is re- laxed, and resting on the basis of the tongue stimulates to continual efforts to swallow and sometimes to vomit, and excites cough. After a while, the dryness of the membrane is succeeded by a secretion of ANGINA SIMPLEX. 15 stringy mucus. The membrane covering the tonsils is coated with a grayish layer. If the inflammation extends into the nasal cavities along the Schneiderian membrane, the voice is affected and becomes nasal; there is, also, sneezing, and a sensation of heat and dryness of the part, followed, as in the case of the mucous membrane of the throat, by an increased secretion, which gives relief to these unplea- sant feelings. As breathing through the nose is not easy at this time, the patient sleeps with his mouth open, and in consequence, when he awakes, the throat is dry by the evaporation of the mucus, and the first efforts, on awaking, to clear it by hawking and spitting are troublesome and rather painful. Cough with hoarseness may be associated symptoms, when the inflammation spreads to the glottis and larynx. Causes. — This kind of angina is most common in spring or in an open and damp winter, and it is most frequently excited by sudden exposure to changes of temperature, and particularly from heat to cold, and more by partial application of the cause, as when a person is much heated, and afterwards sits in a current of cool air from a window, or door, or crevice, than if he were blown on in all direc- tions. Alcoholic drinks, very hot or very cold liquids, caustics, irri- tating vapours, are also exciting causes. Sometimes it comes on without any obvious cause ; but this is more especially the case when it prevails, as it does, at times, epidemically. The subjects most readily affected with this kind of angina are the youthful and those of a sanguineo-lymphatic temperament. The symptoms have been already described. It may be well to know in addition, that simple angina is not so readily recognisable in young children, whose mucous membrane lining the throat is habitu- ally of that degree of redness which would simulate the colour of inflammation. It is, therefore, with subjects of this class, the more necessary to inquire carefully whether there is fever, any difficulty in deglutition or a regurgitation of food, and alteration of the voice ; and also, whether the redness, in place of being general, is not in patches or circumscribed. The termination of simple angina is, for the most part, in resolu- tion ; although sometimes suppuration takes place in the uvula or arch of the palate. When an abscess forms in the uvula it is known by the increased size, while abscess of the velum is easily distin- guished by the difference in the size and shape of the two halves, the one being depressed and convex, the other raised and of a con- cave or semilunar form. The presence of matter will also often be indicated by the sensation communicated on the application of the finger, as if pressing on a soft or fluctuating substance. Commonly the abscess is left to break of itself; but if it should be troublesome by its size and duration, so as to offer much impediment to degluti- tion, it ought to be opened by a bistoury with a sharp point and dull or covered edges. Our prognosis in simple or diffused angina is favourable ; but as the disease is sometimes symptomatic of scarlatina, our opinion must be expressed with more caution if the latter disease be prevalent at the time ; for of its results we cannot commonly speak with confi- 76 DISEASES OF THE DIGESTIVE SYSTEM. dence, varying as it does in its character from season to season. If the inflammation be restricted to the pharynx, remembering the pos- sibility of suppuration taking place, and the risk of pressure on the glottis and its consequences, 'we should be careful not to speak lightly of the disease, nor to hazard a favourable prognosis without some qualifying considerations. Another, but happily rare, variety of diffused angina, is gravida; the symptoms of which are more violent, but of an analogous cha- racter to those of the common variety. It runs its course with rapidity, sometimes destroying the patient in two days. Angina has been divided also into primary and secondary. The latter occurs after, or is associated with, other inflammations or specific dis- ease, such as the exanthemata. It, also, may be either mild or grave. Treatment. —In the milder and common cases of angina, rest in a medium temperature, abstinence from exciting food, and restriction to and the use.of demulcents and mucilaginous drinks, with a laxa- tive, such as a Seidlitz powder, and warm pediluvia, will generally suffice for a cure. But if there be fever, much soreness of the throat and pain in swallowing, and the habit full and plethoric or sanguine, a more decided impression must be made on the system by venesec- tion followed by purgatives ; or if the constitution illy bears general bloodletting, leeches may be applied beneath the angles of the jaw, and afterwards fomentations or cataplasms to the throat; and the disease persisting, the part is then to be rubbed with stimulating lini- ments. I think that I have seen marked beneficial effects result, both in this and other forms of angina, from the leeches being applied on the back part of the neck, or below and behind the mastoid pro- cesses towards the occipital protuberances. Failing to procure leeches, cups to this last mentioned region and on the nucha will form a very good substitute. An abatement of the more urgent symptoms having been procured by these means, we may trust the treatment for the remaining period, until resolution is completely effected, to mild antimonials and salines; and for the relief of the local irritation, to the inhalation of the vapour of warm water and vinegar, which is less fatiguing to the throat, and answers the indi- cations better than gargles. In some years more than others we meet with diffused angina associated with a fever of a low kind, — hot skin, frequent and soft or readily compressible pulse, loaded and white tongue, gastric uneasiness, and some thirst and headache. The chief noticeable symptoms are those of the affection of the throat, although I think we must regard this as rather a part or an effect of the derangement of the system generally, than as the main disease. Under these cir- cumstances an emetic is often serviceable, both by its relieving the stomach and abating the irritation of the throat. Stimulating lini- ments externally, and gargles, such as of the chlorides and of capsi- cum, are also to be had recourse to. These applications are the more called for, if the bright redness of the mucous membrane at the onset of the disease be soon succeeded by grey or ash-coloured spots. The bowels will be acted on by some of the stimulating purgatives, — calomel and jalap, senna and salts, and the compound colocynth TONSILLITIS. 77 pill. Mild diaphoresis induced by the acetate of ammonia, Dover's powder and the warm bath, will in these cases be entitled to confi- dence, after suitable evacuations of the bowels. Akin to these remedies are counter-irritants to the lower extremities, sinapisms, stimulating pediluvia, &c. Seldom is bloodletting called for — most generally indeed it will be injurious in the variety of angina now under notice, or that which is commonly called typhoid. Sometimes the diffuse or simple angina becomes Chronic : its chief features are a puffiness, owing to some slight submucous infiltration and a relaxation of tissue, alternating with dryness of the parts. In these cases moderate action of the bowels induced by the blue mass, and rhubarb and magnesia, or infusion of senna, and gargles of solu- tion of sulphate of copper, or of alum, or tannin, will suffice. If it still persist after this treatment, the iodide of potassium in solution, and touching the parts with the nitrate of silver, will be used with success. Without any difference in the cause or in the nature of the disease, the force of the inflammation is spent at times on the soft palate, or velum palati, or on the uvula, which parts become excessively en- larged. I have had a case in which the uvula was the size of one's little finger, and hard and rigid ; but although the symptoms were severe, the disease was quite amenable to venesection and purga- tives. The uvula was slow in returning to its natural size. Neither palatitis nor uvulitis requires a peculiar treatment, or one differing from that of simple inflammatory angina. The relaxation and elon- gation of the uvula after frequent returns of catarrhal inflammation may become so troublesome, by irritating the epiglottis and exciting cough, as to require strong astringents and stimulating gargles to be used, or even excision of a part of it with a scissors or other instru- ment. That which I prefer is the one introduced by Dr. J. K. Mitchell, of the Jefferson Medical College. LECTURE IX. DR. BELL,, Tonsillitis—Most common in young subjects—.Symptoms, duration, treatment-^- Importance of bloodletting—Purging—Gargles.—Chronic Tonsillitis—Incon- venience and even danger in this disease—An indirect cause of spinal curvature —Treatment, local and general ; by caustics and inunction and internal reme- dies—Diseased follicles of the tonsils—Morbid secretion,—how distinguished from tuberculous matter.—Morbid states of hearing and deafness caused by en- larged tonsils, and diseased mucous membrane of the throat.—Voice and speech modified from similar cause—Change of voice after extirpation of tonsil. Tonsillitis; or Amygdalitis — Angina or Cynanche Tonsilla- ris. — To this variety of angina the popular term of quinsy is more especially applicable. Often the inflammation in angina affects at the same time the tonsils, commonly on the surface, but sometimes, also, in their substance, as manifested by some enlargement of these bodies. The remark' just made respecting palatitis and inflamed 78 DISEASES OF THE DIGESTIVE SYSTEM. uvula, is applicable to a moderate degree of tonsillitis. The case is one of simple angina, and is to be treated as such. But it fre- quently happens, also, that, the tonsils are the chief seat of inflam- mation and of swelling, to such a degree as to render deglutition excessively painful, and for a while impossible;—the fluid being either rejected by the mouth, or returned by the way of the posterior nares through the nose. Tonsillitis is flne of the most common inflammations to be met with in northern and middle latitudes, in which the vicissitudes of weather, particularly in the spring and autumn, are so frequent. Sometimes it recurs periodically, and it is known, also, to prevail epidemically, and especially after the prevalence of measles or of scarlet fever. Its most usual cause is transition from heat to cold and moisture when the body has been previously heated. It often appears in women just about the time of the menstrual flux, if they have been suddenly chilled, or even after immersion of the hands in cold water. It may appear under the operation of the other causes, already enumerated, of simple angina. But it must be acknow- ledged that sometimes this disease shows itself without obvious cause. Tonsillitis affects all ages and both sexes, but it has been said to more frequently attack children and women. This popular belief is not, however, sustained by the observations of MM. Louis and Rufz, who found that, of sixty-four cases of tonsillitis, thirty-nine were met with in men and twenty-five in women. It would also seem to be the result of inquiries, instituted with the view of determining the question, that the disease is more common among boys than girls in boarding schools. Do not these results coincide with the expe- rience of most physicians, deduced from their own practice ? The inflammation is seldom confined to one tonsil. Out of forty-eight cases, both tonsils were affected in forty-one. Symptoms. — Tonsillitis may come on without precursory symp- toms or prodromi, and manifest itself by a sensation as if there was some extraneous substance in the throat, and by a difficulty of swallowing. More commonly it is preceded by the characteristic symptoms of all inflammations; such as chills, headache, thirst, loss of appetite, and febrile reaction. After a period of variable duration this state is succeeded by pain* in the throat, and a continual but often ineffectual desire to swallow. Deglutition is painful and diffi- cult ; the efforts to hawk and spit are frequent, and alternate with a hoarse and guttural cough ; the mucus expelled is clear and stringy ; the voice is muffled or entirely extinct. If the swelling of the ton- sils be great, so that they nearly meet, respiration is impeded, and, on occasions, to an alarming degree. On inspecting the throat, a duty never to be omitted in any dis- ease, however slight, of this region, by depressing the lower jaw, and keeping the tongue down with the handle of a spoon, or a paper folder or spatula, we see the enlarged and inflamed tonsils, and their investing membrane of a deep red or scarlet colour and dry, or presenting whitish concretions, or an exudation of lymph. The uvula and palate are commonly more or less affected at the same TONSILLITIS. 79 lime, and the former, particularly, is inflamed and elongated, and thus largely contributes to the frequent efforts at swallowing and desire to cough. Inflammation extending to the Eustachian tube, the hearing is affected, and sometimes even temporary deafness is the result; there is also complaint of ear-ache. With the local are associated, also, general symptoms of more or less intensity, such as headache, flushed face, tumid and glistening eyes, thirst, nausea, morbid heat of the skin and other concomitants of the febrile state. The bowels are constipated; and the urine, of a high colour, is not discharged without some feeling of heat or scalding. The duration of tonsillitis is from six to eight days: its termination is for the most part by resolution; but it is far from uncommon for it to be in suppuration. We infer that this latter has taken place when, without diminution of the swelling, the pain is considerably abated. and yet the difficulty of swallowing and of respiration is as great as ever. Inspection at this time shows that the abscess is pointing, or by its ready yielding to pressure manifests fluctuation. The bursting of the abscess is sometimes brought about by efforts of retching, or in coughing, and sometimes it takes place when the patient is asleep. The pus is generally of a fetid odour, and at times fetor is the an- nouncement of the bursting of the abscess. It is not often that both tonsils suppurate. There are instances of the opening for the dis- charge of the matter being external in place of into the throat. This is an unusual termination of tonsillitis; but I have had a case of the kind in the person of a beautiful girl, whose neck was much scarred by the cicatrix of the sore, which was slow in healing, and assumed for some time a scrofulous appearance. I did not see the patient until the tumour had attained considerable size externally, and the fluctuation was so manifest as to leave no choice but to give issue to the pus by a lancet. Treatment. — Without some strong contraindication depending on the temperament and shattered constitution of the patient, or the ex- haustion caused by prior disease, we may safely begin the treatment of tonsillitis by venesection. The earlier we have recourse to this remedy after the disease is fairly established, the greater the proba- bility of its terminating in resolution. Sydenham used (in quinsy} to " bleed plentifully in the arm, and presently after in the veins under the tongue." I pass over his mention of the gargle and lini- ment, which he directed, in order to repeat what he says again about bloodletting and purging. " I bleed again in the arm the next morn- ing, " he says, " unless the fever and difficulty of swallowing be in some measure abated, in which case I give a gentle purge, much experience having taught me that this is highly necessary and useful after bleeding." Nor does he even yet put aside the lancet; for he proceeds: " If this fever and other symptoms are like to be violent even after purging, which yet seldom happens, they are to be quieted by repeated bleeding, and applying a large and strong blister to the back." Here, in a few words, we find the rule of treatment of ton- sillitis laid down, which has been generally followed since the time of Sydenham by British and American practitioners. Sir John Priu- gle was content to adopt the practice of his distinguished countrymen so DISEASES OF THE DIGESTIVE SYSTEM. in the treatment of quinsy, as it appeared in the British army in Flanders. He tells us —"Its tendency to bring on suffocation re- quires speedy and large bleedings, purging, and blistering." He added another, and still a popular remedy, viz., the application of a strip of flannel moistened with volatile liniment to the throat, renewed every four or five hours. I have found that, notwithstanding recourse has been had to one or even two bleedings from the arm, the inflammation-will some- times persist, and with so much accompanying distress in deglutition and breathing as to require farther and active treatment. Under such circumstances, I do not hesitate to direct a considerable number of leeches, say from twenty to thirty on each side, to be applied under the angle of each jaw on a spot corresponding externally with the tonsils inside. In the course of a few hours after the application the greatest relief is obtained; either resolution takes place, or the suppurative .process is accelerated, and the abscess breaks. Pringle Was no stranger to the value of leeches in this disease, as he informs us that, at times, he has applied seven or eight leeches under the fauces; and he adds, in confirmation of the practice of Sydenham, " when the patient has been brought low by the loss of much blood from the arm, 1 have opened one of the veins under the tongue, and taken away two or three spoonfuls." Small as the quantity of blood here mentioned may seem, and few the leeches applied, a moderate acquaintance with the phenomena of disease shows us that a slight hemorrhagic, effort, as in a very small discharge of blood from the nose, or from hemorrhoidal tumours, will'sometimes be followed by an abatement, if not removal, of symptoms indicating violent disease of the brain or some other vital organs. By leeches in the vicinity of a diseased part we may sometimes simulate a critical hemorrhage, and procure speedy and complete relief far beyond that which would follow on the loss of a much larger quantity of blood from the arm. This remark, as far as it is meant to recommend leeching to your favour, is applicable chiefly, in the disease before us, to tonsillitis with little accompanying fever, or to that stage in which this state of the system has been materially diminished by venesection. In well-marked tonsillitis, attacking the young and robust, and associated with fever and a full and active pulse, we cannot hesitate, however, at least in the beginning of the disease, to give a preference to the lancet over leeches. Sometimes it will be desirable to apply the latter to a remote organ, to the vulva or anus, in cases of tonsillitis succeeding suppressed menses or hemorrhoids. Purging ought to follow bloodletting as pointed out by Sydenham. In the extent to which the former is to be carried, as well as in the selection of purgatives, we must be influenced by the temperament and functional habits of the patient. If he be of a lymphatic temper- ament and bowels habitually slow, we should purge freely with calomel and jalap, compound powder of jalap, infusion of senna and salts, &c. If, on the other hand, he be of a sanguine, or sanguineo- nervous temperament, and liable to, or suffering at the time from, chronic gastro-enteritts, we shall be content with a common laxative of rhubarb and magnesia, or of castor oil, and occasionally an enema TONSILLITIS. 81 to relieve the bowels. After bloodletting in this class of persons, febrile and inflammatory action is kept down by emetic tartar with neutral mixture, and Dover's powder. In all cases, after the abstraction of blood, warm, or even hot and stimulating pediluvia are to be employed. This measure is the more necessary after leech- ing the throat, in order to prevent an additional afflux of blood to this region ; an inconvenience which sometimes occurs after the operation of leeching. In cases in which local bloodletting is indicated, and leeches can- not be procured, the method practised by Pringle might be had re- course to with advantage : or, preferably still, cups applied to the back of the neck and behind the ear. Blisters to the throat, as some- times used by Pringle, and still a favourite remedy with some, I hardly ever employ. The local treatment of tonsillitis is for the most part simple : the inhalation of the vapour of hot water, warm water held in the mouth for gargling is too painful, and fomentation or cataplasms to the throat externally, after v.s. and leeches, being the chief means in the acute state When the disease persists in a sub-acute form, or when acute supervenes on chronic inflammation of the tonsils, and deglutition is impeded and respiration also interfered with, it be- comes sometimes necessary to scarify freely these bodies. This is done with a sharp-pointed bistoury, covered with muslin up to within an inch of its point; or what is safer in less experienced hands, a bistoury concealed in a sheath or a canula, from which the former is protruded when it rests on the tonsils. The point or edge will be used according as we intend either to puncture the abscess, or scarify by incisions the inflamed tonsil. If the swelling be accompanied with infiltration, and the redness not intense, touching the tonsils with nitrate of silver will occasionally stimulate the parts to a more vigorous absorbent action, and cause a diminution, if not removal, of the enlargements. Should more active applications than simple vapour or warm water be thought desirable, as the disease advances and the inflammation abates, and when there is a secretion of tough viscid mucus, causing constant efforts by hawking and spitting for its expulsion, a solution of acetate of ammonia or acetous acid may be added to the water; to the hot for the purpose of inhaling the vapour from the mixture, and to the warm, but of less strength, to be held in the mouth as a quasi gargle. The free secretion and dis- charge of mucus may itself become a means of diminishing the in- flammation ; and hence some stimulating solutions applied to the mucous membrane of the throat will be of service to aid the elimina- tion of the viscid phlegm, and favour its farther secretion. But we cannot promise ourselves much, or indeed any benefit from gargles in the common fashion of using them by the patient himself. The solution, of whatever nature it may be, as of chloride of soda or of lime, or of acetate of ammonia, alcohol and water, or even astringents, such as of alum, or the compound infusion of roses acidulated with diluted sulphuric acid, to be usefully applied must be directed on the parts by the aid of a syringe. This method, which some may regard as a refinement of late date, is especially recommended by Pringle3 82 DISEASES OF THE DIGESTIVE SYSTEM. who tells us that he found " little benefit from common gargles," or rather, it should be said, from the common method of using gargles. His "composition is thirteen ounces of barley water (or sage tea), with two ounces of mel rosum, and one ounce of vinegar." Some- times he added a spoonful of mustard for a greater stimulus. In all cases, whether of simple quinsy, or of angina maligna hereafter to be described, Sir John directed five or six syriugefuls to be injected, one after another, as far into the throat as the patient can bear, and the operation to be repeated three times a day. Chronic Tonsillitis — Enlarged or Hyperlrophied Tonsil.— In saying that enlargement of the tonsils is characteristic of, or equiva- lent to, chronic disease of these organs, we but indicate one of the most common symptoms; but with this may be associated morbid secretion or disease of the follicles, or morbid growth of the cellular tissue, or inflammatory engorgement kept up by vascular injection. Although hypertrophy of the tonsils is commonly the effect of fre- quent attacks of acute inflammation, it is sometimes congenital, or readily induced by slight catarrhal irritation, and maintained with- out apparently adequate cause. This is more especially true in re- ference to children and other young persons of a strumous or scrofu- lous habit. But although originating from slight causes, and in its course pro- ductive of little pain or distress, this early enlargement of the tonsils cannot be regarded with indifference, nor treated with neglect. It is a frequent sustaining cause of a troublesome cough in children of the habit already specified; and with some of them becomes indi- rectly the origin of spinal curvature posteriorly. The continued cough tends to draw up the shoulders, and throw the head forwards, and to cause a strain upon the walls of the thorax which extends to the spine. The little patient becomes round-shouldered, stoops, and after a while exhibits posterior curvature of the upper dorsal verte- bras. Hence, so soon as we discover enlarged tonsils in a delicate child of a lymphatic temperament, it becomes our duty to use all appropriate means, not only to remove this local affection, but to build up by wholesome food, pure air, and moderate exercise, the osseous system and locomotive apparatus generally, whilst attending also to the state of the digestive system as an important step towards the attainment of our object. Iodine has been recommended under such circumstances, and I have myself derived considerable advan- tage from prescribing it. Adapted as it is to correcting the predis- position to scrofula, of which we see so many evidences in the en- larged cervical glands, tumid lips, and other characteristics, we shall be the more encouraged to employ it for the removal of hyperlrophied tonsils. This medicine is to be administered in the form of iodide of potassium, both by inunction of the neck at the part correspond- ing externally with the tonsils, and also in solution internally. Chalybeate preparations are indicated on such occasions ; but more than all, must we lay stress on light yet nutritive food, much, but not fatiguing, play and exercise in the open air, and the tepid salt bath, with frictions in the length of the spine. A similar treatment is applicable to older and adult subjects with chronically enlarged CHRONIC TONSILLITIS. 83 tonsils. To such persons we can give, in addition and with more freedom, narcotics ; sometimes combined with purgatives, sometimes with tonics, and at times, but after mature deliberation, and with great caution, blue mass or calomel. The tonsils may also be cau- terised with nitrate of silver, butter of antimony, &c. All proper medicinal agents, general and topical, having been ap- plied, but without success, we invoke the aid of surgery for the re- moval of enlarged and hypertrophied tonsils. This is done either by the ligature or by excision. The latter is now the mode generally preferred. Various instruments have been devised or modified after the discoveries of others, for this purpose. That which I prefer my- self for use, is the one devised or improved by Dr. Fahnestock. But as there is a very natural aversion to submitting to an operation for the removal of the tonsils, which really has quite a formidable ap- pearance, although in general it is comparatively easy and safe, a physician is only justifiable in urging it on the patient whose health is materially injured, if not life endangered, by these morbidly en- larged glands. There are some persons in whom the tonsils are so hypertrophied as almost to meet together, and to render deglutition difficult, and breathing through the mouth during sleep laborious. With them a slight additional enlargement, as may readily happen from catching cold, will bring on the worst features of acute tonsil- litis, and extreme suffering if not imminent danger. After some abatement of the phlogosis an operation is both proper and impera- tively required. There are cases, on the other hand, and particu- larly in children whose tonsils remain enlarged after scarlatina or even acute tonsillitis, in which, finally, and without any treatment, these glands recover their normal size. A knowledge of this fact, which I have had occasion to note within the circle of my own practice, as well as to be apprised of analogous ones by other phy- sicians, will very properly induce us to pause before we recommend excision unless the call be urgent; and this can hardly be considered such, unless both tonsils are much enlarged and tend to a close ap- proximation. In many cases, the removal of one, even where both are diseased, will serve to render the patient comfortable. It has been already intimated that, associated with hypertrophy of the tonsils, there may exist a morbid state of their follicles. This is manifested by depraved secretions, as of a fatty or sebaceous mat- ter, or concretions consisting either of indurated mucus or of saline substances, such as phosphate of lime. The mucous concretions are susceptible of a change to such a degree as to become putrid and give rise to an insupportable fetor of the. mouth, constituting one of the causes of " bad breath." The true concretions sometimes distend the tonsils, and dilate the opening of the lacunas to such a degree that they may be seen with the naked eye, and even touched with a probe, if the mouth be opened and the tongue depressed. Persons who are thus troubled, sometimes spit them out, after they have fallen into the mouth or the pharynx. M. Blandin {Dictionnaire de Medecinc et de Chirurgie Pratique) states, that he frequently extracted concretions of this nature from the tonsils of a young man affected in this way. The operation, when necessary, is readily 84 DISEASES OF THE DIGESTIVE SYSTEM. performed by means of a long and delicate forceps. The annoyance may be so great, from the number and size of these morbid forma- tions, as to make it desirable to remove their cause by the extirpa- tion of the tonsils. There are persons, otherwise in good health, from the follicles of whose tonsils and pharynx are secreted fatty masses, which have a general resemblance in colour and consistence to the granules of phthisical expectoration. " From these latter, however, they may be at once distinguished by heating the substance on paper : if the secretion be derived from the follicles of the pharynx or tonsils, it is sebaceous, and leaves a greasy stain on the paper, which is not the case with pulmonary or tubercular granules." (Tweedie — Cyclop. Pracl. Med.) Impeded hearing. — A morbid state of the mucous membrane of the throat and enlarged tonsils are not unfrequent causes of impeded hearing, and even deafness. Mr. Yearsley {On Deafness from Morbid Conditions of the Mucous Membranes of the Stomach, Throat, and Ear, the Effect of Cold, Scarlatina, Measles, &c.) points out the various circumstances under which these morbid causes are operative. One of the most striking causes of deafness, and fortunately one most easily remedied, is that in which, after catarrhal inflammation of the Eustachian tubes, the tubes and middle ear are gorged with thickened mucus, which often remains fixed the whole life-time, unless accidentally displaced by a sudden respiratory action, as sneezing, or.during the effort of vomiting. The most ra- tional way of cleansing out the obstructed cavities would seem to be the injection of tepid water through an "Eustachian catheter, as per- formed by Wathen. The same end is obtained, and much more agreeably to the patient, by the injection of compressed air, after the manner of Deleau. Mr. Yearsley adopts the latter, and finds that a few operations, or even one, will break down the agglutinated mucus, and admit air to the tympanum, so as to reproduce the hear- ing in a most remarkable manner. Morbid growth of the tonsils is a more frequent cause of deafness, in Mr. Yearsley's experience, than has ever yet been supposed. Simple inspection is not enough to apprise us of the degree of pro- jection of the tonsils, as they are often hidden by the anterior pillar of the palatine arches and the soft palate. Were the parts examined, as they ought to be, by the finger, the enlarged tonsil would not un- frequently be detected, growing upwards and encroaching on the mouths of the Eustachian passages The enlargement, on the other hand, which is productive of thick- ened speech, strikes the eye immediately on the mouth being opened, and extends downwards in a direction opposite to that which is cal- culated to produce deafness. If the upper margin of the morbid growth be visible, thick speech only is the result; but if the growth ascend so as to interfere with the movements of the uvula and soft palate, then we may have, associated with the thickened speech, nasal speech. The enlarged tonsil which interferes with swallowing is that which projects into the pharynx, almost or entirely meeting its fellow ; and each is generally attached to its site by a narrow base. CHRONIC TONSILLITIS. 85 In those cases, continues Mr. Yearsley, where the enlarged gland, have an extended base, reaching from the vicinity of the Eustachian tubes to the bottom of the pharynx, we may look for defective speech hearing, and breathing, altogether associated, more particularly if the uvula enters into the diseased condition of the parts. With such a state of the throat, on getting up in the morning the sensations are most disagreeable. The vitiated mucus collected during the night, and adhering to the throat, produces nausea, or even vomiting for some time, till the tenacious phlegm can be expelled by hawking or coughing. A person thus affected does not often feel himself fitted for the duties of the day until an hour or two after rising. Of the persons most liable to tumefied states of the throat, children of a strumous diathesis rank foremost. Enlargement of the tonsils may often be inferred to exist from the presence of glandular swell- ings of the neck. Frequently, when the tonsillary growths are not so large as to in- terfere materially with the freedom of the Eustachian tubes, their diseased state excites a morbid secretion of mucus, both in the tube and tympanum, which of necessity obstructs the hearing. In this state catheterism and the air-douche will effect a temporary restoration, but as the cause of the disease remains untouched, the deafness is speedily re-established. In old age, when absorption is much more active than the depo- sition of new matter, enlarged tonsils invariably disappear. Mr. Yearsley has never seen a case where the enlargement remained after the fiftieth year; but, unfortunately, the removal of the morbid growth, as age advances, does nothing towards a restoration of hear- ing, when this sense has been impaired by the long existence of the evil. As it does not come within the scope of my design at this time to treat formally of deafness, I will just remark incidentally, that, where this disease is connected with a morbid state of the mucous membrane of the throat, manifested by thickening and perverted secretions in the throat, nose, and ear, we may advantageously recommend a few leeches, once or twice a week, either behind the ears, or within the nostril to the side of the septum narium, followed by moxa, blister, or emetic-tartar applied behind the ear or along the inner margin of the lower jaw, and catheterism with the air-douche. If this diseased state of the auditory function and of the throat be complicated with depraved digestion and nutrition, excellent effects are obtained from the iodide of potassium (hydriodate of potassa) given in small doses, as of one or two grains largely diluted. No medicine, within the knowledge of Mr. Yearsley, has an equally beneficial effect on the ear with this. In such high praise I willingly concur, from having been repeatedly witness of the good effects of the iodide under such circumstances. While on the subject of morbidly enlarged tonsils, and adverting to the means of relief occasionally had recourse to by their excision, it is proper that I should prepare you for finding sometimes a change of voice in your patient after this operation. The fact is one of some vol. i.—S 86 DISEASES OF THE DIGESTIVE SYSTEM. interest, and has been lately introduced to the notice of the College of Physicians, of this city, by Dr. Isaac Parrish {Quarterly Summary of the Transactions, &c). The modifications of the voice is of a peculiar kind, — a hissing or whistling sound. LECTURE X. DR. BELL. Angina Membranacea — Its varieties.—The simple and the malignant — Symp- toms and treatment of AnginaSitnplex— Malignant Angina or Diphtheritis — Earlier notices of it— Causes— Connexion with scarlatina — Persons most liable —Epidemical and endemical, and sometimes sporadic—Symptoms—Diagnosis — Its anatomical characters. — Membranous exudation — Is sometimes ulcerous and gangrenous—Prognosis—Age, temperament, particular exposure and lodg- ing modify result. In addition to the common inflammation of the mucous membrane of the throat, the chief varieties of which, as far as they may be sup- posed to depend on the parts specially affected, I haVe described in my last lecture, there is inflammation of a particular, perhaps we might venture to say, specific kind. Its distinctive anatomical trait is membranous or pellicular exudation, and hence its designation of angina membrunacea or pseudo-membranosa. The exudation is sometimes preceded and accompanied by mild constitutional disease ; at other times, and more frequently, with symptoms of violence and danger, which the result does not by any means belie. I shall speak of these two varieties under separate heads, and first of— Angina vel Pharyngitis Membranacea Simplex. — Simple or Benignant Membranous Angina. — This has been called, also, acute membranous angina, but not, as I think, with propriety ; for the next and formidable variety is also acute ; eminently so, indeed, if we allow this word to designate a disease which sets in with great violence, at least with great perturbation of function, and often runs its course with rapidity to a fatal termination. Simple membranous angina begins, like the diffused variety, with some uneasiness in deglutition, increased redness of the mucous membrane of the pharynx and palate, and swelling of the tonsils. A membranous exudation, at first in patches, and afterwards con- tinuously diffused, soon appears, and the difficulty of swallowing is increased, but the pain not in a corresponding degree. The pre- ceding and accompanying symptoms are those of common guttural or anginose inflammation : the pulse is moderately full, but without much frequency, and the skin is warm. In some instances, as first more distinctly pointed out by M. Guersent, the exudation appears in the form of portions of lymph on the inner surface of the throat, of a gray or yellowish-white colour, of a soft consistence, easily detached and seized by any hard body, and easily renewed. They readily extend to the oesophagus, but never to the larynx. To this variety the term angina pultacea or caseiformis has been given by M. Guersent ; but we do not see in ANGINA MExMBRANACEA MALIGNA. 87 the difference of the form of morbid secretion or of exudation any adequate cause for regarding this as a distinct variety, requiring a separate name. The treatment of simple membranous angina is not different from that of the diffused angina without membrane. If the subject is robust and of sanguine temperament, we bleed at once without hesitation; or if there be no contraindication, iu weakness of habit or from special exposures, and the symptoms of febrile excitement are considerable, we still have recourse to the lancet. Purging, the cooling regimen, and mild antimonials with warm pediluvia, will generally complete the cure. Local depletion by leeches or cups, in the manner already indicated, may be sometimes necessary after venesection ; sometimes also in place of this operation. Calomel in moderate doses, repeated at short intervals, exerts a good effect on this, as I shall have occasion to tell you, it does on the other variety, or malignant angina. Angina Membranacea Maligna.— Cynanche vel Angina Ma- ligna. Putrid, ox Ulcerated, ox Gangrenous Sore Throat — Diph- therite of Bretonneau, and Angine Gangreneuse of some French writers—Secondary croup of Dr. Stokes. In giving the above titles to the diseases of which I am about to speak, I do not by any means affirm that they are synonymous, or that the symptoms are identical; but merely that there are traits enough in common to justify us, for the present, in speaking of them together. Although the term diphtheritis be of recent introduction into medical literature, the lesions which it is intended to desig- nate are not by any means of such modern date. Few epide- mic anginas, especially those called malignant, either separate, or, as was most commonly the case, combined with a cutaneous febrile eruption, have proved fatal, without numerous instances having occurred of the complication of a diseased state of the mucous membrane of the fauces and pharynx with that of the larynx and trachea. In the novelty of nomenclature and refinements of morbid ana- tomy, there is some danger of our forgetting that the disease in ques- tion is one which has been fully described by several English as well as continental writers, anterior to the present century. There is no malady which, at times, has committed more ravages and been less amenable to medicine than malignant angina, or putrid sore throat. The accounts of the disease are numerous, and have been detailed with accuracy in nearly all particulars, and the treatment laid down as ably in the generation preceding our own, as we can lay claim to for our own day, — except in two important points. The first, as respects description, — in our having learned that the diseased mucous membrane is neither ulcerated nor gangrened in the cases generally met with, even when of a fatal kind: the second, as respects treatment, is in the greater stress laid on topical applica- tions to the throat itself. Huxham, about the middle of the last century (1751), Quarin, of Vienna, and Fothergill in the last quar- ter of the century (1781 and 1784), have severally left us full histories of this disease. Nor has it been overlooked by the cautious and 88 DISEASES OF THE DIGESTIVE SYSTEM. practical Heberden in his " Commentaries." I say nothing of Cul- len, Pinel {Nosographie Philosophique, t. ii., p. 24S-58), and other systematic writers up to the present time, a reference to whose pro- ductions is so easy. It may be convenient to admit two principal varieties of this dis- ease, viz., the primitive, and the secondary, restricting the latter to the anginose phenomena supervening in the exanthemata, typhoid fever, and sometimes in pneumonia. Causes, — The close connection between angina or cynanche maligna and scarlatina has been generally noticed. Heberden re- marks on this point : "it seems highly probable that they are both names of the same distemper, with some little variety in a few of the symptoms; and this opinion is confirmed by our finding that they are both epidemical at the same time. Even in the same family, where a number of children have been ill either together, or imme- diately after one another, some have had the distinguishing symp- toms of the scarlet fever, and others of the malignant sore throat." Cullen believes them to be specifically different; but he admits their affinity, and that there may be scarlatina anginosa resembling cynan- che maligna sine eruptione, just, as on the other hand we see scar- latina sine cynanche, or without an affection of the throat. That angina depends upon a specific contagion identical with that of scarlet fever is a common belief. By some this opinion has been modified, into affirming an analogous but not identical cause ; and they tell us of the eruption which accompanies malignant angina, and which makes its appearance sometimes on the first, and at other times not until the fourth day of the disease of the throat. It gene- rally shows itself first about the neck and breast, and sometimes with itching of the skin, more frequently without this symptom. The eruption, often attended with some degree of swelling, gradu- ally spreads over the trunk and extremities. As in the case of scar- latina it comes out in stains which, when nearly inspected, appear to be composed of small prominent papula?, with the interstices of a natural colour. Their prominence may be distinguished by the eye, but more readily by the touch. It rarely happens, however, that the eruption is uniformly diffused in severe cases of malignant membranous angina; but it more generally comes out in blotches or small points scattered over the trunk and extremities, which are of a dark purplish or livid hue, and terminate in a very scanty de- squamation. The class of persons most liable to this disease, children and young persons, would seem to favour the idea of its analogy to scarlatina ; but, on the other hand, we cannot overlook the fact of its being both endemial, as in parts of France, (Touraine and Picardy,) and epide- mical, and of its prevailing chiefly in most situations in the spring months, — as well as in hospitals and workhouses ; and in these places it is confined to young children ; the first cases occurring in the most crowded wards. Under these last circumstances it spreads with frightful rapidity. When adults are attacked, it is often after being exposed to the operation of similar causes, viz., a close, impure atmosphere, the effects of which were increased by accidental wet- ANGINA MEMBRANACEA MALIGNA. S9 ting of the body or feet,*and mental anxiety and depression. Whe- ther sporadic or epidemical, or obeying the influence of seasons, we shall generally find angina maligna to have resulted from causes which attack "the springs of life," — prostrate the nervous system, deteriorate, if not poison, the fluids, and pervert all the secretions. Now, while we know that contagion is eminently calculated to pro- duce these effects, we cannot deny that other agents will produce ana- logous ones, and of these the most potent is impure and noxious air. Under epidemical and complicated influences, or if there be unity of cause it is as yet beyond our ken, angina maligna is not by any means confined to children or those of tender age. I have seen adults and old persons iu large numbers sink under it, with more or less of the complications hereafter to be described. At such times angina will be found to be the precursor, sometimes the associate of epidemic catarrh or of measles, as well as of scarlatina proper. In some of the worst cases of small-pox which I have had under treat- ment, the fatal complication was evidently that of membranous angina, in which this exudation extended to the larynx and trachea, and in this way destroyed the patient, at a time when he was appa- rently out of danger from the eruptive fever. As respects the immediate cause of the membranous exudation, M. Roche {Diclionn. de Med. et de Chir. Prat., Art. Angine) is in- clined to believe that it is colourless fibrin thrown out by a hemor- rhagic inflammation of the mucous membrane, the engorgement of which, with dark blood in patches, visible when the membrane is detached, is cited as farther evidences to the same point. Symptoms. — Angina maligna, diphtheritis, (from J«p6s/>*, skin,) as it was first called by M. Bretonneau, of Tours, or the secondary croup of Dr. Stokes, {A Treatise on the Diagnosis and Diseases of the Chest, 2d edit., Philadelphia, 1844, p. 190,) commences with stiffness in the muscles of the neck, pain in the throat, difficulty of swallowing, and general febrile symptoms. Inspection of the fauces shows us (hat the tonsils are swelled and reddened, and have upon their surface patches of thick, opaque, whitish concretions, which at this period of the disease are easily detached from the mucous mem- brane. If allowed to go on unchecked, the inflammation and the mem- branous exudation spread by continuity to the adjacent parts, the soft palate and pharynx ; the glands at the angle of the jaw begin to swell, and deglutition becomes more difficult, the face is puffed, and the eyes glistening and watery. If the concretion be detaehed from the mucous membrane beneath, the redness is greatly augmented on the denuded parts, and another and thicker concretion is soon formed, which adheres to the mucous surface with more tenacity than before. Frequently it happens, that some days after the com- mencement of the attack, the disease becomes milder, is less disposed to spread, and even ceases altogether without reaching the air-pas- sages, in which case there is very little reason to fear the conse- quences. In most instances, however, at the end of four or five days laryngeal symptoms begin to display themselves, such as a hoarse cough, alteration of the sound of the voice, and dyspnoea. 90 DISEASES OF THE DIGESTIVE SYSTEM. From this time the patient has every appearance of suffering from severe croup, with the addition of an almost complete inability to swallow ; the breathing becomes quite laborious and sonorous, the voice is soon extinct, the countenance livid, and pulse small and in- lermitiing; paroxysms of suffocation take place, till, in one more severe than the rest, death closes the scene. Delirium is frequently associated with these symptoms. The appetite is often not lost during the whole course of the dis- ease ; and the digestive system is undisturbed by vomiting and diarrhoea. There is frequently but slight febrile excitement. The pseudo-membranous concretion is detached and renewed several times. Sometimes the disease is terminated by resolution and the false membrane is absorbed. Commonly the last formed becomes softer and is expelled in fragments mixed with sanguino- lent mucus. The extension of the inflammation to the nasal fossa? is followed by a discharge from the nostrils of a serous, yellowish, bloody, and very fetid matter. The anginose affection often engages exclusive notice, to an oversight of the broncho-pneumonia which is sometimes associated with it, even though the laryngeal symptoms be not very intense, and which destroys the patient when he is thought to be out of danger. The duration of diphtheritis is various. In some instances it has caused death in the course of a few hours: generally when the angina is complicated with laryngitis the patient sinks under the dis- ease from the third to the seventh day. If the inflammation is re- stricted to the pharynx and fauces, it may last for two or three'weeks. It is rarely chronic, although M. Roche says that he has seen a case of eight months duration in a female, and M. Girouard relates one of a membranous inflammation of the tongue and fauces which lasted two years. In both these cases the false membrane was from time to time detached, and replaced by a fresh one. As regards the precise seat of the false membrane, we learn, from MM. Barthez and Rilliet, that, in twenty-one cases, it was found, in the tonsils alone, in six; in the tonsils and a small part of the palate, in four; in the tonsils, velum palati, and pharynx, in six ; and in the tonsils and pharynx, in five cases. Diagnosis. — The chief anatomical character of diphtheritis is the false membrane, or lymphatic exudation, which gives a name to the disease : it is either continuous or in patches, occupying sometimes the nasal fossae, the velum palati, tonsils, pharynx, oesophagus, larynx, trachea, and even the divisions of the bronchia. M. Guer- sent has seen it extend into the frontal sinus, and M. Bretonneau once on the concha of the ear. Sometimes, the exudation is found in the stomach, with an interruption of continuity, however, on the oesophagus. Often, if not in a majority of cases, its range is more circumscribed, covering only the pharynx and tonsils; sometimes extending to the epiglottis and rima-glottidis, but without passing this latter. It is commonly adherent to the velum palati, the ton- sils and the pharynx, whilst on the other hand it is, for the most part, loose, or hanging in shreds in the trachea. In thickness it varies from that of a leaf of paper to a line. Its colour is whitish, ANGINA MEMBRANACEA MALIGNA. 91 greyish, or slightly yellow, giving the appearance designated by the term lardaceous. Contrary to what was generally imagined, before a careful inspection of the parts in late years, the subjacent mucous membrane is neither ulcerated nor gangrenous. The numerous patches with which it is studded, and the central depressions on these, and the dark-red colour of the mucous membrane, together with the extreme fetor of the breath, gave rise at one time to a be- lief that these organic changes were the consequence of gangrene, and hence one of the names of the disease, gangrenous sore throat. But there was error in all this — the pseudo-membrane is the result of either inflammation or of hemorrhage, which does not even end in gangrene. Diphtheritis is occasionally sporadic, but much more frequently epidemic. It attacks individuals of all ages ; displaying, however, a marked preference for children of either sex from the age of four or five to the time of puberty, and more particularly for boys. Ac- cording to M. Bretonneau it is decidedly contagious, and especially when combined with, or secondary to, scarlatina, which is one of its most frequent complications. We must regard as diphtheritis the epidemic croups which are on record. The epidemic which prevailed during the winter months in successive years, from 1813 to 1816, in so many parts of the United States, presented numerous examples of diphtheritis, in which the pneumonia and bronchitis were sometimes apparent, but in other cases they were completely masked by the anginose symptoms. Then, however, although but a student, I remember very distinctly that adults and those advanced in life were the greatest sufferers and most numerous victims : in somii.of the oldest persons the anginose symptoms were chiefly pre- dominant. But, whilst admitting this complication, it is a refinement beyond the facts, it seems to me, to believe, that all epidemic anginas are really diphtherites in the sense laid down by M. Bretonneau, viz., the extension of the membranous formation to the air-passages. Still less tenable is the position, that croup and diphtheritis are one and the same disease. In admitting that angina membranacea maligna, or diphtheritis, is the same disease with cynanche maligna or angina, and that the identity of scarlatina simplex with scarlatina anginosa and scarlatina or angina maligna, and the sore throat without efflorescence on the skin, are merely varieties of the same disease, as affirmed by Dr. Tweedie, we cannot see a common origin nor symptoms identical in all. That angina maligna appears at times without specific conta- gion, we can hardly doubt — certainly diphtheritis does; and, as regards the complication of membranous inflammation of the throat and air-passages, which is thought to distinguish diphtheritis, although this is met with also in many cases of malignant membranous angina, U is not in all. In scarlatina anginosa, we are told expressly by Rayer, that although the exudations of lymph often extend to the lateral parts of the pharynx and occasionally as far as the oesophagus, they are never observed after death in the larynx or trachea. This coincides with the experience of Dr. Tweedie, who has not seen in the dissections of scarlatina with anginose inflammation which he 92 DISEASES OF THE DIGESTIVE SYSTEM. has made, an instance of membranous exudation extending to the larynx. In diphtheritis there is no ulceration nor gangrene ; the removal of the membrane leaves the parts beneath entire, with some of the mucous lacunae larger and more open than usual. In the malignant sore throat of scarlatina or secondary angina maligna, on the other hand, cases occur in which, on the clear testimony of Huxham, Fothergill, and Heberden, more recently of Barthez and Rilliet {op. cit., t. ii., p. 2SS), there are deep ulcerations, the consequence of gan- grenous eschars, which cannot be confounded with any crust or coat formed and spread in the mucous membrane itself. Sometimes the uvula and portions of the palate are entirely destroyed in this way. The tendency to affections of the larynx and trachea by the spreading of the inflammation from the pharynx was pointed out and known long before MM. Bretonneau and Guersent indicated the fact. Dr. Johnstone had many years ago (1769) proposed, on this account, to divide the disease into the cynanche maligna tonsil- laris and cynanche maligna trachealis. But that which the British writers, and I might add the name of Heberden to the list, regarded as occasional, the French pathologists insisted on being a constant and diagnostic feature of the disease. Opposed to this extreme view is the recent testimony of MM. Rilliet and Barthez, {Archiv. Gen. de Med., Dec. 1841,) who give a case of membranous angina with gangrenous ulcerations of the pharynx, in which the nasal passages were lined by a pseudo-membrane. They present also cases in which a diffused gangrene occupied the velum palati, the half arches, the tonsils, and the pharynx. You may expect, there- fore, after what I have laid before you, to meet with simple tyein- branous pharyngitis or angina, alone, and also with malignant mem- branous angina or malignant angina ; this latter sometimes restricted to the throat, sometimes extending into the larynx or trachea — generally without ulceration, rarely with ulceration and gangrene. In epidemic angina or diphtheritis it is common to find the face and the glands of the neck swelled. In sporadic diphtheritis, as in the case recorded by M. Marie, {Archives Gin., Mars, 1841,) there was no swelling of these parts, but the whole throat and air-pas- sages, from the nasal cavities to the bronchia inclusive, were lined with a false membrane. Prognosis. — Stress has been laid, by some, on the appearance and fluctuations of the eruption, as guiding us in our augury of the kind of termination of malignant angina ; but in this there are no certain rules. Thus, while it is said that a florid colour, uniform diffusion, and large desquamation, give us a good prognosis, we learn, at the same time, that the eruption may be full and hi»h- coloured, and yet death ensue, as in cases related by Huxham, in which the patients were covered with " the most fiery rash" he ever saw, and yet they died iu this disease " of a phrensy." So also, Heberden observes, that where this redness was the most florid, the patients have not seemed at all the better, nor have they been ap- parently hurt where it has faded and disappeared. Increase of anx- iety, coma, difficult respiration, with impaired tone of voice or ANGINA MEMBRANACEA MALIGNA. 93 aphonia, and an aversion to take any food or drink, are unfavourable signs. Hemorrhage from the intestines, nose, mouth, or ears, is of bad augury ; so also is exhausting diarrhoea, and the excretion from the mouth of mucus mixed with blood and sanies. A general moisture of the skin about the time of desquamation ; a copious sediment in the urine ; the pulse preserving its fulness and becoming slower ; the breathing clearer and less hurried ; tha fauces and pharynx losing the lividness of colour, which they may have previously acquired ; increased ease of deglutition; saliva rather than bloody mucus flowing from the mouth; abatement of the swelling of the parotid and cervical glands, are encouraging signs, and may allow us to utter a favourable prognosis. WTe are not, it will be readily understood, to expect to see all or a majority of these signs at once. The presence of any two or three will give us hope. "The younger the patients are the greater is their danger," is a remark of Heberden, the correctness of which is generally proved by the issue of the case. But there are many exceptions to the opinion advanced with some confidence by Fothergili and others, that not only are adults less subject to the disease, but it seldom proves fatal to them. In the winter epidemic of 1814-15, in Virginia, to which I have already referred, the proportion of adults attacked was greater than that of children; and the deaths among the former were unhappily very numerous. A lymphatic temperament and pre- viously sickly habit are unfavourable. We shall have less hope of a happy result if the patient is in a close and crowded room, and have suffered from penury and destitution, before the coming on of the disease. The prognosis will be more encouraging towards the de- cline than at the beginning of epidemic angina. Great differences are met with in different epidemics, in regard to the rapidity and violence of the attack. Termination. — The mortality in this disease, in all its visitations and under all modes of treatment, is excessive. To the affection of the throat and air-passages is superadded a malignant form of fever, either of which is sufficient to destroy life. The disease generally reaches its height at the sixth or seventh day. In fatal cases it has terminated in two or three days. In favourable ones it will remain for fourteen days, although the imminent danger is over in half the time. LECTURE XL DR. BELL. Angina Membranacea Maligna—{Continued).—Treatment — Bloodletting1 some- times admissible — Emetics — Revulsives — Stimulants — Calomol — Blisters, under what indications required—Topical treatment — Stress laid on it in malignant angina — Chief articles employed. — Summary of treatment in some of the worst cases marked by suddenness of invasion and prostration of the powers of life. — Angina vel Pharyngitis Gangrenosa — Two varieties — The circumscribed and the diffused— Circumscribed gangrenous angina described__ Its denned limits — Diffused variety. —Its anatomical characters, seat, symptoms, diagnosis, prognosis, causes, and treatment. Treatment. — If we carry in our minds the antecedent and ac- companying circumstances by which diphtheritis is modified, we 94 DISEASES OF THE DIGESTIVE SYSTEM. shall begin the treatment with less hesitancy, certainly with less chance of serious error than they have done who, under the influ- ence of an exclusive pathology, insisted either on its being a disease of pure asthenia, with a rapid tendency to gangrene, or on its being a phlegmasia. Iu those persons of a feeble frame and exhausted constitution, who have been badly fed and lodged, the prostration is great and the reaction slight. On the other hand, the strong, plethoric, and sanguine, exhibit, with great severity of the local symptoms, a frequent, full, and resisting pulse, and a general and almost acrid heat of the skin. In some, the angina is associated mainly with symptoms of gastric disorder: in others, the membra- nous exudation extends, in the manner already described, into the air-passages,and thechief complications will be laryngitis, or broncho- pneumonia. Now it is very obvious that the same treatment cannot be applicable to all these varieties, and that, while venesection may be imperatively required in cases of the latter, it would be eminently prejudicial, if not fatal, in the former; and so, also, local and general stimulants, which might be clearly indicated in one kind, would be worse than useless in the other. In the same epidemic to which I have already referred, and in which, from the necessity of the time I was allowed to act a part as well as entertain an opinion, I well remember the opposite views and practice adopted by physicians. Some, who saw the anginose character predominate, and the accom- panying cold skin, feeble pulse, and general prostration, would not admit the safety of any other remedies than of emetics, stimulating gargles, blisters to the neck, and diffusible stimulants. Others, wit- nesses to distinct pneumonia and less-marked angina, shaped their practice accordingly, and bled their patients. Some, again, who met with a predominance of gastric disorder and hepatic derange- ment, relied on calomel and purgatives. In premising that bloodletting is less called for in malignant, plastic, or membranous angina, than in other inflammations of the pharynx, tonsils, and larynx, we ought not, however, to exclude it entirely from our list of remedies. The plethoric and the sanguine, or the cases in which bronchitis or pneumonia is complicated^ with the angina, will be benefited often by venesection. M. Roche, among others, gives cases of the benefit of this practice, and I have tried it myself with advantage. In more doubtful circumstances, but in which the pulse has still some fulness and resistance, and in which there is evidence of great determination to the throat,'marked by redness and swelling, leeches may be applied under the angle of the jaw, and on each side, and in front of the neck, or cups to the nucha and under the mastoid processes. Even the cautious and skeptical Heberden says on this point: " Yet, in some few persons whose strength seemed able to bear it, and whose heat and head- ache, and manner of living, seemed to require it, I have known blood taken away once, and even twice, in the beginning of the distemper, with safety, and perhaps with advantage." Here, as in acute laryn- gitis, we should have a definite object in view in detracting blood, viz., to produce a decided impression on the diseased membrane'; failing to do this, we only aggravate the disease by encouraging a ANGINA MEMBRANACEA MALIGNA. 95 morbid reaction. Hence, if the first leeching or cupping do not produce the effect proposed, the operation should be repeated after a brief period. In the cases, on the other hand, in which the patient has but little vital energy, owing to his having been badly nourished or exhausted by prior disease, as phthisis, for example, or in which there is little or no augmentation of action of the pulse; but on the contrary a cold skin, yet slight pain of the throat, and the voice nearly extinct, bloodletting, either general or local, is clearly contraindicated, and could hardly fail to be prejudicial. In this state of disease, revulsives of various kinds are serviceable ; among which emetics are entitled to a trial first, provided the stomach be not inflamed. A combination of ipecacuanha and of the infusion of polygala senega would be pre- ferred here to the tartar emetic, the use of which is applicable to the cases distinguished by vascular excitement and calling for previous detraction of blood. In croupal complications the emetic practice is still more requisite. Carrying out the revulsive treatment, we pre- scribe calomel, conjoined with jalap or scammony or colocynth, in such doses as shall purge freely. Medicines of this class are entitled to a preference over salines, which exhaust by copious watery eva- cuations without exciting to active secretion the intestinal mucous follicles and the liver. With a view of continuing consistently the course thus begun, we should endeavour to stimulate the lower ex- tremities by warm pediluvia, sinapisms and liniments, and to excite the cutaneous function generally by the warm bath, and by the warm infusion of polygala or eupatorium. Calomel has been extolled as admirably adapted to bring about a removal of the membranous ex- udation in secondary, as it is believed by so many to do in primary croup. Its administration with this view will not be incompatible with the employment of the remedies just named. It should follow purging, and be conjoined with the external revulsives already named, as well as with those to be next specified : the dose may be a grain every hour or two, with a very minute fraction of opium if the bowels are loose, or of ipecacuanha. Among the revulsives vesication has always been a favourite. Like certain other remedies, however, it has retained its vogue from very opposite causes. Some prescribe a blister in angina, because it has been prescribed by others; some, because they have seen positive good result from its application ; and others, because they do not. know what else to advise. It would argue prejudice, on my part, were 1 to tell merely of the frequent suffering without any corresponding adequate relief which I have seen to be caused by blisters applied in the common fashion on the anterior part of the neck, under the chin : and yet my earlier remi- niscences of this kind are much more distinct than those of any de- cided good from (he practice. On the nucha, or over the trachea just above the sternum, is a preferable spot for the application of a blister; and if counter-irritation be still thought advisable near the affected part, an ammoniacal or turpentine liniment may be rubbed on the neck, from the angle of the jaw downwards and forwards over the larynx. But, whilst a trial is made of some, or all, of these remedies in sue- 96 DISEASES OF THE DIGESTIVE SYSTEM. cession, we ought to be aware of the importance, from the first, of making applications to the diseased mucous membrane of the fauces, tonsils, and pharynx, — not because, as M. Bretonneau would per- suade us, this is the main and almost sole plan of treatment, but be- cause it is of no little moment for preventing the farther spread of the plastic exudation, and thus far saving the larynx, and air-pas- sages generally, from dangerous participation in the disease. The chief topical remedies are hydrochloric acid, nitrate of silver, and alum. Of these, the two latter are to be preferred. The safest and easiest of application is the alum, blown on the part by means of a tube, with gauze applied on the end next the throat, or reduced to a paste by mixture with water and honey, and applied to the dis- eased surface by means of a small brush, or the handle of a tea- spoon. It, as well as sulphate of copper, may be inhaled through a tube, one end of which is carried back to the fauces or pharynx. The nitrate of silver may be used in the same way, or that which will be found to be more expedient and complete, is to fasten a piece of the caustic, properly secured to a quill, and run it rapidly over the mucous surface ; the mouth being kept open by means of a spoon pressed on the tongue. Gargles have always been largely used in diphtheritis, as well as the simpler forms of angina. The popular one, composed of vinegar, salt, and capsicum, is often well adapted to the disease in question. The chlorides of soda and of lime, of late years, have been a good deal used, and with results which warrant a ready repetition of the practice. Creosote has, also, its eulogists at the present time. As a preventive measure of the farther spread of diseases of the throat, we can only anticipate benefit from topical means in the membranous variety. In the ulcer- ous and gangrenous they are of less efficacy : when used they should be introduced by means of a syringe. In secondary maligna or membranaceous angina, as in scarlatina, the exudation is sometimes in large lumps, slightly adherent to the tonsils and pharynx, which interfere greatly with deglutition and respiration. In such cases the physician ought, however, to use a rod, with a piece of sponge or fold of linen tied to one end, and, while washing the throat with a gargle, to detach the exuded matter. The usual attendants in the sick room will be too timid to attempt this little manipulation. The same end may be accomplished by the introduction of the index finger, the end of which is suitably covered, and the application of the powder or gargle to the tonsils. Before I conclude this outline of the treatment of angina maligna, I must impress on your minds the necessity of making your practice quadrate with the pathological view which supposes in some cases a deterioration of the system, a poisoning, as it were, by which the blood and fluids are depraved, and the nervous system depressed and almost prostrated. The affection of the throat is but secondary to, and merely symptomatic of, the violence of the general disease, just as black vomit is of the worst forms of yellow fever and the blue stage of fatal cholera. The sufferers have been ex'posed to depressing passions, loss of sleep, a close and almost pestiferous atmosphere, as in crowded court-rooms, jails, and certain places ANGINA MEMBRANACEA MALIGNA. 97 misnamed asylums and hospitals: — their food has been scanty, or of bad quality; and, in fine, the functions of digestion,-respiration, and circulation, and innervation so interfered with, that neither good chyle is formed, nor is the blood adequately changed in the lungs : this fluid now circulates in a more than usually carbonated condition, dete- riorating and almost poisoning the organs. When the patient com- plains of his throat, and his friends are solicitous about him, and the " physician is sent for, the mischief has been done. What are the resources of art on this occasion ? The routine of practice will little avail against the weakened heart, the feeble and frequent pulse, the illy elaborated blood, the poisoned nervous system and brain, with depraved and impeded sensation and intellect, muttering delirium, &c. We may give an emetic to empty the stomach, and really, under the olden faith of evacuating it of sordes, at least of matter, which only interferes with vitality, and can no longer be converted into a homogeneous and nutritive chymous mass, and chylous fluid. But how alter the diseased blood, unless by inducing the patient to inhale the freshest and purest air, — and perhaps by a free use of saline drinks. The skin may be changed from its now morbid state of dryness, burning and acrid heat, or in regions unnaturally cold, by the prolonged use of the warm bath, and preferably, if it can be got ready, the vapour, followed by frictions or sponging with dilute hydrochloric, or nitric acid, or of solution of one of the chlorides. The nervous system already depressed, or rather stunned, requires no sedatives, and has not strength enough to bear much stimulus. It may be appealed to by remedies applied to the skin, such as those just mentioned, and by stimulating pediluvia, frictions of stimulating liniment on the spine ; to the stomach by substances readily soluble and absorbed, possessed of some stimulant pro- perty, without causing much excitement, such as by acetate of ammonia in solution, carbonate of ammonia, turpentine with spirits of nitre, and small doses of the fluid chloride of soda. In the inter- vals between these you will give minute portions of calomel, and if the mind be very disquieted and restless, or there be muttering delirium, small doses of Dover's powder; its effect on the skin, to be aided by light and pleasant drinks—of such a temperature as the patient himself may crave. If penury and want, deficiency of food, or impeded nutrition from other diseases, have preceded and contributed to bring on this form of anginose fever or plague, and the skin be cold, and capillary excitement less than natural, wine whey will come in most timely in conjunction with carbonate of ammonia. We must, however, carefully watch its effects, so that they shall not transcend the line of proper excitement, for if they do, and hence the disadvantage of diffusible stimulants of the alcoholic class, the nervous system is enfeebled, and digestion and hematosis are more or less impeded, whilst the vitality of the membranes de- pendent so much on that of the capillaries, suffers in an especial manner. In those cases where there is an urgent call for increase of tone, the sulphate of quinia should be given early in small and repeated doses. If the skin be of an acrid heat, and the pulse excessively frequent, vol. i.—9 98 DISEASES OF THE DIGESTIVE SYSTEM. but without fulness or force, we may abate the morbid excitement of the heart by small and repeated doses of digitalis, and indirectly by sponging the surface with tepid, or even cool water, to which a little mineral acid or common salt has been previously added. By this means we determine to the kidneys, and procure discharges, more or less meriting the name of critical. The mineral acids diluted with • sweetened water or mucilage have been given with advantage. The hydrochloric acid, in a more especial manner, was freely pre- scribed on thestrength of the recommendation of Sir William Fordyce, who used to promise his patients a cure if he could have time to pickle their juices with the spirit of sea-salt. The bowels should be acted on by enemata, at first laxative, afterwards saline, and, if the strength sinks, terebinthinate. During all this lime we are not to forget the throat; but whilst making suitable applications to it, we must ever remember that this is but a secondary part of the treatment. Of the various substances to be used, as gargles, the chlorides will be entitled to the preference in the variety of disease now under notice. Angina vel Pharyngitis Gangr2enosa.— I have already ad- verted to the existence of gangrenous sore throat in angina, while admitting that it is a rare disease. MM. Barthez and Rilliet, quoted at the time, have, in their late valuable and extended work, to which reference has been repeatedly made by me in these lectures, given a description of the morbid anatomy, symptoms, progress, semeiology and treatment of this division of angina, as it appears in children. To them I shall be chiefly indebted for the following brief summary: — Gangrene of the pharynx, for so the disease is specifically desig- nated by them, presents itself under two forms, viz., circumscribed and diffused. The first, or the circumscribed pharyngeal gangrene, is seated at the lower portion of the pharynx, where it unites with the oesophagus; and at other times at its anterior surface on a line with the angle formed by the thyroid cartilage. Its figure and size varies; being sometimes oval, sometimes round ; as does its size, which is seen to be as minute as small peas, and again as large as a twenty-five cent piece. The gangrenous patches are depressed, are of a deep grey or brown, or even quite black, and exhale an odour characteristic of gangrene ; their borders are jagged and of a yellowish hue. On removing the gangrenous portion, we find that the mucous and sub-mucous tissues have disappeared ; and some- times even the muscular coat is denuded. This latter exhibits its usual colour, and has undergone no change. The contiguous mucous membrane is noways altered; nor is it covered by any pseudo-membranous exudation. The gangrenous eschars, although restricted at the beginning, may extend to the epiglottis, and even penetrate into the larynx ; continuing, however, to exhibit the same regularly rounded and defined appearances as in the pharynx. When the eschar is detached, the ulcerated surface becomes covered with false membranes, which, it might be alleged, was of anterior formation to the gangrene ; but, as MM. Barthez and Ril- ANGINA MEMBRANACEA MALIGNA. 99 liet have noticed, these appearances of gangrenous spots and false membrane only occur consecutively in subjects who have perished from eruptive fevers (measles or scarlatina). They have, both of them, the same form and extent and the same seat. Sometimes the gangrene is confined to the tonsils, which then assume, a greyish or brown colour, are soft and almost liquefy under the slightest pressure; or they leave between the fingers a pulpy, amorphous and fetid detritus. Diffused gangrenous angina does not present those regular eschars met with in the circumscribed kind. The gangrene seizes on the entire extent of the velum palati and its arches, the tonsils and the pharynx : and the limits between the sound and gangrenous tissues are not well defined. It is sometimes superficial, sometimes deep- seated, and generally of considerable extent, and tending to en- large itself; so that it reaches, occasionally, the parietes of the mouth, the tongue and gums ; and, in another direction, it has been known to attack the mucous membrane of the epiglottis, the supe- rior part of the larynx, and even to penetrate into the cavity of this latter. The diffused is more frequently met with than the circum- scribed gangrene. In all the cases analysed by Barthez and Rilliet, gangrene of the throat was consecutive on some other morbid condition,and in many instances was coincident with gangrene of other organs ; as when gangrenous angina occurred at the same time as gangrene of the lungs, or of the vulva, or even of the mouth ; healthy surface inter- vening between this latter and the disease of the pharynx. Tuber- cles were frequently found in subjects affected with gangrenous angina. The symptomatology of this disease is by no means easy, espe- cially in that variety in which the lower part of the pharynx, that out of sight, is attacked. When the palate and tonsils are the seat of lesion we can detect the dark violet line running into a decided black, and a lacerated and jagged appearance of the soft parts. The breath at the same time exhales a fetid odour. This latter symptom is one of great value, since it is that which sometimes is the first to excite suspicions as to the real nature of the disease ; and is, at times, the only appreciable one : but it is not pathognomonic, as the breath is fetid, also, in gangrene of the lungs, and even in some cases of membranaceous angina. Still, it is desirable that the physician should approach his face to the mouth of the young patient, and smell the breath in cases in which the diagnosis is otherwise doubtful. Pain may be supposed to be a common enough symptom of the inflammation preceding gangrene; but it is not suflicient to indicate the imminence or presence of this latter. General symptoms belong more to the primary disease than to the gangrene itself. Some- times a great alteration of the features has been noticed, with pros- tration, and a small and weak pulse. Pharyngeal or anginose gangrene makes rapid progress, and often before we have reached a certain diagnosis, the disease has de- stroyed a considerable extent of parts. Its duration is variable ; being from two to six days. 100 DISEASES OF THE DIGESTIVE SYSTEM. In doubtful cases a diagnosis may be reached by applying caustic to the suspected spot. If it be simply the seat of membranaceous angina, the exudation will corne away and leave the mucous sur- face exposed and entire. The prognosis of this disease is discouraging; not only on ac- count of the organic changes themselves, but, also, of the alarming diseases or state of the functions, anterior to the appearance of the gangrene. More hopes of cure may be entertained in circumscribed than in diffused gangrene. In preceding remarks, when speaking of gangrenous angina as a secondary disease, we have, in a measure, anticipated a specification of causes. These are, eruptive fevers, and particularly measles and scarlatina, alone or complicated with small-pox. It may also occur in the latter stage of other acute febrile diseases, such as secondary pneumonia, peritonitis, diphtheritis, and typhoid fever; and it has been seen to supervene on hooping-cough and tuberculisation. The angina, which is one of the symptoms in eruptive fevers, might seem to be an adequate cause of the gangrene in these cases; but when we find that other parts, besides the throat, are liable to be struck with gangrene in the exanthemata, we must seek for a general cause, and this will be found in the extreme debility, and the deterioration of the blood at this time. The treatment of gangrenous angina is similar to that of the membranaceous kind with typhoid fever. Emetics are recom- mended to detach the gangrenous eschars and to expel from the sto- mach putrid matter that may have been swallowed, and might other- wise be absorbed into the circulation. The mortified parts are to be cauterised with hydrochloric acid, or, preferably, to be subjected to repeated applications of the chloride of lime, in the manner already described. Infusion and tincture of bark are to be used as gargles or injected into the throat; and the strength is to be kept up by these preparations taken inwardly. It will be desirable also, indeed in- dispensable for a cure, that the patient be removed from the dele. terious influences of bad air or deficient ventilation, and of scanty or unwholesome food, to which he may have been previously subjected.. LECTURE XII. Pathology and Treatment of Diseases of the Digestive System__Different forms of gastritis—Pathology of this disease imperfectly understood by the an- cients—Gastritis and enteritis not always found in connection—Phenomena cha- racterising acute gastritis—Symptoms and sympathetic relations—Diagnosis —Gastritis simulating other diseases. Gastritis. — The consideration of the pathology and treatment of diseases of the digestive system will occupy our attention to-day. I shall commence with the study of gastritis, and to this subject I would entreat your undivided attention ; not that I have anything very new to communicate, but because I believe that many of the statements, which are connected with this disease, will be found to PATHOLOGY OF GASTRITIS. 101 rest on the basis of fact and truth, many of them will be found useful in your future practice, and this subject, I fear, is not sufficiently considered in schools of medicine of this and the sister countries. The olderauthors describe gastritis as occurring under two different forms, one of which they termed phlegmonous, and the other ery- sipelatous. The advanced students know the meaning of these terms, and that they are admitted as significant of different modifi- cations of the inflammatory process, but to those who are not ad- vanced I shall state that it is very difficult to give an accurate idea of these terms, so far as they are applicable to cases of internal dis- ease. But we may attempt a general definition by saying, that phlegmonous inflammation occurs in a good constitution, and under favourable circumstances, that it is an inflammation of a bold and distinct character, requiring and admitting of depletion, and, like that on the external parts, terminating in healthy suppuration, or ad- hesion. Erysipelatous inflammation is (described to be) a disease of a different kind, occurring in bad and debilitated constitutions, and under such circumstances that the same treatment, employed in the phlegmonous form, is more or less inadmissible; and when stimu- lants are necessary, if not in the commencement, at least at a very early period of the disease. It is quite impossible to found any system of pathology on this division into phlegmonous and erysipelatous ; we are, however, sometimes obliged to make use of it for want of a better. The terms themselves are highly calculated to mislead. Healthy inflammation, which is all but a contradiction in terms, may occur in a debilitated constitution, and erysipelatous in a strong one. The latter of these, too, is particularly erroneous, as we now know that erysipelas may occur under opposite circumstances. In the one case, requiring the lancet and leeches, and purgation ; in the other, demanding a stimulant and tonic treatment. In speaking of gastritis I do not intend to adopt this division, because it would be likely to embarrass you, and, in truth, it is unnecessary, as there is no difference in the (principles of) treatment, whatever may be the form of this inflammation. The proper way to consider gastritis is to look upon it as a disease, presenting, on the one hand, symptoms of extreme violence and urgentdanger ;on theother,feeblyshadowedout by the phenomena of ordinary and slight indigestion. Between these there are many shades and numberless gradations. The phlegmonous gastritis of the old authors implied a violent and extensive inflamma- tion, in which all the coats of the stomach were implicated ; but, in treating of the subject of gastritis in these lectures, I shall only allude to inflammation of the mucous membrane and glandular apparatus of the stomach. The other tissues are sometimes engaged, but the mucous membrane, constituting the most important of these tissues, and forming an exquisitely delicate vasculo-nervous expansion, is, in the great majority of cases, the principal seat of inflammation.", and to this I would direct your particular attention. The true pathology of gastritis was but very imperfectly under- stood by the ancients. They knew enteritis and gastritis as intense inflammations of the coats of the stomach and intestinal canal, ac- companied by violent pain and fever, but they had no conception, of 9* 102 DISEASES OF THE DIGESTIVE SYSTEM. their various shades and modifications. For a knowledge of the true nature of gastritis, and of its numerous varieties, we are indebted to modern pathology, and it is the boast of pathological anatomy to say, that in this instance its labours have shed a broad and vivid light on a class of diseases previously involved in deep obscurity.* * [Dr. Stokes has only mentioned, incidentally, the anatomical lesions in gastritis. Valuable observations, on this head, and espe- cially as applicable to the diseases of the digestive system in children, are given in the late work of MM. Barthez and Rilliet. The chief characters of inflammation are pointed out by these gentlemen as follows:— 1. Redness. — One of the essential characters of inflammation, but not of itself sufficient to establish this pathological state, is a more vivid hue of the mucous membrane. Whatever may be its other changes, it is not inflamed unless it be reddened. Nor will redness alone suffice to insure correct diagnosis ; for it then merely indicates (with some rare exceptions) a sanguineous congestion, or a hyper- semia. Inflammatory redness is exhibited in three forms: 1, in venous arborizations, with or without stellated ecchymoses: 2, in bands or vascular or pointed lines : 3, uniformly intense redness. These two last are always inflammatory, and they are generally accompanied by softening, and often by thickening of the mucous membrane. 2. Next, and almost of equal importance to redness, is inflamma- tory softening, without the existence of which it would be difficult to prove the reality of inflammation. Sometimes it is carried to such a degree that the slightest scraping of the mucous membrane reduces this latter to an amorphous pulp, leaving the sub-mucous tissue ex- posed; and hence the rubbing of the scalpel or enterotome, when laying open the digestive cavity, may sometimes carry off patches so as to induce, in the inexperienced in post-mortem examinations, a belief that there are erosions or ulcerations. It is only, however, in certain cases of great gravity that softening is manifested in such a high degree. More generally the mucous membrane preserves some degree of consistence, but still yields to a moderate scraping, and is easily removed, but not in any strips. 3. Thickening. —When thickening is joined to redness and soften- ing, the two latter being themselves characteristic symptoms, there can be no doubt of the existence of inflammation. For the most part the thickened patches project somewhat from the surrounding healthy tissue. It is only in some cases of chronic disease that the tissues subjacent to the mucous are altered by thickening. We must not confound with this morbid state the contraction in different parts of the digestive tube. These three diagnostic characters united constitute the most sim- ple and ordinary kind of inflammation of the gastro-intestinal canal; such as we see in gastritis, enteritis, and more frequently still in ery- thematie colitis. 4. A product of inflammation of the digestive mucous is false membrane, which occurs more frequently than might be supposed, liable as it is to be carried away by the stream of ingested liquids PATHOLOGY OF GASTRITIS. 103 It has been stated, that it is impossible to separate the symptoms of gastritis from those which characterise enteritis, and the reason and the abundant mucous or purulent secretion, as the case maybe, when it is not very adherent or extensive. It may be, in cases of simple enteritis, that there had been false membrane, although this was not revealed by post-mortem inspection ; just as, in some cases of croup, we find no pseudo-membranous exudation after death, al- though it was seen to be discharged during life. 5. Ulceration.— This is by no means an uncommon termina- tion of inflammation of the gastro-intestinal surface. We meet with it in typhoid fever, and in tuberculisation of the intestine. The variety now to be considered is that of the mucous membrane itself or of its intestinal follicles. The former are sinuous in their direc- tion, and resemble the track made by a worm on linen. Their bor- ders are soft, sometimes redder than the rest of the mucous membrane; their bottom, of a whitish-grey, is formed by the sub-mucous tissue, which itself is only thickened but not ulcerated. 6. Pustules is the last but happily uncommon variety of inflam- matory lesion of the gastro-intestinal surface. MM. Barthez and Rilliet have only met with it after the administration of tartar emetic. 7. There remains to be noticed, besides the organic changes, such as congestions and hyperemia already adverted to, a lesion which is not inflammatory, but which is of no unfrequent occurrence in the digestive mucous membranes. We refer now to simple softening other than the cadaveric,orthatresulting from the entire loss of vitality of all the tissues, and partial putrefaction of some of them. There are some distinctions, in reference to the region which is the object of inspection, worthy of remark. In the case of the sto- mach, for example, we may expect to meet with both cadaveric and morbid softening ; but if under evident conditions of elevated tempe- rature or lapse of time from death to the autopsy, varying from twenty-four to forty-eight hours, we discover softening of the great curvature of the stomach, we are authorised to infer the probability of its being cadaverie or putrefactive rather than morbid. In the instance of the intestinal mucous membrane the reverse of this proposition obtains ; and it may be assumed as a general rule, that simple softening is more frequently morbid than cadaveric. In cases, it is true, in which we see evident signs of putrefaction of the body, as when there is a diffuse and deep discoloration of the chest and abdomen, and when the intestines themselves are of a dull red colour in bands or in patches, there will be strong suspicion of the alteration being cadaveric or the result of the putrefactive process. Non-inflammatory Softening is of the simple variety when the gastro-intestinal surface presents its customary appearance ; but yet is softened to such a degree as to allow of no strips, or, if any, only those of extreme minuteness, being torn from it. In such cases, there is usually a slight grey discoloration prevailing over the spot; and the membrane, especially at the curvature, is notably thinner than com- mon ; indeed it is sometimes entirely wanting. A more serious variety of gastro-intestinal softening is that in which the mucous membrane has become almost transparent, resem- 104 DISEASES OF THE DIGESTIVE SYSTEM. given for this is, that the two affections frequently coexist. This is a proposition of vast importance. It is said, that in cases where bling mucus, or rather a colourless and tremulous jelly. This change is designated by the terms gelatiniform softening. It does not often reach such an extreme degree; and it has been noticed by MM. Rilliet and Barthez only in the great curvature and the CEecum : but in the first degree it often implicates the larger part of the gastro-intestinal mucous membrane. There is yet a third variety of softening, in which the mucous membrane is nearly of its natural thickness and of a milk-white colour; its surface and polish being normal; but it presents the appearance of a layer of concrete albumen mixed with the mucous tissue. In summing up the different descriptions, we find that the morbid alterations in question are exhibited under three distinct varieties, viz., 1, simple or pultaceous softening; 2, gelatiniform softening; 3, white or opaline softening. The two first of these may coexist with a dull rose colour through imbibition; and may, also, occur in the order mentioned. It would seem probable, indeed, that the second is but a more advanced degree of the first variety. There is not unfrequently coincidence of inflammation and simple softening in the same subject, which is not the case with the gela- tiniform variety. It may happen, indeed, that inflammation, not being completely resolved, passes by successive stages into a lesion which is not at all inflammatory. It is thus that we find tubercle, which is not itself an inflammatory process, does yet succeed to in- flammations. 8. Fluid Secretions. The mucous membrane in its morbid state is often lined with a coat of mucus. Iu its normal state this secre- tion is transparent, colourless, ropy ; sometimes it is turbid, al- though it still retains its other characters. At other times, again, it becomes thick, gray in colour, grumous, and adherent;. and in such cases it is usually very abundant. Extreme secretions of mucus must be regarded as morbid, and sometimes the result of inflammation. But inflammatory secretion is not always mucous alone ; it is purulent or muco-purulent, and of a mixed grey and yellow colour, thinner and more fluid, and more miscible with other matters in the digestive canal. Gastritis and Softening op the Stomach. — Most of the le- sions above described, as common to the gastro-intestinal canal, are, of course, met with in the stomach. By a kind of reaction, or swing from one opinion to its very opposite, it is the fashion just now, with some pathologists, to speak of gastritis as an exceedingly rare dis- ease, and of the stomach as possessing an immunity against inflam- mation, and especially against the effects of irritants directly applied to the stomach itself. This assertion, true in the main, as regards adults, is incorrect in the case of children. Still, it must be admitted that primitive or idiopathic gastritis is comparatively not a violent disease in this latter class of subjects; but it is often an. accompani- ment, an epiphenomenon, or even a sequence, of other violent dis- eases. It is generally, in children, an acute disease. MM. Rilliet and Barthez differ from some other estimable; SYMPTOMS OF ACUTE GASTRITIS. 105 you have gastritis, the chances are that there is more or less of en- teritis ; but, according to this doctrine, if a man has gastritis the pro- bability is that he has inflammation of some other portion of the intestinal canal. Broussais, in the 13Sth proposition, makes the following observations : " inflammation of the stomach, or, as it is called, gastritis, is never found except in conjunction with disease of the small intestine. It is better, therefore, to give it the name of gastro-enteritis ; and even in those cases, in which we have enteritis, we have gastritis as the irritative." Now if this proposition is true, it is one of very great importance, and entitled to a large share of our attention, in studying the phenomena and treatment of inflammation affecting the digestive tube. Pathology, however, has proved that these inflammations are not always found in connection. Andral gives many cases, in which disease existed separately in one or other portion of the intestinal canal; when it was found in the stomach and not in the duodenum or ileum, and when it was found in the ileum, but not in the duodenum or stomach. I myself have seen many examples of gastritis without disease of any other part of the digestive tube, and disease of various parts of the digestive tube without the coexistence of gastric inflammation. But I believe the proposition is generally true, particularly in cases of fever, in which you have secondary inflammation of the digestive tube during the course of the disease. When inflammation attacks the intestinal mucous surface during the progress of a fever, you will, in most cases, have these two diseases combined; the patient generally pre- senting symptoms of gastritis, and, at the same time, symptoms of enteritis affecting the lower third of the ileum.* Symptoms. — Let us now proceed to investigate the phenomena which characterise acute gastritis. Here I must remark, that, as an idiopathic disease, acute gastritis is extremely rare. This is a very curious circumstance. When we compare the stomach with other viscera, we shall find that one of the most remarkable differences between it and other organs is, that it is much less liable to be at- tacked by violent inflammation, as an idiopathic affection. This^is writers on the subject, in their belief, that softening of the stomach is very seldom a primitive disease, or one that subjects the whole economy to its influence, or distinguishable by special symptoms and a regular march. They do not admit that there are diagnostic signs between inflammation and softening of the stomach. Acute crythematic gastritis most frequently shows itself in the shape of red and softened lines or bands at the summit of the longi- tudinal folds of the stomach, in both directions, commonly along the greater curvature; but it is seldom limited to one region. Pseudo-membranous gastritis does not constantly occupy the cardiac region. The false membrane is seldom of any extent. Ulcerous gastritis is not uncommon : it exhibits erosions or linear ulcerations, less tortuous than those of the intestines; and, also, ulcerations with multiform surfaces. — B.] * [A state of things this very common in our remittent fevers, as well bilious as those which soon assume a typhoid character. — B.] 106 DISEASES OF THE DIGESTIVE SYSTEM. an interesting fact. So rare, indeed, is the violent form of gastritis, that our knowledge of the symptoms which indicate intense gastric inflammation is principally drawn from the study of cases of acute gastritis caused by swallowing corrosive poisons. We very seldom meet with an inflammation of the stomach, presenting those decided characters so frequently witnessed in similar affections of other organs. We may attempt to explain this fact, by considering what the. func- tions of the stomach are, and by recollecting that it is the organ of the body, whose functions require that it should be most frequently in a state of great vascular excitement. Every one is aware that the vascularity of the stomach is amazingly increased during the act of digestion; but it is to be remembered that this is a physiological and not a pathological condition. If the stomach were as liable to in- flammation as other organs, it could no longer carry on its functions with safety ; every meal would prove a stimulus sufficient to excite inflammation — every digestion would be followed by gastritis. Nature has provided against such accidents. Let us take a brief review of the symptoms of acute gastritis : — Intolerable thirst, desire for cold and acidulated drinks, constant nausea and vomiting, pain and burning sensation of heat about the stomach, and fever— these are the symptoms of a violent gastritis. It has been stated, that in gastritis the fever is at first inflammatory and afterwards typhoid. If authors mean by this, that the patient rapidly falls into a low typhoid state, the observation is true. There is no form of inflammation, except that which accompanies severe peritonitis, in which the typhoid state comes on so rapidly. Inflam- mations of the digestive tube differ, in general, from similar affections of other organs, chiefly in this — prostration rapidly supersedes excitement. A patient labouring under inflammation of the brain will exhibit, for a long time, the decided symptoms of high excite- ment, and of what has been termed the phlogistic diathesis ; acute pneumonia and inflammatory affections of other parts will go on for days, without prostration, and require the use of the lancet: but gas- tritis is a disease in which the inflammatory symptoms, as they are called, last but for a very short time. In violent cases the irritation of the stomach is excessive, and every thing is rejected. I have seen cold water thrown up almost immediately ; I have seen effervescing draughts rejected the moment they were swallowed, and make the patient evidently worse. The epigastric region and the left hypo- chondrium are exquisitely tender on pressure, and the tenderness differs from that of peritonitis in this, that it is almost always local- ized. The patient screams with agony when you touch the epigas- trium, but will bear pressure freely on the lower part of the abdomen. Now, with respect to the sympathetic relations of gastritis, I have to remark that they are very numerous. First, as to respiration__ it is extremely quick and hurried; the heart, also, is violently ex- cited ; and hence gastritis has sometimes been mistaken for pneu- monia and pericarditis. Sometimes we have bronchitic cough; the patient is restless, gets no sleep, and is extremely uneasy ; his 'skin is hot, his bowels confined, his pulse rapid and small. In the second SYMPTOMS OF ACUTE GASTRITIS. 107 stage, he is beginning to sink, his features become contracted, his skin cold and pale, his extremities sunk below the natural tempera- ture ; he now bears pressure; the vomiting is changed for regur- gitation of everything he swallows: low delirium supervenes, and he dies. It is of the greatest importance to attend to the sympathetic rela- tions of gastritis, for this reason, that in many cases the local symp- toms are all but wanting, and the disease is only to be known by its sympathetic relations. Before I enter on this subject I shall make one or two remarks on some symptoms which have not been attended to by many practitioners. One of these is an incapability of swallowing, sometimes so great that all ingesta, whether fluid or solid, are rejected. This will sometimes arise from spasmodic stric- ture of the oesophagus or cardiac orifice of the stomach ; and, as there has been no other cause revealed, by dissection, in several cases in which this symptom was present, we must admit this as one of the causes of the dysphagia, which, on some occasions, attends gastritis. This symptom is most commonly accompanied by tightness and oppression about the prcecordia. The patient, feeling a load or weight, as he expresses it, in this situation, thinks it would be re- lieved by vomiting, and begs his medical attendant to give him an emetic, which is sometimes administered, and produces very bad effects. There is only one case in which an emetic can be given in gastritis, and that is, where indigestible or irritating substances in the stomach give rise to irritation, and when we cannot expect a favour- able termination until we effect their removal. There is another most disagreeable and distressing symptom, generally occurring in cases in which there is inflammation about the cardiac orifice of the stomach — I mean hiccup. Hiccup is a most harassing symptom ; it does not allow the patient a moment's rest; in his brief and uneasy slumbers he is conscious of it, and is constantly awakened by it. Now, this is also one of the results of gastritis, with inflammation about the cardiac orifice. I say this, because I have seen it in many cases, in which there was distinct evidence of inflammation about the cardiac orifice of the stomach ; and, in three instances, I have verified it by dissection. I do not mean to say that every case of hiccup is indicative of disease of the cardiac orifice, but I believe it is a very frequent accompaniment. The case of a celebrated professor of languages was a remarkable example. A short time previous to his death, he came from Liver- pool in one of the steam-packets. He was always subject to sea- sickness ; but on this occasion he was extremely ill, and vomited during the entire passage or sea-voyage. He complained of his stomach for some time, and then got hiccup, which resisted every kind of treatment, and continued without any abatement up to the time of his death. On opening the stomach, this organ was found in a state of intense inflammation, particularly about the cardiac orifice. You can see the stomach (of which a very good prepara- tion has been made by Dr. Houston) in the museum of the College of Surgeons. There was another very remarkable case in the Meath Hospital. A patient was admitted who had laboured under 105 DISEASES OF THE DIGESTIVE SYSTEM. acute pneumonia, for which he was treated with tartar emetic, and the symptoms rapidly declined, but vomiting and hiccup came on, and the latter symptom continued until death. We opened the body eighteen hours after his demise, and found the lung quite healthy; but the stomach, and the cardiac orifice iu particular, were, as in the case I have just mentioned, in a state of intense inflammation. When hiccup is the result of inflammation of the cardiac orifice, you will also frequently observe that the patient complains of pain in the lower part of the chest, along the course of the diaphragm. These are some of the relations of gastritis, their connection with which is proved by their being relieved by draughts of cold water, leeching, and every other means calculated to remove inflammation of the stomach. We come now to consider the state of the tongue. A vast deal of error and misconception prevails among British practitioners on this subject. Nothing is more common, than from the condition of the tongue to form an opinion as to the state of the alimentary canal. For instance, whether it is in a state of inflammation, whether there are sordes present or not, and whether it requires this or that medi- cine. All this is behind the actual state of medicine, and it is melan- choly to think what a vast quantity of mischief is done by those practitioners who take the tongue as the index of an inflammatory or non-inflammatory condition of the intestinal canal. The schools of Abernethy and Broussais are wrong in stating that the tongue will point out the state of the digestive tube. The connection be- tween the state of the tongue and that of the stomach has been lately made the subject of extensive clinical investigation by M. Andral: listen to his sentiments on this point. From the experience of a vast number of cases, he declares, " that there is no constant rela- tion between the state of the tongue and that of the stomach." In the next place he states," that there is no modification of the one corresponding with any special modification of the other." Thirdly, the stomach may be found in a certain state after death, with vari- ous conditions of the tongue during life." " Fourthly, we may have a diseased stomach with a healthy condition of the tongue, and diseased appearance of the tongue with a healthful state of the sto- mach." These are facts of the greatest importance. Let us now refer to Louis. In giving an account of the gastritis which accom- panies fever, he states that in many of the worst cases the appear- ance of the tongue was natural; in fact, that there was not the slight- est relation between the tongue and the stomach. It is fair, how- ever, to observe here, that both these pathologists drew their infor- mation only from cases of gastritis, occurring in fever. But it has also been frequently observed, that even in idiopathic cases there is a want of correspondence between the condition of the tongue and stomach, and we have seen several instances of this in the Meath Hospital. I believe we should be wrong in taking the tongue alone as our guide in the treatment of intestinal derangement, whether existing in the stomach or any other portion of the tube ; and this I state as the conclusion which I have drawn from my own experi- ence, in gastric and enteric inflammation. Yet how many will vou SYMPTOMS IN GASTRITIS FROM OTHEK SYSTEMS. 109 see taking the tongue as the unerring index of various conditions of the digestive tube? hundreds and thousands. It is unquestion- ably true, that in certain cases of gastritis, particular morbid appear- ances, as redness, dryness, pointing, and a tremulous state of the tongue, are observed, but what I wish to impress on you is, that it is necessary that these phenomena should coincide with other symp- toms. I do not wish you to believe, that the inspection of the tongue, or the knowledge derived from its appearance,is useless, particularly in cases of fever: the state of the tongue is never to be overlooked, but you should understand on what principle it is to be examined. You should examine the tongue not so much as to guide to the . knowledge of local disease, but as an index of the condition of the general system. For instance, if, during the course of a fever, the appearance of this organ changes and becomes more favourable, it is a sign that the whole disease has taken a favourable turn, and vice versd. This is the proper way to look at the tongue in fever, not as reflecting any particular state of the intestinal canal, but as being indicative of some modification of the whole economy.* Symjitoms derived from the Respiratory and Nervous Systems.— Let us now consider the sympathetic relations of the nervous and respiratory systems in gastritis. This is a very curious and interest- * [I know well a person, who, for twenty-five years, never had an entirely clean tongue; and who for years used to awake every morning with his tongue dry, furred, and yellow, or often brown, and sometimes giving out a little blood mixed with the first saliva. In fact, the tongue of this individual often resembled that of a patient iu the advanced stage of typhoid fever; and yet he has been seldom laid up by sickness. His digestion was regular, but slow and labo- rious; and was particularly troublesome in the colon, in its being attended with flatulence, and alternate diarrhoea and constipation. His renal secretion was habitually disordered by the presence of uric acid. He was a moderate eater, and abstinent generally from all kinds of intoxicating liquors. He found that the appearance of his tongue and the dryness of his mouth, together with epigas- tric heat and tenderness, were increased much more evidently by late hours of even quiet study, than by indulgence in suppers, or the occasional excesses of the table. Of late years, his brain and nervous system have been less continually excited, and he now awakes in the morning with a moister and less morbid tongue ; al- though his dyspepsic symptoms are nearly as before. But whilst thus adducing evidence in support of the opinion advanced in the text, I ought to add, that any unusual article of food, salted or smoked meat, pastry, or an apple at dinner, will cause disturbed sleep and a drier tongue the next morning in this individual. A circumstance worthy of notice, in his case, is, that, when he happened to awake in the night, or at two, or three, or four o'clock in the morning, his tongue was moist, and his mouth without any feeling of dryness or discomfort: but after the last sleep, and at the common hour of rising, the tongue and month would be dry and parched, and other- wise changed, as above described. — B.] vol. i.—10 110 DISEASES OF THE DIGESTIVE SYSTEM. ing point in the study of gastric disease. I may mention here, that these relations are subject to considerable variety, and differ accord- ing to the peculiar predisposition of the individual. If a person oi nervous habits gets gastritis, he will be very liable to have sympa- thetic affections^of some part of the nervous system; but it he is a person with unsound lungs, the irritation will be transferred to the respiratory apparatus. Can we define these irritations? I believe the best definition we can give of them is, that they are affections of some organ, which are the result of sympathy; and that they are at first functional, but afterwards become organic. A person of nervous habit, labouring under gastritis, will frequently have his head sympathetically affected ; he will complain of headache, more or lessmtense ; toss about and get no sleep ; still he has no actual disease of the brain. But let the cerebral irritation go on, let the pain and uneasiness and watchfulness continue, and he will finally get arachnitis. So, too, with respect to the lung ; the patient has hurried breathing and cough, without any of the stethoscopic signs of pul- monary disease ; but if these symptoms continue for any length of time, or if the irritation be severe, he will get pneumonia or bronchitis. Observe the importance of this law with reference to treatment, be- cause it shows you that you cannot always expect to remove sym- pathetic affections by attacking the original source of disease ; for if functional derangement, produced by sympathetic irritation, has gone so far as to become organic, you must direct your attention to parts which have been secondarily engaged, as well as to those which are primarily affected. Every one is aware of the effects of par- ticular states of the stomach on the brain, and of the influence which the brain exercises over the stomach. Most individuals know, that by grief or strong mental emotion the appetite is completely removed; and that after a surfeit, or from taking bad and indigestible food, a person will get sick headache. If this happens every day under ordinary circumstances, and where the original affection is so slight that it does not interfere with the usual avocations of the patient, you can readily conceive how intense the sympathetic irritations may be in a case of violent gastritis. The headache is frequently intense, the patient is extremely restless, there is considerable intolerance of light, delirium, tetanic spasms, and other symptoms characteristic ot inflammation of the brain. There are numerous cases on record in which these symptoms were particularly noticed, and it was supposed that the brain was in a state of inflammation, but on dissection there was no disease found except in the mucous membrane of the stomach. There are many cases, too, in which medical men, not aware of the extent of these relations, looked upon the disease as a pure cerebral affection, and directed their whole attention to the brain. They certainly succeeded in modifying the apparent disease, but as they took no steps to remove its cause, the patients generally sunk from an unsuspected gastritis. There is one important law with respect to inflammation of the stomach, which perhaps may be fairly applietl to all inflammatory affections of the digestive tube. When inflam- mation of the stomach or any other portion of the intestinal canal has continued for some time, and when the disease has attained a GASTRITIS FROM SYMPATHETIC IRRITATION. m certain degree of violence, the local symptoms may subside, and the gastritis or enteritis will be represented by disease of some other organ, by symptoms of an affection of the brain or its investments, or by symptoms of disease of the lining membrane or parenchymatous tissue of the lung. I shall endeavour to explain this. Here is a case taken from the Clinque Medicate of Andral. " A middle-aged man, four days before his entrance into the hos- pital, was seized with bilious vomiting, epigastric pain, and fever. (Here is a certain case of gastritis.) In about twenty-four hours after the invasion of these symptoms, he first perceived a difficulty in depressing the lower jaw, and a violent trismus was established, which continued for the two following days ; at the end of this time he entered the hospital in the following state : —Trismus, the head drawn backwards and forcibly retained in this position by the muscles which are inserted into the occipital region ; rigidity of all the ex- tremities; abdomen hard as a board; intellect perfect. Notwith- standing the trismus, the patient could articulate with sufficient dis- tinctness to give the above account of his case. From the time when the first tetanic symptoms appeared the vomiting and epigastric pain ceased. He died on the evening of his admission. On dis- section no appreciable alteration of structure was found in the brain or spinal marrow ; the meninges of the brain were very slightly vas- cular, but those of the spinal marrow pale. The whole surface of the stomach presented an intense red colour, which was at first con- cealed by a thick layer of mucosities. The remainder of the diges- tive tube was perfectly healthy, and the thoracic organs were natu- ral." This may be called a case of tetanus; and it is a curious fact, that when the tetanic spasms came on, the vomiting and other symp- toms of gastritis subsided. Now this is what I wish to direct your attention to. A man dies with symptoms of an affection of the brain, the head is opened after death, there is no trace of cerebral disease found, but the whole surface of the stomach is discovered to be in a state of intense inflammation. That the stomach was in- flamed is proved by the vomiting and epigastric pain which existed during life,as well as by the vascularity which was revealed by dis- section ; and there can be no doubt that this condition was the result of an intense inflammation, as there was no other cause to produce it. Last year a patient was admitted into the Meath Hospital, labour- ing under violent maniacal excitement, his eyes bloodshot, and his aspect ferocious. He had thirst, a dry,fissured tongue, a quick, weak pulse, and constipated bowels. There was no epigastric tenderness, no vomiting, in fact none of the prominent symptoms of gastritis complained of. On the third day the belly was slightly tender and tympanitic. The cerebral symptoms increased so as to require the use of the strait waistcoat, and continued with violence until a short lime before death, which occurred on the eighth day. On dissection there was no appearance of infl.immation found iu the brain or its membranes, but (here was a vast extent of disease in the digestive tube. The splenic extremity of the stomach presented several patches of vascularity, and its mucous coat was softened; the lower half of the ileum, the ccecum, and part of the ascending colon, were 112 DISEASES OF THE DIGESTIVE SYSTEM. in a state of intense inflammation, and dotted all over with number- less ulcerations. You observe of what importance the knowledge of these facts will be to you in practice, and how much it should become the object of your study, since you will thereby be able to make the diagnosis of gastritis from the sympathetic relations, though the usual symptoms are more or less absent. Even in cases of this kind, in which the symptoms have subsided on the appearance of these sympathetic irritations, the judicious practitioner will not be diverted from directing his attention to the source of the original mischief; nor will he, because the local symptoms have disappeared, conclude that, the disease has therefore been removed from the stomach. Many examples of this apparent transition of disease are to be seen in cases of children, in which an inflammation of the upper part of the digestive tube frequently simulates hydrocephalus, and where the headache, delirium, and intolerance of light, are completely re- moved by the application of leeches to the epigastrium. I have seen this occur many times, and would entreat your particular atten- tion to it. I believe many children are lost from the want of cor- rect notions on this subject on the part of their medical attendants.* * [Unless we are fully acquainted with the precursory symptoms and the admitted cause, such as external injury, sun-stroke, &c, of cerebral affections, whether manifested by delirious ravings and jactitation, or by convulsions, either in children or in adults, we shall find the gastric to be the safer pathology, and we ought to pre- scribe accordingly. Among other instances which might be related, I remember, very distinctly, the case of a child between three and four years old, whom I found with flushed face, eyes shining and in- jected, and somewhat incoherent and raving, with occasional spasms, short of convulsions. The mother of the patient thought that it had been eating stramonium seeds. I believed, on inquiry, that it hail made too free with cherries, and, accordingly, gave it an emetic, which made it throw up a goodly number of this fruit, and brought, in consequence, speedy and complete relief. The symptoms, a little before, would have justified bleeding,cold applications to the head, &.c. A case which occurred under my observation, when I was yet a student of medicine in Virginia, made a permanent impression on my mind. A child, about two years old, had eaten of some fruit, the kind I do not remember, which caused violent convulsions, fol- lowed by coma and strabismus, in which state it remained for three days. At last, to the wonderment both of its physician, who barely hoped, and of the attending crones, who had been moaning, and croaking death around its cradle, it revived, and ultimately re- covered its healih. In other cases, although the offending substance may have been ejected from the stomach, this organ soon after becomes inflamed, and the cerebral symptoms return with violence. Then must we have recourse to leeches to the epigastrium, and other means of re- moving the gastritis; and in so doing, we shall find that there is a subsidence of the disorder of the brain. — B.] PATHOLOGY OF r.ASTRITIS. 113 The phenomena present in such cases are certainly those which cha- racterise hydrocephalus ; but you should always investigate them with care, and ascertain whether the disease has commenced with symptoms of inflammation of the mucous membrane of the stomach, or bowels; and if you find that it has originated in this way, and that the cerebral symptoms have not gone too far, direct your treat- ment in the first place to the digestive tube. It is extraordinary how rapidly all the symptoms of apparent cerebral disease subside under this plan of treatment. I must mention here to you a very remarkable case of enteritis, which simulated local disease of the substance of the brain. A girl who had received an injury was ad- mitted into the Meath Hospital; she was treated with purgative medicines, and was "discharged cured!" In a few days after- wards she was readmitted with pain in the head, and violent spas- modic contractions of the forearm, by which the fingers were bent so forcibly that the nails were driven into the hand. There was no thirst, vomiting, or abdominal tenderness. She died a few days after her admission ; and on dissection the brain was found perfectly healthy, the viscera of the thorax were in the normal state, the sto- mach presented nothing remarkable, but the ileum was almost one sheet of deep and recent ulcers. The result of this case is important, also, in another point of view. You know that spasmodic contrac- tions of the upper extremity are believed by certain pathologists to pointout an inflammatory softening of the optic thalamus, and its pro- longations. Here we had the symptom, at all events, without the corresponding lesion. I shall reserve the subject of sympathetic irritations of the respira- tory system until my next lecture, when I expect to be able to finish the pathology and treatment of gastritis. LECTURE XIII. Gastritis—No one symptom decidedly indicative of the particular condition of any organ—Sympathetic irritation liable to terminate in organic disease__Sym- pathetic relations as connected with the viscera of the thorax—Treatment of simple acute gastritis—Antiphlogistic remedies—Purgative medicines injurious —Enemas and injections—Use of ice beneficial—Effervescing medicine hurtful. You recollect that at our last meeting I endeavoured to lay before you some of the general facts connected with the pathology of gas- tritis, and showed you that the statement made by Broussais, that inflammation of the mucous membrane of the stomach is always accompanied by a similar affection of some part of the intestines, has not been confirmed by the investigations of more recent ob- servers ; but, on the contrary, that their experience goes to disprove, in various instances, the validity of this assertion. But, when I say that this statement his been disproved, it is only as taken in the general and extended sense. The fact of their frequent coexistence has been proved ; the statement that they are always associated has been found incorrect. Another thing connected with this, which 10* Ill DISEASES OF THE DIGESTIVE SYSTEM. has been also established by repeated observation is, that the cases in which they are commonly combined are those in which a secon- dary affection of the mucous surface of the digestive tube comes on during the course of a fever; so that, if in fever a gastritis super- venes, you will commonly have enteritis ; or if the fever be compli- cated with enteric inflammation, the mucous surface of the stomach will partake in the diseased action. I have described some of the more prominent symptoms of gas- tritis, and directed your attention not only to the ordinary symptoms, as mentioned in books, but also to others which have either been passed over, or slightly noticed, by authors ; as, for instance, dys- phagia, oppression and sense of constriction about the praecordia, globus, pains relieved by cold and acid drinks. £cc, and that obsti- nate hiccup, which, in cases where there is reason to suspect gas- tritis, marks inflammation of the cardiac orifice of the stomach. I stated that hiccup alone does not prove the existence of inflamma- tion of the cardiac orifice of the stomach, unless where symptoms, indicative of gastric inflammation, prevail at the same time. I laid before you the actual state of the case with respect to the value and certainty of diagnosis, as derived from an inspection of the tongue; and showed you that no reliance can be placed on it, since it has been proved that we have the most opposite conditions of the digestive tubes, accompanied by a similar condition of the tongue ; and that there is no peculiar modification of the one, corresponding exactly and constantly with any peculiar modification of the other. The conclusion to be deduced from these facts is, that in the treatment of inflammatory affections of the digestive tube, we are not authorized, and would frequently err, in taking the tongue alone as our guide in practice ; and you may lay down this as a rule, and an important one; — if we look through the whole range of the history of medi- cine, we shall scarcely be able to point out any symptom which, taken singly, is decidedly indicative of any one particular condition of an organ. You will find that this proposition is not only exten- sive in its scope and relations, but also of extreme value in its ap- plication. You will commonly hear persons saymg, that is such a disease, for this symptom is present, and that is such a disease, for such a symptom is extremely well marked. But there is no single symptom which points out, with certainty, any peculiar condition; and to arrive at a just and well-grounded diagnosis, you must always take the whole group of existing phenomena, connect the lights which they collectively throw upon the case, and then make a cau- tious decision. It may be objected to this that there are particular signs : as, for instance, the stethoscopic, which point out distinctly particular states of organs. It is said that gargouillement is deci- dedly indicative of a phthisical cavity, that aegophony points out a particular stage of pleuritic effusion, and that metallic tinkling is an unequivocal proof of pneumothorax. This, however, is not the fact; even in these cases you are not authorized to depend on any sign or symptom taken alone. If you ground your decision on any indi- vidual sign, you will very often fail in arriving at the truth. I showed you that the sympathetic irritation of gastritis varied THORACIC COMPLICATIONS WITH GASTRITIS. 115 according to the peculiar character of the disease, and the habit and degree of susceptibility of the patient; that, generally speaking, the more intense the disease is, the more numerous are its irritations ; but that, in all cases, they are considerably modified by predisposi- tion (I use this term for want of a better), the sympathetic irritation being reflected on the lungs in cases where these organs are naturally unsound, and on the brain, where the patients have a tendency to disease of that organ. I endeavoured, also, to impress on you the fact, that these irritations are at first functional; but when long con- tinued, or marked by extreme severity, they are very apt to termi- nate in organic disease. I illustrated this point by several exam- ples ; I shall give a few more of this kind before I enter on the treatment of gastritis. If a patient labouring under acute gastritis has a bad cough, if respiration be very much hurried, and the distress of the chest great, and that these symptoms are overlooked or neglected, you will find that the cough, which was at first only a result of functional disease, will at last point out an organic affection of the lung. Again ; let a patient, labouring under gastritis, have severe headache, restlessness, and irritation ; suffer these symptoms to go on and increase in vio- lence, and the great probability is, that they will terminate in arach- nitis. The obvious deduction from these facts is, that when a sym- pathetic irritation has existed for some time in a state of considerable intensity, it is very probable that there is more or less of organic derangement produced, and we are not. to expect to be able to re- move it by merely attacking the original seat of the disease. The last great rule which I endeavoured to impress upon you was, that where these sympathetic irritations, these affections of the ner- vous, respiratory, and circulating systems, were extremely well marked, the ordinary local symptoms were more or less wanting, but that this does not by any means imply the subsidence of the ori- ginal disease. This is a most important law in pathology. Sympathetic Thoracic Irritations. — In my last lecture, I entered into a detail of the sympathetic irritations connected with the brain and other parts of the nervous system ; to-day we shall consider the sympathetic relations, as connected with the viscera of the thorax. If you look to the cases of acute gastritis, mentioned in works on toxicology, you will find that in cases of gastritis, produced by swallowing corrosive poisons, the patient has often frequent, hard cough, the breathing is at first hurried, then becomes protracted and laborious, and that death is generally ushered in by tracheal rattle. The same symptoms are observed in cases of acute idiopathic gas- tritis; hurried breathing, extraordinary hard and almost laryngeal cough, sometimes occurring in paroxysms, sometimes constant. For the first few days it is, generally speaking, dry ; as it progresses, there is more or less expectoration. At first, it is the result of sym- pathy ; there is as yet no organic affection of the respiratory system, and (he disease is purely functional ; still it is of importance, and entitled to your particular attention, because, in consequence of the apparent identity of the symptoms, it is often mistaken for disease of the substance of the lung, or its mucous lining. The existence of 116 DISEASES OF THE DIGESTIVE SYSTEM. a gastritis is frequently overlooked; the ordinary symptoms of pain in the region of the stomach, tenderness on pressure, and thirst, are overlooked, and the sympathetic relations alone are attended to. Observe what mischief*may result from this error. The treatment of acute affections of the lining membrane, or parenchymatous tissue of the lung, is very different from the treatment of a gastritis. In the one case Bleeding is necessary ; iu the other, its efficacy may be doubtful, or the practice even dangerous. In one, tartar emetic is one of the best and most expeditious means of effecting a cure ; in the other, the use of antimonials has the worse effect. It will strike you that in such cases percussion and the stethoscope are of inesti- mable value. You are called to attend a patient in fever; you find he has cough, hurried breathing, and perhaps pain in the chest; from a consideration of the history of the case, and the primary symptoms, you have reason to think the case is one of gastritis, and you wish to know whether the symptoms be purely sympathetic, or caused by organic disease of the lung. In such a case, a person without the knowledge of the stethoscope is completely helpless, and unable to decide the point. This, I assure you, is a very common case, and should be a strong inducement to the study of the stethoscope. What advantage does a knowledge of the stethoscope give? It leads to the formation of an accurate diagnosis ; it points out either that there is no disease in the lung, or if there be, that it is not suffi- cient to account for the symptom, and therefore that you should look for its cause in some other situation. You find a person with laboured and rapid breathing, perhaps fifty or sixty a minute ; you are struck with the apparent lesion of the respiratory system, but on percussing the chest, and using the stethoscope, you find the respira- tion perfectly clear, or perhaps a slight bronchitis, insufficient to ac- count for such violent symptoms. Where such phenomena are ob- served, you will often find that they are connected with a gastritis, particularly where there is fever, and the local signs of a gastric in- flammation. I can tell you, from a most extensive experience, that in such cases you can inform the patient's friends, that the most sudden and decided relief will be experienced from the use of iced water, and the application of leeches to the epigastrium. You can have hardly an idea of the rapidity with which all the symptoms of pulmonary irritation are removed by this practice. Cases of this extraordinary sympathetic irritation are very common in children, but you will also frequently meet with them in adults. Diagnosis of Gastritis and Pneumonia. — I have been called to decide the question, whether a disease was pneumonia or gastritis, where there was a difference of opinion between two practitioners. Now, it is very easy to come to a proper decision in such cases. There is one point which you should always hold in view, and that is, the length of time the symptoms have lasted. If symptoms of pulmonary disease have been going on for four or five days, and, at the end of that time, you find that there is no perceptible organic disease of the lung, you may be certain that it is gastric irritation ; because if it were organic disease of the lung, it would have shown itself before that time, and could be detected by percussion or by the TREATMENT OF GASTRITIS. 117 stethoscope. We have had many cases of these sympathetic irri- tations of the lungs in the Meath Hospital, which recovered under the treatment for gastritis; and where the patients, by some excess or error in diet, brought on the pulmonary symptoms again, they were removed a second time by putting them on a low diet. Before I quit this subject, I wish to make one remark, by way of caution. When you have discovered the existence of those sympathetic irritations, you should not be thrown off your guard, and consider them only as functional affections. You should examine the next day and the day after, for you may find that in a very short space of time actual disease of the lung has taken place. You should be, therefore, watchful, and never omit making a daily examination: for if the sympathetic irritation be severe, it is very apt to run into actual organic disease. YYe now come to speak of the treatment of simple acute gastritis. Here there are three principal indications. One of these is to remove inflammation as speedily as possible. You cannot, as under other circumstances, leave this disease to nature ; the organ affected is one of the utmost importance to life ; and if you do not cut it short at once, a typhoid state comes on, to which the ordinary and efficient means of antiphlogistic treatment are inapplicable. The first indication, then, is to cut short the inflammation as speedily as possible. The next thing is to prevent the introduction of anything into the stomach which will excite the physiological action of that viscus. You are aware, that while the stomach is engaged in the process of digestion, its vascularity is very much in- creased, and that this, which in health is merely a physiological con- dition, is unaccompanied by any kind of danger. But in a state of disease it proves a source of violent excitement, and superadds very much to the existing inflammation. You must, therefore, be ex- tremely cautious with respect to what enters your patient's stomach, and carefully remove every thing capable of adding to the excite- ment which always attends gastritis. The third indication in the treatment is to modify and remove the sympathetic or secondary irritations. Treatment of Gastritis. — Now I shall suppose that we have to treat a case of simple acute gastritis, not produced by the swallowing of corrosive poisons, or indigestible food. Here we have a patient labouring under violent inflammation of one of the most important organs in the body ; and the question is, are you to adopt the ordi- nary and usual mode of stopping inflammation by opening a vein in the arm ? I must here state, that we are very much in want of a series of well-established facts to guide our practice on this point, and to inform us how far general bleeding is useful in acute inflam- mation of the stomach. At the present period, the question is. by no means settled, and the practice is uncertain. I believe, however, that when we are called in at an early period of the disease, where the patient is young and robust, the stomach previously healthy, the fever high, and the pain great, we may have recourse to general bleeding with advantage ; bearing this in mind, however, that you are not to expect to cut short the inflammation by the use of the US DISEASES OF THE DIGESTIVE SYSTEM. lancet. Inflammations of the mucous membrane of the stomach and bowels, and perhaps of the hums, are not to be overcome at once oy the lancet; the only cases in which yon can expect to cut short an inflammatory attack, are those in which the parenchymatous tissue of an organ/or its serous membrane, is affected. This is a general and important law. You will often be able to cut short a hepatitis or pneumonia bv a single bleeding, but yon will not by the same means be able to repress a bronchitis or an inflammation of the mu- cous membrane of the intestines. If you bleed m gastritis bleed at an early period; not too largely, or with the expectation of cutting short trie inflammation, but in order to prepare your patient for the grand agent in effecting a cure — local bleeding. This is the prin- ciple on which you are to employ the lancet. In the treatment of gastritis there is nothing more useful, nothing more decidedly efficacious, than the free and repeated application of leeches, whether the case be idiopathic, or produced by the swallow- ing of a corrosive poison. In this treatment of acute gastritis, you will frequently see, perhaps, the most striking instances of the rapid and decided utility of medical treatment; you will see the vomiting subside almost immediately, the epigastric pain and tenderness dis- appear, the cough and headache relieved, the fever subside, and the tongue change, after the application of leeches. To remove these symptoms, the best and most effectual means are leeches ; and these must be applied again and again, according to the duration and ob- stinacy of the symptoms. Here I wish to make one remark of im- portance. From an opinion, very prevalent in former times, that pain and inflammation were inseparable, the older practitioners thought that when the pain ceased the inflammation also ceased; and hence many of our predecessors, and 1 fear some of our cotem- porahes, never think of reapplying leeches, no matter what the ex- isting symptoms may be, if pain has been relieved by the first ap- plication. Nothing is more erroneous than this practice. It fre- quently happens that the pain and epigastric tenderness are removed by the first application of leeches, but the breathing is still quick, the fever high, and the thirst ardent. So long as these symptoms re- main, the inflammation of the stomach is still going on. The mere subsidence of pain or tenderness of the epigastrium should never prevent us from resorting to the application of leeches. In leeching the belly for inflammation of the stomach or bowels, it is a common practice to apply a poultice over the leech-bites, with the view of getting away as much blood as possible. I am not inclined to ap- prove of this practice. The weight of a poultice is frequently trouble- some, and the heat produced by it disagreeable ; the patients desire cold, and for this purpose they will often throw off their bed-clothes, feeling a degree of relief from exposing the epigastrium to a stream of cool" air. Some practitioners have applied pounded ice over the stomach with good effects, and we see it frequently applied to the head with the same results in cases of encephalitis. Again: the application of poultices causes an oozing hemorrhage, the amount of which it is impossible to calculate, which is often hard to be ar- rested, and which, in debilitated persons and children, has the effect ATTENTION TO THE BOWELS IN GASTRITIS. ] 1 9 of lessening the powers of life without removing the original disease. It is much better to leech again and again than to do this. Where there is not much epigastric tenderness, you may apply a cupping- glass over the leech-bites with advantage, as you can get away as much blood as you choose, and the tendency to after-hemorrhage from the leech-bites is diminished by the application of the cupping- glass. In very young subjects, the tendency to obstinate hemorrhage from leech-bites is so great, that many practitioners are afraid to use leeches, and I believe some children have been sacrificed to this fear. The best mode of managing this is, if the leech-bites cannot be stop- ped by the ordinary means (and in very young children they seldom can), to stop them at once by the application of caustic. Do not lose time in trying to arrest the flow of blood with flour, or lint, or sticking-plaster; wipe the blood off the bite with a piece of soft, dry lint, plunge into it a piece of lunar caustic, scraped to a point, give it a turn or two, and the whole thing is settled ; and you can gene- rally go away with the agreeable consciousness of having prevented all further danger, and without being uneasy lest your patient should bleed to death in your absence. Management of the bowels. — With respect to the management of the bowels in acute gastritis, a few observations will suffice. You will always have to obviate the effects of constipation ; both in the acute aud chronic forms of the disease there is always more or less constipation ; in fact the same condition of the bowels is gene- rally observed in both. Now, if you attempt to relieve this consti- pation in acute gastritis, by administering purgatives, you will most certainly do a vast deal of mischief. Nothing can exceed the irri- tability of the stomach in such cases; the mildest purgatives are instantly rejected, even cold water, or effervescing draughts are often not retained, and a single pill or powder is frequently thrown up the moment it is swallowed.* Under such circumstances, it is plain that the administration of purgative medicine is totally out of the question. Even though the stomach should retain the purga- tive, you purchase its operation at too dear a price; for it invariably proves a source of violent exacerbation, kindling fresh inflammation in an organ already too much excited. In this state of things, the best thing you can employ to remove constipation is a purgative enema, repeating it according to the urgency or necessity of the case. Where there is no inflammation in the lower part of the intestinal canal, you may employ injections of a strong and stimulating nature, with the view not merely of opening the bowels, but also of exer- cising a powerful revulsive action. I shall mention here an interest- ing fact, proving that stimulant injections have a decided revulsive effect; and that their influence extends not only to other portions * [I have, in some cases, after venesection and leeching, given calomel with advantage in gastritis: — its action on the duodenum, liver, and large intestines, renders it decidedly revulsive. I prefer it alone, to its union with opium, under these circumstances. I can speak favourably, also, of a laudanum enema in gastritis after san- guineous depletion. — B.] 120 DISEASES OF THE DIGESTIVE SYSTEM. of the intestinal tube, but also to distant parts of the system. In South America, where, from the heat of the climate, and the preva- lence of bilious affections, sick headache is a very common and dis- tressing symptom, a common mode of cure is to throw up the rectum an extraordinary enema, composed of fresh capsicum and other aro- matic stimulants. The irritation which this produces acts as a very efficacious and speedy revulsive, causing the almost immediate re- moval of the cerebral symptoms. In those cases of gastritis, where not only purgatives, but even the mildest substances, are rejected, the plain common-sense rule is to give nothing. Where cold water is borne by the stomach, it may be taken in small quantities, as often as the patient requires it. Solid ice, too, may be given with decided benefit. There is a mistake which prevails with respect to the employment of ice in gastritis, which I wish to correct. Some persons object to its use, and reason in this way :—Persons who have taken a quantity of cold water, or ice, when heated by exercise, have been frequently attacked with gastritis and fever, and consequently the use of these substances must be attended with danger in case of gastric in- flammation. This, however, is false reasoning; you need not be afraid to order your patient ice, ad libitum ; depend upon it, there is no danger in employing either ice or cold water in gastritis. There is nothing so grateful to the patient as ice. Let a quantity of it be broken into small pieces, about the size of a walnut; let your patient take one of these pieces, and, having held it in his mouth for a few moments to soften down its angles, let him swallow it whole. The effect produced by this on the inflamed surface of the stomach is exceedingly grateful, and the patient has scarcely swallowed one portion when he calls for another with avidity. It will be no harm if I should here mention to you a secret worth knowing. There are few things so good for that miserable sickness of the stomach, which some of you may have felt after a night's jollification with a set of pleasant fellows, as a glass of ice; Byron's hock and soda-water are nothing to it. After the first violent symptoms of the disease have been subdued, I believe the very best thing which can be given is cold chicken- broth.* The point which we are always to keep in view is, to re- move inflammation from the stomach, and this should regulate the use of everything taken into the stomach. I believe we might de- rive much advantage from anodyne injections in gastritis. I can- not say that I have ever employed them in such cases ; but if I were to reason from their utility in other forms of abdominal inflam- mation, I should be induced to look upon them as entitled to some consideration. There is another point to which I will briefly advert. In the treatment of acute gastritis, there is nothing more commonly used than effervescing draughts; yet I have frequently seen them produce distinct irritation of the stomach. In cases where gastric * [There are cases of gastritis in which even this simple animal food is inadmissible thus early in the disease, and before conva- lescence has set iu. — B.] AFTER-TREATMENT OF GASTRITIS. 121 irritability is excessive, I would not advise you to give effervescing draughts, or if you do, watch their immediate effect ; see how the first one has agreed with the stomach before you venture to give any more. Patients labouring under this disease should be kept extremely quiet, as frequently a slight motion brings back the vomiting. Everything which is swallowed should be in small quan- tity ; a large quantity of any substance frequently causes a return of the vomiting, by distending and irritating the stomach. One of the best things you can give, and the best way of giving it, is iced lemonade, giving a tablespoonful from time to time. The extremi- ties, which are generally cold in cases of intestinal disease, should be swathed in warm flannel. I shall mention here a rule which should be carefully observed in the after-treatment. A patient has recovered from the violent symp- toms of the disease; the fever, thirst, pain, epigastric tenderness, and sympathetic affections, have subsided ; but he still is confined to bed, and in a state of great debility. Some patients, under these circum- stances, have been unfortunately lost by allowing them to sit up in bed, or on the night-chair. The nurse will sometimes, through igno- rance, suffer a patient, thus enfeebled, to risk his life by sitting up in bed ; sometimes, during the course of the night, she is overcome by sleep ; the patient has a call to empty his bowels; and not wish- ing to disturb her, attempts to get up, and is found, some time afterwards, sitting on the night-chair quite dead. This is an unfor- tunate termination for the physician as well as the patient. A Ger- man author, Hoffmann, has written a treatise on the danger of the erect position after acute diseases; and in the course of the work, which is a very interesting one, he cites numerous instances of its bad effects. Not very long since a patient was lost in the Meath Hospital, by the nurse allowing him to sit up after a severe attack of enteritis. Such, also, was the melancholy cause of death in the case of the late Mr. Hewson, one of my best and earliest friends. He got a severe attack, which was subdued with difficulty, and his convalescence was doubtful and protracted. One night, in the absence of his attendant, he got up for the purpose of emptying his bowels, and was found, some time afterwards, on the night-chair, nearly dead. He was immediately brought back to bed, and the necessary means employed to relieve him, but without much benefit, for he never recovered the effect produced on his debilitated frame.* * [Not only in cases of great prostration from hemorrhage, cho- lera, &c, but in the advanced stage of all diseases of an acute cha- racter, the patient should be prevented from rising or even sitting up in bed. A bed-pan slipped under him will be the substitute for a close-stool; nor should any foolish prejudice — a thing not uncom- mon with persons who have heretofore enjoyed good health, — pre- vent its use. — B.] vol. i.—11 122 DISEASES OF THE DIGESTIVE SVSTEM. LECTURE XIV. Pathology and Treatment of Gastritis —Application of blisters— Emetics can be seldom used in acute gastritis — Hematemesis and delirium tremens compli- cated with gastritis-Treatment of these affections —Dyspepsia, or chronic gastritis-—Hypochondriasis —Termination of chronic gastritis, There is one point connected with the treatment of gastritis which 1 have not yet touched upon —the use of blisters; and as this is. the first time I have spoken of them, I shall make a few remarks on their general application. It is a great error to think that blistering is a matter of course in inflammatory diseases, or that the proper period for their applica- tion should not be carefully marked. It is a common idea, that if a blister does no good it will do no harm ; that it is probable some benefit may result from its employment, and that you may try it at all events. I need not tell you that all this is wrong, and that we must be guided by exact principles in this as well as in every other part of practical medicine. I am afraid there is a great deal of loose reasoning and empirical practice connected with this subject, even at the present day. Here is the general rule by which you should be invariably guided. No matter what kind of disease you have to deal with, if it be inflammatory, blistering in the early stage of it is decidedly improper. I might amplify this rule, and say, that if the diseasebe inflammatory and in its early stage, or if, under such circumstances, the symptoms require the general or local abstraction of blood, blisters cannot be used with propriety. The truth is, that many persons take a very limited view of this subject; they look upon blisters as merely revulsive agents, which, by their action on the surface, have the property of diminishing visceral inflammation. This I am willing to allow is true to a certain extent, but there is abun- dant evidence to prove, that blisters have sometimes a direct stimu- lant effect on the suffering organ. That this occasionally occurs has been established by many facts in medicine ; and I have not the slightest doubt that the application of a blister over an organ in a state of high inflammatory excitement will certainly be productive of injurious consequences.^ But if you apply them at the period * [Not only in primary gastritis, but, also, in gastritis as a com- plication with fever, some practitioners, either from not fully recog- nising the nature of the disease, or not appreciating the operation of blisters, are in the habit of applying them forthwith, so soon as the patient complains of heat and pain or tenderness of the epigastrium. This is bad practice in a double sense ; bad in itself, as tending to aggravate the disease ; and bad indirectly, by preventing the appli- cation of leeches, and of ice or cloths immersed in cold water. We cannot afford to give away the epigastric surface in this manner, in the first stage of either gastritis, gastro-enteritis, or of fever gene- rally. The judicious practitioner will regard a blister as among the remedies to be the last employed in most of the acute diseases. See Article Epispastics, in Practical Dictionary of Materia Medica, by John Bell, M.D. APPLICATION OF BLISTERS IN GASTRITIS. 123 when stimulation is admissible and useful (and there will always be such a period in every inflammation), you then act on just princi- ples, and will generally have the satisfaction of finding your prac- tice successful. The greatest empiricism is sometimes practised in the application of blisters to the head in acute inflammation of the brain. You will see, in Mr. Porter's admirable work on the Patho- logy of the Larynx, how strongly he is opposed to the early use of blisters in acute laryngitis. Dr. Cheyne, also, may, among many others, be quoted in support of this doctrine. If there is one system more than another likely to be injured by early blistering, it is the digestive. Broussais says that blisters should not be applied in any of the stages of acute gastro-enteritis, and that in the early stage their application is the very height of malpractice. I do not go so far as to say that they should not be applied in any period of the disease, for when the skin is cool, the pulse lessened, and the local inflammation so far reduced as not to require the abstraction of any more blood, I think you may employ them writh very considerable advantage. I shall again return to the subject of blisters; and will for the present merely remark, that blistering is almost always mismanaged, in consequence of persons who apply them being ignorant of their stimulating effects on organs. They generally allow them to remain on too long, and the conse- quence of this is often violent excitement of the organ over which they are applied, great constitutional irritation, strangury, and bad sores. The best mode of using them is to direct the person who prepares the blister to cover it with a piece of silver-paper before it is applied, and having put it on with the paper next the skin, to let it remain until a decided sense of smarting is produced, when it should be immediately removed. By adopting this plan, you will save yourself and your patient a great deal of inconvenience ; you will have no strangury, stimulation of the whole economy, or excessive local irritation, and the inflamed surface will heal kindly. The mode (too often practised) of applying a blister sprinkled all over with an additional quantity of powdered cantharides, and leaving it on for twelve, twenty-four, or even thirty-six hours, par- ticularly in the case of females, is nothing better than horse-doctoring. During a seven years' experience in the hospital at Tours, Breton- neau, by attending to this principle, never had a case followed by these troublesome symptoms, and yet he never failed in producing the necessary degree of counter-irritation. The active principle of cantharides, being soluble in oil, exudes through the silver-paper in sufficient quantity to produce the necessary effect on the skin, without exposing the patient to the risk of having too much irritation excited by the direct application of the blistering plaster to the cutaneous surface.* * [Mr. Trousseau has recently recommended an ethereal extract of cantharides, which is obtained from the action of sulphuric ether on the powder of cantharides. Portions of blotting-paper of various sizes are imbibed with this extract and form so many blisters. Blistered surfaces may be kept running by applying to them the extract of cantharides mixed with yellow wax, in the proportion of the former of one-tenth to one-twentieth. — B.J 124 DISEASES OF THE DIGESTIVE SYSTEM. With respect to emetics, I need not tell you that they can be very seldom used in acute gastritis, and that all your efforts should be directed to obviate and remove vomiting. But are we to interdict their use altogether ? There are some few cases where we are com- pelled to use'them ; as, for instance, in cases of acute gastritis caused by swallowing corrosive poison, or by the irritation of indigestible food remaining in the stomach. The first step to be taken in a case of corrosive poisoning, is to evacuate the stomach. In the same way, when you are called to treat a case of gastritis produced by indigestible aliment, you must commence by giving an emetic. But even here the emetic is admissible only in the early period ; and you should never trust to its operation for removing the gastritis alto- gether, unaided by other therapeutic means; nor are you to con- clude that because you have produced vomiting you have succeeded in curing the disease. The same principles apply to the use of pur- gatives in enteritis as to emetics in gastric inflammation ; we should never have recourse to them except where inflammation is kindled and kept up by the presence of irritating matter. Hematemesis and Delirium Tremens. — There are two cases in which certain affections are complicated with an acute gastritis ; and as these complications are not sufficiently known, and have been scarcely noticed by systematic writers on gastritis, I am anxious to draw your particular attention to them. One of these is hematemesis, the other that disease which has been termed delirium tremens. There are cases of vomiting of blood, which are little more than acute gastritis, in which there is a copious secretion of blood from the mucous surface of the stomach. Vomiting of blood may arise from various causes. It may be vicarious, as in the case of females, where the menstrual flux is suppressed ; it may be accidental, as from the rupture of a bloodvessel; or it may be caused by mechanical obstruction to the circulation, either in the liver, spleen, heart, or lungs. But there is a species of gastritis, in which there is a copious vomiting of blood ; or there is an hematemesis, of which the cause is gastric irritation. How are you to recognise this form of the dis- ease ? — The patient is vomiting blood ; but then he has fever, hot skin, and excited pulse, Again, you will see some peculiar modifi- cation of the tongue ; you will find ardent thirst and longing for cold drinks ; you will observe fulness and tenderness of the epigastrium ; you may have severe local pain; finally, you will have all these symptoms occurring in a person who, previously to the attack, exhi- bited nothing capable of accounting for the hematemesis. Here, then, we have-an hemorrhagic gastritis, very little known, and too often improperly treated. The ordinary practice, in such cases, is to give astringents. Astringents are very good and useful where they are clearly indicated ; but there are many forms of disease where their routine employment is productive of a great deal of mischief; and I believe lives are sometimes lost by looking upon this affection as a simple hematemesis, and by practitioners contenting themselves with the use of astringents. But where you riave the symptoms of this form of gastric irritation present, where, in addition to the vo- miting of blood, you have fever, and thirst, and hot skin, and pain, and COMPLICATIONS WITH GASTRITIS. 125 epigastric tenderness, you may be sure that it is a gastritis, and that the best treatment is leeches, iced water, and the other means re- commended in the treatment of gastric inflammation. It may hap- pen that, under this treatment, the vomiting of blood will not entirely subside: but the pain, the thirst, the fever, and epigastric tenderness will subside, and then you can with propriety give astringents. The best thing you can do in the commencement is to leech freely, give iced lemonade, and cold water ; prohibit everything purgative, stimu- lant, or astringent; and then, when you have reduced inflammation, if the hematemesis continues, have recourse to astringents. A few words now with respect to the other complication — deli- rium tremens. You have all seen cases of delirium tremens, but you are not, perhaps, aware that it arises under two opposite classes of causes. In some cases, a patient who is in the habit of taking wine or spirituous liquor every day in considerable quantities, meets with an accident or gets an attack of fever. He is confined to bed, put on an antiphlogistic diet, and in place of wine or whiskey- punch gets whey and barley-water. An attack of delirium tremens comes on, and symptoms of high cerebral excitement appear. Another person, not in the habit of frequent intoxication, takes to what is called a fit of drinking, and is attacked with delirium tremens. In the first case the delirium arises from a want of the customary stimulus, in the second from excess. In each the cause of the disease is different; and, consequently, with this view of the subject, it would be a manifest departure from sound practice to treat both cases in the same way. Yet, I believe, this error is frequently committed, even by persons whose authority is high in the medical world, and is part of a system not yet exploded — the system of prescribing for names and not for things. The patient is treated for a disease which has been called delirium tremens, the present symptoms are only attended to, and the cause and origin of the affection are overlooked. What are the true principles of treatment? —In the first variety, where the delirium is produced by a want of the customary stimulus, there is no doubt that patients have been cured by the administration of the usual stimulants, by giving them wine, brandy, and opium. Indeed, this seems to be the best mode of treating this form of the disease. But is it proper or admissible in the second variety, where the delirium is caused by an occasional excess in the use of ardent spirits ? — Certainly not. \et what do we find to be the ordinary practice in hospitals, when a patient is admitted under such circumstances ? — A man, who has been attacked by delirium tremens after a violent debauch, is ordered a quantity of porter, wine, brandy, and opium ; and the worse he gets, the more is the quantity of stimulants increased. JSow this practice seems to me as ridiculous as the old principle of treating a case of hydrophobia with a hair of the dog that bit. Let us consider what the state of the case is: —A large quantity of stimulant liquors have been taken into the stomach, the mucous surlace of that organ is in a state of intense irritation, the brain and nervous system are in a highly excited condition from the 126 DISEASES OF THE DIGESTIVE SYSTEM. absorption of alcohol, or in consequence of the excessive sympa- thetic stimulation to which they have been subjected. Are we to continue this stimulation ? — I think not. What would be the obvious and natural result? — Increased gastric irritation, encepha- litis, or inflammation of the membranes of the brain. The super- vention of inflammatory disease of the brain in delirium tremens is not understood by many practitioners, and they go on administering stimulant after stimulant, totally unconscious that they are bringing on decided cerebral disease. I have witnessed the dissections of a great many persons who died of delirium tremens, and one of the most common results of the dissection was, the discovery of unequivocal marks of inflammation in the brain and stomach. Broussais considers all such cases as merely examples of gastritis, and ridicules British practitioners for inventing a " new disease ;" but in this he is certainly wrong, for there have been several cases in which no distinct marks of gastric inflammation could be dis- covered. In all cases, however, where the delirium supervenes on an excessive debauch, there is more or less of gastritis; and though it may occasionally happen, that a patient under such circumstances may recover under the stimulant treatment, yet I am convinced that the physician will very frequently do harm by adopting it. This complication of delirium tremens with gastritis is also ex- ceedingly curious in another point of view, as it illustrates how completely the local symptoms are placed in abeyance, and as it were lost during the prevalence of strong sympathetic irritation. The patient's belly will not be tender; the tongue may not be red; the symptoms present may be indicative of a mere cerebral affec- tion, and yet intense gastric inflammation may be going on all the time, and all the appearance of cerebral disease be quickly removed by treatment calculated to subdue a gastritis. Is this all theory ? No; for we have practised on this principle with the most extra. ordinary success in the Meath Hospital. We have seen cases of violent outrageous delirium subside under the application of leeches to the epigastrium, and iced water, without a single drop of lauda- num. I beg of you, if you meet with any cases of delirium tremens under such circumstances, to make trial of this mode of treatment, and record its effects, for it is important that they should be more extensively known. I have seen the whole train of morbid pheno- nema, the delirium, the sleeplessness, the excessive nervous agitation, all vanish under the application of leeches to the epigastrium. In some cases where, after the sleeplessness and delirium were removed by this practice, and the tremors alone remained, we have again applied leeches to the epigastrium, and succeeded in removing the tremors also. On the other hand, where a stimulant plan of treat- ment was employed, and the patients died, we have most com- monly found inflammation in two places, in the stomach, or in the brain or its membrane. The rule, then, is this — in a case of de- lirium tremens from the want of a customary stimulus, use the stimulant and opiate treatment; but when it comes on after an oc- casional violent debauch, such remedies must be extremely im. proper. Adopt here everything calculated to remove gastric irri. CHRONIC GASTRITIS. 127 tation. We have facts to show that most decided advantage may arise from the application of leeches, even where the symptoms of gastritis are absent.* Chronic Gastritis. — We come now to consider chronic gastritis, an extremely interesting disease, whether we look upon it with reference to its importance, its frequency, or its Protean character. It is commonly called dyspepsia, and this term, loose and unlimited in its acceptation, often proves a stumbling-block to the student in medicine. Dyspepsia, you know, means difficult digestion, a cir- cumstance which may depend on many causes, but perhaps on none more frequently than upon chronic gastritis. In the great majority of dyspeptic cases the exciting cause has been over-stimulation of the stomach, either from the constant excess in strong, highly-sea- soned meats, or indulging in the use of exciting liquors. Persons who feed grossly, and drink deeply, are generally the subjects of dyspepsia ; by constantly stimulating the stomach they produce an inflammatory condition of that organ. Long-continued functional lesion will eventually produce more or less organic disease ; and you will find that in most cases of old dyspepsia there is more or less gastritis. But let us go farther, and inquire whether those views are borne out by the ordinary treatment of dyspeptic cases. When you open a book on the practice of physic, and turn to the article dyspepsia, one of the first things which strikes you is the vast num- ber of cures for indigestion. The more incurable a disease is, and the less we know of its treatment, the more numerous is the list of remedies, and the more empirical is its treatment. Now, the cir- cumstance of having a great variety of " cures" for a disease, is a strong proof, either that there is no real remedy for it, or that its nature is very little understood. A patient afflicted with dyspepsia will generally run through a variety of treatment, he will be ordered bark by one practitioner, mercury by another, purgatives by a third ; in fact, he will be subjected to every form of treatment. Now all this is proof positive that the disease is not sufficiently understood. What does pathology teach in such cases ? Iu almost every instance where patients have died with symptoms of dyspepsia, pathological anatomy proves the stomach to be in a state of demonstrable dis- ease. It appears, therefore, that, whether we look to the uncer- tainty and vacillations of treatment, or the results of anatomical ex- amination, the case is still the same ; and that, where dyspepsia has been of considerable duration, the chance is that there is more or less of organic disease, and that, if we prescribe for dyspepsia, * [In my own practice, in former years, I have met repeatedly with gastritis in women brought on by the secret use of mixed liquors, cordials, &c. In one of these cases the attack was exceed- ingly severe, requiring the most energetic means for relief. As too often happens, I was kept, at the time, in entire ignorance of its cause. Those vile compounds, true poisons, sold and drunk by the common people, and in greater proportion by females, under the name of cordials, are, to my knowledge, frequently causes of Gas- tritis, both acute and chronic. — B,] 128 DISEASES OF THE DIGESTIVE SYSTEM. neglecting this, we are very likely to do mischief. I do not wish you to believe that every case of dyspepsia is a case of gastritis. This opinion has brought disgrace on the school of Broussais. His disciples went too far; for whether the gastric derangement depended on nervous irritation, of anaemia, or disease of the liver, or mental emotion, they prescribed leeches and water-diet, and thus very often brought on the disease they sought to cure. We may have func- tional disease, independent of structural lesion in the stomach, as well as in any other organ ; it is no unusual circumstance, and the practical physician meets with it every day. A great deal of con- fusion, however, arises from the similarity of the symptoms. I re- member an accomplished, friend of mine getting into disgrace with one of the members of a board of examiners on this subject. He was asked to tell the difference between the symptoms of chronic gastritis and dyspepsia, and in reply stated that he could not. For this he was nearly rejected ; but, I believe, on a candid review of the circumstances, you will agree with me, that he knew more of the matter than the learned professor. In ninety-nine cases out of a hundred of chronic gastritis there is no fever, scarcely any thirst, often no fixed local pain, and this leads persons away from any idea of the existence of an inflammatory condition of the stomach. What are the symptoms of a chronic gastritis ? pain of occasional occurrence, flatulence, acidity, swelling of the stomach, fetid eructa- tions, sensation of heat and weight about the epigastrium, and perhaps vomiting. Well, these are also the symptoms of dyspepsia, whether it be accompanied by inflammation or not. How, then, when called to a case of this kind, are you to determine the point ? I must mention to you here, that it is often hard to do this with certainty. There are two circumstances, however, which you should always bear in mind, as they will afford you considerable assistance in coming to a correct diagnosis; first, the length of time which the disease has lasted; secondly, the result of the treatment which has been employed. You will find, that where the disease is a chronic gastritis, that it has been of some duration, that it has come on in an insidious manner, and that it has been exasperated by the ordinary treatment for dyspepsia. Many persons think, that if you give a patient medicine, without regulating his diet or issuing a prohibition against full meals, that you can cure him, and that, as he has no fever, and can go about his usual business, there is no necessity for antiphlo- gistic regimen. But as the disease goes on, he complains of pain in the stomach during the process of digestion, feels uneasy after dinner, there is an unpleasant degree of fulness about the epigastrium, he also experiences a variety of disagreeable symptoms, sometimes being annoyed with pain in the chest, sometimes he says he feels it in the region of the heart, and sometimes about the cartilages of the eighth and ninth ribs. These symptoms subside after the pro- cess of digestion is completed, but during its continuance they harass the patient. Very often relief is obtained by vomiting, and hence some persons are in the habit of throwing up their food for the pur- pose of relieving themselves, and consequently can have no benefit ACUTE AND CHRONIC GASTRITIS. 129 by it.* In some cases digestion goes on until the food seems to reach a particular point, and then an acute feeling of pain is expe- rienced. In these cases the gastritis is generally circumscribed, and is likely to terminate in circumscribed ulceration. Various fluids are rejected from the stomach during the course of a gastritis : some- times acid, sometimes alkaline, sometimes insipid and sweet, some- times bitter and bilious. There is generally a degree of fulness about the stomach, and the epigastrium is tender on pressure, but no decided tumour, either of the pylorus, liver, or spleen, although the epigastrium presented that appearance of fulness and tension termed by the French " renitence." The bowels, too, are constipated, and this is a matter worthy of your attention, for it sometimes unfor- tunately happens that the practitioner, mistaking the gastritis for simple constipation, goes on prescribing purgative after purgative, until the patient gets incurable disease of the stomach. I know a case of a lady who gets one stool a week by taking eight drops of crolon oil. Some years ago she was in the enjoyment of excellent health; her bowels happened to get confined, and she was treated by a systematic practitioner with continued purgatives; her bowels are now completely torpid, except when they are subjected to this unnatural stimulus. There are thousands of persons treated in this way, because practitioners look to consequences and not to causes. One great difference between Acute and Chronic Gastritis. — There is one remarkable difference between acute and chronic gas- tritis, which deserves your attentive consideration, as it exemplifies a law applicable to all viscera under similar circumstances, and this is, that the sympathetic irritations are not so frequent or so distinct in chronic inflammation as in the acute form, and hence, in a case of chronic gastritis we almost never have fever, and the affections of the nervous respiratory or circulating systems are by no means so well marked. It may even go on to actual disorganization of the stomach, and yet the patient will not complain of any particular symptom during its whole progress, which you could set down as depending exclusively on the sympathetic irritation of gastritis. Some of these cases, called dyspeptic phthisis, by Dr. W. Philip, are most probably examples of the sympathetic irritation of the lungs from chronic gastritis. Another case, respecting which much error prevails, is what has been call hypochondriasis. Persons labouring under these affections are condemned to run the gauntlet of every mode of treatment; sometimes (and fortunately for themselves) they are sent to travel, sometimes they are treated with musk and anti- spasmodics, then with the mineral acids, then with purgatives and mercurials, and lastly, with bark, nitrate of silver, and stimulants. They go about like spectres from one practitioner to another, try- ing remedy after remedy, alternately sanguine with hope or sad- dened by disappointment, until at last they die, and to the asto- * [I have been told by a person who was in the habit of familiar intercourse with Lord Byron,in Italy, that this was a common prae> tice of the noble poet. — B.J 130 DISEASES OF THE DIGESTIVE SYSTEM. nishment of all the doctors, the only disease found, on dissection, is inflammation and thickening of the mucous surface of the stomach. A condition which, under these circumstances, it was difficult to say whether it was the original disease, or produced by "/air trials" of a number of powerful agents. Hypochondriasis is not always gastritis; but it is now found that, in many cases, it commences and terminates with disease in the upper portion of the digestive tube and the assisting viscera. This you must always bear in mind. Chronic gastritis terminates in various ways. Sometimes the in- flammation is limited to a particular spot of the stomach, and here we frequently discover circumscribed ulcerations. In very bad cases these ulcers go on perforating the various coats of the stomach, until at last the contents of that organ escape into the serous cavity of the abdomen, and the patient rapidly sinks under a fatal peritonitis. It does not follow, however, that, in all cases of perforation, the con- tents of the stomach get into the peritoneum, causing death. Very often adhesions are formed, and the base of the ulcer is the serous covering of some other portion of the digestive system, or a false passage may be formed into the colon. One of the most common terminations of a chronic gastritis is, that the inflammation extends to other viscera ; the patient gets disease of the liver, spleen, perito- neum, or lungs, and sinks under a complication of disorders. It was somewhat in this way that Napoleon died. He laboured for a considerable time under chronic disease of the stomach, which seems to have been overlooked by his medical attendants, and this ter- minated in the extension of disease to various other organs. LECTURE XV. Treatment of Chronic Gastritis. — Frequent excitement of the vascular system necessary to the performance of the functions of the stomach — Local bleeding — Regimen — Counter-irritation over the stomach — Treatment of Broussais — Use of vegetable tonics — Oxide of bismuth — Acetate of morphia — Friction with croton oil — Attention to diet during convalescence — Organic disease of the stomach— Principles of treatment —Diet and attention to the bowels. I shall begin to-day with the treatment of chronic gastritis, and I beg of you to bear in mind what I mentioned at my last lecture, that this disease, in its true and pathological meaning, is not sufficiently recognised. In general, it gets some wrong name or other ; and as many practitioners are in the habit of prescribing for names, it gene- rally meets with wrong treatment. It is called everything but what it is, and its remedies are as numerous and as various as its appella- tions. By some, it is called dyspepsia, and is treated with bitters, astringents, and stimulants ; by others, it is termed constipation, and treated with purgatives; the school of Abernethy look upon it as an affection of the liver, and prescribe blue pill and black draught; others give it the name of hypochondriasis, and exhaust the whole catalogue of nervous and anti-dyspeptic medicines in attempting its removal; in fact, it is called everything but what it is, and the result is an unsteady and mischievous empiricism. TREATMENT OF CHRONIC GASTRITIS. 131 You will recollect a fact, to which I alluded in my last lecture, that the physiological condition of the stomach requires that it should be subject to frequent excitements of its vascular tissue, and that this increased vascularity being the consequence of a natural process, digestion is, generally speaking, exempt from any kind of danger. If the brain or lungs were to experience an equal increase of vascu- larity, sensibility, and excitement, the consequence would be danger- ous, or perhaps fatal, and we should have pulmonary and cerebral diseases produced. But though the stomach enjoys such a remark- able exemption from the liability to acute inflammation, under cir- cumstances of repeated vascular excitement, yet the slow, insidious, chronic gastritis, is an exceedingly common affection. I feel con- vinced that many persons die of it, or of the extensive class of fatal diseases which it frequently induces. But I rejoice to say, that we have good reason to hope that the progressive amelioration of medi- cal science will materially diminish the amount of human suffering from this cause. As physiological medicine advances, the number of those who die of unrecognised chronic visceral disease will be less and less, because diagnosis will become more extended and certain, and practice more simple and successful. The first thing you should do when called to treat a case of dys- pepsia, is to ascertain whether it be a purely nervous disease, or a chronic gastritis. The majority of practitioners give themselves no trouble about this matter, not recognising the fact, that of the number of dyspeptic persons who seek for medical advice, a con- siderable proportion are really labouring under a chronic gastritis, and forgetting, that, in consequence of long-continued functional injury, what was at first but a mere nervous derangement may afterwards become complicated with organic disease. You must also bear in mind, that the stomach is perhaps placed under more unfavourable circumstances for bringing about a cure than any other organ, because the life of the individual demands that the stomach, though in a state of inflammation, should still continue to perform its functions. Iu treating disease of other organs, you will have the advantage of a comparative state of rest; but, in a case of the stomach, if you wish to preserve life, you cannot prohibit nutri- ment, and, consequently, you must run the risk of keeping up these periodic vascularities which its condition requires, which, though harmless in health, become a source of evil when the stomach is dis- eased. The obvious deduction from this is, that the cure of chronic gastritis depends as much upon regimen as upon medical treatment, and particularly where the symptoms have arisen from long-con- tinued excitement, as in the case of persons who live highly. Here the treatment chiefly depends on regulating the diet, and if your patient has sense enough to live sparingly for a few weeks or months, you may be able to effect a cure without other treatment. The great error is, that most practitioners attempt to cure the disease by spe- cifics, and when these fail, they then go to the symptomatic treat- ment, prescribing sometimes for acidity, sometimes for nausea, some- times for flatulence, sometimes for constipation, or '• the liver," or debility. 132 DISEASES OF THE DIGESTIVE SYSTEM. You should be careful in the examination of such cases, and should try to ascertain whether these symptoms may not depend upon in- flammation of the stomach ; for as long as the patient is in this state, the less you have recourse to symptomatic or specific treatment the better. It is hard to mention one single medicine, which, in this state, will not prove stimulant, and if the stomach be unfit for stimu- lants, it must be unfit for the generality of medicines. There are numbers of cases of persons labouring under chronic gastritis, which have been cured by strict regulation of diet, and by avoiding every article of food requiring strong digestive powers. We find that arti- cles of diet vary very much in this respect; some are digested with ease, some with pain. We might express this otherwise, by saying, that some require very little excitement of the stomach, and others very great vascular excitement. Patients, in this irritable state of stomach, can scarcely bear any kind of ingesta ; and when you con- sider the great vascularity, thickening of the mucous membrane, and tendency to organic disease, you will be induced to think that every- thing entering the stomach should be of the mildest kind, and not requiring any powerful determination of blood to that organ.* If you continually prescribe for symptoms, neglecting or over- looking the real nature of the disease, giving arsenic to excite the system, and iron to remove anaemia, and bitter tonics to improve the appetite, and alkaline remedies for acidity, and carminatives to expel flatus, you will do no good; you may chance to give relief to-day, and find your patient worse to-morrow ; and at last he will die, and you may be disgraced. On opening the stomach, after death, you are astonished to find extensive ulceration, or, perhaps, cancerous disease. Very often, in such cases, practitioners say that it is can- * [This course, so conformable with reason and experience, and so readily understood by the attentive inquirer, is, however, the most difficult to be carried out in practice. Our patients will take every kind of nauseating drug without much grimace : they will consent to be blistered and cauterised and punished, after every medical fashion : but so soon as we wish to substitute a regulated and restricted diet for this polypharmacy, they all at once discover innumerable difficulties in the way. We then become cruel, starv- ing doctors ; without good bowels of our own, it is believed, and of course without compassion for the bowels of others. In fact, a physician will be much more likely to preserve his reputation in a family, whilst, bringing on chronic, perhaps incurable, gastritis, by the needless administration daily of arsenic, than whilst he is suc- cessfully attempting the cure of a case of this disease by a very restrict- ed diet. After all, however, it will be found with this, as with many other prejudices of the people, that they are but the reflexion or echo of former opinions and now exploded hypotheses of the profession. If physicians, generally, would cease, indolently perhaps oftener than ignorantly, to administer to the whims of their dyspeptic patients, the latter seeing a general concert of opinion among medi- cal men, would be less reluctant to follow out literally the adfvice of their immediate professional advisers.—B.] treatment:of chronic gastritis. 133 cerous disease, and that no good can be done. But the thing is to be able to know, when you are called to a case, whether it is a case of mere nervous dyspepsia, or chronic inflammation of the stomach. Some of the best pathologists think that most of the cancerous affec- tions of the stomach are, in the beginning, only chronic inflamma- tions of that organ. I believe we have not yet in this country adopted the plan of moderate application of leeches to the epigastrium in cases of chronic gastritis. I have seen, in many cases, great benefit result from the repeated application of a small number of leeches to the epigas- trium, at intervals of two or three days. Here is a point which you will find very useful in practice. You will meet with cases which have lasted for a long time ; cases where there is strong evidence of organic disease, and which have resisted the ordinary dyspeptic treatment. You will be called frequently to treat these three dif- ferent cases : —wher»"the disease has been of long duration ; where there is distinct evidence of organic disease ; and where the disease has resisted the ordinary dyspeptic treatment. Here is a case of a patient labouring under what is called indigestion, and which has resisted the stimulant, and tonic, and purgative treatment. Here is one fact. In the next place, the disease is chronic, and the proba- bility is that there is inflammation, and consequently that there is chronic gastritis. Now if, in such a case, you omit all medicine by the mouth, apply leeches to the epigastrium, keep the bowels open by injections, and regulate the diet, you will often do a vast deal of good. I have seen, under this treatment, the tongue clean, the pain and tenderness of the epigastrium subside, the acidity, thirst, nausea, and flatulence, removed, the power of digestion restored, and all the symptoms for which alkalies, and acids, and tonics, and purgatives, were prescribed, vanish under treatment calculated to remove chronic inflammation of the stomach. What is next in importance to regulated regimen and local bleed- ing ? A careful attention to the bowels, which in chronic gastritis are generally constipated, and this has a tendency to keep up disease in the upper part of the digestive tube. Is this to be obviated by introducing purgative medicine into the stomach ? No. If you in- troduce strong purgative medicine by the mouth, you will do a great deal of mischief. You must open the bowels by enemata, or, if you give medicine by the mouth, by the mildest laxatives in a state of great dilution. A little castor-oil, given every third or fourth day, or a little rhubarb, with some of the 'neutral salts, will answer in most cases.* The diet, too, can be managed, so as to have a gently laxative effect.t The use of injections is, however, what I princi- * [ Salts are often singularly unfriendly to the stomach of a dyspep- tic. Rhubarb and soap pill, or rhubarb and carbonated magnesia, well mixed, with a little cinnamon or ginger, are preferable. — B.] t [And for this purpose bran or rye bread, rye mush and milk for breakfast and spinach for dinner, are among the best articles. But- ter-milk in season, and melasses and water for occasional drink, will tend to the same end. —B.] vol. i.—1^ 134 DISEASES OF THE DIGESTIVE SYSTEM. pally rely on. I have seen many cases of gastritis cured by the total omission of all medicine by the mouth, by giving up every article of food which disagreed with the stomach, and by the use of warm water enemata. I have seen this treatment relieve and cure persons whose sufferings had lasted for years previous to its employ- ment, and who had been considered by many practitioners to labour under organic disease of an incurable nature. It is important that you should bear this in mind. The old purgative and mercurial treatment of gastritis, I am happy to say, is rapidly declining; and British practitioners are now convinced that they cannot cure every form of dyspepsia by the old mode of treatment. I do not deny that many diseases of the digestive tube may be benefited by the mild use of mercury and laxatives, but I think I have every reasonable and scientific practitioner with me in condemning the unscientific rou- tine practice, which was followed by those who took the writings of Abernethy and Hamilton for their guide. I do not say that, where cases of gastric inflammation, treated after the plan of Mr. Aber- nethy, have proved fatal, the medicines have destroyed life ; I merely assert that the patients died of inflammation, over which these medi- cines had no control; and the error lay in mistaking and overlooking the actual disease, as much as in its maltreatment. You will find some practitioners (they are becoming fewer in number every day), who seem to have but two ideas, the one a purgative, the other a potful of feces ; but the connecting link — the gastro-enteric mucous membrane — that vast expansion, so complicated, so delicate, so important, seems to be totally forgotten. But practitioners are now beginning to see that purgatives are not to be employed empirically; that they should be administered in many cases with great caution, and with a due attention to the actual condition of the alimentary canal, and that they have been a source of great abuse in the medical practice of these countries. Next to leeching, and a proper regulation of the bowels, is the employment of gentle and long-continued counter-irritation over the stomach. This may be effected by the repeated application of small blisters, or by the use of tartar emetic ointment. I have been in the habit of impressing upon the class, that the tartar emetic ointment used in these countries is too strong, the consequence of which is an eruption of large pustules, which are excessively painful, and often accompanied with such disturbance of the constitution as amounts to symptomatic fever. In fact, tartar emetic ointment of the ordinary strength produces so much irritation, that few patients will submit to it long. The form which I recommend you to employ is the follow- ing :— Take seven drachms of prepared lard, and, instead of a drachm of tartar emetic, which is the usual quantity, take half a drachm, directing, in your prescription (this is a point of importance), that it be reduced to an impalpable powder; and you may add to it, what will increase its action, one drachm of mercurial ointment. This produces a crop of small pustules, which give but little pain, and are easily borne; and the counter-irritation may be kept up in this way for a considerable time, by stopping, for a few days, until the eruption fades away, and then renewing the friction. I have often seen the utility of this remedy exemplified in cases of chronic TREATMENT OF CHRONIC GASTRITIS. 135 gastritis, where the symptoms of gastric irritation, which had sub- sided under the employment of friction with tartar emetic ointment, returned when it was left off, and again vanished when it was re- sumed. The case of the celebrated anatomist, Beclard, furnishes a very remarkable proof of the value of a well-regulated diet and re- peated counter-irritation in the treatment of this disease. While he was engaged in the ardent prosecution of his professional studies he got an affection of the stomach, which he considered to be a chronic gastritis, and immediately put himself under a strict regimen, using, at the same time, repeated counter-irritation. He kept up the coun- ter-irritant plan for a considerable length of time, for he found that, when he discontinued it, the gastric symptoms had a tendency to return. In this way he got completely rid of the disease. Several years afterwards he died of an attack of erysipelas ; and, on opening his stomach, the cicatrix of an old ulcer was discovered in the vicinity of the pylorus, which was exactly the spot to which he had referred his pain during the continuance of his gastric affection.* There is, perhaps, no science in which the motto, " medio tutissi- musibis," is of more extensive application than in medicine. Some physicians on the continent, particularly the disciples of Broussais, having repeatedly witnessed the advantages of strict regimen and local depletion in chronic gastritis, have pushed this practice too far. They seem to forget that the system requires support and nutrition, which can be effected only through the agency of the stomach ; they saw the evils which result from the use of stimulating food in cases of chronic gastritis; and, looking to these alone, they ran into the opposite extreme, the consequence of which was, that they kept their patients so long upon low diet that they actually produced the very symptoms which they wished to remove. The patients became dyspeptic from real debility of the stomach and the whole frame. You remember a general law of pathology to which I have alluded on a former occasion, and which I shall again mention, as it illus- trates this point, namely, that opposite states of the economy may be accompanied by the same symptoms. Thus, we observe tha't palpitation may depend on two different causes — on a sthenic or asthenic condition — on the presence of too much or too little blood in the heart. Now, it frequently happened that patients, labouring under chronic gastritis, and who had been treated for a long time after the strict plan adopted by the Broussaists, finding themselves not at all improved, went to other physicians who had different views, and were rapidly cured, by being put upon a full nutritious diet. In this way numerous cases, which water-diet and depletion had only aggravated, were relieved, and the consequence was, that a mass of facts was brought forward and published, not long since, by a French author, against the antiphlogistic treatment of dyspepsia and chronic gastritis. It must be stated, however, that the cases which he pub- lished were chiefly those in which the depleting system had been carried to excess, and that they cannot, therefore, be received as proofs of the value of a stimulating diet in the treatment of chronic * [For additional means of producing counter-irritation, see rav lecture on chronic rheumatism. — B.J 136 DISEASES OF THE DIGESTIVE SYSTEM. inflammation of the stomach. Bear this in mind ; the sooner you can put your patient on a nutritious diet the better will it be for him. It would be absurd to keep a patient for many months, as the Brous- saists have done, on slops and gum-water. It will be necessary for you to feel your way and improve the diet gradually. Commence by giving a small quantity of mild nutritions food ; if your patient bears it well, you can go on ; if the gastric symptoms return, you can easily stop. If a small portion of the milder species of food rest quietly on the stomach, you may increase it the next day, or the day after, and thus you proceed to more solid and nutritious aliment, until the tone of your patient's stomach regains the standard of health. Never lose sight of this fact, that you may have a case of dyspepsia depending on a chronic gastritis, in which, though you remove the inflammation by a strict antiphlogistic treatment, you may not by this remove the dyspepsia ; and if you continue to leech, and blister, and starve your patient, after the inflammatory state be removed, you will do great injury. Such a patient, falling into the hands of another practitioner who treated him on a different system, might be relieved, and his case quoted against you and your treatment, though this, at the commencement, was judicious and proper. With respect to internal remedies, the school of Broussais think that there is nothing required but cold water and gum. This is going too far. In a former lecture, I have drawn your attention to the fact, that in the treatment of acute inflammation there is a point where antiphlogistics should cease, and where tonics and stimulants are the most efficient means of cure. Of this fact, the disciples of Broussais appear to be ignorant, and they consequently declare against every remedy for chronic gastritis except leeches and cold water. Now, is this right. ? I think not. We find that, in all cases of gastric inflammation, a change in medication seems to be useful at some period of the disease, that is, a change from an- tiphlogistics to tonics and stimulants ; and I believe that in cases of chronic gastritis these remedies may be used with very great advan- tage, having, of course, premised depletion and counter-irritants. I believe, too, that most of the remedies, which we see every day un- successfully employed, would have acted beneficially, if the prepa- ratory treatment, which I have mentioned, had been adopted. Among the best remedies of this kind is the oxide of bismuth; I have seen more benefit from the use of this than of any other medicine, after the treatment already alluded to. Generally speak- ing, the list of internal remedies for chronic gastritis is very small, but after the use of antiphlogistics, you may prescribe the vegetable tonics and oxide of bismuth with advantage. The most decidedly valuable remedy, however, in the after stage of a chronic gastritis, is the acetate of morphia, which, I am convinced, has a very" power- ful effect in allaying chronic irritation of the stomach. Dr. Bards- ley, of Manchester, in one of his published works, entitled " Hos- pital Facts and Observations," adduces many cases of gastric irri- tation which were completely relieved by the use of this remedy, and I am perfectly satisfied of the truth of his statements. It may be said that Dr. Bardsley's cases were only instances of dyspepsia. But as his cases were extremely numerous, some of them of Ion" TREATMENT OF CHRONIC GASTRITIS. , 137 standing, and the symptoms very severe, the great probability is, that some of them at least must have been cases of chronic gas- tritis. I know very few books, the perusal of which I would more strongly recommend to you than Dr. Bardsley's accurate and instruc- tive work. The great besetting sin of medical writers is, that their statements of successful practice are grounded on a very limited num- ber of cases, or that, in publishing the result of their practical inves- tigations, they only give their successful cases, and leave out those in which the treatment recommended has been found inefficacious. Yet this is a circumstance which should never be neglected. If a man declares that he has discovered a cure for gastritis, or dyspep- sia, and brings forward one hundred cases in which the remedy has done good, the statement is still unsatisfactory and insufficient, be- cause there may be one thousand cases in which it has totally failed. Unless he comes forward and gives both his successful and unsuc- cessful cases, of what value are his statements ? Dr. Bardsley, with the candour and good sense which always characterize the philoso- phic inquirer, gives the result of all his cases, forms them into tables, and then leaves his readers to judge for themselves. From an in- spection of these tables, you will be convinced of ^the efficacy of acetate of morphia in the treatment of chronic gastritis. I have been in the habit of using it with the most gratifying results after leeching, regulating the diet, and paying proper attention to the state of the bowels. There are some forms of the disease in which it is more useful than others. The particular form, in which it proves more serviceable, is where there is a copious secretion of acid from the stomach (that form in which all kinds of alkalies have been ex- hibited), where severe pain and constant acidity are the prominent symptoms. Here I have seen the acetate of morphia act exceed- ingly well. You may begin with one-twelfth of a grain made into a pill with crumb of bread, or conserve of roses, twice a day; the next day you may order it to be taken three times, and you may go on in this way until you make the patient take from half a grain to a grain and a half in the twenty-four hours. I shall here mention the circumtances of a case, which I do not mean to bring forward as an instance of cure, but as an illustration of the extra- ordinary power which acetate of morphia possesses in relieving gastric irritation. A gentleman of strong mind and highly culti- vated intellectual powers, which he kept in constant exercise, got a severe chronic gastritis; his appetite completely declined; he had frequent vomiting of sour matter; fetid eructations; and such violent pain in the stomach, that he used, when the attack came on, to throw himself on the ground, and roll about in a state of indescribable agony. He applied to various practitioners, had seve- ral consultations on his case, and the opinion of the most eminent medical men was, that he had incurable cancerous disease of the stomach. These symptoms continued for several years, but for the last two or three years they were quite intolerable. He had re- peated cold sweats, vomited everything he took, even cold water, was reduced to a skeleton, and led a life of complete torture. Un- der such circumstances he tried for the first time, by my advice the 13S DISEASES OF THE DIGESTIVE SYSTEM. acetate of morphia. He tried it first in doses of one-tenth of a grain three times a day, and experienced the most unexpected relief. On the third day all his bad symptoms were gone. He had no pain, no vomiting, no sweats ; his spirits were raised to the highest state of exhilaration, and he thought himself perfectly cured. He went out in the greatest joy, visited all his friends, and told them that he had at last got rid of his tormenting malady. In the evening he joined a supper party, indulged very freely, and next morning had a violent hematemesis, to which he had been for some time subject. All his old symptoms again made their appearance. He again had recourse to the acetate of morphia, and again immediately ex- perienced relief, but the vomiting of blood again returned, so that he discontinued the remedy. This gentleman is now in the enjoy- ment of good health. He regulated his diet, left off all medicine by the mouth, used warm water injections, and thus recovered from his supposed cancer. I do not bring this case forward as an instance of the curative effect of acetate of morphia, but as an instance of its powerful effect in allaying gastric irritation. I could adduce other cases in proof of its value in the treatment of the after stage of chronic gastritis, and particularly of that form in which pain and acidity are the prominent symptoms ; but I perceive my time has nearly expired. In speaking of the employment of counter-irritation in cases of chronic gastritis, I forgot to mention the use of friction with croton oil which has been found beneficial in many cases of chronic in- flammation. It has been extensively used by many practitioners in the treatment of chronic affections of the joints, and in various forms of pulmonary disease; and I have employed it myself in some cases of chronic gastritis with benefit. I cannot say that the cases in which I have used it presented all the symptoms of chronic gastritis, but they were certainly cases of chronic gastrodynia, with severe local pain, nausea, and loss of appetite. It is an excellent counter- irritant, and gives very little pain. The mode in which I employ it is this — take a few drops of croton oil, five or six, for instance, drop them on the epigastrium, and rub them in with a piece of lint or bladder, interposed between your finger and the skin, and the next day you have an eruption of small papulas, which you can increase at will. There is one interesting circumstance connected with the use of croton oil frictions, which you should be made acquainted with. The liability to produce counter-irritation, seems to depend upon the absorption or non-absorption of the croton oil; if it be ab- sorbed it will purge, but if it be not it will produce counter-irritation. In cases of this kind, therefore, where it produces the necessary de- gree of irritation in the skin, the chances are, that it will not act dis- agreeably by bringing on catharsis. I have only seen one case where there were both the eruption and catharsis. This was a gen- tleman who had lately suffered from dysentery in warm climates. I may also mention, that, in convalescence from an attack of chronic gastritis, you must pay great attention to diet for a long time, because there is no affection of any organ in the body, in which an error in diet so rapidly induces a return of the original symp- toms, as in diseases of the stomach, while each return of the disease TREATMENT OF CHRONIC GASTRITIS. 139 renders the attack more dangerous and unmanageable, until at last disorganization takes place. This leads me to speak of organic disease of the stomach. On this subject I shall be very brief; the best mode of communicating infor- mation will be to exhibit these preparations; you will derive more instruction from their inspection than from any lecture I could deliver. (Dr. Stokes here exhibited a number of beautiful preparations from the Park street museum, illustrative of various organic lesions of the stomach.) Here is a case, which some pathologists would call cancer, others chronic gastritis. I may remark here, that pathologists are divided as to what is the cause of cancer of the stomach, but the best informed are of opinion that in those cases of gastric disorganization which are called cancer or scirrhus, all that can be demonstrated by the knife is referable to the results of chronic inflammation. This is a different proposition from saying that chronic inflammation alone will produce cancer. As yet we know little of cancer ; dissection of cancerous organs gives but scanty information ; but this seems cer- tain that, in particular conditions of the economy, an inflammation of the stomach will end in cancerous disease. Here is an excellent preparation of the stomach of a person who died of cancer of that organ. For several years before his death he had a jaundiced look, an emaciated appearance, frequent vomiting, and severe pain towards the termination of the digestive process, a circumstance which denotes disease of the pylorus. He also had hematemesis. You see, the inner surface in the vicinity of the pylorus presents ulcerations of the mucous membrane and thickening of the sub- mucous cellular tissue. The pylorus itself does not appear to be at all contracted, but the parts around it are in a state of extraordi- nary disease. Look at the preparation again, and say what could bitters, or acids, or alkalies, or tonics, have effected in a case of such extensive disease. Here is a stomach in a state of long con- tinued chronic inflammation, and exhibiting lesions, which some would designate as cancer of that organ. Now, though I do not know the treatment which this patient underwent, I would venture to say that he took plenty of the usual anti-dyspeptic medicines. Yet, in a vast number of cases, where enormous quantities of these remedies are taken daily, the stomach is in as bad a state as that preparation exhibits, and I feel the more strongly convinced of this, because I am aware that many persons die after having gone through the whole routine of anti-dyspeptic practice, and, when they are opened after death, incurable disease of the stomach is discovered. Here is an example of vast cancerous disease of the stomach ; here is a very interesting specimen of chronic gastritis, chiefly representing a most remarkable and circumscribed ulcer at the termination of the stomach. Here, you see, is the ulcer, with raised, thickened, and introverted edges. Now, in all probability, this ulceration was exceedingly chronic, for you perceive nature has been at work with it, and has made some attempts at repara- tion. It is in such a case as this that patients generally refer their pain to a particular part of the stomach: digestion goes on without any pain until the food reaches a certain point, when*acute pain is felt, and this continues until it is relieved by vomiting. The 140 DISEASES OF THE DIGESTIVE SYSTEM. occurrence of this symptom, after an attack of acute gastritis, would lead vou to suspect the formation of one or more ulcers, and the persistence of this localized pain should induce you to persevere in employing every means in your power calculated to remove the disease. ^The preparation which I now exhibit is interesting, as it shows the effect of corrosive poison on the stomach. The patient, to whom this stomach belonged, died in consequence of swallowing a quantity of sulphuric acid; here you see the consequences— the mucous membrane is black and disorganized, exhibiting this ragged appearance. In some cases of malignant fever we have found the stomach presenting somewhat similar appearances; and the same state of the stomach is described by some writers as occurring in cases of intertropical fever. Here is a preparation which you should inspect; chronic gastritis with a large ulcerated patch in the centre of the stomach. Here is another example of extensive cancer- ous disease. A very few words will suffice for the state of the science on the subject of cancer of the stomach. It is very hard, nay, even almost impossible, to draw a line of distinction between the symptoms of cancer of the stomach and chronic gastritis, and I believe it is admitted on all hands that the same causes give rise to both. Long continued irritation will, in one case, produce cancer of the stomach, in another, chronic gastritis. Again, it is admitted by many, that what is called cancerous ulceration of the stomach has no appreciable difference from ulceration in various other organs; and hence some other per- sons have gone so far as to say that there is no such thing as cancer of the stomach (separately considered); and that all the cases ad- duced of it are nothing more than so many forms of chronic gastritis. In the present state of medicine, we are not, indeed, possessed of any data which would enable us to come to a final determination on this question. It is certainly impossible to determine this point; but if there be anything peculiar in cancerous matter, similar to tubercular or melanotic matter, there is no reason why, under the influence of inflammation, it should not be developed in the stomach as well as iu any other part of the body. But whatever views we entertain on this subject, we must confess that, in the majority of cases, there is a chronic gastritis, and that the principles of treatment which would alleviate the patient's sufferings and prolong life, are those which are calculated to prevent the occurrence of gastric inflamma- tion. The more you approximate the treatment of cancer to that of chronic gastritis, the greater comfort will you afford your patient, and the more will you prolong his existence. The most celebrated case on record of this affection is that of the Emperor Napoleon. He died with extensive ulceration of the sto- mach, which, of course, was called " cancerous" and there were also distinct traces of disease of the liver, the mucous coat of the in- testines, and the lungs. His disease was believed by himself to have originated in the stomach, and to this opinion he adhered, notwith- standing the results of some solemn consultations, at one of which his affection was declared to be an " obstruction of the liver," with a"scorbutic dyscrasy." At another it was pronounced to be a chronic hepatitis," and a course of mercury recommended ! When CAUSES AND CONCOMITANTS OF DYSPEPSIA. 141 we reflect on this, and read in the account by Gaubert, (which you will see in the Examen des Doctrines Medicates,) the regimen which was used, and the list of stimulating medicaments employed, you will not wonder at the words of this great man, when he was pressed to take more drugs, to swallow the universal nostrum, mercury, to which he had the greatest aversion. " Your disgusting preparations are good for nothing. Medicine is a collection of blind prescriptions, which destroy the poor, sometimes succeed with the rich, but whose whole results are more injurious than useful to humanity." But he got mercury, notwithstanding, mercury for his " digestive organs;" to "excite the liver;" to " remove its obstruction," and mercury to create bile, and purgatives to remove it; and tonics, and antacids, and stimulants; and he died in torture, and his body was opened, and the stomach was found " cancerous." I should not omit mentioning to you, that in those cases of chronic gastritis which run on to an incurable stage, the best treatment con- sists in a careful regulation of diet, in keeping the bowels open by enemata, or the very mildest laxatives, and in avoiding everything capable of producing excitement. You will also derive advantage from the employment of gentle counter-irritation, and from the internal use of narcotics which in such cases appear to have a more beneficial effect than any other class of remedies. With the exception of these, I do not know any other kind of medicine you can safely employ? and I believe that, in the majority of cases, you will find that the patients have taken already too much medicine. Anxious for relief, and urged on by the hope of obtaining some remedy capable of re- lieving their sufferings, they have recourse to every grade of quacks, are persuaded to swallow every kind of drug, and are subjected to every form of harassing and mischievous treatment. The diet which you prescribe for such patients should be sparing but nutritive ; give the stomach as little to do as will be consistent with the support of life and strength ; and you may take it as a general rule in the treat- ment of all chronic affections of the digestive tube, whether cancer of the stomach, scirrhus of the pylorus, or stricture of the intestines, that there are two great principles of general application — preserv- ing a gently open state of the bowels, and allaying inflammatory excitement. • LECTURE XVI. DR. BELL. Dvspepsia.— Temperaments and Constitutions most liable to the disease — Habits of life inducing it — Concomitant diseases — of brain, liver, skin, lungs, uterus, and kidney —These are sometimes causes, sometimes effects of dyspepsia — A complex disease, sometimes caused by, sometimes causing spinal irritation — Modification of treatment required — Andral's case and reflexions — Dr. Chap- man's notice of chief causes — Tobacco, its injurious tendency and effects — High excitement of brain in England and United States.—Dyspepsia with Morbid Gastric Secretion — Pyrosis or JValer-brash— Its causes and treat- ment. — Cardiulgia, its mixed nature and treatment— Mercury—Ipecacuanha — Sulphuret of potassa — Gunpowder. Doctor Stokks has pointed out, with his usual judgment, the fre- quent dependence of dyspepsia on chronic gastritis; but in making 142 DISEASES OF THE DIGESTIVE SYSTEM. this latter the subject of his lecture, he has not had scope for exhi- biting the various functional disturbances that give rise to and keep up a state of the stomach which is not inflammatory, but which en- tails on its possessor all the horrors of dyspepsia or indigestion. I shall endeavour, in this and the two following lectures, to point out the chief causes and concomitants of this disease, or series of dis- orders, and the remedies best adapted to each particular class of cases. Causes and Concomitants. — Dyspepsia, (from J»t3 difficulty, and ■i4«, digestion, and primarily, a-ur™, / digest), that kind of func- tional derangement which interferes with thecon version of aliment into chyle,isfound in all temperaments,but more in the sanguineo-nervous and the nervoso-bilious than in others. The varieties are numerous. I shall mention only apepsia, bradyspepsia (from Gg* pyrosis (from m$, fire); and bulimia (from jgouc, an ox, and *t[Ao;, hunger); cardialgia (from *»g^*, or *«§, heart, and «*>«£, pain); gastralgia (from >*cT»g, stomach, and axj-oV pain ;) gastrodynia (from >*cr»g, the stomach, and oSw», pain). The lymphatic and the nervoso-lymphatic are less frequently sufferers, and when attacked their cases are more readily cured than those of the other tempera- ments just indicated. In some the stomach suffers by irregular in- nervation,— its nervous system at times over-excited, and at others wanting its appropriate nervous stimulus, — as we see in nervous and hysterical persons of either sex, for hysteria in all its essential phenomena is far from being confined to females. Persons of this class, particularly if they are of a rheumatic diathesis, often suffer from a sudden transference of irritation to the stomach, with pains and cramp. So, also, we can readily believe that there is, at times, an original deficiency in the secretion of gastric juice, just as there is of cutaneous or renal secretion : and that, although the stomach is fully competent to digest, in limited quantity, any kind of food, yet it suffers if more is introduced in it. This state of things, we have reason to believe, exists where the digestion is very slow, but without pain, eructation, heat, thirst, or distress of any kind during the entire period from ingestion to defecation. Of the acquired predispositions, that induced by sedentary life in a constrained posture, with the mind intent on some exclusive sub- ject, and its possessor inhaling a close or impure air, merits the first notice: and of the exciting causes which operate directly on the stomach, the continued use of alcoholic liquors is entitled to con- spicuous mention. Dr. Beaumont has shown, in his experimental observations on Alexis Martin, that all these drinks irritate the gastric mucous membrane and pervert the secretion of gastric juice. The same remark applies to spices and condiments, and in degree to coffee and tea. Of course, therefore, whatever may have been the habits of the patient anterior to the disease, he is bound to desist from all these articles when he is actually suffering under " —ProTvjdedheishoiiestly intent on getting cured. Impure air, which I have mentioned as a predisposing, is also frequentlv a powerfully exciting cause of dyspepsia ; so much so, indeed, that I should dread its secondary effects on the stomach more than its primary ones on the lungs, even though the latter were also weak and predisposed to disease. Late hours, deprecated for the invalid CAUSES AND CONCOMITANTS OF DYSPEPSIA. 143 by physicians and writers of hygiene, are chiefly hurtful, if he be exposed, as in a crowded company, or even in his own room or study, to close, impure and imperfectly renewed air. Inadequate atonement for this kind of exposure is made by those who pass the night in a close and badly ventilated chamber. Among the concomitants, which are sometimes causes and some- times effects of the disorder of the stomach constituting dyspepsia, may be enumerated derangements in the functions of the brain, skin, lungs, uterus, and kidneys. Anterior even to these, in the opinion of some,is that deficient action of the lower bowels marked by consti- pation. Dr. Burne, in his " Treatise on the Causes and Conse- quences of Habitual Constipation," has enlarged on this theme. But we shall find it difficult to determine how far this state is a cause or a concomitant and consequence of dyspepsia. That it is not neces- sarily a cause, we are assured by the knowledge of cases in which, with obstinate constipation, there is vigorous, and complete gastric and duodenal digestion. Continual excitement of the brain in the mere exercise of intellect, and, still more, in the conflict of passions, exerts a prejudicial influ- ence over the stomach, and is a too common, though not yet suffi- ciently recognised cause of dyspepsia. Nor is the evil confined to those whose aspirations are for this world's wealth and honours alone. An over-heated imagination, extreme direction of the feelings to the subject of religion, intentness on doctrinal disquisitions, devo- tion to an excessive routine of external observances and the acerbity of sect, in place of the active discharge of personal and social duties under religious guidance, induce a morbid state of the nervous sys- tem, which is often felt in irregular and painful digestion. Persons, under these influences, are too prone to forget that, in their eager- ness to do what they believe to be acceptable to the Deity, by carry- ing out the various observances of form, they act in direct opposi- tion to the natural laws which are also his, and a conformity with which is a necessary condition for their enjoying health. They act, often, as if they believed that an exception to these laws would be made in their favour: and that meetings, night after night, during which they respired over and over again the same close air, and encountered transitions from excessive heat within doors, to the cool- ness and dampness of the outer air, and often amidst the greatest in- clemencies of weather, would not be productive of the customary bad effects on the bodily frame, because their mental was in such zealous exercise. If worship were penitential, instead of the offerings of grati- tude and entreaty for protection and aid, we might admit that people are consistent in subjecting themselves to present suffering and future disease by this voluntary privation of air, and by over-excitement and subsequent languor and lassitude of the body generally, and of the nervous system in particular. Derangement of the hepatic function is a cause of dyspepsia, but not nearly to the extent that it has credit for. I would say that the cause, when present, is adequate, but that it does not really exist in a majority of those cases in which its presence is assumed. Hepatic disease is often, as I will show you hereafter, supposed to be present 144 DISEASES OF THE DIGESTIVE SYSTEM. when the real derangement is duodenal dyspepsia. The circum- stances of atmospheric exposure and of irregular living, including errors both of physical and moral hygiene which bring on hepatitis, are also well calculated to give origin to dyspepsia. Great and manifold are the gastric disorders of all kinds, from simple heartburn up to chronic gastritis, — that are produced by impeded function of the skin, by which I do not mean merely sup- pressed perspiration, but that low degree of vitality kept up by con- tinual exposure to cold and moisture and unclean things, without adequate clothing and even common ablution. There is not a viscus that does not suffer in every imaginable degree by this means, and the stomach more, if we except perhaps the lungs, than any other. In maritime exposures, and particularly if easterly winds are preva- lent, people are greatly troubled with dyspepsia, which assumes a variety of shapes, and becomes so aggravated as to simulate scurvy itself. Under such circumstances the morbid impression is first and chiefly made on the skin. The influence of the lungs in the process of digestion will be generally understood by reference to their function of hematosis, any impediment to which, by causing imperfectly elaborated blood to circulate and reach the stomach, must modify injuriously its vitality, and prevent the requisite secretion of gastric juice. In another way, also, or by sympathy, the direct deleterious impression of impure air on the mucous membrane of the lungs is transmitted to the analogous membrane of the stomach, — both organs being su pplied by the same nerve, the par vagum — and both, also, having other intercommunication by means of the ganglia and plexus of the sympathetic. It is in these two ways that want of ventilation is so injurious to the gastric function, and is so frequent a cause of dyspepsfa. In the suspended or perverted function of the uterine system, as in amenorrhcea and menorrhagia, and even in the plenitude of its exercise, as in pregnancy, we have frequent occasion to note the injury done thereby to the stomach, which is at these times singu- larly, even for it, capricious and irregular in its appetites and powers. Derangement of the uterine functions is truly a concomitant of dyspepsia ; being at one time an obvious cause, at another an equally evident effect of this latter disease. Nor is it by any means easy always to declare the order of causation. Impeded or perverted function of the kidneys is, we know of late years a more common cause of disordered digestion than was at one time dreamed of. The fact that it was a frequent effect of gastric disorder we were tolerably familiar with, but it was reserved for the more careful observations of modern pathology, aided by chemistry, to show that chronic disease of the kidneys, as in their state of albu- minous secretion, injures permanently the function of the stomach. The sympathetic irritation transmitted by the kidneys, in a state of acute inflammation, to the stomach, was noted by everv tvro in pathology,— I was going to say, by every reader of nosology A very snght knowledge of physiology and observation of morbid phenomena prepare us to find all the organs already enumerated. MODIFICATION OF TREATMENT IN DYSPEPSIA. 145 which cause, by their morbid state, dyspepsia, becoming themselves functionally disturbed, and even undergoing lesion of tissue in con- sequence of protracted gastric disease. Of gastric origin are the depression, gloom, and terrors of the hypochondriac; as likewise the irascibility and violent passionate excitement in other cases,— all manifesting a sympathetic morbid state of the cerebral functions. Continued irritation of the stomach and duodenum is a frequent cause of hepatic derangement, which singularly aggravates the primary disease. What a tribe of cutaneous disorders, to say nothing of the perversion of the functions of secretion and absorption, and the modification of sensibility of the skin, result from chronic disease of the stomach, in dyspepsia. So, likewise, we meet with a host of disorders of the lungs, from simple hurried breathing after a full meal up to confirmed phthisis pulmonalis, the consequences of gastric de- rangements. When tubercles follow prolonged dyspepsia, as in some cases they undoubtedly do, we must attribute this effect to the imperfectly elaborated blood and interruption to nutrition, rather than to a direct sympathetic irritation of the lungs with the stomach. Continuing our illustrations,— we are able to point out the readiness and frequency of uterine derangement after gastric disorder, and to show how entirely obedient, in many cases, the uterus is to impres- sions, at first morbid and afterwards therapeutical, made on the stomach. In all these cases the stomach, whether transmitting morbid im- pressions to, or receiving them from other organs, may be in a state of chronic phlogosis, or it may manifest functional disturbance with- out manifest organic lesion. Hence, although attention to the con- comitants of dyspepsia is of paramount importance, both in investiga- ting this disease and in aiding us to devise a proper treatment for its removal, it alone will not indicate the actual condition of thestomach. Nor will the remedies be always essentially or materially different, according as the dyspepsia is primary or the result of reflex irritation on the stomach from some other organ. We may have, for instance, dyspepsia connected with chronic gastritis from errors of regimen directly affecting the stomach, or a similar morbid condition from mental causes, an over-excitement of the brain indirectly affecting the stomach. From the operation of the same causes, direct and indirect dyspepsia may result, without any inflammation or equivalent mor- bid change of gastric mucous tissue. In thus directing your attention to this large circle of morbid associations with dyspepsia, and of its possible numerous causes, my aim is to show the necessity of a careful inquiry into all the antecedents of the disease which may have given rise to it, and all the concomitants by which it may be supported. Dyspepsia is a complex disease, the chief and most annoying feature of which is generally, but not always, gastric distress and disturbance. The stomach is often the centre whence radiate irritations to numerous other organs, whose functions are troubled in various ways ; but it is, also, often that cenire to which converge irritations from these same organs. At one time you will see it, by its transmitted irrita- tion, forcing the spinal marrow and its motor nerves into a state of vol. i.—13 146 DISEASES OF THE DIGESTIVE SYSTEM. morbid excitement, evinced by irregular contractions and spasmodic movements of some part of the muscular system ; at another, into indirect debility from prior excitement, and then there is inability to move, — partial paralysis, in fact, in some of the limbs. And again the stomach is itself the recipient of spinal irritation, and it is tor- mented with pain and spasms, which disappear with the removal of the primary disease. For details, with illustrative cases of these various sympathies, I refer you to Dr. Langston Parker's treatise — " The Stomach in its Morbid States, &c." The successful treatment of a disease, or one might say congeries of diseases, such as dyspepsia is, must obviously be rational rather than empirical: it must be also hygienic as well as therapeutical, and often partake more of the former than the latter. He who bases his treatment on the belief that dyspepsia is uniformly the effect of chronic gastritis, is not more in error than he who contends that the stomach in such cases is never inflamed, but that its derange- ments of function depend on debility and imperfect or irregular secretion of gastric juice. The duty of every physician, who feels his responsibility as he ought, is to ascertain, by a careful observa- tion of all the symptoms, whether the stomach of a dyspeptic patient be in a state of chronic inflammation, or whether the disease depends on transmitted irritation from other sources, but yet without causing any organic lesion. If inflammation be present, then will he refer to the excellent remarks in the two preceding lectures by Dr. Stokes. In illustration of the other condition of things — severe and even fatal dyspepsia without inflammation — you will thank me for re- peating the following case from Andral's Medical Clinic, as trans- lated by Dr. Spillan, — volume Diseases of the Abdomen, Amer. edit. " A woman, thirty-eight years of age, entered the Pitie in the month of April, 1831. She stated that since the last seven or eight months she entirely lost her appetite ; every time she took food she felt an insupportable weight in the epigastrium, and occasionally rather an acute pain. From time to time she vomited some whitish mucus. Strong pressure on the epigastrium produced no painful sensation in this region. The remainder of the abdomen was soft and free from pain ; the patient was habitually constipated; tongue- natural ; no disturbance of any other organ ; the patient was very much emaciated and very feeble. She mentioned that she had begun to lose her appetite and her powers of digestion after having been subjected to severe mental distress. " We considered this woman as labouring under chronic gastritis, and in consequence of the perfectly natural appearance of the tongue we apprehended the existence of a cancerous degeneration of the submucous cellular tissue. We prescribed milk diet, and esta- blished a seton over the epigastrium. The woman wasted away gradually,and eventually died without presenting any new symptoms. Towards the latter period of her life she even refused to take milk, and admitted nothing else into her stomach except a few spoonsful of gum-water. " Post-mortem. The brain, lungs, heart, and abdominal viscera were all found in a perfectly healthy state, as also the trisplanchnic and pneumogastric nerves." MODIFICATION OF TREATMENT IN DYSPEPSIA. 147 The reflexions on this case by M. Andral himself are so pertinent, and at the same time corroborative of the strain of my own remarks, that 1 shall repeat them to you. " Thus, in this case, anatomy was entirely unable to reveal to us the cause of the symptoms and of death. This stomach, so very much disturbed in its functions, was perfectly healthy in its texture. " It was not therefore of chronic gastritis that this patient died ; for gastritis leaves behind it traces of its existence. Was there in this case neurosis of the stomach, or atony of this organ ? Who could prove it? We know so little by what forces chymifaction is accomplished, that we cannot appreciate all the causes which pre- vent its going on. " On the other hand, the sympathetic connections between the stomach and the other organs are so numerous, that the disturbance of one of these organs must necessarily modify the functions of the stomach, without this modification being necessarily an inflamma- tion, or even simple irritation. May it not be in this respect the same with the gastric mucous membrane as with the skin? As in the course of most chronic diseases the cutaneous covering is often found considerably modified in its several secretions, without its being in the slightest degree inflamed or irritated; why, under such circumstances, might not the functions of the mucous mem- brane of the stomach be also more or less seriously altered ? In a word, by virtue of this wonderful law of synergy, of which the animal economy presents us with such continual examples, it seems that the functions of the stomach, in which the act of assimilation commences, must tend to become suspended, for this sole reason, that other organs of nutritive life (small intestine, lungs, liver, &c.) have themselves ceased to fulfil their functions. Of what use, in fact, would it be that chyme should be formed, if the further changes of the aliment could not be produced, if it could become neither chyle, nor blood, nor an integral part of the tissues of the individual ? Professor Berard, of Montpellier, seems to have expressed this idea with as much strength as accuracy, when he said that the system digested by means of the stomach." I have, in the remarks already made, anticipated much of what would be regarded as belonging to the etiology of dyspepsia. The causes more directly operating on the stomach, are errors in diet. On this point, I shall borrow the expressive language of Dr. Chap- man, in his admirable lectures on dyspepsia. {Lectures on the Most Important Diseases of the Thoracic and Abdominal Viscera, 1844.) " The causes of this affection are such as act directly in the stomach, or indirectly through the intervention of other portions of the system. Of the first, among the most operative, are indulgences in eating and drinking, so as preternaturally to stimulate or distend the stomach__ or the use of unwholesome or imperfectly cooked articles, or an un- due limitation of diet, as is practised to reduce obesity, or to subdue protracted diseases. The most opposite modes of living, the full or stimulating, or the penurious and abstemious in extremes, are alike productive of indigestion." " The most pernicious articles in excess, are acid, vinous, malt, or 148 DISEASES OF THE DIGESTIVE SYSTEM. spirituous drinks, especially in the shape of punch, or strong green tea or coffee — exclusive vegetable matter, if it be crude or flatu- lent — or gross animal food, whether fresh or salted, or smoked — many of the condiments, and nearly all the things included in the term dessert. " Taking, habitually, drugs, conduces to the same end, as the fre- quent repetition of emetics or purgatives, or opiates, or other nar- cotics. Tampering, however, with any medicine or medicines, so much the practice with some people of valetudinary dispositions, is very detrimental. Every ache or discomfort, real or imaginary, must be relieved by a recurrence to some supposed remedy, till, finally, the powers of the stomach are worn out, and derangements, either functional or structural, take place." On the detrimental effects of that vile weed, tobacco, which the members of all the professions, the clergy among the foremost, con- sume, as it were, in rivalry, Dr. Chapman holds the following lan- guage : — " The most common of the causes of disease, in certain parts of our country, is the enormous consumption of tubacco in its several forms. Certain I am, at least, that a large proportion of the cases of it, which come to me, are thus produced. It is usually verv ob- stinate, and sometimes of a truly melancholy character. Easy as it were to cite numerous instances to this purport, I must be content with a limitation. "By a member of congress from the west, in the meridian of life, I was some time since consulted, who told me that he laboured under the greatest physical and moral infirmity, which he was utterly unable to explain, and that, from having been one of the most healthy and fearless of men, he had become, to use his own phrase, ' Sick all over, and as timid as a girl.' He could not present even a petition to Congress, much less say a word concerning it, though he had long been a practising lawyer, and served much in legislative bodies. " By any ordinary noise he was startled, or thrown into tremu- lousness, and was afraid to be alone at night. His appetite and digestion were gone — he had painful sensations at the pit of the sto- mach, and unrelenting constipated bowels. "During the narrative of his sufferings his aspect was ghastlv, approaching the haggard wildness of mental distemperature. On inquiry I found that his consumption of tobacco was almost incredible, by chewing, snuffing, and smoking. Being satisfied that all his misery arose from this poisonous weed, its use was discontinued, and in a few weeks he entirely recovered." Dr. Chapman relates other cases in which- symptoms of delirium tremens were induced by the use of this poison. Even when it is not an exciting cause, it very often becomes a predisposing one ; and the stomach and nervous system, deteriorated by tobacco, are readily excited into open disease by some other cause which, but for this morbid predisposition, would be either re- latively innocuous, or produce merely temporarv disorder. Vain will be our hopes of permanent cure, or even of marked amendment, SYMPTOMS AND CAUSES OF PYROSIS. 149 of dyspepsia, so long as the patient wilfully persists in the use of tobacco. Of external causes, compression of the chest and abdomen by corsets is not an unfrequent one among females. Dr. Chapman says that he is " habitually consulted for dyspepsia and its associate affections assignable to this fantastic usage." I have already adverted to the influence of the brain, through the intense and exaggerated manifestations of its faculties, including intellect, sentiments, and propensities, in the production of dyspepsia. With some slight modifications, the picture drawn by Dr. Dick {On the Organs of Digestion : Philadelphia edition), of the combination of the causes as operative in England, will apply to the state of things in the United States. "All the moral concurrents which are fitted to excite human pas- sion are rife in our country. A free government; unbounded license to social and individual enterprise; an unrestricted press, permitting zealots of all sorts to stimulate prejudice, political and religious ; a daily press ministering, with systematic art, fuel to feed the flame of parties ; vast wealths juxta-position with dire poverty ; all the feverish anxieties and terrible reverses .incident to commercial, ad- ventures and negotiations, conducted on a scale greater .than else- where through the earth ; perpetual monetary fluctuations; an over- populated country ; wherein well educated and respectable youth of both sexes cannot in many cases make bread by honourable means, but are almost literally reduced to the dreadful alternative to beg or die of want; high civilization and refined education,by which the intellectual faculties are apt to be cultivated at the expense of the physical, and the moral affections to be quickened into a false sensibility, rather than fortified and purified ; great religious and political fears and dissensions. Such is the heated moral atmosphere in which the people of this country live : and who.can wonder that digestion, the earliest of all the actions of the body to be affected by moral causes, should be, in such circumstances, strongly predisposed and prepared forderangement, on the appearance of exciting causes ?" %« I regret to be obliged to say, that the remark which immediately follows this passage is so strictly applicable to the United States, which must divide with England the disgrace of neglect of such paramount questions as those of mental and physical recreation, since they are part of the grand problem of education, both in its physical as well as intellectual and moral aspects. " I have to add," continues Dr. Dick, "that there is in no civilized country in the world in which the art and duty of mental and phy- sical recreation are less understood and less cultivated than in this ; and that, at the same time, there is none in which attention to that art can be with less impunity dispensed with." DYSPEPSIA WITH MORBID GASTRIC SECRETIONS. Pvrosis — Symptoyns and Causes. — Noticing, first, the forms of dyspepsia depending on morbid states of the stomach itself, and pass- ing over gastritis as already adequately commented on by Dr. Stokes, 13* 150 - DISEASES OF THE DIGESTIVE SYSTEM. we meet with the variety which consists in a disease of the mucous follicles of the stomach, and hence it might be called follicular dys- pepsia. It is that form designated bv the term Pyrosis, or water- brash,— the leading symptom of which is the discharge from the mouth by eructation, of a tenacious, ropy mucus, possessing some- times acrid properties, preceded by a burning heat at the epigas- trium. It is common and sometimes endemic in the northern coun- tries of Europe, and from time to time presents itself among our dyspeptics at home. The persons most liable to it are those under middle age ; it seldom appears before puberty, and very rarely in advanced life. Females are more frequently affected with it than males ; and of the former, the single more than the married, although it sometimes occurs during pregnancy. The combination of cold and moisture with a poor diet, may be regarded as a more common cause than any other. Extraordinary mental emotions are, also, an occasional cause. It is rendered very probable that pyrosis is often the effect of an excessive activity of the salivary giands, by which their se- cretion, poured out in excess,and being swallowed, is,after accumula- tion in the stomach, rejected. Often, indeed generally, the salivary glands are themselves irritated from sympathising with gastricdisorder. (See Wright, ut supra.) The symptoms have been well described by Cullen. " The first symptom of it is a pain at the pit of the stomach, with a sense of constriction, as if the stomach was drawn towards the back. The pain is increased by raising the body into an erect pos- ture, and therefore the body is bent forward. The pain is often very severe ; and after continuing for some time it brings on eructation of a thin, watery fluid in considerable quantity." The paroxysms usually come on in the morning and forenoon, when the stomach is empty. Morbid Anatomy. — The appearance of the stomach in cases in which it has been examined after the death of those who had suf- fered long from pyrosis is variable. Sometimes the mucous mem- brane has been found perfectly natural, or of a uniformly morbid colour, as red or brown, or darkened, like melanosis. In a case which came under Dr. Watson's observation {Lectures on the Prin- ciples and Practice of Physic, Amer. edit., p. 697), and in which not less than three pints of the tasteless liquid was brought up every day, the stomach, after death, was found to all appearance healthy; but it had been pressed upon by an enormous liver. At other times the mucous follicles are observed to be remarkably developed and pale ; and again, together with the enlargement, we see vascularity. In some cases, again, there is hypertrophy of the mucous membrane of the stomach, or thick and adherent mucous exudation, with or without specific .marks of inflammatory action. The inference to be deduced from these different states and ap- pearance of the gastric mucous membrane in pyrosis, is, that this disorder is rather symptomatic than primary, and, at any rate, like other forms of dyspepsia, has frequent complications which are not essential to the production of the ordinary symptoms. Treatment.— The treatment of pyrosis will consist of the occa- sional administration of an emetic of ipecacuanha, to expel the CARDIALGIA. 151 mucus which often remains for a length of time in the stomach, and is the cause of irritation during all this period ; and also to modify somewhat the secretion of the gastric mucous follicles. Partly with the same intentions, and also to remove an occasional accompaniment, costiveness, a laxative compound of blue mass and rhubarb will be advisable, alternating with aloes and some aromatic bitter. Astringents have had their eulogists, but we must believe, on speculative grounds, and under a belief that excessive discharge was the chief symptom to be combated. We shall gain little, how- ever, unless we remount to the original cause, — a morbid state of the mucous follicles of the stomach, or, as some would persuade us, of the pancreas, the secretion from which, say they, constitutes the matter discharged from the stomach. Opium has been found use- ful, alone and in combination with soap, rhubarb, and extract of gentian. Linnaeus, who saw much of pyrosis, recommended mix vomica in doses of ten grains three times a day. Granting the value of this remedy, it will be safer to prescribe it,in the beginning, in much smaller doses. Strychnia, as an article of uniform strength and easily measured, to the extreme of subdivision, would seem to be still preferable to the mix vomica ; and it has accordingly been used in these cases with benefit in the dose of from a sixteenth to a twelfth of a grain, two or three times a day. The success attending the use of the sub or tris-nitrate of bismuth in gastrodynia, prompted to trials of this medicine in pyrosis, and with results quite encou- raging. Dr. Bardsley, of Manchester {Medical Reports of Hospital Practice), believes it to exert a local and specific action upon the organs of digestion, restoring the stomach to a state of vigour and consequent healthy secretion, essential to the removal of the symp- toms of acidity, spasm, and pain. Acetate of lead and spirits of turpentine are also recommended on occasions. Baillie, who was skeptical of the curative power of any medicine in this disease, tells us, that a drachm of compound tincture of benzoin, rendered misci- ble with mucilage, was found by him to be the most efficacious. Reference being had to the salivary origin of pyrosis, remedies calculated to give tone to the glands (sub-maxillary and parotid, &c.) will be called for. With this view various astringent gargles have been used with advantage if there be relaxation and paleness of the buccal mucous membrane. Rose water with tincture of myrrh and caechu answers the indication very well; or the following, as used by I)r Wright:—&. Decoct, cinchonas, ovii.; Tinctura myrrhae,3ss.; Tinctura conii, sss. Fiat gargarisma, saepe utendum. If we look for a radical change in the secretory apparatus of the stomach, we must procure it by means of a regulated diet and atten- tion to the function of the skin. With this view acescent vegetables, common fruits, much or imperfectly prepared farinaceous matter, fermented drinks, tea and coffee, condiments, and smoked meat or fish, are to be abstained from, and in their stead a small portion of plainly dressed animal food, with stale bread or biscuit and milk, or milk and water and broad, sago, or arrow-root. Caiidialuia. — This term, of Greek origin, signifying pain of the heart, has been-repealed in the language of the'different nations of 152 DISEASES OF THE DIGESTIVE SYSTEM. modern Europe in the same sense. Thus, we have the correspond- ing term in English of heartburn, in French of mal de catur, and German, hetzens-angst, or heart-pain. Greek writers were accus- tomed, however, to call the upper orifice of the stomach cardia,ox even cor («,g), and t0 this Part did tne>r refer the morbld sensations by which the disease in question was designated. Cardialgia is akin to pyrosis, and is the anorexia humor alls or pituitosa "of the nosologists, and the follicular gastric dyspepsia of some late writers. The greater regularity of discharge of a viscid fluid in the morning, and the addition of cramp and a sensation of gnawing complained of in anorexia, are not, I think, grounds for any specific difference between this and pyrosis, nor between either of these again and cardialgia. The differences are more in the temperament and constitution of the persons affected, than in any organic change or peculiarity of functional disturbance of the stomach. They all exhibit the characteristic in common of pain with more or less heat, and the secretion and discharge of a morbid mucus, sometimes insipid, at other times acid and acrid. They belong to the Diacrises of Gendrin {Traite Philosophique de Medicine Pratique, t. hi.), and are regarded by Good, with all his fondness for nosological refinement, as kindred disorders, the treatment of which need not be studied separately. The painful sensation at the cardiac orifice, as of heat and scalding, and which has given the popular name of heartburn to cardialgia, is often more an evidence of the morbid sensibility of this region of the stomach than of any peculiarly acrid qualities in the fluid secreted. Sometimes this is manifestly acid, at other times neutral. Gendrin {op. cit.) speaks of the varieties of cardialgia under the head of acescent or cardialgic dyspepsias. The origin of this fluid is not accurately determined : since by some it is regarded as a peculiar morbid secretion ; by others the result of chemical change of healthy secretion in the stomach, and by a third party, again, as a depraved stale of the gastric juice itself. We can hardly doubt that cardialgia, marked as it is by morbid sensibility and morbid secretion, may de- pend on different states, or at least degrees of vascular and nervous irritation of the mucous membrane and mucous follicles of the stomach. In one case there is merely a morbid condition of the nerves of organic life, and accompanying morbid secretion, with but little exaltation of the nerves of animal life or of sensation. In another these latter are greatly excited, and the pain is considerable ; while in a third, again, associated with disorder both of secretion and sensation, we meet with capillary excitement and incipient phlogosis. The first symptom of an attack of cardialgia is pain in the epigas- trium, felt under the xiphoid cartilage, and often extending into the right hypochondrium. The pain is either dragging or pulsative and burning, — beginning usually a short time after eating, and increas- ing in violence progressively for two or three hours, and then gradu- ally declining so as to reach its minimum in four to five hours after the meal. During this time the patient complains of dryness and heat of the throat, nausea, and often a strong desire to vomit. Some TREATMENT OF CARDIALGIA. 153 relief is given by eructations, either tasteless or acid and burning. The salivary glands are excited to the secretion of a viscous liquid, which is continually discharged by spitting. The tongue is large, moist, and trembling. The patient complains of headache, and ex- hibits an anxious expression, with tumid features and leaden com- plexion. He is easily fatigued, and is subject to vertigo on making the least intellectual effort. The appetite is usually diminished ; at any rate irregular during acute cardialgia. Constipation is a com- mon and troublesome symptom. Treatment. — Obviously must our treatment vary with the vary- ing condition of the stomach in these cases. Simple nervous car- dialgia— some pain and acid eructation and vomiting, without increased heat of skin or activity of pulse, will require opiates and other narcotics, or preferably quinia and iron and bitter tonics, in alternation with carbonate of ammonia and other antacids. If, on the other hand, the fluid be acrid, and evidences of morbid irritation be present, so far from discountenancing the use of herbaceous vege- tables and an acidulous diet, which were prohibited in the first variety, these may be even recommended with good effect. In morbid capillary excitement of the gastric mucous membrane, mani- fested by a red tongue, tenderness of the epigastrium, dry skin, and an ever-craving thirst, leeches below the ensiform cartilage ought to precede other treatment. Inability to procure these, or prejudices against them, will authorise the substitution of a succession of small blisters in their place. After this, if the disease is not cured, we have recourse to other general means adapted to the presumed state of the organ and its mucous secretors. Mercury is generally prohibited in dyspepsia, but on a very im- perfect pathology of this disease. No doubt that, in strumous habits and in nervous temperaments and subjects, in whom the skin is cold, and there is little or no vascular excitement, — the tongue moist and clean or simply loaded, and the urine secreted in its cus- tomary abundance,— mercurial preparations are s'eldom called for, indeed ought to be withheld. But in more mixed cases of excite- ment with morbid secretion, dry, and occasionally hot skin, and im- perfect renal discharges, small doses of the blue mass, or of this with ipecacuanha, or mercury with chalk, will exert a very bene- ficial effect. In making this remark, let me add, however, a cau- tion against continuing this medicine, or giving it in such doses as will affect the constitution. Ipecacuanha, made popular by Daubenton, has, since his time, been much used by practitioners in the treatment of dyspepsia, when characterized by morbid sensibility and depraved gastric secretions. The French practitioner just mentioned, gave the medicine in small doses, or from a quarter of a grain to two grains early in the morn- ing fasting. Dr. Thomson was accustomed to divide a full dose of ipecacuanha into several equal parts, which he directed to be taken in the course of twenty-four hours. This article is sometimes con- veniently combined with an aperient, sometimes with an alkali. Both these indications may be fulfilled by its union with rhubarb and soap, as iu the following prescription: — 154 DISEASES OF THE DIGESTIVE SYSTEM. R. Pulv. Ipecac, gr. xii. Pulv. Rhei, Sapon. aa. 3SS- M. ft. mass, in pil. xviii. dividend. Give a pill morning, noon, and night. Where nausea is easily ex- cited, we ought to give in combination with it a little subcarbonate of ammonia, aromatic powder, cayenne pepper, or sulphate of quinia. With this last, joined to ipecacuanha, I have had frequent cause to be pleased, in the treatment of the forms of dyspepsia now under notice. The prevalence of acidity will call for lime-water, and if the system be in an atonic state, subcarbonate of ammonia or aqua ammonia with the ipecacuanha. The sulphuret of potassa is another remedy which has enjoyed the credit of exhibiting a specific operation on the diseased mucous follicles. It is given alone, when not contraindicated by too great gastric sensibility, in doses of from a few grains to half a drachm, or it is combined with subcarbonate or ammonia, bitter extracts, aromatics, carminatives, or with rhubarb, aloes, or pil. galban. comp. I have at different times, incases of dyspepsia with amenorrhcea, de- rived very good effects from the combination of sulphuret of potassa and sulphat of potassa with aloes, in such doses as to act on the bowels. Sulphurous waters have been found to be efficient reme- dies in the varieties of the disease now under notice. For heartburn with eructations, gunpowder has been recommended by Dr. Dick {On the Digestive Organs, p. 128, Phil, edit.) in very decided terms. "Its effects are to heal the putrescent eructations characteristic of this form; to allay the sensation of heartburn; to restore the secretions along the whole intestinal canal, as is proved by the production of healthy, easy, soluble, bulky stools. I am not certain that I know one laxative that is a safer, surer, and more gen- tle restorer of irregular and morbid intestinal action, than the sub- stance I now introduce to your notice. Its good effects, moreover, are not confined to the intestinal tract. It restores, simultaneously, the action of the bowels, that of the skin, kidneys, and lungs. Dur- ing its employment, an occasional dose of castor oil or of magnesia may be interposed." The gunpowder should be of a fine quality, and ought to be taken dry, or in some glutinous vehicle, as melasses, jelly, or a solution of gum. LECTURE XVII. DR. BELL. Gastrodynia, or Gastralgia—Its symptoms—Diagnosis—Causes__Treatment —Hygienic means the first to be attended to—Alleviation of pain—Caution re- specting stimulants—Draughts of hot water—Blending of gastritis and gastralgia —Hydrocyanic acid—colchicum— emetic tartar in small dosss—oil of turpentine —subnitrate of bismuth—oxide ofzinc—subcarbonate of iron—carbonated chaly- beate waters—nitrate of silver.—Periodical gastrodynia requires sulphate of quinia—Danger of alcoholic stimulants—Superiority of water as a drink—Atten- tion to the lower bowels—The kind of food proper—Regulation of the cutaneous tunctions—Mental habits to be studied—Change of scene and travel. Allied to cardialgia by some of its symptoms, but best characterised by excessive morbid sensibility of the stomach, and often concomi- SYMPTOMS OF GASTRODYNIA. 155 tant spasm or cramp, is gastrodynia ox gastralgia, the irritable gas- tric dyspepsia of Dr. Todd {Cyclopaedia of Practical Medicine), and the morbid sensibility of the stomach of Dr. Johnson. In the same case we may have a succession of morbid states indicated first by the symptoms of pyrosis, then those of cardialgia, and, finally, of gastrodynia. The last is sometimes a termination, also, of common inflammatorv dyspepsia. Gastrodynia is marked, not only by a pain in the stomach but by the varieties of this pain, which is at one time acute and gnawing, at another obtuse, and again burning, as in cardialgia. It may be brought on and sometimes alleviated by eating. It is relieved, but not uniformly, by pressure. On occasions, the morbid sensation con- sists of coldness, or of itching, tickling, or formication. Its accom- paniments are often yawning, anxiety, feeling of fulness and tension, and pulsation at the epigastrium. Its usual time of paroxysmal ac- cession is early in the morning, or any time after midnight. The slightest causes, — physical or moral, — an unpleasant dream, unex- pected news, the impression of cold, a simple change of posture, will suffice to bring it on, or to aggravate it when present. Abnormal sensations, often of an exquisitely painful nature, are complained of in other organs, sometimes coincident with, but more commonly replacing, the gastralgia; such are pain of the head, alternations of heat and cold on the cutaneous surface, horripilation, frequent pal- pitation, distension of the abdomen, feeling of suffocation, being strangled, &c.; spasmodic pain in the uterus, bladder, or urethra, or neuralgic pain in some part of the body, in the uterus, testicles, or rectum. Frequently a fit of hysteria, even in men, supervenes. Or the patients may feel restless and unquiet, or be seized with a fit of depression, or of ungovernable impatience or anxiety. These symptoms generally terminate with digestion, but may be renewed by taking the mildest food : they are usually accompanied with coldness of the extremities; and early in the attack a discharge of pale limpid urine takes place. The appetite is capricious, often voracious, sometimes wanting, or craving unaccustomed articles. The tongue is pale and moist; at times covered with a mucous coat and larger than natural. Although under active irritation it may be dry, yet no thirst is complained of. There is, in fact, a deficiency of saliva, but the patient is endeavour- ing to get rid of a white frothy secretion which covers the tongue and lips. At times the tongue is furred as if, to use the comparison of Dr. Todd, a fine white gauze were thrown over it: "sometimes it is covered with a thin, milky-white fur, as if the patient had just been drinking milk, and sometimes it is besmeared with a thin, frothy mucus." In a majority of cases the bowels are obstinately con- stipated. So exquisite, after a while, is the sensibility of the stomach, that not only does it receive the impression from the ingesta when swal- lowed, and in their mutation into chyme, and the passage of this into the duodenum, but, also, as a Parisian lady suffering under the dis- ease told Pinel, it feels pain, pleasure, and all the moral affections. A disobliging look struck her sensibly, as it were, on the stomach,__ "1 think even by the stomach," was her expression. 156 DISEASES OF THE DIGESTIVE SYSTEM. Diagnosis. — Gastralgia, or gastro-enteralgia,has often been con- founded with gastritis and gastro-enteritis. Sometimes the two dis- eases attack at the same time, and then it is not easy to unravel their complications. In a majority of cases, however, the symptoms are sufficiently contrasted to enable us to establish a correct diagnosis. Thus, the natural or pale and moist tongue in gastro-enteralgia con- trasts with the red and furred appearance of this organ in gastritis. In the latter the appetite is deficient or wanting entirely, and there is an aversion both to stimulating food and drinks, which are often sought for with avidity by the gastralgic patient. When vomiting occurs in gastro-enteralgia it is of glairy mucus and simple fluids,— in gastritis it is of alimentary substances. There is no thirst, the skin is soft and satiny, and of a natural temperature, the pulse natural or slow : fever, if it appears at all, is intermittent and with morning paroxysms in gastro-enteralgia. In gastro-enteritis, on the contrary, the thirst is troublesome, the skin is dry and harsh and often hot, the pulse is frequent and the fever continued, or if it exacerbates, it is in the evening. The physiognomy is little changed, and the fulness of habit not materially reduced in gastro-enteralgia, whereas the fea- tures have a parched appearance, and the complexion is muddy, and there is often great emaciation in gastro-enteritis. The disposition, often singularly altered, the patient becoming fitful and irascible, in gastralgia, is little affected in gastritis. The diagnosis in the former is obscure, and the prognosis favourable ; in the latter the diagnosis is easy, and the prognosis is of an unfavourable nature. Between gastralgia and pneumonia in anemic habits it is not easy at first to distinguish, when the pains in the former dart, as they sometimes do, through the chest and impede respiration, and are accompanied with cough. Not unfrequently violent derangement of I he action of the heart, to such a degree as to induce fears of organic disease, is asso- ciated with gastralgia. Causes. — Various are the causes of gastralgia. Among those depending on errors in the use of ingesta the most conspicuous is poor, and indigestible food, as restriction to potatoes, from which cause the Irish peasantry are often afflicted with this disease and pyrosis, and to oatmeal, which produces similar effects on the Scotch. The poor in large cities are frequent sufferers in this way, — and certainly in their case the chief cause is stint quan- tity and unwholesome quality even of the food which (hey do par- take of. Long fasts come in as a powerfully contributing cause, with those persons already enfeebled, even when their scanty nutri- ment is taken regularly. Sudden transitions from high to low living, and even refinement in restricting one's-self in the choice of food, are recognised causes. Certain ingesta, as green tea and coffee, drastic purgatives, interruption in the use of narcotics, as of opium and tobacco, also bring on this disease. Small, however, is the temporary discomfort from ceasing to use these narcotics, compared to the manifold ailments and distresses which follow in their train, in certain temperaments, such as the irritable or nervous, who are so open at any time to an attack of the disease. In such persons, moral causes, as anxiety, jealousy, morbid indulgence of senti- TREATMENT OF GASTRALGIA. 157 ment, kc, are apt to induce gastralgia, which reacts with fearful force on the temperament and morbid frame of mind, aggravating all their ills, and investing common events with the most malign fea- tures. Exhausting discharges, as by hemorrhage or venesection, predispose the stomach to be perniciously affected by certain articles, which, although of difficult digestion, would hardly have displayed those morbid effects but for the predisposition thus induced. Trans- mitted irritation from other organs, of which I spoke in the begin- ning of this lecture, as causes of dyspepsia, sometimes brings on gas- tralgia of considerable intensity. Such are dysmenorrhoea, leucor- ' rhoea, pregnancy, hysteria, inflamed kidney, strictured urethra, irri- table testicles, and other painful local complaints. Treatment. — A knowledge of the causes of gastralgia or gastro- dynia w-ill suggest much that is necessary and useful towards its cure. Errors in regimen must be corrected by the substitution of nutritive for poor food; of that easy of digestion, for the crude and the gross : abstinence from noxious beverages is to be enjoined; and the entire mode of living altered or brought back to the standard sanctioned by general experience, as deduced from sound physiology and hygiene. Under these heads are included a due control of and direction to the feelings, healthy occupation of mind as well as of body, and an avoidance, of course, of all excesses and extremes, whether of mere sensual indulgence, or of privation from a mistaken sense of duty. The hygienic means of cure, instead of being regarded as secondary or incidental, ought to have the precedence over the pharmaceutical, which, although they may alleviate and soothe, and procure intervals of repose, are incompetent, alone, to remove the disease. The period at which gastralgia often makes its attack, early in the morning, and when the stomach is empty of alimentary matter, would naturally suggest the administration of food, as a means of temporary relief at least; and, in fact, a few morsels of common food — a bis- cuit, a crust of. bread, or small piece of meat, adequately masticated, has sufficed to relieve. Anything which stimulates the stomach, as an aromatic or spice, in substance or infusion, or a bitter tincture, will, on occasions, have the same effect. Vomiting, although it merely expels some mucus, will give a lull to the symptoms. A draught of hot water, camphor mixture, water of ammonia, I have found, •ah, on occasions, to answer this purpose. Alone, or in combina- tion with some one of the articles already mentioned except emetics, opium and its preparations are most and deservedly relied on to remove the more intense pain and often accompanying cramp in •cvere gastralgia. The first and most urgent call, during the paroxysm, is an allevi- ition or removal of pain ; and this is proposed to be brought about generally by stimulants, antispasmodics, and opiates or narcotics. Hut even at the very outset, and during the imminency of distress, •vu ought, if possible, to take early note of all the circumstances, — concomitants and complications, — which modify the character of the .lisease. If gastralgia be, as it sometimes is, a sequel, or one of the accompaniments, of dysmenorrhoea, in a full and plethoric habit, vol. i.—14 153 DISEASES OF THE DIGESTIVE SYSTEM. stimulants of all kinds ought to be withheld ; first, because they gene- rally fail even to alleviate the pain ; and secondly, because they in- crease subsequent distress, light up fever, and endanger phlogosis both of stomach and uterus. More is gained, in such cases, by repeated draughts of hot water, or by emptying the stomach by draughts of warm water, or of salt and water, and by pediluvia and an opium pill. Sometimes, there is a blending of gastralgia and gastritis, in which case we must endeavour lo reduce the disease to its simplest or ner- vous element by removal of the phlogosis. A few leeches to the epigastrium, a laxative by the month,, or a purgative enema,— sim- ple mucilaginous drink and an opiate will greatly contribute to this end, which will be further expedited by the warm bath. In these mixed cases some remedies are applicable to meet both indications, viz., to abate iieuropatliia and capillary excitement. Hydrocyanic acid, colchicum, and minute doses of emetic tartar, are of ibis class; and they have ihe additional advantage of producing an impression beyond the period of the paroxysm, and protracting that of its return. Of hydrocyanic acid I know little from personal experience, but the good opinion of its efficacy in gastrodynia, originally expressed by Dr. Elliottson, has been confirmed by too many persons since to allow me to doubt it. Dr. A. T. Thomson has recommended it as an adjunct to tonics, in those forms of dyspeptic irritability of sto- mach which are accompanied with heat and soreness of ihe tongue. But, the great difficulty of preserving this acid of a suitable and equal strength, the danger from differences in recognised formulas, and the uncertainty of therapeutical effect under the most careful administra- tion, are drawbacks which we cannot overlook when it is the subject of our deliberations. Hydrocyanic acid, prepared according to the processes directed in the last United States Pharmacopoeia (1842), contains two per cent, of pure anhydrous acid. With the good effects of colchicum, in the shape of vinous tincture of the seeds, in doses of twenty or thirty drops every two hours, or of half a drachm twice or thrice a day, mixed with some aromatic water, I am more familiar. The same may be said of emetic tartar, and particularly when combined with minute quantities of opium ; an addition, this last, which enhances, in the circumstances now before us, the virtues of the colchicum. In enteralgia, I know of no remedy equal to the colchicum, when united to magnesia, or alternating with one of the alkalies. In gastralgia, if there be heartburn or cardialgia, these last mentioned remedies may be advantageously conjoined with ihe wine of colchicum seeds. Strychnia, as advised in pyrosis, will, sometimes,. be found to be decidedly remedial in this disease. In cases in which the disease has been of long duration, and the patient exhausted by its violence, I have found the oil of turpentine, in drachm doses every hour or two, mixed with simple mucilage, give earlier and more complete relief than any one article with which I am acquainted. If constipation be present, a larger dose, or from two drachms to half an ounce, joined to half an ounce of castor oil, may be given with the double view of relieving the gastric pain and emptying ihe bowels. A long interval of ease will sometimes follow this single dose. TREATMENT OF GASTRALGIA. 159 For permanent effect various mineral preparations are prescribed in gastralgia. Of these, siibnitrate or trisnitrate of bismuth, oxide of zinc, subcarbonate of iron, nitrate of silver, and arsenical solution, have been the most extensively employed. If the former be pre- scribed, it should be at first in a dose of four or five grains, gradually increased to twenty grains. Some French writers speak of prescrib- ing it familiarly in quantities of eighteen, thirty, and even seventy grains iu the course of a day. (Trousseau and Pidoux, Traiti de Thcrapenlique et de Ma Here Medicate, t. ii., p. 776.) The obser- vations of Odier of Geneva, on the siibnitrate of bismuth ki pains and cramps of the stomach, recorded in 1786 {Journal de Medicine), seem to have been quite forgotten, if we may form an opinion from the emphatic reference to writers of our own time on this subject. Our obligations are, however, due to M. Bretonneau for a more precise and definite description of the circumstances under which this remedy can be used with the greatest advantage. The siibni- trate of bismuth is more particularly adapted, as we learn from the French writers, to laborious digestion, accompanied with nidorous eructations and tendency to diarrhoea. When the eructations are acid or the flatus inodorous, the medicine almost always fails. It is indicated in chronic vomiting, without fever, which follows acute gastritis, indigestion, or the effect of an irritating medicine, and in the gastralgia complicated with this state. But, on the other baud, if gastralgia be accompanied by habitual constipation, and there is no vomiting, or only of a glairy, insipid, or acid mucus, and complica- tion of chlorosis, or facial neuralgia, or rheumatism, or of leucorrhcea and hemorrhoids, or any other flux, except diarrhoea, the siibnitrate is of small service. In the vomiting to which children are subject, during dentition, and which so often precedes softening of the mucous membrane of the stomach, and, also, to that which is caused by overfeeding and accompanies the muguet {stomatitis with altered secretion), this medicine displays its curative agency in a very satisfactory manner. Chalybeates are beet, if not exclusively, adapted to gastralgia in persons of an anemic habit, and especially in females of a lax and de- licate frame, and who suffer from amenotfthcea and leucorrhcea. The ammoniated iron and the vinu/n ferri have been recommended on these occasions. Preferable to both is the subcarbonate (precipi- tatcd carbonate), iu conjunction with aromatic powder, or a little ginger alone. It has been found that the carbonated chalybeate waters are often successful when no officinal preparation of iron can be borne ; and hence a visit to Ballston, or Bedford Springs, and drink- ing the chalybeate waters there, will give the patient a double ehance of restoration ; first, by the journey and its concomitants, change of air and scene, and change of thoughts and feelings; and, secondly, by the medicinal effects of the waters themselves. Nitrate of silver has of late years been tried, in cases of morbid sensibility of the stomach, by Dr. James Johnson-{M»-bid Sensibi- lily of the Stomach and Bowels), and is well spoken of by Auten- rieth, Hueli, and others, in this disease. For Rueff's practice, see Amer. Journ. of Med. Science, May, J837. By the latter it'has- 160 DISEASES OF THE DIGESTIVE SYSTEM. been given, not only in gastrodynia but in cases of nervous vomiting and other derangements of the digestive organs so common in young infants, and, also, as a palliative in cancer and scirrhus of the sto- mach. The dose of the nitrate is a sixth of a grain, gradually in- creased to three or four grains three times a day, given in the form of pills made of bread-crumb. Objection has been made to this lat- ter, on account of the chloride of sodium which it contains; but the decomposition by this agent, considering its extremely minute quan- tity, must be inconsiderable, if it takes place at all. Some mild vege- table powder with mucilage may be preferable to the bread. Wc must enjoin on the patient the precaution not to take common salt or salted food, either immediately before or immediately after swal- lowing these pills. The dose of the nitrate has been carried as far as fifteen grains by Dr. Powell. I may have occasion, when treat- ing of epilepsy and the remedial value of nitrate of silver in this dis- ease, to speak of the discoloration of the skin of a blue or slaty hue caused by persistence for a length of time in the use of the remedy. Dr. Johnson, on this point, however, asserts, that there is no instance on record where the complexion has been affected by the medicine, when restricted to three months' administration. It will be more prudent, however, to desist, for a while, from its use after a month. Gastrodynia, assuming a distinctly periodical character, or occur- ring endemically as it sometimes does, and at the same time with periodical fever, will be advantageously treated with sulphate of quinia, or a watery infusion of Peruvian bark and a little laudanum ; and, if the bowels are torpid and the secretions unhealthy, blue mass and a little aloes should be used occasionally. When the neuralgia of the stomach alternates with facial or temporal neuralgia, and the system is weakened by their duration, or by other causes, sulphate of quinia in tolerably full doses, as of five grains, exerts a very good effect. Indeed there would seem to be no adequate substitute for this medicine in such cases, although I know that arsenic will be at once suggested by more than one practitioner. Most stimulants, and especially alcoholic ones, ought to be re- garded with great mistrust in gastralgia. That they will often give speedy, though temporary relief, is undoubted ; but the habit of using them, begun in this way, is so often prejudicial in other re- spects,,and so apt to lead to downright intemperance, as well as ultimate aggravation of the disease, or at any rate a conversion of gastralgia into gastritis, that, in no case, ought the physician to allow discretionary privilege to his patient to have recourse to them with- out advice specifically given, and never to direct their continuance beyond the urgency which seemed to call for them at the time of suffering. How many have acquired habits of drunkenness, how many of the habitual use of opium or laudanum, owing to the care- less advice of their physician, to take a little tincture of bark or some aromatic tincture, or a glass of brandy and water, or a few drops of laudanum, whenever they felt the approach of gastrodynia, or other form of neuralgia, or of erratic gout. Medical ethics require a supervision on this point, so as to quicken the sensibilities of phy- sicians to their responsibility for the habits of their patients after TREATMENT OF GASTRALGIA. jgl convalescence from disease ; for these habits are often the result of formal advice, or casual suggestion, offered by medical men at this time. There is no other drink than water for habitual, that is daily, use, which can be taken with any permanent advantage. Drunk quite hot it will often relieve the violence of the paroxysm ; and if, in com- mon, its coldness should offend the stomach of a gastralgic patient, it is easy to correct this by having it boiled, and a piece of toast in- fused in it, or the rawness removed by placing that which is to be drunk in warm water for a few minutes. I speak now, of the daily drink, both that at meals and at other times. When toast and water is directed, the toast should be slowly made, be quite brown and dry, and only allowed, in warm weather particularly, to remain for an hour in the water which had been previously boiled ; after which time this latter should be strained, or carefully poured into another vessel. The state of the lower bowels always demands our attention in gastrodvnia. Generally torpid, they require to have their action quickened in some way or other. This is best performed by mild means,— such as simple enemata, where the stomach is very irri- table, and in common by a combination of rhubarb and magnesia, with ginger in powder, or of aloes, blue mass andsoap, or hyosciamus with aloes and soap, in pills. A tumblerful of hot water, with a tea- spoonful of carbonated magnesia, and a few drops of aqua ammo- nia mixed in it, taken at the time, will often answer a good purpose. Sometimes a little rhubarb and magnesia with a simple bitter, such as gentian or columba, will be found beneficial, by its effects both on the stomach and the colon. But here, again, hygienic means are the only ones on which we can rely for permanently removing constipation. Something will be gleaned from the patient's own experience, something suggested by the physician, in the selection of suitable ingesta. Stale wheat bread, that is, bread baked on the day preceding that in which it is eaten, or bran crackers, ought in all cases to be preferred to fresh, and especially warm bread, than which there is no article more injurious to the dyspeptic, and above all to the gastrodynic stomach. In some cases corn bread agrees better with the stomach than wheat. If butter be added to fresh or hot bread, or to hot toast, and eaten as part, and sometimes the chief part of a repast, no medical skill is equal to devising means of cure of the disease in question. The same difficulty will be inter- posed by the use of green tea and coffee. Nor can chocolate, with its oily ingredients, be received as a substitute for these beverages. On the subject of food generally, it is not easy to specify the arti- cles which will be found to be adapted to every case of gastrodynia, as there are notable differences in gastric sensibility as well as diges- tive capability among persons affected with thisdisease. Milk, often beneficial, is at times positively noxious. Occasionally, boiling it, or diluting it with hot water, or the admixture of a "little rice or arrow-root, or even wheat tlour when it is boiling, will render it more digestible for adults, as it is found to be, by these means, for children, if milk be used, it ought to be for breakfast or early din- 1 !• 1C2 DISEASES OF THE DIGESTIVE SYSTEM i, Ifloio), on which I now propose to make some observations, will include diarrhoea mucosa ENTERORRHCEA. 233 and diarrhoea serosa of systematic writers. The former term is much more distinctive than this latter ; the prefix of . 273) on the appearance presented by the intestinal canal of a child shortly after birth. " When all the liquid parts of the intestinal tube are re- moved, there remains," says M. B., " a layer of thick mucus, ad- hering to the intestinal surface of the canal, forming on it a kind of plastering. This layer may be raised with the nail, under the form of a pellicle, resembling, to a superficial observer, portions of the mucous membrane itself." This secretion, whatever may be its use, remains but for a short time, " and detaches itself, without the assist- ance of any purgative, by a kind of natural exfoliation," in very thin lamellae, which, being rolled together, form the small, white flocculi so frequently met with in the stools of young children. Somewhat later in infantile life, and when a child is attacked with stomatitis with morbid secretion and pseudo-membranous formation, the mucous deposit and membranous exudation sometimes extend into the stomach, and on occasions into the small intestines. In the large intestine, both in the child and adult, membranous formation on the mucous or villous coat is common enough, particularly in dysentery. In whatever part of the digestive canal, from the mouth to the rectum, this morbid formation occurs, it is most probably in the same way, viz., secreted matter from the mucous follicles, which spreads over the surface and becomes concreted into membrane. Sometimes this is the result of simple follicular irritation, sometimes of inflammation of the glands and intervening mucous membrane. Dr. O'Brien describes this false membrane as occurring, in dysentery, both in the large and small intestines, butas being most frequent, and remarkable in the colon and rectum. In some cases he found it ex- hibited in patches, but in others the mucous membrane was covered by a uniform layer of white lymph. Similar observations have been made by other writers on dysentery. M. Roche {Diction, de Med. et de Chir. Prat., Art. Colite) tells us, that he has seen patients, and, what is somewhat remarkable, they were always females, affected with obstinate diarrhcea for months and years, pass daily, during the disease, a large quantity of these false membranes. He adds, that, the cases of colitis (chronic) in which these discharges occur are not, in consequence, mcn-e alarming than others. Elsewhere (Art. Enterite) M. Roche remarks, that pseudo-membranous enteritis is much more common in a chronic than in its acute form; and that a number of persons discharge them in different degrees of size, resistance, and figure. Some are but slightly incommoded in consequence ; only they are troubled, from time to time, with colic, and then they pass more than common of these false membranes. They eat with appetite, and digest well so long as they adhere to their customary diet; but on the slightest deviation their colic returns, and the glairy discharges are increased. Some, on the other hand, evince symptoms of chronic enteritis ; they suffer habitually from dull colicky pains, a feelino- 0f heat and often of burning in a circumscribed point of the abdomen. They go to stool frequently in the course of the day, and pass each lime amorphous pieces of false membrane. The expulsion of these pseudo-membranes is often accompanied with a sensation of burn- ing at the rectum, so pungent that the patient dreads the time for 240 DISEASES OF THE DIGESTIVE SYSTEM. evacuating the bowels. These persons have but little appetite, digest badly ; their tongue is almost always loaded with a whitish or yel- lowish coat; but without any redness at its side or point: the skin preserves almost always its natural heat; the pulse is rarely accele- rated, and there is little or no thirst. Occasionally, in wet seasons, or owing to errors in regimen, and more commonly perhaps to moral causes, the skin is hotter, the pulse more frequent than natural, at the same time that the local irritation is increased. After two or three days the disorder returns in its customary degree; although, sometimes, these exacerbations are prolonged beyond this period. In a former Lecture (XVIII), when describing, after Dr. Todd, the symptoms of follicular duodenal dyspepsia (p. 171-2), I mentioned the quantities of mucus discharged in various morbid states and forms — something like " shreds, apparently part of a membrane, and even perfect tubes of considerable extent are passed." These discharges of mucus appear to take place periodically, and as it were critically, being in general preceded by considerable aggravation of the symp- toms ; and the recovery is attended with evacuations of quantities of mucous or glutinoussubstances. The course and termination of these forms of the disease, which I call enterorrhcea with membra- nous formations, do not justify the prognosis given by Andral, in speaking of chronic enteritis, who says that the presence of pus and of false membranes mixed with the alvine discharges indicates great danger. Not only do they take place in the chronic forms of enteritis described by Drs. Todd" and Roche, but are also quite com- mon in dysentery ; and in all these circumstances the augury from their appearance, though it may be sometimes, it is not necessarily or com- monly sinister. The frequent occurrence of the disorder in females would remind us, even if anatomical inspection did not suggest the fact, of the resemblance of these pseudo-membranes to the decidua, or to the membrane discharged in dysmenorrhoea. I have seen it alter- nate with this last mentioned disorder. Its analogy to the lymphatic exudation in croup is mentioned by more than one writer. Neither the precise causes nor the special seat of membranous exudation with enterorrhcea is known to us. Its duration for years forbids our referring it to any particular cause ; and as to its seat, we can only say that it is sometimes in the small and perhaps oftener in the large intestines. In the treatment of this disease we must be guided by the consti- tution of the individual who is its subject, and the nature and extent of the general sympathies. At first, recourse may be had advanta- geously to local depletion by leeches to the tender part of the abdo- men, if there be such, or to the neighbourhood of the anus, followed by fomentations, the warm bath, and laxative enemata. Having thus removed any enteric complication, and placed the intestinal mucous surface in the best state to be acted on by alteratives of a penetrating and active kind, we endeavour by these means to modify the secreting function of the muciparous glands. This indication will be met by the administration of calomel, where the membranous shreds are still being passed, followed by castor oil and oil of tur- pentine ; or where febrile irritation is present, the blue mass with COLONIC DYSPEPSIA. 241 ipecacuanha, or hydrarg. c. cretd, alternating with balsam of copaiba. The iodide of potassium with syrup and decoction of sar- saparilla furnishes us with a safe and efficacious means of correcting the morbid secretions in this as it does in so many other forms of disease. In a lymphatic temperament and weakened state of the digestive organs, mild mercurials should soon be followed by pre- parations of iron and pure vegetable bitters. LECTURE XXV. DR. BELL. Colonic Dyspepsia—The colon—its extent, situation, and functions.—Atonic co- lonic dyspepsia—Constipation—its general character, symptoms, causes, and vari- ous terminations—Spinal irritation connected with dyspepsia—Treatment of the colonic disease—Importance of a suitable diet. Following, properly enough, an account of acute and chronic inflammation of the large intestine accompanied with discharges of varying character and quantity, will be a notice of that functional enlargement which is entitled to the epithet of colonic dyspepsia. Often secondary and a consequence of disorder of the small intes- tine and of the liver, colonic derangement is not seldom so far primary as to precede in its manifestations functional disturbances of other parts of the alimentary canal, and to singularly aggravate and complicate these latter. Small progress shall we make in our diagnosis of the diseases of the abdominal viscera without an accurate knowledge not only of the structure, but of the situation and extent of each viscus and tissue of the digestive canal, and of their connections with other viscera and tissues. Neglect of attention to the anatomical relations and the locality of organs, has often made physicians confound disease of the colon with that of the stomach, as well as of the liver, and at times, also, of the kidneys. The course and distribution of the colon, contiguous at its transverse portion to the stomach, and running in part under the liver and behind on the kidneys, will show the cause of these mistakes. So, on the other hand, its disorder, as in colic, is often the direct effect of phlogosis or irritation of one of these organs ; and hence, in addition to the variety of gastric origin, we have hepatic or cystic, and nephritic colic. The colon, with its immense mucous surface, its extended muscular coat and its appropriate and double supply of nerves, spinal and organic, and a circulation modified by the vital activity of the parts just mentioned, may naturally be expected to undergo vicissitudes of functions from causes affecting the system at large, such as plethora, excess or defect of innervation, and suspended perspiration, as well as from those acting more particularly on itself, viz., local plethora or congestion, irritation of the spinal nerves distri- buted to it, and above all, the varying quantity or quality of its con- tents or the fecal matter, the residue of digestion, which it is destined for a while to retain and discharge. Although this office appears to be ignoble, it is not by any means unimportant; nor analogous to that of a mere recipient of substances sent into it from the intestines vol. 1.—21 242 DISEASES OF THE DIGESTIVE SYSTEM. above. It has its secretory and absorbent functions, by both of which the residue of digestion is subjected to important changes, very different from those merely physical or chemical, — changes necessary for conversion of this residue into matter properly fecal or excrementitial. Regarded in connexion with the part performed by the csecum, we cannot be ignorant of the fact, that the functional phenomena of the large intestine are too diversified, and their mor- bid sympathies too impressive, to allow of our passing them by in the cursory, not to say slighting manner, which is commonly practised. Of late times, acute disease of the colon, colitis, and its sequela, enterorrhcea or diarrhcea, have been properly elucidated by the aid of morbid anatomy, and their treatment placed in consequence upon a better basis : but we are still wanting in that precision of detail respect- ing the more chronic and less violent deviations from health of this intestine, which bear the same relation to colitis that gastric and gastro-duodenal dyspepsia do to gastritis and gastro-enteritis. I will not promise you to supply the omission, but will at least put you in the track of rational inquiry, and furnish you with some aids to further investigations. Colonic Dyspepsia. — I begin with a notice of certain morbid phenomena which require, I think, that we should class them under this head. If a better title for them shall occur to any of you here- after than that which I use after Dr. Todd, I am not at all tena- cious on this subject, and shall very readily adopt it. There are three portions of the colon in which its disorders are more apt to occur, or at any rate to be manifested by pain and other symp- toms, viz.,— 1, at its beginning, or csecal portion in the right iliac region ; 2, its transverse arch, contiguous to the stomach and liver, in the epigastric region; and 3, its sigmoid flexure in the left iliac region. In all derangements of function of the colon, and in its acute diseases or phlegmasia?, these regions should be carefully exa- mined by touch and palpation ; the posture of the patient, the while, being changed from a recumbent to a stooping, and afterwards, if his strength allows, to an erect posture. Constipation. — Colonic dyspepsia is divided by Dr. Todd (Cyclop. Pract. Med.) into the atonic, the inflammatory, the irritable, and the follicular. A few observations on each of these kinds, deduced mainly from the source just indicated, will place the subject suffi- ciently before you, to prevent false diagnosis, and to guide to the most judicious treatment. I may state, by the way, that Dr. Todd himself professes to have drawn a considerable part of his descrip- tion from the accurate portrait of Dr. M. Hall. Much of the subse- quent details are descriptive of effects commonly attributed to con- stipation, and the treatment is that required for the latter ; and hence I shall be saved the necessity of repetition, or of recurring to the subject of constipation as a separate disease, requiring separate and special notice. The general character of atonic colonic dyspepsia is habitual constipation of the bowels, but with no great alteration of the alvine evacuations, pain or uneasiness in some part of the colon, variable in degree, situation, and constancy; often stridulous noise in the COLONIC DYSPEPSIA. 243 abdomen. A not unusual mistake in forming an opinion of this disease is to suppose that it consists in costiveness, which is, in fact, but one of its symptoms, and indeed a troublesome effeet of colonic weakness. This form is not confined exclusively to either sex ; it is most common in young females, and in delicate boys or young men. Months, even years, may elapse after the first coming on of costiveness, or scanty, even though daily, evacuations before this and concomitant ailments, such as impaired appetite, lassitude, aching of the whole body, or distressing pain in the loins and lower extremities attract serious notice. "There is frequent headache, great nervousness or susceptibility of impression, a tendency to perspiration on the least surprise or exertion, fluttering, faintishness, timidity, discomposure by the least hurry or agitation ; sometimes tremor and vertigo." Among the most marked changes in the physiognomy of the patient, and these do not occur at first, are a dark or sallow discoloration, going on to a greenish-black, of the lower eyelid; a pale, sometimes chlorotic, complexion; and a sen- sibly greater, paleness of the upper lip than any other part of the face. The pain of the colon, for a while shifting from one side and from one part to another, becomes by degrees more fixed in one of the iliac regions, frequently iu the right, in the course of the ascending colon, accompanied by spasms returning in paroxysms, and not rarely by vomiting and great irritability of the stomach (the colica stercorea of some authors). This is every now and then the pre- cursor of stercoraceous and phlegmonous tumours, of which I shall speak under the head of Csecitis and Peri-caecal tumours. A common situation of the pain is in the left side just under the false ribs, and very often in the left iliac region iu the course of the sigmoid flexure of the colon; in which case there is a frequent desire to go to stool, accompanied with distressing tenesmus. " Frequent though ineffectual efforts are made to obtain a stool for several days, and at length a number of small, hardened, and slimy lumps, or scybala, either separately or connected together, similar to sheep's dung. more rarely of a flattened or tape-like form, will be voided, some- times preceded and sometimes succeeded by liquid and sanious stools of various colours, of a frothy consistence, and always ex- tremely offensive. This is the tenesmus a scyballs of some authors, and the dysentery of others, of which inflammation and ulceration of the mucous membrane, and occasionally stricture of the lower part of the colon, are the remote consequences." Sometimes there is pain and soreness at the hypogastric region and a slight pain on urinating. There may be felt a distinct hardness in some part of the colon, particularly on the left side, depending on accumulated and indurated feces. I have had occasion to watch this disease for many years, and have found that the pain was at first, for a year or more, iu the sigmoid flexure of the colon and afterwards in the transverse portion. Iu the latter there is more of an uneasy sensa- tion than of positive pain, which is only experienced when pressure on the part is made. One of the most annoying and common attendants on this disorder 244 DISEASES OF THE DIGESTIVE SYSTEM. is a disagreeable noise, which has been compared to the croaking of a frog, heard in the bowels, and proceeding more especially from the leftside. "This noise is very much under the influence of respiration, and also any state of excitement. For the most part, especially on inspiration, it is similar to the croaking of a frog ; but on expiration it is somewhat less so, conveying the idea of the sound issuing, as it were, from water: often before it ceases it is like the plaintive sound of a dying animal." A curious sensation is conveyed to the hand applied on the left umbilical region, between the navel and the spine of the ilium, during inspiration, as if some liquid was forcibly dashed or squirted against the peritoneum. On expiration this is less per- ceptible. Sometimes this verberation will be felt between the navel and spleen. There is no limited duration of this noise, which, how- ever, seldom lasts more than twenty minutes, and returns at irregular intervals. It is most marked in an erect posture, and will disappear so soon as the recumbent posture is taken. Induced by the first few mouthfuls eaten, it soon abates as the meal advances, and after some intermissions entirely ceases. It has seemed to me to be most frequent and troublesome in the case of female patients when they were tightly laced; and I have procured from them an admission of this fact, in their own cases. The artificial pressure of corsets was not so great as to diminish much the diameter of the colon, while yet it destroyed the tone of the abdominal muscles, and prevented the elastic compression on the intestine which they habitually exert. The assimilating functions manifest disorder by an impaired appe- tite, but frequently without any symptoms of gastric or duodenal dyspepsia, sometimes irritable stomach and ejection of food soon after taking it, accompanied with pain or uneasiness or tightness across the stomach. Sometimes there is faintness with a sense of craving for food. The tongue is loaded or furred, and of a white or yellow colour ; frequently loaded, swollen and oedematous, and marked by pressure against the contiguous teeth ; and at times so large in proportion to the mouth, that from compression it is found more or less divided with sulci or folded into plaits. Foulness of the teeth and mouth, a vitiated taste and viscid saliva, are often accom- panied with a tainted and fetid and almost stercoraceous breath ; but his last is by no means a uniform symptom. I have seen long and tedious cases of the disease, in which the breath was almost uni- formly fresh and pure, unless on occasion of gastric disorder or com- mon indigestion, — although the tongue and mouth, especially in the morning, were as just represented. The bowels are, at first, alwaysconstipated,afterwards constipation and diarrhcea occasionally alternate; but in the advanced stage the latter becomes permanent. The appearance of the feces is various, — being at first indurated and scanty, afterwards fluid, dark coloured, scanty and fetid, often accompanied with mucus and even blood ; sometimes, as already remarked, their discharge is attended with tenesmus, bloody stools, and pain in the right iliac region; an occurrence very common in young females. In the beginning of the disorder the urine is high coloured and apt to be loaded, depositing a whitish sediment, and presenting a supernatant iridescent pellicle ; afterwards it lets fall a CHARACTERS OF ATOXIC COLONIC DYSPEPSIA. 245 mucous deposit, sometimes of a lateritious tinge. I have seen this followed by large deposition of uric acid, which in some cases, in which there is a complication of irritable and atonic colonic dyspepsia, attends every exacerbation. The urine will frequently become limpid, but a slight exasperation of the malady soon restores the de- posit. The pulse is often nearly natural; sometimes it is quick, or easily accelerated ; but usually soft and weak, and becoming some- what more frequent with the progress of the complaint. The skin is in general cool, rather moist and clammy, particularly the hands and feet, which are apt to be obstinately cold; the fingers are rather livid, and the nails assume a lilac hue. Allusion has been made to the patient's complaining of headache, nervousness, and vertigo, and sensation of weakness and aching after slight exertion. " The headache, which is severe on rising from bed in the morning, insomuch as sometimes to excite vomiting, will con- tinue unabated for an hour or two, and is often proportionate to the degree and length of time which the patient has slept." Nervous tremor supervenes on the least excitement or surprise, and is mani- fested in a quivering of the lip or dimpling of the chin in speaking, or under the least agitation by tremor on holding out the hand or carrying a cup of tea to the mouth. Sometimes there is oppression, heavy sleep, or considerable stupor or obtuseness of intellect during the day, and during the night great wakefulness, restlessness, dis- turbed sleep, dreams, and incubus. The following description of an attack of the disease will be ac- knowledged to be faithful, both by the patient who has experienced it, and, what is more to our present purpose, by the physician who has ever been called on to advise for such a case. I transcribe it the more cheerfully, because, although the attacks are common enough, their real nature and cause are often overlooked; and at one time bloodletting, at another opium, or again some antispasmodic is had recourse to, when the real means of relief would consist in relieving an overloaded colon and preventing a recurrence of its torpor. " The patient is liable to violent and sudden attacks, generally induced by some improper article of diet or a more than usually loaded state of the large intestines, such as sickness, vertigo, faint- ishness with cold perspirations, paleness of the countenance, and cold- ness of the extremities. These attacks are sometimes accompanied with spasmodic or convulsive paroxysms, frequently assuming the form of hysteria, more rarely of epilepsy, and occasionally temporary delirium, loss of memory, or absence of mind. Sometimes the attacks consist of spasmodic or anomalous pains ahout the heart or side, or in various parts of the abdomen ; in fluttering, irregular action, violent palpitation of the heart with syncope; in local pains more or less severe, occasionally so severe as to resemble tic douloureux of longer or shorter duration, and in various forms and situations; in some in- stances resembling the passages of gall-stones, in others inflammation of the pleura, of the liver, spleen, kidneys, and intestines or perito- neum, and affections of the bladder. Sometimes there is an extra- ordinary loss of muscular power, especially of the lower extremities, which are so enfeebled as to appear affected with paralysis," 31* 246 DISEASES OF THE DIGESTIVE SYSTEM. In scrofulous constitutions, curvature of the spine has been noticed to be not a rare complication and consequence of atonic colonic dys- pepsia. It is gradual in its approach ; but after a longer or a shorter time, the spine gives way at the third or fourth lumbar vertebra, either by projecting anteriorly or to the left side. " In consequence of the curvature of the spine on the left side, the right hip has the appearance of being enlarged, by reason of the hollowness between the ilium and the vertebral column being increased, whilst the left hypogastric region is more swollen than the right." Dr. Todd controverts the opinion of Dr. Bradley, who supposes that the disease of the spine is the primary affection, of which the stridulons sound and other derangements are only the consequences. I would add that, in general, organic spinal disease, and that which is still less understood, spinal irritation, are more commonly, by far, part of a series of reflex actions, the first of which was in a disease of some viscus, the second its transmission to the spine or spinal marrow, and a third the reflexion of this last on the affected viscus and adjoining organs. I must here supply, in part at least, an omission in my lecture on dyspepsia, among the causes and associated phenomena of what I stated was spinal irritation. When detailing the treatment of dys- pepsia, I forgot to direct your attention to the fact of gastrodynia, or at least of violent muscular pain of the intercostal and abdominal muscles associated with that of the stomach, being not unfrequently controlled and removed by applications to the spot on, and more commonly one side of, the vertebrae, where tenderness was felt on pressure. A few leeches to this spot, or a small blister kept run- ning for a few days, or where the abdominal pain is less urgent, an irritating liniment rubbed in, will often give wonderfully prompt and even occasionally entire relief of all the distressing symptoms. The predisposing causes of atonic colonic dyspepsia are a certain period of life, between ten and thirty years of age; perhaps also a natural conformation of body, and still more a change of habits from childhood to adolescence in the offspring of the rich and the luxu- rious, by which, from wrong notions of what is due to graceful carriage and to the requirements of education, they are deprived of suitable exercise. With the children of the poor, from different motives, similar restrictions are imposed, as in the factories and workshops; in which, in addition to constrained posture, a close and impure air exerts a constant and deleterious operation. An- other, and a quite common and influential cause, is false modesty or shame, by which young persons are prevented from obeying the calls of nature for exoneration of the bowels, when absent from home, or travelling, or in any way exposed to more than customary ob- servation. Serious diseases of the bladder are not unfrequently brought on in this way. The immediate cause, or that which, erroneously enough, in the fashion of the writings of the present day, is called the pathology of the disease, is an atonic state of the colon, and, as a consequence, although we have reason to believe sometimes a cause, also, exces- sive accumulation of feces in its cavity. This condition of parts TREATMENT OF ATONIC COLONIC DYSPEPSIA. 247 is capable of affecting the upper portion of the digestive tube, both by continuity and sympathy, and by pressure on the abdominal aorta and some of its important branches interfering with secretion, and deranging in both ways the nervous system. The colon may suffer by mere sluggishness, owing to a want of proper stimulus in the matters passed down to it from the upper bowels — a want chiefly depending on deficient or depraved secre- tion of bile. Its contents are by this means, however, accumu- lated, become hardened, and irritate the surface of the intestine, causing tenderness on pressure, a feeling of hardness in the part, and all the symptoms of colonic disorder already described. Per- sons thus circumstanced, if they are exposed to high heat alter- nating with cold and moisture, or are under strong and contending emotions, and commit some error in regimen, are liable to a variety of dysentery, in which rectal heat, irritation, and straining, are among the most troublesome symptoms. Possessed of a know- ledge of the antecedent state and habits of the patient, we prescribe with confidence, in this kind of dysentery, a mercurial purge, aided by oil and enemata, with the effect of causing a free evacuation of the large intestines and almost entire removal of the disease. It is generally in such cases that scybala are seen, and that their dis- charge gives manifest relief. But this is in anticipation of the treatment of atonic colonic dys- pepsia, the indications for which, as laid down by Dr. Todd, are, 1, to remove any accumulation of feces by having the bowels full and satisfactorily evacuated ; 2, to facilitate and promote the regular performance of the function of the colon; and 3, to correct the mor- bid condition of this intestine. For fulfilling the first indication we cannot, aWimes, well dispense with purgatives, unless the patient shall manifest determination and perseverance in the use of particular ingesta, and of other hygienic means calculated to prevent and obviate constipation. Rhubarb with sulphate of potassa ; sulphur with cream of tartar; solutions of sul- phates of magnesia and potassa with sulphuret of potassa; pills of rhubarb, aloes, and blue mass, alternating with the infusion of senna, ought to be preferred to other purgatives. In pursuance of the second indication we must insist on the superior power of a due regulation of the ingesta, more than on any kind of medication ; or if an exception be made, it will be in favour of enemata of tepid or warm water, in which, if the constipation is obstinate and of long duration, a small quantity of soap may be occasionally mixed, or of common salt dis- solved. When, of necessity, recourse must be had to aperients, these should be of the milder class, just indicated, and so combined with articles from other classes, that their operation will be adequate, with- out causing irritation and consequent probability of inertia of the colon in consequence of previous undue excitement. If there be febrile symp- toms present, or heat and tenderness in any part of the abdomen, or the temperament of the patient be sanguineo-bilious, we may give with ad- vantage tartar emetic in combination with purgatives; as, for example, a teaspoonful of Epsom salts, dissolved in half a pint of water, and thirty drops of antimonial wine, at bedtime, or the following prescription: — 248 DISEASES OF THE DIGESTIVE SYSTExM. R. Extract. Colocynth. compos., Extract. Hyosciam. aa. 5SS» Antimon. Potassio-Tartrat. gr. i. Syrup, q. s. M. Ut. ft. mass, in pil. xvi. dividend. Sum. aeger ii. vel iii. pro dosi. The extract of hyosciamus is a useful adjuvant, and in this case corrigent, also, to purgative medicines. With aloes, or gamboge and blue mass, it makes a convenient combination in the present case. In prescribing this latter or any other preparation of mercury for occa- sional and repeated use, care must be taken to ascertain the susceptibili- ties of the patient to this medicine, both as regards its direct action on the bowels, and its remote, but more serious one, by bringing on saliva- tion. Whether we direct enemata or aperients for opening the bowels, we must be aware, and press the fact on the minds of our patients, that these are means of temporary benefit only, and can never be continued long, certainly habitually, without injury, and finally aggravation of the disease. The better and more constant means of cure will consist very much in suitable diet, which implies that it should be mild and nutritious, taken in moderate quantities and not at long intervals, or not less than three meals in the course of the day. It should consist of mild animal food, boiled, roasted, or stewed, such as mutton, chicken, game, the tender loin of beef. The last mentioned meat is not as digestible as mutton. Sometimes a moderate quantity of salt meat, as of bacon, with an abundance of vegetable food, agrees very well with the pa^- tient: at other times it invariably produces disorder of digestion, and more especially in the large intestine. Next in importance, if not itself of paramount consideration, is slow and adequate mastication. Few articles of food are easily digested if this rule be neglected ; few will prove very troifblesome if it be carefully attended to, so that the alimentary substance shall be reduced to the greatest degree of com- minution and well mixed with saliva, in order to form a soft, homo- geneous mass. In the selection of vegetables, the experience, and sometimes the idiosyncrasy, of the patient, must regulate our advice. Mealy potatoes mashed answer well for some, to others they are irri- tating in any shape, and more, it has seemed to me, certainly in my own personal experience, to the colon than the stomach and duode- num. The bread should be always stale, or at least of the baking of the day before that on which it is eaten. The pan-loaf, as it is com- monly called, into the composition of which a small portion of corn- meal enters, is palatable, and preserves the requisite softness longer than the loaf of wheat alone. Of the various vegetables for table use, I know of no one at all comparable to spinach, in its laxative pro- perty, without causing acidity or flatulence. Milk, without large dilution, or unless in the state of butter-milk or whey, seldom agrees in colonic dyspepsia. When the stomach is not disordered by°their use, stewed fruits, such as prunes and apples, or those with a pre- dominance of sugar, such as figs, and rye mush and the like, will be found to contribute to preserve a soluble state of the bowels. The same modified advice will apply to the use of melasses, or drink of melasses and water, and cream of tartar whey. For the removal of the atonic state of the colon and constipation INFLAMMATORY ATONIC COLONIC DYSPEPSIA. 249 from this cause, in obedience to the third indication, the union of a bitter, as the extract of gentian or of quassia, with a purgative, should be directed. The same good effects may be expected to follow a combination of a mineral tonic with a purgative, to which a warm gum, as myrrh, or an antispasmodic like assafcetida, can be added, as in the following: — R. Pulv. Aloes, G. Myrrhae, aa. Jss. FerriSulDhat. 9i. M. Syrup, q. s.; ut. ft. mass, in pil. xx. dividend. Take two or three before breakfast. R. Extract. Gentianae, Pulv. Assafcetida, aa. 3'* ----Aloes, 3ss. M. Adde syrup, q. s.; ut. ft. mass, in pil. xl. dividend. Take two or three twice daily. Or the compound aloes pill, made of aloes, extract of gentian, with a little oil of caraway, in doses of from five to ten grains, answers very well to open the bowels. Two five-grain pills, taken two hours be- fore dinner, or about noon, will evacuate the bowels sometimes in the evening, sometimes on the following morning. Sulphate of quinia with aloes in pill, or with the pills of aloes and myrrh, exerts fre- quently the best effects in constipation, or in a torpid state of the colon and of the system generally. Solution of iodide of potassium and compound syrup of sarsaparilla are excellent alteratives in the disease now before us, both by their action on the mucous secretions and on the liver. I have obtained very satisfactory results from their use. The combination of salines and chalybeates, or of sulphur and salines, as at certain mineral springs, if continued for some months, has procured entire exemption from the disease during a considerable period. Among the hygienic means of giving tone to the colon are mode- rate exercise, in which alternate flexion and extension, a gentle com- motion, as in some agreeable sport, or riding on horseback, are im- parted to the body. To the same purport are travelling and change of air and scene, assiduous friciion with kneading of the abdomen, and sponging this region and the spine with cool or tepid salt water. A hot, and, at times, cold douche on the abdomen, is found to be quite successful in Italy and some other parts of the continent. Violent and prolonged exercise are injurious. LECTURE XXVI. DR. BELL. Inflammatory Colonic Dyspepsia—Connexion with chronic colitis—Causes and treatment.—Irritable colonic dyspepsia—Enteralgia—Peculiar temperament of persons suffering from (his disease—Treatment; to be simple and mild—Follicu- lar colonic dyspepsia—its analogy to follicular duodenal dyspepsia—Treatment. Inflammatory Colonic Dyspepsia. — The general character of this variety of disorder of the colon is pain in some part of the intes- tine, prevailing in one particular point, felt always, more before an 250 DISEASES OF THE DIGESTIVE SYSTEM. evacuation of the bowels, seldom increased on pressure ; stools gene- rally liquid, rarely formed, not always more frequent than natural. "The patient," continues Dr. Todd, " is always remarkably lowered, irritated or made otherwise uncomfortable by the action of purgative medicine, and even by the spontaneous action of the bowels, which is always followed by more or less feeling of exhaustion: he feels always most strong and most comfortable when his bowels are con- fined." The pains are accompanied with a somewhat tense and ac- celerated pulse; there is some degree of thirst, but little heat of sur- face. The evacuations vary in consistence and colour; more com- monly they are liquid or pultaceous; sometimes almost white, or yellow and frothy, less frequently green or black; sometimes a tenacious puriform matter streaked with blood. Generally more frequent than natural; they are often not so, an evacuation occur- ring but once in a day, or in two days. " The stools are frequently discharged with considerable force; but occasionally there is tenes- mus without any excrementitious discharge. The appetite is seldom much impaired. The complexion is pale or whitish, sometimes of a remarkably greenish paleness, and the body emits more or less of a cadaverous smell. "The unfavourable progress of the disease is to hectic fever, accom- panied with oedema of the lower limbs and face, dejected features, and gradual exhaustion." Very analogous to the disease just described is that which M. Roche designates as a variety of chronic colitis. It is not accompa- nied with diarrhcea if the palient's diet be simple ; but looseness fol- lows the use of stimulating meats and wine. The patient feels in some part of the large intestine, commonly in the cascum, a dull, sometimes a sharp pain, intermittent or irregular, and which often comes on suddenly, and disappears, after a variable duration, in like manner. So long as it lasts the patient is sad and gloomy, feels a weariness in his limbs, all of which will disappear with the cessation of the pain. Rarely is this last felt in the horizontal posture, except on pressure and in thin persons only, for in those of a full habit the strongest pressure will not give rise to it. It is often calmed by taking food, and by demulcent and narcotic enemata. It is more especially manifested four or five hours after a meal, and also after a long fatiguing walk, or by jolting on horseback or in a carriage; sometimes it is induced by sudden flexion of the body, or throwing it backwards. Grief, crosses, and anger, will bring it on. It mav last a long time without materially interfering with nutrition, provided the patient lead a regular life ; but, at last, sooner or later, if it be not attended to, emaciation will show itself, and sometimes a tumour be- comes visible in the painful region. Stricture of the intestine, can- cerous conversion, and finally ascites, are often the consequences of this phlegmasia when it is neglected. When it has its seat in the cascum, it often happens that the inflammation is extended to the sur- rounding cellular tissue, and gives rise to those abscesses, of which 1 shall soon speak, in connexion with accumulations in the caacum, and inflammation of this intestine. The causes of this variety of colonic dyspepsia are all those which IRRITABLE COLONIC DYSPEPSIA. 251 can excite chronic colitis, and more particularly continuance of the atonic variety, and the use of drastic purgatives, often resorted to for its cure ; also, the irritation of worms, and that of the violent reme- dies sometimes empirically used for their expulsion. Atmospheric changes, by interfering with the regular functions of the skin, seem, also, to be determining causes. The morbid condition of the colon is analogous to that in colitis; sometimes the inflammation is limited in extent, frequently terminates in ulceration, occasionally in thickening or induration. The treatment is tolerably well pointed out by the symptoms and recognised state of the colonic mucous membrane. It will consist in leeches or cups to the affected part, followed by fomentations, flannel rollers round the trunk, and covering of course the abdomen; frictions; counter-irritation by croton oil or tartar emetic. These last I have found to be of considerable benefit when the pain was fixed in one part, as in the right iliac region. The food should be plain, light, and easy of digestion; neither troubling by acescency nor by stimulation. Farinaceous articles with a small quantity of milk, if it agrees with the patient, and after a while light animal broth, made quite thick by the quantity of rice boiled with it, should be used. Tea, when it does not annoy by causing flatulency, is to be preferred to coffee, which is so apt to excite the alimentary canal, and particularly the large intestine. Rest of body, and sometimes a recumbent posture, for a length of time, are requisite means of relief. Exas- perated as the complaint is by purging, we must abstain from all medicines which produce this effect, and confine ourselves to the direction of enemata of warm water to relieve the bowels of their contents in caseof constipation. The warm bath,and someof the narco- tic extracts, either by the mouth or as an enema, will prove to be sooth- ing and useful remedies. Opium, from its inducing a constipated habit of bowels, will of course be withheld, except in cases of extreme and continued pain, when we shall use it as we would do in the like exigency in other diseases, in which it is not abated or removed by bloodletting. Irritable. Colonic Dyspepsia. — Enteralgia — The general cha- racter of this variety, still following Dr. Todd in his description, is in- testinal digestion accompanied with pain, uneasiness in some part of the abdomen, seldom fixed to one spot, but changing its situation and intermitting. This disease is most frequently met with in persons of a nervous and irritable temperament, whose morbid irritability would seem to be frequently concentrated in the intestines, and to give rise to hypochondriasis, with its minute attention to one's own feelings and extravagant opinions of their importance and meaning. There is a complaint of pain or twisting at the umbilicus, or in the course of the colon, seldom augmented, generally relieved by pres- sure ; frequently a sensation of sinking or dragging of the bowels, giving the notion of the intestines falling out: " some patients expe- rience this uneasy feeling to such a degree that they are obliged to confine themselves to the recumbent posture. Sometimes, instead of pain, the patient feels in the intestines an indescribable uneasiness or v eculiar sensation similar to those which are perceived in the sto- 252 DISEASES OF THE DIGESTIVE SYSTEM. mach in irritable gastric dyspepsia ; occasionally the pain and preter- natural sensation exist together, frequently they alternate with each other." Flatulence, with borborygmi, colic, and other spasms, harass the patient, in conjunction with, at times, ptyalism and copious dis- charges of limpid urine. In some subjects there is such an aggra- vation of the svmptoms as to make the disorder in men resemble hysteria : and I have seen all the characteristic symptoms of this last disease,including the globus hystericus,\n men, during a paroxysm of this flahdentia convulsiva. It has been arrested, as we learn from Dr. Todd, by the application of cold to the testicles. Would not the same good effects be still more certainly procured and with less risk of subsequent disorder, by cold applied to the nucha, be- tween the mastoid processes, and over the occipital region ? The un- easy feelings are exasperated during intestinal digestion, which is ordi- narily difficult and laborious. I have watched the phenomena of this disease, and have noted that it is not uncommon for a person thus afflicted to eat his meal with relish, experience no inconvenience during the period of gastric and duodenal digestion, feel pretty com- fortable during the afternoon and evening, and only be apprised in the course of the night, or early in the morning, that he has indi- gestion. This will be manifested by some pain in the lower bowels, sometimes a looseness if he has eaten any unusual article at the din- ner of the preceding day, and, as the morning advances, flatulence, flying pains, and the other symptoms already enumerated. The irri- tation thus felt on the passage of the chymous residue from the ileum into the cascum and colon, producing the diarrhcea, with sometimes a deep feeling of sickness and prostration, early in the morning, is continued during the passage of the fecal matters through the great intestine. The change in the state of the tongue, mentioned in a note of mine to Lecture XII, p. 109-10, in the morning, may have arisen from the incipient irritation of the colon at this time. Motion and travel, which often suspend and relieve the intestinal pain and uneasiness, sometimes, on the contrary, aggravate it. Unset- tled and stormy weather is often an exciting cause. If, to the enume- ration of symptoms, we add the singular fickleness of purpose and conduct of the patient in all that regards his medical treatment — flying from one physician to another, using all remedies in quick suc- cession, without giving any one of them, or indeed any mode of treat- ment, a fair trial — we shall have a pretty accurate idea of the fea- tures of the disease, and be better able to ascertain its nature. The temperament of the individual suffering under this form of colonic dyspepsia is nervous and excitable, and at once predisposes him to be readily affected by stimulants of any kind. jXow, as there is no class in which excesses in quantity and quality, and irregularity of period of application, are so apt to be committed as in the use of ingesta, we are prepared to find a person thus constituted suffer from indigestion. The variety of the disease will be determined very much by his kind of life, his habitual posture, and the particular circum- stances which operate on one part of the digestive canal more than another. But we shall fall short, it seems to me, of a knowledge of TREATMENT OF IRRITABLE COLONIC DYSPEPSIA. 253 its correct pathology, if we suppose merely a morbid irritability of the nervous system at large, without taking into account some par- ticular portion— such as of the dorso-lumbar region of the spinal marrow and its nerves—in explanation of the pain and violent spas- modic movements of the intestine. Still more connected with the causation of other phenomena manifesting derangement in the organic functions, and including anomalous feelings and distress not explicable by any language, is perverted function of the organic or ganglionic nerves. An attempt to locate the disease in the muscular coat of the intestine is mistaking an effect for cause, —a symptom for the dis- ease. There is an entire and morbid change in the impressibility and transmitting or motor power of a portion of the cerebro-spinal axes, and also of that of the sympathetic or nerves of organic life, by which the large intestine is supplied. To correct these, constitutes a more important indication for the cure of irritable colonic dyspepsia than the regulation of the quantity of fecal contents in the intestines, and the precise degree of irritability of its muscular coat. One of the means of controlling and modifying the nervous apparatus more par- ticularly disordered, may, it is true, be in regulating, if possible, the kind and amount of stimulus habitually acting on it; but this is not all. Treatment. — The remarks which I have just made directly bear on the selection of our curative methods in this disease. This ob- viously now, it seems to me, is resolved into two heads; first, that which tends to withhold all morbid stimulants, and diminishes the force of hygienic ones ; and secondly, that which modifies by dimi- nishing the morbid susceptibility of both the special and general ner- vous apparatus, by giving them tone to resist being too strongly impressed by common transient exciting agents. We can neither stimulate nor deplete wilh advantage. Both high living and low diet are equally, though in different ways, injurious. The food should be bland and yet nutritious. In its selection we may perhaps glean useful suggestions, by learning the kind habitually used by the patient in earlier life, and before the habits of luxurious or promiscuous eat- ing were formed, which were contemporaneous with, perhaps partly causative of, his disease. Among the articles which would most readily present themselves to our mind is milk ; and if adapted to his powers of digestion, the patient ought to restrict himself mainly to it, in conjunction with light farinaceous food — well raised but not fresh wheat bread, rice and rice flour, fine hominy or grits. After a while, or where milk does not agree, a limited portion of animal food, and in its selection the experience of the patient will be the best guide, is to be directed. Fluids ought to be taken in small quantity, and the diet generally must not be bulky, so as to fatigue by distension, nor much mixed, so as to irritate by the evolution of new products in the intestinal canal opposed to its vital and assimi- lating action. Content to keep the bowels open by simple enemata or the mildest aperients, we must refrain from giving active and especially drastic purgatives. A beneficial impression will be made on the organic nervous system by narcotics, such as hyosciamus, belladonna, conium, alone, or combined with preparations of iron and zinc, alternating vol. i.—,'J 254 DISEASES OF THE DIGESTIVE SYSTEM. with, or to be replaced bv, narcotics and the pure bitters, as gen- tian and quassia, and preferably, I think, to them all, sulphate of quinia. Extract of hyosciamus and the last named salt, equal parts of each made into four-grain pills, one taken night and morning, will be found to display often a pleasant controlling influence on the dis- ease, by removing pain and spasm, and abating flatulence, while a regular state of the bowels is preserved at the same time. jVux vomica and its active principle strychnia, may be expected to exert a good influence in this, as in some other morbid conditions, in which pain and enfeebled or irregular muscular action constitute the chief characters. Among the agencies which act on both the nervous system of ani- mal and on that of organic life, are exercise on horseback, sail- ing and even long voyages ; and, as much as can be, a succession of pleasing objects in which the patient takes a lively interest. If this kind of change cannot be procured, we must insist on an abandon- ment of those habits, which are known to be so often a positive cause of this disease, as of so many other diseases of the digestive system, — viz., eating in excess or at unusual hours, alcoholic potations of any kind, the use of tobacco in any form, late hours, constrained and particularly a bent posture, confinement in close and badly ventilated rooms, neglect of the state of the skin, either by withholding warm clothes, or refusing to preserve its farther activity by bathing and frictions. Follicular Colonic Dyspepsia. — This disease, which occurs in persons of sedentary habits, and especially in young females, who are generally subject to costiveness and accumulation of feces in the large intestines, has a similar origin, in the morbid states of the folli- cles, to that already explained under the head of follicular duodenal dyspepsia. It often supervenes on the atonic variety, and is marked by acute attacks of pain or spasm, frequently amounting to regular paroxysms of colic. Frequently some violent affection of the ner- vous system is brought on, and children in particular are seized in consequence with convulsions, followed by chorea and sometimes paralysis of the bowels. Young women are attacked with hysteric and various disorders of the nervous and muscular systems, inclu- ding catalepsy itself, and of the heart and circulation generally. Uterine derangements are a common sequence. " Generally the patient becomes pale and delicate looking, but sometimes preserves a natural appearance or even good looks; the skin is cool, moist, and clammy, particularly the extremities; the lips and gums are pale, and the tongue is invariably large, moist, and covered with a thin, clammy coating; frequently it is swollen and (Edematous, divided laterally or transversely by deep cuts or fissures, and retain- ing the impressions of the teeth." The bowels, when relieved of their constipation, which is often obstinate and for a while intrac- table to the most active medicines, discharge matters varying in colour, consistence, and smell,— being sometimes of a chalky-white and inodorous, at others fetid and dark, and occasionally mixed with membranous shreds. There is nothing distinctive in the appear- ance or quantity of the urine. The pulse is almost always weak, DISEASES OF THE CiECUM. 255 small, soft, and generally slow; and there seems to be a defect of capillary circulation. The pathology of this disease need not be detailed here, as it would be little else than a repetition of that of follicular duodenal dyspepsia,on which I have already adequately enlarged(Lect. XVIII, p. 173), as far at least as regards the condition of the mucous fol- licles and their morbid secretion. The most common causes of fol- licular colonic dyspepsia are the habitual costiveness of sedentary persons, repeated irritation of the alimentary canal by crude-and in- digestible articles of food, and the ill judged use of purgative medi- cines. But as these are causes of other forms of dyspepsia, and may be present without inducing enteric follicular disease at all, we must believe that there is a predisposition of a scrofulous nature in persons thus affected, who are, I may add, generally of a lymphatic tem- perament. The treatment will consist of the use of means to evacuate the bowels, to alter the morbid state of the follicles, and to give the re- quisite tone to these organs and the colonic mucous membranes gene- rally. With this view we give castor oil and oil of turpentine, calomel and rhubarb, croton oil, compound powder of scammony, in order to relieve the colon of its accumulated feces. After this we shall endeavour both to preserve a soluble state of the bowels and modify follicular secretion, by blue mass and rhubarb, hydrarg. cum cretd—rhubarb with ipecacuanha, balsam copaiba, cubebs with bi- carbonate of soda, and iodide of potassium in conjunction with some saline and a chalybeate. The tone of the bowels will be maintained by vegetable bitters, with occasionally narcotics and sulphurous and chalybeate waters. LECTURE XXVII. DR. BELL. Diseases of the Caecum.—Peculiarities of position, structure, and function of the caecum—Its liability to be disordered—Symptoms of fecal accumulations in it— Treatment—Importance of enemata—Best means of employing them—Suspicion of hernia being present—Liniments and friction—Attention to diet.—Inflamma- tion of the cxcum—Its varieties.—Stercoral Cascitis—Symptoms and treatment. The diseases of the cascum, of which I am now about to speak, are not of common occurrence; and on this account their diagnosis re- quires to be laid down with some distinctness, in order that they may receive a suitable treatment. They are apt to be mistaken by the inexperienced for other affections; and measures are attempted for their relief which are inadequate or mischievous. We cannot, how- ever, duly appreciate the circumstances of the liability of the cascum to disease without a knowledge of its anatomical character and relations as well as functions. An extensive pouch at the termi- nation of the small intestines, it receives the chymous residue from these latter, including, of course, any crude and indigestible sub- stances which had escaped gastro-enteric digestion: itself liberally supplied with large mucous follicles, which secrete an acid, albu.ui- 256 DISEASES OF THE DIGESTIVE SYSTEM. nous, and solvent juice, it subjects all these matters to a second di- gestion, likened by some physiologists to that of the stomach. A more complete remora of its contents is procured by its mode of con- nexion with the colon, by which these have to ascend against gravity before they find entrance into the latter. In the cascum, the intestinal contents first acquire their fecal odour, which is attributed to a vola- tile oily substance secreted by their follicles ; and on this occasion is generated, together with an acid, hydrosulphuretted hydrogen gas. We can now readily understand how, if the upper and chief digestive organs fail to effect complete ehymosis,either by their being disordered, or forced to yield a passage to crude and indigestible food, if the secre- tions of the liver, pancreas, and upper (small) intestines be of a de- praved or irritating nature, the cascum should be heavily tasked by accumulations and remora, disordered in its function, and, finally, taking on inflammation, be disorganised in its structure. Weakened energies of the digestive system will of course be largely participated in by the cascum, which manifests its disorder by flatus and colicky pains in the iliac region, sometimes ileus itself, and alter- nate constipation and diarrhcea. To this state it is brought, in young, irritable or nervous persons, by the use of much acid and unripe fruit, neglect of the bowels, and tight lacing, or belts round the upper part of the abdomen; and, in fine, by several other of the common causes of dysentery ; some of the most distressing symptoms of which are occasionally connected with accumulations in the cascum, and inflammation of this part. Several instances are recorded by the older writers where the stones of fruit, biliary and intestinal concre- tions, and hardened fecal matters, lodged in the cascum, have occa- sioned severe colic, and even fatal ileus. Most of these are referred to by Dr. Copland, in his Dictionary of Practical Medicine (Art. Caecum), who has himself contributed not a Utile, by his own cases and observations, towards fixing the attention and enlarging the knowledge of his professional brethren on this subject. " When the distension by accumulated matter is great, it may, from rising high in the abdomen and pressing upon the nerves, vessels, and ducts in its vicinity, occasion numbness and oedema in the right lower extre- mity, retraction of the testicle, and derangement of the urinary secre- tion ; and thus be mistaken for disease of the kidney." Dr. Copland observes, also, that besides various indigestible substances which may be lodged for a length of time in the cascum, producing more or less disease, " large balls of worms, both lumbrici and ascarides, collect in the viscus, and occasion much local irritation, or even inflammation, of its inner surface, and constitutional disturbance." The symptoms occasioned by fecal accumulations in the cascum, and by its distension, enlargement, and irritation, are local, symp- tomatic and constitutional. The local symptoms are, more or less fulness, hardness, or distension, in the right iliac region; sometimes on examination carefully with the point of the fingers, the abdominal muscles being relaxed, a doughy hardness is felt. " When the bowels are constipated, and interruption of the passage of matters through the cascum occurs, the paroxysms of pain are very acute, and some- times attended with vomiting and all the symptoms of the most severe ENEMATA IN CjECAL ACCUMULATIONS. colic, and even those of ileus." Some of the symptomatic disorders have been already mentioned, viz., numbness of the right thigh; cedema of the right foot and ankle; sometimes retraction of the tes- ticle, or frequent calls to empty the bladder; to vvhich may be added, hemorrhoids, uneasiness in the right iliac region, often extending to the right hypochondrium; various dyspeptic symptoms and irregu- larity of the bowels, — constipation alternating with diarrhcea, and scanty, offensive, and mucous stools, and severe tormina, even to retching, when the mucous surface and follicles of the organs are irritated. Dr. Copland, whose description I still follow, adds, that he has seen several cases of varicose veins of the leg, or indolent ulcers, and a case of disease of the bones of the feet, the occurrence of which was evidently connected with great distensions and accumulations in the cascum. The constitutional symptoms are very analogous to those of atonic colonic dyspepsia detailed in my last lecture, to which I refer you. The indications of treatment of cascal accumulations and the accom- panying costiveness are the same as those already recommended for torpid colon, under the head of atonic dyspepsia of that intestine. But greater liability to disorder of the stomach and inverted action of this viscus and of the small intestines, in the disease now under notice, requires of us more reserve in the administration of active purgatives, especially those of the resinous or drastic kind. Calomel in a full dose, as from fifteen to twenly grains, will be found to answer better than these; it will, it is true, be very apt to cause some nausea, and even vomiting, when it has reached the ileo-cascal valve, and has entered the cascum ; but, in return, it will bring away much indurated feces; and often by its action on the liver and mucous follicles of the intestines, stimulate these to a free secretion, which, going down with it, will excite the cascum and colon to further peristaltic action and discharge of their contents. Pain, flatus or spasm, being present, will indicate the propriety of adding opium, hyosciamus, or belladonna, to the calomel, or, subsequently, to aloes, in order to insure a complete, yet not painful or irritating evacuaiion of the bowels. Enemata. — Difficulties interposed to prevent the administration of medicines by the mouth or to their full operation after their being swallowed, we must have recourse to enemata, among the best of which is castor oil and oil of turpentine, — one to two ounces of the former and half an ounce to an ounce of the latter, mixed with a pint of gruel or thin flaxseed mucilage. When worms are suspected to be present in addition to olher morbid matters, we may use aloes, and the alkaline solutions, assafcetida, camphor, lime water, ometimes procure free fecal discharges. Croton oil, if the stomach revolt at medicine in bulk, or if the other prescriptions prove unavailing, is a resource in reserve. But if, to the symptoms of stercoral accumulation, be added dif- INFLAMMATION OF THE CECUM. 261 fused tenderness of the abdomen, vomiting, and protrusion of the intestine in the groin, we should have recourse to the same reme- dies which are directed in strangulated hernia. Of these, venesec- tion or leeching, according to the constitutional vigour or evidences of general febrile excitement, tartar emetic, as a sedative and re- laxant, and enemata, will constitute the first part of the treatment. Relief being obtained, we may then give some tolerably active pur- * gatives, selectin? those which are least irritating to the mucous coat. Calomel, therefore, and castor oil, or castor oil and turpentine, will have the preference over the resinous and drastic medicines of this class. Where the muscular coat is partially paralysed by inflamma- tion, or the diameter of the intestine diminished by external tumour, or other causes, it will be desirable to produce a relaxation of the whole intestine, and at the same time diminish the inflammation. Hence we have recourse to free leeching in the neighbourhood of the tumefied part, tartar emetic by the mouth and per anum, and finally, if need be, enemata of tobacco, as used for hernia, and as successfully employed by Dr. O'Bierne in dysentery. We must not forget the means of at least partial relief afforded by the elastic tube introduced some way up the gut, as already recommended. In all cases in which an enema is to be administered, the pipe pro- jecting from the barrel ought to be longer than it is; or the defect in this particular may be supplied by the affixing to it an elastic tube, which, especially in cases of obstinate constipation and colic, or where stricture of the rectum exists or is suspected, should be car- ried high up in the intestine ; as far, at least, as the sigmoid flexure of the colon. Knowing the immense quantity of accumulated feces which have sometimes been retained in and distended the cascum and colon, we ought not to desist from a continuation of our mea- sures for their entire evacuation, even after the fecal discharges have been copious. We may remit, for a day or two, the adminis- tration of purgatives after ease has been procured by large discharges of scybala and feces; and then resume the use of this class of medi- cines, varying the kind so as at one time to give saline, at another resinous, then again oleaginous. The increased activity and milder operation of certain purgatives are obtained by the addition of a bitter, as sulphate ofquinia, gentian, &c. Frequent and regular friction, and gentle kneading of the abdo- minal parietes; the tepid bath at first, and afterwards the cool shower bath or douches along the spine, and moderate exercise in the open air, will be among the measures of restoration, in addition to those already recommended, for the convalescent from this disease. LECTURE XXVIII. Acute CjECITIS.—Symptoms and treatment. — Chronic inflammation of the caecum — Its causes, complications, and cure. — Inflammation of theperi-cxcal tissue. — Perforative ulceration of the caecum and of the appendix vermiformis— Causes —Symptoms—Prognosis—Treatment. Acute Inflammation of the Cecum begins in the mucous mem- brane during the progress of dysentery and enteritis; but sometimes 262 DISEASES OF THE DIGESTIVE SYSTEM. it arises idiopathically and unconnected with any other complaint. In the latter set of cases, the inflammation is usually rapid and in- tense. Its symptoms are, at first, tenderness on pressure and some colic disorder, but then the peritoneal coat is also affected : there is a burning, pungent pain in the right iliac fossa, aggravated by pres- sure and by intestinal evacuations, and frequently extending more or less along the line of the transverse colon. A sensation of burn- ing heat at the anus every time that the bowels act is a common attendant symptom. Usually there is a distressing diarrhcea present, which, in general, diminishes the pain in the iliac fossa. The stools are thin, often loaded with mucus, and not unfrequently bloody. As the disease abates, the mucosities become whiter, and of a thicker consistence, not unlike those which are often expectorated in bronchitis. The mucous secretion has frequently been mistaken for and described as purulent ; and hence a common error, that in this affection the stools are often mixed with matter. The extension of inflammation from the mucous to the muscular and peritoneal coats of the great intestines constitutes the phlegmonous dysentery of authors. With respect to the pain which accompanies inflammation of the cascum, it deserves notice that this usually extends down the surface of the right limb, more especially when the patient walks, or turns his body round in bed. Hence it is apt to be considered as of rheu- matic origin ; and as the muscles covering the inflamed bowel gene- rally sympathize with it, there may be a degree of rheumatic suffer- ing blended with that arising from the enteric disease. In some cases retraction of the right testicle has been noticed ; and in others symptoms of irritated kidney appear. The duration of inflammation of the cascum has never, to Professor Albers's knowledge, extended longer than seven days. The treatment of cascitis may be pretty well inferred from the description of the disease. It will be nearly the same as that of ileitis, and consist of— 1, leeches or cups over the iliac fossa and behind, between the ridge of the os innominatum and the lower rib, and anterior to the psoas muscles, followed by fomentation and poultices;— 2, a blister, which is to be kept freely discharging,and if the symptoms persist, the surface to be dressed with mercu- rial ointment;— 3, antimonials to act on the bloodvessel system, by reducing action ; and afterwards a mild purgative, in order to insure a discharge from the cascum of any retained fecal or imperfectly digested or other irritating matters. Active purging should not be produced by any medicine given by the mouth ; but enemata may be frequently administered, partly with a view of revulsion, and partly of gently soliciting the passage downwards of the matte'rs in the ileum, cascum, and upper part of the colon, the delay of which would prove irritating. Small doses of calomel at intervals will contribute to this end, and be otherwise useful. Salivation has been followed by a cure. Local as inflammation of the cascum is, we ought, nevertheless, in cases in which the pain is fixed and violent and extends over the abdomen, in a young and well constituted subject, not to rely entirely on topical detractions of blood, but must have recourse to venesection, and allow the blood to flow from the TREATMENT OF CHRONC CjECITIS. 263 arm until approaching syncope. Turpentine embrocations applied over the abdomen, and retained as long as it can be borne by the patient, is a remedy of great power. Leeches to the anus will sometimes be of service, the more so if there have been pre-existing irritation of this part by hemorrhoids. Chronic Inflammation of the Cascum. — This form of cascal disease is less commonly an effect of prior acute inflammation than as primary and of slow and insidious approach, and long confined to the mucous surface and follicles of the intestine. It often, as Dr. Copland justly remarks, advances imperceptibly, until serious organic changes have taken place in the coats of the cascum; the general health, although more or less affected, not being so far injured as to alarm the patient. Occasionally on this state may supervene a sub- acute or an acute attack, which may terminate in peritonitis, or in suppuration, or in gangrene. " Chronic inflammation is the most common organic state of disease by which the cascum is affected." The causes of this form of disease are, some of them, common to both sexes, others peculiar to females, who are the most frequent sufferers from it. Among the first may be enumerated the use of unripe or acerb fruits, sedentary occupation, deficient, or occasionally too violent exercise on foot or horseback ; the depressing passions; pre- vious disorder of the digestive organs, particularly costiveness, and habitually or occasionally deferring the earlier intimations to evacu- ate the bowels : suppression of accustomed discharges, such as hemorrhoids; the pressure of an illy-constructed bandage or truss, or blows on the part. The,causes to which females are exposed are contingent on their uterine functions and child-bearing, and their modes of dress. It often occurs among them previously to menstrua- tion, or soon after the climacteric epoch. The symptoms of chronic cascitis are those common to disordered digestion, such as flatus, occasional colic, irregular alvine discharges, loaded tongue with red borders, muco-purulent discharges; and some more distinctive and peculiar, such as the inclination of the patient to lie on the right side, pain or uneasiness in the right iliac region on turning to the left side, which is increased by keeping this position; pain on.pressure over the cascal region, and a deep-seated fulness and hardness here.* The treatment of chronic caecitis differs but in the degree to which we carry the use of remedies from that of acute inflamma- tion of the cascum. " When," says Dr. Copland, " the disease.has gone on to thickening of the coats of the intestine, as indicated by obscure hardness and tumour, uneasiness, &c, in the iliac region, particularly if it be attended with ulceration, as may be inferred from the presence of small quantities of blood or pus mixed in fluid, or but little consistent, muco-feculent, and offensive stools, amend- ment is procured with great difficulty under the most favourable cir- cumstances; but it should not be despaired of, although it maybe long in appearing." The treatment suggested by this author is enemata, laxative electuaries, blue pill, hydrarg. cum cretd, ipeca- * In the sixth volume of Dr. Chapman's Medical and Physical Journal, Dr. Heeztlcy gives an account of a case of Scirrhous Tumour of the Caecum. 264 DISEASES OF THE DIGESTIVE SYSTEM. cuanha, hyosciamus, and camphor, liniments, and repeated blistering, and subsequently the deobstruent plaster. In addition to these, I would recommend mercurial alternating with iodine inunction of the right iliac region, the internal use of iodine, and syrup of sarsaparilla. Inflammation of the cellular tissue round the caecum or peri- cecal tissue — perforative ulceration of the caecum and of the ap- pendix vermiformis. I ought to premise that inflammation and abscess of the iliac fossa is not confined to the right or cascal side, although it occurs in a majority of cases. Thus, as we learn from M. Grisolle, of eighty-three cases, the disease occurred in the right side in fifty-three, and in the left in but twenty. The cellular in- flammation commences suddenly after exposure to cold, irregularity of diet, or taking a draught of cold liquid when the body is heated and perspiring. The pain which attends it is felt at first sometimes near the umbilicus, and at other times in the iliac region. When it begins round the navel, the patient usually complains of slight cutting pains, which do not differ much from ordinary colic: when in the iliac region it is much more intense. Wherever situated it gradually diffuses itself, so that the entire surface of the abdomen soon be- comes exceedingly tender, as is the case in genuine peritonitis. Sometimes the pain extends round to the loins and back, and then the cases may be mistaken for nephritis or psoitis. But at length it is concentrated chiefly in the iliac fossa. When this takes place the disease is fully developed, and suppuration is probably near at hand. The pain is aggravated by any movement of the body, or by the accumulation of flatulence in the bowels, &c. When the pain has lasted for some time there is always considerable tension, swelling, and hardness in the right iliac region, stretching from thence in all directions, but chiefly downwards in the direction of Poupart's liga- ment. These phenomena are more circumscribed than in peritoneal inflammation ; although it must be admitted that the two cases are not easily distinguishable. The following is an example of the diffi- culty of diagnosis : — A child, eight years of age, was suddenly seized, after a chill, with considerable fever attended with severe abdominal pain, which was seated at first in the hypogastrium, and gradually extended itself to the right iliac region, and finally over the whole abdomen. There had been diarrhcea ; but this was replaced by constipation and trou- blesome vomiting. The case was considered as one of genuine peri- tonitis, and treated with bloodlettings, local and general, fomenta- tions, mercury internally and externally,&c. The patient died on the ninth day after the attack. Dissection showed the whole extent of the peritoneum, intestinal as well as abdominal, to be perfectly sound, with the exception of one spot about the size of a dollar over the cascum, where it. was evidently inflamed, and exhibited a few flocculi of coagulable lymph. On examining more minutely the parts at this region, a fluctuation was perceptible ; and, on making an incision there, a large cupful of purulent matter flowed out. The cellular tissue surrounding the cascum behind was found to be greatly destroyed by suppuration, and the pus had made its way between the abdominal muscles forwards to the iliac region. These muscles DIAGNOSIS OF CJECITIS. 265 were quite dissected, as it were, from the subjacent peritoneum ; the caecum also was much softened in texture, so that it was easily torn across; and its mucous surface was of an almost livid colour : no perforation, however, had taken place. All the other abdominal viscera were sound. It will be observed, that in the case now related, there was at first diarrhcea, which was followed by obstinate constipation. Such is the usual occurrence whenever the cellular substance round the cascum becomes inflamed. The constipation here is partly owing, we may suppose, to the loss of contractility in the muscular coat of the intestine by inflammation, and partly to the mechanical pressure of the swelling on the cascum, and on the colon also and small bowels. In addition to the symptoms already enumerated, there is usually pain and a sense of numbness down and about the hip-joint. These symptoms may be owing to the psoas and iliacus internus muscles being peculiarly affected. The excretion of urine is also in many cases more or less disturbed. It is probable that the right kidney sympathizes from the very beginning of the disease, and that the swelling in the latter stage may press upon the ureter. It may be readily supposed that there is generally more or less feverish irritation present. The progress of the disease is often very obscure and slow ; the symptoms being at first inconsiderable, but becoming on a sudden violent and most alarming. The prognosis is in general favourable ; since, out of sixteen cases collected by M. Meniere, only one proved fatal. But if we extend our view to all cases of phlegmon in the iliac regions, the result is not by any means so favourable. Of 73 cases collected by M. Grisolle, there were 20 deaths. Peritonitis destroys a certain number of cases. The duration of the disease may be said to vary from two or three weeks to seve- ral months, or even to upwards of a year. — Termination. It is, we are told, not rare for the inflammation of the cellular substance round the cascum to terminate favourably by resolution, but certainly in the majority of cases suppuration is induced. The pus usually finds its way into the cavity of the gut, either directly, or by burst- ing into the appendix vermiformis. In some of the cases published by Dupuytren, the purulent matter had infiltrated itself as high as the kidneys, and so low in the pelvis as to collect between the rec- tum and bladder. When suppuration takes place there is a sudden change in all the symptoms; the severe pain and the obstinately confined state of the bowels being generally followed by a complete remission of suffering and by a greater or less degree of diarrhcea; so that the patient, and his medical attendant, also, if he be not on his guard, are apt to suppose that a favourable crisis has taken place. Too often, however, this is but a delusive calm ; the strength of the patient becomes weaker and weaker, the stools are found to be mixed with purulent matter, and the system at length gives way. The history of the following case affords a good illustration of the usual progress of the disease : — " Cask. — A man, twenty-nine years age, who had been pre- viously in perfect health, was seized, during the summer of 1833, when the influenza was prevailing, with smart abdominal pains, vol. i.—23 266 DISEASES OF THE DIGESTIVE SYSTEM. which returned at periodic intervals, but were not attended with fever or any gastric disturbance ; diarrhcea, however, was present. By the use of cupping the pains abated, but they became more permanent and more fixed in the right iliac region ; and at the same time a con- stipated state of the bowels ensued. For five days the patient was able to attend to his affairs; and then he was seized with feverish chills followed by flushes of heat. The pain became much more severe, and occasional vomitings supervened ; at the same time the groin was somewhat swollen and very tender on pressure, and the urine was thick and very red. Purulent matter was observed to be mixed with the alvine dejections; all the symptoms became sud- denly very alarming, the extremities being cold and the pulse scarcely perceptible ; and the patient died in a state of coma. " On dissection, a large collection of pus was found behind the cascum, stretching up to the right kidney, and down to the pelvis; the appendix vermiformis was hard and thickened. In the cascum, at about an inch from the appendix, there was a perforation with irregular edges, through which the matter had escaped into its cavity; the right kidney was softened and very red; and the iliacus interims muscle was partly destroyed by ulcerative absorp- tion. " In a few rare cases, the pus makes its way not only into the gut, but also outwardly through the abdominal parietes ; thus an anus contra naturam is established. Occasionally the outward opening alone takes place. When this is the case, the symptoms are gene- rally very severe for ten or twelve days, and then suddenly they subside, when the abscess bursts. Under all circumstances the dis- ease must always be considered as a very dangerous one ; the colli- quative exhaustion that is induced by the protracted suppuration proving in most cases fatal. " With respect to the age, at which peri-caecal suppurations are most frequent, perhaps it is that of youth." The period of the greatest liability is between 20 and 30 years of age. M. Meniere {Archiv. Gen. de Med., t. xvii., p. 213) supposes that adults and the male sex are most liable to this disease. M. Grisolle {Archiv. Gin. 1839,) confirms this statement, in relating that, out of 56 cases not connected with the puerperal state, 46 were males, and only 10 females. Dupuytren tells us that disorders of the diges- tive tube caused by certain trades have a great tendency to produce this diffused inflammation and subsequent abscess. He specifies house-painters, colour-grinders, and copper-turners, as more pecu- liarly liable. M. Grisolle points out the puerperal state as the chief cause in females. Of 27 cases of iliac abscess in women, 19 occurred in the puerperal state. Dr. Burne remarks : The peculiarity in the organisation of the cascum, which bears upon the present subject, is the absence of a peritoneal tunic at its posterior part, where it is fixed and attached by adipose cellular tissue to the iliac fascia, so that in the event of a'perforative ulceration in this direction an abscess would form behind and without the peritoneum upon the iliac fascia, and direct its course to the lumbar region at the outer edge of the quadratus VARIETIES OF C.ECITIS. 267 lumborum muscle. Dr. Burne, in premising that the cascum by its conformation is peculiarly exposed to the lodgement of undigested substances, thinks that the greater number of cases of inflammation of this intestine are to be ascribed to the prolonged irritation of bodies so lodged, and that such inflammations are, therefore, pro- perly symptomatic; a conclusion borne out, moreover, by the man- ner of the attack, which is characterised by a development of the local preceding that of the general symptoms, and by the absence of the chills and rigors which usher in idiopathic inflammation. That the inflammation of the cascum may be idiopathic, and arise from the ordinary excitingcauses, cold and vicissitudes of the weather, there can be no doubt; but these instances are rare, in compari- son with those which may be fairly attributed to the irritation of crude substances which have readied the cascum and lodged in its pouch. The termination of the symptomatic inflammation of the cascum is usually by resolution; the symptoms yielding at the end of five or six days, and subsiding altogether soon afterwards: except iu patients of an inflammatory or gouty diathesis, in whom inflamma- tion once excited will continue in a subacute or chronic form, and require several weeks for its removal, notwithstanding the original exciting cause shall have passed away. The termination by perforative ulceration and abscess of the cascum is rare: but this organic lesion of the appendix is more apt to occur, and is next in frequency to the inflammation of the cascum. The varieties of the disease are— 1. Inflammation, acute or sub- acute, of the cascum, terminating quickly or slowly in resolution or lingering on and leading to permanent organic impairment 2. Perforative ulceration of the cascum from within and abscess' behind the peritoneum, pointing externally in the corresponding lumbar or inguinal region, or in both. 3. Inflammation of the appendix spreading over the peritoneum. 4. Perforative ulcer- ation of the appendix with consequent universal peritonitis ending rapidly in death, or with circumscribed peritonitis and abscess within the peritoneum, sometimes ending in death in the course of ten days, or, life being preserved, it bursts eventually into the cascum and discharges itself by the rectum, or directs its course to the surface of the body and pointing in the right lumbar or inguinal region. As regards the tumour which occurs in the right iliac fossa, Dr. Burne assigns the following as its causes: — 1. Collection of fecal matter in the cascum. 2. The presence of any crude undigested substance, of worms, concretions, or other foreign bodies. 3. In- flammation of the cascum resulting from the irritation of the above. 4. Chronic disease of the cascum. 5. Abscess from perforative ulceration either of the cascum or of the appendix. By M. Grisolle, on the contrary, great doubts are expressed, indeed the fact is denied, of phlegmasia of the iliac fossa, either right or left, being the common consequence of cascal disease. The perforative ulceration of the appendix may be suspected by the 268 DISEASES OF THE DIGESTIVE SYSTEM. more or less sudden development of the local signs, which are always severe, by their being fixed in the right iliac fossa, and not preceded by bowel complaints or ill health; by the supervention of vomiting and constipation, the constipation yielding readily to medicine; yet, having yielded, no amendment following; by the great tension of the ileo-inguinal region, there being always a circumscribed peritonitis and abscess within the peritoneum ; by the sympathetic tenderness of the whole abdomen; and subsequently, by the occurrence of a diarrhcea, and a discharge of pus by the rectum, followed by subsi- dence of the tumour and amelioration of all the symptoms, or by the pointing of the abscess in the form of an emphysematous tumour in the lumbar-inguinal or ileo-inguinal regions. The peritonitis excited at the moment of the perforations of the appendix will not unfrequently spread rapidly and universally over the peritoneum, and destroy life in from twelve to twenty-four hours. The diagnosis in the two varieties of the disease will be the less doubtful by our remembering that the perforation of the cascum is generally preceded for weeks or months by bowel complaints, indi- cating ulceration of the mucous membrane; while the perforation of the appendix is not preceded by such bowel complaints. The statistical information afforded by the cases collected by Dr. Burne is presented as follows: — Termination : 13 recovered ; 8 died. Character: 19 acute; 2 chronic. Varieties: 11 were inflammation of the cascum — all recovered : 2 were chronic disease of the cascum — both died : 1 was ulcerative perforation of the cascum from within, with abscess externally — recovered : 1 was inflammation of the appendix, with circumscribed peritonitis — died: 6 were ulcerative inflammation of the appendix—5 died, 1 recovered. Of the five fatal cases of perforative ulceration of the appendix, one died of dif- fuse peritonitis in about sixty hours ; one of peritonitis and circum- scribed abscess in the peritoneum in nine days; one of circumscribed peritonitis and abscess in the peritoneum in twelve days ; one of cir- cumscribed abscess in the peritoneum in four weeks; and one of ab- scess in the peritoneum, pointing in the right ileo-lumbar region, in eleven days. The one which recovered was a circumscribed abscess in the peritoneum bursting into the cascum. The ages were, two under ten years of age ; seven between ten and twenty; three between twenty and thirty; six between thirty and fifty ; three between fifty and seventy. Sex : sixteen were males; five were females. Occupation : six were gentlemen ; one was a coachman ; one a farmer ; five were boys having no particular occu- pation ; three were destitute ; five were females having no particular occupation. Season : In the autumn and beginning of winter more frequently. The treatment of phlegmon and abscess of theiliac fossa, and of peri- neal inflammation, will be nearly the same as that detailed for cascitis. Bloodletting to be efficient must, however, be employed early; and even then it will oflen fail to prevent suppuration, although it will diminish the extent of the abscess, and render the subsequent treat- ment easier. Leeches ought to be had recourse to in aid of the lancet. DISEASES OF THE RECTUM. 269 "^notwithstanding these measures, theperi-cascal tumour increases and is converted into a vast abscess, M. Donne advises, that no en- deavour should be made to draw it to a head and to open it exter- nally; but that the surgeon should wait patiently the discharge of the purulent matter by the intestine. Where this termination does not take place, and where there is a disposition in the abscess to open externally, the matter should be let out by incision, before the skin heals; and by proper dressings, and especially a suitable position, the abscess entirely evacuated and its cavity obliterated. As the most dependent part of the tumour is towards the posterior part of the body, it has been recommended for the patient to be on his face. When the disease becomes complicated with peritonitis, the remedies for this latter affection are to be employed." {Am. Cyclop., &c. Art. cited. Until of late years inflammation of the cascum and its appendix, as a separate disease, has engaged but little attention. Dr. Burne, and Dr. Albers of Bonn, are our chief guides on the subject — the former in an article on the Inflammation and Perforative Ulcera- tion of the Caecum and of the Appendix Vermiformis Caeci in the Medico-Chirurgical transactions, — the latter on Inflammations of ike Caecum.* To these, for reference, I may add Dupuytren {Lemons Orales), Ferral on Phlegmonous Tumours in the Right Iliac Region (Edinb. Med. and Surg. Journ., vol. xxxvi.), American Cyclopedia of Practical Medicine, &c. (Art. Abdomen — Abscess of, by Dr. Hays), and M. Grisolle— Histoire des Tumeurs Phlegmon neuses des Fosses Iliaques (Arch. Gen., 1839). LECTURE XXIX. DR. BELL. Diseases of the Rectum.—The structure and sympathies of the rectum—Chief diseases of the rectum, viz., hemorrhoids, ulceration, stricture, and cancer.—Dan- ger from neglect of proper knowledge of rectal diseases.—Hemorrhoids—Defi- nition—Disease, both hemorrhage and tumours—Varieties of hemorrhoids or piles—The anatomical characters of the three principal ones,—varicose, erectile, and cystic or spongy (mariscae)—Hemorrhoidal Flux or Discharges—Their sources —Quantity and colour of blood discharged.—Mucous or Sero-Mucous hemorrhoi- dal discharge—Causes—Constipation and drastic purgatives overrated as causes of hemorrhoids.—Consequences and complications of hemorrhoids. The diseases of the rectum merit more consideration than they gene- rally receive ; or, I ought rather to say, that the morbid alterations of this part of the intestine are not studied with the care and attention to which their importance entitles them; and it is only after they have made a progress which is at once alarming and dangerous, and places them often beyond the reach of the art, that the physi- cian and surgeon are appealed to for their removal. The rectum is not a mere continuation and termination of the colon. Its mucous coat is more vascular, and its muscular coat thicker, and it receives a more abundant mucous supply than this latter. Its sympathies are Anri^iSJJ^f1111-8!8? is contLained in the Medico-Chirurgical Review for April, 1840, and from it I draw on this occasion. 23* 270 DISEASES OF THE DIGESTIVE SYSTEM. both organic and animal, — for the reception and transmission of impressions either healthy or morbid. Its susceptibility to irritating purgatives and acrid poisons is manifested in the fact, that often the effects of these are felt more by the rectum than by any other part of the digestive canal, after the stomach and perhaps the duodenum; and hence it is that the chief traces of phlogosis, or analogous struc- tural alterations of mucous tissue caused by the ingestion of poisons, are found in the stomach and rectum. It is a curious fact, says Christison {Treatise on Poisons, p. 318), that the rectum is much inflamed, though the colon, and more particularly the small intes- tines, are not in cases of poisoning with arsenic. A common appear- ance in lingering cases is excoriation or ulceration of the anus, and, in some, it is said that even gangrene has been produced. Often, under the operation of drastic purgatives, persons complain of heat and burning at the lower part of the gut and anus, which, they are told proceed from the irritation caused by bile. Sometimes the ex- planation may be valid ; but more generally these sensations are the effect of the medicines acting on a susceptible portion of the intesti- nal canal. Whenever sensations in this portion of intestine more than those of mere distension, and especially when heat and some pain, however slight, are felt by a person during fecal exoneration, we must suppose that the digestion is not healthy ; and, in fact, it will be found on inquiry that the rectum is participating in a morbid state of the stomach. By its contiguity as well as anatomical relations through bloodvessels and nerves, and in degree also muscles, with the genital organs and bladder, it both receives irritation from and transmits it to these parts. Supplied as its lower portion is with spinal nerves, it readily transmits its impressions by one set, and its muscular coat and levator ani are stimulated in consequence to contraction by an- other or motor set. This is part of the series of nervous actions which takes place in health for the evacuation of the rectum and sigmoid portion of the colon. The entire series includes the call upon the abdominal muscles and diaphragm and their contraction to aid the expulsive movement. When the transmission of impression by the rectum is too quick and too frequent, in a morbidly sensitive state of its mucous surface, there is a corresponding quickness and frequency of motor action, and violent and irregular contraction of its muscular coat and of the levator ani muscle, and tenesmus or straining and expulsive efforts with pain are produced. If, on the other hand, the rectal sensibility be less than natural, the circle of sensitive and motor actions is tardily performed, feces accumulate to some extent, and are retained here; or, in common language, the person is said to be costive. The circulation of blood in the rectum is liable to irregularity chiefly by retardation. This is owing first to the straight veins, which are also without valves, and to their being subjected to irregular and, in cases of constipation, undue and prolonged pressure by the fecal accumulation distending the rectum. In addition to these local causes, there are the remote ones operating through other parts of the vena porta, remora of the blood in which may be caused by ob- struction of the circulation in the upper portion 'of the intestinal canal, and still more in the liver. Undue fulness and congestion of the vessels of the rectum may also proceed from the double cause of im- HEMORRHOIDS. 271 pediment in the capillary tissue of the rectum itself, or in the trunks of the vena porta, of which the upper hemorrhoidal veins are, it will be remembered, branches. Nor is the lower hemorrhoidal plexus which terminates in the hypogastric vein exempt from retar- dation, on the return of its blood, by the same causes; since the lower hemorrhoidal veins composing it anastomose with the upper ones. Among the mechanical causes more or less interfering with the regular circulation of the rectum, and especially with the return of blood by the veins, are distension of the bladder and enlargement of a gravid uterus. The very circumstance of lax cellulo-adipose tissue surrounding the rectum, and particularly abundant at its lower part, which prevents the retarded and irregular circulation from being at first painful or leading to rupture, gives facility for distension to a great extent and for establishing congestion and stasesof blood, which, if by any cause converted into inflammation, are more trou- blesome and difficult to cure than phlogosis and its concomitants when these come on in other regions in a more frank and violent manner. The chief diseases of the rectum are, hemorrhoids, ulceration, stricture, and cancer: complete fistula is, to a certain extent, a rectal disease, as it depends on a solution of continuity in the coats of the intestine ; but it is more commonly regarded as an adventitious one, local, and calling for surgical rather than medical aid. It happens, unfortunately enough, with reference to all the diseases of the rectum, that their constitutional origin and connexions are either regarded as of little moment or entirely overlooked ; and, if we except partial remedies to soothe present irritation and pain, the patient does not think of asking for regular professional assistance until the distress from morbid growth or obstruction is so great as to leave apparently no option. The surgeon is sent for, and the knife or ligature is put in requisition ; the local obstacle is remedied, the parts heal, the patient is rendered comfortable, thinks himself quite well, is prodigal of expressions of gratitude to the operator, who was allowed to have his own way ; but he more than hints dissatisfaction at his physician, whose reasoning on the complicated nature of his rectal disease he could not or would not understand, and whose directions for hygienic, still more than medical treatment he thought were too rigid, and adverse to present sensual enjoyment. But, after a while, uneasy sensations of fulness and oppression are felt in some other organ ; sometimes in the liver, at other times in the lungs, or more frequently, and, worse than all, in the brain, and without speedy relief be , afforded disease of an alarming kind, apoplexy or palsy, supervenes, and death will close the new series of disorders which have taken the place of the rectal ones, the removal of which was so gratifying to the patient at the time, and a cause of so much eulogy by him of his surgical attendant. Equally unfortunate effects have followed the use of various empirical remedies for the cure of diseases of the rectum, which were applied in ignorance of their pathology, and with a view to the removal merely of a local disorder. Hemorrhoids, the first disease of which I shall speak, and to which the preceding remarks are more particularly applicable, is derived 272 DISEASES OF THE DIGESTIVE SYSTEM. from tuftt, blood, and {«<>«, a flux ; the last derived from g«». I flow. The derivation is little different, in the radicles not at all, from that of hemorrhage; and, in fact, by some of the ancient and older writers since, the two were used as synonymous : but yet we have the au- thority of Hippocrates himself in favour of a more restricted desig- nation of the term hemorrhoids, viz., that of dilatation of the veins of the extremity of the rectum, accompanied with a flow of blood; and the vessels of the part have consequently been called the hemor- rhoidal vessels. The definition of hemorrhoids, as given by Dr. Copland {Diet. Pract. Med.), is as follows : Pain, tension, weight, heat, or other uneasy sensation, referred to the rectum and anus, accompanied or followed by tumours in these parts, or by a flow of blood from them when the patient is at stool; recurring after inter- vals, and sometimes periodically. By hemorrhoids or piles we now understand, not merely discharge of blood from the rectal vessels, but also, in addition, tumours, either external or internal to the intestine ; and even these tumours without discharge of blood at all. When the tumours are accompanied or preceded by sanguineous discharge, the disease is called bleeding piles ; and when they are not thus accompanied, blind piles ; so, also, according as they are inside the anus or on its margin, they are called internal or external. A more definite and technical nomenclature has been attempted by calling the bleeding tumours hemorrhois, and the blind mariscas. When blood is discharged without tumours being present, or at least without their being external or readily as- certained, the hemorrhage in this case is not directly distinguishable from entero-hemorrhage higher up the canal. By a careful inspec- tion, however, we shall be able to feel a tumour or tumours inside, an inch or two above the anus, or the dilated vessels and thickening of the mucous coat of the rectum. In hemorrhoidal discharge, the blood generally escapes either mixed with the feces or in jets, squirted out, as it were, just before and oftener just after the passage of the feces by the action of the levator ani and straining of the abdominal muscles and diaphragm. In entero-hemorrhage, even from the colon, the blood is passed per anum in a continuous flow, without rectal irritation, and of a dark colour, unmixed often with any fecal matter : it may escape without any effort at defecation. For the most part, intestinal hemorrhage higher up than the rectum is the result of metastasis from some other important organ, or it is a symp- tom of dangerous visceral disease, and frequently appears in the advanced stage of certain low fevers. Anatomical characters. — Common as is the disease before us and well appreciated as are its general phenomena, its anatomical cha- racters have not been ascertained with that entire accuracy which might be expected. Of late years an approximation has been made, by zealous and pains-taking pathologists, towards this desirable end ; and I shall, therefore, draw from their labours the materials for the following sketch. The rectum itself is found, on dissection of thoie who have had for a length of time hemorrhoids, to exhibit enlarge* ment of its veins, and hypertrophy of its sub-mucous tissues. The veins are seen through and directly under the mucous membrane, ANATOMICAL CHARACTERS OF HEMORRHOIDS. 273 taking a course parallel to oach other for seven or eight inches ; their trunks being, as noted by Dr. Colles, as large as crow-quills. Mor- gagni mentions a case in which they had almost acquired the diameter of a thumb, in the entire length of the rectum and adjoining portion of the colon. The hemorrhoidal tumours themselves, piles, are organised in dif- ferent ways, constituting them into so many varieties. The first organic change is simple dilatation of the capillary tissue, and more particularly of the venous part, which may be followed by hemorrhage, or remain for a longer or shorter period without any evacuation of their contained blood. After the paroxysm has passed off, these ves- sels recover their customary size and tone, and exhibit no traces of vascular engorgement or change. This slighter deviation from health must be of frequent occurrence in most persons, especially when there is derangement of the lower bowels: but the prolonged operation of particular causes and increasing predisposition by age, give the con- gestion a fixed character; the veins become more and more dis- tended, and, at length, varicose, and form small tumours, in clusters, which are chiefly interna], but project more or less beyond the anus. M. Begin {Diet, de Med. et de Chir. Prat.) has sometimes seen the lower part of the rectum as if completely interwoven with a venous network, forming a thick vascular ring, gorged with blood ; the in- cision of which would give rise to dangerous hemorrhages. These are the varicose hemorrhoidal tumours: they are internal, and only after straining efforts at stool are they protruded externally. Another and more common variety is the erectile, consisting of an areolar structure, soft, spongy, and full of blood, but which are shrunken when there is no excitement or irritating cause producing an afflux to them. Numerous capillaries ramify through these tumours in such a manner, that if, after cutting into them, we were, as Chaussier has pointed out, to throw a coloured fluid into the arterial branch, we should see it issue from all points of their surface by innumerable minute orifices. A somewhat remarkable example of this kind is furnished by Sir James Earle, in the case of a young lady in whom the tumour was about nine inches, and altogether like a piece of sponge, bleeding from every pore. It was, however, of a healthy appearance, soft and compressible. Varicose piles are very prone to hemorrhage. In their colour they vary, says Dr. Gross {Patholo- gical Anatomy, p. 285, vol. ii.), from a light red to a deep purple, and they often acquire the magnitude of a common almond. Sometimes these bodies are supplied by vessels of some size, as in the case men- tioned by Dr. Colles, in which, after death resulting from another cause, he had an opportunity of making an examination. On slitting up the rectum, he saw " three bloodvessels, each as large as a crow- quill, running for some way down the intestine, and then dividing into a number of branches; these vessels ramified very profusely, and each seemed, by interweaving of its branches, to form one of these tumours. The trunks and branches were covered only by the lining membrane of the intestine." {Dublin Hospit. Rep., vol. v., p. 152.) A third variety of hemorrhoidal tumour is the encysted or spongy, and technically, marisca, appearing in the shape of a fleshy tubercle.' 274 DISEASES OF THE DIGESTIVE SYSTEM. It is formed between the mucous and muscular coats, by the inter- weaving of distended capillaries and cellular tissue, and contains a centre or cyst filled with blood which had escaped from some of the ruptured capillaries. At first, this effusion disappears after the sub- sidence of the hemorrhoidal paroxysm ; but by repeated congestion the sac remains more or less permanently distended, and gives issue to an oozing of blood, constituting a hemorrhoidal discharge. This kind of tumour projects often far into the rectum, is somewhat solid or spongy, and when divided presents a compact or porous and bloody surface. When the tumour is external it is paler and more elastic, is infiltrated by serum, and is sooner produced and disappears more readily than when it is internal. A modification of marisca is formed by a small fold of mucous membrane, which, with its sub-mucous tissue, has been forced through the anus by the effort of defecation or other strain; and, being pinched by the contraction of the sphincter, is prevented from returning within the bowel; or the thin skin con- necting the internal mucous and external cutaneous membrane, which is naturally puckered, but by slight causes becomes irritated, has its cellular tissue enlarged, and undergoes other changes similar to those just described. Liable, by friction and accidental undue pressure, to inflammation, these tumours become thickened and indurated, and the mucous membrane by continual exposure is transformed into skin. By long irritation from friction and want of cleanliness, they often increase to a large size, and assume, from the pressure of the nates, a flattened oblong form, with a thick, rounded, irregular edge. Their opposing surfaces become abraded and ulcerated ; and fissures and rhagades are produced, from which a thin purulent discharge takes place. These tumours are often exceedingly painful, but do not bleed. Sometimes, small abscesses form in them, attended with a discharge of purulent matter from the anus, and more pain and irritation of this part than usual. Hemorrhoidal Flux or Discharges. — Dr. Copland enumerates the various sources of hemorrhoidal discharges {Did., ut supra) to be — 1st. From congestion of the vessels of the part, followed by exhala- tion or exudation from the internal surface of the rectum. 2d. From irritation of this bowel, followed by vascular determination and san- guineous exhalation. 3d. From the surface of the hemorrhoidal tumours, especially those belonging to the second and third varieties; and, 4th. From the rupture of varicose or enlarged vessels. We may well doubt the fact of hemorrhage from the surface of the tu- mours themselves ; they bleed, owing to compression and rupture of some of their own or immediately contiguous vessels. When the discharge is a continuous stream we may generally suppose it to come from the ruptured varicose hemorrhoidal vein. I have already ad- verted to the perpendicular course vvhich the hemorrhoidal veins take from the anus up the rectum, and to their being unprovided, for the most part, with valves; and hence you must be well prepared to un- derstand why blood will escape in a full stream, and sometimes to a great and alarming extent, in hemorrhage, from a rupture of one of these veins when varicose or dilated. The quantity of blood discharged during a hemorrhoidal paroxysm, CAUSES OF HEMORRHOIDS. 275 at the different times when the patient goes to stool, will vary with the kind of tumour, or according as it comes from the latter or a rup- tured vessel. It may not exceed a drachm or two, or it may amount, at one time, to several pounds. It ought to be known, that a person may lose several ounces of pure blood in the act of defecation, with- out, at times, his being made conscious of the loss by pain or uneasi- ness, either previous of subsequent to the discharge. Sometimes, in place of feces, blood is passed at intervals of a week, a month, or longer, to the amount of half a pint. In fact, there is often no cor- respondence between the size and number of the hemorrhoidal tu- mours, or the irritation to which they give rise, and the quantity of blood discharged. In many cases, the blood flows for a short time only, and is not again seen until the next attack. But, in others, it is observed repeatedly when the bowels are acted upon, or the discharge is renewed when the feces are expelled, for several days. The colour of the blood is generally red, as coming from the arterial capillaries, and it either covers or follows the fecal evacua- tion ; but when it is consequent upon venous congestion or dilata- tion, it is of a darker hue, and follows, or is partially mixed with the feces. A colourless hemorrhoidal discharge—mucous or serous hemorrhoids of some writers — sometimes takes place after, and as a consequence of sanguineous discharge, or it may be associated with the hemor- rhoidal tumours of the third variety, or mariscae. The discharge varies much as to quantity and appearance. When watery, serous, or mucous, it usually exudes slightly from the anus ; when more albu- minous and abundant, it is commonly passed at stool. These varie- ties of colourless discharge, which may be called anal leucorrhcea or Menorrhagia, are most frequent when there is little or no hemorrhage, and when the disease is associated with ascarides, or with pregnancy, and even leucorrhcea. Causes. —Of the predisposing causes, hereditary constitution, age, and excessive alimentation, are the chief ones. A predominance of the venous system, as in persons of a bilious and nervoso-sano-uine temperament and of a plethoric habit of body, like any other pecu- liarity of an organic system, is transmissible from parent to child, and by such means the tendency to hemorrhoids is inherited. In this way, alone, can we explain the appearance of the disease in children, and in all the individuals of some families, although of different con- stitutions, and differently exposed to the common exciting causes. Hemorrhoids is most common in mature age, when the abdominal viscera are in a state of the greatest functional activity and of the fullest organic development. More especially is the vascular system full and almost turgid at this time ; and hence any undue excitement of one part of it will endanger afflux and congestion, which finds tem- porary relief in hemorrhage. Excessive alimentation, by which I mean the use of nutritive ingesta beyond the actual wants of the ani- mal economy, is a common predisposing cause of hemorrhoids. When the system cannot relieve itself of the superabundant nutritive materials elaborated into blood, by the common depuratories, as of urine, sweat, and the pulmonary and intestinal secretions and excre- 276 DISEASES OF THE DIGESTIVE SYSTEM. tions, the bloodvessels become necessarily loaded, and in a more par- ticular manner is the system of the vena portae slow and sluggish, and its circulation liable at this time to be gorged throughout all its ramifications. Animal food 'and fermented liquors, and especially malt liquors, contribute more than other substances to produce both the general and abdominal plethora which predisposes to the disease in question. Their bad effects will not be a little increased by indo- lence, sedentary habits, undue time in bed, and irregular hours in general; all of which may be regarded as additional predisposing causes to this, as they are to another and more fatal hemorrhage, viz., apoplexy. The influence of climate in the production of hemorrhoids is not well ascertained. At first we might suppose that the disease would be more common in hot climates ; but the difference in atmospherical heat in the latter is made up by the artificial in-door heat in colder climates, which is often excessive, and also unequal, and hence more apt to induce congestions in the system of the vena porta?. Partial congestion and remora of the hemorrhoidal vessels are also more readily brought on among the inhabitants of cooler climates by their warm clothing, indulging in warmer seats, cushions, &c„, and pre- serving more the erect position, and being less attentive to topical ablutions, than among the people of more genial regions, who spend so much of their time in the open air, are loosely and lightly clad, and for the sake of luxurious enjoyment have frequent recourse to the bath and other fashions of personal ablution. Seasons exert a modi- fying influence over hemorrhoids: those in which the alternations of temperature are most abrupt and frequent, and the circulation cor- respondingly affected, such as spring and autumn, would seem to be the most unfavourable in this respect; but I have seen the high heat of summer obviously induce large hemorrhoidal discharges, when the bowels were constipated, more than a similar condition of the latter would have effected with the body exposed to a different temperature. Some of the causes already mentioned as predisposing, viz., the sitting posture, and above all, when this is retained for many hours in.succession or habitually on warm and soft cushions, full or rich food, condiments, spices, and highly-seasoned dishes and intoxica- ting beverages, are,at times, exciting causes. The same remark ap- plies to inordinate excitement of the sexual organs, habitual constipa- tion, straight and tight corsets, and the use of irritating injections. Hemorrhoids is liable to occur from any cause which prevents the free return of blood by the hemorrhoidal veins, — as constipation, the lodgement of hardened feces in the rectum or lower part of the colon, and repeated efforts at evacuation ; torpor, congestion, or struc- tural alterations of the liver, and obstructed circulation in any part of the portal system, as from a gravid uterus pressing on the mesenteric veins, diseased ovarium, and disease of the prostate or sphincter ani. Among the exciting causes, we rank all agents by which the rectum is irritated, as drastic purgatives, among which aloes is more parti- cularly supposed to offend in this way, worms, articles used as em- menagogues; also the local influence of cold or of warmth, the first operating by reactive or indirect, the latter by direct excitement,__ CAUSES OF HEMORRHOIDS. 277 as sitting on the ground, or on stone seats or damp cushions, and the habitof standing with the back to the fire, or our more American fashion of being seated before it and the feet raised and resting on the man- tel-piece. Violent mental emotions, either exciting or depressing, induce hemorrhoids, probably by the pernicious influence which they exert over the liver and portal system generally. Great stress is always laid, by writers on this subject, on constipa- tion, as the chief cause of hemorrhoids ; and there are undoubtedly many cases which seem fully to justify the ascription. But I cannot help thinking that its importance is overrated. Constipation and hemorrhoidal predisposition are concomitants in persons of the same temperament, and in whom similar causes are in operation in the pro- duction of both. Hepatic obstructions and retardation of the portal circulation, by interfering with the secretion of bile, and measurably also with intestinal secretions, prevent due stimulation of the intesti- nal mucous surface, and in this way cause constipation. Similar obstruction and retardation, and deficient intestinal secretions, by giv- ing rise to congestion in the rectal vessels, will cause also hemor- rhoids. Constipation may indeed prove to be an occasionally exciting cause; but of itself would have comparatively little effect in inducing hemorrhoids, without the prediposition developed under the circum- stances just mentioned. I believe that inquiry into the history of the cases of hemorrhoids will fail to show their occurrence and that of constipation as always coincident, even in the individuals suffer- ing from the disease. In persons of a sluggish or lymphatic tem- perament, costiveness prevails, but without the accompaniment of hemorrhoids. In those of a sanguineo-nervous temperament, on the other hand, in whom hemorrhoids is quite common, constipation is not of corresponding frequency, nor is the conjunction of the two a matter of general observation. I have frequently seen hemorrhoidal discharges to come on with a loose state of the bowels ; indeed I know that they appear in some cases almost uniformly after looser and more frequent fecal discharges than usual; and in these same cases their appearance is relatively rare during a rather constipated condition of bowels. The fact would seem to be, that the molimen hcemorrhoidale, congestion of the rectal vessels, determined by the general causes already mentioned, requires often slight irritation of the rectal mucous surface to give rise to sanguineous discharge. Con- stipation bears about the same relation to hemorrhoids, as a cause, that picking or pinching violently the nose does to epistaxis. It is one which ought certainly to be withheld, but it can hardly be re- garded of that paramount importance with which most writers seem disposed to invest it, except as a troublesome accompaniment and an effect of imperfect and depraved digestion. Analogous reasoning may be brought to bear on the question of purgatives inducing a predisposition to hemorrhoids, and proving, also, an exciting cause of the disease. The chronically dyspeptic, the hypochondriac and the melancholic, who suffer from costiveness and slow digestion, are habitually prone to the use of drastic purga- tives ; and no doubt often aggravate their maladies, and superinduce gastro-intestinal irritation if not inflammation bv this practice. But vol. i.—24 27S DISEASES OF THE DIGESTIVE SYSTEM. whilst we admit, that hemorrhoids is occasionally one of the bad consequences of this hvpercatharsis, we cannot be blind to the fact, that the disease or series of disorders which provoked to the use of purgatives, was precisely that which also predisposed to hemorrhoids. Of the purgatives which are more especially accused of bringing on this disease, aloes stands foremost, but, as I conceive, without adequate proof. It is the favourite medicine, or basis, at least, of purgative preparations most in vogue with the constipated, and hence has a larger share than other medicines of the class in irritating the bowels. It has, indeed, we know, a decided action on the pelvic viscera, and may be supposed to stimulate the hemorrhoidal vessels; but the proofs are not manifest that its use is so much more mischievous than other purgative medicines, even of a milder kind. In persons whose pelvic circulation is congested and the mucous surfaces irritable, any pur- gative stimulant will suffice to bring on hemorrhoidal discharge. I am prevented, in the case of some of my patients, from prescribing castor oil, on account of their so generally having had an attack of piles when they used it in former times; nor is my experience peculiar in this respect. Epsom and Glauber salts, I know, also, have repeatedly brought on hemorrhoidal discharge, and in some cases for the first time. In persons with irritable intestines, and especially rectum, calcined magnesia has commonly the same effect. The in- ference from all these facts is, that any stimulus to which the diges- tive canal is unaccustomed, whether it be crude ingesta, the remains of chyme not fully elaborated, or medicines, is peculiarly liable to irritate the lower bowels, and of these the rectum most. If at this time there be molimenhcemorrhoidale, blood will be discharged under the irritation of the agents just mentioned ; if there be no disorder in the circulation, the patient will complain of some heat and tormina, and have increased muco-fecal dejections. The consequences and complications of hemorrhoids are both local and constitutional; and merit notice, both as aiding us in our diagno- sis and giving us a proper appreciation of the means of cure and of their relative safety. Inflammation is a no uncommon effect of piles; or ought we not to say, that the irritation by which the afflux to the vessels, causing congestion, and to particular spots of the mucous and cellular tissue of the rectum, causing tumour, being con- tinued, ends in inflammation if not prevented by hemorrhagic dis- charge. Mucous or sero-mucous secretion is not unusuaf at this time. When the phlogosis is severe, it implicates not merely the mucous membrane and subjacent cellular tissue, but also, in a slighter degree, the prostate gland and neck of the bladder, occasioning much pain in the perineum, sacrum, &c, with dysuria or even strangury. In females the uterus becomes sympathetically irritated in this way. Constipation is induced or kept up by the tumefaction of the rectum and spasmodic constriction of the sphincter; and straining and tenesmus are the consequence. Not unfrequently the inflamed tumours, protruded by the expulsive action of the intestine, become inllamed and very painful, and are even sometimes strangulated, and slough. The general system sympathises with the local irritation, and a variety of abnormal sensations and even functional disorders, TREATMENT OF HEMORRHOIDS. 279 particularly of the digestive system, are the consequence, — consti- tuting, at the same time, so many symptoms of hemorrhoids. Among these heaviness and a feeling of fulness of the head are quite common. " In those who have hemorrhoids from or associated with habitual constipation, there will be weight and heat and a sense of fulness about the rectum very constantly, an obscure tenesmus, frequent mic- turition from sympathetic irritation of the bladder, and leucorrhcea from a similar irritation of the vagina and uterus; all of which are temporarily alleviated by the discharge of blood, but are never en- tirely removed, the cause remaining." — Dr. Burne {Cyclop. Pract. Med., Supplement). In the list of troublesome complications, and in degree consequences of hemorrhoids, or of the irritation of parts to which they give rise, are fissures or rhagades of the anus, ulceration ov abscess frequently passing into fistula, tenesmus, or spasmodic contraction of the sphincter, fre- quently with protrusion of the mucous coat of the rectum. Sometimes the protruded mucous membrane is girt so tightly by the spasmodically contracted sphincter as to threaten strangulation, and give rise to symptoms, such as tumid abdomen, colics, borborygmi, nausea, and even vomiting, nearly similar to those from strangulated hernia. A re- verse state may obtain, and after fissures the rectum becomes tumid and relaxed, allowing of the ready escape of blood without defecation, and also the partial escape of fecal matter, which is insinuated into the sides of the fissures, or lodged in little sacs remaining after the hemorrhoidal paroxysm, and forming stercoral abscess, or even ster- coral fistula. LECTURE XXX. DR. BELL. Treatment of Hemorrhoids.—Relief afforded by hemorrhagic discharge.—Disad- vantage of this natural method.—Measures, medicinal and hygienic, required in a first attack of hemorrhoids.—Treatment of the fixed disease.—Difference be- tween arresting and curing a disease.—Attention to the general system, and to the removal of plethora and visceral disease.—Sometimes active measures— v.s., leeching, calomel, &c, required—To vary the treatment, according to preceding or accompanying disease.—Chronic variety—Balsams, turpentine, and cubebs, useful.—Periodical hemorrhoids—treatment of—Precautions to avoid an attack of the disease.—Hemorrhoids with anemia.—Extirpation of tumours prac- tised sometimes with advantage—Danger—Constitutional measures more pru- dent—Necessity of preparing the system for the operation of removal.—Re- stricted regimen afterwards. Treatment. — If we bear in mind the pathology of hemorrhoids, and especially of the causes by which the disease is induced, and of the symptoms preceding the hemorrhagic discharge, we cannot fail to see in it a mode of relief, both to the general plethora which had existed before a first attack and to the abdominal plethora with which hemorrhoids at all times is associated. The discharge of blood relieves the congestion of the liver, bowels, and. indeed sometimes of the whole pelvic viscera, as epistaxis does that of the brain, and hemoptysis that of the lungs. Xature does here that 280 DISEASES OF THE DIGESTIVE SYSTEM. which art, under similar circumstances, accomplishes by venesection, or leeching, or cupping; with the advantage in favour of the former, that the bleeding was of imminent necessity and forced by the state of the bloodvessels of the organ ; but with the drawback, also, of a compulsory repetition of the "discharge whenever the organ becomes turgid and congested, without reference to the state or wants of the general system. While, therefore, we may hail with satisfaction the appearance of a hemorrhage which, like that in hemorrhoids, not only relieves the organ more immediately oppressed by congestion, and sometimes inflammation, but also a more vital organ, as the brain, lungs, or liver, it does not follow that we should desire this kind of evacuation to become habitual; sure, as we are, that, like all frequently repeated or periodical sanguineous emissions, it will either exhaust and bring on anemia, or keep up the very plethora which it first manifestly relieved. If the hemorrhoidal discharge have oc- curred for the first time, under the operation of occasional causes, and be followed by removal of local congestion and inflammation, and of the general febrile excitement, the physician has little, to counsel on the score of immediate action. His advice will be of a negative kind ; viz., to avoid the admitted causes, whether they be of a general or a local nature, and to adopt a rather cooling regimen. But if the rectal irritation be still considerable, and accompanied by a sense of weight, heat, and pain in the sacral and lumbar re- gions, headache, and a quick and a somewhat resisting pulse, the better plan will be to carry out the treatment as we would for in- flammation of any other organ. Not caring to leave to nature far- ther sanguineous evacuations, we take the treatment in our own hands and draw blood from the arm. By this means we reduce both general and local excitement, and at the same time relieve the rec- tum by a kind of derivation. Next, we prescribe remedies akin to venesection, such as antimonials, cooling and acid drinks; and, if the symptoms of fulness in the portal system indicate it, we give calomel, not simply as a purge, but as a means of relieving the con- gestion of the intestinal mucous membrane, and perhaps, also, of the liver, by procuring a free secretion from its muciparous glands, and, by continuous sympathy, of bile also. The compound powder of jalap, castor oil, or rhubarb and magnesia, may severally answer in a mild case to open the bowels, or in a more severe one as a se- quence to calomel. Washes of cold water to the anus, sacrum, and perineum, will be found refreshing and useful after purging; and if there be not much obstruction by hemorrhoidal tumours at the anus, or directly within the sphincter, cold water enema may be used with benefit. In some cases, from peculiarity of constitution, cold is illy borne, and tepid water may be substituted for cold, both for enema and ablution. A recumbent or somewhat reclining posture is to be enjoined on hair sofas or hair mattresses, with just clothing enough to prevent a feeling of chilliness. The diet should be quite simple; chiefly of well-dressed vegetables, ripe or stewed fruits, and all these, as well as the drinks, taken cold or nearly so. By these means, due attention being paid to preserve a soluble state of the bowels, with- out, however, much purging, the local congestion and general ex- TREATMENT OF HEMORRHOIDS. 281 citement will be reduced and gradually disappear, and with them the disease. The more permanent state of plethora and other morbid predisposing causes can then be abated at leisure by a regulated re- gimen and the occasional yet cautious use of laxative and cooling medicines, and other remedies to be hereafter mentioned. To many, perhaps to most persons, these directions may seem to be needlessly particular and minute for a disease which few think of any great moment, and fewer still care to be rid of on such conditions. But their professional advisers ought to impress on their minds the fact, that, although the hemorrhoidal flux is a means of relief of exces- sive fulness of the general system, at any rate of the portal circu- lation, and at the moment prevents much more alarming and even fatal disease, yet that it is an evidence of an unhealthy state of the body, and, unless this latter be removed, the flux may itself become a diseased habit, which cannot be cut short without great danger. Make persons, who are attacked for the first time with hemorrhoids, aware of the real nature of the disease, of its causes, its probable complications and effects, and of its augmentation until life becomes intolerable ; and then the risk of their being drawn, in despair, to submit to violent and harsh measures for the removal of the local malady, at the cost of suffering in some other more vital organ, per- haps of loss of life itself. By placing the question before them in all its bearings, strengthening, it may be, our advice by reference to the known sufferings of their progenitors, or some other members of their families, we may succeed in inducing them to submit to the requisite remedies and restrictions for the present cure of the disease, before it becomes habitual and in every way more complicated and difficult of management. Commonly, however, medical opinion and assistance are not in- voked for the cure or even relief of hemorrhoids, until, by frequent repetition, the disease has become aggravated by the amount of the discharge, or the size and painful nature of the tumours. The very idea of the hemorrhage being a salutary effort of nature for the re- moval or abatement of a disease of a more vital or serious kind than this one set up in its place, makes many slow to ask for professional assistance ; and they either allow the discharge to take its course, and the tumours, if not too painful, to remain untouched ; or they are content to try some nostrum or domestic prescription, or the favourite remedy of a friend, which he knows to be efficacious be- cause he has tried it for the last twenty years. We have, then, we will suppose, an established case of hemorrhoids; one, in fact, of some duration. What course shall we counsel ? Much will depend on a correct view of the subject, or the idea we attach to the cure of a disease. Many confound the cure of a disease with arresting the course of some of its leading or pathognomonic symptoms: but the difference is great; in fact it is one of vast importance to the welfare of the patient. Thus, we may break the concatenation of morbid actions which constitutes intermittent fever, by preventing the return of the paroxysm ; but if, in so doing, we leave or create gastritis, as may be done by the administration of arsenic, the term cure would be misapplied in such a case. So, also, if we have to do with headache, 2 1* 282 DISEASES OF THE DIGESTIVE SYSTEM. associated with gastric disorder, although we may possibly, by cer- tain palliatives, relieve or for a time remove the former, yet if the stomach be still disordered or its derangements increased by our remedies, such as opium and narcotics, it would be mockery to say that we had cured the disease. Now, in the case of hemorrhoids, there is a series of disordered functional actions which have been controlled, and at the same time partially relieved, by a hemorrhage from the vessels of the rectum, of more or less abundance, and fre- quency or regularity of recurrence. Sometimes this hemorrhage ends in a mucous secretion ; sometimes it is replaced by this latter. There are, also, commonly associated with the hemorrhage and remaining in the intervals between its recurrence, tumours of a varicose or cellulo-vascular texture, which after a while acquire something of the structure, as they assume the office of secreting glands. If now the question be repeated — What course shall we counsel ? The reply is — To cure the disease, but not to stop it; to carry off, at least abate the general plethora; to diminish and remove the local con- gestion, and so to alter the habit of the diseased parts that, divested of the pabulum of blood for distending the rectal vessels and for nourishing the tumours, and no longer by local excitement inviting blood into their tissues, the merely local disease, the hemorrhoids, will cease and gradually disappear with the removal of the causes that gave origin and nutrition to them. The modification of treat- ment will depend on the other morbid states and tendencies of the patient, such as of gout, rheumatism, apoplexy, plethora or hepatitis, and the degree of inflammation accompanying the hemorrhoids, and, also, on the irritability of the intestinal canal, and particularly of the lower bowels. During the violence of the hemorrhoidal paroxysm, if the tumours be large and painful and the rectal irritation great, with fever accompanying, we shall more promptly and efficaciously relieve by venesection to an adequate extent—twelve to twenty ounces — than by any other means. In a case of the disease, in a female, before parturition, but which a few days after delivery be- came greatly exasperated, and the tumour of which was very volu- minous, producing exquisite pain and great constitutional disturb- ance, I drew twenty ounces of blood from the arm, directed cooling washes to the tumours, had the bowels opened by calomel, followed by castor oil, and in fine carried out the antiphlogistic practice which I have already indicated as that adapted to a first attack of hemor- rhoids. The disease was entirely removed in this case, without any interruption being given to the lochia? or to the flow of milk, nor was any inconvenience felt by my patient. I attended her in two subsequent labours, but she was not, in either of them, troubled with hemorrhoids. Where the constitution is feeble or contraindi- cations exist to venesection, leeches are recommended to be applied to the tumours; but when this operation is required, it ought to be practised in the vicinity of the tumours, by which they and the con- gested mucous membrane will still be adequately relieved, without making them the direct centre of painful afflux, causing serous effu- sion, and keeping up enlargement for a while as great as that before TREATMENT OF HEMORRHOIDS. 283 the application of the leeches. As a substitute for these latter, or where a great aversion exists on the part of the patient to their being applied, cups to the sacrum and adjoining portions of the pel- vic surface will often give early relief. They may advantageously, in all cases in which we have any doubts about the efficacy of vene- section, be substituted for this latter ; and in some very severe cases, in young and inflammatory subjects, they may still be required in addition to it. Laxatives, which, given at first, would either have failed to operate, or would have increased the irritation of the rec- tum, will now, after bloodletting, exert a beneficial effect. Calomel has been already mentioned as useful in rectal hemorrhage ; it ought, also, to be the preferred medicine in rectal irritation with painful hemorrhoidal tumours, accompanied by constipation. Com- bined with rhubarb, or followed by castor oil, rhubarb and magne- sia, or infusion of senna with salts, it procures the required evacua- tions and relieves the congested vessels by increasing the intestinal secretions. A similar action may be kept up in the sub-acute or chronic form of the disease by means of blue mass with hyosciamus, and rhubarb or aloes. After the subsidence of the acute form of the disease, which is characterised either by hemorrhage or by painful tumours, or by both, we shall have recourse to various medicines which are believed to be more especially useful in certain diseases that were replaced or reached a critical termination by hemorrhoids. Thus, in a gouty habit, we direct colchicum and magnesia, or the alkalies with bitters; and in chronic hepatitis, the blue mass with extract of taraxacum, and small doses of salines; in rheumatism, opium with tartar emetic, and iodine with salines ; in chronic cuta- neous diseases, laxatives, sulphur, sulphurous waters, iodine and sarsaparilla. In all these diseases complicated with hemorrhoids, medicines which act on the kidneys, such as nitrate of potassa, iodide of potassium, colchicum and digitalis, &c, may be expected to manifest excellent effects without irritating the digestive mucous surface as purgatives would do. If the requisite facilities are at hand, the warm bath may be used at the same time with consider- able benefit, as one of the means to equalize circulation and excite- ment, and to relieve the disease by revulsion to the skin. If the hemorrhoidal tumours have appeared in a case in which the consti- tution has not been injured by former disease, such as gout, rheu- matism, hepatic or cutaneous diseases, or incipient phthisis, we may have recourse, after the general treatment already recommended in the paroxysm, to cooling washes, —as cold water, solutions of sugar of lead and of sulphate of zinc respectively. In the more doubtful and mixed cases it will be safer to trust to frequent ablutions of the parts with tepid water. The treatment of hemorrhoids conducted on these principles will be found properly curative and safe: it is that to which we would have recourse in other cases of hemorrhage with inflamma- tory action, and is calculated to reduce or remove the visceral dis- ease from which danger might be apprehended by the mere stop- page or suppression of the hemorrhoidal flux and repelling of the tumours. 284 DISEASES OF THE DIGESTIVE SYSTEM. Guided by the same pathology, we shall know how to direct the treatment in the more mixed and indeed more common forms of hemorrhoidal attacks — occasional discharges of blood with few or no tumours, and these of small size, or tumours commonly indo- lent but occasionally becoming painful; mucous or sanguineo- mucous discharges, and irregularity of bowels, constipation being the prevalent but not uniform derangement. Laxatives, with which blue mass may often be combined, will be here more freely adminis- tered than during the earlier period and acute form of the disease ; and, conjointly with their administration, the hygienic means for obviating constipation, already mentioned in treating of colonic dyspepsia, should be sedulously used. They are, fortunately, of such a nature, — vegetables and fruits, — as that, while they meet the present indication, they also contribute best to remove the plethora and inflammatory condition which gave predisposition to hemorrhoids. Succeeding and alternating with laxatives we give terebinthinates and balsams, and particularly the oil of turpentine and the balsam of copaiba, and also cubebs, in doses respectively of from half a drachm to a drachm of each, in an appropriate vehicle, two or three times a day. For the turpentine a few spoonfuls of common gruel will suffice. These are well adapted to constitutions shattered by other diseases, such as gout or rheumatism, or exhausted by the conti- nuance of the hemorrhoidal flux and the irritation of the hemor- rhoidal tumours. They have been found to procure not only pre- sent relief, but sometimes exemption for a length of time from the disease : and from their diffused action on the mucous membranes generally, and also on the kidneys through the circulation, they are salutary derivatives, of whose therapeutical operation in this case we can have little or no apprehension. Their employment con- stitutes still part of the curative treatment, and harmonises with the views which I advocate in this lecture; — that we must aim at the removal of the morbid condition of the viscus or viscera, and of general or abdominal plethora, of which hemorrhoids is but a part and an effect. Even after hemorrhoids has been, as it were, established and be- come a part of the series of functional movements of the system, or returns habitually at stated intervals, and in so doing has replaced violent headache and old cough, a gastro-enteritis or duodenal hepa- titis, and might lay claim to be a salutary process, we need not be deterred from its removal if we act on the principles of true patho- logy, as enforced in preceding remarks. It is safer, assuredly, to place the patient beyond the contingency of fresh metastatic change, by which, from accidental causes, or his own impatience quickening empiricism into action, the hemorrhoids may disap- pear and the original disease be brought on with complications and renewed violence. We do this by the general and constitutional treatment already laid down ; and advance, thereby, a step farther than the existing dogma sanctions ; so that, instead of a person having the lighter and less dangerous of two diseases, he may procure ex. eruption from both. In the treatment of periodical hemorrhoids we must be governed TREATMENT OF HEMORRHOIDS. 285 by the same principles with those that guide us in periodical diseases generally, viz., — 1, to abate the violence of the paroxysm and ex- cessive determination to the suffering viscus; and, 2, so to change the state of the system during the interval as to prevent the recur- rence of the paroxysm. We are less called on to practise venesection or analogous depletion in this than in the irregular variety; although in both we shall be greatly influenced in our practice by the habit of the patient, and the more or less exhaustion caused by prior attacks of the disease. One great means of preventing an accumu- lation of blood in the rectal vessels, and the general plethora by which this is supported and foundation laid for a hemorrhage, will be to keep up a regular and frequent secretory action from the whole intestinal canal by laxatives, and a revulsive action to the skin and muscles by the tepid bath and moderate exercise. The supply of food, even of a bland kind, ought not to exceed the actual wants of the economy. If the nutritive system have suffered, or a morbid irritability induced by the length of the disease, or that of which it takes the place, tonics come into requisition ; and of these the sulphate ofquinia, as an antiperiodic,is every way entitled, between the paroxysms, to the preference. In addition to the general bath, or, whether it is used or not, ablution, with cool fresh water, of the anus, perineum, and sacrum, every morning after rising, and of sponging the part after a stool in the day, provided the body is not perspiring, will be found one of the most efficacious as it is the simplest and most readily attainable means of prevention. With some few exceptions the practice ought to be enjoined in all hemor- rhoidal subjects. Auxiliary to it is the use of a cold water enema, which, if sufficient to evacuate the bowels, at the same time that it reduces excitement of the rectal mucous membrane and hemorrhoi- dal vessels, fulfils a desirable twofold indication. I have not recom- mended this remedy in an acute attack of hemorrhoids ; for, although in some cases of excessive hemorrhage it may be necessary, yet in general, the irritation, first by the introduction of the end of a syringe or clyster-pipe, and secondly, by the distension of the rectum by the fluid introduced, more than counterbalance the good derived from it. Still more forcibly does this difficulty apply when purgative enemata are administered ; since, both by their ingredi- ents and. their bulk, they must necessarily irritate the rectum not a little. The same objection does not apply to the use of a suppository of opium or hyosciamus, or belladonna, when the pain is great during the efforts at stool. Continuing the directions for treatment during the interval between the attacks of periodical hemorrhoids, and in the main they are ap- plicable to that which elapses between the common or irregular variety of the disease, we should enjoin on the patient to avoid breath- ing hot air, being in hot rooms, seated on soft cushions, or wearing clothes which press upon the anal and perineal regions, or ligatures of any kind, which must, more or less, interfere with an equable cir- culation anddistribution of blood. Internal stimulants, such as spices, condiments, and alcoholic drinks, are likewise to be carefully eschewed; and that other more difficultly abstained from, and, if 286 DISEASES OF THE DIGESTIVE SYSTEM. possible, more pernicious excitement than intoxicating drinks, the in- dulgence in strong emotions and contending passions. So far I have treated of hemorrhoids as the eg^ct of plethora and morbid excitement, and in their progress associated with these states of the system. But it is not always thus. The sanguineous discharge, though not to any great extent, proves, by frequent repetition, en- feebling and exhausting, and brings on a state of anemia. We are in some cases apprised by these effects on the general health of the loss of blood, for'sometimes there is no preceding pain or dulness,or tumour, even to indicate the mischief to the patient himself; or from false modesty, in the case of a female, the physician is not made acquainted with the existence of the disease. Symptoms analogous to those of chlorosis are manifested under these circumstances. " The patient loses flesh,and acquires a remarkable paleness of complexion, which is afterwards exchanged for a peculiar dingy-yellow hue, like that of imperfectly bleached wax. The lips no longer possess their vermilion colour, but resemble those of a dead body ; the tongue, too, has a blanched appearance, very characteristic of the state induced by excessive or continued depletion. These symptoms are attended with great listlessness, or want of energy, both of body and mind, disturbed sleep, irritability of temper, quick pulse, and headache, which is generally increased by rising up more than by lying down. Palpitation and pain in the region of the heart, and difficulty of breathing, are also frequently induced by slight exertion or agitation of any kind." Mr. Syme,from whose workon Diseases of the Rec- tum I have taken this description of the effect of bleeding piles of long standing, then proceeds to show, in opposition to the popular, and still, as I conceive, well-grounded opinion, of the danger of check- ing a habitual discharge like that of hemorrhoids, that the disease may be stopped in cases with entire safety, " even when of the longest standing and greatest extent." He gives the case of a lady who had suffered for upwards of thirty years from hemorrhoids, which went on increasing, " until at length the bleeding, which for seven or eight years had been very profuse, so affected the general health as to excite the serious alarm of her friends. She exhibited, in an extreme degree, the peculiar aspect and other symptoms of exhaustion caused by a continued drain of blood. But very soon after the removal of the hemorrhoidal tumours, which were large and numerous, so as to encircle the aperture of the gut, she regained her strength, together with a healthy look ; and though three years have now elapsed since the operation was performed, she has not suffered any unpleasant symptoms from the sudden suppression of her complaint." Mr. Syme points out an error in diagnosis which is every now and then committed, — by mistaking the disordered function of an important organ for the cause of hemorrhoids, when in fact it is the effect. He adduces, in illustration of this caution, the case of a person who was supposed to labour under disease of the heart, and whose " waxy look, bloodless lips, and defective energy, together with irregular action of the heart, certainly afforded considerable ground for this opinion ; but Dr. Alexander discovered that there was an iiv- TREATMENT OF HEMORRHOIDS. 287 ternal hemorrhoid, which bled profusely every time the patient went to stool, and I removed it," says Mr. Syme, " with the effect of quickly restoring him to health." In cases in which anemia of this decided character is induced by the persistence of hemorrhoids, we may suppose that the sanguineous discharge, like that in other hemorrhages, particularly those called passive, in which the general system is greatly enfeebled, may be properly enough stopped. But when hemorrhoids have followed other diseases, and alternate with and when coming on relieve them, then we have not the same freedom in arresting the rectal disease by local means. It will be safer to institute a general treatment, as we would in other hemor- rhages of any great duration : and to give tonics, particularly the chalybeates, at the same time that we guard against sudden plethora, even in this case, and relieve the congested vessels of the rectum by the regular use of laxatives, into the preparation of which blue mass will enter. It is under such circumstances turpentine and balsam copaiba have been successful. Counter-irritants to the inside of the legs are also proper. In this way we may succeed in imparting the requisite lone to the system, and at the same time abate or carry off the local congestion, including the hemorrhoidal tumours, without the risk which follows extirpation of these latter, and of thus closing up entirely the sanguineous outlet. But there is still greater risk in removing by a surgical operation those hemorrhoidal tumours which do not bleed, nor are associated with hemorrhage, but which discharge mucus or sero-mucus, and which, in fact, have taken on regular secreting action,and become, in a great measure,additional and supplementary organs. They resemble old ulcers, or an issue in broken-down constitutions, the drying up of which is perilous to the individual,to whose system they have served so long as a kind of drain. Their removal by surgical means, without prior preparation of the system, and well enjoined rules of living, pre- cautions to obviate local plethora or determination by the proper revul- sives and particularly laxatives and the warm bath and pediluvia, cannot but be reprobated as empirical and hazardous, tampering with the patient's health and endangering his life. Where alarming consequences, such as apoplectic seizure, asthma, incipient phthisis, convulsions, are threatened after the removal of hemorrhoidal tu- mours, and the entire drying up of hemorrhoidal flux, attempts have been made, with more or less success, to establish an analogous con- gestion and discharge, by leeches to the anus, followed by irritating injections of turpentine, or rubbing tartar emetic ointment on the verge of the anus and the lower margin of the rectum ; a blister to the sacrum, to be kept running by some stimulating ointment; the ad.- . ministration of aloes and calomel by the mouth, and the like. The danger after surgical operations for the removal of hemorrhoidal tumours of the kind just mentioned will be greatly abated by careful attention to regimen, and particularly to a diet as little stimulating as possible consistent with the actual wants of nutrition. Mere ab- stinence from animal food will not always meet the requirements of such a case; it will be necessary to be restricted even in the quantity of farinaceous food, which, as in the instance of bread in abundance, 288 DISEASES OF THE DIGESTIVE SYSTEM. when taken with milk, will induce in some persons a morbidly full and plethoric habit, — particularly adverse to the object proposed in instituting the regimenal course. LECTURE XXXI. DR. BELL. External Hemorrhoids.—-Topical applications —washes, ointments, injections, pads to cause pressure.—Remarkable case by M. Guyot.—Reasons for enlarging on the subject of hemorrhoids.—Ulceration of the rectum —Two varieties—treat- ment of.—Prolapsus of the rectum—its peculiarities and treatment.—Stricture of the rectum.—Mistakes and malpractice respecting this disease—Stricture commonly the result of inflammation. External Hemorrhoids. — I have not pretended to lay down methodically the treatment of external hemorrhoids, and more parti- cularly of tumours, believing that if the means already indicated be adopted this will be of relatively small moment. At the same time I must add, that external applications of an astringent or repelling kind, which, when used alone, are either inefficient or injurious, may prove an auxiliary to the constitutional treatment worth attending to. In the inflammatory stage of hemorrhoids in young subjects of a san- guine temperament, after suitable depletion and the course which I have mentioned, the applications will be of simple cold or tepid water, and solutions of acetate of lead or sulphate of zinc. In the subse- quent attacks, it is customary to apply either cooling washes of this nature or astringents, decoctions, or ointments, into which galls enter and of which tannin is'the active principle. It is very important, as I think I have already recommended, that the anus should be washed with cold water after each fecal evacuation ; or with yellow soap and water, as recommended by Mr. Mayo, before the piles be returned, if they are internal. A more complete aspersion of the parts would be procured by injecting into the rectum some cold or tepid water, with, on occasions, a few grains of sulphate of zinc dissolved in it, imme- diately after each defecation. Advantage has occasionally been de- rived from pressure exerted on external hemorrhoidal tumours, and those which are permanently protruded, by means of a conical pad or piece of ivory, made to slide along a bandage or handkerchief, passed between the nates, and fastened to a cincture or belt worn round the loins, in the form of a T bandage. " The pad may be pro- vided with a concentric wire spring, the more internal coils of which rise in a conical form." Dr. Copland {op. cit.), who suggests this practice, describes, also, a means of combining the internal with the external method of imparting pressure, when the tumours are internal and protrude at stool, dragging the mucous coat with them, or when they consist chiefly of varicose veins. The instrument is that intro- duced by Mr. Mackenzie; being a metallic bougie, of an oval form with a short slender neck, and a conical base to press upon the anus externally : after being carefully introduced into the rectum, it may be attached to the bandage and worn occasionally. It must be obvious, however, that, unless the pressure be equally and uniformly TREATMENT OF EXTERNAL HEMORRHOIDS. 289 applied, it will heat and irritate the parts, and not only fail to answer the purpose, but may aggravate the disease ; and hence the necessity of making a suitable instrument, and neatly and accurately adapting it to the parts. I know not how far back the recommendation of pressure for the piles goes in English surgery; but, although men- tioned in the first French Encyclopaedia of Diderot and D'Alembert, it seems to have been forgotten by the modern French surgeons, until it was introduced anew by M. Guyot. The case that suggested its use to this gentleman, as he details it in the Archives Ginerales, De- cember, 1836, is of a very interesting nature. The subject of the disease had been plagued, for twenty-five or thirty years, with internal soft piles, which had grown as large as a turkey-egg. At first they only escaped externally by efforts at defecation ; but they finally so dilated the sphincter ani that they fell out while the patient was walking and even standing. He was forced, when in this position, to support or to push back the tumours with his hand. Every now and then, after fatigue or a spontaneous fluxionary movement, the tumours, to the number of ten or twelve, formed a lobulated ring, the surface of which became red, inflamed, and exquisitely painful, until relief was afforded by a copious hemorrhage. The patient ap- plied to his friend, the celebrated Delpech of Montpelier, for relief; but the latter dissuaded him from submitting to an operation, either by excision or by ligature, and told him that compression by a sup- pository, such as the bougie internally, would only irritate the surface of the tumour, and might bring on a cancerous condition of the part. Dupuytren and other celebrated surgeons of Paris gave him the same advice. He had mentioned to his friend, M. Guyot, that in the midst of his greatest sufferings, whenever he could support his anus, either by his hand or on being seated, he felt considerable relief; and, also, that after haying passed several days in a carriage on a journey, he could, to his great astonishment, walk more freely than before, and without the tumours coming down for some time. Acting on this information, M. Guyot prepared a T bandage of leather; the poste- rior band from the back becoming wider as it approached the os coccyx, so as to serve for a support to a cushion of soft leather well padded, which occupied the space between the coccyx, scrotum, and the two tuberosities of the ischium ; and at the scrotum divided into two slips, which, coming up by the groins,Were attached to the cir- cular bandage round the trunk above the haunches. In the middle of the cushion he sewed a hard ball, of the form of a hen's-egg cut in two, lengthways, and so fixed that the projecting or central part should correspond with the end he applied to the anus. M. Guyot, after having returned the hemorrhoidal tumours, applied this bandage, and had the satisfaction of discovering that his patient found no incon- venience whatever from it, but was able, at once, to walk with perfect ease and comfort, and ever after was exempt from hemorrhoids. Among the minor but far from unimportant precautions during a hemorrhoidal paroxysm, is for the patient to preserve the recumbent or horizontal posture, and as much as possible during defecation also, in order to diminish the chance of protrusion of the tumours. It will be desirable to resist the second call in the morning to go to stool, as vol. i.—25 290 DISEASES OF THE DIGESTIVE SYSTEM-. this is often merely owing to the irritation of the congested rectal mucous surface, or from blood in small quantity vvhich had escaped from the hemorrhoidal vessels into the rectum. If this feeling be yielded to, expulsive efforts of some force are made; and not only will the hemorrhoidal tumours, if there be any, be protruded, but there will be discharge of blood and eversion of the lower part of the gut, and often without any or very slight expulsion of feces. I have enlarged the more on the subject of hemorrhoids, because, I, it is a common, and a troublesome, and a nasty disease, and, therefore, a large number of persons are interested in its avoidance and cure; % it is associated with many other important diseases; and its cure on this account is not unattended with danger; and 3, the principles involved in its pathology and treatment are analogous to those which must guide us to correct views of hemorrhage in general, and of dis- ease maintained or induced by plethora. Ulceration op the Rectum is chiefly confined to the mucous membrane of the intestine. It is a common sequela of inflammation, as in dysentery, and as such has already been spoken of when this dis- ease was under consideration. In some cases the ulceration is purely local, and restricted to the rectum, which is kept in a state of con- stant irritation, manifested by tenesmus, frequent discharges, puru- lent or mucous, at other times fecal with mucus and pus, and some- times a tinge of blood : at first there may be some fever, but after- wards the pulse is not affected, and the skin is colder than natural, thirst not great, and appetite as usual. This is a complaint common enough to young children, in whom it will last for weeks and even months, gradually disappearing, sometimes without any, at least adequate, treatment. On occasions, we find within the rectum, at a short distance above the anus, an ulcer, unconnected with any other disease. The patient complains, says Mr. Colles {op. cit., p. 156), that he observes his linen stained with a purulent discharge, which often flows when he is not at stool; "on examination this will prove different from healthy pus, frequently containing an admixture of thin, bloody fluid ; at times the quantity of discharge is much lessened, and then the sufferings of the patient are aggravated ; but on the flowing off of a larger quantity he experiences great relief; he suffers sharp pain on going to stool, and this continues for an hour or two. On examination, the finger soon discovers the seat of the disease, which at first feels rather raised and rather rough, but by pressing the finger firmly on this spot the point sinks into a small hollow cup of an ulcer, the edges of which are found in some degree hardened. We may obtain a satisfactory view of the ulcer by pass- ing upon the finger a blunt polished gorget, the cavity of which is to look towards the seat of the disease ; then, by everting the anus as much as we can, we shall obtain a full view of the ulcer, by the light reflected from the gorget." A speculum will be found more convenient for procuring the requisite exposure of the ulcer. The treatment of ulceration of the rectum will consist in the ad- ministration of mild laxatives and enemata, alternating with the bal- sams and terebinthinates; the latter of which may be administered occasionally by injection. Topically, in this way, we use solutions PROLAPSUS OF THE RECTUM. 291 of sulphate of zinc or of copper, and, what is perhaps preferable to either, of nitrate of silver. The single ulcer described by Mr. Colles will be touched, if we can reach it, with nitrate of silver or sulphate of copper, or some stimulating ointment, as of chloride of lime, red precipitate, &c, applied to the part, and retained for a while by a dossil of lint. Spasmodic irritation of the sphincter, which some- times accompanies the ulceration, will be soothed by belladonna ointment, or lotion of the liquor of the sub-acetate of lead. In more intractable cases the remedy is in the domain of surgery, and is thus described by Mr. Colles: —"To introduce into the rectum a con- vex-edged scalpel, and make an incision through the entire length of the ulcer, continuing it through the sphincter, and dividing the verge of the anus ; as soon as this wound has got into a state of suppuration, we should dress it and the ulcer with some stimulating ointment, introduced on a dossil of lint. The cure goes on without interruption, although it is rather tedious and slow of healing. I need hardly add, that the final cicatrisation will be promoted by the occasional application of nitrate of silver." Prolai^us of the Rectum, or,as it is less accurately called,prolap- sus ani, is commonly believed to be more within the domain of sur- gery than of medicine : but its prevention and treatment in most cases depend on measures under the control of the physician, who will generally be able, with suitable care, to prevent the extreme mea- sure of an operation. The disease consists in the descent of the upper portion of the intestine, which become invaginated in the lower part and protrudes beyond the anus. " It has been main- tained by some, that the lower part of the rectum alone was con- cerned in the formation of prolapsus, the protrusion of this appa- rently fixed portion being accounted for by the relaxation of its coats. But this explanation does not agree with the anatomical structure, the phenomena observed during reduction of the protruded bowel within the sphincter, or the appearances which have pre- sented themselves in cases that terminated fatally." (Syme, op. cit.) The disease is chiefly confined to children and old persons. In the former the expulsive efforts to evacuate the bowels are often vio- lent, owing to the frequent sources of intestinal irritation, at the same time, that, owing to the lesser curvature of the sacrum and deficient resistance of the os coccygis and of the attachments of the rectum to adjoining parts, there is less resistance offered by the intestine to these inordinate strainings. Fits of crying cause also a violent con- traction of the diaphragm and abdominal muscles, and bring on, sometimes, prolapsus. In old persons, with weakness of innervation there is corresponding weakness of the muscular system, and one manifestation of this is deficient energy of the sphincter ani, often connected with similar feebleness of the pelvic viscera and lower ex- tremities. At first the prolapsed intestine is like a simple soft ring external to the anus, but after frequent expulsions and aggravation of the disease it assumes the appearance of a globular mass, several inches long, of a red colour: by pressure of the sphincter, and im- peded circulation in consequence, it becomes of a deeper and almost livid hue. When the patient has been long subject to prolapsus, 2n2 DISEASES OF THE DIGESTIVE SYSTEM. the lining membrane of the rectum to the extent of an inch or two is rendered insensible, changes its appearance from exposure and contact with external substances, and approaches in structure to the common skin. The treatment resolves itself into the means required for replacing the intestine, and those to which we should have recourse for pre- venting a return of the complaint. For the successful performance of the first, the posture of the patient is an important consideration. He should be laid horizontally on his side or back, with his pelvis raised, and the limbs bent on the pelvis, so as to remove the weight of the abdominal viscera and relax the muscles of the abdomen, which might otherwise oppose the descent of the gut. The physi- cian or surgeon "then grasps the tumour in his hand, having pre- viously lubricated its surface with oil, and gently but steadily com- pressing its neck, while at the same time he urges in the body of the swelling, gradually pushes the protruded parts within the sphinc- ter." It has seemed to me that more equable pressure is exerted on the prolapsed intestine, by the intervention of a soft and oiled napkin or even rag between the tumour and the fingers which push it gently upwards and a little backwards; or, the two thumbs may be so applied to the end and a little on each side that, by a moderate pressure upwards, and being slightly inclined also to one another, the intestine will glide upwards and come within the sphincter. " There commonly remains, however, some laxity of the integu- ments about and within the canal ; and, in order to insure that the last portions of the mucous membrane are returned within the orifice of the internal sphincter, it is advisable to apply the thumbs or the two indices to the sides of the anus, so as to press the skin inward, and then, by introducing a well-oiled finger within the rectum, we may remove any folds or irregularities that might otherwise keep the cellular tissue on the stretch, or prove a source of irritation to the rectum. When the tumour is very large, it cannot be returned by so simple a proceeding, and it becomes necessary to roll the pro- lapsed membrane towards the orifice of the intestine in the middle of the tumour by means of the fingers; thus gradually reducing the swelling by returning, first, the portions last discharged. In extreme cases this is often a task of great difficulty; and the inexperienced operator should bear in mind the fact, that the membrane may be returned within itself without entering the canal; or, in other words, that the part of the tube which escapes last may be folded within the portion which should line the lower part of the rectum without pressing the sphincter; and may thus increase the difficulty of reduc- tion, while the surgeon thinks that he is gaining ground. The efforts at reduction should never be forcible or rough ; and while the fingers are employed in involving the tube, it is often proper to keep up a moderate general pressure on the tumour with the palms of the hands." (Dr. Reynell Coates, Am. Cyclopedia of Med. and Surg., Art. Anus.) In quoting from this article I must add, that I know not where else to refer you for so full, able, and practical a description of the diseases of the anus and its vicinity, viz., neural- gia, spasm, atony, wounds,prolapsus, inflammation, blenorrhagia, STRICTURE OF THE RECTUM. 293 organic stricture, tumours and ulcers, fissures, preternatural pouches, abscess, and fistula. Where the intestine has been long protruded and is much swelled, it may be necessary to reduce its volume by leeches applied round the anus and cold applications to the tumour itself; immediately after which attempts at reduction in the manner already indicated should be made. The prevention of prolapsus will consist in an avoidance of the exciting cause, and chiefly, in children, of intestinal irritation, inclu- ding that from ascarides: the bowels should be kept in a regular state, exempt alike from constipation and purging. Astringent washes and injections, in cases of great relaxation of the parts un- accompanied by inflammation or fever, are sometimes serviceable ; but their use demands judgment. Mechanical supports, of the same nature with those already recommended for hemorrhoidal tumours, may be had recourse to, particularly when adults and old persons are the sufferers. It is in this class of subjects with prolapsus of the rectum, accompanied by relaxation of the sphincter and skin round the anus, that the operations recommended and practised by Dupuytren and Hey are found useful. By the removal of a few folds of pendulous skin at the margin of the anus, the sphincter is enabled to contract more completely, and a greater consolidation of the tissues is procured, so that adequate resistance will be offered to the descent of the rectum, or the escape of fragments of feces or portions of mucus through the anus, and one great source of irrita- tion is thereby removed. " The scissors, curved to one side, prove," says Mr. Syme, "most convenient for effecting this excision, and should be directed from the circumference towards the centre of the aperture. The folds of skin should be held tense by a hook or for- ceps, and be removed from the distance of about an inch and a half quite up to the mucous membrane, a small part of which should be included in the incision." Alteration, by injection and thickening, of the mucous membrane of the rectum, and its descent and protrusion in adults, constitute properly a variety of hemorrhoids, rather than a case of prolapsus; and demand a different mode of treatment from this latter. Hence, instead of astringents or any mechanical means of support, we should endeavour to amend the morbid state of the mucous membrane of the rectum by local depletion, mild laxatives, enemata of tepid water, and occasionally mercurial alteratives with hyosciamus. If condylo- mata, or hard, white piles, prove a cause of irritation and straining, they should be removed. Means should be taken, among the preventive measures against rectal prolapsus, for the patient to avoid straining at stool; and with this view, besides repeated injunctions to this effect, it will be proper to require him to sit upon a chair so high as to prevent his feet from reaching the ground, which will keep the trunk erect and moderate the efforts at expulsion. Care should be taken, also, to prevent him from being too long or too frequently at stool. Stricture of the Rectum is, happily, not so common a disease as bougie doctors and shallow surgeons persuade themselves, or try to 25* ' 294 DISEASES OF THE DIGESTIVE SYSTEM. persuade their patients, is the case. There are two causes of ob- struction, besides real stricture, to introducing the finger or a bougie up the rectum, which might impose on those who are ignorant of the anatomy of the intestine, but which, in fact, belong to its healthy structure. The first of these is the lacunae, and folds or valves, so well pointed out by Mr. Houston {Dublin Hosp. Rep., vol. v.), and the second, the angle made by the rectum within about the distance varying from two "to four inches of the anus, and where, from fol- lowing the curvature of the sacrum, it makes a sudden turn outward to its termination. As some inveterate bougie introducers, doubtless in ignorance, adduce these natural obstructions to the passage of the finger or bougie as really strictures, I will just repeat as much of Mr. Hous- ton's description of the healthy folds of the rectum as will be neces- sary to guard you against error yourselves or imposition on the part of others. " The valves exist equally in the young and in the aged, in the male and in the female; but in different individuals there will be found some varieties as to their number and position. Three is the average number, though sometimes four, and sometimes two are present in a marked degree. The position of the largest and most regular valve is about three inches from the anus, opposite to the base of the bladder. The fold of next most frequent existence is placed at the upper end of the rectum. The third in order occu- pies a position about midway between these ; and the fourth, or that more rarely present, is attached to the side of the gut, about one inch above the anus." The form of the valves is semilunar; in breadth, they are from half to three-quarters of an inch, extending from one-third to one-half the circumference of the gut; their structure is a duplicature of the mucous membrane with some in- termediate cellular tissue and a few muscular fibres. The relative position of the valves is such, that the one situated opposite to the base of the bladder most commonly projects from the anterior wall of the gut; the valve next above from the left; and the upper- most from the right wall. Confirmatory of this description, Mr. Colles {op. cit. Rep., vol. v., p. 141-2) points out the fact, that in some patients who are free from all symptoms of morbid condition of the rectum, the finger in ano cannot discover any canal in the gut, the entire of its calibre above the sphincter being filled up with soft folds of the lining membrane. As respects the angle and con- sequent obstruction, in some cases greater than in others, at the junction of the colon and rectum, Mr. Colles does not think that the term stricture is ever applicable to it. If to these natural or anatomical obstacles to the ready introduc- tion of the finger into the rectum be added the spasmodic constric- tion of the gut in irritable states of the intestine, when attempts at exploration are made, you will be the less surprised, though not the less pained, at the narratives of so much needless suffering inflicted on patients labouring under constipation or hemorrhoids and sometimes irritation of the. neck of the bladder, by their being subjected to the bougie practice. Mr. Colles, in the work already mentioned, p. 147—Mr. Syme {op. cit. Am. Edit., p. 35). — Dr. TREATMENT OF STRICTURE OF THE RECTUM. 295 Burne {On Habitual Constipation, Am. Edit., p. 103), give other examples of this pernicious meddling, which is severely commented on by all intelligent surgeons. Stricture is commonly the consequence of inflammation, but it is sometimes spasmodic or functional, and felt only when the patient is in a particular posture or straining. Dr. Bushe {A Treatise on Mal- formation, Injuries and Diseases of the Rectum) tells us that he has examined four cases of stricture of the rectum after death which had not caused any disease in the surrounding parts. ." In one, the lesion seemed to be confined to the muscular tunic and cellular tissue; in another, to the cellular tissue alone; and,in two, to the mucous coat and cellular tissue. The alteration of structure seemed to depend upon the deposition of lymph, which gave to the parts more or less hardness. The extent of the stricture varied from one-quarter to one inch, occupying the entire circumference of the gut, but in two cases, while in one it scarcely passed half around it." Any long continued irritation at the extremity of the intes- tine, with straining to evacuate its contents, injury by the pas- sage or lodgement of indurated feces or foreign bodies, as fruit- stones, seeds, bones, &c.; injury during parturition, as well as by common inflammation in any way produced, will be occasional causes of strictured rectum. Stricture of the rectum makes its approach slowly and insidiously ; difficulty in discharging the bowels being a common, though not a fixed symptom, until the disease is established. In its advanced stage, •a diagnostic symptom is the frequent squirting out of thin feculent matters, containing no solid matters, or only very small ones, and mixed with blood or mucus, accompanied by a sensation of cutting or burning in the rectum. " In addition to this," continues Mr. Syme, " the abdomen is distended partly by retention of its feculent contents, partly by tympanitic swelling caused by derangement of the bowels. Pain also is felt in the sacrum, extending down the limbs; and abscesses frequently form in the vicinity, so as to lay the foundation for fistula in ano." The disease is more fre_ quent in females than in males. Extreme emaciation and hectjc irritation are induced by the prolonged continuance of the disease which, after attaining a certain height, seems to remains stationary.' LECTURE XXXII. DR. BELL. Treatment of Stricture of tiik Rectum.—Spasmodic stricture—Fissures—Carci- noma of the rectum—Treatment, palliative.—Neuralgia—Preternatural pouches or sacs.—Blenorrhagia—PruYitus Jini. The treatment of stricture pf the rectum is divided into.two parts,-— the general and topical: the first, by medicines ; the second, by sur- gical means, and of these the chief is a bougie; sometimes, though rarely, the knife or bistoury to cut the stricture. These two parts ought to be carried on simultaneously, but with a leaning in favour 296 DISEASES OF THE DIGESTIVE SYSTEM. of constitutional treatment, by which the bowels are to be kept regular, and impactions of feces in the colon prevented ; the digestive function in general improved ; and absorption made active by a regulated and somewhat reduced regimen and appropriate alteratives. Of these latter we direct blue mass with hyosciamus ; cicuta ; salines to pro- cure semiliquid discharges; iodine with sarsaparilla ; arsenical solu- tion, but with great reserve, and watching its effects on the stomach. If not positively contraindicated by the feebleness of the patient, evacu- ation and derivation may be usefully practised by the application of a few leeches, from time to time, to the anus; or cups to the lower part of the sacrum, and afterwards permanent counter-irritation kept up by a small blister, tartar emetic ointment, or croton oil. The bougie, by effecting pressure, excites the absorbents to a re- moval of the effusion and morbid deposit in the cellular tissue: but if it is retained too long, or too often repeated, or of too great diameter, there will be danger of passing the point of absorbent excitement, and of irritating the parts so as to produce fresh deposit. Experience now happily proves that, instead of the bougie being required to be introduced daily and to remain in for hours, sufficient excitement is caused by the instrument being used every third or fourth day, and withdrawn in a few minutes after being passed through the stricture. Mr. Liston {Practical Surgery, p. 437, Am. Edit.) thinks, that the bougie is more conveniently retained, when it is of such a form and length as to be received entirely within the sphincter." Stricture often takes place at the upper margin of the internal sphincter, and its treatment is identical with that higher up the rectum. Rectum bougies are constructed of various materials; the best is gum-elastic. The physician or surgeon, having satisfied himself by the introduction of his finger into the rectum of the seat of the stricture, passes a bou- gie, lubricated with oil or lard, up to the obstruction, and endeavours, but without violence, to carry it past this. Failing to do so, he tries a smaller bougie, until he gets one to pass through the contracted part, and almost immediately after withdraws it. The patient is to be on his side lying in bed ; the bladder should be emplied and the rectum cleaned out previously. Mr. Colles {op. cit.) does not believe that a perfect cure of organic stricture of the rectum has been effected by any plan of treatment hitherto employed. Spasmodic Stricture of the Rectum, or, more appropriately, we ought to call it, spasmodic stricture of the anus, is usually accom- panied with much pain, and fissures and ulcerations between the folds of the anus. Tiie bowels are evacuated with difficulty and pain; which latter does not come on until after a stool, and is very severe for an hour or two; sitting is uncomfortable, unless the body rests on one hip, so as to protect the anus from pressure; there is an unpleasant sensation of fulness in the perineum, with heat in the urethra, frequent desire to make water, or oilier symptoms of irritable bladder. The anus, continues Mr. Syme, instead of presenting its ordinary conical appearance, looks flat when examined, and hardly presents any trace of the orifice, owing to the inordinate contraction of the external sphincter muscle. •' If the finger be introduced, which is not accom- plished without great pain and difficulty, every attempt to examine SPASMODIC STRICTURE OF THE RECTUM. 297 the gut causing excessive distress, not only at the time, but for hours afterwards, it feels much more strongly compressed than usual. And when the nates are held aside, so as to bring the lining membrane of the anus into view, one or more ulcerated fissures are occasionally observed between its folds." This morbid state is often associated with hemorrhoids, and not unfrequently results from constipation. The pains, as Copland very truly tells us, sometimes extend down to the feet and ankles, and even occasionally assume a neuralgic character in these or other parts of the lower extremities ; or give rise to spasm in various parts, especially in nervous and hysterical females. What- ever tends to irritate the rectum, increases the patient's sufferings. Thus, introducing the finger, or foreign bodies of any kind, within the anus; forcibly expelling indurated matters from the bowels; using stimulating articles of food or drink, and remaining long in a sitting posture, are observed to be hurtful. The treatment is here both medical and surgical. If the first be patiently and perseveringly carried out, the latter may often be dis- pensed with. With this view the bowels should be kept open by laxatives and emollient enemata. Montegre advises the ascending douche or the application in a stream, with some force, of cold water against the anus, and cold water injections. {Des Hemorroides ou Traite Analytique, eye.) In order to render the evacuations more easy, the injection should be thrown up when the patient feels an in- clination to go to stool. Careful ablution of the affected parts is to be practised; and washes of the liquor plumbi diacetatis (Goulard's extract), alternating with ointment of the extract of hyosciamus, or of belladonna or stramonium, directed to be applied to the anus; or a suppository of one of these narcotic preparations, or of opium, may be occasionally introduced into the rectum, with the effect generally of giving relief. Dr. Copland, when advising these remedies, pro- perly enjoins caution in the administration of narcotic injections, vvhich are often rapidly absorbed from the colon and rectum; he has known half a grain of belladonna in one case and thirty drops of laudanum in another produce the most serious effects. The same ob- jections do not apply to their use in ointment, pomade, or suppository. In addition to these means we have recourse to that rational altera- tive treatment recommended in case of organic stricture of the rec- tum, and vvhich, if continued for a suitable period in the present dis- ease, will carry it off, as it would ulceration with chaps and neuralgic pains in other parts of the body. Fissures of the anus are not always associated with spasmodic stricture, nor stricture of any kind, although they are frequent accompaniments of it. By Boyer they were regarded as an effect and complication of anal stricture. Of late years a very import- ant addition to our list in the treatment of this disease, has been made by the introduction of rhatany (Krameria). Its use was suggested to M. Bretonneau on apparently sound physiological principles. Constipation he regarded as the chief cause of the fissures, and of course as the great obstacle to their cure. Now, constipation is often productive of a dilatation of the rectum above the sphincter, in which the feces accumulate, and the more so the weaker and less 298 DISEASES OF THE DIGESTIVE SYSTEM. resisting the rectal coats; so that, when, at last, the patient goes to stool, and tries to relieve himself of the enormous accumulation, he suffers pains little short of those of childbearing, — in fact, more than some women experience in this act. It occurred, therefore, to M. Bretonneau, that in order to overcome obstinate constipation, whether it is accompanied by fissures or not, it is necessary to restore tone to the dilated and weakened intestine. Practising on this view he directed, in a case of constipation with fissure, an enema made of the extract of rhatany root with water, and the addition of a little alcoholic tincture of the same medicine. Success crowned his expectations; and the like results followed this treatment in other cases. Even in cases of fissure in which constipation was not present, the use of the rhatany was successful. The facts in the latter category are as clearly established as the others; but do not rest on the same physiological basis : nor can we suppose that the hypothesis which pointed originally to the practice is tenable. Since then, several French surgeons and physicians have been equally successful in the use of rhatany for the cure of fissures ; and I feel myself justified in recommending this medicine strongly to your attention in this troublesome and hitherto often unmanageable malady. The mode of employing it is thus described by MM. Trousseau and Pidoux {Traiti de Therap. et de Mat. Med., t. i., p. 115). The patient is to take every morning a mild mucilagi- nous or oleaginous enema, so as to empty the lower intestine; half an hour after this has been returned the following enema is given ; water, five or six ounces; extract of rhatany, a drachm and a quarter to three drachms ; alcohol, half a fluid drachm. The patient will try to retain this injection, and then take another of the same kind in the evening. When the pains have entirely ceased, he need take only one injection daily ; and when there is reason to believe that the cure is complete, one every other day for a fortnight. Equal success in the hands of Drs. Johnson and Biddle {Med. Exam., 184f), has attended the use of the rhatany in this country. Another remedy of an analogous nature, and of recent introduction into practice, the Monesia, has likewise been found to be an excellent curative agent for fissures, when employed in the form of enema, or of pomade to the fissures themselves. With all these resources of a medical nature, which I have stated to you, at our command, there will be less necessity for having recourse to the use of the knife, as recommended by Boyer and other surgeons, in order to cut through the sphincter, or even a part, together with the lining membrane of the anus and subjacent cellu- lar tissue, as directed by Mr. Syme. There is, however, a variety of contraction of the anus, with fissure, depending on the slow inflam- mation and condensation of the cellular tissue round the orifice, which may be the consequence sometimes of the excision of hemor- rhoidal tumours; and which requires the use of the bougie and occasionally the cutting through the indurated ring. Caustic applied to the fissure is recommended here, as it has been in the other variety, or the spasmodic stricture, already spoken of. Fistula in Ano is apt to follow stricture of the rectum, by abscess CARCINOMA OF THE RECTUM. 299 forming at the side of the contraction, opening into the bowel above, and occasionally it makes its way to the external surface also. I refer to fistula just now, in order to enjoin caution in attempting its radical cure in cases of incipient phthisis and recent insanity, or where its appearance has evidently alleviated any serious vis- ceral disease. Carcinoma of the Rectum, like all carcinomatous affections, is a harassing, painful, and seldom curable disease. It may consist either of the scirrhous tissue or encephaloid matter. Its chief seat is the subcellular tissue of the bowel, which, being converted into tumours of various size, project either externally into the muscular tissue, or internally into the canal ; and in the latter case are opposed to the progress of the matters in the intestine. The muscular coat is seldom implicated, except by distension and separation of its fibres; sometimes into so many lobuli, as it were, by the morbid cellular ramifications. It may, however, be atrophied by the increased thickness and pressure of the cellular tissue, and even disappear by absorption. The mucous membrane is sometimes intact in the midst of the cancerous tumour; sometimes it exhibits the charac- ters of a chronic inflammation, and after a while, by being ulcerated, allows the cancerous structure to be seen through it: at other times, the cancer begins with the mucous membrane, which, in consequence, becomes covered with vegetations. Whatever may be the seat of carcinoma, its termination is always in ulceration ; and by gradual extension inwardly it may, when higher up in the intestinal canal, perforate the peritoneum, or outwardly, and cause a fistulous open- ing into the intestine. Occasionally the arteries are destroyed, and hemorrhage follows, the nerves remain entire in the midst of the morbid alteration of other parts. (Andral — Cours de Pathologic Interne.) The causes of this disease are predisposing and exciting, or occa-- sional. The first is the most powerful, and depends on a particular modification of the tissues, which we can neither explain nor, when present, appreciate. Of the latter kind of causes, it is usual to cite neglected or ill-treated hemorrhoids, any strong irritation, in fact of the intestine, prolapsus recti, &c. The symptoms of carcinoma of the rectum, are pain in different regions, morbid secretions, and sometimes hemorrhage. The seat and degree of pain vary greatly: there is often only an itching or peculiar sensation like that produced by worms, but after a time this is converted into a true pain, vvhich in some persons is only felt when they are erect or long seated. It may be more or less diffused ; and it is common to find patients cease to complain of pains in the rec- tum, and refer them to the hips, sacrum, and thighs. The pain is aggravated by walking, standing, and defecation, and especially after constipation. The secretion from the rectum is sometimes white, sometimes reddish, and in some cases there is real hemor- rhage. As the disease advances, the fecal evacuations become less and less frequent. Occasionally they resemble fragments of vermi- celli, and seem to have been spun out; in other cases they are flat and ribbon-like, and have mixed with them glairy, sanious, purulent 300 DISEASES OF THE DIGESTIVE SYSTEM. and sanguinolent matters. Sometimes the feces find exit through fistulous orifices made by the cancerous ulceration, and they have been known to come from the vagina and adjoining parts. A gradual and alarming wasting of flesh and strength, and loss of all functional energy, now take place ; and this result*is accelerated if some important organ, such as the bladder, or the uterus, becomes implicated in the disease. If the cancer is very low in the rectum it may be seen exter- nally ; and if higher up in the intestine it may be felt by the finger, by which we discover, at one time, a circular ring surrounding the rectum, at another, abridged mucous membrane and agglomerated projections. The treatment of this horrible disease is merely palliative, unless the cancer be near the termination of the rectum so as to allow of its excision ; but even after the operation there will be great danger of a return of the disease. The pain will be soothed by simple enemata of tepid water, so as to keep the feces soft, and at the same time to allay rectal irritation. This will be still better accomplished by suppositories or enemata of opium, and if there be stricture, by the introduction of the extracts of belladonna or of stramonium, in a fluid form, through a canula, or a projecting terminal tube of a syringe carried past,the obstruction. Bougies have been used,but with very equivocal benefit. By the mouth, narcotics may be adminis- tered conjoined with minute doses of corrosive sublimate or arsenical solution. Washes of chloride of lime or of soda will temporarily abate the cancerous ulceration and remove offensive odours. Iodine, topically applied and administered internally, merits a trial. The hip-bath is a soothing remedy. Recumbent posture and a light yet nourishing diet are to be enjoined. Sometimes bad ulcers and vegetations at the margin of the anus have been confounded with cancer. Their cure may be brought about by mercurials internally, and suitably stimulant applications, among the best of which are nitrate of silver and sulphate of cop- per externally. Neuralgia of the rectum will occur as part of a similar disease affecting other regions, — either remote, as the face, or contiguous organs, as the neck of the bladder and the uterus. Of its associa- tion with spasmodic stricture of the rectum and anus, and fissures, I have already spoken. Where it is unattended by any organic change, we must be content to treat it as we would neuralgia in other parts ; and to find, also, our success to be, as in the latter case, very unequal. Sulphate of quinia, iron, opium, arsenic by the mouth, and belladonna topically applied, have all been used, and all have at times failed to relieve the sufferings of the patient. Some have been benefited by dilatation of the anus by bougies ; others have de- rived no benefit from the remedy. There are certain general rules, however, for our guidance in all cases of neuralgia, which are, of course, applicable to the present variety ; viz., to restore the digestive organs to a healthy state; to make a mild and abiding impression on the system by vegetable and mineral tonics — sulphate ofquinia representing the first, and some preparation of iron the second — PRETERNATURAL POUCHES, ET.C, OF THE ANUS. 3Ql associated with opium or sulphate of morphia ; a few leeches to the affected part, and vesication and counter»irritation in its vicinity or of some one of the vertebrae : in this case it might be at the junction of the last lumbar one with the sacrum. Endermic medication, by the application of morphia and belladonna to a denuded skin, might also be practised with advantage ; and likewise douches of warm or hot water from some height along the whole course of the spine. In- cision, carried through the sphincter, was found, by Dr. Bushe, to give, in one case, entire relief from pain and all the other trouble- some symptoms. If we have reason to believe that the neuralgia of the intestine is secondary to that of the bladder or uterus, or is dependent on the disease of either of these organs, we shall of course address our remedies to them primarily. • Preternatural Pouches or Cavities of the Anus deserve to be noticed in this place, in connexion particularly with neuralgia of the same part. The morbid condition of tissues constituting this disease, was first clearly pointed out by Dr. Physick. The symptoms are thus de- scribed by Dr. Reynell Coates, in the article to which I have before referred. " The patient makes little or perhaps no complaint in the interval between the stools, but more frequently he suffers a con- tinued uneasiness about the anus, which varies in character in dif- ferent individuals. Some state that the sensation is indescribable, but very uncomfortable ; others compare it to the crawling of an insect within the canal; whilst others suffer an intolerable itching, sometimes sufficiently severe to produce insomnolence and extreme distress. It is apt to be most, severe at night. One patient described the uneasiness to feel like the pressure of a ton weight upon the anus. Pain is rarely felt except after a stool, nor is it then present at every evacuation; several days may pass over and several discharges may take place without material exacerbation of the symptoms; yet at the next stool the pain may be excruciating. The exacerbation does not precede the evacuation, as it generally does in inflammatory affections of the anus; but commonly follows after an interval of a few minutes; it is most severe at its first attack, and gradually subsides and disappears in a few hours. Dr. Physick has never ob- served it to be complicated with spasm of the sphincter, as is the fissure of the anus. (See § 11.) When the finger is introduced into the anus, it perceives no well-defined tumour, and seldom any other marks of disease." p. 124, op. cit. Dr. Physick used to explore the lower part of the canal by means of a probe, with about half an inch of its extremity doubled back upon itself so as to form a kind of hook. " If the uneasiness and other symptoms are really occasioned by the presence of these cavities, a little patience and perseverance in causing the probe to advance and retreat along the canal, so as to bring the point to bear successively on various parts of its circum- ference, will render their existence and character sufficiently obvious. The reverted point passes through a small orifice, and enters a cavity or hollow space, of greater or less dimensions, situated imme- diately within or beneath the integument; and it is sometimes so low as to become prominent under the external skin around the margin of the anus. The pouch is so exquisitely sensitive, that the presence vol. i.—26 302 DISEASES OF THE DIGESTIVE SYSTEM. of the instrument gives acute suffering; and so much of its parietes as is formed by the lining membrane of the canal is diaphanous, per- mitting the silver to shine distinctly through." "The mode of operating, devised by Dr. Physick, for the relief of the complaint (one which has proved successful in every instance), consists in drawing down the membranous covering of the cavity by means of a bent probe, and then removing the whole of this por- tion, or as much of it as possible, by the scissors, taking care to in- clude the orifice by which the probe enters in the part excised. The opposite surface is thus laid completely open to the anal canal." Attention to the state of the bowels is requisite as in other cases of rectal irritation. I have the more wjjlingly introduced a description of this disease and the minor surgery by which it is cured, from my knowledge of the real sufferings of the patients who are afflicted with it, and of the shade which for a while rests on the tact and diagnostic skill of the medical attendant who does not appreciate the real cause of the distress. With a very little attention to the case, and the commonest dexterity in the use of an instrument, a practitioner in any section of the country is competent to the treatment of the preternatural pouches or cavities of the anus ; and hence, he need not send his patient to be placed under the care of city surgeons or other professional celebrities. Blcnorrhagia.ox mucous and muco-purulent discharges from the anus, sometimes are met with as resulting from the application of gonorrhoeal matter to the anus, and on occasions without any specific cause. In the former case the inflammation runs high, and demands recourse to vigorous antiphlogistic measures, and cooling washes to the part. After this, the balsams, or the confectiopiperis nigri (Ward's paste), will be prescribed with salutary effect, — followed by or alter- nating with injections of acetate of lead, sulphate of zinc or nitrate of silver, in solution. Common mucous discharge, although a fre- quent attendant on piles, is not necessarily so, as it may be occa- sioned by ascarides or other irritating cause. The expulsion of these worms when they are present will be the first step ; and should the discharge continue or arise from common irritation of the mucous glands, the balsams and local applications, as just advised in the other variety of the disease, will then come advantageously into use. If, again, this discharge be the direct sequence of inflammation of the anus, appropriate measures must be taken for the removal of this morbid state before we attempt to employ any remedy simply for the blenorrhagia. Pruritus Ani. — Itching of the anus proceeds from various causes: in children and young persons, it is induced by ascarides ; in older subjects by erythematic and pruriginous eruption, secretions from the glands of the anus, and a deranged state of the intestines. According to our knowledge of the cause will be the remedies which we prescribe. Ascarides will be removed by aloetic and turpen- tine enemata, and by calomel followed by castor oil and turpentine. If costiveness and a depraved state of the bowels prevail, these are to be corrected by appropriate treatment. The most troublesome variety of pruritus ani is that dependent on cutaneous eruption, COLIC. 303 either centred here, or alternating with a similar disease on other parts of the skin. The treatment ought to be rational in all cases —due attention being paid to placing the digestive functions in order, regulating the diet of the patient by substituting one of vegetable and milk for animal food ; or, if this latter is still allow- able, to discard spices and condiments, and all made dishes and stimulating drinks, among which, in the present case, we must in- clude coffee. The local remedies will be tepid ablution and emol- lient fomentations. After these measures, vvhich will often of them- selves suffice for a removal of the disease, we may, if it still persist, have recourse to the various alteratives, mercurial, antimonial, saline, sulphurous, or iodinic,—in alternation or combination ; and also occasionally drinks of vegetable decoctions, which experience has ascertained to be serviceable in the eruption affecting other parts of the cutaneous surface. At/this period of the treatment some astringent and stimulating applications may be of service; such as infusion of oak-bark or of nut-galls, creosote, and an oint- ment or a solution of nitrate of silver : a good purpose will be answered by running a pencil of nitrate of silver lightly over the affected skin. LECTURE XXXIIL DR. BELL. Colic—Its chief divisions—Community of causes, and of many symptoms and other pathological features of these varieties—Inference to guide us in the treat- ment.__Simple Colic—Its seat and diagnostic symptoms—Varieties of simple col'lc—Treatment—Preliminary inquiries to be made—Remedies according to the cause of colic—from cold, indigestible matters, or stercoraceous accumula- tions — Carminatives — Enemata — Purgatives —Venesection—Cupping— Lini- ments of narcotic substances—Oil of turpentine—Croton oil.—Infantile colic— Two varieties of—the stercoraceous and that from indigestible matters—Modi- fications of treatment in consequence—Importance of attention to the diet and health of the mother—Danger from habit of giving opium to children—Periodical infantile colic. In making colic the subject of the present lecture, I wish, in advance, to apprise you, that under this head I place simple or common colic, including the nervous, flatulent, and stercoraceous; bilious colic; colic of Madrid, or dry bellyache ; ileus, and painters' colic, or colica pictonum. As Dr. Stokes has treated of the last, it remains for me to say something of the other kinds of colic. They all have this much in common, — that there is great exaltation of intestinal sen- sibility, with violent and unequal contraction and dilatation of por- tions of the intestinal canal, — pent up flatus, and its occasional explosive discharge ; constipation, and the occasional occurrence of inflammation. Indigestible matters, or other irritants to the digestive canal, combined with sudden chill and suppression of perspiration, will suffice to bring on cases of all the kinds of colic, even a return of the coliea pictonum, or lead colic, although this last must be traced to the deleterious operation of lead in the first instance. By habituating yourselves to this general picture and community of symptoms and causes, you will the more readily appreciate the pro- 304 DISEASES OF THE DIGESTIVE SYSTEM. priety of a general sameness of treatment, without, however, deter- minately avoiding some specialties called for by certain peculiarities of the case, —as in lead colic. That which we ought to guard against is, making some of the traits of the disease pass for the entire picture, and some of the remedies frequently employed constitute the whole of the curative treatment. Thus, in common flatulent colic, we give often and with advantage, carminatives, and fear little from inflammation; but there are cases in which the phlogosis is going on insidiously without any other premonition than this flatu- lency : and of course carminatives being exciters are injurious. In bilious colic, the discharge of bile and emptying the intestines will often suffice for the relief of the patient ; but perilous will be our mistake, if we always rely on vomiting or purging, or even make them the chief end of our therapeutical measures. In lead colic itself, in which the nervous system is poisoned, we must not rely on antidotes or means purely directed to neutralise the poison, to the ex- clusion of remedies adapted to common inflammation. Spasm, or unequal and violent contraction and dilatation of the muscular coat of the intestines, in which, in most of the kinds of colic, the volun- tary muscles also participate, generally requires at once opium in full doses to allay the morbid excitement of the nerves on which the irregular muscular action depends. But this will only be a step towards a cure, if crude matters remain in the stomach or compacted feces in the great intestine, or morbid secretions and chymous re- sidue choke up the duodenum, or inflammation has seized some portion of the intestinal canal. Simple Colic, — The origin of the word colic, from k&».gv, implies the belief entertained by the ancient writers of the seat of the dis- ease. At the present time we give a much more extended or rather diversified location to colic ; but I should still be inclined so far to respect the opinion of antiquity, as to believe that colic of all kinds is, at one stage or another of its duration, marked by the evolution and irregular escape of flatus, and that this chiefly comes from the colon. I know that air is extricated in the process of digestion in all parts of the digestive canal, and that every now and then such evolution taking place in the stomach is a source of much disturb- ance and pain before it is expelled. But, extrication of gas, the pro- duct of secretion, I regard as one of the diagnostic symptoms of colic, most evident in the simple kind, but met with, more or less, in all; nor can I believe it to be merely the air commonly present in the gastro-intestinal cavity, and retained by more or less weak- ness and distension of the muscular coat in parts of the cavity. With some writers pain and the morbid state of the nerves supplying the intestines on which it depends, are regarded as the chief character- istics of colic, and hence they designate it as an enteralgia. But this, it seems to me, is quite too restricted a view, as is it hat other which would make it consist in a lesion of contractility. To a cer- tain extent both these errors are committed by M. Andral in his In- ternal Pathology {op. cit.), where, under the head of Order I, Neuroses of the Digestive Tube characterised by a Lesion of Contractility, he introduces the second species, or that in the intestines, and its VARIETIES OF COLIC. 305 genera as equivalent to so many colics, including, in the fourth genus, ileus itself: and under Order II, or Neuroses marked by a Lesion of Sensibility, he places, after gastralgia and various ente- ralgias, including the saturnine colic, or colica pictonum, colic from copper, the colic of Madrid, vegetable colic, and nervous colic. Were I to define colic, I should say, that it is a disease of some portion of the gastro-intestinal canal, in which there is morbid sen- sibility and contractility with morbid secretion, commonly that of air; and manifested by acute pain, rolling and twisting, alternating with flatulent distension and spasmodic contractions of the bowels, and often of the abdominal muscles ; with sometimes vomiting, and almost always constipation. The locomotive muscles are sometimes con- tracted painfully and irregularly at the same time. In simple colic, the chief but not the sole derangement is nervous, the result of morbid excitement of some part of this system by any gross irritant, viz., food in the stomach, and sometimes in the small intestine ; in which last the hepatic and pancreatic secretions are now and then additional irritants ; and feces and remains of ingesta unchanged in the colon. An unaccustomed stimulus will sometimes alone bring on colic in a healthy person, as when it follows the taking of unripe fruit, crude vegetables, and certain meats : but when the disease recurs frequently and after slight exciting causes, we must suppose that a predisposition is induced, as by cold and wet feet, or obstructed perspiration, dete- riorated state of the digestive organs by the use of ardent spirits, wines or mixed acescent liquors ; in females by the period of men- struation, &c. I have said that the chief but not the sole derangement in simple colic is that of some part of the nervous system ; but, as already in- timated, I consider the disease to be something more than mere en- teralgia. You will see a patient with the latter disease suffering often acutely, but without spasm and the extrication or escape of flatus, which occur in colic. Not only then is there a lesion in the nerves of sensation and motion, but likewise of secretion, in this latter disease. Still, the predominance of the nervous element and the absence generally of inflammation in colic, are evinced in the circum- stance of pressure being not only tolerated but almost instinctively sought for by the patient; and this is a peculiarity which distin- guishes this disease, as indeed it also does enteralgia, from gastro- enteritis and enteritis. Another diagnostic sign is the little change in the pulse, as regards frequency ; whereas in enteritis it is greatly accelerated. The varieties of common colic laid down by some writers, — viz., the nervous, the flatulent, and the spasmodic, are neither useful nor instructive ; for every colic is nervous, and flatulent, and spasmodic, if these terms are intended to apply to the systems — the intestinal, nervous, and muscular — vvhich are affected, or to the symptoms. But if by nervous we mean to designate the temperament, as well as some of the exciting causes, and the symptoms in remote organs manifesting disorder of innervation, less objection can be found to the useof the word. In females,and in persons leading a studious or seden- tary life and whose temperament is nervous or irritable, and habit of 26* 306 DISEASES OF THE DIGESTIVE SYSTEM. bowels costive, a slight error in regimen, exposure to cold, and often very strong mental emotion, will bring on an attack of colic; in which, besides pain, spasm, borborygmi, and escape of flatus up- wards or downwards, and sometimes both ways, there is a pale and anxious expression of the face, cold sweat, and a sinking and loss of strength almost to fainting away. Colic has been subdivided into numerous varieties, according to its presumed obvious and material exciting cause ; and in this way we read of the colica cibaria, c. constipata, c. constricliva of Good, and colique vegetate of Chomel and other French writers. A knowledge of the immediate cause will be useful to us in treating the disease, but will hardly justify our swelling the nosological catalogue, in con- sequence, by new names. Of the propriety of the term bilious colic I shall soon take occasion to speak. Treatment. — When called to a case of colic our diagnosis should be as complete as possible. First, we are to ascertain whether it is merely symptomatic of disease of some other organ than the gastro- intestinal canal; sometimes inflamed kidney, distended bladder, irri- tated or impregnated uterus, or congested liver, will give rise to colic. Second, we are to inquire, particularly if there is vomiting and intense and continued pain and the constipation has been of long duration, into the previous history of the patient, or whether he has had hernia ; and failing to be satisfied on this head, we should make the requisite examination at the abdominal ring, and in the inguinal and umbilical regions. Thirdly, we are to learn whether any offending substance of an alimentary or other nature has been swallowed for some hours preceding the attack. Fourthly, what cause, either in exposure to cold and moisture, use of alcoholic and acid drinks, menstrual period, or depressing passions, may have predisposed to an attack of the disease. Finally, we ought, by care- ful observation of all the symptoms and palpation of the abdomen, to try and determine the particular part of the intestinal canal which suffers most, and in which there may be an obstruction by feces or other matter impacted in the intestine. In slighter cases of colic, some aromatic water, as of mint, pepper- mint, ginger, cinnamon, dill, &c.,a few drops of essential oil of these and kindred plants on sugar, forming an aeleo-saccharum, or an essence made by solution of the oils in alcohol, will often suffice to give relief, by discharging flatus and equalizing the action of the muscular coat of the intestine. Persistent pain and spasm with a cold skin will require from twenty to thirty and even sixty drops of laudanum, with a little sugar and water, or combined with some aromatic. In nervous and hysterical subjects, infusion of valerian, mixture of assafcetida, oil of turpentine, and some of the balsams, are indicated. Enemata of a similar nature are sometimes called for, where the distress through flatus in the lower bowels is considerable, especially if con- stipation have preceded the attack. The effect of all these substances will be increased by warm bodies, as of hot bricks, bottles filled with hot water, &c, applied to the feet and legs, warm flannel to the abdomen, or, preferably to all of these, immersion in a warm bath to the very limit of a hot one, or at 98° Fahrenheit, for half an hour. STERCORACEOUS COLIC. 307 Colic from indigestible or indigested food, accompanied with pain at the stomach and nausea or slight inclination to vomit, will be be- nefited by evacuating this viscus of its contents. The patient should be encouraged to drink freely of tepid vvater, or salt and vvater; or ten to fifteen grains of ipecacuanha may be administered in a little water. I very early in my medical noviciate learned a lesson touch- ing the value of an emetic in colica cibaria, as Dr. Good would call it. The case Was of a stout butcher, to whom, in the absence of my preceptor, I was required to administer relief. I gave him essence of peppermint, and mint tea, and hartshorn and laudanum, in succession, but without any notable mitigation of his disease, until, happily, owing either to the irritation from the admixture of my medicines, or to that from the offending food which he had eaten a few hours before dinner, he vomited up the latter. The conse- quence of this evacuation was immediate and entire relief. In colic from excessive repletion, or from substances not readily changed in the stomach, but which irritate the nerves of the mucous coat of the whole digestive canal in their passage downwards, after pain in the upper bowels and efforts to vomit there succeed colic in the large intestine and purging, by vvhich the offending cause is more or less completely carried away and the disease removed. It will generally be prudent, however, after an attack of this nature, to administer a laxative, such as castor oil with some carminative, or rhubarb and magnesia with a few grains of ginger; its operation to be aided by diluents — barley or rice water, or gruel and the like. When the stomach is irritable or the taste very fastidious, a calomel pill of ten grains, followed by magnesia or a Seidlitz powder, or cold infusion of senna, will be preferred to the castor oil or rhubarb. Stercoraceous Colic — In other cases, the sustaining if not ac- tually exciting cause of colic is in the colon, and consists of hardened feces, or sometimes of intestinal concretions. We have at this time a collection of symptoms, some of which are indicative of a parox- ysm of atonic colonic dyspepsia, others manifesting a state of things very analogous to stercoral inflammation of the caecum, — described in former lectures (pp. 242, 261). In some tolerably thin subjects we can assure ourselves of the direct cause of this malady by feel- ing the indurated matter in the colon, particularly at its arch and in each iliac region, through the abdominal integuments. In this va- riety of colic there is less distension of the bowels and irregular puffiness in any part of the abdomen; and the pain, which is refer- able to the colon and between the iliac region and the umbilicus, is more fixed than in the flatulent colic. More complaint is made of pain in one of the kidneys and of the scanty discharge of urine, which is high coloured and sometimes quite offensive. The stomach is irritable at intervals, and occasionally vomiting of green matter is met with ; the pulse is not increased in frequency, sometimes it is slower than natural, but at the same time rather full, and often quite hard and resisting; the tongue is white and moist. The indication of cure in this variety of colic is — 1, to procure the evacuation of the impacted feces; and, 2, to prevent their undue accumulation. But the means are not as simple nor as easy of oper- 308 DISEASES OF THE DIGESTIVE SYSTEM. ation as this announcement might seem to imply. Often we have to combat more than mere atony or enfeebled contractility of the intestinal muscles, one evidence of which, Dr. Abercrombie thinks, is the undue dilatation of some part or parts of the canal. Were this all, we need only to give purgatives, with a view to stimulate the bowels to increased contraction in order to enable them to expel their contents; but there is not unfrequently associated with the con- stipation and distension from flatus a spasmodic contraction of parts of the canal, vvhich requires other remedies. Of these the chief ones are bloodletting, more generally from the arm, sometimes by cups or leeches to the iliac or other region of the abdomen, and opium. If the stomach tolerates the medicine we may properly begin the treatment of stercoraceous colic with the administration of castor oil, given with some aromatic water, and its operation to be quick- ened and aided by common purgative enemata, such as infusion of salts and senna, or castor oil mixed with gruel and melasses. Much flatus and distension being present, an assafcetida mixture, or, in less quantity, the tincture, will be added advantageously to the pur- gative enema. An active combination for this purpose is castor oil, Bii.; oil of turpentine, |ss.; gruel or flaxseed mucilage, one pint; tincture of assafcetida, two drachms ; or mixture of this medi- cine, 3i. Sometimes, after the rectum is evacuated, we are unsuc- cessful in procuring the farther discharge of feces, owing to a spas- modic stricture at the lower part of the colon, or at its sigmoid flexure, by which the passage downwards "of wind and feces, and upwards from the rectum of enemata, are alike prevented. In such a case it will be necessary to have recourse to the expedients already mentioned, when I spoke of enemata in csecal accumulations (Lect. XXIV, p. 239) and of the treatment of csecitis (p. 261), particularly in reference to the introduction of an elastic tube beyond the con- stricted part of the colon, in order to allow of the escape of pent-up gas, as well as of the introduction of enemata from a syringe at- tached to the tube. A measure of this kind is still more called for if the obstruction and colic be caused by strangulated intestine, as in hernia. You will find in the page to which I have just directed your attention, one passage that requires some explana- tion and qualifying remarks. It is that in which, after recom- mending leeching of the part, tartar emetic by the mouth and per anum, I add, "and finally, if need be, enemata of tobacco, as used for hernia, and as successfully employed by Dr. O'Bierne in dysen- tery." The question of the property of employing tobacco in this disease is too important to be dismissed thus briefly. In favour of the practice we have, it is true, the opinion of very judicious practition- ers ; but on the other hand, the proofs of its alarming and, every now and then, fatal effects, are loo clearly on record to allow of our regarding it in the light of other means of treatment — as one to be employed or withheld at pleasure. In all the forms and stages of ileus, which is but a higher grade of colic, Dr. Abercrombie speaks of the tobacco-injection as the remedy which, as far as his observation extends, it is of most general utility. He adds, imme- diately after; it should be given, at first, with much caution, — per- STERCORACEOUS COLIC. 309 haps not more than fifteen grains, infused for ten minutes in six ounces of boiling water; after the interval of an hour, if no effect has been produced, it may be repeated in the quantity of twenty grains, and so on, until such effects are produced, in slight giddiness and muscular relaxation, as show that its peculiar action is taking place upon the system. It may then be repeated at intervals of one or two hours, a great many times, if the case do not speedily yield; and, with the precautions now mentioned, I have never seen any unpleasant effect from a free use of this powerful remedy." Even the cautious and skeptical Heberden speaks without drawback of the curative powers of the injection of tobacco smoke and tobacco infusion in ileus; but, on the other hand, both in surgical and medi- cal practice, we have many cases on record in which speedy death was the result of the administration of this powerful medicine as an enema. 1 shall recur to this point when the subject of ileus is before us. Resuming my sketch of the treatment of stercoraceous colic, I have to direct your attention to a state of things of very probable, I may say common, occurrence, not adequately dwelt on by writers and practitioners. It is the gradual coming on of the constipation and morbid state of the intestinal canal, of vvhich this is often a symptom merely, or one of the effects ; and the strong probability of inflammation, not very acute, indeed, but still quite decided, having been established before the patient was laid up in bed and had sent for the doctor. The more immediate and pressing uneasiness with the sick man himself is costiveness, with its concomitants, heat and fuU ness of the part, and some flatulence ; and tq its removal he directs himself with domestic prescriptions. These being found ineffectual, the physician is sent for, who, not seldom, too readily adopts the erroneous pathology, and with it the purgative practice of his patient; and persists in administering purges, one after another, or in combination, and enemata of the same nature. Mere spas- modic colic with fecal accumulations will every now and then be removed by these means ; but if, as I have just intimated, there be inflammation, we ought to lose no time, after the initial and pro- bationary steps of giving some purgative medicine by the mouth and per anum have been tried without effect, to draw blood from the arm, even though the pulse be not frequent and the pain of the abdomen be inconsiderable. After venesection, calomel, in a dose of ten grains with one grain of opium or four or five of hyosciamus extract, may be given, and the patient made to take a table-spoonful, every half hour, of a solution of one ounce of sulphate of magnesia in four ounces of water. The passage of fla- tus downwards and per anum indicate that the bowels are about to yield and to discharge the matters accumulated in them, and at the same time the propriety of giving an enema, either simple or pur- gative. But if, in twelve hours after venesection, the bowels are not moved; if the pain and restlessness return, or the stomach is nau- seated, or bilious and other matters are ejected from it; and, also if the pulse is hard, even though of its common frequency, and there is thirst, we must not hesitate to draw blood again from the arm ; 310 DISEASES OF THE DIGESTIVE SYSTEM. or, at any rate, to apply cups to the lumbar region of each side, or leeches over the abdomen—around the umbilicus, and in the course of the great arch of the colon and the iliac regions. Making now the discharge of feces an affair of secondary moment, we con- tinue to keep up the relaxation which was began by the bleeding, and which alone will sometimes be followed by a stool. For this purpose we direct tartar emetic with opium in small and frequently repeated doses, or hydrocyanic acid ; calomel with hyosciamus every hour ; fomentations to the abdomen and warm vvater enema ; — in fine, all the measures which have been already pointed out for the cure of caBcitis, including even liniments of belladonna rubbed on the abdomen, and a suppository of this medicine. Relaxation of the bowels induced in this way will be evidenced by easy fecal evacu- ations, and may be received at the same time as evidence of the abatement, perhaps removal, of the disease, and not, as before, of one of its symptoms. If purgatives are still required, we can, with safety, have recourse to castor oil and oil of turpentine, in the pro- portion of an ounce of the first and half an ounce of the second, mixed with gruel or with some mucilage, and flavoured with oil of cinnamon or peppermint. Occasionally one drop to two drops of croton oil, mixed with crumb of bread in the form of pills, or with syrup of gum arabic, will answer, in cases of very sluggish bowels in lymphatic temperaments, or where we have no apprehensions about inflammation. If the state of the stomach prohibits the ad- ministration by the mouth of purgatives, they may be introduced into the rectum, as heretofore advised. It should be borne in mind, that, after the colon has been once unloaded of its accu- mulated contents, subsequent motions of the bowels are best pro- cured by mild or laxative medicines and compounds, in which sulphur merits a leading place. Infantile colic is sometimes of the stercoraceous variety ; but more frequently it depends on morbid secretions from the liver and bowels, and on imperfect change which the food undergoes from its want of adaptation to the digestive sensibility. Of the first kind is the colic of new-born infants, or when the viscid meconium adheres to the colon, and is not evacuated. Castor oil warmed,and in doses of half a drachm to a drachm, and in more obstinate cases of retention with the addition of five dropsof oil of turpentine, will generally suffice to give relief in a case of this nature. Doctor Dewees {On the Phy- sical and Medical Treatment of Children) details a case of disease, which, by the way, was not colic, caused by retention of the meco- nium, and in which the common laxatives, castor oil and magnesia, failed to operate. He succeeded at last by the administration of a grain of the carbonate of soda, dissolved in a teaspoonful of lukewarm water, every fifteen minutes, until ten grains were taken. Another modification of stercoraceous colic is met with in infants who are habitually constipated, and whose appetite and growth are both vigor- ous. Purgatives,as is soon discovered,are not the remedy in thiscase. We must be content to palliate until, with time and some natural change in the functions, the bad habit is changed. Laxative enemata of the simple kind, or occasionally a little castor oil, or spiced syrup INFANTILE COLIC. 311 of rhubarb, or manna dissolved in its food, as sweetening, if the child uses spoon-victuals, will generally suffice. A suppository of soap is occasionally useful. I have sometimes given from a quarter to half a grain or a grain of calomel with a little magnesia ; but of course not frequently, still less habitually, in every case. This prescrip- tion is called for when colic proceeds from deficient secretion of bile, as in jaundice. In this disease, as it attacks new-born infants, I have had occasion to be much pleased with the oil of turpentine, in doses of from ten to twenty drops, with a teaspoonful of castor or sweet oil, repeated at an interval of twenty-four or forty-eight hours. It is, also, one of the best medicines for infantile colic with constipa- tion. Simple syrup, with a little of some essential oil, answers well at times, as follows : — Simple syrup, one pint; oil of rue, 8 to 10 drops. Mix. Dose, one to two teaspoonfuls. In the other, and still more common, colic of children, depending on indigestion, our attention must be first directed to the health of the mother. In her, bad digestion or other derangement of health, kept up sometimes by gross and improper food, drinking tea and coffee to excess and malt liquors; sometimes by want of air and exercise, and late hours; and again, by indulgence in strong emotions, or by any cause which irritates the nervous system, must we seek an explanation of the depraved nature of her milk, and, consequently, of colic and other forms of indigestion of the infant. Dr. Dewees {op. cit.) relates a case of serious and alarming disease of a child, beginning with colic and running on to vomiting and diarrhcea with great emaciation, which was produced by the altered quality of its mother's milk, owing to severe and protracted toothache. To the child itself suffering from colic, a few grains of carbonate of magnesia, with some simple car- minative,— mint, or peppermint water, or camphor mixture, or a grain of subcarbonate of potassa, or two or three drops of liquor potassa? in a similar fluid, with sugar, — will often give relief, without interfering with the peristaltic actions of the bowels, or impairing the digestive energy, as all cordials and mixtures into which opium enters are so apt to do. Calamus aromaticus, in powder, with chalk or magnesia, answers a similar intention. In some extreme cases of suffering, a drop or two of laudanum will give the desired relief; but never ought the physician to prescribe it regularly, or to allow of its regular use in the nursery. He can hardly be too emphatic in his cautions against the dangers of the practice of habitual laudanum or opium-taking in child or adult. In some cases, infantile colic recurs so regularly at particular times in twenty-four hours as to force attention to periodicitv, and to suggest its being treated accordingly. I have, in cases of this nature, given the sulphate of quinia in a dose of twelfth to an eighth of a gram in sokuion, with the effect of greatly mitigating the violence of the attack, and sometimes of warding it off entirelv. One may however, reasonably suspect, that this periodical colic is sometimes owing to the recurrence of an external exciting cause, as in the quality of the mother's milk at a particular time in the twentv-four hours, rather than to an internal organic condition of the nervous system which generally gives rise to periodicity. In confirmation 312 DISEASES OF THE DIGESTIVE SYSTEM. of this, I may state one of my boarding-school reminiscences. A boy, whose digestive organs were never very strong, used to have regularly every Monday afternoon an attack of colic; not very severe, it is true, but quite troublesome and well marked in all its symptoms. The cause of this weekly return of disease was almost forced on his attention, after a while, by its uniformly following a dinner on cold beef, which was the regular dish of meat for Monday. Many a dyspeptic, who thinks that his sufferings are entailed on him, of necessity, for life, would discover, by a little retrospection of his diet during" the preceding twenty-four hours, that these are avoidable; and that if he were to omit some article of the cold-beef class, he would escape his special ailment. Before dismissing the treatment of infantile colic, let me enjoin attention to the feet of the child being carefully covered with warm socks and shoes, which ought occasionally in the day to be taken off, and the feet well rubbed by the warm hands of its mother or nurse before the fire, or over a flue of hot air. The early use of a tepid salt water bath, to be followed by careful friction over the abdomen and the lower limbs, will prove to be a useful preventive of colic, as well as corroborant of the system generally. LECTURE XXXIV. DR. BELL. Bilious Colic—Time of its attacks—Causes and Symptoms—Anatomical lesions— Treatment—Venesection—Opiates—The warm bath or fomentations—Purgatives —Enemata—Means of acting on the bowels—Calomel—Caution against too early excitement of any kind—Recourse at times again to bloodletting—Dover's pow- der—Blisters—Practice by others—Sydenham's directions—Emetics sometimes used.—Dry Bellyache—Analogous to bilious colic—Does not arise from lead— Common formerly in the West Indies and in America—Description by Hillary— Paralysis of limbs—Metastasis.—Colic of Madrid—Closely resembles the pre- ceding—Causes of—Symptoms—Anatomical lesions—Devonshire colic—Causes. — Vegetable colic, similar to the preceding—Treatment of this kind of colic, in- cluding the preceding varieties. Bilious Colic — The extension which I have given to my remarks on the subject of common colic and its varieties, by enabling me to notice some of the chief points of the pathology and of the therapeu- tical treatment of colic in general, will free me from the necessity of an elaborate account of bilious colic, the dangerous character of which entitles it, however, to a careful study. First, as respects the name: although, certainly, it is not a proper pathological one, we can hardly see any harm now in retaining it, provided we no longer believe that the disease proceeds either from a deficiency or redun- dancy of bile. Our scruples on this point will be abated, if not over- come, by knowing that the title of bilious colic has the sanction of Sydenham, whose outlines of its treatment are those which, in the main, have proved to be the most accurately drawn. Bilious colic, as far as my own observations extend, is a disease much more frequently met with in the country than in cities: at least TREATMENT OF BILIOUS COLIC. 313 I saw more cases of it when a student in Virginia than I have since met with either in private or public (Dispensary) practice in Phila- delphia. Bilious colic makes its attacks in the great heats of summer, and is a precursor, on the score of time, as it is sometimes more immediately in the same person, of bilious fever. Some are more predisposed to the disease, so as to be much more readily affected than others by its occasional or exciting causes:—These are excess in the quantity, and error in the quality of the food; free potations of spirituous or acescent liquors; cold drinks, as of ice water or milk, especially if the stomach has been weakened by indulgence in the use of strong liquors; hard labour, or excessive exercise of any kind in a hot sun, and subsequent exposure to the cool damp air of night, either by sleeping in the open air or under open windows indoors. A little difference, hardly appreciable, in the constitution of two indi- viduals, and perhaps in the quality of the articles eaten at supper, will cause in the one bilious colic, in the other cholera morbus. Symptoms.—Bilious colic is sometimes preceded by indigestion and slight febrile action : but, often, it comes on suddenly in the night or at an early hour in the morning without other premonition than a slight chill. The symptoms are — irritability of the stomach, and occa- sionally vomiting of bilious matter; pain in different parts of the in- testinal canal and distension by flatus; cramp of the abdominal mus- cles, which is soon participated in by the muscles of the limbs, espe- cially the lower ones; coldness of the surface, particularly of the hands and feet. After a short time, the skin of the abdomen is hot, the face is flushed, and there is some throbbing of the temporal arte- ries ; the pulse, at first small or not materially changed, is now fre- quent, hard, and voluminous ; the tongue is loaded and of a yellowish colour. To these succeeds an expression of anxiety and suffer- ing displayed in the face: the complexion is altered from its natural colour to a dingy-yellow hue, — partially relieved, in the stage of febrile reaction, by a blush on the cheeks. The bowels are almost universally in a constipated state, — a symptom this, diagnostic of the disease from cholera morbus. Sometimes the vomiting is carried so far as to constitute the iliac passion. Numbness and tremors of the upper extremities are occasional symptoms. The anatomical lesions manifested in the bodies of those who have sunk under bilious colic are, chiefly, inflammation and inflammatory congestion of various parts of the small intestine, particularly of the duodenum and the ileum, and similar though less marked alterations in the stomach, and morbid accumulation of blood in the liver. If we connect these appearances with the symptoms sketched above, we can have no hesitation in regarding bilious colic as a true gastro- enteritis, with the occasional complication of hepatic disorder. Treatment. — The treatment of bilious colic with which I became early familiar, is the best adapted, if we except the too free use of purgatives, to the chief exigencies of most cases of the disease. It consists in venesection, from sixteen to twenty-four ounces, the ad- ministration of sixty to a hundred drops of laudanum, or three or four grains of opium, if the stomach was irritable, immersion in the warm bath, or, in its stead, fomentations over the abdomen of cloths squeezed vol. 1.—27 314 DISEASES OF THE DIGESTIVE SYSTEM. out of hot vinegar and water, and sinapisms to the legs and arms. Relief commonly procured by these means is rendered more abiding by large purgative enemata/as of an infusion of senna with salts, castor oil with turpentine and assafcetida, repeated until the bowels are freely evacuated, and at any rate until fecal matter ceases to be discharged. The recurrence of pain will be met by simple enemata of warm water, or by those of fluid in small bulk with which thirty to forty drops of laudanum have been mixed. Having by this active treatment procured a respite from suffering, and a remission, in part, of the disease, the next point to be deter- mined is how far and by what means the bowels should be acted on with a view to their complete evacuation. In the same school in which I was initiated into the early treatment of bilious colic I was taught the advantages of a full dose, say twelve to fifteen grains, of calomel at this time,—either alone, or if the stomach was still irri- table, combined with two or three grains of opium. More commonly this prescription was made with a view to its administration preceding nearly all other remedies by the mouth ; and in place of the laudanum or opium, as before recommended, I now prefer the simple course,— viz., to obtain a cessation of all the symptoms by the treatment which I have laid down, and then to give a calomel pill in the dose just in- dicated. In prescribing this medicine at this time and in this dose, I bear in mind, and indeed participate, in the strong dislike which the Broussais school entertain to drastic or irritating purges in gastro- enteritis. But I do not think that in my practice I am inconsistent with my theory. I believe calomel to be, when judiciously timed in its administration, one of the best remedies we have against phleg- masia of the digestive canal; at the same time it must be acknow- ledged that I am more persuaded of the fact than ready with an ade- quate explanation. The calomel now given, in its passage down- wards, exerts a kindly operation on the duodenum and the ileum, and by its impression on the former being transmitted to the liver it acts on this latter organ, which is, in consequence, relieved from its tem- porary congestion, and secretes bile. The large intestine, obedient to the double stimulation of the bile brought to it from above and of the calomel, now discharges freely its contents, together with those which have been passed down from the small intestines; and entire relief, manifested often in a tranquil sleep, is soon after enjoyed by the patient. It may be, that the calomel is slow in its operation, or that, although it is the first and often the best medicine to tranquilize an irritable stomach, it now, just at the time of its passage through the ileo-csecal valve, causes sympathetic nausea and sickness. In either case we give moderately stimulating enemata — often tepid water with some common salt dissolved in it will answer — and re- peated until there be free evacuations. In desiring free evacuations in colic in all its varieties, I am not influenced merely by the con- sideration of removing irritating matter from the bowels, and dimi- nishing excitement by the discharges from the mucous surface, but also by that of being assured that the regular peristaltic action is re- established in the entire course of the digestive canal. At this juncture, when the violence of the attack has subsided, the TREATMENT OF BILIOUS COLIC. 315 practitioner must be on the alert, in order to ascertain, very positively, whether his patient is now clear of disease, and only requires rest and simple farinaceous diet for his restoration, or is merely in a state of remission. If the latter, he will expect to find the pulse somewhat hard, or slightly corded and frequent, and the abdomen still tender ; not that diffused tenderness which any muscular part will evince after violent exertion, normal or spasmodic, but circum- scribed in some portion, as the iliac region, or round the umbilicus. The tongue at the same time is dry and furred, and the thirst con- siderable. This is a critical period in the disease. If recourse be had now to drastic purgatives, or, from mistaken notions about de- bility, to tonics, the inflammation of the intestine will be aggravated, the distress of the stomach increased, and the disease terminate ra- pidly and fatally. Equally to be dreaded is the ingestion of animal broths or stimulating drinks, sometimes allowed under the idea that the first remission is the actual beginning of convalescence. I have seen the disease terminate fatally after an imprudence of this nature. Should there be doubt about the real state of the digestive canal, the safer plan will be to abstain for a day or two from active medication, and certainly from animal food or diffusible stimuli, under which head I include vinous and distilled liquors, until the characteristic symptoms, one way or another, are more fully developed. But if the symptoms, as indicated at the beginning of these remarks, are present, we should have recourse to the use of leeches, or, if there be not too great ten- derness of abdomen, to cups applied on the iliac regions. Circum- stances preventing recourse to either of these means of local abstrac- tion of blood, we ought to endeavour to attain our end by venesection in small quantities, viz., six ounces at a time ; watching the effect, and repeating in twelve hours the operation, if the pain and tender- ness of a portion of the abdomen corresponding with the intestines beneath seem to call for the measure. During this time we should abstain from irritating the bowels, either by active purging or by strong enemata. Tepid water thrown up the rectum will answer every purpose in procuring regular evacuations. Antimonials with opium, or Dover's powder, given at intervals of two or three hours throughout the twenty-four, contribute to remove the inflammation and to abate febrile action. Revulsion, by blisters over the abdomen or to the lower limbs, and warm pediluvia, may next be used with advantage. Having sketched the course of treatment in bilious colic which my own experience induces me to believe correct, I will add some par- ticulars of the practice of others in the disease. If I refer first to that of Sydenham, it is that I may express the obligation which I, in com- mon with all others whose mode of treating the disease resembles that just described, owe to this great man's precepts on this head. He began with freely bleeding from the arm, and in three or four hours administered an opiate. The next day he directed some lenient purgative, and ordered it to be repeated a second time, at a day's in- terval, and sometimes a third time, "according as the remains of the humour seemed to be more or less in quantity." This phraseology, of the humour, at the present time, seems to us to be misplaced. Is that of 'depraved secretions' very different, or more philosophical? 316 DISEASES OF THE DIGESTIVE SYSTEM. In case the stomach were oppressed " with a surfeit of fruit, or with any other kind of aliment of difficult digestion," his first prescription was free dilution, followed by vomiting, afier vvhich he gave an opiate, and on the following day opened a vein and purged,as just described. Some exceptions will be taken to his advice, in a more violent form of the disease, to give strong purgatives when the milder do not ope- rate. This error is, however, redeemed by his subsequent remark; that where, either through the weakness of the stomach or from the vomiting, purgative pills cannot be retained, he prescribes an opiate and in a few hours after a purgative. But because a purge always increases the pain in this and most other diseases where opiates are indicated, at least when the operation is over, the patient sometimes finding relief whilst it works, Sydenham generally gave an opiate immediately after the operation of the purgative, and ordered it to be repeated daily, morning and evening, on the intermediate days be- tween those in which purgatives were administered. When the affair of purging is over, he endeavoured "to check the violent motion of the humours, which is all that now remains to be done," by exhibiting an opiate every morning and evening. Sometimes, when the case demands it, omitting both bleeding and purging, he recommends the cure to be begun with opiates; as where the patient had been sub- jected, by reason of some preceding illness, to large evacuations, or was in a state of indirect debility from the excessive use of wine or any spirituous liquor. A tendency to recurrence of bilious colic, which, by the way, is quite common, is, according to Sydenham, destroyed by the patient using much exercise on horseback — a remedy which he extols as very successful in most chronic diseases. Emetics have been freely employed by different practitioners since Sydenham's time, and, as may be inferred from the accounts on the subject, with benefit. The stomach is evacuated, by an emetic, of irritating ingesta, vvhich, despite the retching and vomiting that are often part of the disease, would otherwise remain for some time the source of continued distress ; the liver is made to discharge more freely its bile, which finds its exit not only upwards by the stomach, but passes downwards, and may be supposed to contribute to a relief of the lower bowels, by either purging itself off, or rendering the enemata easier in their operation. But, in addition to these commonly cited advantages alleged to follow the'administration of an emetic, there is another and more important one yet which would incline me to this remedy: it is the general relaxation of the capillary system and diminution of vascular excitement. In order to procure this result, a selection should be made of that article the action of which is not limited to the stomach, but vvhich is diffused through both the bloodvessel and nervous systems. I refer, of course, to tartar emetic. Administered in solution in moderate doses, at short intervals, at the outset of the disease, and preceding all other remedies, where the phlogosis and excitement are not thought to be sufficiently great to require the lancet, this medicine not only procures the desired evacuations, and acts as a revulsive by this means, but also, if its use be continued in small doses at longer intervals, it displays its custom- DRY BELLYACHE, 317 ary counterstimulant or sedative power. In colica pictonum, which bears so close a resemblance to the disease in question, I have given the tartar emetic in this way with unequivocally good effect. If the spasm of the abdominal muscles and limbs should continue after the vomiting induced by the emetic, although in general we shall find it abated by this remedy, we may then add to the antimonial prepara- tion small doses of opium, and continue the combination until the spasm is removed, and the skin becomes soft and moist and the pulse has lost its hardness and frequency. The bowels during this time should be acted on by enemata, the operation of which will be easier after the relaxation caused by the antimony. But if free fecal evacu- ations cannot be procured in this way, and if after the operation of the emetic the stomach is still irritable, we then direct calomel in pill, or mixed with a little gum arabic in powder, and either wait or quicken its action in the manner already described — by laxatives and enemata. I have said nothing respecting the effervescing draughts and the prescriptions in common use for sick stomach, because they are for the most part either inefficient or injurious. This organ is best tranquilized by rest from all kinds of stimuli — and by the use of the simpler bland or demulcent drinks in very small quantities at a time; by revulsion, by means of leeches to the epigastrium ; afterwards by stimulating liniments or sinapisms to the same part and also to the extremities, and enemata to evacuate the large intestines; and by opium, administered sometimes by the mouth, sometimes by the rectum. Costiveness, on occasions, continues in bilious colic in despite of the means hitherto recommended for its removal. Much can, I know, be done to prevent this morbid state by the judicious selection and persistent use of enemata, one of the chief conditions for their effica- cious operation being the large quantity of the fluid and the frequency of repetition. By some, tartar emetic in solution has been recom- mended : others lay stress on the relief procured by the administra- tion of calomel in doses of one or two grains repeated every two hours, and after the lapse of a day, sometimes two days, to follow up this course with the use of laxatives, if the stomach will allow of their ingestion. I have seen this last treatment successful, although, at the cost, sometimes of salivation. Relapses will readily occur unless proper care be exercised by the convalescent to protect his skin, and above all his feet, against dampness and cold ; to avoid indigestible or doubtful food, parti- cularly of an evening ; and to keep his bowels regular. If the disease should have made its attack in the latier part of the summer, or the individual is exposed, subsequently, in his vocation to a damp atmo- sphere or raw weather, he will find his advantage in the use of sul- phate of quinia combined with aloes, in pills, in^such a manner that three to five grains of the former and three of the latter may be taken every morning before breakfast. Dry Bellyache.— The disease designated variously as dry belly- ache, Madrid colic, the colic of Poilou, Devonshire colic, and vegetable colic, is analogous to our bilious colic. For a longtime attributed to the 21* 318 DISEASES OF THE DIGESTIVE SYSTEM. action of lead, to the acid wines, or cider, or ihe spirits drank by the inhabitants, or to milk used in too great abundance, and other errors of regimen, it is now admitted generally to be induced by great atmosphe- rical vicissitudes, the operation of vvhich is favoured by improper food, and probably some causes of an endemial nature which cannot be well appreciated. Hillary {Observations on the Changes of Air and the concomitant Epidemical Diseases in the Island of Barbadoes, &c. With Notes, by Benjamin Rush, M.D.) speaks of the class of persons most subject to dry bellyache, and especially those who live in America and the West Indies, in vvhich countries it seems to be endemial. At times it assumed an obviously inflammatory type (p. 34), being, as Dr. Rush tells us in a note, complicated with bilious colic. It was, as we learn from the last mentioned distinguished writer in another note (p. 134), "a common disease in Philadelphia between the years 1760 and 1770. Its rare occurrence [now] has been ascribed to the disuse of punch, and of late and heavy suppers; to the general use of flannel next the skin, and to the abolition of porches, vvhich afforded a temptation to our citizens to expose them- selves for several hours, in a state of inactivity, to the damp evening air." The causes of dry bellyache implied in this sentence, are pre- cisely those which I have described as giving rise to bilious colic. But in the absence generally of inflammation and fever, in the fre- quently protracted duration of the former disease, and the liability, when it does not end fatally, to cause paralysis of the limbs, we find differences between it and bilious colic. " This state of costiveness, pain, and misery," says Hillary, " has continued for twenty or thirty days, and sometimes longer ; for I remember a case vvhich, being thus treated in a wrong manner, ihe patient continued, with some small intervals of being something easier, in this painful condition for six months, or more, and then recovered by a different method of treat- ment in one week's time." The following is a well-drawn picture of the progress of the disease, and especially that part vvhich portrays the transmission of irritation from the viscera to the spinal marrow, and its subsequent irradiation to the limbs, followed by deficient innervation and palsy. The passage would be particularly pleasing to Dr. Marshall Hall, as illustrative of his doctrine of reflex-function of a portion of the nervous system. " When the sick fall into the hands of those who treat them in this wrong manner, the pain con- tinues to be very violent, and at times almost intolerable, and that for a longtime; and then the patient's breath commonly acquires a strong, fetid, stercoraceous smell like excrement, from a long retention of feces, and an absorption of the putrid effluvia from them into the lacteals, by the strong convulsive contractions of the guts ; and when the pain in the bowels has continued long, and at last beg'ms'to abate, a pain in the shoulder-joints and adjoining muscles comes on, with an unusual sensation and tingling along the spinal marrow; which soon afterwards extends itself from thence to the nerves of the arms and legs, and they become weak, and their weakness increases till those extreme parts become paralytic, with a total loss of motion, though a benumbed sensation often remains." The author next adverts to the occasional metastasis from the bowels to the brain, COLIC OF MADRID. 319 producing stupor and delirium, which are succeeded by strong con- vulsions terminating often in death; also, to the sudden transfer from the limbs, which were paralytic, to the bowels or head. The colic of Madrid {entripado, conslipado) closely resembles, in all essential particulars, if it is not entirely identical with, the colic, or dry bellyache of the West Indies. Our knowledge of it has been rendered much more precise, of late times, by the writings of several French medical men, whose residence in Spain with the armies gave them ample opportunities of observation. That the disease does not depend on causes purely local, nor on acid wines, nor on water running through leaden pipes, in Madrid, is proved by the fact of its being common in other parts of Spain, as in Galicia to the north, and Valencia in the south-east. The cause most operative is said to be the sudden mutations of temperature, which are more fre- quently met with in the table-land of ihe Castilles than elsewhere. To great heat by day succeeds coldness of the night; and even a transition from the sun to the shade produces often a feeling of exces- sive coldness. The scanty clothing of the labouring classes and the poor, and their often imperfect protection from the night air during sleep,.give greater effect to these atmospherical 'enormities.' Baron Larrcy supposes the Madrid colic to proceed from this cause and acid drinks, and designates it by the title of rheumatic bilious colic. M. Marquand, during eight months' tour of duty at the hospital of St. James of Compostella, in which there were never less, at one time, than forty or fifty men attacked with this disease, had ample opportunities to study it. He was, moreover, himself a sufferer from an attack ; and hence was well qualified to describe its symptoms and course. At first there were dull but transient pains throughout the whole course of the colon, but more particularly at its transverse portion. In other respects the functions were very little affected : but after a time there followed uneasiness; want of appetite; difficult defecalion, but not constipation; frequent passages in the day, but in small quantity, and accompanied with a discharge of flatus. The patient sutlers less in bed than when up. At the expiration of two or three days more, there is no longer any desire to evacuate the bowels, nor any flatulency; but the gastric symptoms which, hitherto, had not been manifested, now appeared in full force. We next notice pain in the epigastric region; the face pale, and with a sad expres- sion; pulse small, slow, and contracted, but yet regular; urine in small quantity, though natural; skin dry, yet not hot. The patient is ofien seated, leaning forward, with his arms clasped on his abdomen, vvhich he compresses. If he is in bed, his lower extremities are flexed on his trunk. Hiccup and vomiting now supervene; and afterwards there is rejection of the fluid drank, mixed with glairy and yellow bilious matters in small quantity. No sleep, no rest, no suitable posture is allowed to the unhappy patient. If these symptoms con- tinue, the abdomen more frequently becomes flat; pain is begun to be fell commonly in the right hypochondrium, sometimes in the umbilicus, but without any diminution of the epigastric distress. The sclerotica becomes yellow, and after a while the whole body. The disease is aggravated; and death sometimes terminates the series of sufferings 320 DISEASES OF THE DIGESTIVE SYSTEM. above described. It is sometimes preceded by marasmus, sometimes by partial palsy. This disease often has sudden remissions, promising complete convalescence. In addition to these symptoms, Dr. Pascal notes ischuria or dvsuria, and paralysis of both the upper and lower limbs. This writer {Recherch. Anal. Pathol, sur la Colique dite de Madrid) gives, as the result of six autopsic examinations of persons dead of the colic, his opinion, that the disease has its seat in the ganglionic nervous system, which is in a state of either acute or chronic inflammation. In five of the subjects examined he found the thoracic and abdominal ganglia more or less enlarged in size, and of a red colour, studded in the middle with yellowish spots, and some of the ganglia were even of a cartilaginous hardness. M. U. Coste {Mem. sur la Colique de Madrid) is opposed to this opinion; and believes that the disease is caused by an inflammatory irritation of the muscular coat of ihe intestines, particularly of the colon. In this sketch of the Madrid colic, I have followed MM. Chomel and Blache in the Diet, de Medicine, &c, 2me edition. The Devonshire colic and that of Poitou need not be described, ex- hibiting as they do phenomena identical with those just detailed. In connection with the etiology of this disease, the remarks of Dr. Chis- holm are worthy of notice {A Manual of the Climate and Diseases of the Tropical Countries, fyc). The colica pictonum, or dry belly- ache, constitutes, he tells us, one of the most remarkable proofs of intemperance being a principal cause of disease within the tropics. He refers to a work by Dr. Philip Fermin {Traile des Maladies a Surinam), who says, that neither tongue nor pen can describe the horrors of this disease, called by the natives Beillac, or the work of the devil. The common causes, according to Dr. Fermin, are, excessive debauch, the immoderate use of strong drinks, and pass- ing the night abroad in a climate like that of Surinam, in which the nocturnal coolness produces a strong impression because fol- lowing a day of excessive heat. Dr. Chisholm relates, that five and thirty years before the time of his writing (in 1822), when he first settled in the West Indies, colica pictonum was very com- mon, and often most afflictive and fatal.. "At that time excessive abuse of wine, spirits, and malt liquors, was generally practised by all ranks of society; but, more especially among the lower whites, spirits were the principal drink, because easily procured—either raw or slightly diluted." Since then a reform in the mode of living has been followed by a diminution in the frequency of ap- pearance of dry bellyache, until at the present time it is quite a rare disease. " Alternation of heat and cold, doubtless, may have contributed; but that the poison of lead had any share in its produc- tion, within the tropics at least, there is no just ground for believ- ing." In Devonshire, continues Dr. Chisholm, where the disease may be said to be endemic, no lead is employed in the cider-presses or cisterns ; and yet there is every reason to be assured that it is the excessive abuse of this liquor, and the peculiar harshness and acidity of it, which may be considered as the principal cause of its preva- lence in that country. The operation of this cause was thus ex- plained to him on the spot. " In the summer and autumn, when TREATMENT OF DRY BELLYACHE. 321 the husbandmen are laboriously employed in the hay and corn- harvest, the common practices of these men is to drink cider to the extent of their ability to buy, or rather, as it is allowed with- out limitation in hay-harvest, to the extent of the capacity of their stomachs to contain it. The labour at this season produces an in- tolerable heat in their persons. Now the great cold of the cider, together with its harshness and acidity acting against the heat pro- duced by labour, give rise to a spasmodic state of the bowels, vvhich, acquiring its acmi in twenty-four hours, or even less time, in very many instances terminated in death. These labourers are so very inconsiderate, that to allay the excessive heat and thirst occasioned by their work and the great heat of the season, they often drink to the extent of six or eight quarts of cider in the day ; and, not unfre- quently, such is their avidity and the uncomfortable state of their feelings, fill their stomach at one draught. In neither Devonshire nor Gloucestershire is lead used in lining the cistern which receives the liquor from the press." Huxham had long ago attributed the Devonshire colic to the abuse of cider and apples, as Cotys did the colic of Poitou to white wine. Vegetable colic is one of the titles which I stated to you has been be- stowed on the disease of which I am now treating. It is a compre- hensive one; and, although probably not significative of the cause, it is less misleading than some others which would imply a saturnine origin. It is essentially the colic of Madrid, that of Poitou, and of Devonshire, and of the West Indies. At French Guiana this dis- ease prevails ; but it cannot be attributed, in the opinion of M. Segoud, who spent some time at Cayenne, to acerb fruits, nor to the quality of the wines which are drunk, for the former are rare and Utile eaten, and of the latter Bordeaux is the only kind used. It is ihen to atmo- spherical vicissitudes that we must refer the cause of this colic. Thierry and Lepecq de la Cloture held similar opinions. Treatment of Dry Bellyache, Colic of Madrid, or Vegetable Colic. — There is a tolerable unanimity of opinion respecting the suitable practice in this disease, whether it appears in the West Indies, and is designated by the name of dry bellyache ; in Spain, by that of the colic of Madrid ; in England, as Devonshire colic ; in France, as that of Poitou or vegetable colic. The indications are, to calm irritation and spasm by opiates, and to remove feculent obstructions, and restore the secretions by purgatives. With the first view opium is adminis- tered, in doses of a grain every three or four hours, until relief is ob- tained; or an equivalent quantity of laudanum vviih a little mucilage is thrown into the rectum, and repeated, until the same effect is pro- cured. In full plethoric habits, in those of a sanguine temperament, or when the diseases of the season wear an inflammatory type, vene- section, or scarifying cups, over ihe loins and on each side of the spine, will aid, not a little, in the solution of the spasm, and increase the susceptibility to the impression of the medicines to be afterwards given, — whether these be opiates or purgatives. Sometimes the relief is so considerable after bloodletting that opium may be dispensed with, and we proceed at once to purge as we would do in case we had given opium first. Here, as in bilious colic, a full dose of calo- 322 DISEASES OF THE DIGESTIVE SYSTEM. mel will operate more kindly on the bowels, and allay the irritability of the stomach better than any other class of purgatives, — certainly better than any of the drastic variety. It will either follow opium or be combined with it. Dr. Musgrave, a writer of authority on the West India colic, or dry bellyache, recommends, after the first and larger dose of calomel of fifteen grains, smaller ones of five grains combined with a common cathartic. His intention is to evacuate the bowels and to affect the system with mercury. The Spanish physicians are partial to castor oil "in the Madrid colic ; and it may generally be had recourse to at the very outset, combined with laudanum and some aromatic water and sugar; or after calomel, and in a very torpid state of the alimentary canal: when these fail to operate we should give it with oil of turpentine, as so pointedly recommended in other varieties of the disease, both by the mouth and per anum. Of the purgative clysters, one of the simplest is, common salt, an ounce, in a pint of water, is also one of the best. Calomel and rhubarb was the favourite purge of Dr. John Hunter {Observations onlhe Diseases of the Army in Jamaica, &c). He remarks, sensibly enough, on the subject of perseverance in the use of purgatives; " that whatever pur- gative was employed, regard was not had to the common dose, which would not have been strong enough ; but it was repeated from time to time, either till it disagreed with the stomach, or till it operated." For the removal of pain, vvhich is abated by the warm bath and fomentations, Dr. Hunter, in common with many other practitioners, recommends a large blister applied to that part of the abdomen where the pain is greatest; " it was further of great use in promoting the operation of the purgative; for, in general, it was observed, that soon afier the pain became easier free evacu- ations followed." It was long ago a practice among the French physicians to give an antimonial emetic in the dry bellyache, as it still is in the Madrid or vegetable colic at the present time. An emetic is at times an efficient remedy; it evacuates the stomach of irritating matters, which were not sufficiently ejected by previous efforts to vomit; it allays internal spasm, and by urging the bile into the in- testine from the ductus choledochus, it favours the evacuation of the bowels; at any rate predisposes them to be more readily acted on by purgatives. A soluble state of the bowels and freedom from spasm will be maintained by mild laxatives conjoined with the simple bitters, extract of gentian and the like, or sulphate of quinia. A preventive measure of paramount consideration is to wear flannel next the skin, and to secure as much as possible an equable temperature for this organ. This advice is applicable to all the varieties of colic. Paralysis is the most troublesome, and, at the same time, quite a common^ sequence of the disease now under consideration. Acting on the hint furnished by Hillary, in his description of the order in which parts are affected before the limbs are seized with paralysis, and enlightened by a better physiology than heretofore, we should use, after suitable purging, irritants to the spine and its vicinity, such as croton oil, tartar emetic ointment, or the excite- ILEUS. 323 ment of the warm douche or spout-bath — preferably to applying these means to the limbs themselves. This last practice has been followed by a metastasis to the bowels and renewal of all the urgent symptoms. At times, if the habit be full or decided symptoms of irritation be manifested at particular spots between the vertebra?, a few leeches, or cups to draw blood from these parts, will properly precede the employment of the other local means. As an agent of power over the muscular system, strychnia might be used with bene- fit in this stage of vegetable or West India colic, as it is in the similar one of painters' colic. LECTURE XXXV. DR. BELL. Ileus—Affinity between ileu3 and colic—Symptoms of ileus — Causes—Anato- mical characters—Volvulus, or intussusception,—Invagination of intestine—How formed ; its varieties and termination—Diagnosis of intus-snsception—Treat- ment—Preliminary inquiry into the existence of hernia—Localization of intus- susception—For this last, bloodletting, opium and tartar emetic, and enemata— Venesection generally called for in ileus—Blisters—Turpentine epithem—Dry cupping—Purgatives—Stimulants in last stage—Other remedies—cold—tobacco injection—Other narcotics externally and internally—Injections of linseed oil— Crude mercury in quantity—Operation of gastrotomy—its doubtful propriety and dangerous consequences. To a certain extent embarrassed by the nosological divisions of colic, and the ideas still entertained by some of there being several kinds of the disease, I have not been as free as I could wish to present the whole subject in a condensed shape. Early, however, in my penultimate lecture, I warned you not to look for any broad line of distinction between these alleged different kinds, but really only varie- ties, of one disease; differing not so much in the organ or organs impli- cated,as in the extent of the affection. I told you, that colic, beginning as nervous or flatulent, might soon become inflammatory ; and you will have seen that, between stercoraceous colic and bilious colic the traits are hardly differential, any more than between bilious colic and vegetable colic. There is a general community of causes of them all. In all, the stomach is irritable ; often ejects yellow or bilious matter; there is pain, spasm, flatus, and constipation. Fever and inflammation, more manifest in bilious colic, are not always wanting in stercoraceous and vegetable colic, or dry belly- ache ; and venesection, so commonly necessary in the former, cannot always be dispensed with in the latter. Opium and purgatives are the chief remedies in vegetable colic; they will often suffice for the cure of stercoraceous colic, and may be mainly relied on in some cases of bilious colic. I shall now advance a step farther, and give you a description of the most aggravated form of colic disease, the highest grade of the series of morbid phenomena the beginning of vvhich was manifested in nervous or flatulent colic. This close affinity is distinctly affirmed by Dr. Abercrombie ; and I cannot belter introduce the present subject to you, than by using 324 DISEASES OF THE DIGESTIVE SYSTEM. the words of this eminent physician and pathologist in his account of ileus. Symptoms. — " Colic and ileus are different degrees of the same affection, and the name, therefore, may apply to both. The symp- toms, in the early stages, are pain of the bowels, chiefly twisting, with great severity round the umbilicus, obstinate costiveness, and generally vomiting, but without fever, and commonly at first without tenderness ; the pain, on the contrary, being rather relieved by pres- sure. As the disease advances, and if no relief be obtained, the ab- domen becomes tense, tender, and tympanitic ; the vomiting very often becomes stercoraceous, with severe tormina, intense suffering, and rapid failure of strength. In this manner, the disease may be fatal without inflammation, or, at an advanced period, it may pass into inflammation, and be fatal by extensive gangrene." {Patholo- gical and Practical Researches on Diseases of the Stomach and Intestinal Canal and Liver.) In many instances ileus supervenes on some one of the varieties of colic already described ; and hence, in addition to other considerations, the propriety of a general and enlarged view of the entire pathology of colic, and consequent vigi- lance in observing a transition from the slight to the more serious and severe. But seldom, it is true, ileus is suddenly ushered in with the most violent pains in the abdomen, and vomiting; the pa- tient tossing about in the utmost agony, and the other symptoms supervening, and the disease terminating fatally. Sydenham's notice of ileus, or the iliac passion, as it has been often termed, is very short. " In this disorder the peristaltic motion of the bowels is inverted ; cathartics and glysters soon become emetic, and the ex- crements are vomited up." His description of bilious colic is, how- ever, applicable, in its chief features, to ileus ; and Pringle complains of his having transferred that of the latter to the former. The true iliac passion, in which there is a total inversion of the peristaltic motion, is a rare disease : the author just mentioned never saw but one case, and that terminated fatally. The appearance of the tongue varies in different cases and stages of the complaint; but often it deviates little from the healthy state. Pain or local disease is not referrible, at the beginning, to any par- ticular region of the abdomen; sometimes it is felt in the ileo-csecal region ; sometimes in the sigmoid flexure, or in the transverse colon: in others, again, about the umbilicus, or low in the pubic region. I shall not repeat the enumeration of the organic changes in the intestine observed in fatal cases, which Dr. Copland has giveu in his Dictionary ; to which I refer you for these and many other par- ticulars of the disease. Dr. Abercrombie has recorded cases of fatal ileus, in which the intestines were found distended without inflam- mation : others, in which there was gangrene without exudation and also with exudation. He next adduces cases in vvhich there had been " previous disease, of such a nature that it seemed to act by deranging the muscular power without mechanical obstruction ;" and afterwards ileus, with mechanical obstruction or other organic changes in the structure of the parts ; one example of vvhich was presented in a remarkable stricture of the arch of the colon. Tym- VOLVULUS OR INTUS-SUSCEPTION. 325 panites is sometimes associated with ileus, and is always of bad augury. The causes of ileus are very various ; generally they are the same as those of colic and enteritis, with the addition of other depending on mechanical obstruction. Pringle thinks that children and those who are delicate, are, perhaps, more liable to it than men in the vigour of life. It is, I think, more frequently met with in cholera infantum than in any other one disease induced by causes not act- ing primarily by obstructing the bowels. Pringle mentions two cases in vvhich it preceded a fit of the gout. Anatomical Characters. — The observations of Dr. Abercrombie and others leave no doubt that there is a remarkable variety in the morbid appearances in those cases which are usually included under the term ileus: sometimes it is simple distension without any change of struciure, and at other times extensive inflammation and gangrene. Obstruction, which is not an unfrequent cause, is, in other cases, not to be found. "It would, therefore, appear probable," says Dr. Abercrombie, " that, in the cases which assume the characters of ileus, there js great diversity in the primary state of the affected parts ; that, in some, it consists of simple loss of muscular power, though it may pass into inflammation at an advanced period ; while, in others, it is at an early period connected with inflammation as a part of the primary disease." When, in ileus, we find gangrene uncombined with any other morbid appearance, we are, perhaps, Dr. A. thinks, warranted to conjecture that the muscular coat has been the principal seat of the inflammation. As respects the precise part of the intestine diseased in ileus,— the morbidly distended, or the contracted,— Dr. Abercrombie thinks it most probable that "the distended part is the real seat of the dis ease, and that the contracted part is nut contracted by spasm, but is merely collapsed, because it is empty, — its muscular action being unimpaired." Still repeating the language of Dr. Copland on this head, — spasmodic constriction evidently exists ; for, independently of the occasional detection afier death of a more contracted state of a part of the bowel than can be considered natural, we cannot ex- plain various phenomena connecied with colic and volvulus without its aid. Besides, continues Dr. C, its existence is supported by ana- logical evidence ; for it is a principle in the human economy, that all membranous, and, d, fortiori, all muscular canals, contract spasmo- dically or inordinately upon irritation of their internal surfaces. Volvulus or ileus from intus-snspection, invagination of the in tcstine, is not unfrequenily met with in post-mortem examinations. At one time great and undue importance was attached to this change which was supposed to explain and be a cause of the fatal termina- tion of the disease. More careful observation, however, shows, not only that intestinal invagination is ofien unconnected with inflam- mation, but that it is an accidental and not necessarily fatal conse- quence of pre-existing disease ; and even if it takes place some time before deaih it does not present thai obstruction to the passage down- wards of the contents of the bowels and of medicines vvhich was thought formerly to be one of itsinevitable effects. The readiness with vol. i.—23 326 DISEASES OF THE DIGESTIVE SYSTEM. which invaginations are removed by the restoration of the intestine to its normal situation, in the dead body, and the frequency with which they are seen after deaths from acute gastro-enteritis, render it pro- bable that these displacements have occurred and been removed by a natural retraction of the intestine, in those who have recovered from ileus and other diseases, in which strong intestinal commotion has been experienced. The ileum and jejunum are the portions of intestine most frequently implicated by invagination, which may take place from above downwards, or in a contrary direction ; that is to say, sometimes it is the upper portion of the intestine which descends or falls into the lower and dilated portion ; and at other times the upper is the recipient or hood, as it were, of the lower portion. The first variety, however, is the most common ; but it is not unusual to meet with both it and the second in the same subject; and even, sometimes, to see a particular part of the intestine, more dilated than the rest, receive a portion from above and another from below, so that the two varieties of invagination, in different direc- tions, meet at the same point. In the extent of intus-susception there is great latitude; in some cases it is only a few lines, in others as many inches. The whole ileum, and even a part of the jejunum, has been found contained in the caecum and ascending colon ; and we are told of a case in which the caecum and the first part of the colon, filled by the small intestine, themselves occupied the lower part of the colon and rectum. In regular invaginations, the mucous membrane of the dilated or containing portion is in contact with similar membrane of the nar- rower or contained portion above : so, likewise, between the two por- tions on the other, or peritoneal side, the serous surface is also in con- tact with its like. The invagination exhibits, therefore, three thick- nesses of the intestinal parietes, viz., the central or entering portion, the external or containing and the intermediate one, continuous from the first to the second. If we open with a bistoury the external portion, we see in its cavity a sort of cone or nipple, of more or less length, free in all directions, and exhibiting on its surface valvulas connivenles, while at its summit or projecting termination there is an opening vvhich gives passage to intestinal matters : the disposition of parts is, in fine, precisely like that which is seen in prolapsus of the intestine through the opening in artificial anus. I have thought that this description of invaginated intestine, the accuracy of vvhich is easily tested by observation on the body after a case of death from ileus, and for which I am indebted to M. Begin {Diet, de Med. et de Chir. Prat.), would not be without interest and instruction, by serv- ing to correct common misconceptions as to the real nature and effects of this displacement. The occasional causes of intus-susception are worms,inflammatory action of some one of the intestinal surfaces, and as a consequence of dysentery and chronic diarrhcea, particularly the dysentery of warm climates, in the subjects dead from which latter Mr. Annes- ley has frequently found it. Dr. Copland has met with it '« not unfre- quently" in fatal cases of the brain or its membranes in children. One of the most common causes of invagination of the intestine is, VOLVULUS OR INTUS-SUSCEPTION. 037 as the same author justly remarks, the inappropriate use of drastic purgatives. In all the cases of invagination observed after death from dysentery that Dr. Copland has perused, purgatives has been unsparingly and unnecessarily exhibited. He cites a case which oc- curred to M. J. Cloquet, wherein a female died of enteritis occasioned by a polypous excrescence arising from the mucous surface, and which having been pushed onwards by the peristaltic action of the intestine dragged the part to which it was attached along with it. Among the occasional causes may be likewise mentioned costive- ness, which acts by producing local irritation followed by dilatation. The termination of volvulus or invagination is by a restoration of the displaced intestine to its normal state, and removal of the disease; in death without inflammation ; or, finally, in death with, and we may believe on account of, inflammation, and that commonly of the peritoneal coat. It is of this last mode of termination that I shall speak. I mentioned, when describing the changes in the re- lation of the portions of the intestine vvhich constitute invagination, that two parts of the surface of the serous membrane are in appo- sition on one side, as two parts of mucous surface are in similar con- tiguity on the other side. Now, as long as there is no change on these surfaces by inflammation, they are capable of gliding readily on each other; and the subsidence of morbid dilatation in the con- taining part of the intestine, and equalised muscular power in its coats, will enable the displaced part to resume its natural position. But if the serous membrane is the seat of inflammation and throws out coagulable lymph, this will, after a while, become a bond of union between the two surfaces, and they will adhere permanently, or at least so long that the function of the intestine is perverted, and peri- tonitis destroys the patient. The readiness with which a morbid change of this nature is brought about, is much greater when the intestine is invaginated by the protruded or containing portion coming from below. The contents of the intestinal canal, on arriving at the invaginated portion, are suddenly arrested in their passage down- wards by the base of the projecting cone of invaginated intestine, ac- cumulate at the angle made by the turn of the mucous membrane upwards, and, by compressing the base and sides of the cone, con- tribute not a little almost to obliterate the opening at its summit, which was at the best small, and which was the only passage for the transmission of the matters from the upper portion of the intestine. Thus there is established an obstruction equivalent almost to stran- gulation of the intestine, and the life of ihe patient is in imminent danger. Should the invagination be slight, the pressure of the con- tents of the intestine from above against the base of the invagi- nated cone may help to remove it, and things then take their natural course. If, on the other hand, the invaginated portion be from above and project downwards into the cavity of the intestine, the danger is much less. The descending contents, it is true, on reaching the in- vaginated portion, come to a narrower canal than natural, and are somewhat retarded in their course ; but they pass through an open- ing vvhich corresponds with the base of the cone, and escape from its 328 DISEASES OF THE DIGESTIVE SYSTEM. projecting, though narrow mouth, with much more facility than they could have found entrance into it, if it had projected upwards or had been the end of an invagination from below upwards. Even if the parts become adherent, the duplicated or rather triplicate walls of the canal at the invaginated section, become merged into one, which gradually dilates more and more and offers slight resistance to the passage of the intestinal contents. • Even in the worst or upward form of invagination, already de- scribed, unexpected relief by a natural process has been procured. The internal part of the invagination, or the protruded section of the intestine on which the contents of ihe upper portion of the diges- tive tube are continually pressing, becomes gangrened and sepa- rates, but not until adhesions are ready to be formed at the outer base of the invaginated fold, which preserve the continuity of the entire tube. The internal or protruded portion, being now detached in all its circumference, is carried downwards to the rectum, and expelled with fecal matters at stool. Occurrences of this nature, ex- traordinary as they may at first seem, have been proved to take place, by the fact of portions of intestine, some lines in length, and whose structure was accurately ascertained by dissection, having been found, after the expulsion peranum. (Begin, op. cit.) In framing the diagnosis of intus-susception, it has been asked ; whether it is possible to distinguish ileus owing to or connected with this state from colic or ileus arising from other pathological states? Dr. Copland thinks, that in some instances symptoms may present themselves which will enable the observing practitioner to infer the existence of invagination. These are, — sudden invasion of the symptoms of severe colic or ileus after a violent straining at stool; and, subsequently, the constant desire to go to stool, attempts at evacuation being accompanied with violent tormina and tenesmus, and either unattended by evacuation or followed by the discharge of a little bloody mucus, and these by symptoms of enteritis. "In some instances, also, the sudden occurrence of an elongated tumour, in addition to these symptoms and before abdominal distension comes on, will further guide the opinion ; particularly if the invagination be extensive, and seated in the crecum or course of the colon. Much, however, will depend on the precision and tact with which an exami- nation of the abdomen is made. In all such cases the rectum should be examined by the finger; and the extent to vvhich enemata may be thrown up observed as an additional means of information ; for, whenever the intus-susception is in the colon, as much fluid cannot be thrown up as in health. Hiccup, and a small, irregular pulse, cha- racterise the advanced disease, and indicate the existence of inflam- matory action in the invaginated bowels." Treatment. — Our curative measures are the same in ileus as in the other kinds of colic, viz., bloodletting, purgatives, enemata, opium, the warm bath, fomentations, blisters and other external irritants. Let me premise, however, to any specification of the relative value and order of administering these remedies, a caution already given when treating of common colic, viz., to examine carefully and mi- nutely the various regions of the abdomen, particularly the two iliac TREATMENT OF ILEUS. 329 and the umbilical, in order to ascertain whether or not the patient is suffering from hernia. Nor must we be satisfied with one examina- tion, nor have our suspicions allayed by not finding a tumour promi- nent externally, or felt with the fingers pressing on the part, for sometimes a very minute portion only of the intestine is strangulated, and yet ileus may exist and death ensue. On this occasion we must be guided to a certain extent in our diagnosis by the symptoms already laid down as indicative of the locality of the invaginated intestine. Thus, if the patient suffers from violent attacks of tormina, occurring in paroxysms, like the strong impulse downwards from the action of a drastic purgative,— the action proceeding to a certain point,— then stopping and becoming inverted, followed by vomiting; and this point referred to is in either of the inguinal regions or at the umbilicus, we may suspect that the intestine is protruded, out of place, and strangulated. A correct diagnosis will not a little influ- ence us in the kind of treatment we are to pursue. If there be inva- gination or hernia, we shall, of course, refrain from active, certainly drastic purgatives, and begin with venesection — followed by opium and tartar emetic; and having emptied the lower bowels by a com- mon purgative enema, administer laudanum per anum. Belladonna ointment or tincture rubbed over the region where the invagination or strangulation is believed to exist, has been productive of good effects. The warm bath is a useful auxiliary to these means; but to be serviceable it ought to be used for an hour or more at a time. In common, knowing the tendency of ileus to end in inflammation, we ought not to be backward in having early recourse to the lancet. There is reason, also, to believe, as Dr. Abercrombie has pointed out, " that there is a modification of the disease depending on inflamma- tion of the muscular coat, and therefore not exhibiting the character- istics of enteritis, but simply of ileus, though in a very violent and rapidly fatal form." On this ground we ought to bleed; and it must have been noticed by every practitioner, as quite recently I have had occasion to observe in a case under my care, that the relief is often immediate, a call to stool being made almost as soon as the arm is tied up. Pringle {op. cit.) recommends bleeding largely and often as long as the violence of the symptoms remained, or whilst the strength permitted. "If after the first bleeding the patient was not sensibly better, in a few hours ihe vein was opened a second time, and imme- diately after a blister (as large as the palm of the hand with the fin- gers) was applied over that part of the belly which was most affected." More than once the author tells us, that he has known the patient to be relieved in his bowels as he felt the burning of his skin, and at the same time have stools by a purge or clyster which had been given before without effect ; and hence he concludes, that the blister acts more a.s an antispasmodic than an evacuant. To the same practice is Dr. Abercrombie led ; and indeed it is that which most observing practitioners must have found efficacious under similar circumstances with those now described. If time and opportunity favour, I premise a pack of leeches over the affected spot, and after the blood from them has ceased to run, apply, the symptoms still seeming to require it, a blister. A better application even than the blister, especially after 28* 330 DISEASES OF THE DIGESTIVE SYSTEM. leeching, is a hot spirit of turpentine fomentation placed over the whole abdomen, as strongly recommended by Dr. Copland. Dry cupping on both the loins and abdomen has the authority of Celsus, and, still more, subsequent experience in its favour. Quarm states, that in an extreme case, all other means having failed, he had recourse to dry cupping with porcelain bowls. Relief soon followed, and the bowels were copiously evacuated, their action having been assisted by enemata of infusion of chamomile flowers, and the potassio-tartrate of soda. In general, active purging is not required in ileus; and it may, especially in cases of obstruction from displaced intestine, be posi- tively mischievous. But where ihe stomach is irritable, and the pa- tient vomits from time to time, calomel, from ten to twenty grains, in the form of a pill, with, if the pain be violent, a grain of opium, or ten grains of camphor, will serve both to allay the sickness of the stomach, abate the morbid muscular action of the intestine, and bring on evacuations per anum. Hyosciamus or belladonna may be ad- vantageously united to calomel, if it is tho-ught advisable to repeat its use, at intervals, in smaller doses. When the patient feels that the medicine has traversed his bowels, and there is a passage of wind downwards, and a desire to go to stool, free evacuations may be pro- cured by administering, at this juncture, turpentine enemata with castor oil, as already recommended for constipation in caecal accu- mulation and in steicoraceous colic. Even taken by the mouth, the oil of turpentine is, I think, a good succedaneurn to the calomel, and in its direct effect on the bowels contributes to equalise the action of the muscular coat, and thus to remove some of the most pressing morbid symptoms. This remedy is still more highly prized in the advanced or sinking stage of the disease, in which there is constant and feculent vomiting. I have found that, in some cases, after the most active and approved purgatives,—calomel and aloes, or calomel and rhubarb, compound powder of jalap, &c., have failed to operate, that the infusion of senna and salts has had this effect very entirely. Even Epsom salt alone, taken in small and oft-repeated doses in a considerable quantity of fluid, answers the purpose when many other articles of more power disappoint me. Croton oil in a full dose has procured a passage and given a salutary turn to the disease in some cases apparently desperate. In the advanced stage, stimulants with purgatives, as tincture of wine or aloes, compound tincture of senna, and the like, alternating with ammonia and essence of peppermint or aniseed, and the stimulating embrocation before mentioned, serve wonderfully to revive the strength and sinking powers of life, and to give a salutary turn to the disease. Among the remedies of undoubted power, but which are attended with more risk than the ones already mentioned in ileus, I may men- tion cold and the tobacco injection. Physicians in Germany, France, and Great Britain, have attested to the decidediv remedial"effects of cold, particularly when applied to the abdomen, in the earlv stage of the disease. Some have had cold vvater dashed over the lower ex- tremities and abdomen of the patient while he was kept in a standing posture ; but the preferable method is to apply it to the abdomen TREATMENT OF ILEUS. 331 itself. Dr. Brandes of Copenhagen states, that he has emploved iced drinks, and cloths wetted with iced-wjtfter, to ihe abdomen in ten cases with success ; but that, in some instances, the practice requires to be persevered in for a length of time, and to be assisted by antispasmodic and laxative enemata, and by opiates, with stimulants and tonics taken internally. (Copland, op. cit.) If the conviction of the physician is decidedly strong in favour of the use of cold in ileus, he ought to have recourse to it early, or at least after trial has been made of blood- letting and opium, and before the lone and power of reaction in the system have undergone any notable abatement. The remark just made respecting cold will apply to the use of to bacco. If a purgative will not pass, and purgative enemata are in- effectual, and bloodletting and opium have been employed without success, it will then become a question for the physician to decide, whether he proposes to use tobacco in the case. If he has confidence in its powers, and believes that it can be administered in such a dose as not to be deleterious, he will resort to its use at once, before the powers of life are prostrated by the disease. He will not be unmind- ful, on this occasion, of the cases of death from tobacco enemata wit- nessed by Desault, Ansiaux. Ugard, Sir Asiley Cooper, Sir Charles Bell, and Dr. Copland. Iu the case recorded by this last-named wri- ter, an injection, made hy infusing half a drachm of tobacco in a pint of vvater for fifteen minutes, was followed by death in three minutes after its administration. In most of the fatal cases, however, a large quantity of tobacco, or an ounce to an ounce and a half, was used to prepare the infusion. On the other hand, he will derive encourage- ment from the authority and practice of Sydenham, Heberden, Aber- crombie, and others; the two first of whom recommend the smoke of tobacco, vvhich is milder in its operation, and if we could, by an appropriate apparatus, secure its ready and complete administration, woul'l be generally, if not always, entitled to a preference. Heberden, indeed, tells us:—"Where the proper instrument for giving the smoke cannot be had, then an infusion of tobacco may be used, made of twelve ounces of boiling vvater. poured upon half a quarter of an ounce (one drachm) This infusion has been borne without occa- sioning vomiting or sickness, but has seemed to affect the head more than the smoke." Dr. Abercrombie's lush opinion of tobacco injec- tion, and bis cautious mode of administering this medicine, have been placed before you in a preceding lecture (p. 308), and 1 need not repeat them in this place. Respecting the use of the cataplasms of tobacco leaves on the abdo- men, recommended by some writers in ibis and some other diseases, I have nothing to say in commendation. There is much uncertainty in the operation of tobacco applied in this way: sometimes it has no effect, at other times all the depressing and alarming effects of the drug ensue. Other medicines of the class Solanacese might be em- ployed with a view to produce similar results to those of tobacco and with less danger. Within these few years past we have seen' in the Medical Journals, accounts of cases of incarcerated hernia and' all the symptoms of strangulation, as also retention of urine and spas- modic contraction of the uterus, relieved by the use of belladonna. 332 DISEASES OF THE DIGESTIVE SYSTEM. It was applied in the form of ointment rubbed on the hernial tumour. I have already suggested its use in this way in severe colic; and take this opportunity of recommending it in the disease before us, and especially in case of volvulus, rubbed on the skin of the abdomen corresponding with the invaginated intestine beneath. The bella- donna mightalso be used as a suppository. In the stramonium, whichis so readiiy procured, we have an analogous remedy of the same class, and vvhich may be used both in the form of ointment to the affected region, and internally of pill by the mouth, and suppository per anum. Among the simple remedies to which recourse has been had, and occasionally with success, may be noticed, injections of warm water in a full and continued stream, carried up into the colon; inflation of the intestines by air; large injections of linseed oil — from two to four pints. Dr. Musgrave, who speaks well of the use of this last, directs that it be steadily and slowly thrown up, regurgitation being prevented by pressing the guard of the pipe against the anus. He found it to be remarkably successful, even after feculent vomiting had come on, and the usual means had failed. He recommends, in such cases, the patient to be placed on the right side, with the pelvis ele- vated above the rest of the body; the premature return of the injec- tion being prevented by firmly pressing a ball of linen against the anus. This clyster is to be repeated every three or four hours until relief is obtained ; and, when much exhaustion is present, with the addition of laudanum. The ingestion of crude mercury to the extent of one or two pounds, particularly where invagination is suspected, has been long an occa- sional remedy in ileus ; and there are not wanting cases of success attending its use. Dr. Copland has seen a female, aged between thirty and forty, relieved from this state of disease by the ingestion of two pounds of common shot. This writer very properly recom- mends that bloodletting, the warm bath, and enemata, should gene- rally precede the administration of lead or quicksilver. The last resource, but one of more than doubtful propriety, consists in exposing the invaginated portion of bowel, by making an incision through the parietes of the abdomen, and then freeing it, or allowing it to free itself, of the displacement. Dangerous as this operation must necessarily be, it has, however, been performed, and not always unsuccessfully nor with fatal results. Nuck is referred to by Dr. Copland as recorder of a case in which it was successful. Dr. Fus- chius, also, {Hufei'ands Journal, for February, 1826,) gives a case in which, after an exhibition of the diagnostic symptoms already re- corded, he performed an operation over the place to which the patient referred the sensation of obstruction, and where an obscure oblong tumour, in the situation of the ascending colon, was detected, An invagination of the colon was removed, and the patient perfectly re- covered. (Copland, op. cit.) On Ihe other hand, we must be aware that a tumour, well defined and obviously the seat of pain and distress, may be of chronic growth, and embrace the teguments adjoining the intestine, as at the cascum; and, of course, that it cannot be benefited by an operation. In a case PAINTERS' COLIC. 333 of this nature, marked by constipation, fecal vomiting, hiccup, &c, gastrotomv was performed by M. Monod, one of the surgeons of the Hospital Cochin, at Paris. After exposing a portion of intestine, which proved to be the colon, the surgeon replaced it, and, inserting his finder into the wound, drew down gently a loop of the small in- testine! which was red and tumefied, and into which he took a fancy, for reasons not explained, to make an opening with scissors to the extent of about an inch and a half. A quantity of fecal matter flowed out, and the patient acknowledged that she experienced great relief.—But on such terms! A ligature was applied through the mesentery of the divided intestine, and retained at the edge of the wound by means of strips of adhesive plasters, light dressings were applied, and the patient put to bed. On the following day the loop of intestine was found to have retracted inwards; but it was easily found, and was then fixed more securely than before, by means of two sutures. The patient became rapidly worse, and died on the fol- lowing dav. Examination of the body showed that, while the surgeon had in- flicted an injury on the small intestine which was of itself sufficient cause of death, he had not reached the real seat of obstruction, nor, if he had reached it, could he have removed it. On opening the abdo- minal cavity, some sero-purulent fluid flowed out ; the convolutions of the intestines in the pelvis were coated with semiconcrete pus, and were redder than the other portions of the canal. The intestine which had been opened in the operation proved to be the ileum, eight or more inches above the caput coli; a very trifling adhesion had taken place at the seat of the artificial anus. On examining the intes- tinal canal, for the purpose of discovering where the obstruction had been sealed, it was found to be at the point of junction of ihe cascum with the ascending colon; the contraction of the tube was so con- siderable, that the point of the little finger could scarcely be passed through it. The caecum rested posteriorly on an indurated mass of scirrhous-like formation; but the mucous coat of the gut was not in- jured. The other portion of the intestinal canal exhibited no morbid appearances, with the exception of patches, here and there, of redness. {Archiv. Gen., 1838.) The duration of the disease, which was mani- fested by swelling in the ileo-caecal region, constipation succeeding diarrhcea, and vomiting, at first bilious, and afterwards stercoraceous, ought to have deterred the surgeon from operating. Three months nearly had elapsed from the time of the first symptoms appearing to that of Ihe operation. LECTURE XXXVI. Painters' Cour—Effect of metallic poisons on the nervous system—Symptoms of painters* colic—Pathology of neuroses— Action of lead on the system—Abdo- minal and cerebral symptoms—Species of painters' colic—Dr. Thomson's re- searches on lead—Effects of, in animals—Effects of, on the generative system. A great deal of our time has been already occupied with the diseases of the digestive system — in fact, much more than I originally in- 334 DISEASES OF THE DIGESTIVE SYSTEM. tended; the only apology I have to make for this, is the deep and paramount importance of the subject. The disease next to be considered is called painters' colic, from the circumstance of house-painters being extremely liable to it from com- ing into frequent contact with the poison of lead. Its synonyms are numerous, dry colic, saturnine colic, rachialgia metallica, Devonshire colic, &c, &c. Painters' colic is an example of the effects of a metallic poison on the nervous system. There are certain metals which produce a powerful effect on the system, not by means of their corrosive pro- perties, or by any direct action on the surface to which they are applied, but by a peculiar impression made upon the nervous system. Thus we find'that mercury, under certain circumstances, will give rise to a very singular nervous disease; arsenic may be introduced into the system in such a way as to produce symptoms of nervous lesion; copper exercises a similar morbid influence, and the effects of lead are universally known. I do not mean to say that all these me- tals produce similar effects on the economy, for this is not the case; but there is one point of agreement between them, that all may pro- duce symptoms which are called nervous or neurotic, and the diseases thus produced are classed among the neuroses. What is the meaning of this term neurosis ? A lesion of nervous function, more or less com- plete, occurring independently of any demonstrable organic change. A neurosis, then, is an alteration in the functions of the nerves of or- ganic and animal life, the nature of vvhich alteration we cannot under- stand, neither can it be demonstrated by the knife, nor by any ex- amination of the state of the nervous tissue. In other words, a person will die with the symptoms of a neurosis; and when you come to examine the body, you will be unable to delect, in the minute ramifi- cations of the nerves, the trunks, or the nervous centres, any appre- ciable lesion. Diseases of this description have been divided into two classes — active and passive neuroses. Active neuroses signify an increase or exaltation in the nervous function; passive neuroses are those in which there is a diminution of nervous energy ; in both, there is an absence of perceptible organic change. Take, for instance, an ex- ample from the nerves of animal life: a case of convulsions, inde- pendent of organic disease, is an example of the active neurosis; a case of paralysis, under similar circumstances, is an example of the passive. In the former, there is an exaltation of the nervous function, which is reflected upon the muscular system ; in the latter, there is a diminution, producing a partial or total loss of the power of motion. It has been asserted, by eminent physiologists, that passive rreurosis can only exist in the organs of the life of relation, because the func- tions of the ganglionic system, which presides over organic life, cease only at the death of the individual. But there may be such a thing as semi-paralysis of the organs to which the ganglionic nerves are distributed ; and hence we may have passive neuroses of the system of organic as well as of animal life. We get a good idea of these neurotic affections, by taking some of the most remarkable instances of this kind. Hydrophobia is a remarkable instance of excessive PAINTERS' COLIC. 335 lesion of the nervous function, without any known organic change ; bo is tetanus, and so are some forms of apoplexy, convulsions, and mania. Here we have violent irritations of the nervous system, in which"there is no perceptible organic change; and where the only information we derive from pathological anatomy is of a negative character, telling us what these diseases are not, and leaving thus, as to their actual nature, as much in the dark as ever. We find by dissection that hydrophobia, and tetanus, and hysteria, and convul- sions, and apoplexy, are not caused by inflammation of the brain or spinal marrow, and that is all. Hydrophobia, tetanus, convulsions, and hysteria, are instances of active neurosis; paralysis and apo- plexy,"without any known cerebral disease, are looked upon as ex- amples of the passive kind, because they present either a diminution or abolition of the nervous function. In the present state of medical science, we must admit this divi- sion of the affections of the nervous system into diseases with and without perceptible organic lesion. I grant that it is very difficult, when we come to consider alterations in the functions of parts, to conceive how such changes could be effected without molecular alterations, or that the brain could be deranged in its functions, without some change of this kind. We are, however, compelled to consider such functional alterations of the nerves as changes with which we are unable to connect any process of hardening, or soften- ing, or anemia, or congestion, or, in fact, any known pathological con- dition. Rostan is of opinion that all diseases are organic; that is to say, that they are produced by some molecular change, and this, he says, should be the basis of medicine. Unfortunately for medicine, it has been given so many bases, that it sometimes knows not what leg to stand on. But to return to our subject. Painters' colic is an example of a neurosis, that is to say, it is a lesion of the nervous function, uncon- nected with any known pathological alteration. It presents, com- monly, two periods—the first exhibiting the phenomena of active, the second of passive, neurosis; or, in other words, the signs of ex- altation of the nervous function precede those of depression. In the majority of cases, we find the first stage of this affection character- ised by violent spasm, pain, and convulsions, symptoms indicative of active nervous lesion; whereas, in the second stage, we have pa- ralysis, the diagnostic mark of the passive kind. This is the order in which the phenomena of painters' colic are generally met with, but in some cases the first stage is either very imperfectly shadowed out, or even entirely wanting ; the paralysis comes on in an insidious manner, and without being ushered in by any symptoms of exaltation of the nervous function. In this country, the most common victims to this disease are paint- ers, who are much in the habit of working in white lead, and when vou are connected with the management of any public medical in- stitution (as I hope you will all be), you will often have to treat cases of this description. In Dublin, and all large cities, it is an exceed- ingly common affection, and the patients are for the most part house- painters. JN'oxt to these, the persons who are most subject to it are plumbers, and those who are employed in the melting of lead. 336 DISEASES OF THE DIGESTIVE SYSTEM. When the poisonous particles of lead enter the system in a highly volatilized state, its morbid effects are more certain and extensive. Every house-painter will tell you that the kind of work which is most likely to produce a deleterious effect, is painting " the dead white" or, as it has been termed, statuary uhite. In doing this, they use white lead combined with a large proportion of the oil of turpentine, and, in order to produce the intended effect, they are in the habit of excluding the air as much as possible. By means of the turpentine and the warm temperature of a close room, the lead is volatilized, and, in this slate, appears to have an extraordinary power of impreg- nating the system. Some of the very worst cases of painters' colic are produced in this way. Painting in the open air, even where the same preparation is employed, is comparatively harmless. A poor fellow, who was for a considerable time under my care, assured me that he had escaped for twenty years, and was convinced that he would have enjoyed a much longer immunity, had he not been put to work at the statuary while in a close room. With respect to plumbers, it is now ascertained that this disease is of comparatively rare occurrence among them ; and the reason of this is, that they generally work in the open air, or in well ven- tilated apartments, and have now but little to do with the actual manufacture of lead. The kind of lead which they generally use, sheet and pipe lead, is furnished from the manufactories, and their occupation principally consists in the moulding and soldering of it. We very seldom now see a plumber labouring under colic. Painters' colic may be observed under a great variety of forms; but, for the convenience of studying the disease, we may divide these varieties into four classes. In the first, we have the phenomena of simple colic, without any obvious or marked symptoms of bilious, gastric, or cerebral derangement. In the second variety, the disease assumes a more decided character; the colic is complicated with symptoms of fever of a gastric character, the pain in the belly is more acute, the constipation more obstinate; there is pain and diffi- culty in going to stool, nausea and vomiting, with occasional head- ache, dyspnoea, and sense of constriction about the praecordia; the belly is hard and retracted, and there is often pain in passing urine. In the third variety we have a more formidable array of symptoms. The functions of the brain and spinal marrow are de- ranged ; there are wandering pains in the extremities; and the pa- tient has frequent attacks of violent convulsions, resemblino- those of epilepsy. He also labours under the abdominal symptoms, but in this stage they are not so well marked,or so distinct, as in the former; the lesions of the functions of the cerebro-spinal system beo-in now to exhibit a greater degree of preponderance, and claim the principal share of the attention of a symptomatologist. In the fourth variety there is paralysis, without being preceded by the ordinary symptoms of abdominal or eerebral derangement. A medical friend of mine met with a case of this kind not long since. He was called to visit a child who had lost the use of his limbs. He went, and found the child lying in bed perfectly quiet and easy, his intellect sound, and his spirits good, but labouring under complete paralysis of all his SYMPTOMS OF PAINTERS' COLIC. 337 limbs. He inquired minutely into the history of the case, and made a most scrutinizing examination, but from all he could see or learn, there was not the slightest ground to suspect disease of the brain or spinal cord. There had never been any symptoms of colic. He was puzzled with the case, and tried one thing after another without benefit. At length he found out that the child's father was a painter by trade, and this led him to suspect that the symptoms might have some connection with the poison of lead. He inquired ; and was told by the mother that a quantity of white lead had latterly been kept in the room, and that ii was impossible to keep the child from it. He instantly had the paint removed, a free current of air ad- mitted into the room, and by the use of purgatives, assisted by sti- mulating frictions, the child recovered. Symptoms. — The following is the order of symptoms generally observed in this disease.' First, we have the precursory, denoted by pain and sensation of weight about the epigastrium; a weak, small pulse ; general languor and weakness of the muscular system; want of appetite; cold, clammy skin ; a tremulous and coated tongue. At this period there is sometimes diarrhcea. Then comes some exciting cause, exposure to cold or wet, excess in eating ordrinking, and the dis- * [Prior to the development of the more decided forms of disease, there are effects produced on the system by lead, constituting what may be called " a saturnine diathesis." The principal marks by which this state may be recognised are, according to M. Tanquere), who, in his Traite des Maladies de Plomb ou Saturnines, has entered largely into the subject, are a peculiar bluish or bluish-gray tinge of the gums, which sometimes extends over the mucous membrane of the mouth generally, the teeth at the same time becomingdiscoloured and affected wilh caries; a sweetish, styptic, astringent taste in the mouth, with a peculiar fetor of the breath, sallowness of the skin, and a dull yellow linge of the conjunctiva ; general emaciation, and a small, soft, com- pressible pulse, and, in some rare cases, a considerable reduction in the number of its beats: of these symptoms, the discoloration of the gums and teeth is the most frequent and the most characteristic. It appears to be owing to the deposition of a very minute film of sulphuret of lead on the mucous surface and on the enamel of the teeth, the former becoming of a bluish slate-gray colour, as before mentioned ; the latter of a brown colour, which is deepest at the neck of the tooth, or the part in immediate contact with the gum. The importance of a knowledge of and attention to these premoni- tory symptoms is shown by a statement of M. Tanquerel, from vvhich it appears that, of 1217 cases of this affection coming under notice, 1195 had been previously affected with one or more of the symptoms specified, a timely attention to which, on the part of the person him- self, with temporary cessation from work, has in many instances been successful in averting the threatened attack. — {British und Foreign Medical Review, Oct. 1840.) Dr. Burton lays stress on a blue line along the edge of the gums, bordering the teeth, as a dia- gnostic sign of lead poisoning. — B.] vol. i.—29 338 DISEASES OF THE DIGESTIVE SYSTEM. ease sets in with more or less intensity. The patient is attacked with dreadful pain in the belly, which differs from the pain of inflammation in this, that so far from being increased by pressure, it is in most cases relieved. In fact, so decided is the relief produced in this way, that there is a case on record in vvhich the patient used to get the greatest ease by making one of his fellow-workmen stand upon his belly. This relief from pressure is very generally observedin colicky affections. Indeed, so general is it, that you will hear it frequently stated, that all cases of colic are relieved by pressure. This, however, is not invariably true; for I have seen cases where the patients could not bear pressure, and where it required a careful examination to distinguish the symptoms from those of inflammation. The pain is of a twisting kind, and felt about the umbilicus ; and, in connection with this, there is scanty urine, with more or less pain in passing it, obstinate constipation, and a tense, hard, retracted state of the belly,from the violent contraction of its mus- cles. The upper portion of the belly is sometimes more retracted than the lower, and the pulsations of the abdominal aorta are unusually dis- tinct. The pain remits, and then becomes exacerbated, and the pa- tient's countenance is expressive of acute suffering. In that form of the disease where there is a complication of gastric or bilious symptoms, the patient has a semi-jaundiced look, a hot, moist skin, quick pulse, foul tongue, vomiting, hiccup, thirst, and epigastric tenderness.* In the third form, the chief force of the poison seems to be directed against the brain and spinal cord. There is vertigo, headache, stupor, and sometimes delirium ; the patient has fits resembling those of epilepsy, but of longer duration, and violent convulsions, which * \_Lead rheumatism or lead neuralgia is a common effect of the poison. It may generally be regarded as spasms or cramp-pains of the lead colic affecting the muscles of the limbs instead of those of the abdomen, and is most commonly a mere extension of that dis- ease, although occasionally observed separate. According to M. Tanquerel, this, which he calls arthralgia, is, with the exception of colic, the most frequent result of lead poisoning. The pain, which is the chief symptom, occupies most commonly the lower extremi- ties, then the upper extremities, the loins, the parietes of the chest, the back, and the head. The liability of workers in lead to contract arthralgia is, as a general observation, in direct proportion to their liability to suffer from colic, with, however, one remarkable exception, viz., in the case of the manufacturers of red lead, the flexor muscles are more frequently the seat of pain than the extensors; the affected muscles being, in either case, strongly and spasmodi- cally contracted, and their powers of motion greatly impeded : an exacerbation of pain often occurs during the night; but there is nei- ther preternatural redness, heat, nor swelling of the parts, and the cir- culation is stated to be, for the most part, undisturbed. Yet we are also told, that in forty-five of the cases of simple arthralgia, that is, up- wards of one-fourth of the number of cases of this description, the pulse was found to be hard, slow, vibrating, and, in seventeen of them, irregular, p. 510. — {Brit and For. Med. Rev.) — B.] SYMPTOMS OF PAINTERS' COLIC. 339 sometimes continue with unabated intensity for twelve, or even twenty-four hours. You will see those unfortunate creatures rolling and twisting in every form, sometimes doubled forwards, sometimes in a state of perfect opisthotonos, sometimes moving their limbs with the convulsive action of an epileptic, and foaming at the mouth. In addition to this, it is stated, in the descriptions of this disease, that the patient loses his sight, and becomes amaurotic; this I can confirm, for I have seen it more than once. It is a curious fact, too, that this blindness may come on before the other cerebral symptoms are de- veloped. I recollect a case in which one of the first symptoms was blindness. The patient happened one evening to be indulging him- self in whiskey-punch, and was in a fair way of getting comfortably drunk, when, unfortunately, he found that all of a sudden he could neither see single nor double. . He groped about in a very disconso- late state for his glass, but not finding it, and finding, at the same time, that he had lost his sight, he came to the hospital next morning, and, shortly after his admission, had a violent attack of convulsion. In cases of this kind, I have generally found the pupils contracted. The patients toss about in bed, and are frequently found lying with their heads turned towards the foot of the bed. In some cases, the breathing has been stertorous for a length of time, and the head fixed, but the fingers and hands 'were flexible. I have seen cases in vvhich the coma disappeared, and was followed by perfect blind- ness, lasting for two or three days, and then yielding to treatment. These symptoms, striking and extraordinary as they are, do not seem to depend on the same state of the brain as cases of other dis- eases vvhich are accompanied by sanguineous determination to that organ. The reason I make this assertion is, that many of the most violent nervous symptoms, including profound coma, subside under the use of a stimulant treatment. I think we may look upon these symptoms as similar to what are termed the symptoms of the ner- vous apoplexy of the ancients. A case of this kind, vvhich occurred in the Meath Hospital, is deserving of notice, from the singular effect produced by treatment. The patient was in a state of profound coma, but the head was cool, and the arteries had no inordinate pul- sation. If this was the case which presented the other symptoms of apoplexy, I would have prescribed bleeding, leeches, and cold ap- plications. But I reasoned thus — Here is a case in vvhich there is no evidence of the existence of inflammatory action. Opium has been found to relieve the abdominal symptoms of the disease — may it not also relieve the cerebral ? I ordered the patient to have a free dose of laudanum in camphor mixture. In a few hours he awoke, sat up in his bed, and next morning we found the symptoms of coma had completely disappeared. In two other cases of a similar kind, I have given opium and carbonate of ammonia with the most favourable result. Dr. Clutterbuck mentions a peculiar symptom of this disease —a kind of gouty inflammation attacking the great toe, and followed by relief. I have not seen this. He states that the first joint of the great toe becomes red, hot, painful, and swollen, and that this remits by day and returns again at night. I have never seen this, nor have 340 DISEASES OF THE DIGESTIVE SYSTEM. I ever seen those hard tubercles on the tendons in various parts of the body, which some authors have described. After these symptoms, we come to a new class, namely, the pas- sive, characterised by paralysis of the muscles of animal life.* It is remarkable that this paralysis seems to be principally a paralysis of motion, and that the power of sensation is seldom or never im- paired. Generally speaking, the upper are more subject to paralysis than the lower extremities, and the right than the left arm. The latter circumstance is explained by assuming that the direct influence of the poison is more applied to the right arm. The paralysis of the arm is also frequently partial ; the extensors lose their power, but the flexors do not in so great a degree. You will see a patient with his arm hanging by his side as if it were dead, but if you give him anything to hold he can grasp it firmly. I have known painters continuing to work with a semi-paralysed arm. There is also an atrophied condition of the affected part; and this sometimes comes on with such rapidity, that, in the space of a week or ten days, the affected limb will be scarcely half as bulky as the corresponding one. We cannot account for this remarkable emaciation on the principle of loss of motion alone, for the short space of time in vvhich it occurs, in many instances, is opposed to our entertaining such an opinion, and we must look for some other explanation. On this point science affords us no satisfactory information. This disease, notwithstanding all its terrible array of symptoms, is * {Anaesthesiafrom Lead. — Twenty-three cases of anaesthesia were noticed by M. Tanquerel, in four of which the disease was deep-seated, in seven the loss of sensation was confined to the skin, and in twelve the eye was affected. In the eleven cases of deep- seated and superficial anaesthesia, three times there was paralysis of the corresponding muscles, four times the paralysis of motion and of sensation occupied different parts, and four times the loss of sensation was unaccompanied by loss of motion ; in one case only did amau- rosis and anaesthesia of the skin exist together. The lesion of sen- sation is always partial or of limited extent, sometimes confined to certain parts of the abdomen, of the chest or neck, sometimes occu- pying the limbs; it may be complete or varying in degree,frequently shifting its place, or differing in extent; when deep-seated it is less mobile than when confined to the skin. Usually it makes its attacks suddenly, and rapidly attains its fullest extent, though occasionally it is preceded by a slight numbness. — {BelVs Practical Dictionary of Materia Medica, from Brit, and For. Med. Rev.) It might have been stated, in connection with paralysis from lead, that it is altogether a different affection from what is termed mer- curial paralysis. M. Tanquerel remarks, that in upwards of fifty cases of mercurial tremors observed in the hospital La Charite, in no one instance was paralysis seen to supervene, and his researches among the workmen generally employed in the manipulation of this metal and other metallic substances, lead to the conclusion that lead is the only mineral capable of producing paralysis properly so called. — B.] SYMPTOMS OF PAINTERS' COLIC. 341 very seldom fatal. Hence the uncertainty which long prevailed as to its pathological nature. In the great majority of cases, where a dis- section was made, the patients died of some other disease, which either occurred during its course, or had preceded it. All that appears to be established at present is, that there is no known organic change of the nervous system connected with this disease; that it occurs in all its forms without the coexistence of organic lesion, and that its exciting cause is the poison of lead. It was formerly supposed that all the preparations of lead, whether applied externally, or used internally, were capable of producing colic; but this doctrine is at present considered very questionable. It was thought that metallic lead, and all its salts, were capable of causing the disease; but the morbid influence of this metal is now restricted by the best chemists and pathologists chiefly to its car- bonate. This opinion, I believe, was first put forward by Dr. A. T. Thomson, the author of the London Dispensatory, in an interesting paper published by him in the tenth volume of the Medico-Chirurgical Transactions. The object of this paper is to prove that, of all the preparations of lead employed in pharmaceutical and other purposes, the carbonate is that which is chiefly poisonous, and that the acetate and sub-acetate are comparatively harmless. You have all, I am convinced, heard of cases of colic produced by the external use of the acetate of lead, and you will see some cases in proof of this opinion in Darwin's Zoonomia, and other writings. There is a case on record of a woman, who, having poulticed her ankle with this preparation, for the cure of a sprain, got colic and fell into a state of marasmus. I knew of a deplorable case of burn affecting the abdominal integuments, vvhich was treated with a solution of the acetate of lead. After using it for a fortnight or more, symptoms of colic came on, which, not being recognised, the lead wash was continued, and the woman died in great agony. Dr. Thomson explains all this in a very satisfactory way. He shows that the solution of the acetate of lead, when exposed to the air, attracts a quantity of carbonic acid, and is thus converted into a car- bonate ; of this 1 have very little doubt, for you will find that, by exposing a solution of the acetate of lead to the full influence of the air, the carbonate will gradually ha deposited in the shape of a white powder. In the same way we can understand why it is that a solu- tion of the acetate of lead, added to fermenting poultices, may be converted into a carbonate by the carbonic acid which is evolved. It is also a fact, that the acetate can be used internally for a long time without producing anything like deleterious effects. I have given it for weeks together in full doses, without its having been ever followed by colic, or any symptoms characteristic of the absorption of a poisonous matter. There are cases on record where as much as six drachms of this salt have been taken internally without pro- ducing any sensible morbid effect. As far as my experience goes, all those cases, in vvhich the medical use of the acetate of lead has been attended with disagreeable symptoms, were cases in which it had been used as an external application. There were two cases in the Meath Hospital in vvhich this medicine was used externally, in 29* J 342 DISEASES OF THE DIGESTIVE SYSTEM. which colic, and other indications of poisohous absorption, took place, but not a single one in which its internal employment had been injurious. An excellent practical rule is laid down by Dr. Thomson, that, where you wish to employ the acetate of lead inter- nally, you should take care to combine it with diluted acetic acid. Of the two combinations of lead with acetic acid, the sub-acetate is most liable to be decomposed and converted into a carbonate, so that, if you prevent this by mixing with the sub-acetate, or acetate, a certain quantity of distilled vinegar, there will be little or no chance of unpleasant symptoms being produced, even where the medicine is given in very considerable doses. We are, therefore, I think, jus- tified in concluding that it is the carbonate of lead.which is produc- tive of poisonous effects; and that where bad symptoms have re- sulted from the use of the acetate, it was in consequence of its being converted into a carbonate. I must, however, remark, that it has not been sufficiently proved, as yet, that the use of the acetate is perfectly safe* It is an interesting fact, that many of the lower classes of animals are subject to this disease. Burserius was one of the first authors who directed the attention of medical men to this singular occur- rence. I have got from my father an abstract of some observations made by him on this subject, during a visit to the lead hills in Scot- land. He found that, in the pastures among these hills, and in their immediate vicinity, cows, horses, sheep, dogs, and even poultry, were subject to colic from lead. The symptoms, also, in these ani- mals were observed by him to bear a very close analogy to those of the human subject. Thus, for instance, in cows there was obsti- nate constipation with suppression of urine ; the poor animals seemed to suffer from violent twisting pain in the belly, and sometimes were thrown into a state of furious excitement, running wildly across the country. He learned, also, that during that period it was calculated that at least one-tenth of the cows in this nation had died of the effects of the poisonous absorption of lead. One of the most ordi- nary precursory symptoms, was the animal becoming what is called hide-bound; this was followed by obstinate costiveness, and there was much apparent suffering, with panting, starting, and slavering from the mouth. Where the cerebral symptoms were most promi- nent, the signs of abdominal irritation were by no means distinct; and this, as I have remarked, is the case in the human subject. In some, who had the head affected, and ran wildly through the coun- try, the secretion of milk was stopped ; and this accords, too, with the effect of lead on the human female. Another remarkable cir- cumstance is, that animals living in the vicinity of these lead hills have exceedingly difficult labours. Sheep are subject to epileptic convulsions and paralysis ; dogs have the head principally affected, * [Cases of undoubted authenticity have been recorded in the English Medical Journals, in vvhich the administration of the ace- tate of lead in doses, in one instance, of three grains every three hours in the twenty-four, for hemoptysis, was followed by lead colic. — B. PATHOLOGY OF PAINTERS' COLIC. 343 they run across the country slavering at the mouth, as if in a state of hydrophobia, but they do not bite, and are in all respects perfectly harmless. In barn-door fowl, the generative function was injured, and the hens reared or brought there ceased to lay eggs. There is one fact, mentioned in these observations, which tends to confirm the opinion of Dr. A. T. Thomson, that the poisonous effects of lead are produced chiefly by the carbonate. A distance of a very few miles from the valley renders animals quite free from any liability to the disease; but if they should happen to stray into the immediate neighbourhood, and particularly into a portion of low ground, flooded during the winter months by a river which runs along the valley from the mines, and which, in all probability, leaves behind an efflores- cence of the carbonate of lead, they are very liable to be affected with colic. It is said, also, that the poison is introduced by the volatiliza- tion of lead in the smelting houses, the vapours of which are carried down the valley and through the neighbouring parts. Be this as it may, the Gaelic name of the valley signifies the poisonous vale ; and as it is very probable that this name had been given in consequence of the deleterious qualities of the place long before the establishment of lead works, it tends strongly to favour the opinion that it is the water which contains the poison. ' The mode of cure employed by the shepherds in this place, is to give strong purgative injections, and to remove the cattle from the influence of the poison, by sending them to new and healthy pastures. In this way they frequently recover ; and if we look to the cause of the disease, its symptoms, or mode of cure, we shall observe a striking analogy between it and the colic from lead in the human subject. I shall conclude this subject at my next lecture. LECTURE XXXVII. Pathology of Painters' Colic.—Researches on the state of the nervous and di- gestive systems—Treatment—Use of narcotics, purgatives, tobacco, &c, &c.— Treatment of paralysis from lead—Efficacy of strychnia and brucia—Colic from copper—Poisonous effects of mercury—Remarkable case—Affection of the respiratory muscles. We were occupied at our last lecture in considering the symptoms of painters' colic. I mentioned that it occurs under a variety of forms; that the symptoms are to be attributed to a lesion of nervous function independent of any known organic change ; and that the same disease may be seen in animals which have been exposed to the poison of lead. There are some other facts connected with this disease which should not be passed over, and which I am anxious to lay before you previously to entering upon the treatment. You will recollect that I introduced the subject by stating that painters' colic belonged to the class neurosis, and that I endeavoured to show that this implied a lesion of function of any part of viscus of the body, frequently characterised by the most decided departure from the natural condition, and yet unaccompanied by perceptible 344 DISEASES OF THE DIGESTIVE SYSTEM. organic change. I said, also, that it was hard to suppose the exist- ence of great functional alteration, without any molecular change; but that, in the present state of science, we are compelled, for the want of a better term, to call these affections neurosis, in contradis- tinction to diseases in which there is organic lesions visible. To illus- trate this point, take an example from two different cases. In one case of what is called dyspepsia, we have inflammatory, or, at least, sub-inflammatory derangement of the stomach : here the disease is traceable to organic change; in another we have symptoms of nearly the same character, and yet there is no organic lesion. Painters' colic comes under the latter head ; we observe symptoms of excessive functional lesion, but dissection does not exhibit any organic change. Pathological anatomy tells us what it is not, and we arrive merely at a negative knowledge of its nature. We have decided proofs of extraordinary lesions of the nervous system, and yet, when we come to the post-mortem examination, we cannot find any visible change to account for these striking phenomena?. The old pathologists maintained that spasm of the intestines was the principal cause of the disease, and attributed the symptoms to their contraction. This opinion appears to have some foundation, when we consider the violent symptoms of colic which accompany this affection. Dubois de Rochfort has mentioned, that in such cases he has found intus-susception of the intestines. De Haen says that contractions of the colon are very common; and several authors make the same assertion. The results of more modern observation, however, are against these opinions. I have told you already, that in consequence of this disease seldom or never proving fatal, there is a degree of doubt attached to its pathology ; but it is an interesting fact, that where death from other causes has occurred during the exist- ence of painters' colic, the digestive tube has been found either in its healthy state, or with a few detached spots of vascularity, without any decided inflammatory character, and totally insufficient to ac- count for the symptoms. This, which is all that pathological ana- tomy reveals, may be considered as purely accidental, and only of occasional occurrence, so that we are compelled to look upon the disease as one in vvhich there is great lesion of function without any organic alteration. In the hospital of La Charite, at Paris, a vast number of cases of painters' colic have been treated. In the space of eight years five hundred cases of this description have been admitted; out of these, five died while labouring under the disease; and the following is an abstract of the appearances observed in dissection. In the first case, there was rupture of an aneurism of the abdominal aorta, and the patient sank from loss of blood. On examination, the digestive tube was found in the natural and healthy condition— there was neither vascularity nor contraction. The subject of the second case died of apoplexy. The whole intestinal canal was found healthy, and, con- trary to the doctrines of the school of Broussais, there was neither congestion nor vascularity. In the third case, the patient had fits of an epileptic character, in one of which he expired. The colon ex- hibited a slight degree of redness, but quite insufficient to explain the PATHOLOGY OF PAINTERS' COLIC. 345 Bymptoms during life. In the fourth, the cause of death was the same, and, on dissection, the tube was found healthy. Another patient, after recovering from the symptoms of painters' colic, got a sudden attack of asphyxia and died. His body was examined, but there was no trace of disease in the colon or any other part of the intestinal canal. Here we have five cases in vvhich there was either no disease at all in the digestive tube, or, if there was any, the amount was quite insufficient to account for the symptoms. Louis, in a me- moir which he has published, on sudden and unexpected deaths, gives a case of this disease where death occurred suddenly on the e ghth day. The intestines were found to be in a healthy condition. Mar- tinet gives two cases of persons who died of the cerebral symptoms while labouring under this disease; here, also, the tube was in the normal state. Thus we have eight cases with dissections detailed by various authors, all men of high professional celebrity, having no theory to support, and all agreeing in the statement that there is little or no appreciable lesion of the digestive tube; that in the majority of cases it is in a state of health; that no contraction exists; and that such morbid appearances as have been found must be looked on as accidental. There is one interesting circumstance in these cases which de- serves to be noticed. With the exception of the first and fifth cases, all the patients presented that form of the disease in which the func- tions of the brain are decidedly injured. Here it seems probable that the cause of death was excessive irritation of the nervous system. Now, in the observations I made on the cases which were treatecf*at the Meath Hospital, you will recollect I stilted that where the cere- bral symptoms were predominant the abdominal were more or less indistinct and latent, and that the cause of indistinctness, or even total absence, of these might be owing to the force of the disease being thrown upon the brain and spinal cord. Such was the case in the instances above recited, and such we have also seen to be the result in the case of those animals of an inferior order that have been ex- posed to the poison of lead. How far the predominance of cerebral excitement may explain the want of appearances of disease in the digestive lube may be a subject of consideration. What is the state of science with respect to the brain and spinal marrow? Allow me here to call to your recollection the symptoms of functional derangement of the nervous centres, the coma, the violent convulsions, the amaurosis, the deafness, the delirium, the paralysis. All those are violent symptoms, and you would naturally expect to find them connected with some sensible alteration, some congestion, or inflammation, or ramollissement. But nothing of this kind can be discovered, in all the cases where death occurred under such cir- cumstances, at La Charile, with the exception of some slight appear- ances of cerebral lesion in the second, there was no perceptible dis- ease in the brain or spinal cord. The membranes and substance of the brain presented their normal condiiion ; there was little or no fluid in the ventricles; the spinal cord was healthy and natural in consist- ence and colour, and there was no effusion into its sheath. All these circumstances led to the conclusion that painters' colic is essentially a neurosis. Observe, too, how interesting it is to connect the circunv 346 DISEASES OF THE DIGESTIVE SYSTEM. stance of the absence of organic change with the singular fact which I mentioned in my last lecture, that the comatose symptoms of this affection may be treated with stimulants and opiates. Where we have coma with congestion of the brain, opium has the effect of in- creasing the symptoms ; here it was found to have a contrary effect. So that our experience and the results of pathological anatomy, as far as they go, appear to square exactly. We see, then, that painters' colic is not inflammation of the intestines, or of the brain, or of the spinal cord, and this information, though of a negative character, possesses considerable value in a practical point of view. I do not know any cases of what have been termed neuroses, in which the bearings of pathological research on practice are so extensive and so satisfactory.* Treatment. — It is a fortunate circumstance that this disease is sel- dom fatal, and it is some consolation to think that, although the patient's sufferings are dreadful and often protracted, there is little danger of life, and that the complaint is almost always amenable to judicious treatment/! I have been for some years in the habit of treating it in a routine way, and can speak from experience of its success — of course this treatment is to be modified by circumstances. Suppose a patient applied to you with violent pain about the navel, a hard and retracted state of the abdomen, obstinate costiveness, and the other symptoms vvhich characterise an attack of painters' colic; the first thing I would advise you to do is to prescribe a full opiate. Many persons would object to this, and say that there is constipa- tion enough already, and that opening the bowels would be much more likely to give relief. But opium does not here add to the constipation: indeed, so far from doing this, it sometimes acts as a laxative. At all events, it is a remedy which is perfectly unobjec- tionable. Give, then, in the first place, a full opiate ; it will have the effect of relieving the patient's sufferings, and will enable you to gain time for the employment of other means. The next thing is to place the patient in a hip bath, and keep him in it as long as possible. Do not neglect this, for I know of nothing that gives more decided relief. I have often seen cases where the patient was quite easy while he remained in the bath, but experienced a return of the pain as soon as he left it. If you have no means of procur- ing a bath in this way, the next best thing is to have recourse to * [The impeded and perverted function of the nervous and mus- cular systems in lead poisoning, is now attributed to the presence of the metallic preparation itself in the organs and tissues, consequent on its absorption. The palsy, as of the hand, in wrist-drop, is owing, Dr. Budd thinks, to the local action of lead in the poisoned parts, and not to any change in the central organs of the nervous system. — B.] t [Out of the entire number of cases of lead colic, 4809 observed and recorded by M. Tanquerel and others, 111, or 1 in 43, terminated fatally. It would be more correct to say, that the deaths here were from lead poisoning, as, with one exception, the fatal result is said to be either owing to cerebral affection, to paralysis of the respira- tory muscles, or to some accidental complication with disease foreign to those from lead. — B.J TREATMENT OF PAINTERS' COLIC. 347 emollient stupes containing some narcotic, after the manner first introduced by my colleague, Dr. Graves. One of the best of this kind is the tobacco stupe; if you cannot get this, you may employ poppyheads for the same purpose. The tobacco stupe is much better than the tobacco injection, because its effect can be more easily regulated, but in violent cases I am in the habit of combining both, employing the stupe during the paroxysms of pain, and throw- ing up a tobacco enema every four or six hours, until a decided impression has been made on the symptoms. In the success which has attended my distinguished friend Dr. O'Beirne's treatment of tetanus by the use of tobacco we have seen an analogous effect. In this way you will succeed in giving relief; you should also prescribe a brisk cathartic; and this you may do without any fear of injuring the patient, or exciting intestinal inflammation. The insensibility of the intestines to the stimulus of even powerful purgatives is a curi- ous feature in this disease, and bears strongly against the idea of its being connected with any inflammatory condition of the tube. "Tthe Hospital La Charile the treatment is routine ; it consists of an emeto-purgative [and narcotic] plan, which is continued day after day until the symptoms yield. The purgatives we employ in the Meath Hospital are croton oil, combined with castor oil and mucilage, or given in the form of pill. When the bowels have been freely acted on, the case generally goes on well. After the bowels have been opened, we continue the employment of the hip bath, the narcotic stupes, and anodyne injections, taking care at the same time to persevere in the use of purgatives. Andral makes a good remark on this point: — " Here (says he) are cases in which, from some peculiar alteration in the state of innervation, the mucous surface of the bowels is rendered less sen- sible than in its ordinary condition, and can bear freely the stimulus of powerful purgatives. May not this condition also occur in other states of the ecomony ? We are, therefore, led to conclude that pur- gatives are not, in all cases, direct stimulants. Painters' colic has been treated in Paris by bleeding and leech- ing; but this has not been found so successful as the ordinary pur- gative plan. I have never seen a case in which general bleeding seemed to be called for except one, and this was a most violent case, which had resisted the ordinary means of treatment forty-eight hours. I recommended bleeding from its well known anti-spas- modic power; a quantity of blood was taken, and soon after the pur- gatives began to act, and the patient got relief. With respect to leeches. I have employed them only in those cases vvhich are ac- companied with symptoms of fever and gastric irritation; where there is quick pulse, hot skin, foul tongue, thirst, vomiting, and epi- gastric tenderness. In such cases I have applied leeches, but my experience of them is, that the relief afforded is by no means so great, or so decided, as in cases of intestinal inflammation, and it is a mode of treatment which I do not by any means rely upon for removing the disease." * [In the cases of painters' colic which have fallen under my notice and care, I have found but little benefit from other means, 848 DISEASES OF THE DIGESTIVE SYSTEM. After the violent symptoms have been subdued, the next thing you have to consider is, whether there is any paralytic affection, unless the lancet had been freely used. In one of the two last cases which I treated in this way, with the addition of cups on the abdo- men calomel, and castor oil and turpentine, with opiates occasion- ally'there has been no return of the disease for nearly nine years, although the person has been regularly engaged in his trade ever since. . . , ... Alum is one of the most approved, in fact is the most entitled to our confidence, of any one single remedy, in the treatment of lead colic. In its favour we have the experience of practitioners in Germany, France, and Great Britain. Its administration long constituted the treatment of lead colic by M. Kapeler,at the Hospital Saint Antoine in Paris. M. Montanceix assures us that, in doses of three or four drachms daily, the potassio-sulphate of alumen cures, invariably, lead colic, however violent it may be, in less than six to seven days, and commonly also without relapse occurring. M, Gendrin tells us, that fifty-eight patients attacked with the disease, some of whom had been subjected unsuccessfully to other modes of treatment, were cured without a single exception and inconvenience to the digestive organs. In a dose of a drachm and a half to two drachms, the alum arrested the march of the disease in twenty-four cases, in a period of from ten to fifteen hours; and in six the persons were not obliged to suspend their work. But, he adds, that when the dose exceeds two and a half or three drachms in twenty-four hours, disagreeable effects ensue. The next, and the last lauded remedy for lead colic, is sulphuric acid, to the use of which M. Gendrin was led by his investigations into the modus operandi of alum, and a suspicion that its activity was owing to the excess of sulphuric acid in this salt. He asserts that he has now treated three hundred cases of lead colic with sul- phuric lemonade,— made by adding a drachm to a drachm and a half of the acid to three or four pints of water with sugar. Commonly he carries the dose of the acid as far as two scruples, diluted in a pint and a half to two pints of vvater, suitably sweetened — taking care that this drink shall not be kept in vessels of metal. Unfortunately, however, for science and for medical ethics also, the accuracy of M. Gendrin's results has been not only denied by M. Tanquerel, but denied in terms anything but courteous or civil. This latter gentleman asserts, that the trials made with the sulphuric acid in the Charite were utter failures,and that the physicians, MM. Andral, Dalmas, and Sandras, were obliged, for conscience sake, to desist from its use and to have recourse to the purgative plan. On the other hand, again, we have the averment of Liebig, in his Organic Che- mistry, that sulphuric acid lemonade is a preservative from the in- jurious effects of lead, and that colic is entirely unknown in all manufactories of white lead in vvhich the workmen are accustomed to drink it. The alkaline sulphurets have been recommended in the treatment of lead colic, under an idea that the oxide of the metal would com- bine with the sulphur and form a sulphuret,—a substance insoluble TREATMENT OF PAINTERS' COLIC. 349 and how this is to be treated. If the disease be severe or of consi- derable duration, you may look for paralysis of one or both of the upper extremities with a good deal of certainty. This part of the subject, I believe, more properly belongs to the consideration of ner- vous affections, but, as I have gone so far into the treatment of painters' colic, I mav as well eive the whole together. Ihe para- lysis which follows this- disease is different from that, vvhich is the result of apoplexy ; it is a neurosis of the passive kind, and to be treated as such. The patient, some time after the occurrence of the usual symptoms of colic from lead, begins to complain of weakness in his arm, he feels some difficulty in extending his fingers or raising his hand to his head, and then the symptoms become more marked. The arm and forearm become rapidly atrophied, the paralysis prin- cipally affects the extensors, while the flexors retain a considerable share of power, the fingers are bent, and the arm hangs by the side. Here the first thing you should do is to adopt the treatment recom- mended by Dr. Pemberton in his work on Abdominal Diseases, namely, to apply a splint to the inside of the forearm and hand, so as to counteract the preponderating influence of the flexors. Apply a splint to ihe forearm, wrap it up in flannel, and make the patient keep it supported by a sling. Iu this way you establish a kind of balance between the antagonist muscles, and place the extensors under favourable circumstances for bringing about a cure. If the patient has both arms affected, which is sometimes the case, change the splint from one arm to the other every second day, and continue this alteration until the cure is completed. You will next have recourse to the use of strychnia, one of the best remedies we possess in cases where the paralysis does not depend upon organic diseases of the brain. This is a remedy which is given with good effects even in cases of paralysis from apoplexy, where there is reason to suppose that absorption of the clot has taken place. In cases of apoplexy it can be employed only after some time, and where depletive measures have been sedulously put in force, but in a paralysis of this description you may begin with it and inert in the digestive tube. But practice has not sanctioned the theory. Mercury has been given by different physicians for lead colic, with a view to procure its sialagogue effects ; but salivation will not unlikely predispose more readily to palsy, and we are not, be- sides, reduced to the strait, in this case, of curing one kind of poison- ing by exciting another. But in some of the more unmanageable forms of the disease, attended with great irritability of stomach, lead itself, in the shape of sugar of lead, has been given by Dr. Harlan and others in this disease. Dr. H. combined the salt of lead with calomel and opium, as follows: —li. Cal. ppt., gr. v.; Pulv. opii, gr. ij.; Pulv. sacch. sat., gr. iij. M. ft. pulv.; to be repeated every two hours until relief is obtained,— which, he tells us, is usually the case after two or three powders have been taken. But, iu this pre- scription, we cannot say what is due to the opium, and what tathe suiiar of lead, or the calomel. The same difficulty occurs iu his prescription of sugar of lead with opium as an enema. — B.] vol. i.—30 350 DISEASES OF THE DIGESTIVE SYSTEM. at once. Commence with the exhibition of one-twelfth of a grain of strychnia two or three times a day, and go on increasing the dose gradually, until a grain, or even a grain and a half, is taken in the twenty-four hours. To insure the exact division of this powerful drug, you should direct a grain of it to be dissolved in a few drops of alcohol, and then made into pills of an equal size with crumb of bread or conserve of roses. In this way you will succeed in bring- ing back the lost power of the muscles of the forearm and restoring its nutritive functions. 1 may mention here, that the atrophy of the paralysed limb, vvhich occurs in this disease, cannot be accounted for by supposing that it is produced by want of exercise ; the ema- ciation is so rapid (sometimes taking place in ten days or a fortnight) that we can only attribute it to some unknown lesion of innervation. If the use of strychnia be followed by severe muscular twitches, pain in the head, or convulsions, you must omit it for some time, and then, when these effects have completely subsided, it may be resumed if necessary. You should also bear in mind that this remedy is one of those medicines which have been termed accumulative, that is to say, a patient may be taking it for a considerable time, without any perceptible symptom, and then its effects explode suddenly, the quan- tity vvhich has been accumulating in the system manifesting itself at once by symptoms of great intensity. Here you omit it immediately, and, with a view of relieving the existing symptoms, prescribe a draught composed of camphor mixture, ammonia, and opium. This has generally the effect of calming the nervous excitement, and you will seldom have any more trouble on this account. En passant, I would advise you, whenever you employ strychnia in private practice, to inform your patient of the occurrence of such symptoms, and tell him that there is no cause for alarm. Instead of strychnia, some of the continental practitioners are in the habit rJT prescribing brucia, and it is stated with considerable advantage. I have tried it in two or three cases without much apparent benefit, and I am inclined to think that it is decidedly inferior to strychnia. In France, however, it has been very largely employed, and has the reputation of being a remedy of considerable value in the treatment of paralysis. It has one advantage at least over strychnia, it can be much more easily divided and regulated, so far as respects the quantity given, as it is a much weaker preparation than strychnia, one grain of which is equivalent to six grains of brucia. In addition to these measures, 1 have seen much benefit result from the application of blisters and frictions, with stimulating lini- ments to the spine. It is also of importance to remove the clothes in which the patients have worked ; they are frequently charged saturated with lead, and have a considerable tendency to keep up the disease.* I have often seen an attack of painters' colic reap- * [This precaution is a very proper one. To it should be added that of a regular and careful ablution of the hands and face, and arms, if they have been exposed, and a careful combing of the head and cleaning of the nails, before every meal, and also a daily wash- ing of the feet. The night clothes ought always to be different from those worn during the day. By these means, and temperate living, TREATMENT OF PAINTERS' COLIC. 351 pear so shortly after leaving hospital, and without any evident ex- posure, that I could only attribute it to the circumstance of their gar- ments being saturated with lead. In the foregoing plan of treatment there is nothing new ; it is, in fact, a routine practice, but is one that is borne out by the results of pathology, and vvhich, from long experience, I can strongly re- commend. I may also remind you that the plan of treatment, fol- lowed in the hospital of La Charite, vvhich has more cases of this disease than any similar institution at Paris, is completely routine. Other metals besides lead, as, for instance, copper, produce effects somewhat analogous. Copper is said to produce salivation, colic, and vomiting. Brass-founders are liable to these symptoms, as also other persons employed in the manufacture of copper. I have not seen the disease, but it is said to be analogous to lead poisoning, so far as colic is concerned ; in other respects the symptoms differ. The con- vulsions are not so violent, nor is the paralysis or coma so frequent; there is often considerable fever, thirst, difficulty of respiration, prse- cordial anxiety, diarrhcea, and prostration of strength, so that it comes much nearer to ordinary intestinal inflammation with fever than painters' colic. Yet it is a curious fact,that notwithstanding all its array of symptoms so closely bordering on inflammation, it has been found in Paris, where several cases of this disease have been seen, that it is amenable to the same treatment as painters' colic, and that, under the use of purgatives, the fever, thirst, diarrhcea and tenes- mus subside. Mercury, under certain circumstances, will produce a most extra- ordinary affection, on which I shall here make a few observations. The disease is not of very.frequent occurrence, but it is of import- ance in practice to be able to recognise and treat it properly. It is a proposition well known to almost every one, that many bad effects have resulted from the abuse of mercury ; and I need not tell you how many persons are injured by the empirical employment of this potent drug on all occasions and in all constitutions. It is a common opinion that mercury acts principally on the capillary and absorbent systems, but there can be no doubt that it also acts upon the nerves, and that in a very remarkable manner. I have seen cases where the constant use of calomel has produced a marked derangement of the nervous system, manifested by great irritability, tremors, hysteri- cal excitement, and hypochondriasis. You will see iu the various works on Toxicology an account of the effects produced by mercury on persons employed in quicksilver mines, and on tradesmen, such as looking-glass manufacturers and others, who come in contact with mercury. I shall read for you the notes of a remarkable case of this kind, which was some time back under treatment in the which implies abstinence from all intoxicating drinks, painters and glaziers may escape for a term of years, if not for life, from an attack of painters' colic. As respect the general therapeutic course required in this disease I have not found it to differ materially from that vvhich I have fol- lowed in bilious colic, with the treatment of which the reader is already acquainted. — B.J 35^ DISEASES OF THE DIGESTIVE SYSTEM. Meath Hospital. It may be called a form of the paralysis agitans from the effects of mercury. Similar cases have been described. A man, aged forty-six, was admitted into one of our medical wards in October, 1833. He stated that, from the time he was eight years of age, he had been employed in a looking-glass manufactory, and that his occupation principally consisted in what is technically termed the silvering of mirrors. In this process the operator's right hand is repeatedly immersed in a vessel filled with mercury, while the left fixes a sheet of tinfoil, on which the metal is rubbed. Artizans while thus engaged are in the habit of using a muffle, vvhich covers the mouth and nostrils. This the patient said he had never used, because he found that those who were in the habit of wearing it did not enjoy better health. For thirty years he continued to enjoy tolerable health, with the exception of some bleeding from the gums, with shooting pains and a sense of formication in various parts of the body, accom- panied by a slight loss of power in the hands, which came on at va- rious times, and was generally relieved by the use of ardent spirits. He had been frequently salivated, and when admitted had lost nearly all his teeth. The mode in which he lost them was this: gum-boils formed close to the roots of the teeth, vvhich soon after dropped out, and in this way the local inflammation subsided. About three years ago, he had an attack similar to that for vvhich he had been admitted; he went into the hospital and was put under an active antiphlogistic treatment with relief. From that time up to the period of his ad- mission, he had enjoyed tolerable health, except that the sight of the right eye was considerably impaired, and that his memory was slightly affected. He forgot the names of persons and places, and was frequently at a loss in endeavouring to recollect the persons to whom he had lent his tools. On being brought into the hospital he presented an extraordinary specimen of human suffering, and I was at first unable to give his complaint a name, the case being the first of the kind I had seen. It exhibited the phenomena of a violent spasmodic affection; it was different from tetanus, or hydrophobia, or hysteria, but it bore some faint analogy to chorea. The head, arms, and fingers, particularly on the left side, presented a succession of quick, convulsive, jerking motions. The angles of the mouth were retracted, the eyebrows twitching, the head constantly thrown back, but the agitation scarcely raised the arms. The nostrils were spasmo- dically dilated. The sterno-mastoid, trapezius, scaleni, diaphragm, and the abdominal muscles, were similarly affected. Their contrac- tions were short, rapid, and painful. From the constant hiccup with which the spasms of the diaphragm were attended, and the jerking motions of the tongue, his speech was interrupted and indistinct. He was occasionally free from spasm altogether, but whenever he trans- mitted volition to any part of the muscular system, it became in- stantly affected. When he endeavoured to raise his foot from the ground, it quivered and fell quite powerless and useless. Whenever he attempted to carry a vessel to his lips he generally overshot the mark, carrying the vessel towards his ear, nose, or forehead, and spilling its contents over his face or neck, so that it was a common saying among the patients in the wards, that he did not know the way to his mouth. But if the vessel was applied to his lips by another CHOLERA MORBUS. 353 person he could swallow easily. A sudden blast of cold air, the ap- plication of a cold hand to the skin, or the abrupt entrance of any person into the wards, brought on an attack of spasms. The muscles of the left hand and of the left side were affected much more than those of the right.. The mental powers were not impaired, the pa- tient was intelligent, and seemed anxious to communicate the par- ticulars of his case. During the whole course of the disease he retained a full power over the urinary discharge and defecation. There was some slight tenderness on pressure over the fourth and fifth dorsal vertebras, but the rest of the spine exhibited no increase of sensibility. His skin was cool and dry, his pulse quick, weak,and small, his bowels inclined to be costive, but easily moved by laxatives. Here we see a marked difference between this affection and painters' colic. The treatment adopted in this case was very simple. Leeches were applied to the tender part of the spine, the patient was placed in a warm bath, and got some laxative medicine, followed by an opiate. He was also ordered to have a large flannel shirt, and to be placed in a warm, comfortable bed. He passed the night tolerably well, and next day appeared to be much improved. I shall not con- tinue the daily reports of this case, but shall merely mention, that after a few days a great improvement took place. The spasms of the left side continued, though much less severe. Those of the purely voluntary muscles on the right ceased, while the spasms continued in the respiratory muscles on this side. We found that all the muscles of the face which have been called respiratory by Sir C. Bell, the platysma, scaleni, pectoral, and intercostal muscles, and the dia- phragm, were thrown into violent spasms, while the purely voluntary muscles remained in a state of perfect quiescence. I am not aware that this circumstance has been observed in any other case. As far as it goes, it tends to corroborate the views of Sir C. Bell. In the treat- ment of this case we employed narcotic frictions, particularly those composed of the extract of belladonna, to the spine, with considerable benefit. The patient was cured by very simple means, and at little expense to his constitution.* LECTURE XXXVIII. DR. BELL. Cholera Morbus — Definition — Sydenham's description — Divisions of cholera.-— Sporadic or Common Cholera — Symptoms — Not a very fatal disease — Propor- tion of cases and deaths in the British troops in different regions — Greater pro- portionate mortality in northern than in southern latitudes — Often exceptions to this. — Causes — Mutations of temperature from heat to cold, and errors in regi- men — Seat of the disease — Not often depending on inflammation. — Diagnosis.— Treatment— Diluents—External irritation — Kmetics— Opium — Venesection occasionally — Calomel — Calomel and opium — Laxatives — Occurrence of gastro-enteritis — its appropriate treatment — venesection or leeching —laxatives, diluents, mild diaphoretics, and the warm hath. — Convalescence from cholera- Its treatment. Cholera Mounts, the name of the disease which will form the sub- ject of the present lecture, is a barbarous compound of Greek and * [Sinapisms, following cups to ihe spine, constitute, with some, part of the regular treatment of lead-colic — B.] 30* 354 DISEASES OF THE DIGESTIVE SYSTEM. Latin, as bad as if in our own vernacular language we should say cholera disease. The term cholera itself has been in use since the days of Hippocrates; but respecting its origin, subsequent medical writers differ. Celsus derives it from *«>.», bile, and />««, I flow ; which is, literally, bile-flux. Trallianus, again, supposes it to be derived from xox*s, intestine, and p«» ; intestinal flux. With our present knowledge of the subject we may wish that this last explanation had always been the popular one ; as it would have saved much erroneous speculation and practice, which have resulted from the predominant idea of the disease originating from an excess and acrimony of the bile. A brief definition of cholera as, until late years, it presented itself in the adult subject, is,— griping pains followed by vomiting and purging, very rarely with flatulent eructations and dejections, and always with spasms of the extremities, particularly the inferior, and anxiety. To these should be added coldness of the skin, and often a cold sweat. The nervous and spasmodic character of the disease was dwell on by Cullen, and its affinity to fevers pointed out by Pinel. I shall not occupy your time with repeating the descriptions of cholera by the ancient writers, but come down at once to him, among the moderns, who has treated the subject with the greatest clearness and practical acumen, — I refer now to Sydenham. He tells us, that, " it comes almost as constantly at the close of summer, and towards the beginning of autumn, as swallows in the beginning of spring, and cuckoos towards midsummer;" thus declaring its epi- demical visitations, and the state of weather which gives rise to it. He distinguishes cholera appearing under the predisposing operation of atmipspherical causes from the occasional variety caused by a surfeit, " which happens at any time of the year, which, with respect to its symptoms, resembles the cholera morbus, and yields to the same treatment, and yet it is of a different kind." Sydenham notices a dry cholera, which he admits he saw but once, and which certainly is not, in the absence of retching and stools, and in its alleged causes, "flatus passing upwards and downvvards," entitled to be regarded as cholera at all. The only useful divisions of the disease are into — 1, Sporadic Cholera ; 2, Epidemic Cholera ; and 3, Cholera of Children, or Cholera Infantum. I shall speak of these in succession, and in the order of their enumeration. Sporadic, or common cholera, sometimes is preceded by symptoms of indigestion -—eructations, oppression at the epigastrium, colic, and distressing nausea. At other times the attack is sudden —purging followed almost immediately by vomiting — and the progress of the disease is short. The matters first discharged from the stomach are aliment mixed with fluids, if the attack has come on shortly after a meal. Soon, however, bilious fluid constitutes the almost entire dis- charge; which is unaccompanied with pain, and allows of intervals of some repose. The discharges by stool, after the first or feculent ones, are analogous to those by the mouth. After the lapse of a few hours these symptoms are aggravated; the cardialgia is insup- portable, the violent movements of ejection of the stomach and bowels, and the forced contractions of the abdominal muscles, are accompa- nied by much pain and anxiety; the matter passed by vomitim* and SPORADIC CHOLERA. 355 stool are also changed ; they are now brown, or blackish, eruginous or porraceous, and diffuse a fetid odour; sometimes they are acid, and occasionally sanguinolent. But although the discharges generally are thus dark, they are not always so, particularly in warm climates, Celsus and others have noted their white appearance. The patient is tormented wiih excessive thirst; all his functions are perverted; the breathing is quick and panting; the voice hoarse ; the pulse small, frequent, contracted, irregular, and extinguished by pressure. The „ tongue is dry; the urine scanty. The face, which was at first some- what suffused, assumes a frightful paleness; it is bathed with a cold sweat, particularly evident on the upper part of the trunk; sinking and fainting away are common, and there is an extreme prostration of both physical and mental energy. Notwithstanding this extreme weakness, the muscles still contract, but it is in jerks, or with an almost tetanic rigidity ; the arms and legs are motionless some minutes, until a new pain throws them into a new posture. The patients always complain of very painful cramps. It is difficult for them to take any drinks at this time; the contractions of the stomach reach the oesophagus; all is thrown back by the efforts to vomit and the hiccup; and the introduction of enemata is prevented by the emission of gas from the intestines. Death is not by any means a common result of cholera, even in hot climates, unless it assumes an epidemic form. In the Island of Jamaica the aggregate strength of the troops during twenty years, ending 183G, was 51,517, of which number, in this period, there were 12,282 cases of diseases of the stomach and bowels; and of these, but 21G of cholera morbus, of which the deaths were only three in number. Among all the troops, in both the Windward and Leeward Islands, the aggregate number of whom, for twenty years (1817 to 183G, inclusive), was 80,661, the number of cases of cholera morbus during this period was 1173 ; of which only 24 resulted fatally, or a little over 1 death in 49 attacks. The proportion in Jamaica was but 1 in 72. A better idea of favourable result in this disease will be obtained by comparing it with remittent fever in the same island, among the same force, and for the same time : the proportion of deaths in this latter, was rather more than 1 to 9 attacks. In Gibraltar, ihe cases of cholera morbus during eighteen years was 1230, of vvhich the deaths were but 7, or 1 in 175-7, in an aggregate strength of 60,201). In Malta, during the same period, in an aggre- gate force of 00,269 men, the number of cases of cholera morbus was 451, and the deaths 5, or about 1 in 91. On the western coast of Africa, however, the proportions are different; for, of 9 cases of cholera morbus, in an aggregate strength of 1843 men, the deaths were 2, or 1 in 4| cases of admission to hospital treatment. At the Cape of Good Hope, the number of deaths to cases of cholera morbus was 2 in OS or J to 34. In Nova Scotia, in an aggregate strength of 10,142 men, in a period of twenty years, there were 427 cases of cholera morbus, of which the deaths were 4, or 1 in 10G-7. For the preceding returns I am indebted to the Statistical Reports on the Sickness, Mortality and Invaliding among the Troops at the different Foreign Stations of the British Empire/by Major Tulloch. If we 356 DISEASES OF THE DIGESTIVE SYSTEM. compare Gibraltar with Nova Scotia, we find that the proportion of eases of cholera morbus in the troops was, in the former place. I in 59, and in the latter, 1 in 108, omitting decimal proportions, but that the proportion of mortality to the number of cases of the disease was greater in Nova Scotia than in Gibraltar. In the United States, there are more cholera and colic among the troops in the northern than in the middle and southern division; the annual ratio of cases per 1000 is 145 in the former, and 131 in the latter. In the northern division only 2 deaths in 3221 cases are reported; and in the middle and southern, 7 in 3882 (Dr. Forry,— The Climate of the United States and its Epidemic Influences). Hillary, speaking from his observation on the inhabitants of Barbadoes, thinks that cholera mor- bus is a lighter disease there than at home, in England. Causes. — The preceding details are introduced to show the com- parative infrequency of cholera morbus, and the small proportion in vvhich it it fatal. I oui>ht to have stated, however, in order to make ■th.e comparison more complete, that, in the Windward Islands, where the proportionate mortality from cholera morbus was greatest, or 1 in 49, the proportion of deaths from acute dysentery, during the same period and among (he same number of soldiers, was 1 in 23, and from chronic dysentery, 1 in 5. These details are useful in another point of view, by enabling us to dispute both the propriety of re- garding the disease as the effect of excess or of acrimony of bile, and the division into bilious, flatulent, and spasmodic, as attempted by some writers. There is not a proportion iu the relative frequency of cases of disease, certainly not in mortality, so much greater in southern than in northern regions, to justify a belief in its hepatic origin. The mortality on the coast of Africa from cholera morbus is analogous to that from fevers in that region, but not to that from hepatic derangements. The differences in the amount of bile dis- charged and in the greater or less prevalence of spasmare fortuitous, and will vary at different times iu the same individual. I speak now of merely one of the elements of climate, atmospherical heat, which is believed to be an exciter of the hepatic secretion. But if we extend the range of inquiry, after noting the causes of sporadic cholera morbus, we soon discover that these are more common at particular seasons and in particular localities; and that in such a degree as to render the disease endemic. It has been thus that it appears from time to time in the East Indies, and other tropical regions. Epidemically, or as occurring from a combination of causes produced or measured by particular seasons, it is not uncom- mon in northern Europe and America, according to the description of Sydenham and others. But, however common cholera may present itself sporadically or frequent, and aggravated by epidemical influences, we recognise a general sameness of causative impressions. These are exposure of the body, after it has been much heated and over-fatigued, to a cool and damp air, by which congestion is induced in the system of the vena porta?; the use of indigestible and irritating food, which acts as a morbid exciter to the already irritable gastro-intestinal mucous membrane; and drinking spirituous and newly fermented liquors, which serve still further to irritate this latter. SEAT OF SPORADIC CHOLERA. 357 Seat of the Disease. — The first effects of this irritation are the increased secretion from the gastro-intestinal glands, and by con- tinuous sympathy from the liver; but the prevailing tendency to congestion soon locks up the supply from this last viscus, and the bile, poured out for a short time, is now arrested. The disease con- tinues to manifest its violence, not owing to excess, nor, it may be said,to deficiency of bile; although,certainly th'is last mentioned fluid is after a while deficient; and one of the evidences of an amelioration of the disease and return to health, is the restoration of its secretion. Truly has Dr. Johnson said, "that in no disease has a symptom passed for a cure with more currency or less doubt than in cholera morbus." {On Diseases of Tropical Climates.) You will find many instructive views pleasantly expressed, both in this and other diseases of intertropical regions, in the work just referred to. I stated to you, in my remarks on bilious colic, that a slight modifica- tion in the state of the system of a person attacked with it, would have subjected him to cholera morbus, so much is there of sameness in the causes. Bilious colic is distinguished, it is true, in one essen- tial particular; viz., in the absence of all purging; and in the com- paratively small proportion of fluids discharged by vomiting ; but in both there are gastro-intestinal irritation and congestion, and in both a transfer of this to the spinal marrow and its subsequent irradiation on the voluntary muscles, and cramps and other spasms are the con- sequence. The analogy is still more evident between the two dis- eases in a pathological point of view, when we observe the symp- toms in some cases of cholera morbus in which the vomiting and purging and spasms have ceased. The patient feels at this time some uneasiness in the epigastrium and other parts of the abdomen, vvhich is increased on pressure. The pulse is frequent and resisting, the tongue dry and furred, or red and glazed ; the thirst is great, appetite wauling ; some nausea and constipation. When the bowels are moved the discharges are usually of a dark brown appearance. These symptoms, so closely resembling what occurs in bilious colic after a subsidence of the disease, as I pointed out to you at the time (p. 31 I), indicate gastro-enteritis, and demand no little watch- fulness from the medical attendant. But it would be a grave error to assume that this state of occa- sional occurrence represents cholera, as we commonly meet with it. Irritation we undoubtedly have, and its concomitant in all the mu- cous surfaces, increased secretion, followed, if this go on long, by congestion; but inflammation of the gastro-intestinal tissue is far from being proved: on the contrary, we must admit its absence in the greater number of cases of common cholera. Autopsic exami- nations of the bodies of those who have died of the disease are far from proving it to be a modification of gastritis or of gastro-enteritis ; and the occasional presence of certain spots of discoloration and in- jection, sometimes in one part or other of the stomach or of the small intestine, sometimes on the liver, may be regarded as a casual asso- ciation or effect, rather than the material cause of cholera. These lesions have been found more generally after the appearance and duration of symptoms described as characterising the second but 358 DISEASES OF THE DIGESTIVE SYSTEM. not common stage. Where death has come on rapidly, no organic change was seen. Nor can we derive more aid from morbid ana- tomy in the attempt to give a hepatic pathology to cholera, by en- abling us to point out congested and otherwise morbid conditions of the liver. These are indeed seen, but not with a uniformity or a frequency that can allow of our regarding them either as causes or necessary accompaniments even of the disease. We shall not, it seems to me, be in error, if we admit, as the direct exciting cause of the phenomena of cholera, an irritation of the digestive mucous membrane, beginning chiefly in the duodenum, and extending upwards to the stomach, downwards to the small intestines and their continua- tion ; and in another direction, along the common duct to the gall- bladder and liver; with, as a common sequence of mucous irritation, increased and irregular contraction of the muscular coats of the gastro-intestinal canal, and determination and accumulation of blood in its tissues. Cholera sometimes ushers in another disease, or may lapse into one, such as fever of some kind, or dysentery. Cleghorn speaks of its assuming a tertian type; and Martin relates a case of intermittent cholera. Dr. Chapman mentions it as one of the forms of yellow fever, and states that he met with many instances of it during the prevalence of pernicious intermittents among us. {Lecture on Cholera Morbus, op. cit.) To arrive at a correct diagnosis of cholera morbus, we have to distinguish it from epidemic cholera and from poisoning by acrid substances. Between a severe case of the first and a common attack of the second it is not easy to determine, unless in the circumstances of accompanying atmospherical constitution and epidemical exten- sion of disease. The more precise characters of the epidemic kind will be given in a subsequent lecture, when it will be formally the subject of inquiry. Common cholera is not readily distinguishable from certain kinds of poisoning. The more rapid termination of the latter, in fatal cases, has been alleged by Dr. Christison {On Poisons), to be a characteristic feature, but erroneously. Diarrhcea, common to both diseases, generally occurs almost simultaneously with vomit" ing, or somewhat precedes it in cholera, whereas it comes on after the vomiting where poisons have been swallowed. A common but far from universal difference is, in the sanguinolent fluid being mixed with the ejected matters in the latter case, and its absence in the former; but sometimes this feature is distinctly observable in cholera. The chief diagnostic sign, however, is the sense of heat, acridity, or burning in the throat, and along the oesophagus to the stomach, vvhich is so much complained of in poisoning, and precedes the vomiting. In cholera a similar sensation is far from being so uniform ; and when it does show itself, it is often confined to the stomach, and follows the vomiting. The diagnosis between cholera and colic, ileus, diarrhcea, and dysentery, is easy, and need not be repeated here. Treatment. — That which is generally regarded as the first indica- tion in the treatment of cholera morbus, is to encourage the evacua- tion of the morbid secretions, and to diminish their acrimony. In order to effect this, free dilution is recommended, by the ingestion of TREATMENT OF SPORADIC CHOLERA. 359 simple drinks,-such as herb teas, rice and barley water, and, as Sy- denham prescribed, weak chicken broth or chicken water. But 1 believe that a more important indication to propose to ourselves, is a removal of the irritation of the gastro-intestinal mucous membrane, and the accompanying congestion, on which the morbid discharges are dependent. Hence, our remedies should be addressed to the organs rather than to their secreted products; the quantity and acri- mony of which latter Will seldom be detrimental, if the sensibility of digestive surfaces be brought to a healthy standard. Even to ac- complish this end, diluents and demulcents are not without their value; and of all, there is not probably any one better than water, cold or tepid, or warm or hot, according to the instinctive craving of the patient and his gastric sensibility at the lime. The ingestion of tepid or moderately warm vvater will at first increase the vomiting; and might, if long continued, keep up the nausea ; but, afler a while, the stomach is more composed, and the feelings generally of the pa- tient tranquillized. Cleghorn tells us, that the Spanish physicians found nothing more beneficial in the worst cases of cholera than drinking of cold water. The thirst being great, and the patient still clamorous for drink, water may again be administered—cold, if the inward heat be great and depression not alarming,— hot if an opposite state of things exists. In any case, the quantity of fluid taken into the stomach, after the first draughts of tepid water, should be small. Repeated doses of water, as hot as can be drunk without scalding the mouth, will often be readily retained by the stomach, and act as an ano- dyne to this organ, and diffuse moderate excitement through the system at larue and in a most beneficial manner to the skin. Favouring this latter operation, and at the same time contributing to the relief of the congestion of ihe chylopoietic viscera, will be warm applications, by dry heat, to the extremities, fomentations to the abdomen, or the warm bath, if it can be used without fatigue to the patient, or requir- ing him to change his recumbent posture. Conjoined with this means of procuring cutaneous excitement will be friction with the hand, or soft flannel, or a flesh-brush, steadily but not roughly applied along the limbs and spine. More potent applications are sinapisms, ammoniatcd liniments, &c, to the spine and the extremities, and over the epigastric region. Before detailing the farther treatment in this disease, I must speak of the course advocated and pursued in the first stage, different from that vvhich I have just described. It is to administer an emetic with the intention of exciting the stomach not only to an entire discharge of its contents, but also both it and the small intestine and liver to a healthier secretion. Hazardous as this practice would at first seem, it is not only sustained by plausible argument, but, still more, by successful results. I well remember my feelings of repugnance when I first heard it formally announced and advocated by Dr. Chapman, in the first course of his admirable lectures on the practice of medicine ; and my jirivato (written) criticisms on the occasion. I was at. the time little aware that, in fifteen years from that time, I should be found among those who placed no little reliance on the emetic prac- tice in the more formidable and dreaded variety of cholera. Hillary, 360 DISEASES OF THE DIGESTIVE SYSTEM. antecedently, had recommended ipecacuanha in the cholera morbus, in the Island of Barbadoes, and particularly among children. When we design to administer a remedy of this nature, ipecacuanha should be preferred ; and, as it is desirable to produce a deeper impression on the stomach than simple expulsive contraction of its muscular coat, we had better give the medicine, mixed with vvater, in a dose of two or three grains, to repeated at intervals of half an hour until the dark and morbid matters are all discharged, and the healthier secretion of mucus, mixed with some bile from the liver, is visible. By the opera- tion of an emetic, reaction is brought about more speedily and en- tirely; and the skin, before cold and clammy, now becomes warm and moistened with a natural sweat. There is a greater probability, also, of the purging being abated and checked by an emetic, than if the evacuation of the stomach is left to natural irritation. Relief having been procured from vomiting and purging by these means, either the simpler ones first recommended or the emetic just described, the patient often falls into a slumber; and in milder cases the disease requires little else than a mild purgative infusion of rhu- barb or senna to insure convalescence. But if the original symptoms remain or return after a slight remission, recourse must be had to opium in some form. In a solid state, or by pill, it is most apt to be retained by the stomach ; in its liquid, or in the shape of laudanum, it is best adapted for use as an enema, with a small quantity of warm water or of gruel, or flaxseed tea. At this juncture, the ques- tion may well present itself, as it would do in bilious colic, viz., whether we require the aid of the lancet. The answer will depend not only on the existing symptoms, — the violence of the spasms, the intestinal heat and oppression complained of, obvious determina- tion to some important viscus, and the resistance of the pulse, — but also on the antecedent circumstances, such as gastro-intestinal irrita- tion, chronic phlogosis of some organ, or a course of life well calculated to bring on gastro-enteritis. If this state of things present itself, we ought to bleed, — as a measure of wise prudence, if not of impera- tive necessity. By so doing we shall probably relieve the conges- tion of the portal system, remove any existing gastro-enteritis and the oppression from accumulation in the great vessels and right side of the heart, and favour healthy reaction, besides predisposing the system to be more promptly and beneficially impressed by opium. I say nothing of the various received remedies of the class of aro- matics and spices which are supposed to be efficient in checking vomiting. They are in severe cases of little avail, and in milder cases hardly called for. Their preparation and administration are often indirectly injurious, by diverting attention from more important measures This remark does not apply to camphor mixture, a few drops of tincture of camphor on sugar, or oil of turpentine, also, in small ddses with sugar. Opium, and these remedies, and the sim- pler external irritants failing to check vomiting, or the oppression being great from the beginning, and no adequate reaction manifesting itself, a blister must be applied to the epigastrium. In a large number of cases we shall be content to evacuate the stomach by diluents or a mild emetic, then tranquillize it by opium, and afterwards endeavour to carry off still retained excretions in the EPIDEMIC CHOLERA. 361 intestines, and to restore the proper secretions of these parts. If we can procure a remedy which, whilst it is congenial with the irritated stomach, also meets the indications just mentioned, we shall of course give it the preference. In calomel we have an agent of this nature ; and ten or twelve grains of it, in pill, administered at the out- set, will suffice to soothe the stomach, check vomiting,and act on the liver, and determine downwards the still retained matters in the digestive canal, and finally procure their expulsion. It will be well, in general, in order to secure the first sedative operation of the calo- mel, to give opium, from half a grain to a grain, in combination with this latter. Failure of the first dose, or its incomplete effects, will justify a repetition, of the calomel, either alone or with opium, as the symptoms, particularly the persistence of the spasms, may seem to require. Bile once seen in the stools, or their being coloured green with calomel, will indicate that an adequate effect has been produced by this medicine : and the propriety, if more abundant evacuations are required, of giving a laxative of rhubarb and mag- nesia with ginger, — or castor oil with cinnamon vvater. Should the stomach remain irritable, we must be content with prescribing a few grains of blue pill, once or twice a day, or hydrarg. cum cretd, and enemata to open the bowels. Mention has been made already of a state of things of occasional occurrence in cholera morbus, resembling gastro-enteritis. This is more liable to be met with afier a sudden stop has been put to the vomiting and purging by the premature use of opium and astringents: but it may come on without any such cause. In either case, it re- quires venesection, or, if there be much epigastric tenderness and a red and dry tongue, leeches to the affected part of the abdomen,— then laxatives, simple enemata, diluent drinks, and the milder saline diaphoretics, such as citrate or acetate of potassa with minute doses of tartar emetic dissolved in it, warm pediluvia, or the warm bath. The languor and debility, often extreme, left after an attack of cholera, require great care, by an avoidance of the former causes of the disease, the use of a simple yet nutritious diet, simple bitters with some aromatic addition; and, if these do not suffice, sulphate of quinia, from three to five grains daily, for a few days. LECTURE XXXIX. DR. BELL. Epidemic Cholera.—A counterpart to the pestilences of olden times—The great pestilence in the fourteenth century—Less mortality with advanced civilization. —First appearance of the epidemic cholera in India—fts progress in that country and in Eastern and Western Asia and the islands—in Russia; Poland ; Hun- gary; Austria—lis appearance in England, Scotland, and Ireland; United States; Mexico; Havana; Southern Europe ; Algiers—Order of succession of the ati.vks of cholera.—No regular rale of progress or rule of transmission— Quarantine restrictions useless—Singular limitations of its range by the smallest change of locality. It was reserved for our own time fo present a counterpart of those dreadful pestilences which devastated the world in the latter periods vol. i.—31 362 DISEASES OF THE DIGESTIVE SYSTEM. of the Roman empire, and afterwards in the middle or barbarous ages of Christendom. Many a reader of history must have felt his amaze- ment at ihe extent and violence of those visitations abate by a not ill-founded doubt of the accuracy of the narrator, whose ignorance, ministered to by his love of the marvellous, might have led him into exaggerations. But the appearance and spread of the epidemic cholera over all parts of the civilized world, or wherever men were largely congregated into thickly settled communities, and the frightful mortality which everywhere followed in its train, brought too con- vincing proofs to the mind of the most skeptical that historians, in describing the pestilences in the reign of the Antonines and of Justi- nian, and later in the period which elapsed between the years 1345 and 1350, had not drawn the materials of their narratives either from their own fancy or the stores of fiction. But, while thus reminded, in such fearful characters, of the times of imperfect civilization, or, what is sometimes worse, methodised barbarism ; and although seemingly, for a time, we were reduced to a level with the people of the barbarous ages, we shall soon discover, after a proper comparison, that our arts and sciences and the social influences of our religion and institutions have exerted a conservative power for the benefit of the many, which in former times was imperfectly secured to the few. Let me detain you for a few moments in setting forth some data for a comparison of this nature. I shall draw them chiefly from a small work which, on the spur of the occasion, I prepared in 1832, in con- junction with my friend, Dr. Condie, at the time of the prevalence of ihe cholera in this city. It is entitled "All the Material Facts in the History of Epidemic Cholera: Being a Report of the College of Physicians of Philadelphia to the Board of Health : and a Full Account of the Causes, Post-mortem Appearances, and Treatment of the Disease. Second Edition." The great pestilence in the fourteenth century just adverted to, like the cholera in our own time, is represented to have begun in the east (China).—It appeared in Egypt, Syria, Greece, and Turkey, in 1346; in Italy, and Sicily, in 1347 ; in France, and the southern parts of Spain, and in England, in 1348; in Ireland, Holland, and Scotland, in 1349; and in Germany, Hungary, and the north of Europe, in 1350, lasting generally, it was alleged, about five months in each country. In this period a cornet was visible —also meteors of various kinds ; the seasons were irregular — myriads of insects were seen — domestic animals sickened and died — and fish were found dead in immense numbers. So deadly was the onset of this plague, that at least half, some say two-thirds, of the human race, were destroyed bv it. It was most fatal in cities, but in no place died less than a third of the inhabitants. In many cities, nine out of ten of the people perished, and many places were wholly depopulated. In London, we are told that 50,000 dead bodies were buried in one grave-yard. In Norwich, about the same number perished. In Venice, there died 100 000. In Lubec, 90,000. In Florence, more than three out of five died, or upwards of 50,000 in stII. In the East, it has been said, with what degree of accuracy we cannot vouch, that twenty millions perished in one year. In Spain, the disease raged three years, and carried off two-thirds of the people. EPIDEMIC CHOLERA. 363 In England, and probably in other countries, cattle were neglected and ran at large over the land. The grain perished iu the fields for want of reapers; and after the malady ceased, multitudes of houses and buildings of all kinds were seen mouldering to ruin. Although in the preceding year there had been abundance of pro- visions, yet the neglect of agriculture during the general distress produced a famine. Such was the loss of labourers, that the few survivors afterwards demanded exorbitant wages, and the Parliament of England was obliged to interfere, and limit their wages, and even compel them to labour. See 23 Edward III., a.d. 1350. The disease reached the high northern latitudes; it broke out in Iceland, and was so fatal that the island is supposed never to have recovered its population. It was there called the sorte diod, or black death. (See Hecker on the Black Death, Arner. Edit.) The pestilence was remarkably fatal to the monks and regular clergy of all descriptions. At Avignon, where the disease first ap- peared iu France, 66 of the Carmelites had died before the citizens were apprised of the fact; and when it was discovered, a report cir- culated that the brethren had killed one another. It is an important fact in the history of this epidemic, adverse to a belief in ils contagion, viz., that the disease first appeared iu a city not commercial, nor a sea-port ; and in a monastery which was probably crowded with indolent and not over-cleanly monks. In perusing the narratives of the awful plagues in the reign of Justinian, and in the first part of the fourteenth century, we learn that mankind have suffered more on former occasions from the visi- tations of disease, than, of late years, from the dreaded scourge of cholera; and we infer, also, the ameliorating influence of civiliza- tion— implying improved minds, and knowledge, and a greater amount of means for promoting personal comfort and protection against morbid causes. Dreadful as the mortality from cholera has been, we cannot but see that it is mainly restricted to a par- ticular class, whose situation and habits reduce them to a level with a large majority of the people of the middle or barbarous ages, and expose them to the same calamities in seasons of epidemical disease. When a pestilential malady, call it what you will, yellow fever, cholera, &c, now appears in a city, but a small portion of the inhabi- tants are victims to the disease. In former ages, analogous diseases, passing under the common appellation of plague, would nearly de- populate a city. We have already mentioned the loss of 50,000 citi- zens of Florence, a third of the entire population, by the plague of 1347. In 1359, on a similar visitation, the mortality was estimated at 100,000; whereas the deaths from the cholera iu Moscow, with a population of 350,000, in 1830, were short of 5000. St. Petersburgh, also, with nearly an equal population, encountered the like loss. Vienna, containing 300,000 inhabitants, lost not 4000. Even in Paris, where the mortality was excessive, amounting to upwards of 18,000, if we consider the population of that city, 800,000 inhabi- tants, we cannot but be sensible of the increased advantages vvhich the people of the civilized world at this time enjoy, of either ward- ing off pestilence entirely, or of greatly mitigating the violence of its 364 DISEASES OF THE DIGESTIVE SYSTEM. attacks. London, with a population of 1,500,000, lost but 5000, and in all Great Britain the deaths were somewhat more than 20,000. In Philadelphia, with a population of 160,000 souls, the loss by cholera was under 1000. In the East, the mortality from the cholera has been excessive, but this fact serves to confirm our proposition — since we know that the mass of the people in that quarter of the globe are in the same half barbarous state now in vvhich they were five and even ten centuries ago. Without fear of being taxed with plagiarism I shall borrow with equal freedom from the Report of the College of Physicians in 1832, which I drew up in the name of the Committee on the occasion. First, I shall speak of its reputed origin and geographical range : — Most of the historians of cholera describe it as first showing itself in Jessore, a town 62 miles N.E. of Calcutta, about the middle of the month of August, 1817. But it is known that its appearance in this last mentioned city was nearly contemporaneous, nay, some say anterior, to its breaking out in Jessore. It is distinctly affirmed in the Bengal Medical Reports, that the disease appeared in the Nnd- deah and Mymensing districts in May, 1817, raged extensively in June, and in July reached Dacca. Before the end of November, few towns or villages in an area of several thousand miles escaped an attack. Across the whole extent of the Gangetic Delta, and espe- cially in the tracts bordering the Hoogly and Jellinghy rivers, the mass of the population was sensibly diminished by the pestilence. It is needless to describe minutely, in this place, the ravages of the cholera in the various towns and districts of Hindostan. These were, in one direction, along the Ganges and its tributary streams. Delhi, the ancient capital of that country, on the western bank of the Jumna, was attacked in July, 1818. The disease appeared in Bom- bay, on the western coast, in August, and in Madras, on the eastern coast of the peninsula, in October, 1818. In Trincomalee, in the Island of Ceylon, it was first noticed in December of the same year. Since 1817, Calcutta has been a regular sufferer from cholera every season. The same remark will apply to Bombay, and, with the ex- ception of two years, to Madras. In 1820, we find the cholera to have shown itself in Cochin China, Tonquin, and the Phillipine Islands, and at the conclusion of the year it was in Canton, and the southern part of China Proper. Pekin, the capital, was assailed in successive years, and in Chinese Tartary, cholera appeared at two different times, with a considerable period intervening. In the Island of Java, it broke out in April, 1821, and in the Molucca Islands, and in Canton for the second time, in 1823. In July, 1821, it showed itself at Muscat on the southern end of the Persian Gulf, and in the same year at Bassorah and Bagdad. Persia has been subjected to its ravages five different times from 1821 to 1830. In 1822, the disease was raging in Mesopotamia and Syria, having appeared as far west as Tripoli, on the shore of the Mediterranean Sea, and in the year 1824, at Tiberias, in Judea, on the same coast. In September, 1823, the disease showed itself in Astracan, a large and populous town at the mouth of the Volga, on the northern shore EPIDEMIC CHOLERA.. 365 of the Caspian Sea. But it soon subsided here and did not break out again in any part of the Russian Empire until the close of the year 1829, when'the town of Orenberg was attacked. On the last of July, 1830, it again appeared in Astracan, in vvhich city and province the mortality was this time excessive. Near the close of September, of the same year, it was announced as prevailing in Moscow, and in June, 1831, in St. Petersburgh and Archangel. Riga and Dantzic had begun lo suffer from the pestilence in May of the same year. Its presence was discovered among the wounded and prisoners, who had been conducted to Praga, a suburb of Warsaw, but separated from that city by the Vistula. On the same day it appeared in the Polish army, after the battle of Inganie. Hungary was the theatre of its operations in August of the same year (1831). Constantinople was its theatre in July ; and part of Greece in November. In Berlin and Prussia it appeared in August, in Vienna in September, and in Ham- burgh in October of that year. It reappeared in Berlin, Prague, and Dantzic, in 1837. The first place attacked in England, by the cholera, was Sunder- land, a sea-port town in the county of Durham. The disease had appeared there as early as August, 1831, but did not engage general attention or excite alarm, until the latter part of the year. Ii then manifested itself in Newcastle-upon-Tyne, and many other contiguous places in the north of England ; and in Haddington, Edinburgh, Glasgow, and other towns in Scotland, from January to August, 1832. It showed itself in London in February of this year, 1832; and again, in a more limited degree, in 1833 and 1834 ; and attacked a few individuals in 1837. In the spring of 1832 it was in Dublin, Belfast, Cork, and other places in Ireland. In the early part of April, its presence was announced in Paris, and since then it has appeared not only in the small towns around that capital, but in many other places in France. In June, 1832, it was ravaging Montreal and Quebec. In July, New York ; and in August, Philadelphia, Balti- more, and Washington ; Cincinnati and New Orleans were assailed in October. Boston suffered slightly, in this year, also. Richmond had its turn in the following year. The different military posts of the United States were assailed in succession, during the years 1832, 1833, 1834, and 1836. Mexico was ravaged by it in the summer of 1832, and Havana was a sufferer in the spring of 1833. In 1834 cholera renewed its attacks in New York and Philadelphia, but, especially in the latter city, with miti- gated violence; Charleston, S. C, was visited in 1836. The disease broke out in Portugal in 1833; its first appearance was at Oporto; but it did not show itself in Lisbon until the following year. In 1835, when the cholera had ceased its ravages in the south of France, it showed itself in Piedmont, Genoa, and Florence, and in September, 1830, at Naples; while Rome was not a sufferer until August, 1837 ; Malta also suffered about the same lime. In the king- dom of .Naples, all the machinery of quarantine, aided by the military cordons and the greatest vigilance of the government and its officers, was insufficient to prevent the breaking out of the disease in the capi- tal, and equally unavailing were all the measures of separation and 366 DISEASES OF THE DIGESTIVE SYSTEM. seclusion of the first attacked, to prevent its diffusion. Spain paid the tax of fright and death in 1833 ; Gibraltar in 1834. Algiers and Bona were attacked in 1837. A few observations will naturally follow, on the Order of Succes- sion in which different Countries "and Districts have suffered from Cholera. These will serve to remove the impression which the ac- count of its progress from east to west, apparently along the great highways of trade and social intercourse, might produce in favour of the disease having been extended by contagion. The cholera, during the year 1817, that in which it first appeared in many different parts of Bengal, was mainly restricted to this province. It ceased to pre- vail anywhere on the approach of winter of that year. Up to this time the most southerly point along the coast, stretching to the south and west, which was attacked, was Cuttack, and that to the north and east (taking Calcutta as the centre), was Silhet. In the following year, 1818, the order of procession was remark- ably regular —a month's interval for every degree of latitude. Ganjam, which is in 19° and some miles north latitude, was attacked on the 20th March; and Madras, in north latitude, 13°, October 8th. This was the rate during the dry season, and when there was no interference with the constant commercial intercourse which prevails on the Coromandel Coast. From Madras south, the order of succes- sion was in an accelerated degree. It is worthy of remark here, that for two months, beginning on the 10th of October, the port of Madras is annually closed, and in consequence of the prevailing winds, and of the surf, which during this period breaks upon the whole of that open coast, every vessel is forced to leave it, and the small vessels are drawn high and dry on land. Yet still, as just remarked, the places to the south were assailed by the disease even in more rapid succes- sion than those to the north of this city. Not very dissimilar was the order of succession in which places in the interior of the peninsula were attacked — so that the disease ap- peared nearly simultaneously at the sea-port of Madras, and in places on parallel latitudes, in the interior. At Masulipatam, a town on the Coromandel Coast, and situated near the mouth of the Kristnah river, the disease showed itself on the 10th of July, 1818; and at Punder- poor, on one of the head branches of this river, in a W.N W. direction, and distant some hundred miles, it appeared on the 14lh of the same month, while intervening places were affected at a later period. Bellary, in the centre of the peninsula, in latitude 15°, was attacked on the 8th September. Nellore, on the eastern coast, was first a suf- ferer, on the 20th of the same month—so that we cannot conceive of any direct progression of the disease, or of any substantive cause of its passing from the coast to the interior, nor from the interior to the coast. The long interval also between the appearance of the dis- ease at Cuttack by the last of September, 1817, and at Ganjam on the 20th of March, 1818, forbids our supposing the transmission of any known substantive cause of the disease from one of ihese places to the other—both being situated on the coast, and within a moderate distance of each other. Aska.near Ganjam, in the interior, and on the main route south-west from Cuttack, was not visited by the dis- ease till the 23d April, 1818. EPIDEMIC CHOLERA. 367 In China, we find that the disease one season attacked places in succession in a south-easterly direction from Tartary'to Pekin, and at another time assailed them in a north-west course from Canton to Pekin. Persia was attacked in different years by cholera, and the order of succession and direction not regular. From Bassorah, on the head of the Persian Gulf, through Mesopotamia to Aleppo, and along the coast of Syria to Damascus, the direction was north- west— but the attacks were not in any very marked order—the period between its being in Bassorah and in Damascus was four years. A caravan would traverse the same space in near\y as many months. Esypt, contiguous to Syria,and holding regulai .ntercourse with it both by sea and land, did not suffer from cholera until eight years after its appearance in Antioch and Tripoli, a Syrian sea-port, and nine after its attacking: Aleppo. During the month of May, 1831, the Cholera broke out. in Mecca and other places in Arabia, and in the month of August in Cairo and Alexandria, in Egypt. The disease was in Astracan, at the mouth of the Volga, on the Caspian Sea, in September, 1823. No places to the north and west were sufferers from the disease either on this or the following years, until the month of July, 1S30, when it reap- peared in Astracan. From this time, until the beginning of winter, a great portion of Russia in Europe was attacked with cholera; but in following a given line, from Astracan, along the banks of the Volga, in the north-west course, we cannot find any regular order of succession of attacks of towns and villages. Thus, Astracan, at the mouth of the river, was, as we have seen, the seat of the pestilence in July, 1830. Saratov, higher up, and Novgorod, some hundred miles still farther up the stream, suffered in August of the same year, while Samara, situated between them on the Volga, had no cholera all October. Asof, at the mouth of the Don, was attacked in Octo- ber, whilst the region of country to the north and west, and on as far as Moscow, suffered from the disease in September. Kiow, on the Dnieper, felt its ravages in October, 1830, whilst Brody, on the south- west, had not the disease until May, 1831. On the Baltic, we meet with similar irregularities. In Riga, the disease prevailed in May ; in Mitteau, to the south, in June ; in Liebau, more southerly, in May; and in Polangen, still farther south along the same line of coast in June. If, again, we take a city on the extreme eastern boundary, as Orenberg, for example, we discover that the disease prevailed there in September, 1829, and a year elapsed before places on the great roads, to the west or interior of the empire, were affected. Archangel and St. Petersburgh, the first on the White Sea, ihe second on the Gulf of Finland, were both the seats of the disease in the same month (June), 1831, while Valogda, directly in the line of vvater or commercial communication, was a sufferer in September of the year before, or 1830. The cholera appeared in Warsaw in April, 1S31 ; in Dantzic in May; in Pest (Hungary), on the Danube, in July ; in Vienna, higher up the river, in September of the same year. In Berlin, it broke out in the last of August, 1S31 ; whilst Thorn, more to the east, and holding direct intercourse with Warsaw and Dantzic, escaped. In 368 DISEASES OF THE DIGESTIVE SYSTEM. Hamburg, it appeared in October. Whatever line we may assume, we cannot observe any regular order of succession in which.the dif- ferent cities were attacked — either along rivers or on the great high roads between capital cities. In Russia, Prussia, and Austria, where the greatest efforts were made to set limits to the disease by sanitary cordons, and the most rigid system of quarantine, the periods between the attacks of cities and districts were not any longer than in India, where the most unrestrained intercourse by sea, and along the rivers and roads, was allowed. Any line by vvhich we should pretend to mark the places attacked by the cholera, must be very irregular — sometimes approaching a town or village, and then passing around it — to return after the lapse of weeks or even months. Sometimes the disease would nearly depopulate small villages near a principal station, before it made its appearance Uere. It is worthy of remark, that, at the very time when the western part of Russia and Poland, and parts of Germany, were suffering from the cholera, it raged with great violence in Arabia and Egypt. Perhaps we could not cite a stronger example of the difficulty of explaining, by any known law of transmission or order of succes- sion, an attack of cholera, than its sudden appearance in the heart of Paris—the first city in France to suffer from the pestilence. Equally sudden and unexpected was the bound, as it were, of the disease from Montreal to the city of New York. The annals of cholera prove, that, when it made its appearance in a camp, or a city, so far from extending to every habitation, it was almost invariably confined to particular portions of even the most populous places. Sometimes in an army, for instance, one or two regiments encamped together, or separated by other corps, were the only sufferers in an attack of the disease ; one division in one street only of a town had the disease existing in it — nay, its presence has been known to be limited to one side of a market-place. Removing a camp a few miles has frequently put an entire and immediate stop to the occurrence of new cases; and when the disease prevailed-de- structively in a village, the natives often got rid of it by deserting their houses for a time, though, in so doing, they necessarily exposed themselves to many discomforts, vvhich would commonly be consi- dered as exciting causes of this disease. It has been said, that the course in vvhich the cholera has succes- sively appeared, has been westwardly. This is an error, if we have regard to the chronological order in which it has made its attacks, or assume any place as a point or beginning from which the disease may have been supposed to diverge. Thus, in the year 1823, we find the cholera to have shown itself as many degrees eastward of Calcutta — viz., the islands of Banda and Timor — as it had done westward, or on the shores of Syria and Judea. Nor has the line of its progress been either north-west or north-east. "Assuming the cause of cholera ,to be poison in the air, its mode of progression is singular. Originating in India, it spread east and west, till, having reached China, its extreme eastern point, the stream suddenly wheeled round to the west, and pursuing its course through Tartary it joined in the attack on Europe. On the contrary, the CAUSES OF EPIDEMIC CHOLERA. 369 western branch having reached England [and Ireland], the extreme point of western Europe, the stream has suddenly retrograded to the east through France, Spain and Italy, to Malta, where it seemed to have become evanescent. In pursuing its westward course, it ap- pears to have been developed in two different manners, probably according to the nature of the country, sometimes forming one or more centres, from which disease has radiated in every direction ; and again running in lines of no great breadth, the country on either side being healthy." {Dr. R. Williams's Elements of Medicine, vol. ii., p. 606.) The same writer from whom I have just quoted relates some of the peculiarities of cholera progress, as follows: — " Although the great streams of cholera have, on the whole, steadily advanced, they have not proceeded at an equal pace, the rate of progression varying greatly in different countries. In the year 1817, the cholera had overrun in India, in three months, a space westward of not less than four hundred miles, while to the south it had penetrated no farther than Ganjam, only eighty-eight miles from Calcutta, in six months. In the next six months, however, it had extended in a southerly direc- tion from that point over more than four-fifths of the Peninsular. It reached Pekin in about *he same time that it attacked Muscat, the former being twice the distance of the latter. In Europe its progress was equally capricious. It travelled from the Caspian to Vologda and Pskou, within one hundred miles of the Baltic, at a rate which would have infected all Europe in three months, while it did not reach Riga, only one hundred and eighty miles distant from the latter town, until eight months after. Its rate, however, appears to have been most retarded in its retrograde movements, for it took six years after London was infected to reach Rome. In a word, it took only one year to span the base of the Peninsular of India, while it occupied twenty years to compass the globe." LECTURE XL. DR. BELL. Causes of Epidemic Cholera.—Connexion between cholera and other diseases— Influenza—Influenza and cholera in 1780 and 1781—Both have pursued a similar course, including divergencies from the main line—Prevalence of bowel affections in cholera sea«ons—Increased mortality at this time from other diseases—Scarlet fever with cholera.—The special cause unknown—Predisposing and modifying causes, in weather and season; low situations; poverty, destitution, and vice of the inhabitants ; bad food ; watery fruits and vegetables ; intoxicating drinks ; sudden debility of the nervous system; fear; great and unusual exposure to atmospherical extremes and changes—Atmospheric and other phenomena anterior to and contemporaneous with cholera—Attacks of the disease mainly in the sum- mer-half of the year—Prevalent winds—Sickness and mortality among animals coincident with cholera in different countries—Cholera not transmissible by contagion. Causks. — Before speaking of the probable exciting causes of cholera, I wish to direct your attention for a few moments to the connection between this pestilence and other diseases. Its precursor, 370 DISEASES OF THE DIGESTIVE SYSTEM. in a very remarkable manner in Europe and America, was influenza, which pursued, also, very much the same course as the cholera in those continents. This order of appearance of these two great epi- demics has occurred once before in India, in the latter part of the last century; but at that time the cholera did not pass the Peninsula, nor indeed overspread it then as it did subsequently. But for English rule in parts of India at the period referred to, we should be at this day quite ignorant of such remarkable occurrences as are described by some of the medical writers who were on the spot at the time, or who had early and direct cognizance of the facts from the natives themselves. I shall first describe the course of the influenza, in the words of Dr. Williams, and then mention some of the particulars on record of the cholera, which, about the same time, committed such ravages in parts of India. "In the month of September, 1780, an epidemic influenza broke out in Bengal and on the coast of Coromandel, and continued to pre- vail in India so long a time that the British army beseiging Nega- patam was attacked by it in November, 1781. Whether it spread thence to China, or co-existed there, is unknown, but it prevailed in that latter country also in 1780. From India, or, perhaps, more probably from China, its extreme eastern limit, it appears to have made its way to the west through Upper and Central Asia, to To- bolsk, a city of Russian Tartary, situated about 48° north latitude. From Tobolsk, it continued to advance in the same westerly direc- tion till it broke out in Moscow, a distance of not less than 1200 miles, in December, 1781 ; whence it spread to St. Petersburgh in February, 1782; and these are almost the precise stages by vvhich the cholera penetrated into Europe in 1831-2. From St. Petersburgh it continued its progress westward, so that in April it infected Den- mark, and at the latter end of April, in the same year, it appeared at Newcastle-upon-Tyne, almost the identical spot where cholera first appeared in England. It was certainly in London the second week in May, and, as in cholera, without any of the intermediate towns being infected. In Scotland and in Ireland, it appeared rather later than in England. It is also exceedingly remarkable that this epide- mic, like the cholera, prevailed earlier in England than in France, for it did not reach Paris till June. Again, it is singular that, having reached France, it commenced a short retrograde course to the south- east, passing from that country into Italy ; there it prevailed in July and August, and also in Spain and Portugal, vvhich it attacked in August and September. A course precisely similar to that of cholera." Continuing the account from where Dr. Williams stops, I shall direct your attention to the fact, that in the spring of 1781, as we read in that most industrious chronicler of epidemic visitations, Mr. Noah Webster, the influenza prevailed in North America. At the very time of the influenza prevailing in India, it is on record that cholera destroyed, first at Hurdwar in 1780,20,000 persons, while a festival was held there ; and in 1781, assailed, in its most malignant form, a division of Bengal troops then stationed at Ganjam, the theatre of this terrific disease thirty-seven years afterwards. An CAUSES OF EPIDEMIC C HOLERA. 371 admirable account of cholera, which leaves no doubt of its identity with that since prevalent, was given by Mr. Curtis, who described it as spreading, in the year 1782, in Sir E. Hughes's squadron, then stationed in the East; and as having arisen from communication with an infected port in Ceylon. In the Madras Reports, it is stated to have raged at Arcot in 1787, and was accurately described by Girdlestone. —(See Appendix to all tl\e Material Fads, &c.) The epidemic cholera which has gone round the globe, was in Europe and America preceded by influenza. That the course of this latter, as already described, "is not accidental, but according to some definite law, seems proved by the fact of the influenza of 1830-1-2 having taken a similar course in Europe, and having likewise passed the Atlantic. This epidemic immediately preceded the attack of cholera, and is traced as far back as Moscow, whence it spread to St. Petersburgh, and in eight months had infected all Germany, and reached London; at this point the stream bisected ; one branch taking the usual south-east direction,infected Italy and subsequently Gibraltar, reached America. One remarkable circumstance connected with the origin of this distemper is, that it prevailed, also, in Australia." It seems to belong to the features of great epidemics to affect some par- ticular geographical range; as in the instances of the great plague in the reign of Justinian, and the black death or black pestilence of 1348-50, and the JBgypt sweating sickness which was months in Shrewsbury, but staid only three days in Amsterdam, attacking 500 in a night in that city. Along our Atlantic border, influenza prevailed in 1831-2 with great intensity; ihe mortality was considerable, especially among the aged and among those in the better walks of life. It was here, as it was in the valley of the Mississippi, the precursor of cholera. The diseases which are more particularly blended or alternated with cholera, are bowel affections in general, fevers of various types, and scarlatina. Some persons have argued that the mortality from other diseases was less in the year in which cholera made its inva- sion: but this is an error. If the remark were intended to apply to the year following the epidemic, it would be in general correct. In India and in Great Britain it seems to be proved that the amount of sickness and of mortality was greater than usual; throughout north- ern India the epidemic year was remarkable for remittent and autum- nal intermittent fevers, diarrhcea, dysentery, and small-pox. The medical returns of the Madras army, also, show a marked increase of disease generally during the vears that cholera raged so severely in that presidency, the proportion being from one-fifth to one-sixih greater than usual. In Europe, opinions have been discre- pant on the subject. In Russia, for example, it was thought the total number of deaths was not increased. In France, however, the mor- tality in the cholera years greatly exceeded that of ordinary times. In the north of England it was said that typhous fever disappeared: hut iu London this disease raged with great violence, assumed new characters, and was more fatal and intractable than it had been for many years. According to the bills of mortality, the burials in 1832 exceeded those in 1831 by 5098, or more than one-fourth. (Williams, op. cit.) 372 DISEASES OF THE DIGESTIVE SYSTEM. Our home experience on this point is well represented in the fol- lowing table, prepared by Dr. Emerson, to whose partiality for me- dical statistics, and industry in arranging and combining materials which would otherwise have remained isolated, and in a measure useless, his professional brethren are much indebted. It is called a Table showing- the prevailing- Diseases independent of Cholera ; -what influence it exerted over them ; and the rate of their Mortality. DISEASES. 1831. 1832. June. July. Aug. Totals. June. July. Aug. Totals. Consumption . . Convulsions Cholera Infantum Diarrhoea and dysentery Fevers . . . . Scarlet fever Inflammations in general . Do. in the chest . Do. in the abdo-men Dropsy in the head . Do. in the chest . Do. in general Debility and decay . Apoplexy . Ah diseases (still born de-ducted) . . . . All diseases (malignant cho-lera deducted) Excess in mortality of 1832 Do. after deducting mor-tality from cholera 35 18 45 18 17 5 32 16 16 22 2 6 28 9 294 294 41 26 132 28 24 29 19 10 9 22 4 12 33 8 467 467 33 29 82 49 35 10 26 8 18 29 6 11 29 4 490 490 109 73 259 95 76 24 77 34 43 73 12 29 90 21 1251 1251 44 28 25 15 31 23 28 16 ! 12 2 3 16 4 369 369 75 75 52 29 134 47 35 17 43 15 28 33 4 10 45 8 785 689 318 222 73 39 157 83 65 14 29 7 22 23 3 9 8 7 1431 618 941 428 169 90 316 145 131 54 100 38 62 61 9 22 89 19 2585 1676 1334 425 The mortality in the year subsequent to that of cholera, in 1833, was less by 2259; arid even when allowance is made for the mor- tality from the epidemic cholera, in 1832, the amount still falls short by 1311 of that in this latter year. The rates of diminution are par- ticularly evident, under the heads of Fever, Bowel Complaints, In- flammations and Measles. (Dr. Emerson.—Am. Jour. Med. Science, vol. xv., p. 267.) The shortness of the period of its visit, in most places, may ex- plain why there has not always been a closer relation or interchange of features between cholera and those endemic diseases. Dr. Drake {op. cit.) did not find that so many cases of intermittent and remit- tent fevers commenced and terminated with that febrile type, as might have been expected, though the number was not a few — considering that the epidemic invaded Cincinnati, in the season when those fevers prevailed. It is worthy of remark, that in India and the United States there has been a more manifest affinity be- tween epidemic cholera and paludal fevers, as far at least as regards CAUSES OF EPIDEMIC CHOLERA. 373 their localities, and the exposure to atmospherical influences of the persons who have suffered, than between it and febrile, or indeed any other disease, except those directly affecting the mucous mem- brane of the digestive tube, as set forth in the preceding table. Somewhat to our surprise in Philadelphia, the first cases, and the largest proportion afterwards in the hospitals,came from the outskirts of the town and open lots adjoining the Schuylkill, rather than from the narrow streets and closes contiguous to the Delaware, where we were all on the look out, in expectation of the disease. We had forgotten the Indian cholera, and had fixed our attention on the badly built and badly ventilated and filthy houses, and equally filthy popu- lation, of the parts of European cities which suffered most. Scarlet fever prevailed to a great extent in Philadelphia during the cholera year, as also measles. The deaths from the former were 307, nearly a third of the mortality caused by cholera ; those from measles were, in the same period, 118. Throughout the valley of the Ohio, scarlatina prevailed at the same time with cholera; and was, as we learn from Dr. Drake, a coadjutor with it in the work of death ; but their attacks were made in alternation, and seldom together. In New Orleans, cholera and fellow fever were in con- joint operation for a while. The cause by the operation of which the common and appreciable causes of disease give rise to cholera is unknown to us. That it is in the atmosphere we have every reason to believe; but in what state or how combined, we cannot hitherto ascertain. The most probable supposition is, that it is a peculiar poison. It is, however, encouraging for us to know, as we now positively do, from all which has transpired in the history of the disease, that the concealed general or aerial cause is comparatively harmless, unless effect is given to it by sub- jection to evident modifying agencies. Preceding and accompanying the appearance of the cholera in a country or city, there have been deviations from the usual state of the weather and season — unwonted vicissitudes or extremes, with, often, changes in the electrical state of the atmosphere. These would nqt probably be of themselves adequate to the production of cholera but for the additional predisposing cause of unfavourable localities. The chief home and seat of cholera is in low, damp situations — on the banks of rivers, or near pools and ponds of water, — or which are encumbered with vegetable remains, and filth of any kind. Those pans of cities thus situated and circumstanced, have always suffered most, and sometimes have been the exclusive seats of the disease. In all the chief cities of Hindostan, as in Calcutta, Madras, Bombay, Seringapatam, (fee, &c; of Russia, as in Moscow, St. Petersburgh, Astracan; of Germany, as in Vienna, Breslau, Berlin, Hamburg; of France, as in Paris and other places; of Great Britain and Ireland, as in London, Sunderland, Newcastle, Gateshead, Musselburgh, Dub- lin, Cork, &.c, this fact has been placed beyond doubt. In Montreal, Quebec, and other places along the St. Lawrence in our Atlantic cities, and in those on the Ohio and the Mississippi, similar testimony has been afforded. Additional intensity is given to unfavourable locality by narrow streets and numerous small and ill-ventilated houses, crowded with inhabitants. Low, underground vol. i.—32 374 DISEASES OF THE DIGESTIVE SYSTEM. lodgings increase greatly the risk of their inmates having the disease, and the danger of its terminating in death. Cholera has suddenly appeared with great violence and produced immediate and great mor- tality among the inmates of a prison, as in the instance of the Arch Street Prison, Philadelphia. Experience has also fully shown, that, in regard to the manner of living, the intemperate, the devotedly sensual in any way, they who are unclean in their persons, and who are deprived of a suitable supply of wholesome aliment, are peculiarly liable to the disease, and to perish under its attack. The drunkard has everywhere been singled out as a victim of the disease, on its first appearance in a place. Women of the dissolute and abandoned class were among the fore- most sufferers from cholera in India, as elsewhere. " When Moscow was attacked, the mortality was severe only among those persons living in low, damp habitations, whose diet was poor, and whose conduct was irregular and debauched. The same fact was also observed at St. Petersburgh ; for, in ninety-nine cases out of a hundred, the victims, according to Dr. Gill, were the drunkard, the dissipated, and the poorly fed ; and it may be stated as a general principle,that the ravagesof thedisease have beenconfmed nearly tothe same class of persons throughout the whole of Prussia and Germany." — (Dr. Williams, op. cit.) This remark may be extended to nearly every place where the cholera committed its greatest ravages. The most notable exception is in the case of its attack on Lexington, Ivy. Food of bad quality, irritating the stomach and bowels, has often proved an exciting cause of the cholera. In India, the crops of rice fell short and were damaged, and the inhabitants, whose chief reli- ance for nutriment was on this grain, suffered dreadfully from the disease. Similar deficiencies and badness of quality of the wheal in Russia and Poland, were attended with the like results. Wherever watery fruits and vegetables were largely used and relied on as food, such as cucumbers, melons, cabbages, &c, the disease committed great ravages. Meats, vvhich, though nutritive, task excessively the digestive powers of the stomach, are to be avoided, such as fat pork, smoked beef, lobsters, clams, and crabs. Among intoxicating drinks, distilled liquors are especially perni- cious. At all times improper for a habitual beverage, they are little short of poison when used in seasons of epidemic cholera. Water, under all circumstances the best drink for mankind, may be given of such temperatures, and so prepared by boiling, as to be adapted to every stomach, and to prove both safer and more healthful than any liquid whatever prepared by art. Any sudden or considerable debility of the nervous system is to be greatly dreaded,as of itself laying the body open to an attack of cholera. On this account, anxiety, fear, and the depressing passions in general, should not be allowed an abiding place in our minds. Many have been destroyed by fear alone — but on the same ground as that on which a tranquil mind is recommended to be preserved, an equable state of the senses and functions generally should be maintained, by regular hours of sleep, regularity of meals, and the accustomed daily exercise. Long exposure to the sun and great fatigue have been found to be CAUSES OF EPIDEMIC CHOLERA. 375 powerfully contributing causes of cholera. If circumstances require such an exposure, aditional circumspection is to be exercised in the manner of living in other respects, and an especial avoidance of the night air and dews, or of getting wet with rain. As a contribution of facts, but not as an attempt to assign causes, I shall repeat here some of the notices, vvhich I collected, on Atmo- spheric and other Phenomena anterior to and contemporaneous with the prevalence of the Disease. — Many of the British physicians and surgeons in India describe frequent and great deviations from the usual order of the seasons before and during the existence of cholera ; and they speak of unusually violent thunder-storms, " violent squalls," and storms of wind and rain. Earthquakes were also felt in vari- ous parts of Hindostan. At the time when the grand army under the Marquis of Hastings suffered so dreadfully from the disease, the ther- mometer ranged from 90 to 100° — the heat was moist and suffocating, and the atmosphere a dead calm. The origin of the disease at Calcutta has been attributed to the ex- treme heats and drought of the seasons, followed by heavy rains, and the use ofunvvholesome food, viz., bad fish and ouze, or new rice. In the Island of Java the weather, when the cholera broke out (April), was represented as remarkably dry and hot. At Bombay the fall of rain was unusually great in August, 1S18, in the latter part of which month the disease broke out. The same remark was made of the weather at Madras. It was observed that the different attacks of the epidemic in General Smith's force at Seroor, and other places, were always accompanied by a cloudy, overcast state of the sky, sudden showers, composed of large drops of rain, resembling those of a thunder-storm, and a thick, " heavy" state of the air, giving ita whitish appearance ; and whenever the weather cleared up, the disease disappeared. The person (an intelligent officer) who makes the above remarks, also observed that the disease was inva- riably preceded and accompanied by a large black cloud hanging over the place; and added, that this had been universally remarked, and that the appearance had even received the name of the cholera cloud. Similar notices abound of the connection between the disturbed state of the weather and the appearance of the disease in various parts of India. It was also a subject of very general remark, that Ihe prevalence of southerly and easterly winds seemed to give vigour and force to the disease, while after a change to the north and west, and a dry and pure atmosphere, it almost uniformly sub- sided. However aggravated the disease was in the summer months, or rather from spring to the beginning of winter, it was most gene- rally quiescent in this latter season, iu India. It would seem, however, that, of all the atmospherical pheno- mena, which have been alleged to accompany the disease, none are universally present, except those vvhich indicate a diminution in the density of the air, and a tendency to rain and storms. In other words, the atmosphere, during the prevalence of the dis- ease, is in a rarefied state; and exhibits a great tendency to part with its moisture, forming thick clouds, heavy rain, or haziness- and to become agitated by storms. It has been further said, but not -generally confirmed, that the meteorological occurrences which 376 DISEASES OF THE DIGESTIVE SYSTEM. have been observed to accompany the disease, are either produced by, or attended with, a diminution of the quantity of free electric fluid in the atmosphere. The influence of season on the appearance and virulence of the disease in Persia and Turkey is thought to be as evident as in India : for we learn that, during the three years in which it pre- vailed in succession at various places from the shores of the Persian Gulf to the Mediterranean, in one direction, and to the borders of Russia in Europe, in the other, it prevailed only in summer. In the United States the irruptions of cholera were, without excep- tion, I believe, in the summer half or climate of the year. The weather, before the breaking out of the cholera in Mecca (in 1831), was remarkable for the excessive heat — the thermometer being steadily as high as 102° F., and afterwards heavy raifts, with the wind from the south and south-east. : Before the appearance of the disease in Suez, a very hot south wind prevailed. At Cairo, during the first period of the disease, the wind was from the north-east, and the heat, during the day, suffocating. At Nishni Novogorod in Russia,there suddenly succeeded to a warm and dry state of the atmosphere, in the month of August, 1830, a con- tinuance of cold and wet. At this time the cholera began. Prevail- ing winds south-east. The cholera appeared in Riga at the commencement of uncom- monly hot and sultry weather. In Poland, the cholera increased as the weather in March and April became cooler and more damp. With warmth and dryness of the air the disease rapidlyabated. When, however, in August and Septem- ber the days became very hot, and the nights cold, it again raged to an alarming extent. The prevalence of the disease at Moscow is stated to have been in proportion to the humidity of the atmosphere. At Vienna the cholera broke out on the 13th of September, after a hurricane and much cold rain. At Dantzic so irregular and unfavourable to health had been the weather of the spring, that pestilential diseases were expected as a consequence. Prior to the appearance of the epidemic and during its continu- ance at Gibraltar, easterly winds were uncommonly prevalent. During May and June preceding the cholera period in July and August there were frequent thunder-storms accompanied with heavy showers. But although the attacks of cholera were, in a large majority, at the period of the year between spring and fall, they were not con- fined to this time. Thus, it appeared at Edinburgh in January, at London in February, at Paris in March. The prevalent winds, in most places in which the cholera com- mitted its ravages, have been easterly, from N.E to S.E. These winds, be it remembered, havealmost invariably preceded and accom- panied some of the worst pestilences and various fevers — such as plagues, yellow fever, and violent bilious and intermittent fevers. Among the phenomena worthy of record connected with the his- CAUSES OF EPIDEMIC CHOLERA. 377 lory of cholera, is the sickness and mortality of animals antece- dent to and at the time of the ravages of the disease, in many parts of the world, where it prevailed. The general character of the dis- ease in them was of a choleiform nature. Dr. Holland {Medical Notes and Reflections) has suggested a cause of cholera, viz., the generation of insect swarms, which, in their migration, gave the course of the disease. He adduces many plausible facts and analogies in favour of this opinion, in the paper entitled, " On the Hypothesis of Insect Life as a Cause of Disease ?" In all our reasonings on this subject, the author lays it down, as the first obvious arid assured condition : " that the cause of the disease must be a material poison ; definite in its nature, and specific in its effects." He then speaks of a wandering cause of the disease, a migrating malaria, possessing the power of reproducing itself, and depending, as he supposes, on animal origin and reproduction. " In many respects, indeed, the erratic and ambiguous course of cholera is well represented by the flight, settlement, and propagation of the insect swarms vvhich inflict blight upon vegetable life." " The re- appearance of the disease in the same locality at uncertain intervals, but generally during the latter part of the year, is another fact bear- ing on the same hypothesis." It is explained in " the contingency of fresh swarms arising, or of the development of ova deposited in these places during the preceding incursions of the disease, and called more or less numerously into life by increased temperature or other causes." But I cannot pretend to give you the entire argument of Dr. Holland, which is very plausible, and obviates more objections than any other. Were we to admit it, we must also receive, in a qualified sense, the infectious nature of the disease, and admit " that man, the peculiar recipient of this cause of disease, is also the prin- cipal agent in its diffusion." Is cholera contagious ? The scope of my preceding remarks will have shown my disbelief in the contagiousness of cholera. My opi- nion in this matter is coincident with a majority of those who have seen and written on the disease, although I am aware that a contrary one is held by physicians of acumen and authority. Among these, Dr. Graves is entitled to more conspicuous mention. Dr. Wat- son {Lectures on the Principles and Practice of Physic, Am. Edit., p. 719,) holds the same opinion, and refers to a paper in the 48th vo- lume of the Eainburgh Medical and Surgical Journal by Dr. James Simpson, for a vast number of examples of contagion. Into the whole argument I cannot of course enter at this time, nor even repro- duce all the facts, vvhich I presented in the Report of the College of Physicians before referred to. I must content myself with a mere announcement of the, as it seems to me, prominent objections against ihe creed of contagion : The simultaneous outbreak of cholera in different parts of Bengal, as noticed by the British physicians; a similar peculiarity marked its appearance in most of the cities vvhich it attacked. The utter inefficiency of all quarantine regulations, as instanced in the Island of Bourbon, Astracan, Orenberg, St. Peters- burgh, Breslau, Berlin, Hamburgh, Vienna, Sunderland, Cairo, Alexandria, Naples, &c, &c., to say nothing of attempts of a simi- 32* 378 DISEASES OF THE DIGESTIVE SYSTEM. lar nature here at home, as absurd as they were abortive. The sudden cessation and speedy disappearance of the disease among men, by a slight change of encampment. A corps encamped on low ground, in very rainy weather, was severely visited ; of thir- teen sepoys taken ill, six died. After a few days they moved fo a higher spot, and only one more case occurs, which appears on the march to the new ground. During an attack of the epidemic,in April, 1823, in the sixty-eighth regiment in quarters, at the suggestion of the surgeon, the wings of the corps in vvhich the disease prevailed the most was encamped on a piece of high ground in the neighbourhood, and, he reports, that not a case occurred in that camp. As illustrative of the influence of locality, but as adverse to contagion, the following facts are of interest. In the three grounds of encampment of the centre division of the British army, in the year 1818, the soil was low and moist, the water foul, stagnant, and of a brackish quality, and everywhere not more than two or three feet from the surface of the earth, and the vicinity abounded in animal and vegetable putrefied matter ; whereas, at Erich, where the army regained its health, the situation was large and salubrious, and the vvater clear and pure, from a running stream. The disease, though pre- vailing so fatally in the camp, did not appear in Allahabad for four months afterwards, and yet the intercourse between this town and the camp was very great. Even some corps of the division, sta- tioned at a little distance, escaped, though a diseased party arrived among them from the main body. The crew of a ship from Eng- land were seized with the disease immediately on her coming to anchor in Bombay harbour, before there was any communication with the shore. The rate of transmission of the disease in the order of time, is not explicable by the doctrine of personal communication. Cholera appeared at Orenberg in September, 1829, and yet a year elapsed before places on the great roads to the west or interior of the empire were affected. In Russia, Prussia, and Austria, where the greatest efforts were made to set limits to the disease by sanitary cordons, and the most rigid system of quarantine, the periods be- tween the attacks of cities and districts were not any longer than in India, where the most unrestrained intercourse by sea and along the rivers and roads was allowed. The instances of the incommunicableness of cholera by persons and goods are innumerable. Let a few among these suffice. The persons composing the family of the Persian prince quitted the city of Tabriz after the violence of the disease had already begun to abate. They, however, carried the cholera along with them, and continued to be attacked, from four to six a day, for about ten days, but not a single person in the village through which they passed, or where they slept, took the disease. During the prevalence of the cholera in Moscow, about forty thousand persons quitted that city, of whom a large number never performed quarantine; and yet no case is on record of the disease having been transferred from Mos- cow to other places. (See Report, fycs) The general immunity of the physicians and nurses, and other attendants on those sick with cholera, both in hospitals and in private practice, is utterly irrecon- cilable with a belief in the contagiousness of the disease. Even re- CAUSES OF EPIDEMIC CHOLERA. 379 garded as an epidemic, the general exemption of all these persons is surprising. Their consciousness of the discharge of a high and noble duty, their intentness in watching the disease and studying its phenomena, together with their freedom from fear, will go far to explain the escape of medical men from an epidemic disease, but not from a contagious one. Eight hundred and sixty patients with other diseases were in the hospital of Ordinka at Moscow, during the time in vvhich five hundred and eighty persons were sick with cholera in the hospital, vvhich consisted of three stories, communi- cating by stairs placed within the-hospital wards. Not one of the former class of patients became affected with the disease, although they had the same attendants as the cholera sick. Of these attend- ants, a hundred and twenty-three in number, many of whom were employed in washing the clothes of both classes of patients, two only were affected with cholera, a man and a woman, both of whom were disposed to the disease for very irregular conduct, for which they had been censured. Adverse to the doctrine of contagion is the fact, I believe, that, dissection of subjects dead of the disease were, in nearly every in- stance, performed with entire impunity. Dr. Mackintosh, on this point, says : " In the Drummond-street Cholera Hospital there were 280 bodies examined. Two, and sometimes three, hours were spent in examining each body. The room where these examina- tions were conducted was a miserable place, eight feet square ; generally six or eight persons were present, sometimes more ; and, in an inner apartment, about ten feet square, there generally lay six dead bodies. Not one of those who frequented this den of death, and who had their hands imbrued in the secretions of the dead for six hours out of the twenty-four, were affected with cholera, although their hands were irritated and punctured daily." {Practice of Phy- sic, p. 345.) Unlike contagious diseases, under circumstances of free inter- course, cholera was not spread generally in agricultural districts, except, as in parts of India, and in some instances in the southern and western regions of the United States, where there were obvious peculiarities of an endemic character, which would give additional power to any epidemic visitation. Cholera was chiefly confined to towns, and mostly to particular parts of towns, — a restriction, where no quarantine is in force, not to be expected of a contagious disease. In 1837, when cholera appeared in the seaman's hospital, Dreadnought, in the Thames, none of the nurses or medical officers were attacked; nor did a case occur in any other vessel in the Thames, although, during the prevalence of the disease, patients were discharged almost daily from the Dreadnought, who imme- diately entered other vessels. The persons attacked with cholera were admitted into the Dreadnought for other complaints. Bearing on the present argument is the fact, that while cholera existed in this isolated manner in the Dreadnought, and when other parts of London were free from it, some cases occurred in the Marylebone Infirmary, situated in a part of the metropolis the most remote from and maintaining the least intercourse with Greenwich, where the Dreadnought was stationed. 380 DISEASES OF THE DIGESTIVE SYSTEM. In the United States, the great weight of medical evidence and opinion is adverse to a belief in the contagion of cholera. The almost general immunity from attack of medical and other attend- ants on the sick, and the peculiarities of the circumstances of the appearance and diffusion of the disease, and, indeed, nearly all the facts already mentioned, have been repeated in this country, show- ing that the disease was not communicated nor communicable from person to person. The shortness of the duration of epidemic cholera in a place, the suddenness and rapid diffusion of the disease beyond what could occur from personal intercourse, and its entire disappearance, are facts adverse to a belief that it is contagious. To the same purport is the disorder of the digestive organs among the inhabitants, pre- ceding its regular attack, and anterior, also, to any imputed impor- tation or intercourse of any kind with the sick in other parts. Although cholera in the period of its attacks as well as in their intensity, has been not a little modified by the seasons and atmo- spherical vicissitudes, yet there are facts enough to show that it has appeared in all seasons and states of weather; unless we were to assert that in cities, where alone it has made its attacks in winter, there is a combination of circumstances ever present, which keep up a state of air in many of their close and illy-ventilated courts and houses analogous to that of an unhealthy autumnal season. It has been said of the great plague in the reign of Justinian : " Such was the universal corruption of the air, that the pestilence which burst forth in the fifteenth year of the reign of this emperor was not checked or alleviated by any difference in the seasons." On the ground of the difficulty of explaining the cause of cholera, from any particular con- dition or combination of states of the atmosphere, a telluric origin has been supposed, and by some believed, to be the true one; " for if we suppose it [the poison of cholera] to be generated below the crust of the earth, and consequently beyond the influence of the at- mosphere, it is easy to understand why its course is entirely inde- pendent of the seasons." {Williams.) By some, again, it has been alleged that the poison, if not the electrical or magnetic fluids them- selves, must be extricated by their agency. LECTURE XLI. PR, BKLL. Symptoms of Epidemic Cholera—To be described under the head of diarrhoeal stage, or cholerine ; confirmed cholera, collapse and reaction—Importance of atten- tion to the first, or diarrhceal stage—Time of attack of.—Confirmed cholera— Disorder of the stomach and bowels; of the circulation ; of animal heat—Vomiting and purging vary in extent—Collapse without evacuations—Mind undisturbed —Symptoms of disordered innervation—Spasms and cramps—Symptoms of collapse, or blue stage—Sinking of the circulation the most constant and alarm- ing symptom of cholera—Thirst, and sense of heat in the stomach—Respiration, how affected—Symptoms connected with the blood and circulation—Sameness of cholera in all parts of the world—Stage of reaction, or consecutive fever- Urea in the blood, an alleged cause of the consecutive fever—Analogy between cholera and pernicious or malignant intermittents—Torti cited—The lecturer's case of comatose intermittent. Symptoms. — I shall speak of these under the shape of the several SYMPTOMS OF EPIDEMIC CHOLERA. 381 stages of the disease, viz.: — 1. The Diarrhoeal, or Cholerine.— 2. Confirmed Cholera. — 3. Collapse. — 4. Reaction or Consecutive Fever. Cholerine. — On an early attention to the premonitory symptoms, or to this first or forming stage of the disease, will greatly depend the favourable issue of the case, and of course the life of the patient. He complains of lassitude ; has, frequently, partial uneasiness in the region of the stomach ; but this not to such a degree as to alarm him. He has frequent evacuations from the bowels — from two to a dozen times a day — not attended with much griping. His countenance is sharp and dark. He knows not of this symptom, and it is only recognisable to the eye of experience. Occasional nausea may op- press him : but this is not a very common occurrence. These symptoms may continue, varying in severity, from one to ten days, before the second stage of the disorder supervenes. The evacuations at the first are generally of a dark brown or blackish hue, and not unfrequently bilious. As the looseness continues, they gradually become less and less of a natural appearance, until they assume the consistence and aspect of dirty vvater. Some headache, cramp of the fingers, toes, and abdomen, and almost always slight giddiness and ringing of the ears, accompany these symptoms. Sometimes an intervening two or three days of costiveness supervenes, which is followed again by the diarrhcea, and in a few hours collapse may come on, and in general nausea and vomiting. On the prompt appre- ciation of the nature of this diarrhcea, and timely application to a physician, will greally depend the issue of the cure. Dr. Kirk says that it was found, from regular records of upwards of 4000 patients, to prevail in all. The same fact has been generally noticed in an immense majority of those who have suffered from cholera in the Canadas and in New York, Philadelphia, and other parts of the United Stales. Symptoms of Confirmed Cholera. — From among the numerous minute and graphic accounls which have been published of the phe- nomena by which the epidemic cholera is accompanied, from iis invasion until its termination, it is somewhat difficult to make a selec- tion ; but, as my desire is rather to present a general summary of the symptoms, than a detailed account of every trifling deviation from the ordinary course of the disease, I shall follow very closely the excellent description presented to us by Mr. Scott in the Madras Report. The attack of cholera generally takes place in the night, or towards morning. The patient becomes sick at the stomach, vomits, and his bowels are at the same time evacuated. This evacuation is of a nature peculiar to the disease — the entire intestinal tube seems to be at once emptied of its fecal or solid contents, and an indescribable but most subduing feeling of exhaustion, sinking and emptiness is pro- duced. Fainting supervenes, the skin becomes cold, and there is frequently giddiness, and ringing in the ears. The powers of loco- motion are generally soon arrested ; spasmodic contractions or twitchings of the muscles of the fingers and toes are felt; and these affections gradually extend along the limbs to the trunk oif the body. 382 DISEASES OF THE DIGESTIVE SYSTEM. They partake both of the clonic and tonic spasm, but the clonic form chiefly prevails. In other words, they consist more generally of permanent contraction than of convulsive movements of the muscu- lar fibres. The pulse, from the first, is small, weak, and accelerated, and, after a certain interval, but especially on the accession of spasms or of severe vomiting, it sinks suddenly, so as to be speedily lost in all the external parts. At this time, however, there is strong pulsa- tion of the caeliac trunk, and often of the abdominal aorta. The skin, which at first is suffused with a deep or almost bronzed flush, soon falls below the natural temperature, and becomes colder and colder, and pale; it is very rarely dry ; generally covered with a profuse cold sweat, or with a clammy moisture. During the progress of these symptoms the stomach and bowels are very variously affected. After the first discharges by vomiting and purging, however severe these symptoms may be, the matter evacu- ated is always watery ; and in a great proportion of cases it is colour- less, often homogeneous, and without fecal fetor, but giving out a peculiar odour, which is imparted by all the secretions, and which, once experienced, is afterwards readily recognized. In some it is turbid, resembling muddy water ; in others it is of a yellowish or greenish hue. A very common appearance is that vvhich has been emphatically called the " congee stools," or like rice water, an appear- ance produced by numerous mucous flakes floating in the colourless, watery, or serous part of the evacuation. The discharges from the stomach and those from the bowels do not appear to differ, excepting in the former being mixed with portions of the food which may have been eaten. Neither the vomiting nor the purging is a symptom of long continuance; they are either obviated by art, or the body be- comes unable to perform such violent actions; and they, together with the spasms, disappear a considerable time before death. If blood be drawn, it is always dark, or almost black, ropy, and generally flows slowly, and with difficulty. Towards the close of the attack, jactita- tion or restlessness comes on, with evident internal anxiety and dis- tress ; and death takes place, often in ten or twelve generally within eighteen or twenty hours from the commencement of the altack. Cholera, however, like other diseases, has presented considerable variety in its symptoms ; thus, it may, on one occasion, be distin- guished throughout by the absence of vomiting and by the prevalence of purging; on another, by the excess of vomiting ; and, though more rarely, by the absence of purging. Spasm may be generally present in one instance; in another, it may not be distinguishable. A frequent variety, the worst of all, is that which is marked by a very slight commotion in the system — in which there is no vomiting, hardly any purging, perhaps one or two loose stools ; no perceptible spasm, no pain of any kind : a mortal coldness, with arrest of circulation, comes on from the beginning, and the patient dies without a struggle. Vomiting is sometimes, as already remarked, entirely absent, or, if it has been present, soon ceases from an atonic stale of the stomach, under vvhich that organ receives and retains whatever may be poured into if, as if it were really a dead substance. Purging is a more constant symptom than vomiting, and in a large majority of cases it SYMPTOMS OF EPIDEMIC CHOLERA. 383 is the first in the order of occurrence ; but being a less striking devi- ation from a state of health than vomiting, which instantly arrests the attention, it has usually been spoken of as occurring subsequently to the latter. Purging has been very rarely absent altogether — its ab- sence appears, indeed, to denote a peculiar degree of malignancy in the attack. There is seldom much griping or tenesmus, although the calls to stool are very sudden and irresistible. They also sometimes take place simultaneously with vomiting, spasm, and a suspension of the pulsation at the wrist; as if all these symptoms originated at the instant from one common cause. In advanced stages of the disease purging generally ceases, but in many cases a discharge of watery fluid takes place on every change of posture. The matters evacu- ated after the first emptying of the bowels have been occasionally observed to be greenish or yellowish, turbid, of a frothy appearance, like yeast, and sometimes bloody; but by far the most common ap- pearance is that of pure serum, so thin and colourless as not to leave a stain on the patient's linen. The next, in order of frequency, is the congee-like fluid; the mucus is at times so thoroughly mixed, how- ever, with the serum, as to give the whole the appearance of milk. The quantity of the clear watery fluid, which is someiimes discharged, is very great, and were it uniformly so, it might afford us an easy solution of the debility, thirst, thickness of blood, and other symptoms; but it is unquestionable, that the most fatal and rapid cases are by no means those which are distinguished by excessive discharges. Death, on the contrary, has ensued in innumerable instances after one or two watery stools, without the development of any other symptom affect- ing the natural functions. Collapse has even come on before any evacuation by stool has taken place. The undisturbed state of the mind in this disease has been the sub- ject of general remark : instances are not wanting of patients being able to walk, and to perform many of their usual avocations, even after the circulation has been so much arrested, that the pulse has not been discerned at the wrist. The cases here alluded to are those chiefly in vvhich the disease has begun by an insidious watery purg- ing: and many lives have been lost in consequence of the palients, under these fallacious appearances, not having early taken the alarm and applied for medical aid. In other cases again, the animal func- tions appear to have been early impaired, and the prostration of strength to have preceded most of the symptoms." The voice, in general, partakes of the debility prevailing in the other functions ; it is usually noticed as being feeble, often almost inaudible. Deafness has also been remarked, in some instances, to have been completely established. Coma does occasionally occur, especially towards the termination of the case, when it is fatal: but delirium has seldom or never been observed, unless as a sequela of cholera. Spasm has been held to be so essential a feature of the epidemic cholera, as to confer on it a specific name, Spasmodic Cholera : in so far, however, as relates to the muscles of voluntary motion, and it is thai description of spasm only to which we now refer, no symptom is more frequently wanting. Spasms of the muscles chiefly accompany those cases in which there is a sensible and violent commotion of the 384 DISEASES OF THE DIGESTIVE SYSTEM. system — hence they are more frequently found in cases where Eu- ropeans are the subjects of the disease, than when it attacks the natives of India, and in robust patients more frequently than in the weakly. In the low and most dangerous form of cholera, whether European or Indian, spasm is generally wanting, or is present in a very slight degree. The muscles most commonly affected are those of the toes and feet and of the calves of the legs: next to these, the correspond- ing muscles of the superior extremities, then those of the thighs and arms —and lastly, those of the trunk; producing various distressing sensations to the patient. Stage of Collapse, or Blue or Cold Stage. — In the description of confirmed cholera, which I have just placed before you, no attempt has been made to separate it into two stages, and in fact the transi- tion is somewhat so gradual from vomiting and purging with spasms, to a sinking of the circulation, cessation of pulse at the wrist, shrink- ing of the outer teguments, and blueness or lividnesfs of skin, that we cannot positively define the line between the two. The more obvious features of the stage of collapse may be, however, summed up as follows: — The skin assumes a blue or livid hue; the whole surface appears collapsed, the lips become blue, the nails present a similar tint, and the skin of the feet and hands becomes much cor- rugated, and exhibits a sodden appearance; in this state the skin is insensible, even to the action of chemical agents ; yet the patient generally complains of oppressive heat on the surface, and wishes to throw off the bed-clothes ; the eyes sink in their orbits and are sur- rounded with a livid circle; the cornea becomes flaccid, the con- junctiva frequently suffused with blood ; the features of the face collapse, and the whole countenance assumes a cadaverous aspect, strikingly characteristic of the disease. There is almost always urgent thirst, and desire for cold drink, although the mouth be not usually parched. The tongue is moist, whitish, and cold; a dis- tressing sense of pain and of burning heat at the epigastrium is common; little or no urine, bile, or saliva, is secreted, nor are tears shed; the voice becomes feeble, hollow, and unnatural; the respiration is oppressed, and generally slow, and the breath of the patient deficient in heat. The pulse, from being very feeble, is now extinct at the wrist, and is felt with difficulty at the larger arteries. The spasms are sometimes so violent that the whole body is drawn, as it were, into a ball. In other cases no complaint of this nature is made. The duration of this stage varies from a few minutes to twelve, twenty-four, or forty-eight hours, and even to three days. Of all the symptoms of cholera, none in so invariably present, nor indeed so truly essential and destructive, as the immediate sinking of the circulation. The period at which a marked diminution of vascular action takes place, is somewhat various—the pulse sometimes keeps up tolerably for several hours, though very rarely; it more generally becomes small and accelerated at an early stage, and on the accession of spasm or vomiting, suddenly ceases to be distin- guishable in the extremities. The length of time during which a patient will sometimes live in a pulseless state is extraordinary. SYMPTOMS OF EPIDEMIC CHOLERA. 385 The reduction of temperature at this time is great. A thermo- meter placed on the skin indicates 84° F., or even only 79° or 72°. The blood itself is of reduced temperature : a thermometer intro- duced into the cephalic vein has fallen to 88°, 84°, and even to 82° F. Thirst and a sense of heat or burning in the region of the stomach, are generally connected together and form very prominent and constant symptoms of cholera ; yet not only in individual cases, but even in epidemic visitations, these symptoms have often been alto- gether wanting. Even when they are present in the highest de- gree, the mouth is not parched nor the tongue often dry; on the con- trary, there seems in general no want of moisture in these parts. The sense of thirst seems to subdue all other feelings — cold water is constantly craved and eagerly swallowed. The state of the skirt is cold, generally clammy, and often covered with profuse cold sweats ; nevertheless, varieties occur in this, as in other symptoms of cholera — the skin is sometimes observed to be dry, though cold : and sometimes of a natural, and even in some rare cases of a preternatural warmth. An increase of temperature has been repeatedly observed to take place just before death; but the development of heat appears to be confined then to the trunk and head ; and, in almost all cases, this partial development of heat is found to be a fatal symptom : it is entirely unconnected with any restoration of the energy of the bloodvessels, or any improvement in the function of respiration. Often, at a very early stage of cholera, leeches cannot draw blood from the skin ; when the sweat is thin, it is usually poured out in large quantities from the whole sur- face of the body, but when thick or clammy, it is more partial, and generally confined to the trunk and head. The action of the vapour and hot baths is said to increase the exudation or secre- tion from the skin ; and the application of dry heat, as the natural temperature of the skin augments, appears to restrain these dis- charges. The perspiration or moisture is often free from odour; at other times it has a fetid, sour, or curdy smell, vvhich has been said to be peculiarly disagreeable, and to "hang about the nostrils" of the bystander. In some cases, patches of eruption like urticaria and still more often resembling roseola, or, again, minute miliary vesicles, were observed: the appearance of those eruptions was generally a good augury. That remarkable shrinking of the features of the face, vvhich has acquired the emphatic term of the " true cholera countenance," ap- pears in every case not quickly cut short by medicine. This expres- sion of countenance, vvhich conveys so truly that of death itself, can- not be mistaken, and by an attentive observer it will be perceived that a similar shrinking takes place throughout the limbs and all the projecting parts of the body. Respiration is not usually interrupted in the early stages of cho- lera. In many cases terminating in death, respiration has gone on in its mechanical part with little or no interruption, excepting that it becomes more and more slow. Numerous cases, on the other hand, are noticed, occurring especially in Europeans, where the in- vol. i.—33 386 DISEASES OF THE DIGESTIVE SYSTEM. terruption of respiration was most distressing, and could only be compared to the most violent attacks of asthma. Modifications in this respect must occur when pneumonia is present; for this lat- ter complication was far from being uncommon. Although the breath is stated, in many reports, to have been deficient in heat, it is not clear that this is a general symptom, nor is it understood that this coldness is more particularly observed in cases of difficult and laborious respiration, than in those where the function seemed to be at least mechanically performed without interruption. Dr. Davy ascertained that less than the usual proportion of caloric was de- veloped at this time. No symptoms of cholera are so uniform in their appearance and progress as those connected with the blood and its circulation. It is established by undoubted evidence, that the blood of patients attacked with cholera is of an unnaturally dark colour and thick consistence. The changes in the circulation of the blood are/ like- wise observed to be in direct ratio with the duration of the disease, and, in general, only well manifested after the gastro-intestinal dis- charges have set in. In a great majority of the reports of the physicians in India it is stated unequivocally, that after a certain quantity of dark and thick blood has been abstracted, it is usual for its colour to become lighter, and its consistency less thick, and for the circulation to revive — such appearances always affording ground for a propor- tionably favourable opinion as to the termination of the case. In many instances, however, no such changes have been observed to accompany the operation of bleeding, and yet the result of the case was favourable. The blood is generally found to be less changed in appearance in those cases of cholera which have been ushered in with symptoms of excitement, than where the collapsed state of the system has occurred at an early period. The blood has been occasionally found, on dissection, to be of a dark colour in the left as in the right side of the heart — affording reason for believing that in the whole arterial system it was equally changed. The tem- poral artery having been frequently opened, the blood was found to be dark and thick like the blood of the veins. It is the laboured re- spiration and almost stoppage of the circulation, and darkness of the blood, that have procured for the disease the name of Cholera Asphyxia. But as this, if at all, is only applicable at a particular stage, and that generally the fatal one, or that of collapse, the epithet cannot serve to designate epidemic cholera. In the natives of India, in whom respiration is pretty generally free, until the very last stage, the colour and consistence of the blood in the instances in which venesection was performed, has been very uniformly found to be dark, whether excessive discharges prevailed or not. In the majority of cases, the secretion of urine is diminished — and in violent cases it is entirely suspended through- out the attack. The general symptoms of cholera, as it presented itself in the dif- ferent districts of India, correspond precisely with those observed in the disease during its prevalence in Russia, Poland, the rest of Europe, SYMPTOMS OF EPIDEMIC CHOLERA. 387 the Canadas, United States, &c, &c. This is proved by the history of the disease which is contained in the circular distributed by the Austrian Government, and the elaborate epitome of its symptoms, transmitted by Dr. Keir, of Moscow, to the British Government, and in the accounts received from Montreal and Quebec, as well as our own published ones, in this country. It is needless to dwell on this topic, with a view of establishing the identity of the symptoms of the epidemic cholera vvhich prevailed in Europe and America, with those observed by the English practitioners in the cholera of the East Indies. All the Russian and German reports agree, that in the generality of cases there were the same excessive evacuations, upwards and downwards, of a watery turbid fluid, the same collapse of the skin, coldness of the surface, sinking of the pulse, failure of the strength, lividity of the face, shrinking of the features, spasms of the muscles, sense of pain at pressure on the region of the splanchnic plexus of nerves, entireness of the mental faculties, and blackness and iuspissation of the venous blood; that, in Europe, as in India, some instances occurred of rapid death, with collapse and spasms, and without vomiting or purging; that in other instances chronic irritation of the bowels continued for a long time after the violence of the disease was broken ; and that sometimes symptoms of cere- bral congestion supervened on the violent constitutional disorder which accompanied the intestinal symptoms, and quickly termi- nated in coma and death, when not counteracted by an appropriate treatment. Stage of Reaction or Consecutive Fever of Cholera. — The men- tion of this stage, as coming next in order in those who survive the collapse, suggests the very natural, and, as I think, correct idea, that confirmed cholera is but a stage of fever corresponding with the cold one of intermittents. The forming stage of cholera is marked generally by diarrhcea and some other disturbances of function. The stage of reaction corresponds with the febrile reaction after the chill of intermittent fevers, or still more, after the stupor, coma, &c, of pernicious or malignant intermittents, as they have been termed. In both cases, the collapse and asphyxia of cholera, and the chill and coma of intermittent fever, will kill — in both, escape from these may be followed by fever and phlegmasia, which will often destroy the patient. Mr. Searle, a judicious writer, who witnessed the disease both in India and Poland, observes, that " cholera was generally based upon, or succeeded by, fever of a bilious inflammatory type — in Europe, of a low remittent or typhoidal character. In Europe, the choleric symptoms were less marked than in India, and the succeeding fever evinced less of simple reaction. " I have said remittent, though the first few days I have generally found it lo be intermittent; coming on daily at about the same hour, preceded by coldness of the extremities, quivering of the lip, and de- pression of the circulation ; but from the excitement of inflammation, which but too frequently becomes developed in the organs previously congested, the intermissions become imperfect, and, in consequence, it assumes a remittent, and from the conjoint debility, a typhoidal form." 388 DISEASES OF THE DIGESTIVE SYSTEM. One of the best descriptions of the stage of reaction which I have seen, is that given by Messrs. Haslewood and Mordey, in their " His- tory and Medical Treatment of Cholera, as it appeared in Sunder- land, in 1831." "The fatal termination of the cold blue stage of cholera," says those gentlemen, " occurs often without a struggle, or is preceded only by a few short convulsive heavings of the chest: but in other instances a slight appearance of reaction, indicated by some throbbing of the carotids and warmth of the chest, is succeeded by sleep, from which the patient can only be roused for a moment: per- fect coma succeeds; and the patient survives, perhaps, for a few hours. From the large doses of opium administered in some of the cases, we were at first disposed to attribute this state to narcotism; but we were subsequently convinced that it was by no means con- fined to such cases, and was rather to be attributed to the general tendency of the febrile stage of cholera to produce cerebral con- gestion. " The comatose state is sometimes preceded by a sudden attack of furious delirium; the patient throwing off the bed-clothes, attempting to get up, striking every one within his reach, and raving wildly, the muscular strength exhibited is considerable ; but the struggle is short, and soon succeeded by total insensibility. "When the spasms, the vomiting, and the purging have ceased; when the pulse begins to return at the wrist, and the breathing be- comes unembarrassed, and a genial warmth diffuses itself gradually and equably over the surface, the patient falls into a tranquil sleep, which continues some hours, accompanied with gentle perspiration: he awakes refreshed,declares himself 'quite well,' asks for something to eat, and is ready to be up and away. It is at this period the medi- cal attendant is most likely to be thrown off his guard. Very limited experience, however, will convince him that there is yet a period of the disease calling for unremitting attention and decisive treatment. An almost invariable symptom at this period is a considerable suffu- sion of the eye ; the cornea looks dull; vessels containing red blood are visible on the surface of the sclerotic, and are most numerous at the lower part of the eye.* The appearance differs from that of in- flammation ; the vessels are large and numerous, but terminate abruptly, rarely forming the vascular network observed in ophthalmia; the redness is dusky, and the affection unattended with pain. At the same time there is often some degree of stupor; and if the patient moves the head suddenly, he complains of a dull, deep-seated pain. The tongue is coated with white fur, and rather dry; or becomes red, glistening, and chapped. The secretions are not restored ; or, if re- stored, present unhealthy appearances; that of urine has continued suppressed for four or five days. When this has been the case, its restoration is attended with uneasiness in the bladder, and the attempt to void urine gives great pain, — arising, probably, from the accu- * "The following case occurred in the practice of Dr. Odgen : — December 12, John Parkin, aged 4, attacked with malignant cholera in a severe form : during the cold stage the eyes had a dry and shrunk appearance, and the lower half of each cornea became opaque. The child recovered. In the febrile stage, an onyx was formed in each cornea, where the opacity had been previously observed. For about three weeks the child was in a state of incoherence." SYMPTOMS OF EPIDEMIC CHOLERA. 389 mulated sensibility of the mucous membrane, so long devoid of its natural stimulus. The discharges from the bowels become highly offensive, and contain an abundance of vitiated bile, and of the gluti- nous matter (sometimes in large masses) which gives the flocculent appearances to the earlier evacuations. " The patient is, in fact, labouring under a fever, bearing a consider- able resemblance to the o-dinary fever of this country, — assuming, in mild cases, a remittent or intermittent type, but always accompa- nied with a strong tendency to local congestions, especially of the brain: but where strong predisposition existed, or, in other words, when some organ was, from natural or accidental causes, peculiarly weakened, manifesting itself in it. " The first approaches of coma are aften so insidious as to escape observation; but the pulse continuing quick, with fetid watery dis- charges, and, above all, the continued suppression or insufficient secre- tion of urine, will convince the observer that all is not right; drowsi- ness gradually increases, and his sleep is attended with stertor ; he may still be roused, and will swallow what is offered him, but quickly falls back into the same state. If the eye is examined, the suffusion is found to have increased, the pupil is dilated, and almost or quite insensible to light; and this phenomenon is sometimes confined to one eye. Complete coma succeeds." Urea, which has been found largely in the blood of cholera patients, is regarded by Dr. Roupell, who first noticed the fact, as the cause of secondary fever. But even were this element always found in cholera blood, and other observations have not confirmed those of Dr. R., iis presence alone would not explain the state of the system at this time. No other disease serves as an exclusion of cholera. It attacked in Paris the patients at St. Louis Hospital, heretofore labouring under itch, and the insane at Salpetriere and Bicetre. It was not uncom- mon among the phthisical, and has supervened on the treatment of in- flammations. Analogy of Cholera to Malignant Intermittents and other Fevers.— The views which I hold of cholera being properly a stage of cholera fever, are corroborated by the descripiions of pernicious (congestive) fevers by Torti and Morton. The following case from Torti presents (says Dr. James Johnson) a complete picture of the Sunderland cholera : — " When I reached the patient, he had been several hours labouring under the disease. I found him universally cold as marble, wiih the pulse altogether, if I may so say, absent, "breathing laboriously, and having a leaden-coloured countenance. There was some torpor, but no contusion of intellect {he never mentioned delirium), and his urine was secreted in a small quantity. I prescribed the bark in large doses.. A gentle heat soon pervaded his entire frame; the pulse gradually returned ; ihe respiration became natural ; the face lost its leaden hue ; the urine was secreted in its ordinary quantity, and in three Jays he was quite recovered." I have myself met wiih a still more marked case of complete col- lapse, which represented the paroxysms of intermittent fever. It was of a tertian type, and came on twice. There was complete insensl- 33* 3:90 DISEASES OF THE DIGESTIVE SYSTEM. bility, and with a pulse barely perceptible — coma, in fact. I had the patient leeched over the abdomen in the first attack, and cupped in the same region, and on the temples in the second one. Sulphate ofquinia prevented the return of a third paroxysm, and the man soon got well. He had suffered antecedently from a long, harassing, and dangerous.attack of bilious remittent fever. Dr. Jackson, of the University of Pennsylvania, in describing, the stage of collapse in cholera {Personal Observations and Experience of Epidemic or Malig- nant Cholera in the City of Philadelphia — Am. Jour. Med. Science, vols. xi. & xii.), represents it as " analogous to the last periods of par- ticular cases of malignant fevers, and to the algid form of inter- mittents." ___ LECTURE XLII. DR. BELL. Prognosis of Epidemic Cholera.—Common and individual signs—Modification by age, sex, occupation, and race—Promptness of recovery—Congestions with slower convalescence—Immediate causes of death—Remoter causes, in the con- stitution and habits of the individual—Misleading signs in the consecutive fever. —Post-mortem Appearances: — 1. The adventitious, though common; 2. The peculiar, and in a measure pathognomonic—Automatic movements—Increase of temperature—Textural and visceral changes in the digestive canal, lungs, and liver, and sometimes brain. Prognosis. —=-1 shall first speak of the probabilities of recovery, or of death, depending on circumstances- anterior to the morbid condi" tion of the organs and derangement of function pending the disease1 and, afterwards, of signs derived from these, as constituting the prognosis. The anterior circumstances belong to the history of the patient, and may be regarded as so many predisposing,causes of the disease, and modifying ones, also, of its progress and termination. They may, properly be considered under the heads of age, sex, employ- ment, race. Age. — Thevarious periods of life give rise to differences in the susceptibility to cholera. Children, were less frequently attacked than adults ; and the proportionof deaths to cases was, I believe, less. In the British army, the deaths from this disease have been nearly in ihe ratio of the age of the party. The following table formed from Major Tulloch's statistical reports, will distinctly prove this to be the case : — Mortality in the household Mortality of troops in Ca- Age. troops from cholera per nada from cholera per Gibralta 1000 mean strength. ■ 1000 mean strength. under 18 years 0, 0 •o from 18 to 25 2:3 15-5 47 25 — 33 2:5 25 — 41 33 — 40 4-— 36 54 40 — 50 4-9 70-4 60 PROGNOSIS OF EPIDEMIC CHOLERA. 391 In civil life, although the calculation is less to be relied on, the mor- tality has in almost every country increased with advance of age. The deaths from cholera in Paris were estimated at 18;402 or 23-42 per 1000. Of this number it was remarked that the mortality was least from six years to twenty, greater from thirty to forty, and great- est in old age. In Philadelphia, according to Dr. Jackson, the rate was as follows {op. cit.): — Age. Deaths. Ratio to population. Age. Deaths. Ratio to population. underoneyear between 4 1 in 604 between 40 & 50 159 1 in 46 1 & 2 years 4 1 —503 50 — 60 100 1— 28 2— 5 — 30 1 — 912 60 — 70 71 1 —102 5— 10 — 39 1 — 919 70 — 80 47 1 —212 10—15 — 19 1 — 188 80 — 90 5 1—36 15 — 20 — 22 1— 96 80 — i00 1 20 — 30 — 179 I— 81 100— 10 1 30 — 40 — 228- 1 60 999 In Cincinnati, as we learn from Dr. Drake, the proportion of chil- dren among the whites, who fell victims to the disease, was 22 to 472, or something less than a twenty-second part. Advanced age is not only unfavourable to recovery, but predisposes to the disease. " By a recent regulation, the ages of all sailors who enter the port of London are registered at the custom house. We have obtained permission to examine these registers, and have found that, of 5000 sailors, taken consecutively, 961, or considerably less than 1 in 5, had arrived at the age of 40. But the predisposing in- fluence of advanced age is rendered more manifest by taking, in the two classes, ages still greater. Of the cholera patients, 22 in 160, or more than 1 in 8, were of the age of 50 or upwards; while of the sailors registered at the custom-house, 289 in 5000, or less than 1 in 17, were of this age ; so that the proportion of cholera patients of the age of fifty or upwards, is more than double what it would have been were all ages equally liable to this disease. The influence of age on mortality is even more clearly shown.. The mortality was least in patients between the ages of fifteen and thirty ; and in these the num- ber of deaths was less than that of recoveries ; it was greatest in pa- tients above the age of fifty: of the 22 who had arrived at this age, only two recovered; the age of each of these two was fifty-three: of 13 whose ages exceeded fifty-three, not one recovered." (Dr. Budd Lib. Pract. Med.) K Sex.— The sex probably .has an influence in predisposing to cholera, though this fact cannot be considered as quite determined, since the roporlion has greatly varied in different countries. In Calcutta, Mr. ameson states, that it appears from the returns that, of the native 392 DISEASES OF THE DIGESTIVE SYSTEM. inhabitants attacked by cholera, the males were to the females as four to one. In Bombav, the reverse appears to have been the case ; the deaths of the women being to those of the men as two hundred and fifty-four to one hundred and seventy-two. In other parts of India, also, the results were equally opposed. Mr. Corbyn, however, affirms distinctly that men were generally more susceptible than women. In Canada, the soldiers' wives were observed to suffer nearly in an equal proportion with their husbands; and this was the case at Gibraltar among the civil inhabitants. Age. Estimated numbers of ihe civil inhabitants of Gib-raltar. Number attacked by cholera. Died. Severe. Slight. Men . . . Women . Children . 6000 5000 6000 •193 216 58 345 267 95 104 107 41 In Paris, up to the 20th of July, 1832, of 12,259 persons attacked with cholera, 6,243 were men, and G,106 women. The number of children affected is said to have been few, but the proportion of deaths great. Up to this period only 693 had fallen under seven years of ug:e: and of these, some were not more than four months old. At first the mortality was much greater among women than men in England ; but the entire results do not manifest such a dispropor- tion. In Philadelphia the proportion was, according to Dr. Jackson {op. cit), as follows: — Males. Females. 539 .... 370 Under 20 years of age ... 70 ... . 48 The difference is not in sex, but in the kind of occupation and the exposure of the women. Occupation. — The loss by cholera in one detachment of five com- panies of United States troops, on ihe way from Fort Monroe (Chesa- peake Bay) to Chicago, was equal to one out of every three men. It was at Fort Dearborn, situated on the south-west shore of Lake Michigan, that the disease displayed its most fatal effects among ihe troops. According to the report of Assistant-Surgeon S. G. J. De Camp, 200 cases were admitted into the hospital in the course of six or seven days, 58 of which terminated fatally. The strength of the command at this time was about 1000. In Detroit, the soldiers, then on their march to the theatre of Indian hostilities, suffered greatly; after indulgence in every kind of excess, and being quartered in an old back building on the banks of a river in tne most filthy paris of the town. In a command of 200 men, there occurred, between the 6th and 26ih of July, 1832, 47 confirmed cases of cholera, of which 21 terminated fatally. {Statistical Report of the Sickness and Morta- lity in the Army of the United Slates, p. 81, 86, 90-91.) The total number of cases of epidemic cholera reported during the years 1832, PROGNOSIS OF EPDDEMIC CHOLERA. 393 Deaths. Years. per 100 cases 1834 . 32 1834 . 30 1834 . 28 1832 . 36 1834 . 34 1836 . 32 1836 . 28 1833, 1834, and 1835, was 686, in the United States army, of which 191 terminated fatally ; but this does not comprise all, as many troops became victims to the disease in the campaign against the Sac and Fox Indians in 1832, of vvhich no official returns were made, in con- sequence of the death of medical officers. Dr. Forry, from whom I derive this information {Climate of the United Stales and Its Ende- mic Influences), adds: — "It is a singular fact, that this epidemic exerted its fatal influence in nearly the same ratio among all the troops whose statistics have been investigated : for example — United Kingdom, 1832, 1833, and Gibraltar ..... Nova Scotia and New Brunswick Canada ..... Black troops at Honduras United Stales, 1832, 1833, 1834, and I may remark on the above, that these proportions are not so nearly the same as Dr. Forry indicates, the difference between 28 and 36, or 7 and 9, counting for something. In and around Paris the proportion of cases of disease among the military was 25-66, while that among the inhabitants generally was 2275 per cent. In India it was observed that the disease was less-fatal to the Bramins than to Rajpoots; to Rajpoots than to the lower castes; and to Mussulmen the least of all. Race.—We have not data enough to enable us to institute de- tailed comparisons between the different races of mankind, either in regard to their susceptibility to cholera, or their proportionate mor- tality from it. The disease has, we know, attacked the three great divisions — white, yellow, and black; and in all has committed great ravages among them. In China, Siam, &c, its devastations were excessive. It was thought, a priori, that cholera would spare or pass lightly over our black population, particularly in the southern states; but everywhere, I believe, the deaths were proportionately more among them than among the whites. Their depressed condition socially, and their common degradation and poverty,brought them too surely under the law of cholera mortality. In Philadelphia the ratio of cases in the coloured population was 1 to 41 of their entire num- ber : that among the whites 1- to 74. The entire number of deaths in the former was 338, in the latter 1927. The ratio of coloured people to the white population is 1 to 14; that of cases of the coloured people to the white number of cases, 1 to 6. {Dr. Jackson, op. cit.) The actual mortality is not stated. In Cincinnati, the deaths among the blacks, as we learn from Dr. Drake {An Account of the Epi- demic Cholera as it appeared in Cincinnati), was forty-five, the entire number being 545 ; vvhich gives them a proportion of one- twelfth of the deaths. Their entire population was 1500 ; and hence, the ratio of the loss was three per cent., or, compared to that of the 394 DISEASES OF THE DIGESTIVE SYSTEM. whites, was as one and a half to one. In the slave states the pro- portionate mortality was si ill greater. In Louisiana it was enor- mous. At Honduras " none of the white troops, and but few of the European population, died from cholera. The fatal cases occurred almost entirely among the negroes and natives, and it seems most to have affected those who were irregular, drunken, and dissipated. The inhabitants of the Musquito Shore, who have in general that character, suffered more than any other; few of them having sur- vived an attack longer than six hours." {Statistical Report, fyc, among the Troops in the West Indies, p. 78.) In connexion with our present subject of inquiry, it should be known, that in Mexico the mortality was frightful among its Indian, which is its chief, population. In the States of Central America,the disease committed dreadful havoc. At St. Salvador, a seventh part of the population was cut off by it, and whole villages were de- populated. Drunkenness is a prevailing vice among all these people. Though not a comparison between different races, it is worthy of remark, that the native troops, or sepoys, in the British army in India, were more subject to cholera, and lost more of their number, than the European portion of the army. The circumstances of food and diet generally must, however, be taken into consideration ; the Europeans having greatly the advantage in these respects over the natives. The proportion of deaths to admissions was about 193 per cent, in Europeans, and something more than 23^ per cent, in natives. When medical aid is early administered, and the constitution of the patient is otherwise healthy, the recovery from an attack of cholera is so wonderfully rapid as perhaps to be decisive of the disease being essentially unconnected with any very marked morbid change in the several organs of the body. In the natives of India, in whom there is ordinarily very little tendency to inflammation,the recovery from cholera is generally so speedy and perfect, that it can only be compared to recovery from fainting, colic, and diseases of a similar character; but, on the other hand, when the attack was exceedingly severe, the constitution sank, with scarce an attempt to rally ; and in those who recovered, the stage of reaction was mild and of short duration. In Europeans, iu whom there is a much greater tendency to inflammation and determination to some of the internal organs, the recovery from the disease is by no means so sudden or perfect; on the contrary, it is too often complicated with affections as various as the diseases of various internal organs are known to be in India. The most frequent of the sequela; of cholera are affections of the intestines, brain, liver, and stomach. When cholera, however, is of long continuance, and when the congestions appear to have been thoroughly established, few, either Europeans or natives, who outlive the attack, are restored to health without considerable difficulty. It has already been remarked, that recovery from an attack of cholera is indicated by the return of heat to the surface of the body and rising of the pulse; a deceitful calm, how- ever, sometimes attends these favourable appearances, which too often mocks our hopes and expectations : whereas, on the contrary, PROGNOSIS OF EPIDEMIC CHOLERA. 395 patients have been observed to remain for one, two, and even three days, in a state of the greatest collapse, and yet, contrary to all ex- pectation, have recovered. The tendency to death in cholera consists in a general suspension of the natural, and gradual cessation of the vital functions, rather than in the establishment of morbid actions. Cases have been re- marked, where the vital functions have been more suddenly over- come, and where death took place before the usual development of the symptoms of the disease. Fatal terminations likewise occur from tropical inflammations supervening, as of the stomach, intes- tines, or liver. The intestinal canal seems especially obnoxious to the effects of cholera — numbers of those attacked with it having been subsequently seized with dysentery. It was almost uniformly observed that health was soonest re- stored in those cases in vvhich feculent, black, and acrid motions were easily procured ; and that, on the other hand, their absence was almost uniformly marked by feverishness, sour eructations, flatulence, constipation, and other signs of want of tone and slug- gish action of the hepatic system. This is an observation made by Mr. Corbyn, and is especially applicable to the subjects of the disease in India. Children, we are told, recover sooner than adults from the cata- leptic or collapsed state. The first mark of rallying in them was a slight injection of the conjunctiva, with marks of~general restless- ness and tossing of the head. After these follow often all the symp- toms of cercbro-meningeal or hydrocephalic inflammation, vvhich, unless rapidly controlled, cut off the patient. In one case of this kind, Mr. Fife, of Newcastle, had leeches applied to the head twelve times. In persons with broken down constitutions the period of conva- lescence from the severer forms of cholera has been usually pro- tracted, and several weeks have elapsed before they have regained their usual health. "The most decidedly favourable symptom in the second sta<*e of cholera, is a full and early secretion of healthy urine. On3this symptom we may rely with safety; and without it we can never with confidence offer a favourable prognosis. " The most enduring memento of cholera, however, is the irrita- ble and debilitated state of the mucular system, which continues painful on slight exertion, and subject to constant recurrence of cramps. These attacks occur most frequently at an early hour of the mormng, on awakening from sleep; perhaps the patient is aroused by them: they are also apt to attack after long fastin* or on any slight disorder of the stomach and bowels."— (Haslewood and Mordey.) v In general, they whose constitutions have been weakened bv fatigue and prior disease sink rapidly. The drunkard has rarely survived an atlack of cholera. Almost everywhere the poor and needy, they whose lodgings and food are bad, have been the greatest sufferers, and often the disease was confined to this class But in Paris and London, it took, after a while, a wider ran-e and in th- 396 DISEASES OF THE DIGESTIVE SYSTEM. former capital particularly, it assailed at once those in good circum- stances, who in considerable number fell victims to it during the whole period of its prevalence. This fact is in unison with observations made in other diseases, as typhous fever, small-pox and scarlatina, and points out the direct personal interest, independently of philanthropic considerations, vvhich the rich have to the well being of their poorer neighbours. Casimir Perrier, the prime-minister and favourite of Louis Philippe, died from cholera. It has been said (Griffin's Re- collections of Cholera in Limerick—Lond. Med. Gaz., 1837-38), that although the rich are less liable to be attacked than the poor, yet that the disease is much more fatal among the former than the latter. Previous high health even is thought by some to constitute a similarly unfavourable prognosis ; but general experience leads to a different conclusion. Pregnancy increases the danger of a fatal result. A sudden outset of the worst symptoms indicates speedy death; such as excessive coldness of the body, blue skin or cya- nosis, dyspncea and a rapidly failing pulse. Dryness of the cornea and ecchymosis of the sclerotica were indexes of certain death. They who discharged reddish-coloured serum, or had "port-wine stools," hardly ever recovered. Coma or delirium coming on before reaction were almost always mortal signs. Cessation of the vomit- ing, purging, and cramps, favourable signs in the first stage of con- firmed cholera, are of bad omen in collapse without reaction. Un- appeasible thirst is a very bad sign. A singular, and to those who see it for the first time, misleading appearance, is exhibited in some of the cases of those who pass into consecutive fever. It is hard to conceive, says Dr. Griffin {op cit), how human life could come to its close in a more quiet way than it did with some who lay down and died ; as if a little wearied, they were only enjoying a refreshing slumber. " This treacherous end was slow of approach, and had its forewamings. A beautiful blush first appeared on the cheek, which the day before was of a corpse- like paleness ; there was a constant drowsiness or disposition to sleep, and when addressed, the patient usually answered, perhaps with a smile, but always with a happy expression of countenance, ' Pm finely, sir.' On the succeeding day he was usually found in a still sounder sleep ; but when roused up and questioned, returned the same reply. On the third day he was snoring; it was harder to awaken him, and though yet muttering < finely, sir !' to all inquiries, there was an appearance of stupor and wandering about him. On the fourth morning he was generally found insensible." Post-mortem Appearances. — These were of two kinds;—1, the adventitious or occasional, though common ; 2, the peculiar, and in a great measure pathognomonic. The first depended very much on predisposition to organic disease induced by climate, and its actual occurrence owing to personal habits prior to the coming on of cho- lera. A singular and, to the inexperienced, a terrific trait, witnessed in some of the bodies after death, was automatic muscular move- ment. The arms, extended at the moment of death, have afterwards gradually been brought to the body,and the hands at the same time performed a movement of pronation, as if they were really under the influence of volition. EPIDEMIC CHOLERA — POST-MORTEM APPEARANCES. 397 Another phenomenon, not more unexpected than the one just narrated, is the sudden increase of the temperature of the body after death, particularly if this event occurred in the stage of collapse. In one instance the temperature of the body two hours after death was noted at 105° F. {London Lancet, 1S32.) Commonly this extra heat is lost when cadaveric rigidity comes on. Internally the adventitious or occasional alterations in the viscera are, as noticed in India, engorgement of the lungs, or an excessive collapse of these organs, so as to leave the cavity of the thorax nearly empty; congestion, or a lacerable state of the liver; gall- bladder filled with viscid, pitchy bile, or nearly empty, and gall-duct impermeable; mucous membrane of the bladder and uterus coated with a whitish-coloured fluid. In the head, appearances of conges- tion, and even of extravasation, were frequently observed. Under this division of appearances may be ranked collapse or spastic con- striction, and at other times distension of the intestinal tube into bags or pouches. The stomach was frequently thickened and con- tracted, and the small intestines full of hard knots, from one portion being forced into another. In many, particularly of such as died early, the stomach and intestinal canal were found full of muddy fluid, without the slightest marks of inflammation. In others, the vessels of their inner coats were turgid, sometimes highly inflamed, ulcerated, and gangrened; these appearances were more common in the bowels than in the stomach. A quite common, but yet not an essential appearance, is the intes- tinal canal being full of a muddy fluid and its inner surface, which is lined with a clayey substance of the same nature. The quantity of this earthy-looking stuff was sometimes so large as in a manner to plas- ter the villous coat, and to leave a thick sediment on passing through the sheet in vvhich the body was wrapped. A soft and pulpy state of the mucous membrane was often seen after this matter was removed. Passing over the observations of Dr. Keir in Moscow, and M. Brierre de Boismont in Poland, which I recorded in former lectures, I proceed to notice the anatomical characters of cholera. From the French pathologists in France, where the zeal and ability manifested in the pursuit of morbid anatomy are so conspicuous, we may expect to find greater minuteness in the specification of organic changes, although there was probably not a single new feature in the disease itself, nor of anatomical lesion different from those that were actually present elsewhere. The peritoneum was found to be quite dry, and in general the serous membranes were in the same state, and with little or no serous effusions in their cavities. But a gluey matter has been sometimes discovered, particularly in the peritoneum, which it covers with a fine layer, so minute as not to be readily seen, until we gradually separate two portions or folds of intestine which were previously in contact. We then see this matter stretched out in the shape of fine filaments. Externally the digestive tube was observed to be very much injected and of a rose or violet tint. The surface of the mucous membrane nar ticularly of the small intestines, was deeply injected with various vol. 1.—34 398 DISEASES OF THE DIGESTIVE SYSTEM. ramifications and arborizations. Dilatation and contraction in several parts of the intestinal canal and intus-susceptions were met with, as they had been so commonly in India. A turbid fluid, similar to that discharged by vomiting and stool, was found in the digestive cavity. In the stomach, besides this fluid, ihere was usually a considerable quantity of glairy mucus, more or less adherent to the membrane ; and sometimes, in place of it, a creamy matter, similar to that which lined the small intestines. This last is adherent, and resembles, when scraped off by a scalpel, grains of rice burst in boiling; another more fluid portion, consisting of a muddy serum, like whey not strained, or a mixture of a decoction of rice. A reddish fluid has also, like the grains of rice, been noticed by some French writers as common in the intestines, both large and small, of a dark red, or verging very often to a chocolate colour. These two last are distinctive rather than adventitious appearances. The lungs were often flaccid and collapsed, and sometimes con- gested at their posterior part. Any lesion in the liver, spleen, and pancreas, may be regarded as accidental. The kidneys were noticed to be usually injected with black blood ; but unaltered in their tissue. The pelves and ureters were empty; but a creamy, viscid matter could be squeezed from their tubuli uriniferi. No visible lesion was observed in the brain and spinal marrow,or their membranes ; except we regard as such venous injection with black viscid blood; and patches at the posterior part of the cerebral hemispheres of sanguineous infiltration. The nerves in connexion with the encephalo-spinal centre were, like it, quite sound. By some, alterations in the tissue of the ganglions and plexus of the sym- pathetic were pointed out; but these lesions were not of general, nor even common occurrence. In Great Britain, the visceral alterations were analogous to those already detailed — contractions of the stomach and bowels; these organs, often injected and inflamed in patches, and the mucous mem- brane, even when white, was softer than natural; their fluid contents same as before-mentioned. As had been noticed elsewhere, the mucous membrane of the intestines was more vascular, and often minutely injected as if with size and vermilion. The lungs were fre- quently much engorged, and in six or seven out of twenty-four cases examined by Dr. Craigie at Edinburgh, he found calcareous concre- tions in the lungs, and generally could trace them to branches of veins. He also relates, that a doughy state of the centre of the lungs was often found in the bodies of those cut off by cholera. This lesion, in connexion with bronchial induration, explains, he thinks, the diffi- cult and oppressed respiration which precedes the fatal event. The brain was sound in consistence and colour, but when divided it pre- sented numerous circular apertures of considerable size, and trans- verse fissures, which freely effused generally a dark-coloured blood. In another part of his paper, Dr. Craigie observes, that the organs most frequently and remarkably diseased in both sexes and at all ages, were tho kidneys. In these are witnessed every gradation and variety almost of the morbid changes delineated by Dr. Bright. Simi- lar observations were made by Dr. Mackintosh, {op. cit.) EPIDEMIC CHOLERA—POST-MORTEM APPEARANCES. 399 In the United States the post-mortem observations in cholera were the same as those made elsewhere; and I am not aware of any new feature in the occasional organic changes having been noticed. Of the peculiar and distinctive it is different, as I shall soon have occa- sion to mention. Respecting the appearances already described, they must be regarded as chiefly indicative of, or effects caused by, the early period of cholera and death in a state of collapse. Most of them are referrible to the disorder of the circulation, by which the venous system becomes singularly full and congested and the arterial alwavs uniformly empty, and,as it were, collapsed. That this venous congestion or accumulation of blood in ihe veins of the organs exerted little influence in deranging function or in causing the disease, we are allowed to infer from the little deviation from ihe healthy stale of the cerebral functions, although the brain and its membranes exhibited the same venous accumulations as the other organs. There must have been a change in the vitality of the economy, anterior to that in the vascular system or in ihe blood itself, a removal of which was followed promptly by a return of this system and its contained fluid to heahh. But the stage of collapse survived and that of reaction or of cholera fever begun, then there ensued new and diversified disturbances of function; and if the patient died afterwards there were found organic changes of a different appearance, and, we may believe, character also, from ihose occurring in the early and sinking period, ending in collapse. There was more capillary injection, more inflammation of the tissues, and particularly of the gastric intestinal mucous mem- brane, and often of ihe brain or its meninges. In fine, as the disease approximated to the character of typhous or remittent fever so did the state of the organs correspond wilh ihat observed in these diseases. To my designating certain appearances of organic alterations as adventitious in occurrence, it may be objected, that alterations of the gastro-intestinal mucous tissue are recorded as present in cholera subjects in all countries in vvhich it appeared, and that they ought to be regarded as essential and fixed features. But this is not so; for, although common, as I have admitted them to be, they were not of universal and constant occurrence. Mr. Scott tells us, that in some cases the whole intestinal tube presented a blanched appearance, both internally and externally ; and, again, that the duodenum and jejunum were often perfectly healthy. Sanguineous congestion and even active inflammation are stated to have been more common in the bowels than in the stomach ; but, on the other hand, instances were very numerous where no such indications were detected. Mr. Corbyn {A Treatise on Epidemic Cholera, &c), in recapitulating the morbid appearances found in cholera subjects in India, says, that slight traces of inflammation were occasionally observed in the alimentary canal ; but, in most instances, no mark of increased vascular action was per- ceptible. At Moscow, both the stomach and bowels were frequently of a paler colour than natural, as well internally as externally; but neither thickening nor condensation from inflammation, nor ulceration, destruction of substance, nor abscess, was present in any of the dis- sections witnessed by Dr. Keir. But it is not necessary for me to 400 DISEASES OF THE DIGESTIVE SYSTEM. adduce additional specifications of a fact everywhere admitted ; viz., that in many instances there was no trace of inflammation of the gastro-intestinal mucous membrane, and even where it had a deep suffusion, commonly in patches, this was the result of venous conges- tion, which, like that in the other organs, furnished no great, certainly no fatal, impediment to the discharge of function. LECTURE XLIII. DR. BELL. Distinctive Post-mortem Appearances in subjects dead of cholera—Change in the blood—emptiness and contraction of the biadder—whitish fluid in the intes- tines—exudation on intestinal mucous surface—development and other changes in the follicular glands—psorenterie—Dr. Horner's observations—a vesicular eruption on the entire surface of the digestive tube—exfoliation of epidermic and venous lining of the tube—Great number of the gastro-intestinal mucous follicles—Change's in the fluids,—in the blood,—in the secretions from the bowels—Special pathology of cholera—Analogy to poisoning—Two orders of functions affected—Experiments by injection of poisons into the vein?—Dr. Namias's experiments with cholera blood—Organs and tissues simultaneously affected—respiratory, digestive mucous, and cutaneous—Mortality from cholera— In India—Russia—Poland—Hungary—France—Great Britain and Ireland— Berlin—Naples—Geneva—Leghorn—Sunderland—Glasgow — Quehec — Mon- treal—New York—Philadelphia—Cincinnati—Law of Recoveries and Mortality in cholera. Having in my last lecture described the occasional, and, in some respects, common post-mortem appearances of the organs in subjects dead of cholera, I now proceed to place before you the distinctive, and, as one must say, essential organic features of the disease. The first and most striking to the observer is the blackness of the blood, which is of a shining appearance, and when spread on a white surface resembles in colour the darkest cherry ; it has also been desig- nated as tarry, thick, ropy, syrupy. It fills the right sides of the heart and the great veins, and is found of the same character in the left side and in the arch of the aorta and some of the large arteries. It is less serous than common, and does not readily colour the inner surface of the bloodvessels, not is it reddened so soon by exposure to the air as healthy blood is. The veins and their ramifying capillaries, even on the membranes, contained as much blood after death as during life, and blood could be drawn almost as readily from a vein in the former as in the latter state. Another and almost invariable appearance in the bodies of those who died in the first period of cholera, and before reaction had taken place, was contraction of the bladder, "so as to be as small and dense as a virgin uterus," and its containing no urine, because receiv- ing none from the kidneys. But even to this there are exceptions, few, it is true, in vvhich there was an excessive secretion of urine, which seemed to take the place of the discharges from the bowels. {Am. Journ, Med. Sciences, vol. xi., p. 151-2.) The presence of a whitish or muddy-coloured fluid in the intestines was also a distinctive feature of the post-mortem appearances in the bodies of those dead in the collapse of cholera. In some few instances no fluid of this kind was found in the canal; but it had been dis- EPIDEMIC CHOLERA — POST-MORTEM APPEARANCES. 401 charged freely both upwards and downwards; and its secretion or exudation may be regarded as one of the characteristics of the dis- ease. It was generally watery, with shreds and patches, and coloured so as to resemble rice-water. In addition to this fluid there was generally more tenacious matter, erroneously called mucus, adherent to the mucous membrane, and requiring some effort to scrape it off. Sometimes, this latter was as hard as coagulated albumen, or curd ; and, although of a white colour, it received in spots a tinge of pink, owing to the vascular (venous) congestion beneath. The thick mucus seemed to be produced first, and then the thin fluid. (Fergus — Hist. and Treat of Malignant Cholera at Vienna.) I have mentioned before these fluids as among the occasional yet common appearances in cholera subjects. It would probably be more correct to describe them, as 1 now do, as part of the distinctive characters of the disease ; the exudation on the mucous surface, and the more fluid exhalation in the intestinal cavity, bearing the same relation to the morbid state of the gastro-intestinal mucous membrane in cholera as the exuda- tion on the pleura and peritoneum or effusion into the cavity of the chest and abdomen do in pleurisy and peritonitis. The flaky particles mixed with the scrum consist of albumen and some fibrin. The thick, exuded matter coating the intestine was in relation with, and, we may believe, a product of the glands of the intestines. As we have seen that there was nothing pathognomonic in the injective appearances, or occasional and even frequent congestion and inflammation of the intestinal tube, we must prosecute our inquiries farther, and endeavour to ascertain whether there is not a more uniform organic change in some other system than the vascular. Let us, therefore, see what the amount of evidence is, tending to show a uniform lesion in the glands of the intestines. If I adduce the testimony only of those who have made their observations on cholera subjects in Europe and the United States, it must not be inferred, that the organic changes about to be described were con- fined to these regions; but, that the inspection of the tissues was made with more care, and with more minute anatomical knowledge on the part of those who have recorded their observations. A very frequent alteration in the digestive canal, says M. Andral {op. cit), is that which consists in a development of the glands of Brunner. This alteration is not always of the same nature. Sometimes it consists of an eruption of small miliary vesicles, white and semitransparent, which are spread over the whole mucous membrane of the small in- testines. These vesicles are extremely numerous, and appear to be filled with a liquid. At other times we meet with true patches, having a dark and depressed centre ; and seemingly filled with dense matter. On some occasions, in fine, we meet with true ulcerated patches, a change chiefly observable when the cholera has reached the period of reaction, and assumes the typhoid form. Venous congestion and follicular eruption ; these, in the opinion of M. Andral, are the sole changes in the digestive canal, which, in all other respects, preserves its common properties. Is the mammelated appearance of the mucous membrane of the stomach, noticed by MxM. Louis, Andral, and others, and its eflacement by pressure, with the discharge of a white opaque 34* 402 DISEASES OF THE DIGESTIVE SYSTEM. fluid, connected with a morbid state of the muciparous glands of this organ ? MM. Serres and Bouillaud have also observed the multitude of white or slightly grayish granulations, with a hemispherical pro- jection, disseminated over the mucous surface of the stomach and small intestines. The follicles of Brunner, in fact, distended by a white turbid fluid, are three times their natural size. M. Serres says, that they are so numerous and developed in the small intestines, that the whole mucous membrane seems as if made up by them ; their number decreases towards the large intestines. M. Bouillaud re- marks, that it is not uncommon to meet, at the same time, with a similar lesion on the clustered follicles or patches of Peyer ; and, after speaking of the extent of " this hypertrophy, this species of erection of the follicles of the mucous membrane of the digestive tube," he adds, " this gastro-intestinal eruption, sometimes distinct, at others confluent, imitates, to a certain extent, the variolous eruption in its first stage." He repeats the calculation of M. Lebut, by which the whole number of follicles in the alimentary mucous membrane is esti- mated to be forty-two thousand. Dr. Horner, in a paper soon to be noticed, estimates the number to be forty-six millions eight hundred and ninety-six thousand, of which the stomach possesses about one million three hundred thousand, and the colon nine millions six hun- dred thousand, {Am. Journ., ut supra.) MM. Serres and Nonat be- lieve the eruption to be tumefied papillae, and designate it by the term psorenlerie. They found it to occupy one-half or two-thirds of the intestinal canal, beginning at the end of the ileum, where it is always larger and more confluent. Once they saw it as high up as the duo- denum, the free margin of the valvulae conniventes of which it had reached. Of the like tenor are the observations of Dr. Mackintosh {op. cit), as when he says, " The mucous follicles were generally en- larged, and Peyer's patches, so rarely seen in adult age, were seldom wanting; they were large, elevated, soft, and spongy, and sometimes slightly ulcerated." Dr. Craigie {op. cit.) found that the agminated glands were always rather distinct, sometimes elevated or injected, or reddened ; and the isolated glands were also perceptible in the shape of miliary granules of the size of pin-heads. Doctor Wm, E. Horner, whose patience in investigating healthy and morbid structure is made the more valuable to anatomical science by his accuracy in describing, has given greater extension, and at the same time precision, to the views of the French pathologists whose observations I have just placed before you. In two papers which appeared in the two successive numbers of volume sixteen of the American Journal of Medical Sciences, Dr. Horner assigns ihe fol- lowing morbid anatomical characters to Asiatic {epidemic) cholera, as far as relates to the alimentary canal: — " First A copious vesicular eruption, entirely distinct from the tumefaction of villi, muciparous follicles or glands, and which per- vades the whole canal. " Second. A lining membrane of coagulated lymph, which exists in the small intestines at least, if not in the stomach and colon also, and resembles in texture and mode of adhesion the membrane of croup. " Third. Vascular derangements and phenomena, vvhich are con- fined almost exclusively, if not entirely, to the venous system. EPIDEMIC CHOLERA — POST-MORTEM APPEARANCES. 403 " Fourth. An exfoliation of the epidermic and venous lining of the alimentary canal, whereby the extremities of the venous system are denuded and left patulous. Dr. Horner's observations led him to the conclusion already stated, which, as he tells us, had been reached before by Corbyn in India, and Girardin and Gaimard in Russia ; viz., that the existence of a layer of coagulable lymph on the surface of the digestive canal is diagnostic of cholera. They add, that this layer is sometimes traversed by very fine capillary vessels, vvhich are remarked principally at the points that adhere the most strongly to the membrane of the intestine. The inspissated layer, more or less adherent to the intestinal mucous surface, and described commonly by writers on cholera as mucus, is intimated by Dr. Horner to be more likely of the nature of coagu- lable lymph. I have already adverted to their probable mistake. The last anatomical character of cholera, as stated by Dr. Horner, is a copious vesicular eruption, entirely distinct from the tumefaction of villi, muciparous glands or follicles, and pervading the whole canal. The form of this eruption is that of a spherical vesicle, commonly from one-eightieth to one-hundredth of an inch in diameter, with parietes transparent and empty in a dried state. " This vesicle," says Dr. Horner, " lies upon the surface of what I have designated the superficial venous layer of the digestive canal, perfectly distinct from the follicles ; that is to say, having for its base the venous portion between the follicles." The vesicles are chiefly seen at the base of the valvulae conniventes, and are there closely disseminated, with scarcely an interval between them ; but they decrease in frequency towards the summit of the valvulae. I have already spoken of vesicular eruption {psorenterie) in 1832, by MM. Serres and Nonat. By some pathologists in the north of Europe it has been supposed to consist of tubercular granulations, connected with the lymphatic system, as they are easily filled from it, but not from the bloodvessels. M. Dalmas {Diction, de Med.) describes three degrees and stages of intestinal eruption; the first is of small, whitish, semitransparent vesicles disseminated over the surface of all the small intestine, but neither numerous nor confluent. In the second degree are seen true white follicles, which, M. Dalmas thinks, are the glands of Brunner morbidly enlarged. The third de- gree of eruptive development is ulcerous inflammation of these folli- cles. The eruption is seen, according to this writer, in about two out of five cases of cholera. Changes in the Fluids in Cholera. — Chemistry has come in aid of anatomy to enlighten us on the pathology of cholera. The first attempt in this way, by Dr, Hermann of Moscow, was not, however, successful. Subsequent experiments made by Dr. Foy at Warsaw, MM. Rose and Wittflok at Berlin, Dr. O'Shaughnessy at London, MM. Lecanu and Rayer at Paris, enable us to reach more diversified yet more accurate conclusions than those of the Moscow professor. I shall place before you the chief points. The blood of cholera patients is dark or black, viscous, with a shining appearance like that of varnish. It is less readily oxygenated 404 DISEASES OF THE DIGESTIVE SYSTEM. when drawn and exposed to the air in an open vessel, than blood most commonly is. It is also less readily reddened under the serum. The blood in cholera contains much less water and saline matters and more albumen than common or healthy blood. The chief changes, therefore, in this fluid during an attack of the disease is in its serum, by the escape of its water and saline ingredients, particularly the alkaline carbonates. There is also notable diminution in the quantity of fibrin. The proportion of albumen, on the other hand, is greatly increased. Dr. O'Shaughnessy found that there were 133 in place of 78 pans, the healthy standard in 1000 parts. Urea was detected in the blood of some cholera patients who had secreted very little urine for several days. Urea has also been found in the bile of cholera subjects. The fluid ejected from the bowels was found to contain carbonate, acetate, muriate, phosphate, and sulphate of soda, coagulable lymph, or a compound of albumen and fibrin, some mucus and water. The sediment in the evacuations in cholera is composed, accord- ing to Dr. Bohn of Berlin, of fragments of the epithelium of the mucous membrane of the intestines. Special Pathology of Cholera. — After the detail of the symptoms of cholera, and anatomical lesions of those who have died of the disease, it is natural to inquire into its special pathology, the inti- mate cause and nature of the changes which constitute it. The first and most abiding impression is, that cholera is caused by a poison which finds entrance into the blood, and through it affects the nervous system, and the tissues and organs. But like other poisons, the transmission of its noxious effects through the animal economy may take place at the same time through the nerves—and by its impression on the cerebro-spinal axis, or some part of it, give rise to symptoms of muscular disorder. There are two series of functional disorders which it is worth our while to note on this occasion, as making up collectively the group that represents cholera. The first, consisting of thirst, nausea, vomit- ing, eructations, frequent desire to go to stool, diarrhcea, constriction, as if of a bar on the hypochondrium, heat of the stomach and intes- tines, pains, colic, also tenderness of the epigastric, umbilical, and lumbar regions on pressure, increased pulsation of the ceeliac trunk or of the aorta, are abdominal, and manifest profound disorder of the digestive system. The other series, which includes cramps, convulsive movements, headache, a sense of constriction in the tem- poral region, painful rigidity and reddish injection of the eyelids, oppression and painful constriction of the base of the chest, disposi- tion to syncope on almost the slightest movement, trembling of the limbs, rapid exhaustion of the strength, slowness of pulse, cessation almost of the arterial beats, coldness of the body, of the tongue, and breast, feeble and slow respiratory movements, loss of elasticity of the skin, and its bluish hue, and death by asphyxia, — all these are effects of derangements of nervous centres, and particularly of the spinal marrow. These symptoms belong almost entirely to in- nervation, muscular motion, respiration,circulation,and calorification, — functions more especially under the government of the spinal PATHOLOGY OF EPIDEMIC CHOLERA. 405 marrow. Partial destruction of this axis, particularly the upper por- tion, as in the experiments on animals, is followed by diminished respi- ration, and circulation, and animal heat; and the animal perishes after a while in a state of asphyxia analogous to the blue stage of cholera. In irritation or inflammation, on the other hand, of the medulla spinalis, we find all the symptoms of cholera of the second series, or those vvhich are not abdominal, such as cramps and con- vulsive movements in one person, —oppression, and retarded circu- lation, imperfect hematosis in another; palpitations, syncope, con- striction of the chest, in a third, &c. But, before proceeding any farther with this comparison, or at- tempting to draw any conclusion from it, we must bear in mind the fact that one of these two series of symptoms may be entirely or nearly wanting in some patients with cholera. M. Roche, whose course of illustration and argument {Diet, de Med. et de Chir. Pract, Art. Gastro-Enterite) I now follow, tells us, that he has seen this entire separation of the two series, and appeals to his brother prac- titioners of Paris as witnesses to similar facts. In confirmation of the opinion, that cholera poison produces the group of symptoms indicative of the disorder of functions already detailed, we may cite the histories of the effects of injections of poison- ous substances into the veins, as furnished in the experiments of MM Magendie, Roulin, Gaspard, Gendrin, Bouillaud, &c. Among these, we note vomiting and diarrhoea ; and when the animals on which the experiments were performed were opened, the gastro- intestinal mucous membrane was red and tumefied in its whole ex- tent, and its follicles often enlarged. The symptoms indicative of lesion of the brain and spinal marrow were not less distinctly marked, but varying according as the poison was narcotic or irritant, or nar- cotic-acrid. Sometimes, also, ecchymoses on the heart and the kid- neys were also seen. . Shall I cite, in confirmation of this view, the experiments made by Dr Namias,at Venice, during the prevalence of the cholera in that city in 1S33. He was desirous of ascertaining, whether the blood of cholera patients possessed properties injurious to life. With this view he took a portion of the blood from the heart of a patient dead of cholera ; and through an incision of the skin he inserted it into the subcutaneous cellular tissue of a large rabbit. The animal seemed to suffer but little from the operation ; but five days after- wards it became dejected, its evacuations were less solid, appear- ances of white dejections were observed on the ground, and the animal died on the tenth day. The blood in the heart was found black and grumous, but without any particular lesion of the organs. The blood of this rabbit introduced under the skin of another, caused its death in twenty-four hours. These experiments were several times repeated with the same results. In contrast with these effects were the absence of any positive or deleterious ones ensuing on the introduction of the black, liquid, fetid blood of a person dead from intestinal gangrene, under the skin of a rabbit. 1 he ani- mal's health was not at all affected by it. A similar experiment with the blood of an individual who had died of aneurism gave the 406 DISEASES OF THE DIGESTIVE SYSTEM same result. Experiments of this nature require to be repeated and diversified before we can form positive deductions from thern. I have frequently bad occasion, in my lectures on Toxicology, as part of those on Medical Jurisprudence, to point out the close re- semblance in many, indeed most of the chief and alarming symp- toms of cholera and those caused by certain poisons. The same violent action is set up in thesecretorsand'depurators to free the sys. tem from the deleterious agent in the latter, as there is in cholera; and of these the chief apparatus thus inordinately excited in both is the digestive. (See Christison, passim.) Different from the pathological views of cholera hitherto presented, is the opinion of Mr. Rankin, Assistant Surgeon to the Calcutta General Hospital, given in a letter vvhich he addressed, under date of September, 15th, 1843, to the Medical Board of Bengal. Mr. Rankin believes : — " 1st. That it is in the absorbent system the seat of the disease must be sought. " 2d. That obstruction, from whatever cause, takes place in the absorbents, interrupting the passage of the chyle into the circulation. " 3d. That the chyle, so interrupted in its progress to the recep- taculum chyli and thoracic duct, is regurgitated into the digestive canal ; and " 4th. That the so-called " rice-water" fluid ejected from the sto- mach and bowels is neither more nor less than the chyle so regur- gitated, and vvhich ou?ht to have passed into the circulation, as well for the purposes of nutrition, &c, as to maintain the blood in a suffi- ciently dilute state for capillary circulation, and the sudden inter- ruption of vvhich necessary supply fully accounts for all the pheno- mena of cholera — for the almost immediate and rapid collapse, as well as for the subsequent capillary obstruction so conspicuous in those lingering cases where so much depends on the cautious atten- tion and judgment of the physician." Without indulging in any elaborate comment on this speculation, we may be allowed to doubt its applicableness to the various phe- nomena of the disease among vvhich the immense loss of serum is so conspicuous, a loss that is not a part of the regurgitation of chyle. Whether we study the operation of the probable causes of the disease and the pans primarily impressed, or of the means of cure, we must, it seems to me, direct our attention, in the first instance, to the three great surfaces, viz., the respiratory, the digestive mucous, and the cutaneous, vvhich, both in their organic and functional changes, play so important a part iu cholera. Derangement of any one of these will produce much corresponding disorder in the others, and thence in the whole system. How great and alarming, then, must be the disease which follows the operation of morbid causes acting on all three, as when the cholera poison is inspired with the air,and disturbs the economy throiuh the respiratory mucous membrane, while the sedative influence of cold and moisture following heat is manifested on the skin, and the irritations of unwholesome ingesta — bad food and intoxicating drinks—are at work on the digestive mucous membrane. Each one of these morbid causes is competent PATHOLOGY OF EPIDEMIC CHOLERA. 407 to disturb both classes of function — those of nutrition and those of sensibility; for, even if we were to admit lhata poison had once pene- trated into the blood, and become mixed with it so that its vitality was impaired, we cannot but see that (he nervous system must suffer almost at the same moment. It does so under the influence of the obvious and material causes already mentioned, which derange the functions of the skin and digestive mucous membrane, as we see in the pain, cramps and spasms which accompany bilious colic and sporadic cholera. But how much more impressible, by morbid causes affecting it from the three great surfaces, must the nervous system be, or rather how little prepared to resist the shock of these causes, if it have been previously weakened by ihe prolonged excite- ment of habits of intoxication, or by the deficiency of food ; and that less thought of, but not the less real cause of, nervous disorder, want of personal cleanliness, and habitually impure skin iu consequence. But I cannot farther enlarge on these points now, nor even repeat what I have before said on the subject, in the volume already re- ferred to {All the Material Facts, &c), but must pass, after some observations on the mortality, to a notice of the chief means of cure which were had recourse to during the prevalence of the cholera epidemics in different countries. Mortality. —It will be impossible to have accurate ideas of the real value of the remedies, and treatment in general, in cholera, unless we know the ratio of mortality from the disease, and the modifying influence depending on locality, season, and, above all, the duration of the epidemic. When we learn that, in nearly all the countries in vvhich epidemic cholera has committed its ravages, the mortality has seldom been less than a third, and has sometimes amounted to half of the whole number attacked, we might at first be tempted to declare the nullity of medicine, or, at any rate, the little advantage of one mode of treatment over another. In India, out of a population of forty millions, it has been estimated that the deaths were eighteen millions between 1S17 and 1S30, both inclu- sive. But we soon recover from this gloomy skepticism on learning that, without medical treatment, the vast majority of those attacked with cholera die, and that if medical means be resorted to in the first forming or diarrhoeal stage, cholerine, a correspondingly large majority of those who are thus attacked can be saved; and finally, that under regular treatment, even of a diversified nature, many survive who would otherwise have invariably perished. If all the cases of every degree in vvhich medicine has been administered were recorded, the mortality would not be alarming. Dr. Taylor of Bombay gives the following return: — Medicine administered to 7,450 : of whom died, 441. Being a proportion of nearly six to a hundred. It is stated in the Report of the Medical Board at Bom- bay, that there is reason to believe that of 1294 cases which received no medical assistance, every individual perished ; and, it is added, that it is not ascertained that any case has recovered in which me- dicine has not been administered. Now, although we may not re- ceive this assertion in its literal extent, since undoubtedly out of a thousand persons attacked with cholera in almost auy part of the 408 DISEASES OF THE DIGESTIVE SYSTEM. world, some few will struggle through the disease, by the unaided powers of nature, yet it is in the main correct, and gives additional force to the experience of an opposite course which I am about to narrate. According to the documents collected by the Madras Medical Board, the number of deaths in the army of that presidency during the year 1818 and four subsequent years, was 4,430, of which 695 occurred among the European troops, and 3,735 among the sepoys. The number attacked was 19,494, namely, 3,664 Europeans, and 15,830 natives. The average strength of the army during the period included in the reports being 10,112 Europeans, and 73,254 natives, it follows that, in five years, 23^ per cent, of the troops were attacked, and that of these 22| per cent, were carried off, or 5\ per cent, of the whole army. Of the natives, 45 per cent. died. March, April, and May, are the months in vvhich the disease generally prevails at Calcutta, but May is much the most fatal. These statements, though sufficiently distressing, are still a proud monument to the skill of the medical men employed, and to medical science in general. Subsequently, for the six years, ending 1837, Dr. Stewart {Report of the Committee on the Medical Topography of India), estimates the mortality of the Hindoos from cholera, at 1-26 per cent of the entire population of Calcutta ; of the Mahomedans, at 0-66 per cent. In the seven years, 1832-8, 15,204 died of cholera out of about 157,000 Hindoos; and 2911, out of 60,000 Mussulmans in Calcutta. Of the 18,115 deaths, 8135 occurred in the months of March, April, and May ; 2831 in June, July, August ; 4051 in September, October, November; 1586 in December; 696 in January. The smallest number of deaths from cholera occurs in the month of January, the greatest number (3180) in the month of April, the middle of the hot and, dry season in Bengal, when the temperature rises gradually from 80° to about 90°-95° in the shade. The number attacked in Moscow, from September, 1830, to January of the following year, was 8130, or 54 per cent. In the small town of Redischeft, of 800 sick, Dr. Reimann states that 700 died in one week. Taking the whole number attacked, it is said that the proportionate number of deaths were, at Astracan, as one to three; in the government of Kertroma, a fraction less; in that of Nishni Novogorod, one-half; in Casan and Moscow, as three to five ; and in Penza, the country of the Don Cossacs, as two to three. In Jassy (Moldavia) the deaths were more than 6000 in a popula- tion of 27,000. In the summer of 1S31 the mortality at St. Peters- burgh, Riga, Mittau, Limberg, and Brody, according to the Berlin Gazette, was about one-half, while at Dantzig, Elbing, and Posen, it was about two-thirds of the whole number attacked. {Dr. Robert Williams, op. cit.) In Archangel the deaths were 1200 in a population of 19,000. In Dantzig the mortality was more fright- ful even than that just slated. The whole number of sick was 1387, of whom 1010 perished, in a population of 72,000 persons. It was in this city that the most strenuous and systematic exertions, under the direction of the government, aided by the military, were made, by a rigid system of quarantine, to keep out the disease. PATHOLOGY OF EPIDEMIC CHOLERA. 409 The result was a commentary on tbe absurdity,-—ought we not to say, in reference to all its effects, the wickedness of such an attempt. The period of theseason greatly influences the mortality; and the proportion of deaths to recoveries observed in Moscow, at the vari- ous phases of the disease, has been nearly that of all Europe. At the first onset nine-tenths of the number attacked perished; then seven- eighths, and the proportion of deaths forms a gradually decreasing series of five-sixths, three-fourths, a half, a third, till towards the close of the season, a large proportion of those attacked recover. The uni- formity of this law, although the proportions may differ,in every coun- try'attacked by cholera, whether India, China, Europe, or America, is extremely remarkable. It may be added, that the influence of locality was also manifested at Moscow, as the greatest number of deaths occurred in the marshy sections bordering on the Moskwaand Kanal. These rivers frequently overflow to such a degree that the water reaches the lower windows of the houses in the neighbourhood. In Hungary, cholera proved fatal to 240,000 persons, during its prevalence from July, 1831, to April, 1832. In Paris, the mortality from Cholera was 18,402, in a population of about 800,000 persons. In all France, the deaths in 1832, from this cause, were 95,000 and the cases 230,000. During the three years it lasted in Great Britain and Ireland, not more than 30,000 persons fell victims to it. In Berlin, the cases in 1831 were 2271, deaths 1426; in 1837, the cases were 3561, and deaths 2174. The period of the first attack was 46 days; that of the latter, 16 weeks. In Prussia generally, the estimated mortality among the sick of cholera was 586 per cent. In the city of Naples, with a population of about 330,000 persons, the number of cases from the second of October, 1836, to the last of January, 1S37, were 9725; of vvhich the deaths were 5293. In Naples, the greatest mortality was in the unhealthy districts,and among the poor and ill-fed inhabitants: at Genoa, with a population of 80,000 persons, the mortality was 2,151 out of 4250 cases; and in Leghorn, with a population of 66,000, giving 2031 cases, the deaths were 1146. In Sunderland, where the cholera first appeared in England, the number attacked, from the 26th October, 1831, to the middle of Janu- ary, 1832, was 534, and the deaths 202, in a population of 40,735. In Glasgow, from the 13th of February to the 11th of November, 1832, the number of deaths from cholera*was 3005 out of 6208 per- sons attacked, in a population of 202,426. The greatest mortality was in the month of August, in vvhich there were 1133 deaths. In Quebec, with a population of 37,000 persons, the mortality from cholera during the period of attack, or from June 9, to September 2, was 2218. The number of cases not stated. In Montreal, the mortality was rated at 3000, in a population about the same as Quebec. In New York, with a population of 205,000, the cases of cholera were 5S14, from the ith of July to the 28th of August, 1S32, of which the deaths were 22 15. In 1S34, in vvhich year the disease reappeared, the deaths were about 900. In Philadelphia, in a population of 160,000, the cases of cholera vol. i.—35 410 DISEASES OF THE DIGESTIVE SYSTEM. were,duringits period of invasion, from July 11, or mainly 28, to Sep- tember 13, 1832, 2314 — and the deaths, out of this number, 948. In Cincinnati the mortality was 545, in a population, at the time, of 25,000; and in New Orleans 6000, in a population of 55,000. Law of Recovery and Mortality in Cholera. — Mr. Farr, from 9372 registered cases in 1S37, published by the Roman Board of Health, has constructed several tables illustrative of the chances of recovery and death in this disease. One of these tables exhibited the numbers dying and recovering on each day after attack, and contained calculations from theoretical considerations, which closely approached the amounts derived from facts. The following table will show this more clearly : — Out of one hundred constantly sick: Deaths. Observed. Calculated- 5th day . . 5-471 5-650 6th ... . 5 684 5-056 7th . . . . 4-500 4-523 Recoveries. Observed. Calculated. 6-747 6.747 8295 7-929 9-219 9-317 The following table expresses the probability of recovery and death during the first ten days after attack : — Days. 0 1 2 3 4 5 6 7 8 9 10 Probability of Recovery. . . -422 . . , . . -542 . . , , . . -668 . . . , . . -729 . . . , . . -763 . . . . . -791 . . . . . -821 . . . , . . -843 . • . . . -S62 . . . , . . -873 . . . . . -883 . . . Probability of death. . . -578 . . -45S . . -332 . . -271 . . -237 . . -209 . . -179 . . -157 . . -138 . . -127 . . -115 From the tables may be deduced the following problems: — viz., 1st, the mean duration of the disease; 2d, the mean future duration of the disease at any period; 3d, the probability of dying at any period of the disease. The following table from different data presents the question some- what differently: — Table of the Probability of Recovery from the severer Attacks of Cholera at the end of 12 hours, and 1, 2, and 3 days. Cases. To Recover. To Die. Probability of Recovery. 0 hours 10000 12 ... 9181 1 day 7616 2 ... 6793 3 ... 6291 5093 5093 5093 5093 5093 4907 4088 2523 1700 1198 •509 nearly 1 to 1 •555 .... 1-3 .. 1 -669 .... 2 . . 1 •750 .... 3 . . 1 •809 .... 4 . . 1 TREATMENT OF EPIDEMIC CHOLERA. 411 These facts prove that, in cholera, the probability is generally not in favour of death; they also establish the importance of early treat- ment, for half the deaths happen in the first twenty-four hours. What the practitioner does, he should do quickly. LECTURE XLIV. DR. BELL. Treatment of Cholera.—Study previously of its mortality, and comparison with that in otlier diseases—Almost certainty of death, unless medicine be given— The sedative class of remedies most useful in cholera.—Evidences of increased innervation—Increased glandular secretion—Indications of cure—Treatment of the Diarrhoeal Stage.—Necessity of prompt attention to the first symptoms of irregular digestion—Mild purgatives, sometimes an emetic; laudanum ; diluents ; rest; moderate warmth—Case—Selection of purgatives—Treatment of Marked Cholera.—An emetic—Bloodletting—Sedative or contra-stimulant remedies— Calomel; its primary and sedative effect; is to be given in large doses, some- times alone, ofien with a full dose of laudanum—Opium. Notwithstanding all ihe array of statistics of cholera, we are not in possession of the requisite data, from which to draw the proper de- ductions respecting the results of any one plan of treatment, nor of course the most appropriate course to be pursued in future exigencies. Patients have not been classed, nor have specific returns been made of the different appearances of the epidemic and of its proportionate mildness or malignancy at these times. In another important parti- cular, viz.; in the hospital and other returns of cases and deaths of cholera, there has also been a great want of uniformity : the period of collapse, for instance, conveying different ideas to different writers. In approaching the subject of the treatment of cholera we seem, in our inquries into dynamic forces and organic lesions,to forget,that there is, in each individual, an original, inherent, and constitutional power ot resisting morbid influences— poisons or other destructive agencies, vvhich may be aided, but not increased, by medicinal means. At other times, again, under similar circumstances of violence and assault, this power is insufficient, even with the aid of all the efforts of art. But as these circumstances vary often in a very short period, we must endea- vour to seize the most favourable juncture, ere the powers of life have been too fiercely assailed. Thus, a little assistance on the inception of a disease will enable the constitution to throw it off; the same on the following day will have more doubtful efficacy ; and on the third, will be utterly unavailing. There are some in whom this constitutional power of resistance is so feeble that they almost, of necessity sink under any epidemic disease. They belong to the class of the weak, the sickly, and the diseased; but not to these alone, for sometimes the robust and those of full habit are found to be equally unable to resist the morbid influence.- It has been noticed, in more than one place in vvhich epidemic cholera prevailed, that, although the better classes of the community were less liable to an attack of cholera, yet, if once they did sicken, they were more apt to die than others less favourably situated. As regards the great mortality in cholera, we 412 DISEASES OF THE DIGESTIVE SYSTEM. shall be lessdisposed to call it excessive, by comparison with that in other diseases, if we refer to the ratio of'deaths in some of them. "In typhous fever the inevitable mortality varies according to the virulence of the epidemic; among the poor, from one in ten to one in thirty-two; among the rich from one in five to one in twenty ; being generally the same in the same epidemic. The mortality in the simply confluent small-pox is, according to Dr. Gregory of London, three in five, which is little short of that occurring in the collapse of cholera when judiciously treated. In the common description the mortality is one in four; and on the whole it has been computed that, out of every six persons who take small-pox in the natural way, one enevitably dies." {Griffin, op. cit) In the Statistical Reports, &c, of the diseases among the British troops in the West Indies, I find, under the head of fevers, that the proportion of death to admis- sions in "yellow fevers {Icterodes)," is stated to be 1 in H. Even in 'remittent fever' the proportionate mortality to the cases treated, was 1 in 8. On the western coast of Africa, as we learn from an- other; report emanating from the same source, the deaths from remit- tent fever are nearly one-half the admissions, or in the proporlion to the latter as of \ io 2. In estimating the value of medical treatment in cholera, such as has been furnished in different parts of the world, and with the results of which we are in a measure acquainted, we ought first to ascertain what is the amount of mortality in cases abandoned to nature* At its onset the disease is always violent a:nd causes death in a large proporlion of the persons attacked ; and this is brought and admitted as an argument against the curative power of medicine. But the last is not a legitimate sequence of the first proposition. In the beginning of an epidemic people are igno- rant of its prodromes, do not know the real constructions to be put on their pains and disorders, think these are slight, and either fail to procure medical assistance at all, or send for it when the citadel of life is sapped and about to yield. The true data are yet to be fur- nished on this point, to enable us to ascertain what, if any, is the difference in the success of the treatment of those who are seized at the beginning, of those in the middle, and those at the decline of an epidemic, under similar circumstances of age, constitution, habits, and duration of premonitory symptoms. I have already stated to you some facts, coming under the observation of East India physicians, vvhich place medical treatment and abandon- ment to nature in strong contrast, and entirelv to the advantage of the former. We may on this part of our subject lay down the fol- lowing proposition, which'is almost entitled to be called the expres- sion of a law of cholera. It is thus enounced by Dr. Griffin {op. CH);—« That without medical treatment every person attacked with it will fall into collapse, although they may not eventually die; and that such as recover do not do so by an arrest or cessation of the disease, but by struggling through and outliving all its stages." In estimating, therefore, the probable chances of recovery in all cases left to nature, we may regard them as collapse, the frightful mortality of which is everywhere acknowledged. Sometimes jt has amounted to nineteen out of twenty cases, and under, .the most successful treatment, furnished TREATMENT OF EPIDEMIC CHOLERA. 413 in the most authentic reports of large hospitals, never proving less than seven in ten. But they who are allowed to run the course of the disease without interruption by medicine, are not in the same category with those treated for collapse ; for, even if the former sur- vive in a small proportion, it must be after struggling through the period of collapse into consecutive or cholera fever, or the stage of reaction, in which, if unassisted, they will die. It is, therefore, cor- rect to abide by the opinion of some of the East India physicians, viz., that unless medical treatment be rendered to persons attacked with regularly formed cholera, they will almost inevitably die. Before I proceed to specify, in succession, the remedies which were employed for the cure of cholera, I ought to state that a sedative and evacuating course is much more entitled to our confidence than a stimulating one. Even although pathologists have failed to prove the presence of inflammation in any one organ or apparatus, in a majority of cases of cholera, yet the evidence is abundantly strong to show that often the lungs are great sufferers from pneumonic con- gestion, and that ihe digestive tube, often the seat of inflammation, is almost always that of irritation of its glandular or secretory appara- tus. The venous congestion vvhich takes place in nearly all the organs in distinctly formed cholera, but which is most manifest during the stage of collapse, although often readily removed, may and does complicate the slate of things during the period of reaction or of con- secutive fever; and the danger in this latter is greatly increased by inflammatory congestion of some important organ — the brain, the lungs, or the intestines. If we look at what passes in the nervous system we shall find symptoms indicative of increased and excited innervation ; a craving for sedatives, and especially for cold drinks; an intolerance and dislike of stimulants. It is true, that this inner- vation is not equally active in all the organs of the economy ; but, as in the case of the bloodvessel system, diminished activity in one system only or region augments irritation and danger from accumu- lated action in another. The skin seems to be deficient in nervous power as do the lungs ; the former being cold, the latter not perform- ing its customary depuration of carbonic acid. But these and other phenomenon of apparent debility and weakened nervous power result from the singular severance of function at this time of the nervous and vascular systems in cholera. The two systems, as I have already said, do not act synchronously with each other. "They are not both torpid or dead for the time being, as in svncope and some analogous stales of the body, nor are they both active and morbidly excited, as in the phlegmasia) and inflammatory fever. A strong evidence, and at thcsame time effect of this interrupted harmony of action between the nervous and vascular systems, is deficient calorification. This process requires both innervation and capillary circulation — the former is a prime agent, but it is incompetent to produce the effect without the latter." (Op. cit., 128.) I had just before summed up the reasons for disbelieving that the series of symptoms in cholera mani- fested a simple deficiency of innervation or the operation of a sedative poison. " 1. The brain, the grand centre of nervous power, retains its 35* 414 DISEASES OF THE DIGESTIVE SYSTEM. energy: its peculiar functions in the display of the faculties of the mind are, often not at all [or slightly], impaired. " 2. The spinal marrow, measured in its functions by the irregular and yet often inordinate action of the voluntary muscles in spasms, and even convulsions, and by the sensibility of the skin, is in full ener- getic action. Its appearance after death shows it to have been often preternaturally excited. " 3., Tbe senses generally are not impaired. "As regards innervation in the ganglionic system, or the great sympathetic, we have nearly as clear evidences of its activity in — ' " 1. The strong spasmodic action of the muscles of organic life, vvhich it supplies, as the heart and the muscular,coats of the digestive canal. "2. The copious watery secretion from the inner surface of this canal, and the morbid coaling of matter so often found afier death on this same surface. " 3. The intense sensation of heat and thirst, and the craving for cold and acid.drinks." Glandular secretions of all kinds, as of saliva, bile, semen, and those from the intestines,, are often augmented to a great extent under general as well as partial nervous excitement; and hence, I am dis- posed to regard the immense outpouring from the intestines as the result of such excitement, and by its very excess causing a diminu- tion or entire suspension of other secretions. The: predisposition once laid, any irritant to the digestive canal is suflicient to excite thus morbidly its secretors; and we have, in consequence, vomiting and purging in alarming excess. Sedation of the skin from cold, by accuniulating sensibility in the interior, indirectly produces the same effoct.; If. we place cholera on the same line with the eruptive fevers, as the:appearance frequently observed in the skin and the psorenlerie or eruption on the gastro-intestinal surface, noticed by MM. Serres and Nonat and by Dr. Horner, seem to entitle us to do so, we can the more readily understand why there should be disordered and mor- bidly excited innervation iu it, as; there is so generally in all the exanthema tse. Proceeding to the administration of remedial means under these views, our chief object, at first, will be to remove all irritants of the morbidly sensitive nervous system, whether applied to the brain through the senses, or to the ganglionic system through the sto- mach and .bowels, or. the skin. In fact, it matters little at the moment, whether there be indigestible food, a heavy supper, for example, in the digestive canal, or a changed state of sensibility in its .mucous membrane, by which common and healthy food irri* tates it. In either case the.phenomena are nearly the same, and the mode of relief will not be essentially different. In the first case, it is true, the call will seem to be more : urgent for the expulsion.of the offending matters; .in the latter, for altering or modifying, eilher by direct impression, or by diffusing and;equalising sensation in all parts of,ihe economy, the morbid sensibility. . So far Ihe. problem for solution is comparatively simple, and, happily, it is the .one presented to us in the preliminary or forming stage of cholera, cholerine of the French writers, and thesymptoms of which have been already described. TREATMENT OF EPIDEMIC CHOLERA. 415 Treatment of the Diarrhoeal Stage, err of Cholerine. — The patient, for so he ought to be regarded and addressed at this time, even although his own judgment be faulty as to his real state, will generally exhibit an atony of the skin, with some irritation of the bowels. The two- fold indication here will be, to remove the former by genial warmth, and the latter by carrying off, by mild purgatives, the offending irritant. Our treatment should be, at this time, precisely identical with that in common diarrhoea, when we are very desirous of shortening its duration. We direct the patient to confine himself to the house, and- still better to his bed, as the best means of securing a uniform temper- ature of the skin ; and by mere rest, also, of abating the intestinal discharges. We prescribe at the same lime a laxative, with a view of removing any offending matters, such as food, either originally indigestible, or still, after the full period, indigested, which by their stay irritate the gastro-intestinal surface. Nausea and occasional - pains will be obviated by some slight aromatic, taken either before or after the administration of a laxative. The latter may consist of a few grains of calomel and rhubarb, or of castor oil with a drachm of oil of turpentine-; or you may give rhubarband magnesia with a little ginger, or blue mass with rhubarb, in pills. Of the aromatic class, I should use tincture of camphor, in doses of five or six drops, on a lump of sugar, repeated every hour or so, or cajeput oil in closes of two or three to five drops, taken on sugar or in emulsion. In the value of the first I have great faith, from full experience with it both in this and in analogous affections of common or sporadic occurrence. With the latter I am unacquainted, except through the favourable reports of German and some British physicians. During the opera- tion of the laxative, and after it has ceased, simple diluent drinks, such as barley, rice, or toast water, should be freely taken. This treatment will be found adapted to a great proportion of pa- tients in the first, or forming stage of cholera, who, if they neglect themselves at the lime, will, in large majority, sink victims to the dis- ease, in its more advanced and less curable siages. If the symptoms continue after the evacuation of the bowels by medicine; or there be confusion of head, and increase or persistance of cramps of the legs, with a pulse somewhat full^ the safer practice will be to draw blood from the arm, to the extent of ten or twelve-ounces; and even more if necessary to procure manifest relaxation ; and then to give opium in the dose of a grain, or camphor water one ounce, with twenty drops of laudanum.. Nausea and retching, with more or less pain distinctly referrible to the. stomach, and following the recent intro- duction of food into this organ, will be best removed by a mild emetic, consisting of a few grains of ipecacuanha, or two tablespoonfuls of common salt in a halfpint tumblerful of warm water, the good effects of :which extend beyond the mere removal, important as this is, of a now irritating substance to the stomach. Our great object at this lime is to rosioro the lost balance of function; and, whilst bringing back the. skin to its natural action, to restore the bowels to their healthy secretions.- These indications will be often met by the pa- tient going to bed, getting himself warm, and taking a draught or two of hot herb tea., The warm bath and friction are good adjuvants to 416 DISEASES OF THE DIGESTIVE SYSTEM. the means already mentioned, as applicable to the forming or simple diarrhoeal stage. If the prostration be considerable at an early pe- riod after the coming on of the diarrhcea, it will be most prudent to give at once a full dose of laudanum, say thirty drops, by the mouth, or fifty by injection per anum, and afterwards, if the patient com- plains of disease in any particular region, to follow out the treatment already prescribed. I know that exceptions have been taken to purgatives in the forming stage of cholera, and cases are recorded of their use being followed by hypercatharsis, vomiting and the worst features of the disease, terminating in death itself. Even where constipation had previously existed they have displayed these sinister effects. It is not easv, in cases of this nature, to be able to say how far the imminency of an attack coincided with the administration of purgatives, which may only have been not sufficient to ward it off, though possibly not instru- mental in bringing it on. But the practical question is — Are they adequate to prevent the coming on of regularly formed cholera? In a majority of cases a mild purgative, given under the precautions already laid down, will, I believe, be found to do so. 1 may here introduce, in connection with this subject, the outlines of a case, evi- dently one, I think, of choleric diarrhoea, treated by me in conformity with the views now inculcated. It serves at the same time to show the gradual manifestation of epidemical influence in a place some time before the outbreak of the disease in all its terrific characters. My patient, who had then, and still has, charge of the rooms of the Phi- losophical Society, after having gone to bed one evening in the month of May, 1832, as well as usual, was awoke in the night with urgent desire to go to stool, which was often renewed, and barely allowed of his getting out of bed for the purpose. The discharges were pro- fuse ; resembling, as he expressed it, gruel, and at another time he compared them to rice-water. The comparisons were his own, and not sutro-ested by me, in questioning him about his symptoms and feelings. Some nausea and heat of the stomach accompanied the discharges, which were very exhausting. The tongue was while and loaded ; pulse small, and rather frequent. He complained, also, of severe cramps in his legs. On visiting him by times in the morning after his atiack, I had him bled to the extent of about twelve ounces, and directed rhubarb and calomel pills, the proportions not noted at the time ; and afier their operation in the evening gave him a grain of opium combined with a drachm of carbonated magnesia. Under this treatment he was promptly restored, and passed through the period of the cholera in July, August, and September, without any inconvenience or complaint. I am partial to the combination of magnesia with opium, as the first and best effects of the latter arc not interfered with, whilst its kindly operation on the stomach and intes- tines, in the correction of diarrhcea, is increased, and the tendency to subsequent costiveness and diminished renal secretion, in a good measure, obviated. In directing venesection in this case, I was not so much swayed by the choleric form of the disease, as by my know- ledge, from former attendance, of the proneness of my patient to enteritis. His habit of body was spare: temperament Jymphatico- bilious. TREATMENT OF EPIDEMIC CHOLERA. 417 In prescribing: laxatives or mild purgatives in choleric diarrhcea a preference should be given to those already indicated over the saline, and, h fortiori, over the resinous and draslic kinds, neither of which can be administered without danger. Failing to procure the desired •relief in the forming stage, the patient is thrown into the second stage, or cholera proper. Sometimes this stasze is very short, and the third or fatal stage, lhat of collapse, comes on with great rapidity. Treatment of the Second Stage, or of Distinctly Marked Cholera. — Bearing in mind the fact, that by far the most powerful causes, both predisposing and exciting, are to be found in the diet of the persons attacked ; and remembering the habits of those who are the most ready victims to the disease, as well as its great frequency and mortality in countries, the rural population of vvhich has been com- pelled to use damaged or imperfectly matured grain, or vegetable productions of an indigestible nature, we can hardly doubt of the gastro-duodenal seat of cholera proper. The first symptoms—an uneasy constriction or cramp, deeply seated in the epigastric region, speedily followed by profuse vomiting and purging of watery fluids, would seem to show the duodenum to be the part more immediately affected. Farther corroboration of this view is furnishedin ihe effects of poisonous substances and putrescent animal matter taken into the stomach. After a time, their ingestion is followed not only by vomiting, but by great prostration of strength, cold and clammy sweat, shrunken features, small and frequent pulse, and often vio- lent spasms of the voluntary muscles. Emetics. — The treatment under the circumstances just mentioned which is generally deemed most serviceable is, to encourage the ex- pulsion of the offending matters by a mild emetic, and free dilution by draughts ofvvarm vvater, or some other bland fluid. A similar practice has been adopted in cholera, and, in many cases, on good grounds, especially when the attack is recent, and the discharges are either mixed with the food or are white and inodorous. Inflamma- tion cannot be presumed to exist at this time. The stomach had, up. to the date of the attack, exhibited often its customary craving for food, and was not oppressed by its reception — the tongue and skin and the absence of thirst did not betoken gastritis or gastro-ente- ritis; and hence we are left free to substitute one irritant, a medi- cinal and controllable one, for another of a more poisonous kind, which is acting on the nervous expansion of the small intestines, especially of the duodenum. Some practitioners prefer ipecacuanha, others sulphate of zinc, and some, again, mustard, in order to produce full vomiting in cholera. I can testifv, from personal observation, to the good effects of an emetic of twenty grains of ipecacuanha in cases of cholera, in vvhich there was vomiting and purging, but absence of bile in the mat- ters discharged — extremities cold and clammy, pulse small, re- spiration laborious, eyes suffused. The emetic procured a dis- charge of bile and arrested at once the purgiirg, restored warmth to- the skin and activrtyto the pulse. In one case, in which there was imminent danger of collapse, with most harassing and exhausting eiforls at vomiting and purging, and a discharge of a turbid fluid, 418 DISEASES OF THE DIGESTIVE SYSTEM. kudanum, in a dose of sixty drops, having been promptly rejected, as camphor mixture with bi-carbonate of soda in divided doses, had been before, I gave the Russian vomit of salt and vvater, in the pro- portion of two tablespoonfuls of the salt to a half pint of vvater. The effect was a speedy ejection of the contents of the stomach iu two efforts; subsequent composure of this organ; general quietness and a refreshing sleep, from vvhich the patient awoke in the morning en- tirely relieved, and in fact convalescent. In Paris, great faith was placed in the virtues of ipecacuanha, as an emetic. Testimony of a favourable nature is furnished also of the curative powers of tartar emetic, in doses of two or three grains; but this was given with a different intention than to vomit, as I shall afterwards explain. Mustard in the dose of a tablespoonful had also its advocates. When moderate reaction is produced by these means and no ur- gent morbid symptoms are present, we may very properly follow the advice of the French Academy, to rest satisfied as spectators; ever remembering one important precaution through the whole disease, viz., not to allow the patient to change his recumbent for any other posture. The least muscular effort, as in rising in the bed, is always exhausting and has been fatal. Bloodletting.—But should the patient be of a sanguineous habit, or complain of pain in the abdomen, headache, or vertigo, with accele- rated pulse, or the vomiting and purging be accompanied with much epigastric weiglit, we should have recourse to venesection. This remedy is, of itself, when resorted to at the outset, sufficient to cut short the disease. Even in cases of approaching collapse full vene- section ad deliquium, has, to all appearances, saved life. In a some- what more advanced period of the disease, in vvhich bleeding from the arm would be either difficult or of doubtful efficacy, an emetic of ipecacuanha, followed by cups over the abdomen,has been found a good practice. Where the heat of the stomach and tenderness of the epigastrium are considerable, leeches freely applied over the affected part have given great relief; but as they are slow in their operation, cupping is in general preferable. Bloodletting was for a period the favourite remedy of the East India physicians, but is now, we learn, very generally abandoned. It had also its advocates on the continent of Europe, more particu- larly in Germany, Poland, and Russia. All those who prescribe it, however, lay stress on the necessity of its being early had recourse to — within an hour or two from the coming on of vomiting, &c, and when (lie pulse is yet full. Sedative or Contra-Stimulant Remedies.— A remedy most akin to bloodletting iu its tranquillising effects in cholera, is calomel. It is with no desire to give a novel turn to the direction of your in- quiries into the curative powers of this medicine in cholera and some other important diseases, that I invite your attention to the immediate effects of calomel on the system, vvhich are neither de- pendent on nor proportionate to its operation as a purgative on the one hand or a sialagogue on the other. In India, Great Britain, and the United States, the power of calomel to tranquillise an irritable TREATMENT OF EPIDEMIC CHOLERA. 419 stomach and irritable bowels, is a fact of frequent, one might say almost daily, observation in some form of disease or another. In cholera we have had abundant manifestations of its efficacy in this respect. But, solely attentive to its indirect effects, in promoting the secretion of bile from the liver and of mucus from the intes- tines, physicians generally have failed to recognise'its first beneficial and often eminently curative impression on the nervous and sensi- tive surface of the digestive mucous membranes, and secondarily, or by sympathy, on the respiratory and genito-urinary ones. Could testimony be stronger than that furnished by men of skill and ob- servation in three different continents, and without previous concert or imitating one another, than is found among the physicians in India, those of Great Britain, and those of the United States, re- specting the adaptation of calomel to distinctly formed cholera? Mr. Corbyn, in India, says : '"Calomel, in doses of from fifteen to twenty grains, is a sedative, and has the singular good qualities of immediately stopping violent vomiting and purging, removing spas- modic irritability, producing tranquillity of mind, exciting the secre- tion of the liver, and preventing the progress of inflammation." {Op. cit., p. 197 ) This writer points out the stimulating effect of calomel in smaller doses ; and in thus drawing a proper line of dis- tinction, guides us in the use of the medicine, and presents a proper reason, not an apology, for large doses. His first prescription in a case of well marked cholera was 15 grains of calomel, vvhich he washed down with 60 drops of laudanum and 20 drops of pepper- mint in ten ounces of vvater. In this dose laudanum is sedative. In doses of 15, 20, to 30 drops, he found it to be a stimulant: " the former produces sound sleep, removes pain and irritability, whilst the latter excites considerable uneasiness and convulsive' starlings." After the first attack is over, that is, after three or four hours, if there are much spasm and irritability remaining, the dose of calomel and the draught must be repeated ; the patient, continues Mr. Corbyn, will then fall into a sound sleep, and awake nearly re- covered. Dr. Craigie places calomel and opium next to venesection and apparently on the same line, as remedies against the open and distinct cases marked by vomiting, purging and cramps. The pro- portion of opium, half a grain to calomel ten grains, leaves us to infer that the chief tranquilhsing effects are obtained by the latter medicine. This treatment will, he tells us, infallibly remove the disease, if anything will. Mr. Martin, who has had such long and large experience of the diseases of Bengal, says, that a full dose of calomel with opium will save life in a large majority of cases. Dr. Griffin, at the close of his remarks upon this important part of the treatment of cholera, says: " It is now at leasl evident that, bv the judicious application of one remedy, we can control the disease, or arrest its progiess, in 84 cases out of 100, if the patient be placed under our care before the pulse has ceased at the wrist; and if, after that, no more than two or three can be saved out of ten, it is only to be considered that the stage of collapse in cholera is like the s"tacre of muttering delirium and floccitation in fever, the almost fatal conclu- sion of the disease." 420 DISEASES OF THE DIGESTIVE SYSTEM. ■It is pretty generally known to the American practitioner, that calomel has been given, particularly in some of the Western States, in large and even enormous doses in cholera ; but as we have notbeen furnished either with the numeral estimates of .cases treated, or of the several stages of the disease in which the medicine was given, or the proportion of deaths in each stage, little profit can come of the reports of our home-practice in this respect. Dr. Drake, of Cincinnati, selected on this occasion to represent the therapeutical opinions of his medical brethren of the west, who may all be proud of so able an exponent of their views on such sub- jects, bears similarly favourable testimony to the beneficial effects of calomel in cholera. He had before spoken of it as the best medicine in the diarrhoeal or forming stage, administered alone, or combined with opium, and followed by some common, but not saline, purgative. He, then, after adverting to some of the remedies in the second or choleric stage proper, proceeds to tell us : " But the chief reliance at last was on the calomel and opium, or calomel alone. To be successful, it was necessary to administer them, especially the last, in large doses, and in powder with sugar, so as to promote their rapid diffusion over the surface of the stomach. There is not, I presume, a physician in Cincinnati who cannot testify to the efficacy of this practice. It was worth every other therapeutical means, both external and internal. The most violent vomiting would cease, whenever the stomach could be brought under the influence of this compound, or of the calomel uncombined ; and a speedy return of the suspended secretions of the liver and skin generally followed, after which the patient commonly recovered." {Op. cit., p. 40.) In a well marked case of cholera, after an emetic or venesection, perhaps after both, we should not hesitate to give calomel, as a seda- tive, to allay the inordinate gastro-intestinal excitement, call it catar- rhal, irritative,or inflammatory,as you will, and, to repeat the medicine at intervals, watching its effects until the desired relief is obtained. A suitable time having been allowed to test the impressibility of the system to its influence, we have recourse to other remedies. The relief may be followed by bilious stools, or it may take place without any such immediate or direct effects : but, be this as it may, we shall not think it necessary at this time " to follow up" the administration of calomel by purgatives : the union will not be a happy one for the patient; it is not called for by the intention wiih which we direct calomel in this case. Let us feel our true position. We are not in the dilemma to vvhich the common limited views of the operation of mercury would subject us. Failing to purge we are not obliged to salivate our patients. We shall be content with the simply sedative operation of our medicine, and not push its use so far as to poison the tissues and bring on a fever of reaction, or ptyalism, with all its distressing accompaniments. In cholera, as in dysentery and in bilious remittent and yellow fevers, salivation is an evidence of the abatement, often perhaps crisis, of the disease, but not a cause of this result. Patients are salivated because they recover, but they do not recover because they are salivated. In my lecture on dysentery I TREATMENT OF EPIDEMIC CHOLERA. 421 gave abundant proof to show that the sialagogue operation of calomel or other mercurial preparations has neither a preventive nor a cura- tive power in this disease. The same remark applies to cholera. Dr. Griffin {op. cit.) ascertained by inquiries made in Dublin and Liverpool, as well as by cases detailed to him vvhich occurred in Limerick, that, " not only had patients in salivation for other complaints fallen into cholera, but some who had been salivated for cholera had, during the salivation, sunk back into collapse and died." The use of calomel ought, therefore to be restricted to the first and second stages of cholera; in the one it is primarily sedative and in- directly purgative: in the other it is primarily and mainly sedative, and incidently purgative and cholagogue. Sometimes it is called for in the fourth stage, or that of reaction with fever. Opium. — In speaking of the remedies which experience has pointed out as the best adapted to a disease, we must of necessity mention them in succession, and in the order in which their use is believed to be called for. But it does not follow that they are all required in one case : and hence the student and younger practitioner is sometimes embarrassed in making his selection. In the disease before us emetics may not be admissible ; they may have been ad- ministered without effect before our arrival, or the stomach has been perhaps adequately evacuated of all remains of ingesta vvhich previously disturbed it. The stale of the patient, manifested by want of any fulness or strength of pulse, or of any notable determi- nation to an important organ, may not justify venesection ; our con- fidence may not be great in calomel ; yet the symptoms are violent; there is severe and torturing cramp, continued vomiting and purg- ing, and rapidly increasing debility. It may be that this condition of things exists despite of the other remedies, and we have not a moment to lose. What shall we do ? We should apply cups to the abdomen, plain or scarifying, sinapisms to the extremities and on the epigastrium; and give at once a full dose of laudanum, from 60 to 80 drops. This will often allay the cramps with which the patient is olten tormented, quiet jactitation, and procure sleep ; in fine, remove neurosthenia. The patient should, at this time, be kept in bed, and well but not heavily covered with clothing; warm ap- plications are to be applied to Ins feet, and gentle frictions practised, particularly over his lower limbs ; in order to encourage what the laudanum itself is so well calculated to produce—a gentle but dif- fused perspiration. The opium practice was a favourite one in the East Indies. It is that in vvhich the greatest reliance is placed at the present time. Mr. Orton deems it "probable that a single dose of opium alone, given at the very commencement of the disease, would be found, in a great majority of instances, to put an effectual check to its progress." He warns us, however, against an excessive use of the remedy ; but some might think that the dose of four grains which he recommends is somewhat excessive. The medicine is to be repeated in diminished doses, at intervals of from three to six hours, if a favourable change is not produced {Essay on Epidemic Cholera). The opinion of Mr. Twining is slid more stronglv, per- voi.. i.—36 422 DISEASES OF THE DIGESTIVE SYSTEM. haps also somewhat extravagantly expressed, when he declares, that previously to collapse taking place the disease may be stopped quickly, safely, and with human certainty, by full and energetic doses of opium proportioned to the age, idiosyncrasy, and condition of the individual. On ihe other hand, we know that, both at the Pi tie and at the Holel-Dieu hospitals in Paris, where this drug was at first largely prescribed, the physicians of the former discontinued its use, and those of the second limited its administra- tion chiefly to enemata and liniments. Many of the Parisian prac- titioners continued, however, to use it through the whole course of the epidemic. By some of the Polish and German physicians it was objected to opium, that it was apt to cause congestion of the brain and of the spinal marrow ; but it was found that this state of congestion, so common in the period of reaction, ensued after other remedies of a totally opposite nature, such as cold vvater. In cho- lera, the animal economy often displays a singular toleration of opium in large doses, as we see it in other diseases of neurosthenia, tetanus for example; and it may be laid down as a general rule, that it is least efficacious, if not positively hurtful, in cases in which it manifests no narcotic effects. To be useful in the disease it ought to be given early and in full tioses^ndper anum as well as by the mouth. LECTURE XLV. DR. BELL. Treatment of Cholera {Continued).—Other Sedative Remedies.—Tartar emetic— Ipecacuanha—Magnesia—Sub-acetate of lead—Sub-nitrate of bismuih—External 9edatives—Warm, tepid, and cold baths.—Enemutu—Laudanum—Sub-acetate of lead—Stimulants—Alcohol injurious—Carbonate of ammonia—Spirits of turpen- tine— Camphor—Capsicum.—Aqua ammoniae—Camphorated ether—Kx ternal stimulants*—Blister—Cauterisation of skin—Irritating liniments to spine—Dry vapour to skin—Advantages of dry friction—The hot bath. Other Sedative Remedies. — I next propose to make a few remarks on the potassio-tartrate of antimony (tartar emetic) in cholera, in refer- ence to its contra-stimulant or sedative operation, which it so decidedly manifests in some other diseases. Tartar emetic has been employed in several countries (India and on the continent of Europe) in which cholera prevailed, vviih, in some instances, certainly a good effect, but as a sedative not emetic. When frequently repeated, it was found to operate in the same way as in the phlegmasia?, viz., abating the violence of the symptoms, but without causing evacuations. A good measure,indeed,of the propriety of its use in the disease was a prolongation of the periods of suspension of vomiting. The most accurate report which we have met of the treat- ment by tartrate of antimony, is that published by Mr. Longford of Manchester. He administered it in much smaller doses — half a grain, frequently repeated, with toast and water, or whey ad libitum, prohibiting all heat and friction. The following is the statement of results in U4 cases {Med. Chir. Rev., January, 1834): — " 1st Class. — Cases with the skin and tongue warm, and pulse tolerable, 28 in number: all recovered. "2d Class. — Cases with skin and tongue cool, or icy cold, with feeble pulse, 36 in number: 25 recovered, and 11 died. TREATMENT OF EPIDEMIC CHOLERA. 423 "3d Class. — Cases pulseless, 30 in number: 11 recovered; and 19 died. " By throwing the two first classes together, a comparison may be drawn between the tartrate of antimony, and the calomel, treatment. They amount to 64 cases, out of which died 11, or at the rate of about 17 in 100; the greatest mortality under the calomel treatment in Limerick being 16 in 100. " In the third class, or cases of collapse, there were 19 deaths in 30, or nearly two out of three ; that is, about three recoveries in ten, which exceeds the amount of recoveries from this state when calomel was used, and is equal to the amount obtained when the treatment was limited to very mild cordials and diluents." Influenced by analogy, a very uncertain guide, by-the-by, in medi- cine, we should be the more disposed to put faith in the beneficial operation of tartar emetic in cholera, from the resemblance of the state of the bowels in this disease to that of the mucous membrane of the larynx and trachea in croup; and as, in this latter, the medicine is serviceable, even when no false membrane is formed, so, in cholera, it may be equally so, although no exudation should previously have lined the intestinal canal. In the collapsed stage of croup, tartar emetic is not admissible, — in that of cholera il must, ii fortiori, be still more hurtful. Its sedative and depressing powers are not re- quired at this lime; but, on the contrary, they must be mischievous. Ipecacuanha has, also, been used with some freedom in cholera, as a sedative remedy. Already I have directed attention to the fact of its special influence in dyspepsia and in dysentery. Its relations with the digestive mucous membrane cannot, certainly, be measured by its emetic operation. It is not surprising, therefore, that this medi- cine should have been employed with other intentions than to pro- cure vomiting in cholera. Dr. Thompson, of Madras, found it very successful, given in a dose of only ten grain?, with five every half hour after, until the vomiting subsided. The German physicians were freer in the doses. In Paris, M. Recamier gave the tartrate of anti- mony in the dose of two or three grains; ipecacuanha in a quantity varying from fifteen to twenty, or more, and repeated it at intervals. The vomiting at first increased, but soon ceased altogether, and with it the intestinal discharge; a grateful warmth followed, the skin was covered by sweat, the cramps ceased, and tranquillity of the system was restored. Mr. Corbyn ranks magnesia among the sedatives, which he found to be useful in cholera. He attributes its soothing effects to its neu- tralising acid in the primae viae: this explanation would be too che- mical, even if there were acid to be neutralised ; but when we know that the discharges are rather alkaline than otherwise, it is untenable. The carbonates of magnesia and of lime produce a peculiar impres- sion on the digestive canal, and through it on the system at large, not explicable by any chemical hypothesis. Their operation is at times evidently anodyne; so much so, indeed, that after prescribing chalk mixture to a child with ga'stro-intestinal irritation, I have been repeat- edly asked by the mother whether there was any laudanum in the mixture, for, after taking it, the child slept so much more than usual. 424 DISEASES OF THE DIGESTIVE SYSTEM. Sub-acetate of lead was used at the time by Dr. Harlan of this city, and has more recently been highly extolled by Dr. Graves of Dublin, us a remedy peculiarly adapted to the disease, when united to small doses of opium. The latter gentleman used it largely on tbe second attack of the cholera in Dublin in 1834. Unquestionably sedative as the preparations of lead are, their utility must be more doubtful in circumstances in which, although the neurosthenia is great, there is also feebleness of the circulating apparatus, on which, in a remark- able degree, lead exerts a depressing influence. Dupuytren made trial of sugar of lead nearly in the manner recommended by Dr. Graves, viz., by giving it in combination with decoction of poppy- heads; but with by no means satisfactory results. Dr. Graves's pre- scription is: — li.'Acetatis plumbi, 9i.; Opii, gr. i. M. ft. secund. artem massa in pilul. xii. dividend. In the premonitory diarrhcea, one of these pills is to be given at first every hour, and afterwards, as the stools become less frequent, one every six hours. In the completely developed cholera and in the collapse, give a pill every quarter of an hour. In two hours their effect is perceptible; then a pill is given every hour. Many take more than 40 grains of the acetate of lead in twenty-four hours. Dr. Venables, at the Cholera Hospital of Beth- nal Green, tried the acetate and other salts of lead, but without any good effect. Although classed among tonics by systematic writers on Materia Medica, the sub-nitrate of bismuth is much more sedative than stimu- lating, if we take its operation in gastralgia and cramp of the stomach, sickness, vomiting, &c, as a measure of its remedial powers. Dr. Leo {Ideen und Erfalirungen, eye), who saw much of the cholera at Warsaw in 1832, extols this article in high and extravagant terms. The dose which he recommends, is from two to four grains every two or four hours. Dr. Lefevre, who manifests much judgment in his ap- preciation of the value of various remedies, believes that much good may be derived from the prudent use of the sub-nitrate of bismuth. There is, he thinks, scarcely any other article vvhich seems to quiet the cramps and check vomiting more effectually ; and when employed in moderation, it does not produce those unpleasant effects on the nervous system which follow the use of some of the articles lauded for their curative powers in cholera. In large doses we no longer obtain its sedative effect; it then operates as an irritating poison, causing gas- tro-enteritis, cramps of the hands and feet, disordered viscera, &c. External Sedatives. — In that part of the treatment vvhich con- sists of the use of external remedies there was the same discrepancy of opinion and practice as in that of internal remedies. To wards the last, however, the fact was forced on the attention of medical men ge- nerally, that irritating agents were not serviceable either externally or internally, and that other means must be had recourse to for the relief of the neurosthenia of the skin analogous to those found serviceable for the digestive mucous surface. Of a mixed nature are dry frictions, which have been found to be so signally serviceable in cholera. More directly sedative, and as such allaying neurosthenia, excitement, and cramps, is water employed as a bath, of a range of temperature from the freezing point to within a few degrees of blood heat. Different as TREATMENT OF EPIDEMIC CHOLERA. 425 the cold, tepid, and warm baths are to our sensations, they all come essentially within the class of sedatives ; each, on occasion, varying in its effects with the extent of excitement and the habits or the constitution of the individual. There are many instances of success- ful result recorded from the use of the warm bath, when it could be readily procured, and the patient was immersed in it for a length of time, without his having been obliged previously to rise or assume any other posture than the recumbent one. Let me now ask you not to confound the warm with the hot bath, which most people, and lam afraid the majority of medical men, also, habitually do. The bath above 98°, or blood heat, is a hot bath; it is a powerful excitant, and is applicable to a limited number of diseases, compared with those in vvhich the warm and tepid are so serviceable. But I cannot enlarge on this point at present; and shall merely refer to my work {On Baths and Mineral Waters), in which the requisite facts and illustrations are detailed. You may, perhaps, impatiently ask: whether it is proper or safe to apply cold water to the skin, already cold and sodden with sweat, in the more formidable and ad- vanced stage of cholera. I reply, that this has been done ; and with more alleged success than attended the hot bath and other stimula- ting applications to the surface. I repeat, however, the remark that by far the best means of ex- citing the cutaneous surface is by mild but steadily persevered in and prolonged frictions, with dry cloths or the hands of assistants. Enemata.— While thus endeavouring to rouse the skin to its healthy action as an organ of nutrition—by restoring its circulation and pro- per secreting and absorbing function — and to abate the inordinate neurosthenia of the gastro-intestinal surface by calomel, in the doses already mentioned, it is advisable, indeed exceedingly important, to check as speedily as possible, by enemata, the excessive and inordinate evacuations from the bowels. These are but a symptom, it is true, but they are also an effect, which contributes to exhaust the paiient beyond reaction and recovery. We do not hope to cure the disease by this means, but we may gain time for other remedies to operate in a more diffused and permanent manner. Mr. Annesley {Diseases of India, p. 156), who followed the calomel practice, by giving a scruple of this medicine every two hours, until three or four scruples had been taken, recommends small anodyne enemata with camphor, when the bowels are very irritable, and constantly discharging a waterv fluid. Mr. Corbyn, at the same time that he directed a scruple of calomel, 60 to 80 drops of laudanum and 20 drops of peppermint by the mouth, had also 40 drops of laudanum, mixed with rice water, introduced as an enema. Dr. Craigie found that the best and most effectual means of stopping the purging, " was a small enema of four or six ounces of dissolved starch, containing a drachm of sedative liquor or paregoric, repeated every hour according to its effects, and '• injected as far up the intestines as possible." Dr. Griffin was so fully convinced of the necessity of invariably sup- pressing the diarrhoea in the choleric stage, that he constantly made it a rule to give an astringent injection after each evacuation, how ever frequent, until his object was accomplished. " The injection 36* 426 DISEASES OF THE DIGESTIVE SYSTEM. generally consisted of half a drachm of the acetate of lead, mixed with thin starch, to which a teaspoonful of laudanum was added, either when the injections were repeatedly returned immediately after administration, or the cramps were distressing and resisted other remedies." The term sedative is much more applicable than that of astringent to the preparations of lead ; whether we have regard to their effects on the vascular or on the nervous and muscular systems. And, in fact, the enemata which the gentlemen in India, Scotland, and Ireland, have found most useful, are of the sedative kind, and in harmony with the other part of the treatment, or that of giving calomel by the mouth at the same time. But, whether we re- gard them as astringents or sedatives, we could not feel ourselves jus- tifiable in using enemata in this way, if we prescribe calomel as a purge, and with a view to its procuring feculent and bilious dis- charges, in place of acting as a sedative. We should have, in the one case, to wait its operation on the bowels before we venture to prescribe anodyne or astringent enemata ; whereas, in the other, we feel that we are giving by the mouth and per anum remedies of the same class, and whose effects on the two parts of the digestive tube will be in harmony with each other. Stimulants. — When medicines of this class were resorted to in cholera, it was found, after some experience, that those of the milder kind were the best. Great mischief was done in many places by the early and large use of alcoholic stimulants, such as brandy and the like (Kirk, Practical Observations on Cholera). Carbonate of ammonia, oil of turpentine, and capsicum, are among the safest remedies to cause moderate excitement at this time ; the first, by its alkaline properties, and the two second, by their special action on the mucous membranes, seem to meet the immediate exigencies of the case, without either causing inflammation of these membranes or over-exciting the nervous system. In yellow fever and in puer- peral peritonitis, in which the stomach is so often distressed, turpen- tine in small doses has displayed a very beneficial operation. By many its use in cholera was held to be equally advantageous. When I speak of its special action on the mucous membranes, I would not have you to overlook its secondary powerful action on the nervous system, by which it is of such signal service in epilepsy ; for, bv its double operation in this way, we can explain its efficacy in cholera. More will be gained, I think, by giving ten or fifteen drops on a lump of sugar with a tablespoonful of camphor mixture every fifteen mixtures, or half hour, than in drachm doses at longer intervals. In the form of enema it has also been employed, but with contradictory results. It is no bad succedanenm to calomel, especially in the more advanced period of cholera, short of collapse. Capsicum was a frequent adjunct to calomel, in the dose of two or three grains, repeated every half hour or hour. Another, and a still more popular remedy, both with the profession and the people gene- rally, was camphor, held in solution in alcohol. Its efficacy when manifested is chiefly through the nervous tissue and general nervous system. The camphor alone can hardly be called a stimulant. Its use in this state, or in that of mixture, would bring it more appropri- ately under the head of sedatives. TREATMENT OF EPIDEMIC CHOLERA. 427 When still more active stimulation was deemed advisable, tincture of capsicum, aqua ammonia, or camphorated ether was used. But these should be given with a sparing hand. Mr. Bell, author of one of the best works on the subject (Treatise on Epidemic Cholera), • mentions that some individuals, in whom the disease appeared to be checked by them at first, nevertheless eventually died from their poisonous operation. External Stimulants.—The early use of a blister, while calomel was administered internally, was a favourite prescription of Mr. Corbyn and other East India practitioners. Some express a preference for the hot water blister. As this means of vesication will be found ser- viceable in other cases of violent disease, in which prompt counter- irritation is required, I shall repeat here the directions for its use by Mr. Corbyn. "Have ready a square pad of flannel, which has pretty long tapes sewed to it, and crossed so as to bring one end out at each corner of the pad ; the pad should consist of six folds of flannel, and should be about five inches square. The water being ready at the bed-side of the patient, either at the boiling point, or at such lessened tempera- ture as may be previously determined upon, the flannel pad is to be dipped into it. The operator, holding the pad by the tapes, should give it a smart shake on withdrawing it from the water, and apply it immediately to the skin. By shaking out all the superfluous water, in applying it, the patient is saved from any scalding which might be occasioned by its dribbling down from the pad. If the water be used at boiling heat, a momentary application of the pad will in gene- ral be sufficient to cause vesication. This point, however, must be regulated by the judgment of the practitioner, according to the state of the patient's skin." Irritation or partial cauterisation of the skin, by a mixture of nitric acid two parts with water one part, has also been employed. Strong ammonia mixed with lard or tincture of cantharides, will give rise to speedy vesication. Flannels immersed in a liniment of liquid ammo- nia and oil of turpentine, and applied along the spine, and then a warm smoothing-iron run over them, have been found powerful means of excitement by M. Petit in Paris. Moxa, caustic, and the actual cautery, have, severally, been applied to the same region, with a view of producing salutary reaction. More promising than these extreme measures, of but partial effect after all, is the application of dry vapour, by burning alcohol or sulphur, to the skin ; or simple watery vapour, of an elevated tem- perature, similarly employed. Dry heat, when heat is proper, has been preferred by most writers on the subject. Mr. Kennedy recom- mends it in the first _ stage, after bloodletting, the warm bath, and other remedies vvhich are immediately demanded. He directs that, as soon as the cramps are subdued or have received a decided check, the patient, with all possible expedition, should be removed from the bath, and placed between dry, heated blankets. Dry heat should be further applied by surrounding his body and limbs with bags of heated sand or ashes, bottles of hot water, &c. In the ap- plication of heat externally, as in the use of hot or warm drinks or 428 DISEASES OF THE DIGESTIVE SYSTEM. stimulants internally, we shall be guided not a little by the sensations of the patient, and the pleasure or discomfort which he experiences from their use. Again I must remind you of the superior efficacy of dry frictions, in a uniform manner, sedulously continued, by a mixed movement of pressing and grasping the skin and muscles be- * neath, especially of the limbs and back. Drinks. — Early in the disease the patient becomes clamorous for drink, and it is then a question as to the kind and quantity adapted to his case. A great diversity of opinion exists among the writers upon cholera, onthis point; butthese differences grow out of the different constitutions and gastric habits, as well as idiosyncrasies of the sick, manifestations of which we see continually in gastric irritation and vomiting, in fevers and other diseases. By some, diluents of every kind were entirely prohibited, in consequence of a supposition that they increased the vomiting. The great desire of the patient is for cold water — he appears to labour under the most distressing thirst, the calls of which, it musi be evident, cannot be disregarded, without mate- rially increasing his sufferings, and eventually the disease. Mr. Scott, in common with nearly all the best practitioners, concedes the propriety of allowing some bland diluent, but he maintains that it should be given of tepid warmth : he conceives that cold drinks are always dangerous and mostly fatal. This was the opinion of the surgeons in India. Mr. Annesley, however, gave cold water with a slight impregnation of nitric acid. This was the common drink in the hospital under his care, and was found to relieve that most distressing symptom of the disease, the burn- ing sensation at the stomach. From the experience* of the Eu- ropean physicians, it would appear very fully settled, that cold drinks are not only allowable but beneficial, and when desired by the patient they should be freely given. According to Lefevre, iced lemonade has often been taken with advantage, and even the lower orders of the Russian people drank their quass as usual, and with seeming benefit. The diluted nitric acid, he states, may be added with great benefit to the common drink. By Mr. Bell, also, and some few of the practitioners of India, cold lemonade was allowed. {Bell on Cholera, p. 108. See also Searle's second publication on Cholera.) Fifty drops of the diluted acid, added to a pint of water, sweetened to the taste, is a grateful beverage. Mr. Orton allowed usually only mode- rate quantities of a weak infusion of ginger, with the addition of a little sugar and milk {On Cholera, p. 309). Dr. Dyrsen, of Riga, says, that when the thirst is great, warm or even hot drinks are the best and are often retained and even desired by the patient. He directs infusions of the various mild aromatic herbs, or when these are unpleasant to the patient, of common black tea. But when cold drinks are ear- nestly desired, they may be given in small portions at a time, without fear of any bad consequences. Fresh milk, moderately cool, he states, has been found very beneficial, and when the diarrhoea is con- siderable, a decoction of rice, or pearl barley, thin tapioca, and the like, to which, when there is entire absence of pain or tenderness of the abdomen, a little red (port) wine may be added. A cup of strong TREATMENT OF EPIDEMIC CHOLERA. 439 coffee he has found very readily to suspend the vomiting in this dis- ease : he advises the patient, in case of the drinks being rejected by the stomach, to be allowed to swallow small portions of ice some- % what rounded into the shape of a pill {Kurzgefaste anweisung die Orientalise he Cholera, p. 38) — a practice also recommended by Broussais. Dr. Craigie found, that the liquors vvhich most per- fectly quenched the thirst, and quieted the irritation of the stomach, were coffee, tea, and weak chicken soup. For patients who required a stimulus as well as mere drink, he believed port-wine, diluted with two parts of water, to be the best. Brandy, or ardent spirits of any kind, he rarely used ; having discovered that they increased the thirst, caused burning sensation at the stomach, and aggravated other symp- toms, by increasing congestion of the organs. And this, I believe, was the general experience. The strongest testimony in favour of warm water, is that given by Dr. Sturm, a surgeon in the Polish army. Wriling from the encamp- ment near Kamienka, he says, " the treatment which we now pursue is probably already known to you, as Dr. Helbig had been ordered to publish an account of it in the newspapers. It consists in nothing else than giving to the patient as much warm, nearly hot, water, as he is able to drink, in the quantity of a glassful every fifteen or thirty minutes. By the time he has taken fourteen glasses, the cure is com- plete, with the exception of a slight diarrhoea, vvhich it is not proper suddenly to suspend. The effects of this plan of treatment are so quick and effectual, that in two hours, or often sooner, the patient is well, panicularly when it is commenced with sufficiently early." (Deobachtungen uber die Asiaslische Cholera, von Dr. Hille, page 92.) The inference from all these opinions and clinical experience is plain, viz., that we may safely consult the taste of the patients themselves respecting both the temperature and the taste of their drinks. Thechief restriction that we are bound to impose on them is, respecting quality. Whether we give hot vvater or cold vvater, we ought not to allow more than a mouthful at a time. Pellets of ice gradually melted in the mouth, have the advantage of cooling the inward heat and quench- ing the burning thirst, without oppressing by quantity. LECTURE XLVI. DR. BELL. Treatment of the Stage of Collapse.—Difficulty—Stimulants and sedatives often alike fail—External remedies; friction, ammoniacal liniment; friction with ice; the cold dash—Sudden collapse treated sometimes by venesection— Arteriolomy useless and cruel—Cups to the abdomen—Astringent injections— Stimulant injections—Astringents—Special stimulants; oil of turpentine and capsicum—Ice grateful and serviceable—Cold water treatment—Dr. Shute's views in directing it—Tobacco enemata—The saline treatment—General expe- rience not in its favour—Saline injections into the veins—Delicacy and difficulty of the operation—Treatment of the Stage of Reaction.—This and the diarrhoeal stage less common in India—Convalescence.— 1'kophylaxis.—Chief means are temper- ance, cleanliness, and equable temperature of the body—Importance of early atten- tion to the very first symptoms of the disease. Stage op Collapse. — It is now generally admitted that the resources of our art are chiefly available, first and mainly, in the 430 DISEASES OF THE DIGESTIVE SYSTEM. forming stage of cholera, or that in vvhich some diarrhcea alternates with constipation ; and, secondly, in that of cholera proper, ere it hasTeached the sta?e of collapse. Sedative remedies, and, occa- sionally, depletion, vvhich were chiefly indicated in the antecedent period of the disease, are now either injurious or of slight efficacy ; and the small excitability left forbids the use of strong and diffusible stimulants. With some exceptions to be soon mentioned, the physi- cian is reduced to the condition of an observer, a keen, an anxious, and a discriminating observer, it is true ; but one who must wait for the turn which nature may give to the disease before he attempts decisive action. For want of a precise definition of the stage of collapse, we cannot derive the aid which might be expected from the numerous indications and details of cure laid down by different historians of cholera. The best and most easily recognisable test of collapse, is the cessation of pulse at the wrist, which will serve, at the same time, to define our position in reference to treatment. Of theexternal meansof rousing the sensibility,or perhaps we should say, of diffusing it, and blending the'excitement of organic with that of animal life, as far as the skin is concerned, assiduous friction with the hands of assistants, if (hey are near and willing, or with a flesh- brush or soft flannel, aided by dry mustard-flour, will be the foremost. If more potentialstimulation be deemed advisable,it shouldbe applied along the spine, by rubbing in some active ammoniacal liniment, or warm spirits of turpentine, in the manner already mentioned. It has been alleged, and I fear with too much truth, by Recamier and others, that sinapisms and all rubefacients are equally as unavailing as internal stimulants and tonics in the blue stage of cholera. The remark is strictly correct, if applied to those agents which cause inflammation of the skin, by which this system is merely killed; there is neither diffusion nor transfer of the excitement to the rest of the skin or to the internal organs. Remedies of an opposite effect from stimulants have been tried, at this time, with some alleged suc- cess. Their use by the physician, and still more their toleration by the patient, shows that the neurosthenia, so dominant in the active stage of cholera, still remains, though in a minor degree, in that of collapse. I refer now to the cold bath, and even frictions with ice, which have been employed by some practitioners. Recamier directed, that water of the temperature of 58° to 60° F., should be poured over the patient for a minute or two ; he is then to be well dried and put into a warm bed. Internally he gave, at the same time, a solution of the sulphate or of the bi-chlorate (hypochlorite) of soda, according to the state of the stomach, every quarter of an hour. If the collapse has come on suddenly without much exhausting discharges, or any depleting remedies having been tried, and the patient be strong, robust, and sanguineous, might we not incline favourably to the recommendation of Mr. Aunesley, to have recourse to venesection from the arm, or local detraction of blood by leeches, and after reaction has been established, but not, as he advises, while the collapse lasts, give calomel and purgatives. Arteriotomy, by opening the temporal artery, was had recourse to in a number of cases by MM. Magendie, Recamier, Gendrin, and others, in Paris ; but without any benefit. Some spoonfuls of rose-coloured blood, TREATMENT OF EPIDEMIC CHOLERA. 431 with impaired fluidity, trickled out, as if from a venous tube. In two subjects, the radial artery was opened a little above the articula- tion at the wrist, but the jet scarcely rose beyond the lips of the wound; and, even after reaction came on, there was no hemorrhage, properly so called, and a ligature of the vessed was dispensed with. Still less justifiable was the course of some Berlin surgeons, who opened the brachial, and even the crural artery. No human being ought to be the subject of experiments of this nature. During the time that the blood is flowing, frictions of the limbs should be assiduously practised in the manner already directed, and continued perseveringly until some signs of reaction are evinced. A warm, saturated solution of common salt, weil rubbed in and on the skin, promises to be useful at this time. Commonly, however, venesection will neither be necessary nor admissible in the collapse of cholera. Dry cups and even scarifications over the abdomen have been well spoken of at this time. But of all the common means relied on, injections have been most freely used; and we may infer with relative success : of these the astringent kind are preferred. Some recommend the sub-acetate of lead, in dose of half a drachm dissolved in a liltle water, and then mixed with a suitable measure of starch enema. This was the practice in the Limerick hospitals. In other parts of Ireland, the same astringent was administered in half scruple doses only, combined with equal proportions of the sulphate of copper and alum. Dr. Griffin's plan in cholera was, whenever there was much pain, or the injections were too readily returned, or the patient appeared to be on the verge of collapse, and it was important to prevent even one ot her evacuation, to add a teaspoon fu I of laudanum to the mixture of the solution of the sub-acetate of lead with starch. In making use of the salt of lead alone, Dr. G. was in the habit of repeating it after every evacuation, however frequent. A preference is indicated by Dr. Jackson {op. cit.) for rhatany root in decoction. Hot saline injections have been used in India and other countries, but with limited succrss. Stimulants of great strength are not admissible, even in this stage of such extreme prostration, in which they would at first seem to be so imperatively required. The powers of life are too feeble to bear to be forced into sudden action, even if they manifest suscepti- bility to stimulation. Specific stimulation, as by an emetic, has, in some instances, been productive of salutary effects in this, as it has undoubtedly so often been in ihe earlier, yet marked and violent stage of the disease. The mustard emetic had considerable vogue in Great Britain. Three tablespoonfuls of mustard-flour.are mixed with half a pint of vvater, and the whole given as speedily as possi- ble. A tablespoonful of common salt, and the same quantity of mustard, was also a common prescription. The most approved remedies by the mouth in the stage of col- lapse, are the astringent; such as the sub-acetate of lead, the sul- phate of copper. Dr. Mackintosh gave strychnia at first, in the dose of a twelfth of a grain, gradually increased to a grain, every hour or two ; and he conceived that, besides checking the discharges it had the effect of shortening the collapse, and rendering the reac- 432 DISEASES OF THE DIGESTIVE SYSTEM. tion more permanent. The observation of Dr. Griffin on this class of medicines is a sound one : — "On the whole, I should say, as- tringents, from whatever class they may be selected, and whether given by the mouth or in the form of enema, should form an essen- tial part of the cure of cholera. But none of them have yet been proved capable of absolutely controlling or suppressing the disease to an extent that one would confidently trust to in general practice." The stimulants, whose action was more immediately exerted on the mucous membrane, with but little secondary excitement of the arterial or even nervous system, were sometimes of service at this time; such as oil of turpentine, in a dose of a few drops at a time, with half an ounce of camphor-mixture, or eight or ten drops of tincture of cam- phor on a little sugar; and capsicum, in a dose of ten to fifteen grains. Dr. Hodge, of the University of Pennsylvania, in his paper on Cholera {Am. Jour. Med. Scien., vol. xii.) speaks very highly of capsicum. Our leading object at this time must be to aid the natural powers of the economy in the severe struggle in which they are engaged, but not to exhaust them by over-excitement. One of the chief indications is, to restore animal heat; but this is better done by aiding the organs, and especially the nervous and capillary systems, to develope and diffuse it, than to introduce it, as it were, from without by external applications. They would suggest, what experience indeed has con- firmed, viz , the good effects of impressions made on the region of the spine, with a view to rouse the nervous system of the medulla to in- creased action. For this purpose, assiduous friction should be prac- tised ; or running a smoothing-iron, of a moderate heat, along the surface; and these means failing, then to apply the ammoniacal lini- ment in the manner already stated. Dr. Rankin, whose view of the pathology of cholera has been mentioned in a preceding lecture, recommends with great confidence, in the stage of Collapse, the hot bath, at 110° to 115° F., continued for a full hour or more according to circumstances, until the restored circulation indicates the removal of that obstruction on vvhich he conceives collapse in cholera to depend. There is nothing so grateful to the patient in the stage of collapse and in that tending to it, and really so beneficial at the same time, as cold water, and, still more, ice kept continually in the mouth by the introduction of fresh pieces of a small size (pellets), so soon as the preceding ones are dissolved and the fluid swallowed. Sometimes even the swallowing of the pieces .themselves was productive of much good. The cold water treatment, as it has been called, was first dis- tinctly recommended, in Great Britain at least, by Dr. Hardwicke Shute, who had charge of the Gloucester Infirmary, when cholera patients were received there. Dr. Shute watched the progress of cholera, uninfluenced by remedies, in order to ascertain the natural efforts of the constitution to free it from the disease. The result of these observations and of his cold water experiments is, to enable us to determine, with some confidence, the real value, or, perhaps I ought to say, the absurd pretensions, set up in favour of certain remedies, which, when not negative in their effects, are too often mischievous. TREATMENT OF EPIDEMIC CHOLERA. 433 Dr. Shute tells us very distinctly, that his observations on tbe ad- vantages of the cold water treatment are intended to apply exclu- sively to the stage of collapse. Reliance on it in earlier stages would be a criminal waste of time, and loss of opportunity for the adminis- tration of remedies, without which the disease would most probably run into collapse. The results of Dr. Shute's practice were most encouraging; but they are not presented in such a definite form as we could wish ; that is, the proportion of cases of collapse in the entire number treated are not given ; although he tells us that tbe first cases gave twelve recoveries out of fourteen ; the pulse having been nearly imperceptible in all. Dr. Griffin endeavours to supply the omission of Dr. Shute, by classifying the cases of this latter gentle- man, as follows: — Of 26 cases in the primary stage, died 2, or 8 in 100; of 26 cases in collapse, died 18, or 7 in 10. Total deaths in 5J cases, 20; or more than one-third. This would be the most fa- vourable result we could expect under the common treatment; but Dr. Shute lost only 15 out of the 52 ; and if the cases of collapse ex- ceeded 26, his success was still more extraordinary. Swayed by an hypothesis, that there is a spasmodic stricture of some of the important organs, as of the ventricles of the heart, the intestines, and of the duct of the gall-bladder, and the urinary blad- der, as well as of the secreting organs, some of the British practi- tioners have prescribed a tobacco enema. It was used in infusion, made with half a drachm to a drachm of the tobacco in a pint of water. Mr. Baird, of Newcastle (England), the originator, I believe, of this practice, tells us, that if his pathological "opinion had been at variance with the fact, the powerful remedy he had adopted must of necessity have hurled the patient into the grave ;" although the cases which Dr. Kirk appends to his essay on cholera, would seem to entitle it to some confidence — yet we cannot forget that the symptoms pro- duced by an over-dose of tobacco on a healthy man, are nearly the same as those met with in the collapse of cholera — with this differ- ence, that in the former case the neurosthenia is of very brief dura- tion, or hardly perceptible, and is followed by complete and deadly prostration. As a sedative relieving not tetanic spasm, but the cause of this spasm, excessive neurosthenia, tobacco may be entitled to our notice. Dr. Kirk savs, I have seen ten cases of the exhibition of tobacco myself, and though in two life was not saved, yet in all dis- tinct reaction took place ; and all ihe symptoms were improved. The Saline Treatment—Applicable, it has been alleged, both to the regular stage of cholera and the collapse, is the saline treatment, as it has been termed,which consists in the administration of small doses of neutral andalkalinesalts. It failed, however,to accomplish the won- ders which were promised for it at the time. In India and Eastern Europi', the sulphates and muriates of soda were employed, and they acquired some reputation for the cure of cholera, but did not by any meai is secure the genera I approbation of the profession. By many they were declared to increase the disease and to diminish the chances of relief from other remedies. Dr. Stevens, influenced by his views of the pathology of cholera, its dominant feature, in his mind, being the dark and otherwise altered colour of the blood, as well as by the vol. i.—37 434 DISEASES OF THE DIGESTIVE SYSTEM. change in these respects caused by the addition of certain neutral salts to this fluid out of the body, strenuously urged their use as all-suffi- cient curative agents in cholera. Trials made in different parts of Great Britain and in this country, have not corresponded with these con- fident anticipations. Dr. Mackintosh of Edinburgh, Dr. Tweedie and other practitioners of London, and different physicians in Liver- pool and Dublin, have tried it without success. Dr. Griffin states that it was employed in every hospital in Limerick ; but it proved in a great many of them a failure. The most advantageous, and in some measure extraordinary, exhibition of the effects of the saline treatment, as suggested by Dr. Stevens, was in the practice of Mr. Wakefield, at the Cold Bath Field Prison, and of Mr. Bossey, sur- geon to the Convict Hospital-ship at Woolwich. By the first show- ing of the practice at the former place among cholera patients, the case stood thus: — 50 had bowel complaints, with some degree of irritation of stomach; fluids ejected, deficient in bile; 31 with the above symptoms ; cramps to a greater or less degree; 19 are described as malignant, having been seized with the disease or fallen into col- lapse in the cold wards of the prison during the night. The popu- lation in the prison was about 1300. Out of the first 50 cases none died ; out of the 31 cases 2 died ; out of the 19 malignant 1 died; in all, 3 deaths, or 97 recoveries, in 100 cases. It has been properly objected to this statement, that the introduction of 50 cases in the diarrhoeal or premonitory stage is not correct, since ihe treatment was not anywhere a matter of difficulty, nor can its success be re- ceived as a test of that proper in true cholera. The next 31 cases had cramp with diarrhcea, a state of things certainly demanding vigi- lance and treatment, but hardly entitling them to be called cases oi epidemic cholera. Still there were two deaths in this number,— and it is probable that under the calomel treatment not one would have been lost. A want of specification of the real meaning to be attached to the term malignant, and the group of symptoms charac- teristic of it, must prevent our knowing whether they were approach- ing to or in collapse. If, however, as Dr. Griffin has suggested, we were to take all the supposed cholera cases together, or those com- pared in the second and third sections, they would amount to 50, of whom three died, or six in a hundred. This result is not more suc- cessful than that of the common treatment tested in several hundred cases, in various hospitals and under different physicians. " In a second incursion of the epidemic, which Dr. S;evens describes as more violent than the first, there were 105 cases, and 15 deaths: if they were all absolute cholera cases, with perfect suppression of bile and urine, there was, even here, as great a mortality as appeared in the most unfavourable reports of any of the Limeiick hospitals, ex- cluding the pulseless or cadaverous cases." — Griffin. Mr. Bossey has made more attempts at classification. He had at first 65 cases, out of which 9 proved fatal; afterwards 61, out of which 11 died ; in all 126 cases, — 20 deaths ; rather more, says Dr. Griffin, than the proporlion lost on the average of hundreds of cases in the most unfavourable reports of any of the Limerick hospitals, excluding the cases lost in pulseless collapse; but less by hall than TREATMENT OF EPIDEMIC CHOLERA. 435 the mortality in those hospitals, if all the admissions are taken toge- ther- for in that case, 40 would have been probably the proportion of deaths in 126 cases, instead of 20. But the extraordinary part of Mr. Bossev's statement, is the reporting out of 149 cases, 23 of which were of premonitory diarrhcea, no less than 126, or, m fact, the whole number of true cholera cases, to be ones of collapse. Can we credit, that, in a place where a man who had three evacuations while at labour was immediately placed under observation, and the dejections examined, all the true cholera cases should have run into collapse, unarrested bv the treatment which must have been insti- tuted for them. The contrast is a strange one. The most uncommon want of success in the first instance, allowing in all the supervention of collapse, and the most singular and unparalleled success m curing all these collapses except twenty. There is yet one other report from an anonymous source, at Har- rington (Ensiland), which states that out of 108 cases, 78 were treated in various ways, and all without exception died; whilst of the re- maining 30, vvhich were placed under the saline treatment, only 2 were lost. There is a still more violent contrast in this statement than in that of Mr. Wakefield, already commented on. All deaths on one side —nearly all cures on the other. After proper abatement for the extravagance of eulogy in favour of the saline treatment, we may receive it as, on occasions, adju- vant to other and more active means, such as venesection, and inter- mediate between the doses of calomel, or following the operation of an emetic. The formula recommended by Dr. Stevens is, as follows:— Bicarbonate of soda, 5SS- Muriate of soda, £H- Chloride of potassa, gr. vii. Mix, and dissolve in a tumblerful of water; to be given every hour, until there is evident and well-established reaction. External irri- tants and frictions, together with injections of hot salt and vvater, have, in some cases, been used at the same time. The tranquillising effects of carbonate of magnesia and bicarbo- nate of soda, iu small doses, — as twenty grains of the former and ten of the latter, — I have repeatedly observed, both in epidemic cholera and in analogous derangements of the digestive canal. Aqueous and Saline Injections into the T\>ins — Iu speaking of this kind of medico-chirurgical treatment last, I believe that I give it the place, to which it is entitled, whether regarded on the score of safety or of remedial value. The hypothesis on vvhich it is founded is briefly told It is, that,owing to the immoderate fluid discharges from the digestive mucous membrane and the skin, the bloodvessels have parted with an undue quantity of serum, by vvhich the blood, now thick and fibrinous, becomes prone to coagulate in the great vessels and cavities of the heart, and cannot be circulated — hence, asphyxia, with its concomitants of the collapsed or blue stage. The indication, therefore, is, we are told, to replace, by artificial means, this loss Unfortunately for this speculation, it happens in many cases, that collapse is not preceded either by copious serous exuda- tion from the skin, nor discharges from the stomach or bowels — 43B DISEASES OF THE DIGESTIVE SYSTEM. of course, the blood cannot, in such cases, have lost its fluidity, or rather, its changes cannot be the effect of the loss of its watery and saline parts, or of serum. At no time is there a well ascertained or admitted proportion between the prostration of the functions gene- rally, and the discharge of serum by the channels just mentioned. The change in the blood is, in fact, an effect of pre-existing derange- ment of important organs, those to vvhich we have already directed attention, viz., the digestive and respiratory mucous membranes and the skin ; and unless we alter and amend their morbid condition, by appropriate means, they will neither act nor be acted on by the blood with any chance of permanently good effect. Our attempts to modify directly one of these surfaces — the respiratory mucous, or that of the lungs, by means of oxygen, nitrous oxide gas, chlorine, ammo- nia, or ether, have not, indeed, proved very encouraging. The natural hygienic agent of fresh cool air, is, after all, that best adapted to the condition of the lungs, and one vvhich, in the hurry and eager- ness to afford relief, and the crowding around the patient of anxious friends, and intrusive and idle spectators, is too often lost sight of. There remains the other two surfaces to be acted on by agents, and in modes already fully pointed out. Some of the objectors to the use of saline medicines by the mouth have expressed a favourable opinion of a more direct method of introducing them into the circulation. This has been done by in- jections into a vein previously opened for the purpose. Before re- sorting to so hazardous and daring a practice, we ought to ask our- selves whether, 1st, in the particular state of the patient at the time, there is no other remedial means vvhich presents any fair chance of reviving him ? And 2dly, if this practice do not, though affording temporary relief, introduce fresh causes of subsequent disease, and more certainly seal the patient's final doom ? The notice of this practice, and the commentaries on it by Dr. Griffin {op. cit), are so pertinent, that I shall make use of them for your benefit on the present occasion. " Transfusion of blood into the veins of persons dying of hemor- rhage was long since proposed and practised in this and other coun- tries ; but Magendie was the first who proposed, and, I believe, ventured to inject, water, or medicated fluids, into the veins as a cure for hydrophobia, many years back. M. Hermann, of Moscow, more lately, on observing the quantity of aqueous fluid ejected from the body in cholera succeeded by collapse and death, suggested the injection of warm water into the veins, to preserve the circulation and volume of the blood which remained ; and this suggestion was subsequently carried into execution by Professor Delpech, of Paris, though without any success. The practice in this country, however, did not originate in anything vvhich had been done on the continent; it arose entirely out of the ingenious and clever papers of Dr. O'Shaughnessy, on the analysis of the blood of cholera patients as compared with that of healthy persons. As it appeared that the great loss which the circulating fluid sustained, and which seemed to be the immediate cause of collapse, consisted of water, albumen, and saline matter, it occurred to the late Dr. Latta, of Leith, that TREATMENT OF EPIDEMIC CHOLERA. 437 death might be protracted, if not altogether prevented, and other re- medies become available, by directly restoring to the circulation the materials of which it was robbed by the disease. He instantly put the remedy to the test, and his skill and ability are displayed in nothing so strongly as in the fact, that his first inexperienced appli- cation of it in the cure of cholera was more successful than any trials which were subsequently made, when there had been exten- sive experience of its effects. He saved three patients out of nine in his first set of cases, and five out of seven in his second ; of vvhich number, on the whole (16 cases), it is acknowledged by all prac- titioners in and about Edinburgh, two would not otherwise have recovered, taking the ordinary mortality in such states there as the standard. Injection by the veins seemed, notwithstanding the early encouragement given by these cases, to be losing credit towards the decline of cholera, after having been very freely tried ; and it is well worth consideration, whether this failure of reputation is founded on judicious inferences. " All the published cases of injection of the veins which I can find amount to 282, among which there were 221 deaths, and only 61 re- coveries. As all these cases were in collapse, sometimes very deep and protracted, before this treatment was employed, it only remains to see what portion might fairly have been expected to recover if no such remedy had been resorted to. According to the statements of Drs. Cliristison and Mackintosh, not more than one in twelve re- covered, in Edinburgh, under any previous mode of treatment; and even ibis calculation of recoveries is looked upon by the latter gentle- man as too high. Sixty-one recoveries in 282 cases gives, on the other hand, somewhat more than two recoveries in ten. It may be said, perhaps, that our own reports of the Limerick cholera hospitals give an amount of two and a half, and even three, recoveries out of ten. The average of all the reports from hospitals in that city, how- ever, does not exceed, if it indeed reaches, the average recoveries by venous injections. At the same time it should be considered, that no fair comparison can be instituted between cholera cases occurring among the half-starved pauper population, crowded together in the lanes of Limerick, with those which occurred among the well-fed artizans and labourers of Edinburgh. " It can hardly be necessary to remind the reader of a fact referred to when treating of the mortality of the disease, that persons living on a poor vegetable diet, though much more liable to fall into cholera than those living on a sufficiency of animal food, recovered nearly in the proportion of two to one comparatively. In Limerick the re- coveries from collapse among ihe wealthier classes of the population, in private practice, were, I should say, quite as low in amount as the proportion named in the Edinburgh report; and even in the hospital reports of St. Michael's Parish, the one in which all the wealthy portion <>f tlie population of Limerick reside, and where ihe class of patients admitted consisted chiefly of well-fed servants and small shopkeeper^, the average recoveries from collapse did not exceed one in ten, while in every other hospital in the city it exceeded two in ten. The legitimate conclusion from all I have stated is, that the 438 DISEASES OF THE DIGESTIVE SYSTEM. average recoveries from collapse by injection of the veins has far exceeded the amount by any other treatment, in the same district and under the same circumstances, and has equalled the utmost pro- portion vvhich has been obtained on the average of large numbers, in any district and under any circumstances." " There are certainly two points of great difficulty in applying in- jection by the veins: 1st, a difficulty in ascertaining when enough of fluid has been thrown in; and 2dly, in selecting the most opportune period of the disease for the operation. With respect to the first, Dr. Lawrie's recommendations seem exceedingly judicious: he says, he would cease injecting whenever the pulse was steadily improved — whenever the patient fell asleep, whether the pulse were improved or not — whenever the respiration was much hurried — and whenever acute pain was felt in the abdomen. In the first instance, because injection had done all that it can do ; and in the others, because it had begun to do harm." Dr. Mackintosh employed a solution of 3ss. of common salt, ^iv. of sesqui-carbonate of soda in ten pints of water, of a temperature varying from 105° to 120° F.; this solution was injected slowly, half an hour being spent in the introduction of the ten pints. The most favourable time for injection would seem to be at the earliest period of the collapse, or just previous to its becoming quite decided. If is essential, as Dr. Griffin justly remarks, as soon as the: patient is a little revived, to resume the active medical treatment, as if no such operation had ever been performed, and we were only anxious, as before, to prevent the occurrence of collapse. The greatest nicety and delicacy of manipulation are required in the introduction and adjustment of the injecting syringe, to prevent phlebitis.. Treatment of the Stage of Reaction, or of Cholera Fever. — It would be well if we could almost forget the existence of the previous stage of prostration and collapse, if it so far occupy our minds as to induce a dominant idea and fear of debility, and lead to the exhibition of stimuli, in the reaction, or third stage. It is in the complication of symptoms, by phlegmasia of the gastro-intestinal surface, and oppres- sion of the brain at this period, that the injurious effects of the unre- stricted use of brandy and laudanum in the early stages, including the period of collapse, become evident. At this juncture we must draw upon the resources of rational pathology, and be guided in our practice by the symptoms of lesion and inflammation of the organs. Patience and firmness are now virtues to be put in requisition — the former to prevent undue haste in forcing up the system to an imagi- nary standard of strength by stimuli, the latter to induce perseverance injudicious local depletion and a cooling practice, in,order to mode- rate the excitement of particular organs and prevent disorganizing inflammation in them—-the stomach, intestines, or brain. In two important particulars there would seem to have been a difference in the course and features of the epidemic cholera in India, from that occurring in Europe and in this country. These are in the absence, or comparative infrequency of premonitory symptoms, as diarrhcea, &c, and of secondary fever, in India. When this latter did TREATMENT OF EPIDEMIC CHOLERA. 439 occur, it partook very much of the nature of the common bilious attacks of those latitudes. There was hot, dry skin ; foul, deeply furred, dry tongue ; parched mouth ; thirst; sick stomach ; depraved secretions ; restlessness ; watchfulness; and quick, variable pulse, sometimes with delirium, stupor, and other marked affections of the brain. {Bengal Reports, p. 56.) Generally when the disorder proved fatal after having reached this stage, it assumed the characters of low or typhous fever, with black, hard and furred tongue,teeth and lips covered with sordes. In other cases, again, the secondary fever ran a somewhat different course. The reaction was marked by an unusual degree of energy — the brain was evidently affected ; pulse as high as 120 ; great heat, es- pecially in the large cavities, and distressing thirst-. To this state of excitement that of collapse quickly succeeded. Among other symp- toms at this time, was complete absence of the former unnatural irrita- bility of the stomach. In Europe, and in this country, the consecutive fever of cholera was more common, and put on great varieties, the chief of which, however, were due to the former habits and constitution of the indi- vidual, and the kind of treatment to vvhich he had been subjected during either the second, or the subsequent collapsed stage. The intemperate, the free liver, J.hose prone in former times to phlegmasiae of the organs, are in danger from this reaction, as are also those who have been freely stimulated by brandy, &c, during the first periods of thedisease. In speaking of the stimulating practice of Magendie, in one of the Parisian hospitals, a writer in the Archives GenSrales says ; rf this treatment has been followed by a degree of reaction vvhich it is often difficult to control. The circulation excited by alcohol, soon produces congestions in ihe head and digestive apparatus; and more than one patient sank with delirum, and afterwards deep coma. This congestive state, local and general depletion, were always as inade- quate a remedy, as the application of cold to the head, and the most active revelleut irritants to the feet." Galvanism, electro-puncture, inhalation of factitious gases, are remedies of experiment more than of available use, even if their value were greater than has as yet been shown. I must not conclude the subject of the treatment of cholera without mention of the change of practice in India, or at least in Calcutta, of late years, in this disease. Mr. Martin {OfficialReport on the Medi- cal Topography of Calcutta, ivith Brief Notices of its Prevalent Diseases, Endemic and Epidemic, 1839) tells us that the plan of copious bloodletting, followed by full doses of calomel and opium in the outset of the disease, and topical bleeding and mercurial purga- tives iu the reaction, which was found most successful in the early periods of cholera visitation in 1817 and 1818, is now either ineffi- cient or injurious. Mr. Martin adds a remark respecting the stage of collapse, not very encouraging or flattering to medical science at its favoured seats: " I repeat, that our European and transatlantic bre- thren have not helped us through any of our difficulties in the treat- ment of this stage of the disease." Convalescence. — The diet of the convalescent should be simple 440 DISEASES OF THE DIGESTIVE SYSTEM. yet nutritious, regard being paid, in the selection of articles, to former tastes and habits. With some a milk diet, consisting of rice and milk, or bread and milk, custard, &c, answers very well. In most in- stances the lighter animal broths—such as'beef tea or chicken water, are preferable, to be soon followed by the meats themselves—chicken, mutton-chop, or beef-steak, with bread and rice. The rigorous prohibi- tion of stimuli during the period of the disease, does not extend to that of convalescence. Hence, iu those whose stomachs have long been accustomed to other than simple nutritive excitement, we allow con- diments to their food : such as pepper, capsicum, and mustard. The habitually intemperate, when such recover from cholera, and the free liver and gourmand, may be indulged in a little wine, of that kind which can be obtained the purest. Adulterated as Port so gene- rally is, it must not be the one selected. But by far the safer practice, whether we regard the present period, or future results, is to admi- nister to these persons a simple hitler, and few are so good as the sul- phate of quinia, or, in its stead, chamomile tea, infusion of columbo, &c.,in the day, and where wakefulness is present, to give an opiate at night. By pursuing this course, we carry the patient entirely through the period of convalescence, without ministering to his de- praved appetite for strong drinks, and. in fact, we rather wean him from his evil habit — certainly furnish him with no excuse for after in- dulgence when he is discharged from our care. Prophylaxis. — The means of preventing an attack of cholera readily suggest themselves to the reader, after he has been made ac- quainted with the causes of the disease. The preventive and pre- cautionary measures will consist in a careful avoidance of those situations in vvhich the air is foul, stagnant, and loaded with mois- ture, and of everything vvhich has a tendency to reduce the energies of the system, either by over-excitement or direct debility, to impede the functions of the skin, or to induce disturbance of the digestive canal. The first and most important rule for the avoidance of cholera ia to preserve habits of strict temperance —no excess of any kind is to be indulged in, nor experiments made of what the body will endure, either in the way of abstinence or repletion. The next rule is to observe the strictest cleanliness of person, clothes, and habitation. The third rule is to preserve the body, by means of warm cloth- ing, from the sudden impression of cold following heat, or cold with moisture. More care is demanded at this time than under ordinary circumstances, and garments of cotton, or still better of woollen, next the skin, should be worn, even though they may be thought a little too oppressive. The feet should, above all, be preserved warm and dry. An avoidance of late hours, crowded assemblies, long continued mental exertion and depression, will be so many circumstances worthy of attention by those who would diminish the chances of an attack of cholera. Another important rule is not to sleep in damp beds, or in low, CHOLERA INFANTUM. 441 damp, ill-ventilated apartments, and to shun exposure to the night air, especially that of swampy or marshy districts. In fine, no medicine ought to be taken during the prevalence of cholera in a place, without proper medical advice. All pretended preventives and specifics for the disease, offered by advertising quacks, ought to be ranked among the most effectual means of in- ducing an attack of the disease. During the prevalence of the epi- demic at Montreal, the authorities very judiciously forbade apothe- caries making up and vending, without medical prescription, the medicines and nostrums eagerly sought after, with the hope of preventing or arresting the disease. Similar restrictions were recom- mended in New York. Time is invaluable iu cholera, and much of the success in curing the disease will depend on the early adminis- tration of suitable remedies. But urgent as maybe the demand for assistance, it ought not to be rendered at mere hazard — with the risk often of increasing in place of diminishing the danger of the patient. LECTURE XLVIL DR. BELL. Cholera Infantum.—Is endemial in the United States—Scarcely noticed by the English and French writers—Dr. Cheyne's atrophia ublactatorum resembles it___ Symptoms—Ushered in generally by diarrhcea—state of the circulation—skin__ discharges from the bowels—thirst—nervous symptoms—stale of the brain— expression of the countenance.— fro^no-i*.—Ctiu»r.«—High heat of summer__ Irritation of teething—Errors of regimen—Predisposition—Anatomical lesions— chiefly disease of the mucous follicles of the intestines—softening of the gastro- intestinal mucous membrane—Billard's case—Entero-mesenterio feve/ of Serres and Petit,—dothinenteritis of Bretonneau. Cholera Ixtaxtum, the subject of the present lecture, is a disease vvhich may be considered as endemial in a Urge portion of the United Stales. In some of its features, including sy nptoms and anatomical lesions, it bears a no small resemblance lo epidemic cholera; for, although generally less rapid in its course than the latter disease, it sometimes runs to a fatal termination in twenty-four hours. From European writers we need not hope to procure much information, either as to the nature or treatment of infantile cholera. Neither by Underwood, nor by his annotaiors, Drs. Merriman and Marshall Hall, is it even mentioned. M. Billard, in his excellent work {Trea- tise on the Diseases of Infants), after saving that the cholera of infants is not generally noticed in that climate, proceeds, after due acknow- ledgment, to give the detail of the symptoms from Dr. Dewees's Treatise on the Physical and .Medical Treatment of Children. It is true, that he regards cholera as presenting the svmptoms of a violent gastro enteritis, similar to that which he had just described. M. Billard adds: "and although cholera [infantum] is rare in our coun- try, yet ihere sometimes exist instances of it, particularly in our hos- pitals, where ch.ldren are brought that are born in the midst of the most frightful misery, scarcely protected' by a few rags from the inclemency of the atmosphere. 442 DISEASES OF THE DIGESTIVE SYSTEM. When yet a young student, I read with much satisfaction the small essay by Dr. Cheyne on Atrophia .Iblactatorum, or Weaning-brash, a disease u hi h, as deseribed bv this able writer, resembles more nearly infantile cholera, than any noticed in British productions which have fallen under my notice, except the article Cholera Fever of Infants, by Dr. Copland {op. cit). In many points, Dr. Cheyne's description is applicable to the Ame- rican infantile cholera; as where he says, '-The disease is more fre- quent in children who have been weaned before the eighth or ninth month, and. in particular, in those who, in consequence of some acci- dent happening to the nurse, have been weaned abruptly." In repre- senting it as a disease of the autumn.d months, which he seldom, com- paianveiv speaking, saw before the summer solstice, nor alter the end ol the year, and as most general in sultry seasons, — he gives a parallel etiology, as far as regards atmospherical distemperature, to thai of our <-hoiera. In the climate of Britain, unlike our own, little uniform heat is experienced before the summer solstice The coin- cidence of weaning-brash with the period of first dentition is .mother feature of resemblance. Dr. Cheyne aiso mentions, that " the first symptom is a purging with griping pain, in which ihe dejections are wholly of a green colour. When this purging is neglected, and after its continuing for some time, there is added a retching, with or with- out vomiting: when accompanied by vomiting, the matter brought Up is frequently coloured with bile. " These increased and painful actions of the alimentary canal pro- duce a loathing of every kind of food, and naturally are attended with emaciation and softness of the flesh, with restlessness, thirst, and fevet." A physiognomical trait, which we so generally notice in the subjects of our cholera, is also mentioned by Dr. Cheyne: it is the settled discontent of the features, and also a constant peevishness, the effe't of unceasing griping pain, expressed by the whine of the child. The discharges, he tells us. are sometimes of a natural colour, at other limes slimy and ash-coloured, and sometimes lienleric. "To- wards ihe end of the disease ihe extremities swell, and the child be- comes exceedingly drowsy." The anatomical lesions noticed bv Dr. Cheyne are, singular contractions from the stomach downwards, with one or more imus suscepiinis, and the liver exceedingly firm, larger than natural, and of a bright red colour, and the gall-bladder filled with a daik green bile. I refer the more willingly and freely to this little treatise of Dr. Cheyne, from a feeling ol gratitude for the assistance which I think I derived from it very early in my professional career, and from its being ihe only English work that described a disease analogous to infantile cholera, lo which, even at that time, I was not a stranger. Dr. Armstrong's {Diseases of Children) description of the waiery gripes is analogous to that of cholera infantum. Dr. Copland, whilst referring to his personal experience of the disease in London, and more particularly at the Children's Infirm- ary, of which he was chief physician, draws, notwithstanding, nearly all his description and the chief parts of its treatment from American writers, and particularly Drs. Rush and Devvees. Drs. Evanson SYMPTOMS OF CHOLERA INFANTUM. 443 and Maunsell {A Practical Treatise, on the Management and Dis- eases of Children), do indeed describe a disease under the title of cholera infantum, but it is meagre in its details both of symp- toms and treatment. To home tuition and guidance must the stu- dent look to be enlightened respecting the pathology and treatment of this disease. Si/mptoms. — Cholera infantum is mostly introduced with diar- rhcea, accompanied with more or less pain and fever. After a period of varying duration, the stomach manifests irritability, and vomiting supervenes, which becomes more frequent and distressing, until, finally, hardly anything, even to the simplest drink in the smallest quantity, is retained. Sometimes, after anorexia and slight fever, the vomiting first appears, and is very soon followed by excessive purging. Rarely do the vomiting and irritable stomach persist with, at the same time, a regular state of the bowels. Iu the begin- ning there is considerable pain and spasmodic action of the digestive canal, fever, and restlessness; but as the disease advances, the con- tents of the stomach are ejected with very little effort, and the irre- gular motion of the bowels is manifested chiefly in straining with tenesmus, from irritation of the lower portion of the great intestine. The circulation is, at first, hurried ; the pulse being frequent, but small, and sometimes resisting, though more commonly it is easily compressed. The pulse may be called one of irritation, by its fre- quency and want of volume. The skin in the first period is hot over the whole surface, except during the paroxysms of vomiting; but in the second, or more advanced stage, the feet and legs are fre- quently cold, while the abdomen and head are preternaturally hot. At this time, and in proportion as the disease advances, the skin generally is cold and damp, or sodden, and the cutaneous capillary circulation greatly enfeebled. Toe temperature of the skin will vary with the remissions and paroxysms of the disease, which are fre- quent, but without much uniformity—the fever being, however, in its intensity, in the main, proportionate to the irritability of the stomach. The discharges from the bowels vary, in appearance and consist- ence, with the diffluent stages of the disease. At first, ihey are greenish, and contain some fecal matter, with bile, or consist of mat- ter having a chopped appearance; after a time, they are slimy watery, and involving small whitish lumps, with a brownish eolora tion ; and not unfrequently there is lientery, and the articles of food pass off with lutle or no change. A pink hue in the dejections is regarded by Dr. Chapman as a bad augury. They often give out an unpleasant, sourish smell, in plai e of the proper fecal one; and at times, as mentioned by Dr. James Jackson of Boston, they resemble water in which putrid meat had been washed. Thirst is urgent throughout the whole of the first or febrile stage of cholera infantum ; and the craving for cool drinks, and especially water, is continual. Often, 1 have no doubt, the child seeks with avidity its mother's breast, in order to quench its thirst, rather than from any call of hunger, during this time. The distinction in many cases is imporlant, when we wish to save an iriiialcd.it mav be 444 DISEASES OF THE DIGESTIVE SYSTEM. sometimes an inflamed, stomach, from even a nutrimental stimulus, beyond what is required by the most limited wants of the animal economy. A few spoonfuls of water, especially during the oppressive heat of a summer night, will be both more grateful, and certainly more salutary, under the circumstances, to the little patient, than milk from the maternal bosom, which is so soon ejected after it has been swallowed, during the inception and height of the disease. The appetite at first is small, and at all periods of the disease unequal and capricious. Spoon victuals are often taken by a child that has been weaned, from the same cause thai prompts, in other cases, its draw- ing food from the breast, viz., on account of the fluid portion, which allays thirst. The same advice is applicable, therefore, to this, as to the other case, viz., to allow the child plain water at not unfrequent intervals. In this matter, however, the little sufferer soon contrives to make its wants understood, after it has been allowed to choose between its drinks and its common food. The tongue, at first white and somewhat loaded, becomes subse- quently redder, and finally smooth and chapped at the sides. It and the mouth are often the seat of aphtha? at ibis time. The nervous system is deranged in various ways, as might be anti- cipated from an observation of the causes of the disease, which act primaiily on it, and of the irritation of the stomach and bowels, of which it is made secondarily the recipient. Preceding the disorder of the digestive system, the child manifests impatience, peevishness, and excessive sensibility; and in the first stage of the disease, the expression of the countenance is that of excitement and irritation, as is seen in the contracted brow and shining eye. There is restlessness, desire to change position, or going from one person to another, or tossing about in the cradle or bed; the limbs are somewhat drawn up, sometimes with spasm ; and, altogether, the muscular svstem ex- hibits its participation in the irritated state of the nervous. But as the disease advances, and it assumes the character of chronic diar- rhoea, the decubitus is on the back, and the limbs are relaxed, and the head thrown back. The features are puckered, rather than actively contracted; the eyelids are half closed during sleep. This sign, in advanced disease, was declared by Hippocrates to be a bad omen, except in diarrhcea and other bowel diseases, in vvhich it is quite common, and has no longer ihe same unfavourable meaning. Drowsi- ness and wakefulness alternate rapidly in the first stage of the disease ; but in the second and advanced one, the child becomes indifferent to objects around it ; its fretfulness and impatience are exchanged for feeble querulousness or languid indifference ; it sleeps much, or is in a drowsy state simulating sleep. To this state not unfrequently suc- ceeds a partial stupor, and symptoms of oppressed brain, which, by- the-by, are manifested the more, the greater is the debility of the system at large. If occasionally there be reaction at this period of what may be properly called collapse, it shows itself more in auo-- mentaiion of heat of the surface and renewal of thirst, and frequency of pulse, than in symptoms of well marked phlogosis. Rapid are the changes made in the nutritive system from infan- tile cholera, A fat and stout child is reduced greatly in its dimen- PROGNOSIS OF CHOLERA INFANTUM. 445 sions, even in forty-eight hours of violent seizure ; and if the disease pursues its course unmitigated, the absorption of adipose and cellular tissue is very great, leaving the cutaneous integuments in folds; or, at least, the flesh becomes flabby and destitute of any plumpness or well defined outline. Even where death is long in making its ap- proaches, the outlines of the Hippocratic face are well defined, — in the tightly drawn skin of the forehead, sunken eyes and cheeks, ele- vated eyebrows, nose sharp, and the alae compressed ; cheek and lower lip depressed. This expression of countenance has not the same evil portent in intestinal as it has in other maladies ; and if proof were wanting in the adult subject, it would be manifested in the disease now under consideration. Children will live for days, and even weeks, with this physiognomy, and in some cases ulti- mately recover. 4 The prognosis of cholera infantum is not easy, if drawn solely from the intrinsic signs of the case. Thus, of two children exhibit- ing analogous appearances of disease, we shall augur a greater pro- bability of successful issue of the one who still derives nutriment from the breast of the mother or a good nurse, over the one who is weaned and has no such sustenance. The child in whom dentition has just begun, will have more difficulty to rally under the attack, than the one in whom this process has been in a measure completed. If the subject of a case enjoy the advantage of daily change of air, by a ride into the country, or excursion on the vvater, and a well- aired, spacious room to sleep in, he will be more likely to recover than another who is pent up all day in the city, and confined during the night in a small, close, and imperfectly ventilated room, the air of vvhich is rendered more impure by several of the other members of the family sleeping in it. In general we.augur well of the termination of the disease, if the stomach can retain food and the bowels recover a better tone, ma- nifested by fecal and bilious discharges, even though these be still quite frequent and not unaccompanied by pain ; if the pulse become fuller and slower, the skin of a more equable temperature with a warm moisture. Often, after convalescence has undoubtedly set in, and all fear of fatal result is over, Ihe disposition still retains its irri- tability, and the child is both fretful and cross. Where the appetite has been lost, and the patient begins to exhibit a desire for food, even though it be for some unusual article, we regard it as an en- couraging sign, unless in the midst of others vvhich indicate approach- ing death. So, also, is the abatement of the previously intense thirst. The renewal of any of the former habits, although these may be called tricks of the child, such as that of keeping a finger in the mouth when it is asleep, or taking a particular, though an awk- ward and inconvenient attitude, is favourable. On the other hand, continued jactitation, only relieved by drow- siness, imitative of stupor rather than of sleep ; increase of the vomit- ing and purging, and spasmodic pain ; occasional convulsions ; con- tinued heat of the head ; intolerance of light at first, or, afterwards little sensibility to it; tumid and hot abdomen; dry skin, without any remission by sweat, and unquenchable thirst, are unfavourable signs vol. i.—38 b 446 DISEASES OF THE DIGESTIVE SYSTEM. Aphthae is certainly adverse to speedy restoration ; and in connexion with any other bad sign, must excite great solicitude for our patient; but we often, not to say commonly, notice their appearance in cases of any duration, many'of which end happily. Their increase and extension, with a persistence of the bowel complaint, cold skin, and weak pulse, indicate the probability of a fatal termination. Dr. De- wees mentions one appearance, which he observed to be uniformly a fatal sign : " it is a crystalline eruption upon the chest, of an immen- sity of watery vesicles, of a very minute size.5' This gentleman also noticed another symptom of bad augury: " which is the thrust- ing the fingers, nay, almost the hand, into ihe back part of the mouth, as if desirous of removing something from the throat." 1 have already mentioned the symptom vvhich Dr. Chapman, in his fine description of this disease, regards as indicating deaih, viz., a pink-coloured dis- charge, or rather the napkin is stained in spots of this particular hue ; so also when there is passed from the bowels a fluid resembling greasy dish-water. A cold, damp surface is bad in connexion with other symptoms of sinking, and especially if no nutriment is taken or can be retained ; but I have often met with it in cases in which, although the subjects were greatly reduced, they finally recovered. Such a symptom is more common in protracted disease and towards the end of the summer, and when the air is much reduced in tempera- ture, than under other circumstances. Causes. — Physicians are generally agreed as to the obvious causes of cholera infantum. Some are inclined to add not only a less appreciable but at all times a very doubtfui, and in the present case, a very improbable cause — malaria. The disease appears in our cities with the first heats of summer, and continues through the months of July and August into September; but abating in this latter month, as the weather becomes cooler. But although thus mani- festly connected with high atmospherical heat, cholera infantum cannot be said to be the product of this alone; for otherwise it ought to increase in violence in proportion to the warmth of the climate, or as we advance south; which is not the case. Such ought to be the state of things, also, if malaria were the cause. We believe it will be found that it is a more common disease in Boston, for example, than in Charleston; certainly it is more so in Philadel- phia than in New Orleans. The explanation I take to be this: that the system of a child, on the approach of its first and even second summer, is very much in the same condition as that of a person newly arrived from the north at a southern city. The susceptibility to heat being great, its effects are felt more sensibly on the nervous system, which it excites, and through it on the vascular system, and even still more, the tegumentary ; the skin first and afterwards the mucous membranes. These last are kept in a state of irritation short of phlogosis by the high and continued heat acting on the skin ; and the digestive ones, in their turn, transmit the irritation to the liver, which is often excited in consequence. Now, if in this state of predisposition the person be exposed to close and impure air, the circulation and nervous system become more and more disturbed, and there is the very imminence of violent disease, which only requires for its coming on an excess or irregularity in food, loss of rest, or any morbid ex- CAUSES OF CHOLERA INFANTUM. 447 citement of the nervous system, whether from bodily pain or mental anxiety. In a child, the disease will be cholera ; in an adult, bilious remittent fever, or yellow fever. In both there will be great gastro- enteric disorder, with hepatic and cerebral complications. In recurring to the original proposition, that the disease is brought on by high atmospherical heat in our cities, we cannot overlook the fact of this being the chief and main endemial agent, — without which other coinciding causes, such as the irritation of teething and of in- digestible food,Would be generally insufficient for its production. It is, however, the high heat following winter's cold, acting for the first time on an infant whose functions have barely acquired the neces- sary rhythm, certainly are not accustomed to such stimulation. An infant, exposed from birth to a mild temperature, might be expected lo feel less even ihe great heat of our cities during the summer months. Atmospherical agency is made manifest in the amelioration of existing cases of the disease, and fewer fresh attacks during the interval of a few cool days at any time in the summer; and, on the other hand, augmentation in both during great heats, and particularly during a close and damp state of the air, when the thermometer is at the same time high. In a table now before me, I find the number of deaths from cholera infantum in Philadelphia, during a period of ten years (from 1823 to 1831), to be 2323, or on an average 232 ; the maximum having been in 1831, or 303, and the minimum in 1824, or 155; and those from cholera morbus during the same period, of subjects over ten years of age, 114. You will have observed, in my last lecture on epidemic cholera, that the cases of infantile cholera were augmented in 1832, the ' cholera year,' to 316 in 3 months, as were, indeed, all the dis- eases of the bowels in that year. In 1833 the amount was 197, or less than it had been for eight years preceding. The influence of a tropical climate, for under this designation the summer in one of the large cities of the Middle States is entitled to be spoken of, is well illustrated in the following memoranda of dis- eases of the digestive apparatus among children in Philadelphia and New York, for the years 1838 and 1839. In the former city, with a population of 200,000, the entire mortality of 1838 was 5118; of vvhich the deaths of children from cholera infantum were 382: of these, 364 were under two years, viz, 247 under a year, and 116 in the second year after birth. In 1839 the deaths from this disease were 230 ; the excess in 1838 being explained by the unusually long period of high atmospherical heat in the summer of that year. The number of children who thus perished within the first year from birth was 142; in the second 75; and between the termination of the se- cond and the fifth year, 13. The entire mortality from the diseases of the digestive canal was as follows: — 1838. 1839. Cholera Infantum ..... 382 . . 230 Diarrhcea......65 . . 96 Dysentery ...... 45 . . 68 Inflammation of the Stomach and Bowels 80 . .83 572 477 448 DISEASES OF THE DIGESTIVE SYSTEM. In Washington, the proportionate mortality from cholera infantum is considerable, as might, h priori, be inferred from the excessive heat of its summers, without the mitigation of sea-breeze, by which even Charleston and Savannah are made more tolerable for infant life. Dr. Lindsly, in his article already referred to, gives us some useful information on this point, which is best conveyed in his own words. " It will be seen by the following table, that of the whole number of deaths in the months of July and August, nearly one-half, and in two instances more than one-half, were under two years of age ; and that of this number, almost three-fourths died of what is usually termed here " summer complaint," under vvhich general term are included cholera infantum and simple diarrhcea of children. Also, that the cases were much more numerous in July and August than in June, that a slight diminution took place in September, and that in October the number was again very small. The ratio of cases of infantine cholera in the above table is about the same as that exhibited by the record for several years past, and this may therefore be assumed as the proportion of victims annually destroyed by this fatal disease in Washington, during the months re- ferred to." In Boston, also, we still find that the summer gives a tropical cli- mate, particularly for children under two years of age. Fora period often years, from 1821 to 1830, inclusive, in which ihe entire num- ber of deaths was 10,731, the mortality of children under two years, in the months of July, August, September, and October, was 1537 ; the whole mortality of this class, for the entire period, being 31S2. Hence we see that the deaths of children between birth and two years old, in Boston, in the four months in vvhich the summer temperature predominates, was just one-seventh of the entire number, and one- half of the particular class; or, in other words, the deaths are as numerous among children of this age in these four months, as in the remaining eight of the year. The deaths from cholera infantum, during the above period of ten years, was 149. Those from 1831 to 1839, or a period of nine years, was 407 ;— the annual average of twenty years was but a little over 27. This is quite a small proportion of deaths from cholera infantum, in a population averaging, during the entire period of twenty years, about 65,000, and which, in 1840, was 93,470. But if we add the kindred, and probably in most instances identical diseases, reported under the head of gastritis, teething, and dysentery, the amount of cases of deaths of children from gastro-in- testinal disease, in the summer months in Boston, will be more easily accounted for; and place this city, on the score of infant mortality, in a line with, but quite behind, Philadelphia and New York. For much valuable information on the vital statistics of Boston, I refer you to the paper by Dr. Shattuck in the Am. Jour. Med. Scien., 1841. The aggravation of disease by the irritation of teething is manifest to every physician : it aggravates bronchitis in winter and cholera in summer: it might even be said to cause them, by inducing a morbid susceptibility — a predisposition to cold and moisture, in the former season, and to great heat in the second, without which these atmospherical extremes would be relatively innocuous. But that CAUSES OF CHOLERA INFANTUM. 440 teething is only < f secondary importance in the etiology of cholera, is maniiest irom the faet that, however suffering from this irritation at other seasons, rarely will children then have cholera. The same reasoning applies to weaning, and the additional irritation to which the digestive system of the little being is exposed by new and unac- customed articles of food in the stomach. Still, that weaning, or the privation of breast-milk is an active contributing cause, is shown in the greater proportion of children attacked at this time over those which continued to be suckled. I may go still farther, and while repeating the language used by me in another place {Underwood on the Diseases of Children, Philadelphia edition), truly say, in reference to teething and weaning, that " even these causes combined, powerful- as they would seem to be in the production of disease, and at times fully adequate to bring it about, are borne with relative impunity by a majority of children, as far as the digestive function is concerned ; unless the irritation of high and continued heat, with its too common associate of close and confined air, be added. Teething and high atmospherical heat frequently give rise to the disease." Let it be observed, also, that children have, on occasions, been attacked with cholera under the exposure of heat, but without the irritation of un- usual food or of teething. It would be an error to suppose that cholera infantum is confined to our cities, and does not prevail in the country. I believe that in all parts, in villages and even farmsteads, as in cities, in which the extremes of temperature in the seasons occur, this disease will be found. Were it of malarious origin, it ought to be most frequent in rural districts, and bear a close proportion to the cases of intermittent and remittent fevers, diseases so commonly accredited to this cause. But this is not ihe case. Dr. Blue {Western and Southern Med. Rev., Jan. 1842) of Missouri, represents infantile cholera to have been epi- demic, within the sphere of his own personal observation at Chariton, Missouri. There is often a great predisposition depending on temperament and constitution, to be acted on by the common causes of cholera, so as to develop the disease. Thus, I know some families residing in the eastern part of this city (Philadelphia), in closely built streets, whose houses, though comfortable, are without gardens, and any facility for procuring a ready renewal of air, the children of which hardly ever suffer from cholera; although they are not robust, and I am often required to prescribe for them for other diseases. While, on the other hand, some children living in spacious houses, and sleep- ing in large and well-aired rooms, with opportunities for airina in gardens adjoining, are frequent sufferers, and would sink under^the disease, notwithstanding my best efforts, but for a removal to the country. If I were to hazard an opinion, derived from my own ob- servations, which were on a large scale, owing to my long connexion with the Philadelphia Dispensary, and practice among the class of our population whoso children are the greatest sufferers from cholera I should say, they were most readily attacked by the disease whose temperaments were lymphatico-nervous, and whose constitutions might be regarded as anemic, and'with a tendency, in after life to 450 DISEASES OF THE DIGESTIVE SYSTEM. scrofulous disease. A great development of adipose and cellular tissue, common in children of a strumous habit, is often an external character in those who suffer most from cholera. Anatomical Alterations. — Connected with a knowledge of organic causes of cholera infantum, is an inquiry into the extent and significa- tion of the anatomical changes in subjects dead of this disease. These are not identical in all subjects examined, either as regards the degree of alteration or the organ affected. In some we find follicular inflam- mation, with redness of the mucous membrane of the intestines; in others a softening of this membrane, with scarcely a trace of existing. inflammation, although the latter is believed by many to be a cause of the softening. By some, perhaps I ought to say the majority of American physicians, the liver is regarded as the organ chiefly if not mainly implicated ; although, for my own part, I am disposed to regard the enlargement of this organ and some other less frequent vices of growth, as an effect of the pre-existent derangement in the intestinalcirculation. But still, it cannot be denied that, when hepatic disorder is once established, it may become itself a secondary and powerfully disturbing cause. The relation, if not identity of follicular gastro-enteritis with cholera infantum, has been set forth in the strongest light by Dr. W. E. Hor- ner {A Treatise on Pathological Anatomy, p. 171-190), who leans to the belief that it is a disease, like hooping-cough and measles, peculiar to man. He has repeatedly seen, in dissections of those who died of the disease, clusters of muciparous glands or follicles of the small intestines, very distinct to the naked eye, and with their orifices en- larged and tumid, and often studded with minute ulcerations. A softening of the mucous membrane of the stomach, so that in one case it could be scraped away easily in the form of pulp wilh the finger nail, is mentioned by Dr. Horner, when describing the post- mortem appearances of some of the fatal cases of infantile cholera : but he is hardly prepared to speak of this appearance as a morbid peculiarity. By Billard, Cruveilhier, and other French pathologists, it would be called a gelatiniform softening of the digestive mucous membrane, of which there are two varieties described by the first of these writers {op. cit), viz., the inflammatory softening and gangrene, and. the white softening of this membrane; the latter of which is seen in children who die in marasmus, and who had suffered from insufficient food. For a designation of this state of organic alter- ation, I refer you to my note to the lecture by Dr. Stokes on Gas- tritis. Dr. Gross {Patholog. Anatomy, vol. ii., p. 229) slates, that he has repeatedly noticed softening of the mucous membrane of the stomach and colon in the subjects who had died of cholera infan- tum. In a few instances, it was also seen in the lower half of the ileum. A few pages before, he speaks of chronic inflammation of the mucous membrane of the alimentary tube, as common in infantile cholera, " of which, and of almost all the protracted fluxes of the bowels, it is the principal cause, the affections themselves being merely the symptoms. M. Billard records cases of inflammation of the fol- licular apparatus of the intestines, which closely resembled the symp- toms of our cholera infantum. In this case there was a perfect identity of symptoms with those SPECIAL PATHOLOGY OF CHOLERA INFANTUM. 451 of cholera infantum, and of the post-mortem appearances with those described by Dr. Horner. The injection of the brain and effusion of serum, particularly the latter, are common in the advanced stage of protracted cases of cholera infantum. But the remarks of M. Billard would give a different turn to our opinion of the causes of the disease ; as when he tells us, that it is not until about the seventh, eighth, or tenth month, that this follicular inflammation produces any pecul ar symptoms, the assemblage of which constitutes the disease described under the name of entero-mesenteric fever by MM. Serres and Petit, and dothinenteritis by M. Bretonneau. To this form of disease,— diarrhcea with slow remittent fever,—reference has been made by Dr. Stokes {Lecture on Ileitis and Tabes Mesenterica). We may regard as analogous in its character " Inflammation of the Mucous Membrane of Infants," described by Dr. Abercrombie {op. cit.); " it frequently occurs about the period of dentition, and in many cases appears to be connected with weaning." LECTURE XLVIII. DR. BELL. Cholera Infantum {Continued).—Farther dissections exhibiting inflammation of the small intestines and follicles—Dr. Horner's opinion of the nature of cholera infantum—M. Billard's view of the cause of follicular development applied to the pathology of infantile cholera.—Resemblance between this disease and epi- demic cholera—Hepatic pathology of cholera infantum not sustained by autopsic examinations—Mode in which heat causes hepatic derangement—Contents of intestinal canal.—Treatment—Indications to guide us—To reduce excessive sensibility and to remove irritations—Modification depending on temperament and constitution—Treatment of first stage—Demulcents, chalk mixtures,—an opiate, if the teeth irritate—Calomel in minute do^es—Oil of turpentine—Cold affusions and cold water injections—Sugar of lead. The hepatic pathology of cholera infantum is the favourite one among nearly all our writers on the disease, including the last among them, Dr. Condie, whose habits of critical research would, we might suppose, have led to a different and more correct conclusion, even if my lecture on this point had not met his eye. I do not think that the evidence will bear him out in saying: " The enlarged and congested state of the liver is noticed by most writers upon the disease." This state is assumed to exist by most writers, but is not described to be present by them. Dr. James Jackson of Boston, in a well written account of cholera infantu n, under the heads of its history, causes, and treatment, gives the results of numerous autopsic examinations made by himself and Dr. J. C Warren. Among these we find marks of disease of the digestive mucous membrane in every case. In the stomach, one or two small spots of irregular shape, of a red colour inclining to purple, at which also the membrane was swollen; in ihe intestines, the duodenum invariably exhibited one or more spots larger than those on the stomach, inflamed and swollen. In almost every case such an inflamed patch has been found at the very commencement of the duodenum. "In other portions of the small intestines, other such inflamed portions of ihe same membrane have been seen, varying in size." Marks of disease were rarely observed in the large intestines, 452 DISEASES OF THE DIGESTIVE SYSTEM. unless when dysenteric symptoms had existed. In one case, through- out the whole of the large intestines, the membrane showed "strong marks of inflammation, and had frequent small ulcerations resembling the canker spots of the mouth." If minute anatomy had been as commonly attended to at that time (1812) as it is now, Dr. Jackson would probably have noticed at the inflamed spots of the intestine enlarged follicles, and have designated the small ulcerations as those of the follicles. In the New York Medical Gazette, vol. i., p. 291-4, two cases of dissections after death from this disease are described by the editor (Dr. Turner). In both there was much gelatinous softening of the mucous membrane of the small intestines, with enlargement of the mucous follicles; in one case at the lower end of the ileum and the large intestines, and ulceration in the former ; and in the second case; there was development of the follicles of the duo- denum, and still more, amounting to hypertrophy, of those of the colon, particularly at the lower part. Dr. Swett {op. cit., ut supra, p. 294) details the particulars of a dissection, in which the mucous membrane of the small intestines was softened. The glands of Peyer were somewhat enlarged, and some of the solitary glands at the lower part of the ileum were ulcerated. The follicles of the large intestines were generally enlarged, and many of them ulcerated in their centres; some near the rectum penetrating quite to the peri- toneum. Dr. Dewees describes the mucous coat of the alimentary canal as manifesting the effects of previous inflammation during the life-time of the patient. " Dark livid spots are disposed over this part of the stomach and small intestines, particularly the duodenum near the pylorus," coincident with the observation of Dr. Jas. Jackson. " Coa- gulable lymph is also, in some instances, spread over the surface, or is found iu detached pieces." A morbid state of the follicular apparatus of the intestinal canal being admitted as the chief organic cause of cholera, at least of the more urgent symptoms of vomiting and purging, with fever, it remains for us to ascertain the circumstances under which these glandular bodies have become thus morbidly developed and ulcer- ated ; or, in other words, why they should become specially the seat of irritation and inflammation at this time. Dr. Horner leans to the opinion that'the follicular disease constituting or giving rise to cholera infantum is analogous to the exanthemata?, both in its anatomical characters, and in its attacking all persons, with more or less intensity, at some time or another, and but once in their lives. An inference from this opinion would be the contagiousness of cho- lera infantum, of which we cannot be said to have even plausible evidence. Dr. Horner's theory rests on what may be called inevi- table pathology, — that is, organic change and sympathetic functional disturbances, occurring, of necessity, to every individual, although quickened into display earlier, and rendered more violent, by certain occasional causes. There is yet another view of this subject, vvhich I would say was based on inevitable physiology, or the development of the follicular apparatus, and its greater functional activity in every individual, at SPECIAL PATHOLOGY OF CHOLERA INFANT (JM. 453 a particular epoch, or, at any rate, period of his life. Disease may ensue, but it is not a necessary consequence of the great susceptibi- lity of the follicles at this time. This is the view taken by M. Bil- lard, in reference to the greater readiness of follicular iaflammation in the mouih, or follicular stomatitis, and of follicular gastro-enteritis and entero-colitis in children, from the eighth or tenih month to the first few vears from birth. Aphthae or thrush (follicular stomatitis), I have before told you (Lect. III., p. 35), is the most common kind of sore mouth in children ; and it is lhat vvhich is a frequent accom- paniment of chronic diseases of the gastro-intestinal mucous surface in subjects of all ages. I ought to have said of acute and chronic, for in the specification which follows most of the diseases,and among them cholera infantum is mentioned, are acute. Now, I wish to apply this view of Billard to the pathology of infantile cholera. Coinciding with the period of first dentition — from eight months to two years from birth — there is a very great increase of growth, and organic and functional activity, of the follicles of the whole digestive system, keeping pace with that of the lymphatic glands. Teething, although of itself a physiological process, and one that may be gone through without pain and disease, is often productive of both, or at least of a high degree of nervous irritation, vvhich is readily converted by any occasional cause into serious disease. We have seen that it is competent to impart a morbid excitement to the mucous follicles of the mouth and pharynx, one of the manifestations of which is aphtha?, or follicular stomatitis. Nor does the irritation stop here : it is some- times transmitted to the stomach and bowels, the follicular apparatus of which is disordered, and there is diarrhcea, griping, and sometimes vomiting; often loss of appetite, and great thirst. But the causes which more especially affect this division of the follicular system are, irritating ingesta acting primarily on the digestive mucous mem- brane itself, and atmospheric heat acting secondarily on it through the skin and pulmonary mucous membrane. If this view be admitted, we have a ready explanation of the oc- currence of cholera infantum in children at a particular age : that in which the digestive follicles are most notably developed, and most susceptible to new impressions; and also that in which this suscep- tibility is liable to be injuriously acted on by the irritation of teeth- ing. But the physiological predisposition may and does often pass away, if the process of dentition be easy ; and it requires the opera- tion of another cause to generate open and violent disease. This cause is found in high heat; and we see now why there must be coincidence of a particular age or of a predisposition with a parti- cular exciting cause or even causes. Follicular development and susceptibility, teething and high atmospherical heat, can only be brought into conjoint action to the production of diseases within a limited period : it is that in which cholera infantum takes place. You cannot fail to have been struck with the resemblance between some of the symptoms, and still more of the lesions of the follicular apparatus in epidemic cholera and in cholera infantum, now that both have been detailed to you; and let us remember that for a knowledge of the anatomical features which establish the resemblance 454 DISEASES OF THE DIGESTIVE SYSTEM. we are indebted to the same indefatigable and truthful observer, Dr. Horner. Dr. Lindsly {op. cit.) mentions another feature, tending still further to show the affinity. It is, an empty, shrivelled state of the bladder — noticed by him in three or four cases, in his dissec- tions of subjects of cholera infantum. Diminished secretion of urine, amounting to suppression, is mentioned by Dr. Abercrombie in the disease referred to at the end of my last lecture. Dissections of subjects who have died of cholera infantum do not, I repeat, sustain the hepatic pathology of this disease. The only case of very marked organic change of the liver was that related by Dr. Turner {op. cit.). This viscus occupied both hypochondria; and " it could be squeezed into a pulp between the thumb and forefinger, and scraped away in a fluid state with the knife; on incising it a drop of blood appeared at each venous orifice." Dr. Gillman detailed a case to Dr. Turner, in which the liver was healthy. Dr. Baxter (New York Med. and Phys. Journ., 1836, p. 276) describes the post- mortem appearances of a subject of this disease which he examined; the liver was healthy ; and a yellowish mucus was found through- out the intestines. The chief evidence of a morbid state of the liver in subjects dead of infantile cholera, is its enlargement; as in the cases mentioned by Dr. Lindsly, in vvhich this organ " was so immensely increased in size as to fill very nearly one-half of the abdomen." But we should remember, that in children the liver still retains somewhat of the large, and, as compared with the adult, disproportioned size which it had in the period of foetal existence. Both the frequency and ex- tent of hepatic congestion, or of congestion of the abdominal viscera generally, are greatly overrated, and are assumed on speculative grounds as the necessary result, it is thought, of deficient action and torpor of the cutaneous system, than demonstrated by the appearances of these viscera on dissection. I early advocated (in my Inaugural Essay — Upon the Liver, &c), the doctrine of what has since been called, by Dr. James Johnson, cutaneo-hepatic sympathy; but I cannot consent to the common hydraulic explanation of the mode in which the liver and skin exert a reciprocal action on each other. The proper it seems to me, and vital action, is that by which the atmospheric heat excites the skin, and with it simultaneously the capillaries of the portal system. In both, there is at first increased activity of cir- culation and augmented secretion — of sweat from the skin, and bile from the liver. In both, after a while, there is indirect debility from over-excitement, and then there is suspended secretion; the skin is dry and parched, or at times cold and sodden; the liver ceases to secrete, or separates a watery and imperfect bile. This is, I believe, a truer representation of the state of things in cholera infantum, as well as in cholera morbus and in certain forms of dysentery, as far as the liver is concerned, than the hypothesis of flux and reflux, and congestion, owing to the blood being driven in from one quarter and accumulated in another. That derangement of hepatic function, manifested chiefly by a diminished and depraved secretion of bile, is one of the complications of cholera infantum, is, I think, very pro- bable ; but that it alone or mainly constitutes the disease, and gives TREATMENT OF CHOLERA INFANTUM. 455 rise to the chief remote and sympathetic phenomena, I cannot, with a knowledge of the inflammation of the intestinal follicles before me, admit. The last is of uniform occurrence, or nearly so, in cholera infantum ; congestion of the liver and other lesions of its structure are only occasional. The character of the contents of the intestinal canal in the subjects examined is a point of some interest — as showing that the function of the liver is not implicated to the extent assumed. The large in- testine is represented, by Dr. James Jackson, to contain feculent matter, and mucus, sometimes without bile, but usually coated yellow or green by that fluid. This, it will be remembered, like the picture drawn by that gentleman of the lesions of the mucous coat, is in- tended to represent, without particular specification of period, a common feature of the disease. Dr. Horner, in the three cases more particularly detailed by him {op. cit.), found bile in them all. In the first, " the upper part of the small intestines contained yellow bile, almost pure, excepting some mixture of mucus. In the large intes- tines the contents were also bilious, but greenish, like the discharges which had prevailed." The case had been of three weeks' dura- tion. In the second one, in which the disease lasted two weeks, the little mucus contained in the small intestines was here and there greenish. The large intestine contained no feces, but its two inferior thirds were occupied '; with pure pus, of a cream colour, proper con- sistence, as well elaborated as ever I saw, and destitute of any ex- cepting a very faint odour." In the third case, Dr. Horner found healthy bile in the duodenum, and abundant fecal matter of a light yellow colour. " There was, also, fecal matter in the caecum, of a light yellow and chapped appearance, but none in any other portion of the large intestines" The contents of the intestines are not noticed in the cases recorded by Drs. Turner, Swett, and Parker. As already mentioned, it is not uncommon to see, in the more ad- vanced stage of the disease, some effusion into the ventricles and on the surface of the brain. The viscera of the thorax were, with very few exceptions, healthy. Treatment.—The symptoms of the disease and the post-mortem appearances, indicate, with tolerable clearness, the course which we have to pursue in the selection of curative means. They are, in the first stage of cholera proper, to remove gastro-intestinal irritation, which is sometimes merely functional, but in a majority of cases depends on follicular enteritis, associated not unfrequently with ery- fhemoid inflammation of the mucous membrane of the intestines, and occasionally of the stomach. In the second stage, or the chiefly diarrhoeal one, we have to bear in mind the probability of softening of the intestinal mucous membrane taking place, and that the fol- licular disease is either on the decline, or has reached the stage of ulceration. Our treatment of cholera infantum would be not a little modified, at least as regards energy, if we are to believe in its being a disease dependent on specific follicular inflammation, to which all are subject, and which when once fully developed must run its course, from inception to increment, height and decline, and termi- 456 DISEASES OF THE DIGESTIVE SYSTEM. nation in resolution or ulceration, commonly both, in different patches of the intestinal mucous membrane. This is the view sug- gested, rather than very positively affirmed, by Dr. Homer. Against its accuracy we may object the very different periods which the dis- ease is observed to run in different individuals ; its relapses, and dis- tinct renewals after intervals of some duration — a course of things quite at variance with the uniformity observed in the exanthemata?, to which infantile cholera is supposed by this pathology to be ana- logous. Taking the physiological basis, or the development of the intestinal follicles and their irritability at the age in which children are chiefly liable to cholera, we can readily understand why, under a renewal of the exciting causes, there should be a return of the disease. Removal of Irritants. — A review of the causes, chief symptoms of cholera, and of the anatomical lesions observed after death, will go far 10 guide you to the treatment,both hygienic and medicinal, of the disease, and, what is yet more important, its prophylaxis. All the irritants by vvhich the' mucous and respiratory membranes pri- marily, and the nervous and vascular symptoms secondarily, are ex- cited, must be removed, and their force mitigated. They are, high heat to the skin, hot and impure air to the pulmonary mucous, and new and disproportionately exciting ingesta to the digestive mucous membrane. Unless we succeed in reducing the morbid sensibility of the system, kept up by these causes, we shall gain little mastery over the disease ; and in order to accomplish this end, we must, from the very outset, draw on hygienic agents, viz., cool and pure air, cool water for bathing and drink, and mild, unirritating ingesta. Without we enlist these in our service, and from time to time, as the symptoms indicate, abate the irritation of teething, by topical and chiefly surgical means, we must not hope for much from medicinal means, prescribed with the common intention of restoring the healthy secretions of the liver and muciparous glands, and giving tone to the digestion, &c. The different diagnostic value of certain symptoms will prevent your becoming routinists and reposing implicit confidence in a mode of treatment for the whole disease, which is applicable only to a particular stage, or for the beginning, which is only proper in the concluding period. Thus, for example, heat of the skin and a burn- ing heat over the abdomen, a frequent and somewhat active pulse, restlessness, intense thirst, scanty urine, bilious and acrid discharges, will call for a different treatment from a cold and clammy skin, small and feeble pulse, watery and nearly colourless discharges or scour- ings from the bowels, a moist tongue and aphthae, and heaviness and somnolency approaching to stupor — even though in both we have vomiting. The modifications depending on temperament and pri- mary constitution, are not to be lost sight of: they will form ele- ments in our calculations as to the intensity of the disease and the propriety both of selecting certain remedial means, and of insisting with more or less freedom on their use. In the first stage, or that of more manifest gastro-intestinal irrita- tion with exalted sensibility, the treatment will consist in a prompt TREATMENT OF CHOLERA INFANTUM. 457 withdrawal of all but the simplest nutritive articles, and an avoid- ance of medicinal irritants. The drinks should be cool, mild, and mucilaginous; the lungs should be subjected to fresh air, the skin to tepid bathing. Suspicion of indigestible substances having been recently given will authorise a mild emetic, as of ipecacuanha, or the state of the stomach forbidding this, a laxative enema, to be followed by simple mucilaginous ones. Vascular excitement being manifest, a few leeches over the epigastrium will be of service; their ap- plication to be followed by emollient cataplasms or warm stupes, extending over the abdomen : or if the temperature of the surface be unequal, the warm bath should be used. The state of the gums will early engageattention, and if they are swollen and inflamed, orspongy, and the teeth may reasonably be expected to appear, the former should be freely lanced. The more obvious and probable causes of irritation in the gums and contents of the stomach and bowels being removed, and any tendency to high irritation or inflammatory action being abated or subdued, recourse, if need be, is proper to dif- ferent medicines and compounds, with a view of quieting the stomach. Of these the simplest are to be preferred, such as mucilage of gum- arabic, alone or mixed with lime-water, or mint, or peppermint, or camphor-water ; then small doses of the alkaline carbonates with mucilage, or chalk powders or mixtures ; one effect of vvhich is to allay the gastro-intestinal irritation and to soothe the nervous system. Restriction togum-wateror cold infusion of theleavesof the bene plant is often alone sufficient in such cases without any drug being used. On this point I shall say more when speaking of drinks. The temporary controlling power of opium is often manifested so far as to procure a cessation of the vomiting and purging, while its hypnotic effects last; after which the symptoms return as before. We gain little by persevering in iis use under these circumstances, unless the child be irritated and wakeful and restless by a protruding tooth ; or in a state of great exhaustion by the prolonged vomiting and purging, and want of sleep. A suspension of the disease for a single day is often of great moment under these circumstances. But narcotism is to be deprecated, as deranging still more the nervous system, and increasing its susceptibility to existing morbid causes. Calomel. — Sometimes relief is obtained at once, though seldom a cure, unless suitable prophylaxis be attended to, by the administration <>f minute doses of calomel, as when an eighth to a twelfth of a grain mixed with five grains of gum arabic, is given every three or four hours. Of late years I often prescribe, in place of gum, about the same quantity of prepared chalk to be carefully mixed with the calomel, on vvhich it exerts of course a chemical, and, in reference lo its therapeutical activity, what might be called a reducing power. A practice, occasionally successful, consists in giving in the early stage, in advance indeed of any other remedy, one to two or three grains of calomel, regardless of its causing a sickness of stomach and vomiting itself, as those soon subside: the subsequent purging and evacuation of green, slimy, and bilious stools are regarded as proofs of beneficial action on the liver, by exciting it to a freer secretion, and thus unloading it of congestion. With similar therapeutical vol.. i.—39 458 DISEASES OF THE DIGESTIVE SYSTEM. intentions, small fractional doses of calomel, as above, are used by many practitioners, especially in Philadelphia. There is not, I be- lieve* any one remedy whichdisplays such strikingly curative powers, in either arresting the disease or mitigating its violence as this does: but a recurrence or relapse is frequent after its use, and then a repe- tition of the remedy will not be followed by the same sanative eftect as before. Oil of turpentine, in a dose of from three to five drops on a few grains of sugar, has acted favourably in relieving vomiting. Cold Affusion and Cold Enemata. — When the heat of the skin, and especially that of the abdomen, is great, cloths dipped in cold water, or even affusions of cold water on this region, have been used with, as we learn, very satisfactory results. I have found such means afford temporary relief, by abating tbe fever and restlessness; but they did not exert any controlling power over the disease. More might be expected during the period of febrile excitement and gastric irritation by the injection of cold or even iced water, as recommended by Dr. Miller. He refers to Cleghorn's report of the Spanish medi- cal practice of allowing the drinking of cold water to patients with violent cholera. I have often directed, with soothing effect, an enema of water of the common temperature of the air, at the time, between 65 and 70° F.; and upon the whole, I am inclined to believe this to be the better practice. Sub-Acetate of Lead. — Sugar of lead is found to be well adapted to allay the vomiting and abdominal pains, and certainly may be had recourse to long in advance of any other medicine of the class (astringents) under which it is, but, as I conceive, somewhat arbi- trarily ranked. The sub-acetate of lead is certainly more distinctly sedative than astringent, and is best adapted to follicular inflamma- tion of a sub-acute or chronic kind ; hence its use in chronic diarrhcea and leucorrhcea, and as an injection in this latter disease and in gonor- rhoea. Failing to tranquillise the stomach in twelve hours, the use of this medicine should be withheld until the disease falls into the diarrhoeal stage, when recourse may be had to it with greater benefit. If its use is thought proper in the stage of which I am now speaking, it will be given in a dose of a fourth, to a third, or half of a grain, combined with a few grains of gum arabic, every two hours.. It is given often in conjunction with opium, so often indeed in this as in all the diseases in which it is used, that there would seem to be a neces- sary, I was going to say inevitable connection between sugar of lead and opium. The fact illustrates both the strong adherence to routine practice, and some mistrust in the iherapeutical powers of the salt of lead. Better, by far, particularly in the early stage of gastro-intesti- nal disease, give it alone, and if it fail to produce the expected effect, then, either to suspend its use, or to combine with it a minute quantity of opium. The same remark applies with equal force to calomel in cholera, as well as in many other analogous diseases. TREATMENT OF CHOLERA INFANTUM. 459 LECTURE XLIX. DR. BELL. Cholera Infantum (Concluded).—Caution not to irritate the stomach by needless repetition of either food or medicine—Danger of relapse during hot weather— Remedies for the diarrhoea after vomiting has ceased—Nitrate of silver—alumina —Dr. Durr's cases, illustrative of German practice-Astringents,—of secondary value—Treatment when the disease remits—Renovation by fresh air—Treatmen in the state of collapse with diseased brain—Proper food for the patient- Drinks,—great importance of selecting them and regulating their use—Remova- of irritation from teething—Paramount importance of pure air, day and night— Bathing—Continued watchfulness on the part of the mother to withhold all irri- tating ingesta—Preservation of equable temperature of the skin—Prophylaxis,— cool air, cool bathing, cool drinks, and proper food at stated intervals. Avoidance op Gastric Irritation. — In the administration of both medicines and food at this period, and when the patient is no longer harassed by vomiting, but still has irritable stomach, it is a point of the greatest importance to let suitable intervals elapse be- tween the dose or the meal. Not unfrequently we have the mor tification of learning that the first dose stayed the vomiting, while after the second it came on, must we not say, was brought on. So in respect to food, whether derived from the mother's breast or given by the bottle or by spoon, it is deemed by many highly necessary that the supply should be frequent but in small quantities. Now, this is a means itself of keeping up perturbation of the stomach. The preferable plan is, to allow the child nearly as much as its appe- tite craves at the time, and then not present any food to it until a period has elapsed when we may suppose it has passed from the stomach. Frequent feeding I hold to be as bad as excessive reple- tion at long intervals. Nor can prolonged abstinence be recom- mended in the disease now under consideration. It alone will ren- der the stomach irritable, or at least less able to retain and digest the proper allowance of food afterwards. Towards the decline of the first stage of cholera proper, or that of vomiting and purging, the least indiscretion on the part of the mother or physician will renew the sickness of stomach. The slightest change in the food, as when the mother allows herself to be irritated or needlessly annoyed, and secretes bad milk in consequence, or care- lessly gives cow's milk, which is ever so little turned, or yielding to the persuasion of the last intrusive gossip, some new specific, will bring back the vomiting. Medicine continued after the more pressing indications for its use iu the first instance are fulfilled, will sometimes have the same etfect. Change of posture from the recumbent to the sitting, or that approaching to it in the mother's or nurse's arms, will also bring back the vomiting; and hence the injunction, on both mother and nurse, to keep the child iu a posture of half re- cumbency, whether it be in the arms, in the nursery, or in the open air, or iu a carriage. A hot night, during which fresh air has been excluded from the room, will also have the same deleterious influ- ence, which is not a little increased, if, in place of quieting the rest- lessness of the patient by giving it a few spoonfuls of cool toast and 460 DISEASES OF THE DIGESTIVE SYSTEM. water, or plain water, it is attempted to be soothed by being put fre- quently to the breast, or, more than all„ allowed to remain at it asleep. The vomiting once checked, and the more immediate distress of stomach removed, there is often such an abatement of the other symptoms as to promise speedy convalescence. This result cannot, however, be considered permanent, so long as the great heats of sum- mer prevail, and the irritation of teething is continued. There is a risk that the complaint, after a temporary cessation, will assume a fixed diarrhcea, varying in its character; in its being sometimes bilious, but more commonly serous or mucous, and gradually by its persistence wearing out the strength of the patient. If it continue, the symptoms of cerebral disease increase, and towards the fatal con- clusion of the disease, they might impose on a person, who had seen the case only in this stage, a belief of its being true hydroce- phalus, or dropsical effusion on the membranes of the brain. Diarrhoea. — It is not necessary to enumerate the different reme- dies and their combinations which are supposed to be applicable at this time, as most of them have been noticed at the time when speak- ing of ' Diarrhoea.' Of those which may be considered as of more recent introduction and use in cholera infantum, sugar of lead stands high in the opinion of some practitioners, — both in the first cholera stage, and, still more, in the second or diarrhoeal. Nitrate of silver, also, you may remember, I pointed out to you as an available remedy in dysentery, and in the chronic diarrhcea of children (Lect. XXIII., p. 229). Some years ago it was used in the case of his own child, by Dr. Skinner, of Hertford, North Carolina (Am. Journ. Med. Science, vol. xi., p. 253). Dr. S. gave the nitrate, in the advanced or diarrhoeal stage, in a dose of a grain mixed in a teaspoonful of mucilage of gum arabic, every four hours; gradually, after the first day, increasing the dose, and giving it at shorter intervals. It was discontinued on the third day; all the urgent symptoms having been removed, and convalescence fairly begun. The dose of one grain is larger than it would be thought advisable to begin with in a sub- ject of the age of Dr. Skinner's child, which was seventeen months old. M. Trousseau advises a fifth of a grain for a dose, and a grain for an enema. Prepared alumina (argil) has been extolled by some German prac- titioners, and particularly by Dr. Diirr, as a remedy adapted to even the earlier stage of cholera infantum. To be successful with its use, the doses must be pretty large, as from half a drachm to a drachm in divided quantities, in syrup, or any proper vehicle, during the twenty-four hours. It will not be without instruction, if I repeat here the outlines of the practice of Dr. Diirr, as somewhat illustrative of the treatment of the disease in Germany, where it prevails, I should suppose, to a greater extent than in France or England. I will even go further, and premise a sketch of the symptoms as I find them laid down by the writer in question in the British and Foreign Medical Review, vol. i. " The chief symptom of this dangerous affection, which runs its course in from two to ten days, is profuse vomiting, without any effort, of a sour-smelling fluid, varying in consistence; in many TREATMENT OF CHOLERA INFANTUM. 461 cases diarrhoea had lasted a whole week, when the first alarm was excited by the sudden appearance of vomiting. Collapse and rapid emaciation of the body followed, with depression of the anterior fontanelle : hollovvness of the eyes, paleness, alteration and shrinking of the features, cold extremities, hot occiput, and more or less fever ; agrypnocoma, or a lethargic state without actual sleep, restlessness, crying, whining, throwing itself from one arm of the nurse to the other, drawing up the feet to the abdomen, want of appetite, great thirst, stiffness in the nape of the neck, and the stomach so distended that it projected in the left hypochondrium like a distended bladder. Dr. Durr's practice in this disease was to quiet the irritation in the stomach and bowels by emollient oleaginous remedies in combina- tion with the argil; to excite the activity of the skin by extr. cicutae internally, and the application of an epispastic powder ex- ternally. The immediate effects of this were diminished frequency of the evacuations, the natural yellow colour returning, quiet, exco- riations in the folds of the skin about the neck and groins. In very young children the cerebral affection was often allayed merely by the chlorine water (aqua oxymur.) ; in older children, or where the symptoms were more violent, by leeches to the scrobiculus cordis, or behind the ears, according to circumstances; the dryness of the skin, the lethargy and coldness of the extremities, were treated with baths of chamomile and salt, and with cold lotions to the head ; warm stimulating aromatic fomentations were used from time to time, and enemata of elder and linseed, to which the yolk of an egg rubbed down with linseed oil was added. Dr. D. assures us that, in other acute diseases also, where the rough, dry state of the skin had defied the usual remedies, gentle perspiration had followed the use of these enemata. The epispastic powder vvhich he mentions, was first described by Autenrieth ; it consists of fresh prepared mezereon bark powdered. When the skin is not very delicate, it not unfrequently fails to produce any effects. Dr. D. has used it combined with calomel, and in very severe cases with corrosive sublimate, with great certainty and effect. The spot to which it is applied usually becomes red in the course of from six to twelve hours, and in about as much more time, moist and excoriated. If the powder will not stick, he moistens the spot with a little saliva or lard. " The result of his practice is decidedly favourable : of 67 children from the lime of birth to the age of fifteen months which he has treated for this disease during 1833 and 1831, he lost only seven. Dr. Diirr has given several interesting cases, both successful and unsuccessful, together with the examinations of the latter after death. Great con- gestion of the cerebral vessels, and considerable softening of the sto- mach, so that portions of it were quite pulpy, were the chief features; and in one case there was perforation." It is not necessary, nor to be expected^of me, to enumerate every astringent vvhich by one practitioneror another has been used in cho- lera. In their strictly curative powers, I have small faith. Early in the disease they are injurious ; later they may commonly be dis- pensed with, unless we are assured that there is simple anemia, and 39* ' ' 462 DISEASES OF THE DIGESTIVE SYSTEM. as regards the follicular apparatus, a simple relaxation of tissue with- out inflammation either of the glands or the intermediate mucous membrane. When we have recourse to them, it is better to take one or two from the class which contain in largest proportion the tannic acid, or we may administer this latter itself in suitable dose ; and thereby avoid the risk of offending the stomach and intestines by woody and inert extractive matter. Next to tannin will come nutgalls in powder, tincture, or infusion, rhatany (krameria), and kino. Tincture of kino or of rhatany with chalk mixture forms one of the best preparations in infantile diarrhcea, when the fever and abdominal heat are inconsiderable. Country practitioners, on whose judgment in the treatment of diseases and the relative powers of medicines with which they are familiar, we may repose considera- ble confidence, employ several indigenous plants of the astringent class in the diarrhcea of children. Of these cranesbill or geranum, rubus villosus and r. trivialis, or blackberry and dewberry roots, uva ursi or bearberry, and chimaphila, or pipsissevva, are the most esteemed. The tincture of the sesquichloride of iron, the tinctura ferri mtiriatis, I have found to check obstinate diarrhcea in children. Dr. Chapman speaks highly of the bi-sulphate in solution with sugar, in a dose of a fourth of a grain. Starch, with a few drops of lauda- num or infusion of rhatany and as an enema, will be of service on the subsidence of the acute stage. Remedies for the Remittent Form. — In my own practice I rely more on the means before indicated, both of a hygienic and medici- nal character, for the reduction of gastro-intestinal irritation, and of nervous and vascular excitement, than on any specific operation from a particular remedy, or class of remedies. Following out this view, if, after a subsidence of the vomiting, and an abatement of febrile action, there should be daily paroxysms or distinct remissions,I pre- scribe sulphate of quinia, in a dose of from an eighth to half of a grain twice in the early part of the day; and a minute portion of Dover's powder, or a fraction of a grain of calomel with chalk, or chalk and ipecacuanha in the evening; and direct the warm bath at the same time. In a degree of the disease beyond this again, it is not unusual to find the little patient with the skin cold and clammy, and the prostration and torpor of the system considerable. He lies nearly all ihe time listless and unobservant of anything passing around; but when roused, will take food with considerable avidity. It is now that animal broths, especially beef and chicken, from which the fat has been carefully skimmed, can be given with advantage: but not to the exclusion of the farinaceous food heretofore used by the patient. At this time I have derived the best effects from sul- phate ofquinia administered in solution. It invigorates the patient, serves to correct the morbid stale of the bowels, and every way exerts a cordial effect. Its use does not, of course, prohibit the continuance of other remedies adapted to particular symptoms,— such as the chalk mixture, Dover's powder, or ipecacuanha and magnesia. Oil of turpentine is used; in the advanced stage, with benefit, and even in the earlier stages sometimes quiets the irritability TREATMENT OF CHOLERA INFANTUM. 463 of the stomach. The warm* or if there be any reaction, the tepid bath, to be followed by assiduous frictions over the body, and parti- cularly the abdomen, along the spine and the lower limbs, is an ex- ceedingly useful adjunct to the remedies already indicated. Rube- facients over the epigastrium or other parts of the abdominal surface are to be preferred to vesication, from vvhich, and especially if re- peated, I have seldom seen good to result. The restorative effects of fresh air in cholera infantum are strikingly evinced in the relief procured to many hundreds of children every summer in Philadel- phia, by their simply crossing and recrossing the river Delaware in steamboats once or twice a day. New life is restored to the little beings, who on leaving their homes in the city seemed almost exani- mate and in the last stage of incurable exhaustion. In the stage of collapse with symptoms of oppression and effusion on the brain, as insensibility to light, dilated pupil, or strabismus, stupor alternating with restlessness and slight spasm, or more decided convulsive movements, a modified treatment is demanded. Some- times the heat and sensibility of the skin are still considerable, and the pulse frequent. In such a case, a few leeches may be applied to the temple, cold cloths to the head, and warm pediluvia or stimulating liniments to the feet; a cold dash over the chest and abdomen will at times be proper as a means of rousing the patient by the first shock and subsequent reaction. Calomel is to be given, either alone at short intervals, if the bowels are still loose, or alternating with small doses of castor oil and a few drops of oil of turpentine, if they are not free. Collapse, on the other hand, attended with cold skin, slow and very feeble pulse, and general insensibility, requires counter-irritants to the feet by sinapisms, to the nucha by blister, or to the whole scalp by a similar application* and oil of turpentine and assafoetida mixture as an enema, and in smaller doses, alternating with volatile alkali, by the mouth. Wine-whey, by teaspoonfuls often repeated, is at times signally useful. When reaction is established with febrile excitement, we suspend the use of stimulants, but not too suddenly ; and give calomel if the stomach and bowels be still in a morbid state. Food in Cholera Infantum. — As regards the food of the patient, simplicity is to be our first and chief study. Milk must be regarded as its chief aliment. If, unfortunately, the disease appears soon after the child has been weaned, measures ought to be taken to procure for it the breast of a healthy nurse. This being out of our power, a period of some months having elapsed since weaning, or the age of the child no longer making; this point a question, we must see that our patient receives food the most resembling that received from the maternal fount. Milk, with the addition of a small quantity of hot water, and some sugar, at first, and afterwards of a little rice or arrow-root flour to thicken it when it is in the process of boiling, will be the best succedaneum. In the more advanced stage of the dis- ease, cream is sometimes better borne by the stomach and better digested by it and the intestines than milk. By some, pounded or grated crackers, or ground rice; by others, wheat flour, mixed with milk, in its boiling state, is preferred for the child's food.- The dif- 464 DISEASES OF THE DIGESTIVE SYSTEM. ference is inconsiderable except in the case of the flour of wheat, including, of course, that in the form of crackers or bread baked, which, by its gluten, has an additional nutritive principle to that of fecula : this latter makes up, you know, the chief bulk of rice, arrow- root, sago, tapioca, potato, starch, Iceland moss, tous les mois, &c. In the beginning of the disease one or other of these articles may be given, as nutriment, boiled in water to the consistence of jelly and sweetened. Afier the stomach is composed, a little milk or cream may be added to the powder thus prepared with water. We can better proportion the quantity of milk in this way than when it is originally boiled with the arrow-root, or rice, &c. The addition of a little nutmeg, cinnamon, or ginger, gives flavour, and often enables the stomach to retain it more readily. There are peculiarities in respect to the precise kind of food which best agrees with an infant, worthy of notice. Sometimes milk, which alone disagreed with the stomach, and kept up purging, becomes easily digestible by the addi- tion of a little wheat flour or rice flour. At other times common pap, or milk boiled with wheat flour, continually disagrees. As the disease advances and symptoms of mere feebleness and im- perfect nutrition — cold skin, weak pulse, diarrhoea, without thirst or fever — are manifested, animal food may be more freely given, either in the form of broth carefully divested of its fat, or of a jelly, pre- pared by long boiling, of a little veal or chicken, or finally, by allow- ing the child to suck the juice of a piece of meat, but without swal- lowing it. At this time, good effects have been procured by salt meat, such as a piece of ham, used in this way. The salt itself is a healthful stimulant to the weakened digestive function, and. when tolerated by the taste of the child, it may very well be subslituled for sugar in its common food. It is sometimes preferred, even alone, to the latter. Plainly boiled rice with salt, I have every now and then found to be well relished by infants. Quite a palatable and nutritious broth is made by boiling two handfuls of rice in a pint of water slowly to half the quantity, after an ounce of good beef, or the leg of a chicken, divested of its skin, has been introduced. Drinks constitute one of the chief means of treating cholera in- fantum with advantage. Not only are they required for quenching thirst, but they exert a no small influence over the vomiiing and purging, when judiciously administered. The drink entitled to the preference over all others is cold river or rain water; if these cannot be procured, spring or well water first boiled and then made cold. So long as there is vomiiing the quantity at any one time ought to be small. If the ihirst continue urgent, notwithstanding a reasonable allowance of simple water, a little gurn-arabic should be added. Gum-water has the advantage of sheathing, as it were, the mouth, tongue, and fauces, and preventing the rapid evaporation and dryness of these parts, on which the sensation of thirst and craving for drink depends fully as much as on the state of the mucous membrane of the stomach. Gum-water I have often found to suffice in place of all medicine in cholera infantum ; at first to allay the vomiiing, and afterwards to restrain the purging. Whenever you feel yourselves embarrassed in the treatment of this disease by the want of the ex- TREATMENT OF CHOLERA INFANTUM. 465 pected effects of the customary medicines, and by seeing that every- thing you prescribe seems to irritate the digestive canal, or at any rate fails to check its morbidly frequent discharges, you may, with no little confidence, withhold all of them, and give gum-water alone, in their stead. I have repeatedly succeeded, by its exclusive adminis- tration for a day or two, in giving a most salutary turn to bowel complaints which seemed, from the bad success of all the most ap- proved remedies, to be unmanageable. The quantity of gum in the water will vary according to the intention, — either as a mere drink, or as a demulcent, and for nutrition. In the latter case it may be slightly sweetened. On the same line with gum is rice or barley- water, especially if it be drank slightly salt. But as I have already enlarged on the virtues of these articles in diarrhoea, I shall not far- ther speak of it in this place. Both the rice or barley-water, and gum-water, may be given cold, and even iced during the first and more evidently febrile stage of the disease, when the thirst is urgent and the heat of the skin is great. Grains of ice in water will be found both grateful and salutary at this time, to check the vomiting and nausea. As the tastes or appetites of children differ much respecting the temperature of their drinks — some preferring them cold, others warm — we may safely trust to their inclination on this point. Slightly acidulated drinks, rendered so either by vegetable or mineral acids, tea of any of the milder herbs, such as of balm, toast and water, &c, will be relished by many. Irritation of Teething. — The irritation of teething I have mentioned as one of the causes of infantile cholera. This in a child under two years of age is always to be suspected, and when present will be found to give additional power to any existing disease, whether it be of the digestive or respiratory apparatus. It will be enough for me to refer you to my remarks in a former lecture (On the Diseases of Dentition), for the course proper to be pursued in the emergency. Opiates are, as I slated a few minutes ago, more admissible, indeed more called for, in cholera with troublesome and painful dentition, than where this complication is not present. The warm bath and warm pediluvia are also more serviceable than in the simple disease of the digestive passages, unaccompanied by much nervous irritation. But with all our skill in the selection and administration of the best therapeutical means, and of suitable food and drinks, we shall not make sensible progress towards a cure, unless we can improve and alter the deleterious air breathed by our little patient. Its deleterious- ness is not from any malarious impregnation, but from its want of perflation and renewal, and the excess of heat, of which it is the con- ductor. Direct experiments, and accidental occurrences, from ex- posure of individuals and of numbers crowded together, render it certain that the stomach and digestive apparatus generally are as much offended by the inhalation of impure air as by the eating of indigestible and even poisonous substances. " Water! water !" was the cry continually repeated by the unfortunate persons who w*ere confined in the Black Hole of Calcutta; and their sufferings from thirst and a burning heat and sickness at the stomach were greater than from their oppressed breathing and disordered circulation, caused 466 DISEASES OF THE DIGESTIVE SYSTEM. by the impure air inhaled and acting on the lungs. Having availed myself of this illustration, I shall continue the remarks which follow it in my supplementary chapter to Dr. Combe's work on the Physio- logical and Moral Management of Infancy, p. 294-7. Hygienic and Prophylactic Treatment. — The indispensable condi- tion, therefore, in a vast number of cases for the avoidance of the disease as well as for its cure, is the access of fresh and somewhat cooler air both to ihe lungs and skin — a condition this, also, for re- storation from the irritation, and feebleness, and fever, which harass so often in the summer months a child during the process of teething. Parents who are desirous that their children should avoid bowel complaints, under the various narrfes already mentioned, must contrive to change the air which their children breathe, by taking them into the country. Some do this for the whole summer; others take their children daily out a riding ; others, and the larger class, have not the facilities of either of the other two classes, but they have still much in their power. They can so manage that their children shall enjoy early in the morning the air of some of the public squares of the city; or at this time, or if it must be, later in the day, the still fresher air on the water in one of the many steamboats vvhich are plying at all hours. I am sure that the lives of many hundred children are saved annually in Philadelphia, by their mothers availing themselves of the resource offered in crossing and recrossing once or twice a day the Delaware, and by spending a while on the Jersey shore. Still greater and more diversified facilities are presented in New York. The period of the severest trial and greatest suffering of children in the cities, and particularly in the less favoured parts already speci- fied, is during the night. The heat which was absorbed during the day by the walls of ihe houses, and the pavements of the streets, is now in process of being Typhus . 5* u 3 — 2 19 Bronchitis 5t73 5 3 — 1 H 24 Phthisis . . 5£ -1-} 23 ! H 8 Rheumatism . 5,W V* + 3 1 2* 24 Hepatitis . . H 4£ H S2 A but there was no appearance of pointing. At this time the patient was visited and examined by a number of medical men, and all agreed that it was a case of deep-seated suppuration of the liver. Under these circumstances it was thought advisable to make an incision through the integuments down to the peritoneum, as recommended by Dr. Graves, and to keep the wound open by filling it with lint. This operation was performed, and the wound kept often for several days, but no matter came. On the sixth day the patient began to sink, his face became hippocratic, his extremities cold, and every one thought he was dying. During the course of the day it was observed that there was a circumscribed tumour, with a distinct sense of fluctuation, situated close to the wound, and towards the right side of the mesial line. Here is an important stage of the case; — a man presenting evidence of suppuration in the liver has an operation performed on him to favour the exit of pus externally, and some time after this we find a circumscribed fluctuating tumour, nearly in the situation of the wound. We concluded that the he- patic abscess was pointing in that situation, and it was determined to pass a lancet cautiously into the tumour. This was done, but, to our astonishment, instead of pus, pure bile escaped through the incision. It was clear that we had mistaken a distended gall-bladder for an abscess, and this I need not tell you was a seriotis error. It is singular, however, that the accident was not followed by any bad consequences. About two hours after the operation the patient went to stool, and passed two large evacuations, consisting chiefly of a vast quantity of purulent matter. Next morning he was sur- prisingly well, and the hepatic tumour had considerably diminished. His countenance recovered its natural expression, his spirits were quite elated, his pulse had become tranquil, and the liver was manifestly returning to its ordinary dimensions. He began to sit up, was put upon generous diet, could walk about the ward, and was talking of leaving the hospital. From the period, however, at which the discharge of pus took place he had an obstinate diarrhcea, and though he took a great deal of nourishment he was still pale and emaciated. Twenty-two days after the subsidence of the tumour, another swelling began to make its appearance in the epigastrium, which increased daily, and it was obvious that another abscess was forming in the left lobe. About a fortnight after this he was sud- denly seized with excruciating pain in the epigastrium, followed by symptoms of peritonitis. The tumour in the epigastrium subsided, but the patient sank in a few days of the peritoneal inflammation. Let me recall the circumstances of this case. First, we have obscure signs of the existence of abscess, then the sudden escape of matter from the bowels, accompanied with subsidence of the hepatic tumour; in the next place a persistence of diarrhcea and emaciation; and, lastly, we have a new tumour in the epigastric region, disappearing DIAGNOSIS OP HEPATIC ABSCESS. 527 on the supervention of symptoms of acute peritonitis. From a con- sideration of all these circumstances I stated to the class that I should expect to find evidences of the abscess in the right lobe, which was ihe first affection, and I ventured to say, that the opening between it and the intestinal tube was slill pervious. I was led to form this opinion from observing the persistence of the diarrhcea, to check which all the ordinary remedial means had failed. This was the first part of the diagnosis. In the next place I stated my belief that the gall- bladder had been punctured, but could not explain why the bile had not escaped into the peritoneum. Thirdly, I said that an abscess had formed in the left lobe, which had discharged its contents into the peritoneal cavity. All this was stated publicly, and on consider- ation you will find that there was no great difficulty in making the diagnosis. On dissection, we found a cavity in the right lobe with a small quantity of matter in it, and having a free communication with the duodenum. The fundus of the gall-bladder was found ad- hering to the parietal layer of the peritoneum, and the mark of a lancet wound in it was evident. A recent abscess was discovered in the substance of the left lobe of the liver, from which the matter had escaped into the peritoneum by a passage capable of admitting a small quill. Every part, therefore, of the diagnosis of this case was perfect, and borne out by the necroscopic appearances. You will see the details of this very interesting case in a paper published by Dr. Graves and myself, in the fifth volume of the Dublin Hospital Reports. This case is exceedingly interesting, because it illustrates two remarkable terminations of hepatic abscess: in one instance, by opening into a cavity which had an external communication, in the other into a shut sac. The patient recovered from the first abscess, and would have done so effectually if the fistula had closed (no un- common event); but he could scarcely have recovered from the second, because, where the matter escapes into the peritoneum or pleura, tbe patient almost invariably dies of acute inflammation of ihese cavities. This case derives additional interest from the cir- cumstance of the gall-bladder having been opened. I believe this is the only case on record in which an opening made into the gall- bladder has not been followed by fatal consequences. I might detail many other cases of hepatic abscess, but I must at present refer you to the paper already alluded to, in which we have published the results of our experience on the subject. Some authors have mentioned gangrene, or mortification of the liver, as one of the modes in vvhich acute hepatic inflammation may terminate. It is now, however, agreed, that this is one of the rarest terminations we can meet with; in fact, that there is hardly any organic disease vvhich so seldom occurs. Mr. Annesly states, that in all his dissections (and these were very numerous) he never met with a case of gangrene of the liver. Andral, who has examined some thousands of bodies, has only met with a single case: this, with another vvhich was under the care of Dr. Graves, and appears to have been a genuine example of mortification of the liver, are almost the only cases of which I have any distinct recollection. The case 528 DISEASES OF THE BILIARY APPARATUS. under Dr. Graves was that of a patient in Sir Patrick Dun's Hospi- tal, who laboured under chronic inflammation of the liver, with ascites, jaundice, swelling of the lower extremities, and an incapability of lying on the left side. After this man had been about eleven days in the hospital he began to complain of tenderness and pain of the belly; he was next seized with vomiting, and threw up a large quan- tity'of fetid matter. Soon after this he sank, and, on dissection, numerous marks of chronic disease were found in various parts of the substance of the liver: but in the left lobe there was a cavity which was distinctly gangrenous, and had in the centre of it a large mass of slough. I think that there can be no doubt that in this case the disease was actual gangrene of the liver. I think, too, it may be very fairly doubted whether gangrene of the liver is the result of inflammation, properly so called, in any case; and I believe it would be a very interesting subject for inquiry, to consider how far this disease may be the result of hepatic apoplexy, or effusion of blood into the substance of the liver. This is an accident to vvhich the liver, as well as any other parenchymatous organ, is subject; and though effusions of blood into its substance are by no means so com- mon as similar occurrences in the brain and lungs, still it does not enjoy anything like immunity from such lesions. We have good reason to believe, that in many cases blood effused into the substance of parenchymatous organs may, under certain circumstances, either undergo putrefactive decomposition, and form a gangrenous abscess, or that, although no longer circulating in its vessels, and effused into the parenchyma of an organ, it may still retain its vitality to a certain extent, and, being modified by the powers of life, may give rise to the formation of various morbid products. In this way it is thought that various tumours—cancerous, steatomatous, melanotic, and encephaloid—may originate. I am inclined to think that this some- times occurs in the brain and lungs, and it is probable that it may happen in the case of the liver also. Further researches, however, are necessary, with respect.to the elucidation of this matter, before our opinions on it can possess a higher character than that of veri- similitude. While on the subject of hepatic abscess, it will be necessary to allude to one of its occasional complications — distended gall-bladder — because this may be mistaken for the pointing of an abscess, and an operation be performed, and that this has happened more than once is a positive fact. A distended gall-bladder has been mistaken for the tumour formed by the pointing of an hepatic abscess, an open- ing has been made into it under this supposition, bile has escaped instead of pus, and this, getting into the cavity of the peritoneum, has given rise to rapid and fatal peritonitis. A remarkable case of this kind has been detailed with great candour by the late Mr. Todd, in one of the early numbers of the Dublin Hospital Reports. He was called suddenly to visit a girl, whom on his arrival he found to be in a dying state, labouring under great distension of the belly, almost insensible, moaning constantly with her jaw fixed, and pre- senting a distinct tumour in the hypochondriac region, which, from the history of her case, he was led to consider as an hepatic abscess COMPLICATIONS WITH HEPATIC ABSCESS. 529 pointing externally. He divided the integuments and muscles down to the peritoneum', and having introduced a trocar drew off nearly three pints of bile, with apparent relief. Shortly afterwards violent peritonitis came on, and the patient sank rapidly. After death the liver was found to be healthy, and the tumour to have been formed by a distended gall-bladder of enormous size. From this, after the operation, the bile had escaped into the peritoneum, causing intense and universal peritonitis. In making a diagnosis in such a case as this, everything will depend upon your knowledge of the history and previous symptoms. The circumstances vvhich produce distension of the gall-bladder, you will find, upon examination, do not bear any distinct resemblance to those vvhich precede or accompany inflam- mation of the substance of the liver. We may have it from the obstruction caused by biliary calculi, and here you can make a tolerably sure diagnosis. We may have it from disease of the duo- denum, or of the head of the pancreas, or from the pressure of aneu- rismal tumours in the vicinity. Abscess of the liver is generally accompanied by symptoms of inflammation of that organ, but dis- tension of the gall-bladder does not. present any corresponding train of phenomena. There may be some exceptions to this rule, but in making the diagnosis we must strike a balance of probabilities. The first part of our diagnosis then is this — the occurrence of a tumour in the hypochondriac region, not preceded or accompanied by any of the symptoms which characterise hepatic inflammation. Another important diagnostic, and vvhich I think will apply in several cases, is this. In a case where abscess was formed in the liver, the fluctua- tion, which is a sign of the existence of fluid, is often preceded by a condition of the part in vvhich there is no sign of the presence of fluid ; we have first induration and swelling, and then the signs of fluctua- tion ; but this is not the order of succession in the phenomena vvhich characterise distension of the gall-bladder. In abscess we have a hard tumour which gradually softens ; in case of distended gall- bladder, we have the tumour soft and fluctuating from the commence- ment. If, then, we have a tumour in the hypochondriac region, not preceded or accompanied by symptoms of hepatic inflammation, accompanied by jaundice, with a sense of fluctuation from the begin- ning, and unattended by hectic, the chances are indeed very great that it is not an hepatic abscess, but a distended gall-bladder. You will perhaps be surprised, that, in treating of the diagnosis of distended gall-bladder, I do not lay any particular stress upon position. The reason of this is, that the situations in which a dis- tended gall-bladder may be felt are extremely various. First, we may have it appearing in different parts of the hypochondrium, under the cartilages of the ribs. In the next place, we may have it between the cartilages of the ribs and the spine of the ileum. It has been observed by Andral in the iliac fossa, and he has seen it in the epigastric region. In a case which occurred in the Meath Hospital, it presented itself in the epigastrium, a little to the right of ihe mesial line. Again, in severe cases, you may have the whole of the liver filled with bile, and having a distinct fluctuating feel, not produced by the existence of pus in that organ, but from the vol. i.—45 530 DISEASES OF THE BILIARY APPARATUS. enlargement of its ducts, ivhich are gorged ioith bile. In one case mentioned in the Medico-Chirurgical Transactions, this curious cir- cumstance occurred. So far, then, as diagnosis is concerned, posi- tion appears to be of very little consequence ; but when we have this, in addition to the other circumstances mentioned, it will tend to give additional certainty to our diagnosis. In all cases on record where there was distended gall-bladder, the patient laboured under jaundice, except in that which I have detailed in the early part of this lecture; but perhaps if our patient had lived longer, he would also have had jaundice. There is one disease more which may be, and I believe has been, confounded with acute hepatitis and abscess of the liver. This affec- tion, which has not been sufficiently noticed by authors, is inflamma- tion and abscess of the abdominal parietes over the hepatic region; and this is a very singular disease. It is sometimes trifling, but I have seen a patient die of it. With the original nature of this disease I confess that I am not at all well acquainted ; nor can I say whether the inflammation first attacks merely external parts, or whether it is a primary affection of the liver, and that the external parts take on diseased action from sympathetic irritation. In such cases we fre- quently observe many of the symptoms of inflammation of the liver, as pain, tenderness, biliary derangement, foul tongue, and morbid stools, with a tumefied state of the integuments. After these symp- toms have continued for some time, the tumour increases in size, becomes softer, and matter forms. You give exit to the pus by open- ing the abscess with a lancet, and the patient gets well. This occur- rence I have frequently witnessed. From a consideration of all the circumstances, it strikes me that in this disease the first morbid action in all probability commences in the liver itself, and that the external inflammation is an example of the strong sympathy which subsists between disease of deep-seated parls and integuments which cover them. Of this fact you have several illustrative instances. In pleu- ritis we frequently find the integuments of the chest remarkably tender on pressure ; and in cases of inflammation of the brain, the integuments of the scalp have their sensibility much increased. The same thing occurs in hepatitis? and in this disease one of the first distinct symptoms is this tenderness of the superincumbent skin. Now, you can conceive that, if this morbid sensibility of the investing parts should increase, in place of having some pain and tenderness, accompanied by swelling, we may have suppurative inflammation set up in these parts; and that, under such circumstances, the inflam- mation may leave the internal organ where it first existed, and be thrown upon the external parts in its vicinity. It strikes me that this is not unfrequently the case in this curious affection. In the case of this disease which I have seen prove fatal, the following circum- stances were observed : — Evident symptoms of inflammatory fever; pain and tenderness in the region of the liver, followed by the appear- ance of a tumour; vvhich became fluctuating, was opened, and a quantity of matter discharged with considerable relief to the patient. She left the hospital, but returned again in about a fortnight or three weeks, with an enormous tumour in the same place, which was again COMPLICATIONS WITH HEPATIC ABSCESS. 531 opened, and a vast quantity of purulent matter evacuated. Though the matter continued to flow freely, she did not recover strength; und on inquiry it was found that before her second admission she had spit up some blood. One day while dressing the abscess, the gentleman who attended her observed that when she coughed air passed out through the wound, proving the existence of a fistulous communication with the lung. On examination after death we found an abscess, the base of vvhich rested upon the peritoneal surface of the liver, without engaging its substance. From this the matter had made for itself a double passage, one externally, the other through the diaphragm and pleura into the substance of the lung. This was the only case in which I have seen this disease prove fatal; and in it death appears to have been caused by the extent of the disease, and by the abscess opening into the pleura and lung.* * [One of the most extraordinary instances of the termination of hepatic abscess is recorded in the Eclectic Journal of Medicine for January, 1839. It was a discharge through the colon downwards and the lungs upwards. The- subject of the case was, at the time, under the care of Dr. Colledge, at Macao, China. He had suffered from hepatitis from the 6th of August, 1836, in Canton, to the last of the month, for which he had been bled, leeched, and blistered, and had taken calomel freely. From the 1st to the 13th of September, he was occasionally leeched, look small doses of calomel, with rhubarb and castor oil, and enemata, and was subjected to counter-irritation from blisters and tartar emetic ointment. On the 13th, the patient felt himself all on a sudden relieved — was sensible of something having given way within him. On examining his intestinal dis- charges the next day, a very considerable quantity of purulent matter was seen in them and in those which he passed for some days after — warranting the opinion that had been held of an abscess having formed in the liver. For ten or twelve days from this time he improved con- siderably, when another return of the symptoms took place. The same remedies were applied as before, together with anodyne fomen- tations, but with the same want of success. He got daily worse, and serious apprehensions were entertained regarding his recovery, when, on the lib of October, he experienced another sudden change for the better. But this time the abscess burst into the thorax instead of the colon, and the matter was discharged by expectoration. He soon became convalescent, and sailed for England. In a letter from St. Helena, on his way home, dated February 7lh, 1837, he says that " he was gaining strength and flesh, and enjoyed the cool weather at sea amazingly." At Berhampore (Hindostan), Dr. W. O'Shaugnessey opened the body of a soldier, in 1831, who died of phthisis. In this subject there was found adhesion by cicatrix, evidently caused by an old abscess, to the diaphragm and lungs, and another to the colon. Dr. O's! was not able to obtain the previous history of the case, but he had never suspected liver disease —in fact, there was none at the time of his last illness. — B.j 532 DISEASES OF THE BILIARY APPARATUS. LECTURE LVIL Aneurism of the Hepatic Artery—Distension of the liver with bile—Treatment of hepatitis—Employment of mercury—Symptoms of Suppuration—Dr. Graves's operation for fiving exit to matter in hepatic abscess—Rupture into the perito- neum—Chronic hepatitis—Complication with disease of the heart—Embryonary state of the liver. You may remember, in one of my past lectures, I alluded to a case of aneurism of the hepatic ariery, of vvhich I had procured a prepa- ration: to-day I shall be able to exhibit to you the morbid appear- ances in this very remarkable case. It would appear that aneurism of the hepatic artery is an exceedingly rare circumstance. At a late meeting of the Academy of Medicine of Paris, a specimen of aneurism of the hepatic artery was presented to the society; and that celebrated pathologist, Cruveilhier, stated that it was the first of the kind he had ever seen. I wish to bring this preparation before you, not merely from the interest which its rarity excites, but also because the disease, in this instance, produced that distended condi- tion of the gall-bladder to which I drew your attention on a former occasion, and which in this case was recognised before death. The gall-bladder formed a distinct pyriform tumour, situated a little above the iliac fossa, and the patient was deeply jaundiced. I shall state, from recollection, what I know of the details of this case. The pa- tient was brought into the Meath Hospital, labouring under jaundice, which he stated to be of some days' standing. He was thin and weak, and when questioned respecting his age, he said he was thirty- five, but he appeared to be upwards of fifty. His habits he described as being uniformly temperate and regular. Some years before he had suffered from an attack of apoplexy, but after this had enjoyed good health, until the occurrence of the present illness, which began with vomiting of blood, and which continued for some days, and then yielded to medical treatment. He now experienced a loss of appe- tite, became quite dyspeptic and constipated ; he also began to lose flesh, and under these circumstances applied at a dispensary, where he got various remedies without any benefit. Some time after this he observed, on getting up one morning, that his arms and legs looked rather yellow ; on the following day he had a decidedly bilious tinge with yellow vision, and in this state he entered the Meath Hospital. On admission he presented symptoms of general jaundice ; the urinary secretion was deeply coloured ; the skin, eyes, and nails yellow ; the stools white and without any trace of bile. On examin- ing the abdomen, the liver was apparently greatly increased in size ; in ihe epigastric region there was a tumour of considerable dimen- sions ; and in the iliac fossa we observed a separate pyriform tumour, which could be traced up to the edge of the enlarged liver. I men- tioned at that time to the class, that there was something about the case which I could not understand. The disease was of inconsider- able standing; the patient had, a short time previously, been in a state of good health, and yet, reasoning from analogy, this hepatic tumour could only have occurred as the result of chronic disease. ANEURISM OF THE HEPATIC ARTERY. 533 It must have been the consequence of disease more or less chronic, and yet the historv of the case was at variance with the idea of its chronicity. After some time the patient got miliary eruption, then petechial spots; he continued in a low and weak state, and nothing did him any good. On the morning of the day of his death he did not appear worse than usual; he answered our inquiries respecting his health in his ordinary manner ; in the evening he sat up in bed gasping for breath, with a look of extreme distress ; he then leaned back on his pillow and expired. On opening the peritoneum we found a vast quantity of blood efl'used into its cavity, and my first impression was that it was aneu- rism of the abdominal aorta. On closer inspection, the aorta proved healthy, and the aneurismal tumour was found to be connected with the hepatic artery ; this had ruptured close to the gall-bladder, and its contents had been effused into the cavity of the peritoneum. We now found that the cause of the jaundice had been the pressure which this tumour had exercised on the biliary ducts. In consequence of the obstruction to the flow of bile, the ducts of the liver were dilated to an enormous extent; some of them were capable of admitting the largest-sized finger. This dilatation affected not only the largest trunks, but even extended to their most minute ramifications, even up to the surface of the liver; and here we found that the biliary tubes were dilated into sacs, some of which were as large as a hazel-nut. When these pouches were punctured the bile gushed out freely. A similar condition of the ducts has been noticed by Mr. Lioyd as ex- isting in connection with obstruction of the biliary duct, from disease of the head of the pancreas, in his paper on Discharges of Fatty Matter from the Bowels. (See Med. Chir. Trans.) I have got the preparation of this singular disease before me, and I regret that in one respect it is defective, inasmuch as it does not show satisfactorily the condition of the biliary ducts. A portion of the preparation which exhibits this appearance I gave to Dr. Houston, the curator of the Museum at the College of Surgeons, and I am sure that he will give admission to any gentleman who is anxious to examine it. This preparation, gentlemen, is too large to send round. It exhibits the hepatic artery wilh its aneurismal tumour, and the opening by vvhich the artery communicates with the aneurismal sac. Here is the place in vvhich the rupture took place, and here is the gall-blad- der greatly extended and thickened in its coats. Here, then, we have a new cause of jaundice, where the disease is the result of the pressure of an aneurismal tumour of the hepatic artery — a cause which has hitherto been unnoticed by writers on jaundice. The great interest of this case consists in this, that dis- section explained the difficulty which I felt in making the diagnosis at first, for it showed that the hepatic tumour was formed, not by an hypertrophied, but by a distended and displaced liver. It proved that it was formed, not by a process of chronic growth, but by the rapid formation of an aneurismal swelling and the consequent ob- struction of the gall-bladder, accompanied by distension of the liver itself. With recent symptoms, then, we had, in this case, an enor- mously large liver, not the product of inflammation, but of disten-. 534 DISEASES OF THE BILIARY APPARATUS. sion of all the biliary ducts up to their most minute ramifications, and arising from mechanical obstructions. As far as it goes, this case appears to me to be perfectly unique. Treatment of Acute Hepatitis. — Let us turn now to the treat- ment of acute hepatitis. It is unnecessary for me to say, that in all cases of acute visceral inflammation, in the healthy subject, the first consideration is bloodletting, either general or local. In the early period of acute hepatitis, all authors have agreed in strongly recom- mending the use of the lancet; and there can be no doubt that when the disease is in its early stage, and the patient robust, the prac- titioner who omits employing these measures must be culpably negligent. It should always be borne in mind that the liver is an organ of paramount importance to life. There are two circum- stances, also, which are in favour of bleeding in the case of an acute hepatitis, — there is less chance of its being complicated with typhous fever, and general bleeding exercises a powerful influence over the acute inflammations of parenchymatous organs. Hence, we bleed with greater advantage in a case of acute hepatitis than in the in- flammation of the mucous membranes. Our first bleeding should be large, and such as will make a decided impression; and it will frequently be necessary to bleed a second and even a third time if the disease be very acute and the constitution strong, taking care to diminish the quantity at each successive bleeding, and to watch its effects. I have here to make one remark— that general bleeding is not the same heroic remedy, nor has it the same decided influence in arresting acute hepatic inflammation, as in checking pneumonia. A copious detraction of blood has, under favourable circumstances, often succeeded in completely removing an attack of pneumonia, and the patient has recovered without the employment of any other reme- dial measure; but acute hepatitis is seldom or never cut short in this way. Still venesection is of the greatest importance ; and if it were performed merely with a view of preparing the patient for leeching and other depletive measures, ils advantages would be unquestion- able. I would recommend you, therefore, when you meet with a case of hepatitis in the early period, first to bleed freely, or in such a manner as to make a decided impression on the symptoms; next, to empty the bowels by prescribing a purgative draught, assisted by an enema; and, lastly, to cover the region of the liver with leeches. You will find great advantage in employing your thera- peutic means in this order; for if you begin wilh leeches before you have had recourse to venesection, or the use of purgatives, your practice will not be so scientific, nor will your success be so com- plete. Bleeding, purgation, leeches, and the application of cupping- glasses over the leech bites (if necessary) will give you breathing time ; and after the lapse of twelve or fourteen hours, you will find that all symptoms of urgent danger will have passed away. Dur- ing the progress of the case, the remedy vvhich I should principally rely upon is local bleeding, frequently repeated. If you apply thirty leeches to-day, I would not have you repeat them to the same amount to-morrow ; but you might, perhaps, apply fifteen or eigh- teen, and the next day ten or twelve. By proceeding in this way you will find a great abatement in your patient's symptoms ; and I TREATMENT OF HEPATIC ABSCESS. 535 know of no circumstance which, taken singly, proves the value and benefit of your treatment so well as the diminution of the hepatic tumour, vvhich you can accurately and satisfactorily ascertain by means of the pleximeter. When you find a gradual subsidence of swelling, I think you may be pretty sure that, even though the other symptoms exhibit little or no improvement, the hepatitis is on the decline, and will soon be removed entirely. You have all, I am convinced, heard a great deal of the use of mer- cury in hepatitis ; and there appears to, be in the minds of most medi- cal men a strong connection between mercury and all diseases of the liver. So far has this impression gone abroad, that to some prac- titioners it would appear perfectly heterodoxical to think of attempt- ing to cure an hepatic inflammation without this accredited panacea. I must, however, confess, that it is my belief that several cases of hepatic inflammation may be cured without it; and, if this be true, as I am convinced you will find by experience, it is so much the better for the patient. I do not mean to deprecate the value of this powerful remedy in making this assertion ; — it is undoubtedly a useful adjuvant, but it is only an adjuvant. It is decidedly secondary and inferior to general and local antiphlogistics, followed by counter- irritation ; and you should always bear in mind, that if you wish to bring about the full action of mercury on the system, you must pre- cede its employment by means calculated to reduce the intensity of local inflammation. By premising general bleeding, leeching, and purgatives, you give the mercury an opportunity of exerting a de- cided influence on the salivary glands; and in such cases it is that the most unequivocal advantage is derived from it; for, as I have ob- served in a former lecture, salivation appears often to be the result of the reduction of inflammation to a certain degree, and not its cause. In all cases of hepatitis occurring in delicate females, but par- ticularly in persons of low, scrofulous constitutions, endeavour to dispense with the use of mercury if possible.* You will have considerable difficulty in divesting yourselves of early prejudices, and combating those of others; but when you have an opportunity of acting for yourselves, I would have you make trial, and you will find that many cases are curable without mercury. If, after having regularly and carefully employed the means recommended, you per- ceive that two or three days pass without any improvement in your patient's symptoms, and that the hepatic tumour remains undimi- nished, then indeed you may have recourse to mercury. But if you have been so fortunate as to have struck a decided blow in the com- mencement, and that the case is going on well, I should ask, why should you expose your patient to the misery and danger of saliva- lion ? 1 am not by any means opposed to the employment of mercury in cases of liver disease ; on the contrary,if we compare inflammation of the lungs, brain, and liver, with respect to the power which it has over each, I believe that it is much more applicable to cases of hepatic inflammation than it is either to pneumonia or cerebritis. * [In cases of this description I have directed the iodine (Lugol's solution and the iodide of potassium in solution) with excellent effect. — B.J 536 DISEASES OF THE BILIARY APPARATUS. There is nothing more common than a complication of disease of the liver with disease of the upper part of the digestive tube; and here you will find that calomel will frequently cause great irritation of the bowels, vomiting, and increase of fever. Under such circum- stances, you must omit the internal use of mercury, and have re- course to frictions, directing your patient tomb in a drachm of campho- rated mercurial ointment every six or eight hours until the gums are affected. A very good auxiliary means is to place a drachm of the mercurial ointment in the patient's axilla, and leave it there; the action of the arm will, to a certain extent, answer all tbe purposes of friction. Dr. Graves is much attached to this mode. Where you have employed blisters, you may cut off the cuticle, and dress the raw surface with mercurial ointment. This also will contribute materially to produce the intended effect on the system. With respect to blisters, the same rules are to regulate their application as I have mentioned before, when speaking of the treatment of gastro-enteritis, namely — that they are not to be used until active antiphlogistic treatment has been employed; for it is then, and then only, that the stimulus of a blister can be useful. I believe it is seldom necessary, or even safe, to apply a blister before the third or fourth day in cases of acute inflammation of the liver. The physician who purges to- day, and blisters to-morrow, and bleeds next day, is a very injudi- cious practitioner indeed : he should bleed first, then purge ; and hav- ing by these means reduced the symptoms of active inflammation, he may proceed to the use of blisters with advantage. It is unnecessary for me to remind you that you must enjoin a strict antiphlogistic diet in all cases of acute hepatitis. Recollect the powerful influence which all dietetic stimulants exercise, not only over the digestive canal and general system, but also over the liver ; bearing this in mind, you will, for the first few days, keep your patient on a water and slop diet, and then on a mild farinaceous food and chicken-broth. Suppuration or the Liver. — But suppose that after all this, after having employed all the resources of the science and art of medi- cine, your patient becomes gradually weaker, his face pale and ex- pressive of much constitutional suffering, his skin flaccid and be- dewed with perspiration, his pulse small, rapid, and compressible, that the hepatic tumour increases in size, and when you throw aside his bed-clothes the whole of the right side appears manifestly enlarged ; and, if the bowels are empty, you see the hepatic tumour extending far downwards into the abdomen; in addition to these symptoms, suppose the patient has had shivering fits, not only once but re- peatedly ; that his perspirations are profuse, and have a sour smell ; that his tongue is dry and glazed; that his cheeks are hollow, and sometimes present a circumscribed flush ; and that he is low, weak, and restless. Under these circumstances you may be sure that suppuration is commencing, or has been already established ; and the question is, what are you to do ? You must change your hand, you must give up antiphlogistics, you must omit the employment of all measures which have a tendency to reduce strength, you must prescribe a light nutritious diet and anodynes to relieve irritation. When suppuration is fully established, the next consideration is, in SUPPURATION OF THE LIVER. 537 what direction the contents of the abscess may escape; and here I need not remind you that it is much better that the abscess should open externally, through the integuments of the abdomen, or into some cavity having an external communication, rather than into a shut sac, as in the latter case it is almost certain and often immediate death. At this period of the case it will be proper to support your patient's strength by allowing him wine, increasing the quantity if the hectic symptoms threaten to run him down, and taking care that his diet be nutritious and of easy digestion. You will also take care to re- lieve his sufferings, and irritation attendant on the disease, by the judicious employment of opiates. When after some time the tumour becomes more elevated and distinct, the pain concentrated in one particular part of the liver, and the abcess is evidently pointing towards the surface, the question then is, whether we shall open it and give exit to the matter, and how this may be best accomplished. That the contents of the abscess should be evacuated as speedily as possible is true,but theconsideration is, how far it can be done with safety. Now, I beg your attention to this point, as it has not been sufficiently attended to in works on the practice of medicine. Recollect what the anatomical condition of the parts is under such circumstances, and that, in order to get at the mat- ter, you have to pass through a serous cavity. It is obvious that if you make an incisioninto the tumour through the peritoneum, and if this be in a state of health, and without any adhesions between its layers in the situation of your incision, you run the risk of having the contents of the abscess effused into the peritoneal sac, and you know that this is almost of necessity fatal. The condition, then, for success is, the circumstance of adhesion taking place so as to prevent the matter from getting into the peritoneum. Well, it seems to be a very simple thing to give exit to the matter of an hepatic abscess which presents a distinct pointing. Persons will say, adhesion has formed long since, the integuments are swollen and painful, the matter has crossed the peritoneum and lies close under the skin. Here, however, is a curious fact; of all the serous membranes in the body the peritoneum is that which is least liable to general or partial adhesions, and it is well known, with respect to hepatitis wilh suppuration, that you may often have abscess so large as to form a distinct tumour on the surface, which shall be fluctuating, discoloured, and painful, and with all these conditions, so favourable to the notion of matter being actually under the skin, the patient dies, and on dissection we find not the slightest trace of adhesion. If you plunge a trocar or abscess-lancet into the tumour, what would be the consequence? — death by peritonitis. Dr. Graves and I, in our report of the cases of hepatic abscess which occurred in the Meath Hospital, were the first who drew the attention of the profession to this interesting pathological fact, and subsequently to this, Mr. An- nesly, who has vast experience in hepatic abscess, states that in his practice he found that the existence of adhesion between the layers of the peritoneum in the vicinity of the abscess, even after swelling, tenderness, and discoloration of the integuments, is by no means a necessary consequence. 538 DISEASES OF THE BILIARY APPARATUS. It appears, then, to be quite certain, that the opening of an hepatic abscess is a matter of considerable nicety, and requiring a great deal of caution. The best mode of proceeding which can be adopted is, in my opinion, that which has been recommended by Dr. Graves, and which is founded on the most accurate pathological views. He makes an incision through the integuments, over the most prominent part of the tumour, and carries it through the cellular substance, fat, and muscular tissue, until the peritoneum is nearly laid bare, and there he stops. The wound is then kept open by plugging it up with lint, and after some time the abscess bursts in this situation wilh per- fect safety to the patient. This operation was performed, under his direction, for the first time, in a case of abscess where there was no distinct pointing. It was the first operation of the kind, and every one who witnessed it waited with anxiety for the result. Five or six days passed away without any appearance of matter; but about this period the abscess began to point, shortly afterwards there was a large gush of matter through the wound, and the patient recovered perfectly in three weeks. Since that time the operation has been performed on two patients with success and safety. In the case of one patient it was performed twice at no very considerable interval. Now, I believe you are all aware that in cases of deep-seated col- lections of pus, it is of the greatest importance to remove the obstruc- tion to its exit Qxternally, and that matter will always point towards the place where there is the least resistance. The performance of this operation not only tends to remove the resistance, but also has this advantage, that the existence of irritation in the neighbourhood of the abscess, and immediately over the peritoneum, has a strong tendency to produce adhesion at this point; a circumstance vvhich I was able to verify in a fatal case, in which the abscess had pointed, but never burst. In this case we found on dissection six or seven small tumours near the surface of the liver, without any traces of adhesive inflammation in the peritoneum over them, but over the situation of the tumour, in the direction of which the incision had been made, there was a considerable quantity of organized lymph, and the two layers of the peritoneum were closely adherent. That this effusion of lymph had not been accidental, is rendered probable by the rarity of its occurrence, from not being observed in other cases in which an operation had not been performed, and lastly, from the success of the operation in those cases in which it had been employed. I would advise you, therefore, in all cases of hepatic abscess showing a tendency to point, but particularly if this pointing be distinctly to- wards the surface, to make an incision down to the peritoneum, fill up the wound with lint, and you will often succeed in causing the abscess to break externally, and without any danger to your patient. With respect to the bursting of an hepatic abscess into the cavity of the peritoneum, I have stated before to you, that it is almost neces- sarily fatal. I say almost, because I have seen two cases of this termination, of which one recovered completely from the peritonitis, and the other lived eight or nine days after the discharge of matter into the peritoneum, and on dissection it was found that a process of cure had been going on. The first of these cases was that of a youn« CHRONIC HEPATITIS. 539 woman who had a vast chronic abscess. An attempt was made to make this opening externally, by destroying the soft parts over it with caustic, but this not succeeding, a lancet was introduced through the eschar made by the caustic. The patient was immediately after- wards attacked with severe pain in the abdomen, and distinct symp- toms of peritonitis. As she was very weak and emaciated, Dr. Graves, under whose care she was, gave her opium in full and re- peated doses, allowing her the free use of wine and porter ; no blood was drawn, no depleting measures of any kind used, but everything done to support strength and relieve irritation. Under these circum- stances (wonderful to relate) she recovered from the peritonitis. She afterwards sunk from the abscess, and on dissection we found that the peritoneal cavity was obliterated, just as the serous investment of ihe testicle has its opposed surfaces glued together after an operation for the radical cure of hydrocele. In the other case, the patient lived eight or nine days after the occurrence of symptoms of peritoneal inflammation. On dissection, we found a large quantity of transpa- rent lymph effused on the surface of the peritoneum, in the substance of which several large bloodvessels had been developed. The principles of treatment in a case of this dreadful accident is to support strength and remove irritation, laying aside all antiphlo- gistics. I am sure that, under such circumstances, the ordinary modes of treating peritonitis are inapplicable and useless. As I shall return to this subject when I come to speak of peritonitis, I shall here merely state, that the treatment of such a case as this is to be conducted upon the same principles as peritonitis, produced by rupture of the intes- tine, or a perforating ulcer. Chronic Hepatitis. — Gentlemen, I shall occupy your minds briefly in treating of chronic hepatitis. You will find a full description of ihe symptoms of this disease in almost every book on the practice of medicine, and it is unnecessary for me to detain you with details of this kind. If we are to judge from British practice, chronic hepatitis is a very common disease, and, if we look to the practice, it is an affection under which half the community labour. I believe, indeed, that the chronic form of this disease is much more frequently observed in this country than the acute, but still I think it is anything but a disease of universal prevalence. I shall not, as I said before, take up your time in stating what you will find in any medical work ; I shall merely mention that in chronic hepatitis we have generally derangement of the bowels, chiefly affect- ing the stomach and upper part of the digestive tube, and in addition to this we have more or less pain, tenderness, and swelling in the region of the liver, and often dulness of sound over the lower part of the right side. When we meet with this train of phenomena, we say that the patient has the symptoms of chronic hepatitis. But no one under such circumstances could undertake to say whether the patient will die of hypertrophy or atrophy, of cancer or hydatids, of tuber- cles, or of fatty discharge, or of any peculiar disease of the liver. There is another point, too, of which I am anxious you should be aware. Chronic hepatitis is a disease which has been, and is, fre- quently, confounded with various other affections; — with scirrhus 540 DISEASES OF THE BILIARY APPARATUS. of the pylorus, with chronic disease of the duodenum, with chronic disease of the pleura, and empyema of the right side. There is one circumstance which you should bear in mind when you are in doubt with respect to a chronic hepatitis, that one, two, or three of these affections may occur in connection with chronic inflammation of the liver. For instance, a patient labouring under chronic hepatitis may have also at the same time empyema and disease of the duodenum. I believe the subject of disease produced, as it is said, by contiguity in separate organs, has not as yel been sufficiently investigated, and that our knowledge on this important point is extremely scanty. There are two circumstances connected wilh this part of the sub- ject, on which I shall say a "ew words. One common error is that of confounding affections of the heart wilh those of the liver, and this I regret to say is an error of very serious consequence, and one which is frequently observed in the consultations of medical practitioners. A patient complains of palpitations, a physician is called in, and pro- nounces the disease to be hypertrophy of the heart; another is called in, and gives it as his opinion that the liver is affected ; a third is summoned, and says that both the liver and heart are diseased. In such cases you should always make a careful examination, and weigh well the circumstances of the case in your mind before you venture to pronounce an opinion. In the first place, you are to recol- lect that organic disease of the heart may produce disease of the liver. Secondly, that disease of the liver (though not so often) frequently brings on morbid affections of the heart and nervous palpitations. Thirdly, that these affections act to one another reciprocally as cause and effect. If a person has disease of the heart, the current of the circulation through that organ is obstructed, and you may have dis- ease of the liver, not as the result of any original affection of that organ, but as the effect of chronic obstruction to the passage of blood through the heart. The consequent congestion and disease of the liver may, in such a case, be reflected on the digestive tube, and this in turn may react on the heart. The heart sympathises then with the irritation of the digestive tube; we have nervous palpitations, and if these continue for a length of time, we have the disease of the heart increased. Again, suppose a patient has chronic disease of the liver, causing more or less obstruction to the circulation ; the heart begins to sympathise, palpitations commence, go on increasing, and finally terminate in hypertrophy of the heart. The mischief does not stop here ; the effects of obstruction extend to the vena cava hepatica, this in turn reacts on the liver, and we have in ibis way a curious train of phenomena ; first liver disease, then heart disease, and lastly, liver disease again. Let me once more impress upon you that, under such circumstances, you cannot be too diligent in making an exami- nation, or too cautious in pronouncing an opinion. There is another thing connected with hepatic disease which you should be aware of. A patient labouring under the following train of symptoms, comes to consult you ; — he has pain in the right hvpo- chondrium, loss of appetite, deranged bowels, morbid stools, a dirty, bilious hue of countenance, and, in fact, all the symptoms of diseased liver. You examine the liver and find it very much tumefied ; in TREATMENT OF CHRONIC HEPATITIS. 541 fact, its size is so much increased that you would at once be inclined lo say that it was extensively diseased. Now, there are some cases of great tumefaction of the liver accompanied with more or less of the symptoms of hepatic derangement, and yet in such cases you may have no disease of the liver at all, at least none of the ordinary forms of hepatitis: these are cases in which there exists, in adults, a per- sistence of the embryonary condition of the liver. If we compare the condition of this organ in the infant and in the adult, we find many essential points of difference. In the infant it is comparatively large, and, as it were, hypertrophied ; it descends far below the margin of the ribs, and occupies a large portion of the abdominal cavity. On the other hand, if we examine its state in the adult, we find that it has shrunk beneath the short ribs, and that its size and dimensions are comparatively much reduced. Now, this physiological atrophy of the liver is a natural and healthy process. There are certain indi- viduals, however, in whom this change does not take place, and who grow up with the liver bearing the same proportion to the other organs as it did in the foetal condition. This curious condition is one of the varieties of arrest of development, and is, in almost every instance, observed in those persons whose constitutions present that train of phenomena to which the term scrofula has been applied, and which (if I have time) I shall show you is explained, or at least great light is thrown upon it, by the theory of arrest of development. In such subjects the tumefaction of the liver is by no means a measure of actually existing disease. If you were to suppose this tumefaction of the liver to be the product of actual recent disease, and proceed to treat the patient in the same way as you would treat a case of hepa- titis in the healthy subject, you would not only do no good, but, in all probability, a great deal of mischief. I know the case of a gen- tleman, in the enjoyment of good health, who has this tumefaction of the liver to a very great degree. He is of a thin, spare habit of body, with a full, round, and prominent belly ; he is pursuing the avocations of an active profession, and yet you will hardly credit me when I say that his liver extends below the umbilicus, and close to the ante- rior superior spine of the ileum; yet he is very active, and to all appearance a healthy man. You will often meet with this condition of the liver in children who are attacked at an early age with symp- toms of tabes mesenterica. At the next lecture I hope I shall be able to finish diseases of the liver, and proceed to the consideration of other affections of the system. LECTURE LVIII. Treatment of Chronic Hepatitis.—Neuralgia of the liver succeeding hepatitis- Connection of hepatic with gastro-intestinal disease—Modes of transmission of disease from the mucous surface of the liver—Phlebitis of the vena porta—Ob- struction of this vein—Case of pulmonary, hepatic, and intestinal fistulse—Hepa- tic neuralgia. We now come to the consideration of the treatment of chronic hepatitis. It is of great importance, in a case of this kind, to place vor.. i —16 542 DISEASES OF THE BILIARY APPARATUS. your patient under such circumstances as will insure the full and favourable action of the remedies employed. The use of wine, spirits, and all kinds of exciting food, must be laid aside ; the patient must not use anything capable of producing fever during the process of digestion. So long as any kind of food or drink produces uneasi- ness and sensations of heat and fulness, you may be sure that it will do more harm than good. Give him what will support his strength without exciting the vascular or nervous systems during the process of digestion. You must next prevail on your patient to give up the use of active purgatives by the mouth. This is a point which you should strongly and firmly insist upon, as in consequence of the ordinary costive state of the bowels which accompanies chronic inflammation of the liver, the patient is generally in the habit of having recourse to those temporary and hurtful remedies. It is the same thing in cases of chronic hepatitis as it is in chronic gastritis; you will find the subjects of these diseases taking different purgatives every day. Break your patient of this practice, if possible ; you will have some difficulty in doing so, for he has been long habituated to it, and you must exercise all your authority in putting a stop to the pernicious habit. Instead of purgatives by the mouth, make him use every day an emollient injection. You may, if necessary, give occasion- ally mild laxatives by the mouth, as Rochelle salts, manna, castor oil, or something equally mild; and in this way you will be able to secure a regular alvine discharge, once in the twenty-four hours at least. But where there is considerable pain and tenderness in the region of the liver, this plan alone will not be sufficient; you must apply relays of leeches, a practice which has a most admirable effect in chronic hepatitis. I would advise you to apply cupping. glasses over the leech-bites; by doing this, you get as much blood as you wish, and you will generally save your patient from the annoyance of an oozing hemorrhage. When piles exist, it will be useful to apply leeches to the anus, followed by the hip-bath. But I have no hesitation in saying, that, as a general mode of relieving hepatic disease, the application of leeches to the right hypochondrium is far preferable in every point of view. You may, in the next place, have recourse to blisters; and I have frequently employed blisters, alternately with leeches, with the best results. Tartar emetic oint- ment, in the form which I have already mentioned, croton oil fric- tions, and other modes of counter-irritation, will assist materially in bringing about a successful termination. But these must be continued long, and used over an extensive surface. In this way, by regulating your patient's diet, keeping his bowels open by enemata, or the mildest laxatives, by small and repeated local bleeding, with counter-irritation, you will frequently succeed in removing all the symptoms of chronic hepatitis without the use of mercury. But if, after having carefully employed all these measures, the symptoms manifest a degree of persistence, if your patient has not already taken a large quantity of mercury (which is not likely to be the case in this country), and if he be not of a scrofulous habit, I see no reason why you should not have recourse TREATMENT OF CHRONIC HEPATITIS. 543 to mild doses of mercury. For this purpose, nothing answers better than to prescribe, once or twice a day, a pill composed of hydrarg. c. creta, blue pill, or a small quantity of calomel, combined with rhubarb, extract of hyosciamus, and taraxacum. It will be seldom necessary to bring on actual salivation; but if the pain continues to be severe, the swelling undiminished, the symptoms obstinate, and no contra-indication existing, you may bring him under the influence of mercury, and keep him so for a short time. The best mode of doing this is to direct him to rub in a drachm of the camphorated mer- curial ointment every day; and if you have employed blisters, you can assist the frictions by dressing the blistered surface with mer- curial ointment. Some practitioners are in the habit of substituting the nitro-mu- riatic acid for the mercurial treatment, and there appears to be evi- dence that it is an advantageous mode of practice in these cases. The best mode of using this remedy seems to be the endermic; and hence, bathing the feet, or sponging the right hypochondrium with the acid, are most recommended in chronic affections of the liver. As it is convenient to have a formula for making the nitro-muriatic solution, I shall give you the following : — Take of strong nitric and muriatic acids of each four ounces, and add to these eight ounces of pure water. Here you have a sixteen-ounce mixture; of this com- bination you may take from two to five ounces, and mix them with three gallons of warm water. This, I believe, is the form recom- mended by Mr. Annesly. Having placed this solution in a foot- bath or tub, you should direct your patient to keep his feet in it for twenty minutes or half an hour. If the bath be of proper strength, it will communicate to the skin a prickling sensation; if not, you may increase its strength by adding an ounce or two more of your mixture. The same solution will answer for sponging over the liver. There is no doubt that, in certain cases of chronic hepatitis, this remedy has been found decidedly useful, and as its employment is unattended with any dangerous or disagreeable consequences, it has strong claims to our notice. The cases of chronic hepatitis to which it seems to be peculiarly adapted, are, first, those where mercury has been used irregularly, or for a long time without any benefit; and, secondly, where the patient is of a broken down constitution, and where you are anxious to dispense with the use of mercury, if possible. Here the nitro-muriatic treatment is of decided value. I need scarcely remark to you, that this acid frequently acts upon the system somewhat like mercury, producing tenderness of the gums and ptyalism. Such an effect as this, furnishes us with an ex- ample of these cases, in vvhich we find other remedies, as well as mercury, producing a decided effect on the salivary glands, and exercising a very powerful influence over hepatic and syphilitic affections. An interesting fact, bearing on this point, is related by Mr. Cox, in his account of his residence on the Columbia river. Several of his party, who used a strong decoction of the fresh sarsa* parilla, was salivated. There is one circumstance, connected with the treatment of 544 DISEASES OF THE BILIARY APPARATUS. chronic hepatitis, which I believe has not been sufficiently dwelt on. \ou may have a case in which there was distinct evidence of chronic inflammation, and where, under the influence of judicious treat- ment, the signs of inflammation and organic derangements subsided, but where severe pain still continues to be felt in the region of the liver. The nature of this pain is often mistaken ; it is supposed to depend upon a continuance of inflammation, while it is, in reality, nothing more than a mere neuralgic affection — a remnant or suc- cessor of the former disease, to which the antiphlogistic treatment is totally inapplicable. Under such circumstances, the patient goes from one practitioner to another, taking different medicines, and sub- mitting to repetitions of the usual modes of treatment, but with little or no benefit. Now, I have seen, in several cases, this symptom yield completely to treatment calculated to remove purely neuralgic affec- tions. In a case lately under my care, of a gentleman who had been attacked with enteritis and hepatitis in India, and who had taken enormous doses of calomel " for the liver," and of croton oil " for the bowels," this circumstance occurred. When first I saw him, he was emaciated, the skin yellow, the urine high-coloured, with thirst, cos- tive bowels, and great tumefaction in the region of the liver. These symptoms completely subsided under treatment, but a violent pain, running at intervals, continued obstinate. This was rapidly re- moved by a course of the carbonate of iron, and the use of the bella- donna plaster. It is of great importance, in the treatment of chronic hepatitis, to bear in mind the state of the gastro-intestinal mucous membrane. You are aware that the disciples of Broussais are of opinion that almost all cases of hepatic inflammation are secondary to a gastro- enteritis ; that the first morbid action is on the surface of the intes- tinal tube, and that it is transmitted from this to the liver. I have taken a considerable share of pains in investigating this subject, and have examined very carefully the question as to the complication of hepatic inflammation with disease of the gastro-intestinal surface, and the conclusions to which I have come, are the following : — In the first place, that most cases, whether of acute or chronic inflam- mation of the liver, present the complication, more or less, with dis- ease of the intestinal mucous surface, and that in the majority of in- stances there is some degree of actual disease of the digestive tube. It would appear, also, from observation of different cases of hepatitis, that in a great many the affection of the liver has been secondary, and that symptoms of disease of the digestive tube have preceded those of hepatic irritation. But, on the other hand, we must admit that the hepatic affection may be primary ; that the liver has the initiative, and that disease has been subsequently propagated to the gastro-intestinal mucous surface. Lastly, we may have hepatitis, both acute and chronic, quite independent of any disease of the mu- cous coat of the stomach and bowels. This, I believe, is the rarest case; still it does occur. You observe, therefore,that the doctrine of the physiological school, that all hepatic inflammations are se- condary to a gastro-enteritis, is not supported by the authority of facts. It is therefore wrong to say that every case of acute or TREATMENT OF CHRONIC HEPATITIS. 545 chronic hepatitis is preceded by gastro-intestinal inflammation. Facts have been brought forward to show that not only has inflam- mation of the liver been observed in the simple state, and inde- pendent of any complication with intestinal disease, but that the affection of the liver has distinctly preceded the symptom of gastro- enteric disease. On the other hand, however, I am free to admit that these are the exceptions rather than the rule, and that, in the majority of cases, hepatitis is either secondary or complicated with disease of the gastro-intestinal surface. Now, a very interesting question comes to be considered, and this is, how does the disease come from the gastro-intestinal surface to the liver ? Pathology informs us that irritation may be transmitted from one organ to another in three different modes. First, sympathetically, as through the medium of the nerves. Thus, long-continued stimula- tion of the stomach is reflected upon the liver, the liver sympathises with the suffering organ in its vicinity, and finally becomes diseased itself. It is in this way that many chronic affections of the liver and stomach terminate in affections of the neighbouring viscera and dropsy. The first mode, then, in which disease may come to affect the liver from the gastro-intestinal surface, is by sympathetic irrita- tion. The next mode is supposed to be the actual transmission of disease along the biliary duct from the duodenum to the liver. In- flammation commences in the duodenum; this creeps along the ducts until it reaches the liver, which takes on the inflammatory action in its turn. Several persons of high authority have supported this view of the question, and assert that they can actually demon- strate the passage of inflammation along the ducts. Without denying the possibility of this, yet I feel convinced that it is rare. I have never been able tp discover this mode of propagation of inflammation from the duodenum to the liver; and it must be remembered that, in the great majority of cases of duodenitis, we cannot detect inflam- mation in the liver or its appendages. The last mode by which dis- ease may be transmitted, is the propagation of inflammation along the course of the veins belonging to the portal system, that is to say, there is phlebitis of the portal system, and the inflammation travels along the veins until it arrives and attacks the liver. That this has occurred, is proved. But we may suppose that, in certain cases, disease of the liver may result from a phlebitis of the minute me- senteric veins, without a continuous spread of inflammation to the larger trunks; just as the lung is affected in cases of phlebitis of the extremities, not by actual spread of inflammation, but rather, as Mr. Arnott has shown, by the transmission of the products of that inflammation. Inflammation of the portal veins is a circumstance which possesses great interest in a pathological and practical point of view ; it is a curious process, and there are some singularities connected with it which have a claim on our attention. In the Clinique Medicate of Andral, there is a case given of a patient who, after labouring for some ti ne under symptoms of fever and gastro-enteritis, was attacked with pain and tension in the region of the liver, followed by jaundice. On dissection, marks of inflammation were found in the stomach and 46* 546 DISEASES OF THE BILIARY APPARATUS. ileum ; there was also some disease in the colon, and the liver was found to be enlarged, and presenting the ordinary marks of inflam- matory action. On a more minute examination, nearly all the me- senteric veins, and the trunk of the porta, were discovered to be in a state of intense inflammation ; wdiile, on the other hand, ihe lining membrane of the vena cava was found to be in its normal and healthy condition. Here we have a very remarkable coincidence between disease of the liver and of the portal system. First, the patient had fever, with gastro-enteric inflammation, and then pain and tension in the region of the liver, followed by jaundice. On dissection, the me- senteric veins and the trunk of the porta are found inflamed; this condition extends to the liver, the substance of which is found tume- fied, red, and friable. I believe there can be no doubt that disease of the liver may be brought on by disease of the abdominal veins, par- ticularly those of the portal system. It is a very curious fact, that with symptoms such as many practitioners would not hesitate to call chronic hepatitis, we may have phlebitis, terminating in obliteration of the porta, and even of the vena cava. In such cases, nature gene- rally makes an effort to keep up the venous circulation; in conse- quence of the obliteration of the internal abdominal veins, the external ones become enlarged, and produce a supplementary circulation to a certain extent, and in this way life is prolonged. This drawing, which represents the appearance of a patient labouring under this form of disease, will give you some idea of the matter. You observe the patient's belly is enlarged and prominent, his extremities cedema- tous ; and here you see those enormous veins passing along the sur- face of the belly, and keeping up a collateral venous circulation. In the patient, from whom this drawing was taken, the porta and cava were obliterated. These are the epigastric and other superficial abdominal veins which ascend to anastomose wilh the thoracic, in- tercostal, and axillary veins. I shall now relate, as briefly as possible, the particulars of this very remarkable case. The patient, who was the subject of it, laboured for more than twelve months under jaundice, accompanied by wasting of flesh, and prostration of strength, but for the first eight months he had not been confined to bed. He suffered, how- ever, very considerably, even at this period, from constant pain in the epigastrium, and swelling of his feet. Now, in this country, we would be very apt, under such circumstances, to say that he was labouring under chronic hepatitis. At the end of the eight months he became bedridden, and the large veins, vvhich you here see, began to make their appearance. Although he was wasting in flesh, still he had a canine appetite, and was always complaining that he had not enough to eat. This is an interesting fact. It has been observed in other cases, and tends to throw some light on the share the mesenteric and other abdominal veins have in the process of absorption. In tabes mesenterica it has been often remarked, that the little patients have generally enormous appetites ; and, as it would appear from the same cause, a deficiency of nutritious absorption, wilh this difference merely, that in the disease before us it is the veins that are d seased, whereas in tabes mesenterica it is supposed to be TREATMENT OF CHRONIC HEPATITIS. 547 the lymphatics. But to return to our case. This patient had, as I remarked, a very voracious appetite, by indulging which, he brought on repeated attacks of constipation and colic. He then got diarrhcea and dropsy, for which he was tapped twice without any benefit. From observing that there was in this case an extraordinary supple- mental circulation, leading to the inference that there was obstruction of the deep-seated veins; from remembering that the appearance of the patient, and the more prominent symptoms, coincided with those of a former case, in which obliteration of the porta had been dis- covered after death; from these circumstances, and the remarkable voracious appetite, M. Reynaud, under whose care the patient was, came to the diagnosis of phlebitis of the portal system, extending to and affecting the liver; and this diagnosis was subsequently confirmed by dissection. He was, however, unable before death to explain one symptom which was present, namely, infiltration of the lower extremities. You are aware, that when the general venous circula- tion is obstructed either in the chest or belly, we have anasarca of the lower extremities, but when the obstruction affects only the portal system, then we have ascites as the first phenomena. If you had two cases of dropsical effusion, in one of which there was,first, oedema of the lower extremities, in the other, first, ascites, you could thus determine where the primary obstruction existed. M. Reynaud was at a loss to account for this symptom in the present case, as he had not observed it before in the other case, and as the swelling of the feet had preceded that of the belly. On dissection, it was found that the right branch of the porta had been obliterated by the growth of a yellow substance, somewhat like the middle coat of arteries ; the same was found to exist in the corresponding hepatic veins, and the inferior cava was found obliterated to the distance of three inches from the left auricle. The left branch of the porta was pervious, the corresponding hepatic veins much enlarged, and the superficial epigastric veins inosculated freely wilh the intercostal and axillary veins. The vena azygos was very much dilated; and, what is extremely curious, a large vein was seen to arise from the union of the sub- peritoneal branches on the convex surface of the liver; this passed through the diaphragm, and emptied itself into the cava close to its termination. Here we have an entirely new vein. It was also ob- served, that the sub-diaphragmatic veins were much increased in size, and apparently varicose ; these passed through the diaphragm, and inosculated with the pericardial and superficial thoracic veins. Some of them ran up and opened into the great coronary vein of the heart, which was as large as the crural vein. The remaining pecu- liarities of this curious case were inflammation of the duodenum and gall-bladder. The cavity of the latter was half filled with purulent fluid. 1 am fully convinced that I have seen instances of this disease, although I was not so fortunate as to have an opportunity of verify- ing the diagnosis by dissection. I have seen patients who had wasting of flush, pain and tension in the region of the liver, and jaun- dice, with this singularly varicose state of the external abdominal 548 DISEASES OF THE BILIARY APPARATUS. veins; some of them had ascites; and I recollect distinctly that in one case the appetite was very great, and the patient had a tendency to diarrhcea. lam satisfied that in such cases you would be fully justified in making the diagnosis of obstruction of the portal system; and if, in addition, there was infiltration of the lower extremities, there would be a probability that the disease had extended to the cava itself. Hepatic Neuralgia. — Before I proceed to the consideration of a subject to which I have already alluded — hepatic neuralgia — it may not be amiss to exhibit some specimens of organic lesions of the liver. Here is an example of abscess of the liver : — you perceive the softened yellow degeneration of the substance of the organ ; and here is the cavity of the abscess, in which you may observe a loose slough suspended. This portion Which surrounds the abscess may be looked upon as a fair specimen of the yellow softening of the liver, before its substance breaks down into a purulent mass. Here is an- other specimen exhibiting the same phenomena. Here is a very curious example of hepatic abscess, vvhich perforated the diaphragm, and made its way into the substance of the lung. I regret that the whole of this preparation has not been preserved. The rest of the preparations before me illustrate chronic disease of the liver. Here is an example of the disease which has been called cancer of the liver. Time will not permit me to enter into a detail of the pathological circumstances of this case. The patient was a female, who had cancer of the breast, scirrhus of the pylorus, and aneurism of the aorta, with this disease disseminated through the substance of the liver. Here is another preparation of what would be called by many per- sons pure cancer; the patient, a female, had cancer of the mamma. This, and the preparation on the other side, exhibiting a mass of white, firm, semi-cartilaginous substances, are examples of what has been called tubercle of the liver. Here is an example of the disease which has been termed whiskey liver, a disease which is said to be ordinarily found in peTsons who indulge in the use of ardent spirits. This, however, is a term vvhich has been often abused and misap- plied ; for persons indulging in the use of whiskey may have every form of disease of the liver, and the appearance before you may be detected in the livers of persons of the most temperate habits. On the label of this preparation is written —" A Specimen of Whiskey Liver," but this you will not mind. There is a very remarkable fact, however, respecting this kind of liver, verified by Professor Carsvvell, namely, that this condition of the liver is always accom- panied with more or less ascites. I may add, that I have never met with this disease without ascites. I remember a most remarkable case of disease of the liver, which occurred during my stay in Edinburgh. My lamented friend and instructor, the late Dr. William Cullen, whose loss to pathological medicine was irreparable, and whose splendid attainments and high character justly and rapidly raised him to an elevated rank in his profession, brought me to see a patient. One of the most curious circumstances connected with this case was, that when the patient sat up in bed, a fluid of a serous character was poured out in consi- NEURALGIA OF THE LIVER. 549 derable quantity from the anus; but while he remained in the hori- zontal posture this did not occur. The patient died shortly after- wards ; and, on dissection, it was found that be had a gangrenous abscess of the right lung, communicating with the pleural cavity, which contained a quantity of sero-purulent fluid, and a mass of hy- datids, some broken down, others perfect and entire. On continuing the dissection, it was found that the cavity of the pleura communi- cated with the right lobe of the liver through the diaphragm. In the right lobe of the liver the same kind of sero-purulent fluid, and a quantity of hydatids, were discovered ; and, what was still more extra- ordinary, the cavity of the liver was found to communicate with the colon by a distinct opening. There was, then, in this very remark- able case, a direct communication between the bronchial tubes and the colon, through the pleura and liver. We can thus see that, when the patient assumed the erect position, the fluid would immediately pour into the colon. As I am anxious to finish the subject of hepatic disease to-day. I shall now draw your attention to one of the last points Connected with this subject, namely — neuralgia of the liver. It is a singular fact, that a patient may labour under severe and harassing pain in the region of the liver ; that this pain may last for months and years ; that he mav die of some other affection; and that, on examination after death," we may find the liver without the slightest trace of dis- organization; and, also, that the organs in its vicinity present no ap- pearance of any organic disease. Many cases of this kind have been observed ; and it is the opinion of the best pathologists that they are examples of neuralgia, the seat of pain being the hepatic plexus. It is a disease of no very unusual occurrence, and is often found in females of a nervous and hysteric habit. It is constantly mistaken for hepatitis, and there is no greater mistake than this, or one which is likely to entail more misery on the patient. The persons who are subject to this affection are, as I remarked before, generally of a ner- vous and hysteric habit; they complain of pain in the right side, of more or less constant occurrence ; and this pain, during its exacer- bations, is often most excruciating. Now, this circumstance furnishes us with a sort of key to diagnosis ; for with this dreadful pain, and, in some cases,exquisite tenderness in the region of the liver, we have the skin cool, the pulse tranquil, no fever, no permanent derangement of the bowels, no tumefaction of the liver. If this were the pain of acute inflammatory disease, a fatal result would be produced ; or if it belonged to a chronic affection, it would terminate in organic de- rangement ; and yet we find it existing with a clear colour of the skin and eve, healthy feces, calm pulse, and absence of swelling in the re- gion of the liver. Add to this, that the disease may have lasted for a considerable time, and that it occurs in a person of hysteric and ner- vous habit. Moreover, if the patient has been treated for hepatitis unsuccessfully, you may make up your mind to the diagnosis of he- patic neuralgia. Here is the diagnosis ; pain in the region of the liver, with occasional violent exacerbations, and accompanied by tenderness of the integuments, but without swelling, symptoms of fever,or abdominal derangement; the disease being of longstanding 550 DISEASES OF THE BILIARY APPARATUS. in a person of nervous habit, and having resisted bleeding, mercury, and even counter-irritation, or being made worse by those measures. Now, it is no uncommon thing to see this disease mistaken for acute hepatitis ; and I need not tell you how ruinous to the patient's health such an error must be. When you are in practice, you will meet instances of females labouring under this affection, who have gone through a variety of treatment. When you recollect that the disease occurs generally in hysteric females, and that such persons are injured by depletion, you can conceive how much mischief may be done by repeated bleedings and courses of mercury. Some of the most deplorable cases I have witnessed, were those in vvhich neu- ralgia of the liver had been mistaken for hepatic inflammation, by a number of practitioners, and the patient subjected to such modes of treatment as gave her constitution a shock from which it never recovered.* The treatment of this disease must be both general and local, but by no means what you would call antiphlogistic. You will have some difficulty in preventing the patient from getting herself blooded ; for though the lancet is inadmissible, yet its employment gives a temporary relief, and this encourages the patient to have recourse to it again. What I would advise you to do in this disease is, first to pay attention to the general condition of the patient. You must pursue a general anti-hysterical plan of treatment, remove every source of irritation and excitement, and take measures to improve the general health by exercise, regimen, moral improvement, and the judicious employment of tonic medicines. With respect to the pain, one of the most powerful means of arresting and removing it appears to be the use of the carbonate of iron in full doses; and this is an interesting circumstance, when we recollect the power which it possesses in removing pain in other nervous diseases. I would advise you to try this after having premised the use of purgatives, and continue it for some time, for you will often find that it will not * [The pain being limited to one side, and its being increased by pressure, may strengthen the suspicion of the liver being the organ affected ; but we shall generally discover, with a little care, that the tenderness is more muscular and cutaneous than hepatic—the patient often shrinking from the first application of the physician's hand to the side. We can also commonly trace the pain and tenderness from one or two of the vertebrae over the muscles on to the hypochondriac region, but more above the margin of the ribs and external to them than below and inwardly. The practice which I find most useful in this variety of simulated hepatitis, or hepatalgia, is to apply about twenty or thirty leeches near the sensitive vertebras, and afterwards to produce counter-irritation with a small blister, or the tartar emetie ointment or croton oil; to act on the bowels by the blue mass and aloes, and then to administer five grains of sulphate of quinia daily for a week or a fortnight, as the symptoms, and the occurrence of damp and rainy weather, may seem to require. Afterwards, if the neuralgic symptoms return, the sub-carbonate of iron should be given, as directed in the text. — B.] DISEASES OF THE PANCREAS. 551 only cure the pain, but also improve your patient's strength and ap- petite. While you are giving it, order your patient to take some mild purgative, as compound rhubarb pill, to prevent constipation. When you are about to prescribe a course of carbonate of iron, you should prepare your patient to find the stools coloured. I have known this circumstance taken hold of and turned to their own advantage by quacks. The patient is told that his complaints arise from the existence of morbid and dark-coloured matters in his bowels. Pre- parations of iron are given, and the black matter begins to come away, greatly to the credit of the empiric. After a time the medi- cine is omitted, and some purgative substituted; the stools become natural, and the trick is complete. During the paroxysms of pain, a mustard plaster, or anodyne stupes, and anodyne enemata, will give relief; and, in the intervals, I would advise you to use the belladonna plaster, after the following formula : — Take of extract of belladonna three parts, of gum ammoniac and soap plaster each one part; spread these on a piece of leather with an adhesive margin, and make the patient wear it over the region of the liver. If there be any tender- ness over the lower dorsal vertebrae, you may apply a few leeches, followed by narcotic stupes, or counter-irritation. I have seen this hepatic neuralgia without any hysteric complica- tion. I remember the case of a lady who had three or four healthy children, and had never been subject to hysteria. This lady came up to Dublin to be treated for liver disease — in fact, to be salivated; but happening to fall into the hands of a judicious friend of mine, who recognised the true nature of her complaint, she was treated with carbonate of iron, and cured effectually. I knew another case of a young gentleman, in whom (after being treated for symptoms of chronic hepatitis) this pain continued for a considerable time, and was at length removed by carbonate of iron, and the use of the bella- donna plaster. LECTURE LIX. DR. BELL. DISEASES OF THE PANCREAS AND SPLEEN — CHLOROSIS. Pancreas—Its pathological states not well appreciated — Symptoms of inflamma- tion of the pancreas — Few positively diagnostic ones — Post-mortem appear- ances of the organ — its morbid secretions — Connection of these with pyrosis__ Diagnosis.— Treatment — Moderately depleting remedies, with opiates and nar- cotics, and counter-irritants.—Diseases of the Spleen. Connection between the spleen and the liver, and stomach, and bowels — Community of affection with these organs in paludal fevers —Organic lesions of the spleen and their sympathetic disturbances — Exploration of the spleen —Its situation and size.__ Splenitis. Obscurity of its symptoms — Enlargement—Characters of the tumour — Structural changes. — Chronic Splenitis. Symptoms equivocal__Ter- minations of inflamed spleen — suppuration — softening — congestion — Sympa- thetic disorders from splenitis. The size, vascular supply, and secretory function of the pancreas, and the part which its fluid performs in the assimilation of food, entitle this gland to the notice of the physiologist; and, reasoning from all 552 DISEASES OF THE PANCREAS. the analogies of other organs, they would lead us to suppose that ita pathological changes must be of some importance, certainly not unat- tended by various sympathetic disturbances. As yet, however, little can be said in the way of accurate diagnosis of the diseases of the pancreas, and, of a consequence, of their treatment. The symptoms which, according to M. Mondiere and a few other writers who have made the subject their special study, characterise inflammation of the pancreas, are diarrhcea, the discharges in which, at'first bilious and watery, soon resemble saliva ; epigastric pain, at first obtuse, afterwards pungent, and accompanied by cough and dyspnoea. The pain is fixed and deep-seated, increased by fulness of the stomach and strong inspiration, and by pressure on the stomach, particularly the pyloric region; sometimes it prevents the patient from sleeping on the back or on the left side. A febrile state of more or less distinctness accompanies these symptoms. There is, often, also present at the same time, with thirst, a sense of heat in the throat, pyrosis, and gastralgia, nausea, and occasionally vomiting of ropy and saline fluids. Constipation alternates with diarrhcea at first, and subsequently predominates. Sometimes, when the pain in the epigastrium is very acute, there is an enlargement of the pancreas; and on pressure a circumscribed and nearly circular tumour may be felt; distinguishable from scirrhus of the organ by its yielding under continued pressure. In some few cases, carefully recorded, and the precise nature of which was well ascertained by post-mortem examination, the leading, if not pathognomonic, symptoms were salivation, vomiting, and diar- rhoea, and afterwards constipation, and tumefaction in the epigastric region, with sometimes jaundice and emaciation. Dr. Pemberton expresses his belief, that deep-seated pain in the stomach, of varying intensity, with sickness and emaciation, are symptoms of diseased pancreas, which are never wanting. Dr. Abercrombie finds recorded twenty-seven cases of chronic disease of the pancreas; six of which were fatal, after gradual wasting and obscure dyspeptic complaints, without any urgent symptom. Frequent vomiiing and more or less pain in the epigastric region accompanied the disease in eight other cases: and in thirteen death was preceded by long continued pain without vomiting. In some of these the pain extended to the back ; and in others it was much increased by taking food. In several, there were dropsical symptoms; and in three or four there was jaun- dice, from the tumour compressing the biliary ducts. In the morbid appearances, also, there was very great variety; the pancreas being in some of the cases much enlarged, in others in a state of scirrhous hardness, with very little enlargement. It does not appear, con- tinues Dr. Abercrombie, that any distinct relation can be traced betwixt the urgency of the symptoms and the degree of enlargement; for this existed in a great degree in some of the cases in which the symptoms were slight and obscure; and there was hardness with little or no enlargement in others, in which the symptoms were de- fined and violent (Pathological and Practical Researches on Diseases of the Stomach, &c, &c). In subjects examined after death, who had suffered from inflamed DISEASES OF THE PANCREAS. 553 pancreas, the gland exhibited some one or more of the following appearances: redness, enlargement, hypertrophy,induration, soften- ing, more vascularity than natural, and, when cut into, drops of blood oozed out from its substance. I shall not occupy your time by a detail of the organic alterations following inflammation, such as suppuration and gangrene, or those other slower changes of cartilagi- nous, fatty, steatomatous, and scirrho-cancerous transformations,—any more than cysts, hydatids, and melanosis. The morbid secretions of the pancreas constitute a more interest- ing topic of investigation. To its excess in this way, Portal was in- clined to attribute most diarrhoeas ; and Wedeking the cceliac flux; whilst Dupuytren thought that the pancreas might supply the fluid discharges in cholera. Inordinate serous discharges occurring in a very short timef as recorded by some authors, are referrible, M. An- dral thinks, to this cause. Passing over the facts related of the cure of dropsy following excessive salivation, without any irritation or in- flammatory action of the salivary glands, we find, as more to the point, a description of others in which this disease (one of anasarca and another of ascites) was entirely removed by abundant and re- peated vomiting of clear watery fluid, unctuous to the touch, and of a saline and disagreeable taste. The vomiting was commonly pre- ceded by uneasiness and a feeling of fulness and swelling at the epigastrium. There are some plausible evidences in favour of our regarding pyrosis as depending on diseased function of the pancreas, the secretion of vvhich at the time is increased, and also morbidly changed. M. Guersent believes that, in all cases in which the teeth are destroyed by corrosion, there is a perverted secretion of the sali- vary glands; and, by analogy, it is inferred that the pancreatic secre- tion may be modified in a similar manner, and give rise to those sensa- tions of extreme acidity and burning of stomach and oesophagus expe- rienced by some patients suffering under pyrosis. The symptoms of this disease would seem to point to the pancreas as its organic origin. Thus, we have eructations with the discharge of a limpid fluid, which some patients have themselves compared to saliva, but which is acrid and almost caustic; forward flexion of the body to allay the pain ; retraction of the abdominal parietes inwards to the spinal column ; constipation and salivation. Iu attempting to specify the causes of pancreatic inflammation, we reason more from analogy than from positive observation ; as, for example, what will interfere with the healthy function of the sali- vary glands and the liver; with the former of which the pancreas is classed, and with the latter of which by a common duct somewhat structurally connected. The diagnosis of diseased pancreas is only to be reached by what our French friends term the way of exclusion ; that is, by ascertaining that the complaints and pain of the patient are not referrible to origi- nal disease of the stomach or concave surface of the liver or gall- bladder, or duodenum, or even of the kidneys. Absence of any of ihese, or of tumid hypochondrium, may induce a reasonable belief of the disease before us depending on some organic lesion of the pan- creas. vol. i.—47 554 DISEASES OF THE PANCREAS. The same remark applies to the treatment of diseases of the pan- creas. When we have reason to believe, after minute investigation and inquiry, that our diagnosis points to inflammation of this gland, we shall not hesitate to have recourse to antiphlogistic measures; among which venesection, cupping on the back, and leeches over the epigastrium, and mild purgatives, preceded occasionally by a dose of calomel, will have a preference. Various antacids, such as magnesia, lime-water, and the alkalies, have been occasionally used to palliate the painful symptoms referred to a morbid secretion of the pancreas, as in pyrosis; but unless with these we associate opium or other narcotics, and preferably hyosciamus, belladonna, or stra- monium, we shall acquire little control over the disease. The moderate use of the blue mass with one or other of these narcotics will be serviceable in chronic pancreatitis. In this sf%ge of disease, counter-irritation might, I think, be advantageously established through the means of moxa, or a seton, or a small blister kept dis- charging on one side of the spine corresponding with the region of the pancreas. More benefit may be anticipated from such applica- tions made to this region than to the epigastrium. Dr. H. W. Carter (Cyclop. Pract. Med.) sensibly observes: — " The plan of old practitioners is not to be depised. When they met with cases in vvhich pain of the stomach or of some neighbour- ing viscus was chiefly complained of, yet no good evidence existed of actual disease of any particular part, they gave an opiate draught at bed-time, and a common laxative in the morning." Diseases of the Spleen. — In taking up the subject of diseases of the spleen at this time, I abandon the natural order which would require my treating, next, in succession, of the diseases of the secretory organs, or at any rate of those of the glandular ones. But it is ex- tremely difficult to follow out any natural order under the guidance either of physiology or general anatomy. The latter would indicate the propriety of treating uninterruptedly of an organic system or tissue in whatever region found; as the mucous, for example. To a cer- tain extent I have done this in the case of the digestive mucous mem- branes; but even here it seemed proper, instead of passing to another division of these, as the respiratory, first to inquire into the morbid states of the glands, which contribute to the function of digestion, viz., the liver and pancreas; the salivary ones having been a subject of observation in connexion with the mucous membranes of the mouth. For a while I shall now deviate from the line both of general ana- tomy and of physiology, and, in acknowledging the force of propin- nuity and some community of general though not of special function Detween the spleen and the stomach and liver, direct your attention to the diseases of this first mentioned organ. The connexion between the liver and spleen is obvious, in the union of the splenic veins with the vena porta; and hence, whatever disturbing causes may prevent the free passage of the blood of the vena porta through the liver, must, to a certain extent, operate on the circulation in the spleen. This organ suffers also in those diseases in which the liver and sto- mach and bowels, are so much and so often implicated, as in palu- dal fevers; and although we cannot tell its functions, we are pretty ORGANIC LESIONS OF THE SPLEEN. 555 well assured that they are in close relation with those of the chylopoietic viscera proper; and hence the propriety of describing its diseases at the same time that these latter are described, rather than under the head of disorders of the circulation, as M. Andral has done in his Pathologie Interne. A knowledge of the organic lesions of the spleen and the sympa- thetic disturbances to which these give rise, is the extent to which our investigations lead us. Of functional disorders of the spleen we can say little, for we know very little of its proper or special functions. Hence it is the more important for us to have clear and precise ideas of the physical character, as far, at least, as size is concerned, and of its physical relations; that is, its contiguity with other organs. Thanks to M. Piorry, this task is made easier by his work on Diagnosis and Semeiology, in which exploration of the spleen is treated in considerable detail. At present, I shall content myself with the well digested summary of his directions and details on this point, in the British and Foreign Medical Review, vol. vi., p. 140-1. " The spleen can only be examined by the touch when it is so much enlarged as to extend beyond the edge of the ribs; so that, of 500 cases in which it was hypertrophied, in only one-fifth was M. P. able to detect its extension into the hypochondriac region. Neither is the absolute size of the organ to be ascertained by this means; for, in some subjects, it forms a considerable projection beyond the ribs when only slightly enlarged, in consequence of not rising high under the diaphragm in the normal state. In other cases, on the contrary, it hardly advances beyond the bounds of the chest when its diameter vertically is 65 inches. In this uncer- tainty of the normal extent of the spleen, percussion offers itself as the only mode of examination that admits of accurate results ; and M. P. somewhat exultingly points to his discoveries respecting the state of this organ in ague, as a touchstone of the superiority of percussion by the pleximeter over that by the fingers, which fails in giving such accurate results. As his discoveries on this point of pathology are quite original, we think the following sketch of his mode of proceeding to detect the state of the spleen will be acceptable to our readers. " First, the extent of the left lung is traced downwards in a direct line from the axilla, till powerful percussion indicates, by a dull sound in place of the clear pulmonary resonance, the presence of the spleen deeply seated beneath the ribs; next, by the same means, is found the point where the spleen is in contact with the abdominal parietes; lastly, these two points being determined, and also the limits of the heart, lung, liver, and kidney, it becomes easy to circumscribe the extent of the spleen in the other directions, except backwards towards the spine : but the difficulty of tracing the organ in that direction may be considerably lessened if the distension of the stomach and colon, by solid, fluid, or gaseous matter is removed pre- vious to the examination. u The healthy proportions of the spleen are as follows:__In its vertical diameter it is from 3£ inches to 3f inches, and, in the 556 DISEASES OF THE SPLEEN. transverse, 3 inches. It is situated some inches to the left of the median line, and rarely ever in health projects beyond the edge of the ribs. Its increase of size in disease is usually proportionate in all its dimensions: hence, in the subjoined account, its vertical dia- meter alone is given. In fifteen cases of pneumonia, it was 4 inches ; in 38 of phthisis, 3£ inches ; in thirty-three of gastro-enteritis, 4£ inches ; several of these cases were attended with rigors, and the spleen was contracted by the use of quinine. In twenty-three cases of hepatitis, it was 3f inches; in 130 agues, 5| inches. In most of these cases, its breadth and thickness were equal to the height. These results, and the observation of above 500 cases of ague, have convinced M. Piorry that the spleen is invariably enlarged (hyper- trophied) or painful in ague; but that, in other diseases, a great in- crease in its size is only observed where periodic febrile attacks have occurred; and this has been confirmed by various observers both in France and Algiers." I the more readily introduce these particulars to guide you in the exploration of the spleen, because its morbid enlargement is quite common in those parts of our extensive country in which paludal fevers prevail; and hence, also, it is very desirable to be able to ascertain the extent of such morbid change, so that you may appre- ciate more accurately the probable sympathetic disturbances which accompany its disorders, and institute a treatment accordingly. The anatomical relations of the spleen to the contiguous viscera, are as follows. It is situated deep in the left hypochondrium below the diaphragm, above the descending colon, between the great curvature of the stomach and the cartilages of the false ribs, before the supra- renal capsule and upper part of the kidney of the left side. The up- per and external surface of the spleen which commonly corresponds with the ninth, tenth, and eleventh ribs, is separated above from the diaphragm by a thin lamina of lung. It is not unfrequently covered almost entirely by a tongue-like projection of the liver. M. Maillot, who, in his Traite Pratique de Percussion, gives a good summary in a small compass of M. Piorry's views and practice, de- scribes the position of the patient who is to be subjected to splenic percussion. He is to be placed on the right side, the left arm with- drawn from the trunk, or better still, he is to lie recumbent on his back, inclining a little over the side of the bed, so as to allow of the more convenient application of the pleximeter. The principal organic changes to which our attention is generally directed in the treatment of diseased spleen, are congestion and in- flammation ; but even these, although of undoubted and indeed quite frequent occurrence, are not easily ascertained by diagnostic symp- toms. Acute splenitis, or inflammation of the spleen, is most com- monly brought on by external injuries, and is rarely an idiopathic disease. It may supervene on congestion of the organ, and when this latter state of predisposition exists, a slight bruise, or other vio- lence, will suffice to develop it. Rupture of the spleen is generally the result of external, and, at times, inconsiderable violence ; but it is met with also in congestive fevers of a malignant grade. Splenitis of an acute character would, we might suppose, furnish ACUTE SPLENITIS. 557 us with an order of symptoms similar to those of other inflamed vis- cera ; one of the most distinctive of which is pain in the part affected : but this is not always present in every case of unquestionable phlogo- sis, of either the abdominal or thoracic viscera, and in the case of that of the spleen it is rarely met with. I speak now of pain apart from tenderness on motion or pressure, which last is considerable in sple- nitis. The symptoms laid down by Grotanelli (Animadversiones in Acutse et Chronicae Splenitidis Historiam), are scarcely any one of them strictly diagnostic of acute inflammation of the spleen, since every one is met with in the disease of some other organ or another. Still they are worth recording. They are — after a sensation of cold and partial rigor, a feeling of weight, fulness, and pain in the left side, extending to the left shoulder, increased on pressure and coughing; thirst, some degree of nausea, dry cough, with the usual symptoms of pyrexia. Hematemesis, faintings, or pain on respiration, are occa- sionally observed, but not frequently in the simple form of this dis- order. This author states that a natural crisis is frequently observed after hemorrhage from the nose or stomach ; after a copious deposit from the urine; after the disappearance of the headache; when the hemorrhoidal or menstrual flux supervenes, and after a profuse dis- charge of the lochia?. In violent examples of this disease, those which rapidly terminate in a general dissolution of the splenic tissue, inces- sant vomiting is a prominent symptom, which is often attended by a discharge of grumous or clotted blood from the stomach and intes- tines. — (Dr. Bigsby, Cyclop. Pract. Med.) When the peritoneal coat of the spleen is affected, the pain be- comes more acute ; but then the physician is embarrassed in deciding as to the organ actually inflamed, owing to the proximity of so many other parts, as the stomach, the liver, the diaphragm, the colon, the kidney, and even the lungs and the heart itself. His only resource is, to abstract, as recommended by Dr. Bright (Observations on Abdo- minal Tumours and Intumescence), one by one of these organs, in proof of the lesion of which certain other symptoms are wanting, and he may then come to the conclusion that the pain belongs to the spleen. The most decisive indication of inflamed spleen, as it is, however, of congestion of this organ, is its enlargement, constituting a tumour, which, in connection with the tenderness on pressure, ena- bles us to assert, with some confidence, the organ affected, and the nature of its lesion. The tumour is smooth, oblong, and solid, felt immediately beneath the integuments, proceeding from under the ribs on the left side, a little behind the origin of the cartilages; often advancing to the mesial line in one direction, and descending to the crest of the ileum in the other; often filling the lumbar space at its upper part. This tumour is very generally moveable, feels rounded at its posterior part, and presents an edge more or less sharp in front, where it is often notched and divided by fissures. If effusion takes place into the peritoneal cavity, a thin layer of fluid is early felt be- tween the integuments and the tumour, but the intestines are not at any time found passing behind the tumour. The chief tumours, con- tinues Dr. Bright, which may be mistaken for an enlarged spleen, are, chronic abscesses of the integuments; scirrhous thickening of the 47* 558 DISEASES OF THE SPLEEN. stomach ; enlargement of the left lobe of the liver; diseased omentum; feculent accumulation in the colon ; diseased kidney ; ovarian dropsy; hydatids. The structural changes in the spleen brought on by acute inflam- mation are, in the first degree, a brownish red colour of the splenic parenchyma, which is gorged with blood, and denser than natural, though easily torn. At a more advanced stage the spleen becomes of a greyish-brown, and slill more friable, and when cut into presents a close, sponge-like tissue, tilled with blackish blood. In the third degree of intensity (following now the stages laid down by M. Gen- drin), the spleen is resolved into a pulp, like the lees of red-wine. This last is a common appearance in the spleen of those who are carried off by malignant intermittents. The peritoneal coat is often inflamed, and adherent to the surrounding parts. Aware of the close connection between the spleen and other organs, we are prepared to see considerable functional disturbances following an extension of its inflammation to any of them. Thus, when the diaphragm becomes inflamed, the breathing is hurried, laborious, and painful; with frequent, dry cough, an>d at times palpitation. Chronic splenitis is described by Grotanelli (op. cit.) to be at- tended by a sensation of weight and pressure in the left hypochon- drium, and fulness and swelling in that region; an obtuse pain or sense of uneasiness, especially when turning in bed ; indigestion ; disturbed sleep, and unpleasant dreams ; sometimes dyspnoea, with a dry cough ; defective nutrition ; a sallow complexion ; and sometimes scurvy. The enlarged spleen m-iy occasionally be felt early, and always late, in the disease,quite distinctly. The want of diagnostic symptoms, in any number at least, is as obvious here as in acute inflammation of the organ. Still less distinctive are the occasional disorders of remote parts associated with chronic splenitis; of these are, wandering pains in the limbs, sometimes ending in collections of pus under the integuments of the thigh, arm, &c. Much but undue stress has been laid by systematic writers on the implication of the liver in chronic splenitis. Out of fourteen cases of this dis- ease ending in abscess, the liver was only deranged in some degree in two. Any of the contiguous organs may become diseased as well as the liver, and accordingly the left kidney is occasionally the part chiefly affected in a secondary manner. Suppuration, one of the modes in which chronic splenitis terminates, is not defined by any symptoms of uniform occurrence, or of a distinc- tive character. Dr. Abercrombie (op. cit.) relates the case, which ter- minated fatally, of a gentleman to whom he gave, occasionally, his attention and advice, without either he or his colleague, Dr. Thom- son, being able to detect a symptom from which they could infer what was the seat of the disease. Autopsic examination showed that the spleen was somewhat enlarged, and had a cavity which contained several ounces of purulent matter. " The liver was pale, but other- wise healthy ; the kidneys were pale, with a peculiar degeneration of some parts of them into a firm, white matter. After the most careful examination, no appearance of disease could be detected in any other part of the body." When the investing membranes are CONGESTION OF THE SPLEEN. 559 affected, the sufferings are varied and acute; the pain being frequently accompanied with a sense of beat in the left hypochondrium, and striking to the spine, clavicle, or shoulder. Coagulable lymph invests the membranes together with the adjoining viscera. The filamen- tous tissue of the organ, though bathed in pus, is sometimes quite uninjured; but generally it is pulpy and diffluent. The sac may be fibrous, cartilaginous, or even bony. Cases are on record of the ab- scesses having burst into, respectively, the colon, the stomach, perito- neal cavity, the left side of the chest, or into the lungs, inducing symptoms of phthisis ; or it may burst outwards through the abdomi- nal walls, finding issue by the umbilicus. Iu some instances the abscess of the spleen has acquired a remarkable size. One case is mentioned in the Memoirs of the Academy of Sciences, in which it contained 30 lbs of matter. In some of the soldiers who suffered from the Walcheren fever (congestive, remittent and intermittent), Mr. Wardrop found the spleen entirely reduced to a cyst, full of puriform fluid. Softening is another of the terminations of chronic splenitis. The chief change in the organ is its conversion into a soft, black, broken- down mass like grumous blood ; in some cases being of a pultaceous consistence, or nearly fluid — the membranes at the same time being often inflamed and ulcerated. A modification of this softening, characterised by the destruction of a part, or even the whole of the spleen, and its conversion into a simple sac containing a substance vvhich varies from the state of clotted or grumous blood to that of tar. It is unattended by any of the characteristics of inflammation. Neither the peritoneal coat nor the tissue proper of the spleen are affected. Both MM. Andral and Louis point out the frequency of alterations of the spleen, of this nature, in typhoid fever. In 46 cases of dissection of persons dead of this fever, Louis found this organ natural only in four; in three-fourths of the cases it was softened. A change of this kind seems to be in some way connected with or dependent on a change in the blood, which has less fibrin in its composition than usual. In general, says Andral, the spleen is prone to be softened when there is disorder in the circulation and innervation at the same time, vvhich, in fact, I may add, is the state of the body in fevers, and particularly those of a congestive kind. Congestion of the spleen generally shows itself with enlargement, by which latter name Mr. Twining designates it. This change may be coexistent with chronic inflammation ; or it may appear, as it so often does, as one of the symptoms of cachexia,— its increase or sub- sidence generally corresponding with the unfavourable or favourable changes which are taking place in the constitution. Mr. Twining, in describing the structural changes of the spleen in those who had, when living, suffered from enlargement of the organ, mentions : 1, a soft, rounded enlargement, with a softened texture of the organ, to such a degree that " it resembles a great clot of blood, wrapped in a thin membrane." Coagula were sometimes found in the splenic vein as far as its junction with the vena porta, and entrance into the liver ; 2 greater firmness of texture, the enlargement of the spleen being 560 DISEASES OF THE SPLEEN. oblong, and the edges of the organ thin and notched; 3, opaque patches of various sizes, which he deems to be the result of albumi- nous depositions during superficial inflammation. Mr. Twining's description of the functional disturbances following enlargement of the spleen, are strictly applicable to a similar dis- ease of the organ so common in the eastern parts of the Atlantic states, and in the low, alluvial soil of the Mississippi and many of its tributary streams. Most patients with enlargement of the spleen are, he "tells us, affected with a short and imperfect respiration ; and any attempt to take active exercise excites panting and distress at the chest. " Among the usual attendants on vascular engorgement of the spleen, we may observe impaired appetite, difficult digestion, and imperfect assimilation of the food. There is generally despond- ency and depression of spirits ; inactivity of body and torpor of mind, with much muscular debility ; and this latter symptom is remark- able, although the patient be not much emaciated. When active pyrexia is not present, the urine is pale, often copious. In the latter stages of the disease oedema of the feet is present, and sometimes the face and eyelids are swollen. The majority of protracted cases that terminate fatally, suffer from dysentery or dropsy of the belly ; and when the abdomen is much distended from the latter cause, the superficial veins on the side of the chest and belly appear large and numerous, showing the extent and degree to which the circulation in internal organs becomes ultimately obstructed. " Diseases of the spleen often occur in conjunction with dysentery, intermittent and remittent fevers, scorbutic affections, and sometimes with diseases of the liver." — (Diseases of the Liver and Spleen, Drs. Thomson and Twining —Philad. Edit.) Enlargements of the spleen are sometimes connected with hematemesis, an attack of which is at times followed by a marked diminution of the tumour. The suddenness of the coming on of enlargement of the spleen is a matter of observation with most physicians who have enjoyed an opportunity of witnessing the disease. M. Twining points out its occurrence in the course of the remittent fevers of Bengal. Its sudden disappearance is also mentioned, in the case related by Dr. Abercrombie, of a sailor whom he visited, in conjunction with Dr. Combe, for ague. In the course of a week, the lever being cured, the enlarged spleen, arising from the margin of the ribs and pro- jecting downwards several inches, had entirely disappeared. Some- times considerable and painful tumefaction of the spleen, coming on with the fit, entirely subsides with the disappearance of this latter. Idiopathic enlargement of the spleen occurs in children, and in persons of a delicate and feeble constitution in Bengal; as the pro- duct, according to Mr. Twining, of the combined influence of a damp climate, variable temperature, want of exercise, unsuitable clothing, and insufficient nourishment. I shall not detail the appearances of the other structural alter- ations of the spleen, such as induration, ossification, gangrene, atrophy, hydatids, and cysts. Hemorrhage or apoplexy of the spleen, so distinctly pointed out by M. Cruveilhier, is of more frequent occurrence than we might at first suppose. The apo- TREATMENT OF DISEASES OF THE SPLEEN. 561 plectic deposits are not to be confounded with softening of the spleen, although they are met with under, sometimes, similar cir- cumstances ; as in those who have suffered from intermittent fevers. Rupture of the spleen may be regarded as analogous to, if not iden- tical with, this hemorrhagic condition. Some of M. Bailly's cases of malignant intermittent, observed at Rome, were of this nature. LECTURE LX. DR. BELL. Treatment of Diseases of the Spleen.—Remedies for acute splenitis the same as for other phlegmasia—Mercury in general inadmissible—Avoidance of extreme views and practice—Sedative narcotics useful—Free purging in enlargements of the spleen, or chronic splenitis ; to be followed or alternated with chalybeates— Mr. Twinin of the chyle and blood. ( Red particles ) ( Various acids, colouring matters, &c, formed from, or ac- l. 1 companying, the lithic acid. ( Nitric acid. m. Xanthic oxide. n. Cystic oxide. ( Sugar. o. 1 Oxalic acid. ( Carbonic acid. p. Hippuric acid 1 Benzoic acid 1 q. Prussian blue ; cyanurine. Indigo. r. Bile. Cholesterine. s. Secretion of the prostate gland, &c. t. Pus; and perhaps other matters. u. Kyestein. Met with in pregnancy. I cannot follow Berzelius, Prout or Willis in detailing the properties of all these ingredients, and the circumstances under vvhich they are formed; but must be satified with a few observations on the chief ones. Water, the base of the urine as it is of all the animal fluids, may vary considerably in its proportions compatibly with health: but in some diseases its increase is accompanied by an increase of a natural ingredient, as of urea ; or of unnatural ingredients, as of albu- men or sugar. On the other hand, the proportion of water to the urine is not unfrequently very much below the natural standard, as in the various forms of urinary suppression. Urea was long believed to be peculiar to the urine, and of course to be a result of renal secre- tion ; but it is now ascertained, that it may be formed from the con- stituents of the blood, without the agency of that organ. Urea is transparent and colourless, and without remarkable smell or taste: of course it does not impart to urine either the colour or other pro- perties characteristic of this fluid. Urea is neither sensibly acid nor alkaline. At a high temperature it is converted into ammonia, cya- nate of ammonia, and dry, solid, cyanuric acid. It is soluble in its THE URINE AND ITS INGREDDZNTS. 573 own weight of cold vvater, and in every prgportion in hot water. Urea combines with several acids, but does not neutralise them. Alkalies scarcely affect urea at low temperatures, but when it is assailed by heat, they rapidly convert it (together with water) into the carbonate of ammonia. In certain diseases of the kidney, urea exists in the blood in con- siderable quantities, as ascertained by Dr. Christison and others ; and it has even been found in the matters ejected from the stomach during a retention of urine. It has also been detected in the fluid of dropsy. There are diseases connected both with an excess and a deficiency of urea in the urine. Lithic or uric acid, supposed once to be a product of morbid secre- tion, is now known to be an invariable ingredient of healthy urine ; and present in solution at all ordinary temperatures. If it exists in the blood at all, it is in very small quantity only. Prout supposes it to be combined with ammonia, and not to be secreted in a free state. It is rendered probable by Liebig and Wohler, that lithic acid is a compound of urea and a substance itself composed of cyanogen and carbonic oxide. The lateritious and pink sediment were supposed by Prevost to constitute a peculiar acid, which he named rosaceous ; but these have been found to consist essentially of the lithate of am- monia, and, sometimes, of the lithates of soda and lime,\n small pro- portions. They owe their colouring matter partly to the colouring matter of the urine, and partly to the purpurate of ammonia. The now highly prized manure, Guano or Huanu, imported from South America and Africa, consists chiefly of lithic acid in the form of a very impure lithate of ammonia. This is the residue of the ordure of sea-birds. The colouring matter of the urine consists of yellow pr. -- ciples, more or less acted on by nitric acid, which Prout supposes to be in some way an ingredient of healthy urine. The next and most important form in which lithic acid appears in the urine, is that of lithic acid gravel, the immediate cause of the pre- cipitation of which is the lactic acid, which is generally at this time secreted in excess, either separately, vvhich is comparatively rare, or in a state of combination with urea, which seems to be the rule. The frequent presence of sugar in urine depositing lithic acid gravel and the frequent appearance of lithic acid gravel in slight forms of dia- betic disease, are explained by our learning, "that the lactate of urea and the saccharate of urea are, in fact, but modifications of the same substance, and may be considered as the representatives of gelatin ; the lactic acid being, as we have said, only a modification of the saccharine principle." The lithic acid is, on the same authority (Prout), a principle of albuminous origin, and may be readily distinguished by the develop- ment of the purpurate of ammonia, by the aid of the action of the nitric acid and heat. The sulphuric and the phosphoric acids appear to exist in healthv urine in union with soda, potassa, and ammonia, and partly with magnesia and lime. The muriates of potassa and soda occur both in the blood and the urine. Muriatic acid exists only, in the urine, in combination with ammonia. I shall not make any remarks on the other constituents of healthy urea, but devote a few words to the 574 DISEASES OF THE URINARY APPARATUS. foreign substances which are occasionally found in it; and one of which, albumen, has of" late become an exceedingly important dia- gnostic test of certain diseases. Albuminous urine, on being exposed to a high temperature, under- goes coagulation ; and its albumen at first collects on the surface, and then is deposited. Nitric acid added to the urine has the same effect. The chief component parts of calculi merit a passing notice. Of these are the xanthic acid (the uric or lithic oxide of Liebig), and the cystic oxide, which last is peculiar to the urine, and sometimes forms whole calculi. Prout, however, regards its presence in the form of calculus to be quite rare ; but admits its not uncommon occurrence in certain states of' disease. Sugar is not found in the blood in a state of health ; but is generally recognised in the blood of diabetic individuals, where it probably always exists in a greater or less degree: nor is it a natural ingredient of the urine, although found in large quantities in diabetes. Oxalic acid is neither met with in the blood nor in the urine in a state of health; but in certain forms of disease it probably exists in both fluids. It is usually found in con- junction with lime, forming the oxalate of lime or mulberry concre- tion. Sometimes it appears as an amorphous sediment: in rare instances as gravel. Bile, in certain diseases, and particularly jaundice, makes its way not only into the blood but into the urine. " Urine containing bile is generally of a deep brownish-red colour, when in considerable quan- tity and viewed by a transmitted light. But when contained in small quantity, it has sometimes a yellowish-green appearance. A piece of white linen, it is well known, will be stained yellow by bilious urine; and the addition of muriatic acid renders it green. In organic affec- tions of the kidney and liver, Prout has occasionally seen in the urine a crystallized fatty substance, similar to that frequently met with in encysted tumours and various malignant affections, and vvhich has been considered as cholesterine by Caventou, Breschet, Dr. Christison, and others. The secretion of the prostate gland sometimes appears in the urine. In general it may be distinguished from mucus by its albuminous properties, and by its peculiar appearance. Pus occasionally appears in the urine in great abundance, so as to render its presence unequi- vocal. Most generally it is accompanied by mucus ; and between the two there seems to be a close relation. " Pus, when well marked, may be distinguished from mucus by being essentially composed of particles. Hence, when diffused through the urine, which it readily may be, pus, after a time, again subsides to the bottom of the vessel, in the form of a pale, greenish-yellow, pulverulent deposit, and the urine assumes its transparent character. Urine containing pus is almost always invariably albuminous. Pus may be detected if it and mucus both are present in the urine, by this fluid becoming alka- lescent; the ammonia evolved converts the pus into a peculiar glairy substance, which imparts to the urine a ropy consistence. To facilitate a recapitulation of the preceding details, which are derived from Prout, and often given in his own words, I place before you the following table, also found in his work: — ALBUMINOUS URINE AND BILE. 575 TABLE.—Exhibiting a contrasted view of the relations between the principles of the blood and of the principles of the bile and of the urine, formed either mediately or immediately from the blood. a CD . S .2 > O 3. ! a « «" s a > £ S ca 05 £* u g'W U ° O S3 c ^ ~ : * a'S 5 £ 5 2 ='-5 ° °: 'ufL, f< t> ™ a. o- »5 w - o — J3 P5U Aq duufl aqj ui pajuasajda^j _____'._________A.__________ E "« r^^\ r^-o — 32 a ca .2 s CD a> ca 3^ -c'C C3 Ml 5 2 "a = '5 s.s S .-3 ca & > .2 3 ca a "3 C9 jCq 9jig aqj ui pajuasajdag _____1______X__________ 3 ."K .-S L/vn-> V-^v^J oj juajBAinba = *« a ►5 2 9 r^o^ r^-n l.i ca a — 03 3 >"1 01 ra 3 53 S on of S ^ s "3 2 .a a o 9 3 O E C3 ■s » s .5 ■£ "3 s a S3-. 3 TI £ o " « T) - S g_"3 a d ca -.:-. a J= 5 a ^'a'" u,=- 3 3 e- „ CJ CS a rt n A a ca "O r-03 ."3 ulp rin wi ~ o £ 3 3 o a .3 ca 576 DISEASES OF THE URINARY APPARATUS Semeiological Relations of Urine. — The changes which the urine undergoes in various diseases are sufficiently marked to aid us in diagnosis as well as prognosis— when we possess an accurate knowledge of the organic constituents of the urine in its healthy state. In most febrile disturbances, and in organic diseases of an acute or sub-acute character, the urine commonly contains albumen, mani- fested by chloride of mercury, alum, and nitric acid. This remark applies to fever in general, also anasarca, itself the result of diseased kidneys or heart. In this state of disease, precipitation of albumen occurs on the addition of chloride of mercury even when the urine has an acid reaction. Albuminous urine with deficiency of urea is met with, also, in chronic affections of the liver, complicated with dyspepsia ; also towards the termination of all diseases that are ac- companied by hectic fever and cause emaciation. In rheumatism, the urine is generally acid, depositing sediment oftener than in health. The quantity of lithic acid is also increased, in a noticeable proportion, in this disease. In diseases of the liver the urine leaves a yellow stain on linen when dried. In cholera mor- bus the appearance of the urine is very variable. Vogel found in it the colouring matter of the bile, which first turned green and then red, on the addition of nitric acid. In colic the urine is clear but browner than natural, owing to the brown colouring matter of the bile, which could be precipitated by a small portion of the chloro- hydric acid. In hysteria and analogous nervous and spasmodical disorders, the urine sometimes becomes altogether colourless and as clear as water. Rollo says, that at this time the urea and organic ingredients are entirely wanting, and only the customary saline matters are found in it. The secretion of lithic urine has been several times observed. The colouring matter is not known. Black colouring matter has also been noticed. Of the saccharine ingredients in urine in dia- betes, I shall have occasion to speak more iu detail hereafter. Milk has been found in the urine of both sexes; but under circum- stances hitherto not determined. For farther details in the compo- sition and general characters of the urine and concretions formed from it, I refer you to Berzelius's Animal Chemistry, and more particularly to the accessible portion of it on this very subject trans- lated by Drs. Boye and Learning and published separately, under the title of " The Kidneys and Urine," 1S43. Diseased Structure of the Kidneys. — In order the better to ap- preciate the extent of the morbid changes in the kidney, we ought to know its standard or healthy appearance. As regards weight, we learn from Rayer that the mean weight in thirty males, from 16 years to 76 years of age, was four ounces three drachms, to four ounces and a half. The density of the organ is variable ; its weight not being always proportionate to its use. Multifarious experiments, at first by M.Comhaire, in 1803,and sub- sequently by M. Rayer and his pupils, demonstrate the little sensi- bility possessed by the kidney. Hence we are bound to regard with attention any apparent trifling pain or tenderness on pressure in the region of this organ, and to endeavour to ascertain its cause. We also learn from this fact that nephritis may make considerable pro- NEPHRITIS. 577 gress without the patient being apprised of it by pain. As regards injection of the renal tissue evincing disease, M. Rayer assures us that, whenever their anterior is more injected than their posterior portion, in subjects who have laid as usual, on their back, this con- dition is to be ascribed to morbid action. He lays stress on this, be- cause the phenomena of hypostatic engorgement of the cadaveric species is of regular occurrence in the kidneys. The assimilation of both substances, medullary and cortical, of the organ to the same colour, by imbibition of blood, when considerable, is very frequently mistaken for an effect of disease. When abdominal putrefaction advances with rapidity, the separation of the fibrous capsule is a common phenomenon, and is produced by the softening of the cel- lular membrane interspersed between the capsule and the substance of the organ. The alterations of colour of the kidneys are often very rapid, so that an artist intent on copying them, is sometimes greatly puzzled to catch the original one. Maceration, although it obscures some morbid states of the kidney, renders others more evident; and of these latter are the granulations observed in Bright's disease. The impregnation of the surrounding cortical substance with water renders it semi-transparent, and so throws out the dull, milky hue of the granulations. M. Rayer de- scribes these bodies as more distinctly visible at the anterior part of the right kidney than elsewhere ; an appearance which he attri- butes fo putrefaction commencing earliest in this portion of the organ. Exploration.—The examination of a patient in whom we sus- pect disease of the urinary organs cannot be conducted with too much care. Manual examination and percussion will be found im- portant aids. By the former the degree of sensibility of the kidneys, the extent, form, direction, mobility, and resistance of visible enlarge- ments, may be ascertained. Percussion will aid us in making out the origin of tumours in the lumbar regions; but it is to be borne in mind that the dull sound elicited may be due to the enlargement of other solid organs. . The examination should be extended to the ureters, bladder, prostate, and urethra. Important aid to diagnosis will be found in the characters of the urine, as determined by certain chemical tests and experiments. Nor must we stop here, but, as M. Rayer has very wisely pointed out, we ought to inquire into the state of the constitution before we can safely determine the causes of the disease, or the mode of treatment advisable. LECTURE LXII. Nephritis.—Its species—Hyperemia common to them all in the beginning.— Symptoms .• organic and functional; remote or sympathetic—May be confounded with organic disease of stomach and bowels—Attention to state of the urine.— Causes,- traumatic and constitutional.—Jnatomical lesions.—Chronic nephritis- its symptoms, lesions, and causes.—Nephralgia. — Treatment of nephritis in gene- ral—The acute form requires active antiphlogistics—Nephritis in fevers.— Suppuration of the Kidney— Directions taken by the abscess—Most frequent ca• It may be asked," says the writer, " why pass the instru- ment into the neck of the bladder at all, and why state that an inch in front ofthe neck of the bladder is a point beyond vvhich the caus- tic instrument shall not penetrate ? Why, again, the spot where acute pain is indicated, during the passage of the bougie, may not be regarded as the proper place for applying the caustic ? In many persons the uretlira is very sensitive, and the patient complains so frequently, that a little ditficulty is experienced in deciding with that test; but when you have ascertained that from the orifice of the uretlira to the neck of the bladder is seven inches and a half, and when you farther find that in the passage of the bougie the most acute pain was experienced a little more than six inches from the orifice, you can then, with much confidence, cauterise the space bstvveen the sixth qnd seventh inches, satisfied that the orifices of 694 DISEASES OF THE ORGANS OF GENERATION. the ejaculatory ducts will not escape. It imy be thought by some persons that all these precautions are unnecessary ; this may be true • but offhand surgery I dislike, and in one case, by the neglect of such attention, I cauterised the neck of the bladder; and in another case applied the caustic entirely in front of the seat of mischief, my con- science will not acquit me of blame. " The foregoing precautions having been taken, the caustic must be exposed and slightly revolved along the floor of the urethra, for half a minute without fear of harm, and rarely does it excite much pain — very rarely, indeed, does the patient complain of it." It may as well be stated here, that the space which M. Lallemand usually cauterised is from the neck of the bladderto the membranous portion ofthe urethra; but sometimes he brushes over the internal surface of the bladder itself to a greater or less extent. He cautions us strongly against repeating the operation too soon, and advises ns to wait two or three weeks before we apply the caustic. Many of his cases appear to have been cured by a single application. In the British and Foreign Medical Reviev, for April, 1843, there is a good practical article on the subject now before us, in vvhich the writer adduces his own experience and that of other surgeons with whom he corresponded on the subject, in its favour. As an occa- sional substitute for the application of the solid nitrate of silver, one of them recommends an injection of the solution, another the cau- tery to- the externa! orifice of the urethra and for about an inch down. Mr. Phillips has no confidence in the injection of the ni- trate, and its application to the orifice will be found to be more pain- ful than when the part affected is directly touched with it. Mr. Curling has found that the Pulv. Cubebis, in small doses of from gr. xv. to gr. xxx. combined with the tincture of henbane, taken twice a day, by its influence on the urethra, materially aids the cure of the disease. Indeed, he adds, in very slight cases this remedy and the occasional introduction of a catheter or bougie are sufficient to correct the morbid condition and sensibility of the mu- cous membrane without the caustic. Among the unpleasant effects that sometimes ensue immediately from the use of the caustic are pain and a slight discharge of blood; but they disappear at the end of from twelve to forty-eight hours. In one of M. Lallemand's cases, they are described as lasting three weeks ; but this is a rare exception. Syncope occasionally results. The conversion of the emissions from diurnal into nocturnal, and the fact of their being once more accompanied with erections and plea- surable sensations, are regarded by the writer just named as a sign of the good effects of treatment and prospect of cure. I shall conclude by repeating Mr. Curling's description of the in- strument and his mode of using it, which, taken in connection with the observations of Mr. Phillips already quoted, will make you mas- ters of the affirmative side of the subject. " M. Lallemand's instrument consists of a slightly-curved platina canule or tube, rather smaller than a middle-sized catheter, through which plays a caustic holder, having at its further extremity a narrow groove, eleven lines in length for the purpose of receiving the caustic. TREATMENT OF SPERMATORRHOEA. 695 After filling the groove with the nitrate of silver by fusing it over a spirit lamp, the caustic becomes so securely fixed that there is no dan- ger of its escaping. At the other end there is a sliding screw or stop, by which means the application of the caustic may be limited to any extent less than the length of the groove which contains it. In em- ploying this instrument I proceed as follows: — Having regulated the caustic holder so as to admit of nearly the whole of the groove being uncovered, and having closed the instrument so as to conceal the caustic, I introduce it well oiled as far as the prostatic part of the urethra, its arrival there being easily ascertained by the pain expe- rienced by the patient, and by my being able, after the instrument is depressed and has passed the triangular ligament, to carry it freely onwards.* I then thrust forwards the caustic holder, and after passing it once or twice backwards and forwards instantly close the appara- tus and then withdraw it. At one time I used to employ a straight instrument, which may generally be introduced without difficulty; but one slightly curved is rather more convenient." I have said that you are now masters of the affirmative side ofthe practice of cauterisation in the prostatic urethra for the cure of spermatorrhoea. On the negative side I will only adduce the names of MM. Civiale and Donne. M. Civiale (Mem. Sur I'Emploi des Caustiques dans quelques Maladies de I'Uretre), is almost as decided in this reprobation of this remedy as M. Lallemand is in its favour. He denies that the caustic in many cases reaches the part to which it is said to be applied, and when it is, it produces the alleged effects. He admits the good faith of those who leport cures; but he explains by saying that the parties treated by caustic apply afterwards to a dif- ferent professional man for the disease brought on after a while by caustic. He is adverse, also, to the use of caustic for stricture of the urethra, vvhich disease is, he thinks, always better treated by dilatation than by cauterisation. M. Donne (op. cit.), assures us that the cases which have come to his knowledge are not favourable to M. Lalle- mand's practice; he has seen persons treated by cauterisation, some even cauterised by the professor of Montpellier himself, who were not cured. M. Donne prefers the general or the more distinctly recog- nised therapeutical means already stated, and particularly cold baths. A well devised regimen is ofthe highest importance in spermator- rhoea. It should be such as to increase the tone of the system without excitement; and hence all substances vvhich stimulate unduly the gastro-intestinal surface and by sympathy the genito-urinary organs must be sedulously withheld. Spices and other condiments have often a strong action on the rectum, through which, even if they have not a coincident one on the neck of the bladder, they irritate the genital apparatus. In this way costiveness is an occasional exciting cause of seminal discharges. All alcoholic liquorsshould be abstained from, *" At first I used to pass a wax bougie down to the prostatic portion of the canal, in order to ascertain its distance from the meatus, that I might be exact in cauter- ising the particular part affected, but after a little practice in the use of the instru- ment 1 found this unnecessary." 696 DISEASES OF THE ORGANS OF GENERATION. and coffee also is of the prohibited class. Tea is indirectly hurtful by interfering with the soundness of sleep, and thus increasing the chances of nocturnal emission. Exercise, already indicated as one of the remedies, both preven- tive and curative, for masturbation, is entitled to great confidence in spermatorrhoea. Of course it must be regulated by sounddiscretion, so as not to cause a strain upon any part of the muscular apparatus and particularly of the back, which has itself at times given rise to the disease. Change of air and of scene, and particularly change from town to country, and the use of sea-bathing will often restore the pa- tient to health. The pantaloons and drawers should be loose enough not to compress or expose the parts to friction of any kind in walking or riding or in still more active exercises. In the case of young per- sons the dress about the pelvis should be as cool as possible compati- ble wilh the avoidance of other diseases of a catarrhal or rheumatic character. At night the bedclothes ought likewise to be relatively tight, so as to induce almost a slight feeling of chilliness on the part of the patient, who, it is understood, of course, in all these cases, sleeps on a hair or straw maitrass. Impotence. — The loss of procreative power is either temporary or permanent. In the first it may be caused by mental emotion, disorder of the organic functions and more especially of the kidneys, stricture of the urethra, certain acute diseases, excessive indulgence in venereal pleasures, masturbation, the prolonged use of narcotics. Of the per- manent causes we may enumerate paraplegia, congenital deficiency of the penis. Although in reference to this latter itis not easy to say in what the defect shall consist, for if the semen can be excreted at all and deposited in the vagina, conception is liable to follow. Original deficiency or subsequent loss of the testicles, for it must be of both these glands, is necessarily a cause of impotence. Under this cate- gory we place, also, early and excessive sexual indulgence and mas- turbation, by which the virile power is lost in the maturity of life. The treatment of impotence will of course be regulated by the cause. If dependent on some known organic disease, as of the testicle or urethra, this must be removed, or functional disorder of other organs, as of the digestive or renal, it is to be carried off by appropriate means. General languor, debility from prior excesses implies, as a preparation for its ultimate cure, if this be still possible, a cessation from those criminal indulgences. The medicinal means for farther restoration will be at first a hot, then a warm douche along the spine and sacrum, liniments or small blisters to the nucha and mastoid processess, electro-galvanism and the sedulous admi- nistration of chalybeates alternating with vegetable bitters. Prompt but temporary restoration of virility has been procured by the use of nux vomica both in cases of impotence with paraplegia and where no lesion of the nervous centres existed.—(Trousseau et Pidoux, Traite de Therapeutique et de Matiere Medicate, torn ii., p. 1D2.) In cases in which the weakness depends upon mental emotion or on the imagination, the means will sometimes suggest themselves to the patient and sometimes be advised by the physician. Both par- ties will get useful hints on this poiut from the quaint, egotisti- FEMALE ORGANS OF GENERATION. 597 cal always amusing and often instructive Montaigne. — See Book i., chap. xx. of his Essays. Hunter has some useful remarks on this subject in Chap. xii. of his work on the Venereal Disease. LECTURE LXX1V. DR. BELL. Diseases ok the Female Organs of Generation.—Organs included in the genital apparatus of the female—Selection of the more important diseases—Anatomy does not indicate the vital actions and sympathies of the uterine system—Phy- siologically considered, the changes under functional exercise are diversified and marvellous—Three functions or stages of function of the uterus—What general anatomy points out—Genito-urinary system of mucous membranes—Connection between the uterus and vagina and other contiguous organs—Importance of cer- vix uteri and os tmcx—Knowledge of these things aids a comprehension of uterine diseases, and suggests better treatment—Examples—Attention not to be fixed on the uterus alone in studying any of its diseases—Diseases of the genital apparatus of three kinds ; neuralgia, textural or organic, and functional—Means of better diagnosis; by the touch and with the aid of the speculum—Both these indispensable in every fixed disease ofthe uterus.—Hysteralgia.—Symptoms— Coincident neuralgia of the vagina—Accompanying phenomena—Inatomical character and causes—Diagnosis—Treatment—Result uncertain—Occasionally if congestion be present, local bloodletting—Nitrate of silver to the cervix— Simple neuralgia to be treated by chalybeates and narcotics—also nitrate of silver, with some narcotic—Ergot—Use of the pessary—Remedies when dys- menorrhoea is present—Rest and recumbent posture, all important in hyster- algia—Neuralgia of the Ovaries.— Amkxorrhqsa—Two forms, that of retention and that of suppression.—Amenorrhea after puberty—Treatment depending on presence of plethora or anemia; in the first, depletion and revulsion; in the latter, chalybeates and other tonics, as in chlorosis—Suppression ofthe Menses—Acute or recent and chronic—Causes of acute suppression—Etfects 6erious and alarming—Treatment by free depletion, in some subjects of a full habit—Purgatives and antispasmodics in spare and delicate women—Chronic Sup- pression.—To study the functions generally—It may be either cause or effect of constitutional disorders—Symptoms—Treatment—Sometimes purgatives, or blue- pill, chalybeates and purgatives—Sulphate of potass and aloes or rhubarb— Emmenagogues so called—The best are preparations of iron and of iodine, and of mercury and ergot—Various stimulants to vagina and uterus—Vaginal injec- tions—Travel, and mineral springs—Dysmenorrhea—Difficult or painful men- struation—Definition—Appears in different temperaments—Its gravity—Symp- toms—Varieties—Neuralgic, plethoric and congestive—Diagnosis—Difference between membrane expelled and the decidua—Prognosis—Treatment—Membra- branous not proof of prior inflammation — Sometimes local bloodletting in derivation from the arm—Treatment resolves itself into that during the pains and that in the interval—Anodynes and narcotics, ergot, acetate of ammonia, volatile tincture of guaiacum, warm hip-bath in the first period—Mercurials, chalybeates, and other tonics, and cold bahing in the second—Dysmenorrhoea from mechanical obstruction treated by metallic bougies introduced into the canal ofthe cervix—Dr. Mackintosh's success—Dr. Churchill's admission. He who proposes to himself or promises to others to describe the diseases of the genital apparatus ofthe human female, must be aware that his engagements include a consideration ofthe uterus, vagina and external organs, and of the ovaries and fallopian tubes: but as all these are not equally interesting to the practitioner, nor equally liabl5 to present themselves for his action, he restricts himself to those vol. I.—59 693 DISEASES OF THE ORGANS OF GENERATION. which he conceives to be the most important by their functional activity and consequent liability to disease. Anatomy aids us little, if at all, in drawing any inference respect- ing the importance of the apparatus in question. If we except the plexus of veins ofthe uterus, there is no remarkable vascularity, nor is the supply of nerves considerable — two tests ihese of great func- tional activity and power. The small, hard, and apparently semi- fibrous structure of the uterus itself—I am speaking now of the unimpregnated one and anterior to menstruation—gives little evidence of any vital properties or of extended sympathies. Bui when once the first function of the uterus is manifested by the appearance of the menses, or physiology becomes our guide, how great and marvellous the change wrought in the whole organism. In the second function of the uterus or pregnancy, the reception of an ovum and the development of a new being, arise another series of new and diversified actions modifying "every function and eliciting almost every modification of sensibility and sympa- thies. Finally, in that still other state of function or expulsive ac- tion of the uterus by which the new being is born, we have cause to marvel at a new series of movements. Nor do the secondary and remote, but remarkable phenomena, end here. The still excited uterus calis into action the function ofthe apparatus for lactation, and widens the sphere of sympathetic actions. From the date of the second series of the functional exercise in pregnancy, tbe nerves of the uterus which are supplied from the great sympathetic and sacral nerves become gradually enlarged so as to impart a higher and more active range of organic movements and sensibility to the organ. But still more, with the enlargement of its system of nerves, is that also of its coats, bloodvessels, and absorbents. It is chiefly by the influence of these nerves that the uterus performs the varied func- tions of menstruation, conception, and parturition; and it is solely by their means that the whole fabric ofthe nervous system sympathises with the different morbid affections of the uterus. So far the means by vvhich the uterus more directly establishes its relations with the organs of the body ; but there are certain points of resemblance between parts of its structure and parts in other re- mote viscera, coming under the head of general anatomy ; and also certain connections between it and its annexes and the contiguous organs, which you must carry along in your minds in order to be able fully to appreciate the pathological phenomena, direct and re- mote, of the uterine system, and lo understand the indications for the cure of its diseases. It behoves you to know that the vaginal canal, extending from the uterus to the external parts, is lined with a mu- cous membrane, continuous in one direction with the entire lining membrane of the uterus and fallopian tubes, and in another with the bladder, constituting that division of the system of membranes in the female which Bichat designated by the term genilo-urinary. In ihe male it forms a more directly continuous system along the canal of the*urethra in the bladder, and thence by the ureters to the pelves of the kidneys; the only deviation being along the vasa deferentia to ihe testicles. Like other divisions of the mucous membranes, the FEMALE ORGANS OF GENERATION. «99 genito-urinary has its direct and remote causes of excitement and disease ; ils catarrhs, its profluvia, its morbid sensibilities and asso- ciated irregular muscular contraction or spasms. As respects the different degrees of sensibility and organic properties possessed by the different pans ofthe vagino-ulerine structures, it is well to know that the cavity of the vagina has these more active than the cavity of ihe ulerus proper ; but that the cervix uteri with its canal con- taining compound mucous ducts or lacunas, and its termination the os tineas, are both more sensible and more irritable, more pione to affect the functional exercise of the uterus and to modify its diseases than any other part of the system. The os tincae particularly is the sentinel of the uterus, which gives alarm, and sometimes is ihe chief sufferer in approaching disease of the organs. In pregnancy, also, no matter how great may be the growth of the gravid uterus and how apparently prepared it may be for the expulsion of the foetus, this process cannot be accomplished, if at all, without great risk of loss of life itself to the mother, unless the cervix uteri have been cor- respondingly and fully dilated and thinned so as to allow of the pas- sage along it of the new being In menstruation, although ihe changes are not as remarkable, yet still they are chiefly evinced by some variation in the state of the os tincae. A knowledge of the anatomical connexions between the vagina and uterus and the adjoining organs is essentially necessary to a clear understanding of the symptoms of the uterine disease. When we learn, for example, that the vagina adheres firmly by cellular membrane to the urethra, the bladder, and the rectum, we cease to be surprised that it should both impart to and receive irritation from these organs. So, also, the position of the uterus is to be noticed be- tween the colonbehind and the bladder in front; the latter being in direct contact with its cervix. When a female complains of a frequent desire to urinale, and asks you' for a remedy to relieve or remove the dis- order, you will, with a preliminary anatomical knowledge, be induced to suspect that ihe irritation of the bladder is here but secondary to that of the uterus. So, on the other hand, when complaint is made of pain in the region of the uterus without any other symptom of organic affection or correspondence between it and menstruation, you will take pains to ascertain whether the patient have suffered from cos- tiveness ; and should this be the case you will administer a pretty smart purge or two instead of opiate or anodyne or antispasmodics and you will generally carry off or greatly mitigate the uterine pain. Hemorrhoids, ascarides, fissure of the anus, may, you can now readily conceive, become so many causes of vaginal irritation, manifesting itself in leucorrhaea or of uterine disorder manifested in deranged menstruation. And again, when a female patient complains of pain in the groins and somewhat diffused in their vicinity, you must re- member that the round ligaments of the uterus, composed of some of ils fibres with bloodvessels and nerves, pass down through the abdo- minal rings and are lost about these regions. By its direct anatomical connections, its portion ofthe system of mu_ cous membranes and its relations with other organs through the nerves" the uterine system has, we may readily suppose, numerousand diver' 700 DISEASES OF THE ORGANS OF GENERATION. sifted sympathies with all parts of the animal economy, and must be impressed disadvantageous^ by derangement of function of any one of these, as in its turn it will act on them by its own primary disorders. There is, therefore, no disease of the uterus, functional or even organic, in which the attention can be exclusively fixed on this organ alone and to an oversight of the state of any other one. After some observation of the diseases of the genital apparatus of the female, we discover that they are of ihree kinds: viz., 1st, the neu- ralgic, or that in which the nuropathic state prevails; 2d, the tex- tural or organic, with its consequences of morbid functions; and 3, the functional, consisting chiefly of abnormal or defective secretion. One of the first, and indeed the most difficult part of the diagnosis of uterine diseases, is to distinguish perverted and otherwise morbid sensibility from inflammation and its disorganising processes, and both of ihese from simple disorders of the secretory function. In some in- stances, as in dysmenorrhoea, we have all three combined ; excessive pain, membranous matters extruded, and secretion considerably per- verted. Before I speak even in a cursory manner of the different diseases of ihe uterine system embraced in these three divisions, I must say a few words on the means of studying the symptomatology and enlarg- ing their diagnosis. Among these means are the use of the senses of touch and sometimes that of sight, in the way that we would judge bv them of the condition of external parts; or in other words, the examination per vaginam conducted through the touch, and introduc- tion of the speculum uteri. By the first we learn the temperature, hardness, or softness, extent of fulness or tumefaction of the os iincaeand cervix uteri, and, if necessary,of the body itself of the uterus; also its actual and relative position, and whether it is displaced; points these which it would be impossible for us to learn by other means, or the still common fashion of asking the patient to describe her feelings, and of feeling her pulse, looking it her tongue, &c. By the aid of the speculum, so as to allow of our seeing the mucous surface of the vagina and the mouth and neck ofthe womb, we are enabled to tell whether there be redness and tumefaction or ulceration ; in fine, the state ofthe parts indicative either of inflammation or of specific dis- ease. The same channel through which we inspect the parts allows also of the introduction and application of leeches, or, if re- quired, of caustic. In the existing state of our diagnosis and improved treatment of diseases of the ulerus and vaginal passage, no physician can pretend to do his duty to his patient or justice to himself who is not able lo turn these precious means to account. Beyond some obviously neces- sary prescription to regulate the bowels and to allay febrile excite- ment, not a step can be usefully taken in the treatment of any settled or of recurring disorder ofthe uterus without recourse to Ihe touch at any rate; and if this do not satisfy the doubts of the physician, he must avail himself of the additional aid of the speculum. It is chiefly in a more ready resort to these aids and somewhat greater facility from practice in their use that the city physician or professor has any claims or confidence superior to that of his professional brother in tbd HYSTERALGIA _ IRRITABLE UTERUS. 701 country. On the score of greater knowledge of the resources of therapeutics or judgment in applying them, the former can have supe- rior claim. Hysteralgia—Irritable Uterus.—This is thechief neuralgic affection of the genital apparatus. The term (from «""§*, uterus, and from **>«, pain) is sufficiently expressive. Hysteralgia may be ori- ginal or symptomatic; the sole disease, or a troublesome addition to another and more serious one, such as metritis, or inflammation of the womb, or a fibrous tumour of this organ. It is characterized by severe pain during menstruation, increasing in severity for some days after the discharge has ceased, and independently of ihe periods in question, frequently attacking the lumbar and hypogastric regions. The pain is increased by exertion and mental emotions, and speedily relieved by the recumbent posture: a perfect interval of ease rarely oc- curs. Sometimes violent spasm accompanied by a smartingand stinging sensation attacks the sphincters of the vagina and rectum, particularly in the sitting posture: the excessive sensibility may even extend to the pubic region and abdominal parietes. Sometimes the whole of the vulva and the vagina, especially at its orifice, are slightly swollen ; and when the disease is thoroughly confirmed, any movement by which the neck of the uterus is brought into sudden, jarring contact wilh the surrounding part excites severe suffering. Hence defecation, if il be difficult, and even the evacuation of ihe bladder, are most painful operations. Leucorrhoea is a frequent attendant. Hysteralgia may replace rheumatism in other paits and is often associated with, as we must in such cases believe it to be dependent on, deviations or malpositions of the uterus. This organ is represented to be almost always a little lower in the pelvic cavity than natural, and by some authors it is said to be constantly prolapsed. The for- mer of these opinions expresses more nearly the fact; but to it there are exceptions. It has happened to me, before now, to give atten- tion in cases in which all the usual symptoms of prolapsus uteri were present, and yet, on examination per vai/inam, I found the womb in its place, and even quite high up. But the touch revealed the true character of the disease by apprising me of the great sensi- bility of the os tineas and cervix at the time. In irritable uterus or hysteralgia, the cervix is often somewhat shortened and expanded, and occasionally puffy and swollen, and the lips of the mouth (os tincse) are more" than naturally closed. The speculum often shows a redness of the cervix ; and at times a dusky-red stale of ihe vagi- nal mucous membrane ofthe neck, associated, perhaps, wilh abrasion of surface or patches of superficial ulceration. Anatomical Characters and Causes. —The opinion advanced by Dr. Gooch, to whom the profession is indebted lor the first descrip- tion of the disease, lhat irritable uterus is purely neuralgic and un- connected with organic change and formation of new products, has not been sustained by subsequent observations. Ihe constitutional sympathies are sometimes slight; ihe pulse being natural, the tongue clear and the appetite good. But in other cases there is vascular excitement, with a quick, compressible pulse, and in plethoric women it 59* 702 DISEASES OF THE ORGANS OF GENERATION. is harder and fuller. Evening fever and its concomitants, also head- ache and dyspepsia, on occasions, add to the distress of the patient. The general health is more liable, however, to suffer from the con- finement to the house, and mosily to a sofa or bed, and consequent privation of fresh air and exercise, and from the use of narcotics to allay pain, than from hysteralgia itself. That the disease is closely allied to inflammation or congestion seems the more plausible opi- nion, since we have most of the phenomena of one or other of these morbid states present; and, moreover, the treatment, in some cases at least, is that applicable to chronic inflammation. Dr. Ingleby (Clinical Lectures on Diseases of the Puerperal State) has kept notes of seventeen cases of irritable uterus, three of which were un- connected wilh any appreciable cause ; one were attended by descent ofthe ovary into the uterus: one by descent of the uterus soon after marriage ; one originated in extreme distension of the uterus during pregnancy; seven followed delivery, and four was connected with fibrous tumour. Dr. Ingleby adds a remark interesting in connection with the symptomatology ofthe disease: viz., that in several of these cases there was one prominent — excessive irritability ofthe vagina. One of the most distressing cases of neuralgia of the uterus which this writer met with, arose from an enormous distension of the organ by the liquor amnii in connection with an acephalous foetus. So severe were the symptoms at the sixth month of pregnancy that it was determined to induce labour by puncturing the membranes. Great and instant relief followed the operation, but the acute suffer- ings returned soon after delivery and continued for many monihs. According to Dr. Ingleby's experience the irritable uterus frequently depends upon a severe labour. Among other causes have been enu- merated a too powerful injection for the cure of leucorrhcea, and cold ablution ofthe vulva, and also a sudden stoppage of the menstruation from alarm. Sexual intercourse is undoubtedly an occasional cause; and it will be found on inquiry that some of the greatest suf- ferers from the disease are those wretched beings who live by pros- titution. In the diagnosis of hysteralgia the chief difficulty is to distinguish it/rom chronic, inflammation, supposing, what is not always the case, that they are different diseases. We must in forming our opinion be guided both by the history of the case, its duration, and ils being asso- ciated often with menstruation, and the disproportion between the symp- toms and the degree of tumefaction of the vaginal portion of the womb. In chronic inflammation we rarely find tenderness of the vagina even near the cervix, which latter is sensitive in this disease as well as in neuralgia. The treatment of hysteralgia will be undertaken with a confidence that relief can be afforded, but without an assurance of a permanent cure. This latter result can never be procured unless any obvious excit- ing cause, such assexual intercourse, be abstained from. The indications are twofold: 1st, to mitigate, and, as far as any textural change is present, to remove the local lesion ; and, 2d, to improve the general health and invigorate the constitution. If there he redness, heat, and congestion of the cervix uteri, a few TREATMENT OF HYSTERALGIA; 70S leeches applied by means of the speculum will give, I know from ex- perience, great and prolonged relief. Scarifications by a cornea- knife passed down the speculum, seven or eight in number, and cru- cial in direction, so as to abstract three or four ounces of blood, is also an excellent remedy. Where, in addition to redness and tume- faction, there is some abrasion of surface or minute ulcers, nitrate of silver should be used after the leeching, and in some cases will of itself suffice. It may be applied either in its solid state by touch- ing the parts affected, or in solution and introduced by injection. The first is the preferable method when a speculum is at hand. But when the disease is clearly neuralgic and the uterus and its cervix are small, dry, and as it were shrivelled, no benefit can be pro- mised from leeching or scarification. In this case as well as in the other variety, after local depletion recourse is had to the various reme- dies applicable to neuralgia, such as chalybeates with narcotics, to the exclusion, however, of opium. Where dysuria prevails, as is often the case, tincture of the chloride of iron is the best form,and if neces- sary tincture of hyosciamus may be added. Dr. Ingleby recom- mends as a substitute for opium a combination of extract of hen- bane, camphor, and ipecacuanha, in doses of from four to five grains of the two former and half a grain of the latter. The extract of belladonna sometimes displays remarkable soothing effects in the dose of a grain or a grain and a half to be taken at bed time, or a smaller quantity to be taken at intervals of six hours. In intermittent neuralgia ofthe uterus sulphate ofquinia or infusion of bark gives prompt relief; or one may give extract of hyosciamus and extract of cinchona combined. Preferably to any of the sub- stances yet mentioned in the cure of hysteralgia is, according to Dr Inflebv's experience, the nitrate of silver, varying from one-eighth of°a grain to half a grain, combined with three or four grains of the extract of conium. In some cases of what Duparcque calls congestive engorgements of the neck of the uterus, which I have known to be associated with neuralgia, I have used on his recommendation ergot of rye, in doses of five^grains two or three times a day, with very marked, but I must add temporary benefit. There remains a remedy to be yet mentioned, which at first would seem to be illy calculated for this disease, in which the slightest contact of a foreign body often gives exquisite pain. I refer now to the use of the pessary. In some cases in which the os uteri had sunk low in the pelvis and even rested on the perineum, and which the patient had suffered for years, the introduction of a small-sized pessary has been followed by striking and permanent relief. The benefit on these occasions might be attributed to a renewal of ihe dragging of the uterus, but in"others, and I have had such cases myself, the pain and irritation were removed bv the introduction of the pessarv, although there had been htile or no displacement of the ulerus. May we not rather then refer the relief to sustained pressure of the instrument on the lips and neck of the uterus, which we sometimes find serviceable in other forms of neuralgia. On this principle, and from the analogy of the benefits of the bougie in irritable and strictured rectum aod 704 DISEASES OF THE ORGANS OF GENERATION. urethra, some have used this instrument in irritable or neuralgic va- gina. Regarding the latter, however, as for the most part sympto- matic of irritable uterus, the practice to which other objections will naturally apply can hardly be called for, except in some peculiar and rare cases. When neuralgia of the uterus is associated with dysmenorrhoea, the warm or the tepid bath and warm pediluvia are of service: but in other cases not so connected, the cold bath is sometimes of ser- vice. Aware of the association between irritation of the spine,or rather of the intervertebral portion of the spinal nerves, and neuralgia of remote parts, an examination should be made of the spine on both sides, and if any evidence of morbid sensibility be detected, a few leeches or a small blister ought to be applied to the part. Rest in a recumbent posture is essentially necessary, both for the avoidance of pain and to facilitate the operation of direct treatment. If possible, however, the patient should have at the same time ihe en- joyment of a fresh and pure air; and if circumstances allow of it in the warmer season, ihe advantage of sailing, or the passive exercise of riding on a railroad. Neuralgia of the Ovaries has not been described; but taking into consideration the seat and character of the pain, we cannot doubt that this variety prevails more than is generally supposed. When the diagnosis can be established we should use the remedies found ser- viceable in other forms of neuralgia, several of the more active of which have just been detailed. I proceed to another of the three divisions, laid down by me, of ihe diseases of the uterine system; but I shall deviate from ihe order in which they were enumerated to speak first of junctional diseases of this system. These will consist of deviations by privation or ex- cess of the function of the uterus and its appendages in unimpreg. nated females ; for, at present, my remarks will be restricted lo this class of subjects. The deviations from the rhythmical function of the uterus called menstruation, are—1. Amenorrhcea, iu which this discharge is wanting. 2. Dysmenorrhoea, in which it is de- ficient in quantity and otherwise abnormally altered; and, 3. Menorrhagia, in which it is in excess. Amenorrhea.—This may be briefly defined as the absence of menstruation, and consists of two forms: 1, the amenorrhea of retention; 2, the amenorrhea of suppression. The fiist of these again includes three varieties; viz., amenorrhcea dependent on con- genital deficiency, malformation or structural disease of the geni- tal organs ; that' where, independently of deficiency or malforma- tion, there is either a slow or a partial development or an entire absence of puberty; and, finally, the amenorrhcea, after puberiy is fully established. The amenorrhcea of suppression, where men- struation, having existed for perhaps a length of time, has, inde- pendently of pregnancy or lactation, become suppressed, includes two varieties—viz., recent or acute suppression and chronic sup- pression. Where amenorrhcea occurs from congenital deficiency art can do AMENORRHCEA. 703 but little; if the ovaries are wanting, nothing at all; for, as your physiology will teach you, we have now good reasons for believ- ing thai all ihe phenomena of menstruation depend upon the ova- rie>. and that at each period a Graafian vesicle bursts and its con- tents escape. The removal or destruction of both ovaries is fol- lowed by the absence of menstruation. In the circumstances of lardy puberty connected with slow and imperfect development, time is the chief element of relief, aided by hygienic means for aiding nutritive life and imparting additional tone to the system. Amenorrhcea after puberty is fully established will be treated according to the predominance of plethora or of anemia. In the first kind, we deplete by venesection or by cups over the loins and sacrum, mercurials and saline purgatives and reduced regimen, while the exercise should be regular and carried to the point of faiigje. All the excretions, pulmonary, ronal, and culaneous, are to be mainiained and moderately increased. Exer- cise on foot will have this effect on the first and last, while the second is to be kept up by mild diuretics and watery vegetables. No attempt should be made either by drastic purgatives or by supposed specific emmenagogues to act on the uterus until plethora and vascular excitement be reduced and the functions of the body at large brought to a healthy standard. This general result ob- tained the special one or procurement of menstruation will gene- rally follow. Failing in this expectation, the requisite local afflux may be obtained by leeches to the labia, inner surface of the thigh, the groin, and os uteri, followed, if need be, by the warm or vapour hip bath, continued for half an hour at a time, enemata of warm water, and injections of the same into the vagina. Leeches to the mammas sometimes bring on the menses. Tne regimen should be simple and in greater proportion of vege- table matters, with an abstinence from spirituous or vinous drinks and malt liquor. Amenorrhcea,on the other hand, in delicate and irritable subjects, and in those prone to hysterics, will require a different treatment. Often a series of symptoms present themselves designated by the term chlorosis, of which, as a form of anemia, I have already spoken and described its pathology and treatment. Nearly all that is said there will apply to the present kind of amenorrhcea ; and I shall not repeat it here except to remind you that the chief pathological con- dition is an impoverishment ofthe blood by the great diminuiionof its globules, and the chief therapeutical indication is to restore them and its lost colour. We fulfil this latter by the regular and pro- longed use of chalybeates, generally combined with purgatives — often with vegetable bitters. Suppression of the Menses, or the amenorrhcea of suppression, was stated to be recent, or acute and chronic. I shall speak of the for- mer first. The two great causes of acute suppression are mental emotions and the application of cold. Sexual intercourse during menstruation, fever, idiopathic or secondary, hemorrhage or vene- section, severe purgatives or emetics, iced water and ice cream are auxiliary and less frequent causes. In a young and middle aged 706 DISEASES OF THE ORGANS OF GENERATION. woman, fleshy, of a plethoric habit and ruddy complexion, the im- mediate suppression of the secretion will be followed by congestion if not by inflammation. While in a woman, delicate, ihin, and spare, of sallow aspect, and highly nervous, the more probable conse- quences are irritation, attended by spasm and paroxysms of severe pain, with intervals of ease. In the former case there will be sen- sations of weight and pain in the head and loins, tension and acute and constant pain in the region ofthe uterus aggravated on pressure, short breathing, a hot skin, and a full, hard and rapid pulse; occa- sionally there will be violent hysteria and not seldom delirium. Apo- plexy, hysteria approaching to epilepsy, partial and transient para- lysis, are occasional consequences of suddenly suppressed menses. (Ashwell — Practical Treatise on the Diseases Peculiar to Women, Part I.) Inflammation of the uterus ought to be added to this enu- meration. Treatment. — Time is not allowed us in the alarming emergency of suddenly or acutely suppressed menstruation in full habits, to attempt to restore the discharge. Venesection should be immediately practised and repealed in a short period ; or if an impression has been produced by the first bleeding leeches to the uterine region, as over the pubes, or cups to the sacrum will suffice. Tartar emetic with a little opium or calomel, and opium may be given every two hours. The warm bath, in which the patient ought to remain half an hour, will be a useful auxiliary to the more active treatment just detailed. Much distress and agitation still remaining, it would be well to act on the rectum, at first by a saline enema, and afterwards by one of oil of turpentine with mucilage, to which a few drops of laudanum have been added. Suppression in the case of a delicate and spare woman, who is highly nervous and irritable, is perhaps a still more frequent occur- rence than that just described. Even here inflammation may occur, although it is an event of unfrequent occurrence. According as it is present or absent, and as the pain is either neuralgic, spasmodic or inflammatory, will be the readiness to deplete or abstain. As a general rule, venesection will be seldom called for; and after local bleeding and counter-irritation by a sinapism or stimulating embrocation, the pain is often quickly transferred from the uterus to the head, or from the head to the chest or heart, and again from those parts to the intostinal canal (Ashwell). More reliance is placed on free purging than on bloodletting in this variety of suppression; to be followed by a warm bath at 96° to 98°, or a warm mustard hip-bath, or mustard pedilu- via. An antispasmodic draught may be given every two or three hours till the symptoms begin to subside. Liquor of acetate of am- monia, tincture of assafcetida and camphor mixture, make a useful combination for this purpose; or a pill containing two or three grains of camphor may be taken every three hours. I have occasionally found free drinking of hot water give great relief from pain and spasms in some cases of this nature. But still more soothing and even decidedly beneficial are enemata of laudanum or of laudanum with assafoetida mixture. Chronic suppression of menstruation may result from an acuta TREATMENT OF AMENORRHEA. 707 attack, or it may gradually come on either from defective activity of the uterus or from functional derangement in other organs affecting the general health. Before we engage in a course of treatment for suppressed or very scanty menses, we ought to know the history of the patient and her habit in this particular. In some cases record- ed by Dr. Dewees there was a great anticipation of the period of the decline and cessation ofthe menses, as where the function ceased altogether before the twenty-fifth year. The symptoms of chronic suppression are various, and some of them anomalous, being the product of disorders of the nervous system which may simulate nearly every other complaint. Hence, we meet with peculiar sensations in the head, disorders of the senses, breath- ing and spasms, dyspnoea, palpitations, pains in the chest, , I flow)— Difficult or Painful Menstruation. This disorder has been defined : Menstruation, preceded and accompanied by acute and often lanci- nating pains in the uterus and adjacent parts, and occasionally in the mammas, with derangement ofthe secretive function; the catamenia being usually though not invariably s?.anty in quantity, and in the severer and more chronic cases, clotted, shreddy or membranous. (Ashwell.) Dysmenorrhoea is quite a common and a painful disease, attacking, as far as my own observation extends, females of very different tem- peraments and external appearance and constitution — the other- wise healthy and of florid complexion, and the thin, the nervous, and the pale; sometimes the sanguineous, some'imes the lymphatic. It often prevents conception, and, in the cases of single women, lays the foun- dation for future organic disease of the uterus. Lisfranc (Clinical Lectures on Diseases of the Uterus) asserts, that it is hereditary, and that on inquiry it will be found that other members of the patient's family have suffered in a similar manner, and have died of disease of SYMPTOMS OF DYSMENORRHEA. 709 the uterus. Mere pain in the pelvic region and fulness and tightness of the head are not to be regarded as dysmenorrhoea if these disturb- ances pass away with the flow of the menses. Scanty menstruation is not always difficult; nor is the opposite state free from suffering. Symptoms. — This disease may exist with different conditions both of the uterus and of the constitution, being sometimes plethoric, some- times neuralgic, and again congestive. Menstruation comes on at the usual time in those subject to dysmenorrhoea, but with an inten- sity of pain, scarcely exceeded by that of labour itself. In some cases of the neuralgic kind the symptoms are of short duration, con- tinuing only for the first day or two of the period; when, after the expulsion of a small clot, not always firmly coagulated, the discharge assumes its natural consistence, and is unaccompanied by more than the usual local uneasiness. In others the whole time is one of intense suffering, commencing with sharp, darting, lancinating pains in the uterus and vagina, and extending apparently to the uterine appen- dages. There is acute sympathetic pain in one or both breasts; the lumbar pain, running down the sacrum to the thighs and groins be- comes excessive : and during the emission of the discharge the ex- pulsive pains, resembling the throes of labour, add much to the suffer- ing. During the whole period little febrile excitement exists, and the amount of constitutional injury, from one or even several of these attacks, is inconsiderable. But with the continuance of the disease the case is different: the digestion suffers and the health begins to fail. In plethoric dysmenorrhoea the menstrual period will be preceded by headache, flushing of the face, full and quick pulse, a sense of weight in the pelvis, rigors, and sometimes by delirium. These pre- cursory symptoms are followed by the catamenia, which are some- times profuse and with more or less of coagula. More frequently, how- ever, the discharge is scanty, and consists of clots with portions of membrane; and ihe difficulty of emission is extreme. Still availing myself of the description of the varieties of this disease by Dr. Ashwell, I shall next notice congestive dysmenorrhea, which often becomes so by mismanagement, owing to a stimulating treatment informer attacks and thelarge and indiscriminate use of iron and al >es. The premonitory symptoms in this variety are comparatively slight. A sense of weight in the pelvis, with the bearing down pains of prolapsus, lumbar pain, frequent micturition and constipated bowels denote an enlarged uterus. But it is not till the function is about to commence that the very severe symptoms arise. There is often intense uterine pain, with a sensation as though some foreign body were shut up in the uterine cavitv; and in the attempts at its expulsion the uterus is aided bv the voluntary as well as involuntary efforts. One marked peculiarity in this form is the absence of inflammatory symptoms. The pulse is rather weak, sometimes quick and irritable; the skin is perspirable, and there is exhaustion, not inflammation. During the intervals of congestive dysmenorrhoea, where false membranes are con- stantly expelled, there is generally abundant leucorrhoeal discharge, the health becomes increasingly disordered, the mammae shrivel, and the legs are oedematous. It is in this variety that spurious abortion most VOL. I.—60 710 DISEASES OF THE ORGANS OF GENERATION. frequently occurs. A mass is ejected from the uterus, which is made up of a condensed or laminated coagulum with portions of membrane, or a membrane moulded to the cavity of the uterus inclosing a large coagulum. Diagnosis.—The general character of dysmenorrhoea is pro- claimed sufficiently by the symptoms, and it is only in cases of what are called spurious abortion, or expulsion of coagula, and membrane resembling the decidua, that doubt may be entertained respecting the real character ofthe disease. We shall be aided in our opinion by a knowledge of the duration of the disease, the nature of the menstrual secretion in former periods, and the enlarged state ofthe uterus from congestion, as ascertained by examination through the vagina and the rectum. Dr. Montgomery, in the ninth chapter of his admirable work on The Signs and Symptoms of Pregnancy, distinguishes the two products, that in dysmenorrhoea and that in pregnancy, in the following passages: "The substance expelled in such cases will be found deficient in several of the characters ofthe true decidua ; for although produced by an action in the uterus analogous to that by which it prepares the decidual nidamentum for the reception and support of the ovum, it differs therefrom in two essential points; first, that it is a morbid product; and secondly, that, not being intended, like the true decidua, to become an organ, or at least a medium, of nutrition for the ovum, it is not furnished wth a structure such as would only be required for the performance of such an office ; hence, it is thin, flimsy, and very unsubstantial in its texture, of a dirty white or yellowish appearance when slightly agitated in water, devoid of the soft, rich, pulpy appear- ance, deep vascular colour, and numerous foramina for the reception of the nutrient vessels from the uterus, which are always so distinctly observable in the true decidua, which, however, in one point it resem- bles, having its inner surface smooth, and the outer unequal, but of a ragged, shreddy appearance, unlike that of the healthy uterine decidua, and it is, moreover, entirely destitute of the little cotyledo- nous sacculi already described as an essential character in the latter structure. " In texture, it more nearly resembles that of the reflexa than any other structure ; but no trace of the transparent membranes of the ovum can be discovered within it, or attached to it, and should it happen to come away entire, in the form of a hollow triangular bag, we never find within it a duplicature of itself forming an inner pouch or reflex layer, as in the case of the natural decidual enve- lopes of the ovum. Morgagni has given a very accurate account of this accidental product, as it occurred in the case of a noble matron of his country, who expelled it almost every month with pains like those of child-birth, having its external surface unequal and not without many filaments that seemed to have been broken off from the parts to which they had adhered ; but internally hollow, on which surface it was smooth and moist, as if from an aqueous humour which it had before contained." (Epist. xlviii., art. 12.) Prognosis.—This ought to be very guarded. The opinion of Den- man, that no woman in the habit of forming this membrane has been known to conceive while such habit exists, is not correct. Cases of TREATMENT OF DYSMENORRHEA. 711 its disproof must have occurred to most practitioners of much expe- rience in female diseases. Treatment. — This cannot be satisfactorily carried out unless we are able to ascertain the actual state of ihe uterus, whether it is con- gested, or its cervix thickened or not. An examination during the in- ter-menstrual period, if allowed, will enable us to prescribe with judgment on these occasions. It has been argued that the membrane discharged from the uterus, and evidently a coat formed in its mucous membrane, is proof of inflammation, and the croup has been referred to as an analogous case. It cannot, however, be denied that this membranous formation on mucous membranes is formed at times in states of very moderate arterial or capillary excitement, as in epi- demic angina or diphtherite, and also in that disease which I desig- nated by the title of enterorrhoza wilh membranous formations (Lec- ture XXIV). It is a little curious, as I stated at the time, that some of the most marked cases occurred in females, who, while affected with obstinate diarrhoea for months and even years, passed daily a lan,re number of these membranes. Hence we are not allowed to assume the presence of inflammation in every case of well marked dysmenorrhoea, and to deduce from this view an antiphlogistic treat- ment. When, however, plethora is present and the cervix uteri con- gested, we ought to draw blood by means of cups to the loins or leeches to the vulva or cervix itself. A derivative bleeding from the arm to the extent of a few ounces will also be serviceable in such cases. For the most part the treatment resolves itself into that during the period of pain or menstruation and that during the interval. If de- pletion, as just described, have been used, we continue the effect by ipe- cacuanha or tartar emetic in doses approaching to a nauseant opera- tion. I have, from analogy of the disease to rheumatism, directed wine of colchicum with, I believe, good effects. It may be well to know that rheumatism or the rheumatic diathesis sometimes mani- fests itself in the female by dysmenorrhoea. Undue confidence is placed in anodynes from the narcotic class for the relief of pain in the disease now under notice. When combined with ipecacuanha, as in Dover's powder, or with tartar emetic, they are more reliable. Camphor sometimes gives much comfort, and by Dr. Dewees (Diseases of Females), it was said to be "the most efficient and uniformly certain that he has yet discovered." In violent sympathetic ex- citement of the nervous system an opiate may be given in the even- ing or an anodyne enema or suppository directed in its stead. In aid ofthe expulsive efforts of the uterus, ergot, either in decoction or tinc- ture, may be repeatedly given. Just now the medicine which enjoys most vague in dysmenorrhoea is the liquid acetate of ammonia, in doses of°from fifty to seventy drops, which may be repeated four times in the twenty-four hours. In smaller dose its effects are hardly appreciable. Its administration is followed by a sort of temporary intoxication. We must not neglect to inquire into the condition of the bowels, and if constipation have prevailed, to empty them by an emollient clyster, or a more active one of castor oil and turpentine in neuralgic cases. 1 712 DISEASES OF THE ORGANS OF GENERATION. have given a full doseof calomel with opium atnight, and wineof colchi- cum and magnesiain the morning, with evidently soothing effect. The warm hip bath or the general warm bath is comforting and service- able; but to be so the patient ought to remain in it until a sensible lan- guor is experienced. Dr. Chapman thinks very highly of the poly- gala senega, and Dr. Devvees of the volatile tincture of guaiacum in painful menstruation. When consulted in dysmenorrhoea, I take pains to tell the patient or her friends that scarcely any thing beyond mere palliation can be accomplished during menstruation or the period of suffering. Our curable efforts should be made during the interval. With this view an alterative course of blue pill or calomel and hyosciamus, if the digestion has suffered, or there be evidences of uterine engorgement or congestion. In more clearly neuralgic cases I direct chalybeates, and chiefly the iodide of iron and the tincture of the chloride, alter- nating with laxatives according to the state of the bowels. I have administered iodine and chiefly the iodide of potassium in four cases of females who had been married for some years, but who, on account of their dysmenorrhcea, had never conceived, but yet who, after having continued the medicine for some time, became pregnant and bore healthy children. Arsenic is worth a trial in the more violent cases of dysmenorrhcea; before having recourse to it sulphate of quinia should have been used in tolerably full doses. The cold bath and cold hip bathing, and cold injections in the vagina, are said by Dr. Locock to be attended with much benefit, as 1 understand him during the inter-menstrual period. Dr. Mackintosh (Principles of Pathology and Practice of Medi- cine) believing that some cases of dysmenorrhcea depended on me- chanical obstruction by occlusion of the os tincse and passage into the uterine cavity, recommended and practised the introduction into this canal of a very fine metallic bougie. He reports twenty-four cases of cure in twenty-seven of disease. "Nine of the women had suffered for a shorter period than two years ; some for three or four ; and others ten." Dr. Churchill divides the disease into three spe- cies; the inflammatory, the neuralgic, and the mechanical. He cites Capuron as enumerating mechanical obstruction among the causes of dysmenorrhoea. Dr. Churchill mentions a case in which he and Dr. O'Reilly distinctly ascertained the presence of a stricture about halfway up the canal ofthe cervix. This stricture they succeeded in dilating. But he frankly admits, in proof of the disease depending on something else than mechanical obstruction, that although the stric- ture was relieved the dysmenorrhcea continued as before. SYMPTOMS OF MENORRHAGIA. 713 LECTURE LXXV. DR. bell. Menorrhagia—Divisions into active or acute and passive, the latter including: the congestive.—Acute menorrhagia —Symptoms — Causes—Diagnosis— Similarity of menstrual to common blood—Treatment—Passive menorrhagia—Risk of organic cause—Necessity of examination by the vagina— Leucorrhcea—Whe- ther a disease of the vagina or uterus—Sometimes is a metro-vaginitis— More commonly is vaginitis—Definition of leucorrhcea—Acute vaginitis — Symptoms—Subsidence of symptoms—Alternations of disease and suspension— State of the cervix uteri—Chronic or gleety vaginitis—Symptoms—Causes of va- ginal and uterine leucorrhcea—Diagnosis—That between leucorrhcea and gonor- rhoea cannot be made—Treatment—To withhold astringents and special medica- tion during the first sta or on horseback in older forms of disease; sea-bathing when it can be be procured, and easy-fitting garments, complete the hygienic treatment. GONORRHEAL VAGINITIS—TREATMENT. 725 Gonorrhoeal Vaginitis—Gonorrhoea in Women. — As the symp- toms of this disease are so closely analogous to and in a great mea- sure identical with those of leucorrhcea, so the treatment is the same in both diseases. In both the approach is sometimes so gradual as -''not to excite attention ; and a women may, sometimes innocently, as regards her veracity, deny she has any gonorrhoeal taint. But in other cases, again, the first acute stage is marked by symptoms of con- siderable violence, more as a general thing we might say in gonor- rhcea than in leucorrhoea. In the former, also, we may expect to meet more than in the latter with swelling of the nymphae and labia, ac- companied by serous infiltration requiring incisions, and also by vagi- nal abscesses. Ovaritis, considered as a complication of gonorrhcea, requires antiphlogistic treatment commensurate with the intensity of the symptoms. Leeches applied to the lateral and lower parts of the abdomen, anus, and sacral region ; venesection, sometimes aided by emollient fomentations and cataplasms, generally succeed. The bowels ought to be kept open by gentle laxatives. Here, as in orchitis, frictions with mercurial ointment made upon the abdomen may pro- mote resolution. In some cases in which acute gonorrhcea proves intractable to the antiphlogistic regimen, and in which the vaginal mucous membrane is still red and turgid, M. Ricord tells us that he has obtained asto- ishing results from the use of nitrate of silver, used in its solid state, to cauterise the mucous surface, or in solution applied by means of lint. After the use of the cautery, a tampon of dry lint must be introduced to prevent the contact of the parietes of the vagina. This suggests the mention of a treatment to which M. Ricord is partial in the gonorrhcea in both sexes. I have already described it in treating of urethritis'in the male. In the case now before us, he fills the vagina without much distending it with dry lint, renewed two or three times a day, accord- ing to the quantity of the discharge, which, in the cases that termi- nated successfully, was white and milky, and proceeded from the vagina alone. Ulcerations and papulous granulations must be cauter- ised with nitrate of silver, which is to be preferred, or with nitrate of mercury by means of a bit of lint. Like other portions of the mucous membrane of the sexual organs, the internal orifice of the womb is frequently the seat of ulcerations, which the means hitherto pointed out cannot cure. To meet the emergency, M. Ricord has injected into the uterine cavity one part of nitrate of mercury in eight parts of water; but the effects were so violent as to incline him to diminish the strength ofthe solution by adding to a grain of the nitrate twelve parts of water. Subsequently he substituted nitrate of silver, six grains 1o the ounce of water, and found that in some instances a chronic purulent dis- charge was cured after two or three injections. M. Ricord states that nitrate of silver, applied to ihe cervix and cavity of the uterus, frequently acts as an emmenagogue. After the cure of vaginal and uterine gonorrhcea, M. Kicord advises injections of cold water to be continued for some time, once or twice a dav; taking care to discontinue them four or five days before the VOL. I.--62 726 DISEASES OF THE ORGANS OF GENERATION. period when the menses are expected, and again employing them four or five days after the cessation. Organic Diseases of the Uterus. — I cannot treat formally at this time of organic diseases of the uterus or its appendages,nor shall* I even pretend to enumerate them. My only design is to direct your attention to a few practical points in their diagnosis and treatment, with a view to your making the necessary investigations and ascer- taining what really is the disease of which your patient complains, so that you can make up your mind as to your ability to undertake the treatment ofthe case or transfer it to more experienced persons. Metritis—Inflammation of the Uterus — you will not often encounter in its acute form. When it does occur, you will meet, in addition to the symptoms common to metro-vaginal" disease, such as irritation at the neck of the bladder, sometimes heat and uneasiness in the pelvic region, pain on pressure above the pubes, and enlargement of Ihe size of the uterus fell on vaginal examination, paroxysms of sharp pain in the back, dartihg through the symphysis pubis and down to the groins and thighs. After a while the rectum and vagina, as well as the urethra and bladder, participate in the irritation ; both faeces and urine being discharged with considerable pain. An irri- table stomach and disordeied digestion are among the remoter sym- pathetic disturbances. The treatment will not differ from that of the phlegmasia? in general; and if carried out in this sense boldly, the result will be successful. Our main reliance is on venesection, cups to the sacrum, leeches to the vulva or groins, tartar emetic and opium, and calomel and opium ; with counter-irritants to the sacrum and on the inside of the thighs, of turpentine, croton oil, and tartar emetic, preferably to a blister, which, if it produce strangury, will greatly add to the distress of the patient. While we take care to keep the rectum empty, we ought not to induce much purging in acute metritis. Cooling and diluent drinks with mild diuretics will be useful. Chronic Metritis is a much more common disease than the acute form, and still more does it occur as a partial than an entire inflamma- tion of the organ. It comes on for the most part slowly, and inde- pendently of any acute attack. The symptoms, though of the same kind, differ in degree from those attendant on the former inflammation. To its consequences we attach the most importance. These are ulceration, suppuration, and indurated enlargement of the substance of the uterus generally, and especially of its neck ; of the existence of which you can only assure yourself by examination both by the touch and introduction of ihe speculum. Pain of some part of the cervix on moderate pressure with the finger will usually be felt. The ele- vated state of the mucous follicles, termed granular inflammation of the cervix, and in other cases abrasions and ulcerations, are ascer- tained also in the same way. The constitutional disturbance from chronic metritis is manifested often in the sallow countenance, the impaired appetite and digestion, TREATMENT OF PROLAPSUS UTERI. 727 abdominal pain, slight emaciation, and a gradual loss of strength and appetite. The treatment of this form of inflamed uterus will consist in lopical depletion, by cupping on the loins, leeches to the perineum, and still better, if possible, to the cervix itself, and scarification of this part. As justly observed by Dr. Ashwell, it cannot be too strongly urged that iodine, mercury, conium, lime, or arsenic, will exercise no beneficial influence in exciting absorption, till local de- pletion, aided by other means, such as saline laxatives, a plain yet nutritious diet, as that of milk, for example, recumbent posture, absti- nence from sexual intercourse,country or sea air, and abstinence from every kind of excitement. Friction of the inside of the thighs by solutions of tartar emetic, but not to pustulate, is a remedy recom- mended by Duparcque, and, also, ergot, in congestion and chronic phlogosis. From this last I have procured for a while much relief for my patient. A small blister to the sacrum kept discharging for some weeks might be of service. You will be the more solicitous to ascertain the presence of chronic inflammation of the cervical region of the uterus, when you learn that its consequences are disorganizations and malignant diseases, vvhich art may measure the stages of, but can seldom cure. Such are corroding ulcers, cauliflower excrescence, and cancer ofthe uterus. Prolapsus Uteri.—As quite a common and troublesome, and by the uninitiated little understood, and, therefore, often a misma- naged disease, I wish to put you on your guard as to its leading symp- toms. Every now and then a female will consult you or get a friend of her own sex to speak for her ; more generally, too, the advice will be asked for sideways, and when you are visiting some other mem- ber of the family. You will be asked what is good for strangury, or a frequent desire to pass water; and perhaps, with great simplicity, you may prescribe some diuretic or an anti-lithic; but in vain. Your patient still complains, and will now, perhaps, add that she has pain in her back or loins, and a feeling of dragging and bearing down, and that her bowels are sometimes disturbed without any apparent cause, and without relief by evacuation. She, also, has leu- corrhcea, which, perhaps, she regards as her disease, and therefore one to be treated by nurses, prescriptions rather than by the doctor. It mav be that she does not allude to any pelvic annoyances, but will describe to you the feeling of emptiness or gnawing at her stomach, or pain ofthe left side; she will also have hysterical disorder. Now all these symptoms are frequent, I do not say invariable attendants, on prolapsus uteri, which, once suspecting your patient to be troubled with, you will ascertain positively by an examination per vaginam. There are many degrees of displacement of the uterus, from the descent of the organ an inch or two in the pelvis to its falling down so low as to rest on the perineum. To the first mentioned displace- ment the name of relaxation ofthe uterus is giveii. The treatment is general or constitutional, and local. The first will consist in a restoration to health ofthe digestive apparatus, and 723 DISEASES OF THE ORGANS OF GENERATION. especially the removal of costiveness, the straining by which sometimes brings on the disease. Coughing and violent vomiting have produced the same effect. Rest in a recumbent posture for a length of time is one of the chief means of restoring the tone of the uterine ligaments above and that of the vagina below, by taking off the strain of the uterus. Not unfrequently, however, the general health suffers by such long confinement; and hence a call for some means by which the uterus can be supported and the patient allowed exercise. These objects are met by the introduction into the vagina of an instrument called a pessary, made in different figures aud of differ- ent materials. In Dispensary practice I used most the cork pessary well coated with wax. In common, preference is given to ivory, box-wood, glass, and still better to silver, gold, or platina. Sponge and gum elastic are bad, as they soon become offensive by imbibi- tion ofthe vaginal and uterine fluids. The globuHfr or oviform are those the figure of which is generally preferred. For a description of the fashion and material of pessaries, and arguments respecting their use, I refer you to Churchill's full and learned work, heretofore named and quoted, and also to Blundell's. My object is to suggest to you the circumstances under which the instrument may be required, but not to describe or detail its use. Pads and compresses under different names have lately been much substituted for pessaries; but until the novelty is over, we cannot estimate their true value. Sometimes we meet with cases of partial prolapsus caused by the weight of an engorged and congested uterus, which is too heavy to be supported by its ligaments, even when, as is mostly the case in the disease, the vagina is unduly enlarged and its walls relaxed. The remedies in this case will be, to remove the uterine congestion and to keep the patient at rest in a semi-recumbent as the less fatiguing posture. In closing my remarks on the Diseases of the Female Genital Or- gans, I refer you, for abundant and instructive details, often de- duced from sound principles, to the authors of different works on the subject, to which you can procure ready access. They are Dewees, Blundell, Churchill, Lisfranc, Waller, Ingleby, Duparcque, and ere long the translation, by Dr. Meigs, of the great work of Co- lombat d'Isere. On the subject ofthe chief diseases of the puerperal state, including uterine inflammation, crural phlebitis, and peritonitis, you will consult Dr. Robert Lee's Lectures on the Theory and Prac- tice of Midwifery; and also a volume introduced by Dr. Meigs, con- sisting of the essays of Gordon, Hey, Armstrong, and Lee. It is a source of pleasurable reflection that "three ofthe volumes here named have been brought into notice through my Select Medical Library. END OF VOL. I. R&C: Philadelphia, 293 Market Street, |3 >^f Jannarv. 1845. S> ■.' ' January, 1845 STANDARD WORKS ANATOMY, MEDICINE, SURGERY, !/>tt, CTlie Collateral Sciences, PUBLISHED BT ED. BARRINGTON & GEO. D. HASWELL, M EDICAL BOOKSELLERS AND PUBLISHERS. MOTH THE Ea,S©cifaKa@KIV ®P TTHB PBSSSo Orders forany of the books mentioned in the accompanying Catalogue, | can be executed by the principal Booksellers and Druggists in the United States. % »• t-^iaSK»3^^^^S5TOW35^5B5TO BARRINGTON &. HASWELL'S BARRINGTON & HASWELL Respectfully ask the attention of the Profession to the SELECT MEDICAL LIBRARY, EDITED Bt JOHN BELL, M.D., Lecturer on Materia Medica and Therapeutics; Fellow ofthe Collegeof Physicians, Philadelphia Member of the American Philosophical Society; -- Corresponding Secretary of the Medical College of Philadelphia, etc., etc. Each No. of the Library is issued quarterly, in January, April, July, and October, and consists of one or more approved works on some branch of Medicine, including of course, Surgery and Obstetrics. 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" We recommend this volume most warmly to the attention of our readers."—London Lancet, No. 937. " This volume may, in fact, be denominated with no small degree of propriety, an encyclopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases with which we are ac- quainted."—JV. Y. Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and dis- eases comprehended under the term dyspepsia, united with a very large proportion of original matter, both in the form of able comments on other writers, and practical information derived from the author's own experience."—Med.-Chir. Rev. EPIDEMICS OF THE MIDDLE AGES. I. F. C. Hecker, M.D. EPIDEMICS OF THE MIDDLE AGES. From the German of I. F. C. HECKER, M.D., Etc, Etc. Translated by R. G. BABINGTON, M.D..F.R.S. NO I. THE BLACK DEATH IN THE FOURTEENTH CENTURY. "Hecker's account of the'Black Death,'which ravaged so large a portion of the globe in the fourteenth century, may be mentioned as a work worthy of our notice, both as containing many interestingdetails of this tremendous p^tih-iicc, and as exhibiting a curious specimen of medical hypothesis."—Cyclopedia of Practical Medicine. NO. II.---THE DANCING MANIA. "Medical History has long been in need of the chapter which this book supplies; and the deficiency could not have been remedied at a better season. On the whole, the volume ought to he popular; to the profession it must prove highly acceptable, as conveying so much infor- mation, touching an important subject which had almost been suffered to be buried in obli- vion, and we think that to Dr. Babington especial thanks are due for having naturalised so interesting a production. The style of the translation, we may add, is free from foreign idioms: it reads like an English original.''—Land. Med. Gaz. 12 MEDICAL PUBLICATIONS. TETANUS. Thomas Blizard Curling. A TREATISE ON TETANUS. BEING THE ESSAY FOR WHICH THE JACKSONIAN PRIZE WAS AWARDED. By THOMAS BLIZARD CURLING, Assistant Surgeon to the London Hospital, etc., etc. 1 vol. Svo. muslin. "This book should be in the library of every surgeon and physician. It is a valuable work of reference. It does not pretend to originality, for originality on such a subject was not wanted. But a compendium of facts was wanted, and such a compendium is this volume. We cannot part from Mr. Curling without thanking him for the information we have received."__ Med. Chir. Rev. INSANITY. James Cowles Prichard. A TREATISE ON INSANITY. By JAMES COWLES PRICHARD, F.R.S., M.D., Corg, Member ofthe Institute of France, etc. 1 vol. 8vo. sheep. " The author is entitled to great respect for his opinions, not only because he is well known as a man of extensive erudition, but also on account of his practical acquaintance with the subject on which he writes. The work, we may safely say, is the best, as well as the latest, on mental derangement, in the English language."—Mcdico-Chir. Rev. I. G. Millingen. APHORISMS ON THE TREATMENT AND MANAGEMENT OF THE INSANE, WITH CONSIDERATIONS ON PUBLIC AND PRIVATE LUNATIC ASYLUMS, POINTING OUT THE ERRORS IN THE PRESENT SYSTEM. By I. G. MILLINGEN, 31.D., Late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, etc. 1 vol. Svo. sheep. "Dr. Millingen. in one small pocket volume, has compressed more real solid matter than could be gleaned out of any dozen of octavos on the same subject. We recommend his vade mecum as the best thing ofthe kind we ever perused."—Dr. Johnson's Review. M. Esquirol. A TREATISE ON MENTAL DISEASES. By M. ESUUIROL. A 13 BARRINGTON 8c HASWELL'S -*---------------------------------------------->. CHEST. Charles J. B. Williams, M.D. LECTURES ON THE PHYSIOLOGY AND DISEASES OF THE CHEST. INCLUDING THE PRINCIPLES OF PHYSICAL AND GENERAL DIAGNOSIS, Illustrated by an Exposition of their Physical Signs. WITH NEW RESEARCHES ON THE SOUNDS OF THE HEART. By CHARLES J. B. WILLIAMS, M.D. Third edition. 1 vol. 8vo. sheep. " Evidently written by a man thoroughly acquainted with his subject."—Lancet. " We strongly recommend this work to the attention of auscultators."—Med. Chir. Rev. " I gladly avail myself of this opportunity of strongly recommending this very valuable work."— Dr. Fbrbes's Translation of Laennec. "Of all the works on this subject, we are much inclined to prefer that of Dr. Williams."—Med. Gazette. W. W. Gerhard, M.D. LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE CHEST. - Br W. W. GERHARD, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc. 1 vol. 8vo. sheep. " A series of clinical lectures—concise, lucid, and eminently instructive. We have no more able expositors of diseases of the chest than Dr. Gerhard, and any work of his on these important subjects is certain of grateful acceptance by his professional brethren."—New York Lancet. " To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and most judi- cious manual, in relation to the diseases of the chest, which they can procure."—Western and Southern Recorder. "These lectures constitute a useful and practical digest of the existing knowledge ofthe diseases of the chest (lungs and heart)."—Bulletin of Medical Science. G. Hume Weatherhead, M.D. A PRACTICAL TREATISE ON THE PRINCIPAL DISEASES OF THE LUNGS. CONSIDERED ESPECIALLY IN RELATION TO THE PARTICULAR TISSUES AFFECTED, ILLUSTRATING THE DIFFERENT KINDS OF COUGH. By G. HUME WEATHERHEAD, M.D., Member ofthe Royal College of Physicians, Lecturer on the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, etc., etc. 1 vol. Svo. muslin. 14 MEDICAL PUBLICATIONS. Wm. Stokes, M.D. A TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE CHEST. \ By WM. STOKES, M.D.,M.R.I.A., Etc Second Edition, with an Introduction and Numerous Notes, BY THE AMERICAN EDITOR. 1 vol. 8vo. sheep. " Altogether this is one of the most useful of the publications that have recently issued from the press,—one thatjshould be studied by every man who presumes to treat the class of diseases on which it is written. It is delightful, indeed, to contemplate the sound pathology and rational therapeutics which it inculcates ; — so diiferent from the swelling egotism, the groundless assertions, the illogical conclusions, and often empirical treatment, recommended in some of the modern works on these and other important medical subjects."—Med. Examiner. " The present edition has been much enriched both by the author and editor. No inconsiderable part of the book is made up of Dr. Bell's notes, and it now constitutes one of our most useful treatises on the diseases of the chest, characterized by sound pathology and rational therapeutics."—New York Journal of Medicine. " So well-known are the writings of Dr. Stokes, that no effort of the medical press in this country is necessary to increase their circulation. Young practitioners would find this volume a pathological guide, which they would be unwilling to part with, when made familiar with its intrinsic value." Boston Med. and Surg. Journ. THE HEART. T. A. Aran. A PRACTICAL MANUAL ON DISEASES OF THE HEART AND GREAT VESSELS, Translated from the French, By WILLIAM A. HARRIS, M.D. " This is an excellent epitome of a large and important class of diseases—especially as to diagnosis."—Med. Chir. Rev. "The Treatises of Senac, of Corvisart, of Laennec, of Bertin, of M. Bouillaud, of M. Gendrin, and especially the excellent work of an observer whom death has pre- maturely removed from the field of science (Dr. Hope), have been our principal guides."—Extract from the Preface. " This work, though issued under the modest title of a manual, is yet so comprehen- sive as to afford minute instruction on every point of which it treats."—Philad. Med. Examiner. « We do not know of any production in which so much positive knowledge has been compressed within moderate limits, and yet clearness of description presented, as in this manual. >-Bulletmof Med. Science. . " We horje this manual, comprising, as it does, a summary of what has been published in more elaborate works! will be extensively^read, and that the study of it may lead to a more correct appreciation of the character of these diseases."-WEsT. Jour, op Med. and Surg. « The nresent treatise will prove of great value, as it really contains all that is well known on this most difficult yet important branch of pathology and therapeutics."-WEST. Lancet. BARRINGTON & HASWELL'S L _---------------------------------:------------------------&. John Marshall, M.D. PRACTICAL OBSERVATIONS ON DISEASES OF THE HEART, LUNGS, STOMACH, LIVER, ETC. OCCASIONED BY SPINAL IRRITATION; AND ON THE NERYOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By JOHN MARSHALL, M.D. 1 yoI. 8vo. muslin. CUTANEOUS DISEASES. Samuel Plumbe. A PRACTICAL TREATISE ON DISEASES OF THE SKIN, Their Constitutional Causes and Local Character, etc. By SAMUEL PLUMBE, Lale Senior Surgeon to the Royal Metropolitan Infirmary for Children, &c. /A Illustrated with Splendid Coloured Copper-plate and Lithographic Engravings. New ^J edition in preparation. Plumbe on Diseases ofthe Skin.—"This excellent Treatise upon an order of diseases, the patholnzy of which is, in general, as obscure as the treatment is empirical, has just been repub- lished, edited by Dr. John Bell, of this city. We hail with pleasure the appearance of any new work calculated to elucidate the intricate and ill-understood subject of skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the 'best pathological and prac- tical treatise on this class of diseases, which is to be found in any language.'"—Phil. Med. F.xam. " This work is one of the most excellent on the Diseases of tbe Skin in tbe English language." — West. Jour, of Med. and Phys. Sciences. Thomas Nunneley. A TREATISE ON THE NATURE. CAUSES, AND TREATMENT OF ERYSIPELAS. By THOMAS NUNNELEY, Lecturer on Anatomy, Physiology, and Pathology in the Leeds School of Medicine, Surgeon to the General Eye and Ear Infirmary, &c, &c. 1 vol. Svo. sheep. " The work in its entireness is one which will be accounted necessary to every physician's library."—Western Journ. of Medicine and Surgery. "Nothing short of a perusal ofthe entire book will do justice to the author or reader."— Western Lancet. " Did our space allow, it would be both interesting and'profitable to enter into a fuIKanalysis of this work; but we would advise our readers, one and all, to purchase it, and thus judge of its value from a personal examination of its pages."—N. Y.Jour. Med. and Collat. Sciences. A A if. MEDICAL PUBLICATIONS. CLINICAL MEDICINE. P. M. Latham, M.D. LECTURES ON SUBJECTS CONNECTED WITH CLINICAL MEDICINE. By P. M. LATHAM, M.D., Fellow ofthe Royal College of Physicians, and Physician to St. Bartholomew's Hospital. 1 vol. Svo. muslin. " Wc strongly recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals.''—Lond. Med. Gaz. - Graves and Gerhard. CLINICAL LECTURES. By ROBERT J. GRAVES, M.D., M.R.I.A., Professor ofthe Institutes of Medicine in the School of Physic, Trinity College, Dublin. WITH ADDITIONAL LECTURES AND NOTES, By XV. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania, Physician to the Philadelphia Hospital, Blockley, &c. 1 vol. Svo. sheep. " In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most appropriate and acceptable addition to those of Dr. Graves. Between these two distinguished physicians we can trace many points of resemblance. We find in both tho 6ame professional zeal, — the same powers of close and correct observation,—the same discriminating tact, — the same disregard of idle theory, —and the same decision in the application of right principles. No stu- dent or practitioner should be without this volume. It is in itself a library of practical medicine." —N. V. Lancet. G. Andral's CLINIC ON DISEASES OF THE ENCEPHALON. „ „ ABDOMEN. CHEST. Either ofthe works can he had separatei —each forming a distinct volume. Three vols. Svo. sheep. " The ' Clinique Medicaid is the great work of its distinguished author. It is an immense store house of invaluable information in pathology and therapeutics. No medical library can be complete without it; and every physician, with the smallest pretensions to scientific attainment, or who is desirous of discriminating disease accurately, and of treating it skilfully, should study Its pages by day and nipht." , t. . . .. ,, .. "AndraJ's extensive researches in pathology entitle all his works to the careful considera- tion ofthe profession ; and all must agree that this great philosopher has enriched tbe science with many important truths, derived from that fruitful source, clinical observation and induc- tion.''— Western Lancet. BARRINGTON & HASWELL'S «t-----------——-—.---------------------------------.----.-----&• URINARY DISEASES. Robert Willis, M.D. URINARY DISEASES AND THEIR TREATMENT. By ROBERT WILLIS, M.D., Physician to the Royal Infirmary for Children, etc., etc. "We do not know that a more competent author than Dr. Willis could have been found to undertake the task ; possessing, as it is evident from his work that he does possess, an accurate acquaintance with the subject in all its details, considerable personal experience in the diseases of which he treats, capacity for lucid arrangement, and a style of communication commendable in every respect." " Our notice of Dr. Willis's work must here terminate. It is one which we have read and trust again to read with profit. The history of discovery is successfully given ; cases curious and important, illustrative of the various subjects, have been selected from manynewsouws, as well as detailed from the author's own experience, chemical analyses, not too elaborate, have been afforded, w liich will be most convenient to those who wish to investigate the qualities ofthe urine in disease ; the importance of attending to tins secretion in order to a proper un- derstanding of disease is strongly insisted upon: in short, a book has been composed, which was much required, and which we can conscientiously and confidently recommend as likely to be useful to all classes of practiiioners."—Brit. % For. Med. Rev. SURGERY, John Hunter. LECTURES ON THE PRINCIPLES OF SURGERY. By JOHN HUNTER, F.R.S. With Notes, by JAMES F. PALMER, Senior Surgeon to the St. George's and St. James's Dispensaries, etc., etc. With Plates, 1 vol. 8vo. sheep. " We cannot bring our notice ofthe present volume toa close without offering our testimony to the admirable manner in which the editor and annotator has fulfilled his part ofthe under- taking. The advancements and improvements that have been effeeted, up to our own day, not only in practical surgery, but in all the collateral departments, are constantly brought before (he reader's attention in clear and concise terms."—Brit. $ For. Med. Rev. Samuel D. Gross, M.D. INTO THE NATURE AND TREATMENT OF WOUNDS OF THE INTESTINES. By SAMUEL D. GROSS, M.D., Professor of Surgery in the Louisville Medical Institute. Illustrated by Engravings. 1 vol. 8vo. muslin. " We consider it a valuable contribution to our literature, and as worthy ofthe high reputa- tion ofthe author.''—Philad. Med. Eiam. "We dismiss the 'Experimental Inquiries,'fully persuaded that the valuable truths with which they abound, will be the best recommendation to the medical public."— N. O. Med. Jour. MEDICAL PUBLICATIONS. W Robert Liston. ELEMENTS OF SURGERY, By ROBERT LISTON, Fellow of the Royal College of Surgeons in London and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and County of Edinburgh, Professor of Surgery in the London University, etc., etc. Edited by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Elements of Patho- logical Anatomy, etc., etc. Third American, from the Second London Edition, with upwards of one hundred and sixty illustrative Engravings. 1 vol. 8vo. sheep. " We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in compre- hending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type ofthe same size as that of th.; text. This obviates almost entirely whatever objec- tions can be alleged against foot-notes.''— Western Jour, of Med. and Surg. "We are here presented with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical and learned friend, Dr. Gross. He has added ' copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants ofthe surgeon. Professor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They may be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise. The execution of the book is good; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour. "In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are douMy described; first by the author and editor, and next by the graver of the artist."—Bull. Med. Scien. " Mr. Liston's reputation as a clear, accurate, and scientific surgical writer, is so widely known and admitted, th.a formal panegyric is quite unnecessary. Dr. Gross has discharged his duties as editor, with all the sound sensed accurate discrimination, and experienced judgment, which all who knew him expected. The additions and notes are indeed profitable and interesting ; and our only regret is, that they are not still more numerous than they are. The volume is inscribed to Profes- sor Parker, ofthe College of Physicians and Surgeons in this city,—the beauty of its typography, and • getting up,' will be readily taken for granted by all who know the publishers—and the illus- trative engravings are executed in a style very creditable to American art."—JV. Y. Lancet. " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume writtun by such a man, more really valuable practical instruction is to be derived than from all the books that were ever compiled."—Western and Southern Med. Recorder. "This is a work of established reputation. It has gone through twoeditions in Great Britain, and the same number in this country. The additions of the American edition are copious, and add materially to the value ofthe work."—Amer. Jour. Med. Sciences. " The author is bold and original in his conceptions, accurate in deductions, plain and con- cise in style ; a combination of good qualities not often found united in a single volume. The notes and additions by Prof. Gross, are well arranged and judicious, supplying some evident deficiencies in the original work."—Western Lancet. Sir Astley Cooper, Bart. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. By FREDERICK TYRRELL, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. Fifth American, from the last London Edition. 1 vol. 8vo. sheep. -=4 ui3=*— BARRINGTON &. HASWELL'S Sir Charles Bell. INSTITUTES OF SURGERY. Arranged in the order ofthe Lectures delivered in the University of Edinburgh. By SIR CHARLES BELL, K.G.H., Etc, Professor of Surgery in the University of Edinburgh, etc., etc. 1 vol. 8vo. sheep. "In a work on Surgery, of 448 pages, by Sir Charles Bell, we would expect every line to contain Important matter; and this is really the case."—Western Lancet. "Respecting the high merit of the present performance, there is an equal unanimity of judgment among all who have examined it."—Maryland Med. and Surg. Journ. Amussat. LECTURES ON THE RETENTION OF URINE, CAUSED BY STRICTURES OF THE URETHRA, AND ON THE DISEASES OF THE PROSTATE. Translated from the French, By JAMES P. JERVEY, M.D. I I vol. 8vo. muslin. >. VENEREAL. John Hunter, F.R.S. TREATISE ON THE VENEREAL DISEASE. With Notes, by Dr. BABINGTON. With Plates. 1 vol. 8vo. "Under the hands of Mr. Babington, who has performed his task as editor in a very exemplary manner, the wqrk has assumed quite a new value, and may now be as advantageously placed in the library ofthe student as in that of the experienced surgeon."—BriuS^ For.Med Rev. "The notes, in illustration of the text, contain a summary of our present know- ledge on the subject; the manner in which these notes are constructed is at once clever and perspicuous; and the modes of treatment prescribed, spring from a right apprehension ofthe disease. We would recommend to the reader the note on the primary venereal sore; the note itself is an essay in e\ery word of which we fully concur."—Med. Gaz. 20 MEDICAL PUBLICATIONS. Philippe Ricord, M.D. A PRACTICAL TREATISE ON VENEREAL DISORDERS, AND MORE ESPECIALLY ON THE EESTOHTS' £MM ^m.m^SMIMm'^ ©IF ©IHL^SIBHo By PHILIPPE RICORD, M.D., Surgeon to the Venereal Hospital at Paris. 1 vol. 8vo. TH E EAR. George Pilcher. A TREATISE ON THE STRUCTURE, ECONOMY, AND DISEASES OF THE EAR. BEING THE ESSAY FOR WHICH THE FOTHERGILLIAN GOLD MEDAL WAS AWARDED BY THE MEDICAL SOCIETY OF LONDON. Bv GEORGE PILCHER, Late Lectureron Anatomy, Lectureron SurgeryattheTheatreof Anatomy and Medi- cine, Webb St., Borough, and Senior Surgeon to the Surrey Dispensatory. FirsfAmerican, from the Second London edition, with Notes and numerous Illustrative Plates. 1 vol. 8vo. sheep. " The perusal of this work has afforded us much pleasure— A work was wanted to place the whole subject within the grasp of all persons who chose to devote some littleexclusive or particular study to the diseases of the ear, and th.s has fairly and well supplied the place."—Med. Chir. Rev. "Mr.Pilcher isanexperienced e,,^ S^ti^TXEX^^*-^"™' MED' T!T TaNnd must Z. . . , ki„ .^o,u» iiinstratprl with elegant plates, is a standard work, and must N. Y. Herald. -k$i BARRINGTON 8c HASWELL'S GUMS. George Waite. THE GUMS: WITH LATE DISCOVERIES ON THEIR STRUCTURE, GROWTH, CONNECTIONS, DISEASES, AND SYMPATHIES. By GEORGE WAITE, Member of the London Royal College of Physicians. TEETH. John Hunter. A TREATISE ON THE By JOHN HUNTER TEETH. With Notes, by THOMAS BELL, F.R.S. With Plates. 1 vol. 8vo. muslin. " The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the greatest minuteness and care; and in appropriate notes at the foot of the page corrects the author with the air of a gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to the text; and without aiming at the slightest display of learning, they at the same time exhibit a ready knowledge on every point, and an extensive information both of comparative anatomy and pathology."—Med. Gazette. MINOR SURGERY. Henry H. Smith, M.D. MINOR SURGERY: By HENRY H. SMITH, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, etc., etc Illustrated by numerous Engravings. 1 vol. 18mo. muslin. " And a capital little book it is.....Minor Surgery, we repeat, is really Major Sur- gery, and any thing which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's."—Med. Chir. Rev. " This beautiful little work has been compiled with a view to the wants of the pro- fession in the matter of Bandaging, &c, and well and ably has the author performed his labours."—Med. Examiner. " To students we would particularly recommend Dr. Smith's work; and with it in their possession, they would be able to carry out to great advantage the advice of an eminent professor of a neighbouring city— ' Provide yourselves each with half a dozen rollers, and after your day's study is over, just before going to bed, amuse yourselves by bandaging each other. It is the only way to acquire an art, ignorantly underrated, but of immense importance.' "—Boston Med. and Surg. Journ. "This is an excellent Treatise on Bandaging,and will prove of great assistance to the student and to the country practitioner." " The book is very handsomely illustrated with a great number of excellent wood-cuts. The paper and type are good. We repeat, in conclusion, our very favour- able estimation of its merits."—Med. Exam. „ " We venture to predict for this little volume a successful career, for we have here a means adapted to an end." " Here are furnished to the student all the various inventions and modifica- tions of bandages and apparatus, more especially by the American Surgeons, Physick, Dorsey, Gibson, Barton, Coates, Hartshorne. and N. R. Smith."—N, Y. Jour, of Med. " We have no hesitation in asserting, that it is an excellent, we were goingto say indispensable, aid to all those who wish to qualify themselves for the practice of surgery."—Bull, of Med. Science. MEDICAL PUBLICATIONS. «=&| i MIDWIFERY AND DISEASES OF WOMEN, Robert Lee. LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY. DELIVERED IN THE THEATRE OF ST. GEORGE'S HOSPITAL. By ROBERT LEE, M.D., F.R.S., Fellow ofthe Royal College of Physicians, London; Physician to the British Lying-in Hospital; and Lecturer on Midwifery at St. George's Hospital. Illustrated with numerous Wood Engravings. 1 vol. 8vo. " Dr. Lee's former reputation for large practical knowledge of obstetrics is fully sustained in the present work." " The style is plain and clear, and the facts and cases are presented with due succinctness. One important feature is the introduction of tables ofthe results of certain operations, as of craniotomy, and of certain diseases of the puerperal state, as puerperal fever; which constitute a statistical basis for future observations and a present support for active and available practice."— Bulletin of Medical Science. " Dr. Lee is too good and sensible an author to be reviewed. He should be read. He has already, though but a young man, become illustrious by his earlier works." —Philad. Med. Exam. "We can cheerfully commend it to the notice of students of medicine."— Western Lancet. " It is the production of a highly cultivated and practical mind, and has been ela- borated with a degree of judgment and care which must render the Lectures a valu- able record of professional learning and experience."—Western Journal of Med. Sciences. "While they are well adapted for the instruction of the student of midwifery, the Lectures of Dr. Lee may be consulted by the young practitioner with much satisfac- tion and profit. The wood engravings, by which the text is accompanied, are well executed, and communicate a very accurate idea of the subjects they are intended to illustrate."—Amer. Jour. Med. Science. " Every passage will indicate in the author a discriminating, practical mind, en- lightened by learning, and extensive observation." " It is a store-house of facts from which the student may enrich his mind, and to which the practitioner may apply to refresh his memory."—Western Jour. " The aim of the publishers was to give to the profession one of the very best systems of midwifery in the language for the least money —to place a volume of unquestionable excellence within the reach of every medical man in the country. They have been successful."—Ibid. James BlundeU, M.D. LECTURES ON THE PRINCIPLES AND PRACTICE OF MIDWIFERY. By JAMES BLUNDELL, M.D. Edited by Charles Severx, M.D. 1 vol. 8vo. sheep. " The eminently fluent and agreeable style —the large and accurate information —the great BARRINGTON 8c HASWELL'S -<--------------------------------------------------------——t- Robert Collins, M.D. A PRACTICAL TREATISE ON MIDWIFERY. containing the results of sixteen thousand six hundred and FIFTV-FOUH BIRTHS, OCCURRING IN THE DUBLIN LYING-IN HOSPITAL. By ROBERT COLLINS, M.D., Late Master ofthe Institution. 1 vol. 8vo. sheep. " The author of this work has employed the numerical method of M. Louis; and by accurate tables of classification, enables hi? readers to perceive, at a glance, the consequences of the diversified conditions, in which he saw his patients. A vast amount of information is thus obtained, which is invaluable to those who duly appreciate precision in the examination of cases."—Bait. Citron. Robert Gooch, M.D. A PRACTICAL COMPENDIUM OF MIDWIFERY. Being the Course of Lectures on Midwifery, and on the Diseases of Women and Infants delivered at St. Bartholomews Hospital. By the late ROBERT GOOCH, M.D. PREPARED BY GEORGE SKISSIB, Member ofthe Royal College of Surgeons, London. 1 vol. 8vo. sheep. PUERPERAL FEVER. Gordon, Hey, Armstrong, Lee, and C. D. Meigs. THE HISTORY, PATHOLOGY, AND TREATMENT OF PUERPERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, Hey, Armstrong, asd Lee. WITH AN INTRODUCTORY ESSAY By CHARLES D. MEIGS, M.D., Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College, Philadelphia. I vol. 8vo. sheep. "We have peculiar satisfaction, in announcinsthe publication of this very judiciously arranged series of treatises, on one of the most important and interesting diseases, which demand the atten- tion ofthe physician." " Dr. Meiss's Introductory Essay is concise and judicious, and will be read with profit. He speaks in the highest terms ,.f commendation of Dr. Gordon's invaluable treatise — a treatise which cannot be too generally dinuscd and studied. Altogether this volume presents the most acceptable and useful compend of the doctrines and practice of the best authorities, wilh regard to ' Puerperal Fever,' wilh which we have ever met."—A*. Y. Lancet. " We are pleased to see the republication of those valuable monographs upon Puer- peral Fever. As they are all of them Essays founded upon an extensive observation , and contain a very large number of recorded cases, they must always be valuable." — New England Journal of Medical Science. " Taken in connexion, the treati~<' it compri>e< present an invaluable mass of facts in relation to Child-bed Fever, without an acquaintance wilh which no one can, with propriety, be considered fully qualified to undertake its management."—Tournal of Medical Science. A UTERUS. Waller, Lisfranc, and Ingleby. LECTURES ON THE FUNCTIONS AND DISEASES OF THE WOMB. By CHAS. WALLER, M.D., Bartholomew's Hospital. ON DISEASES OF THE UTERUS AND ITS APPENDAGES. By M. LISFRANC, La Pitie Hospital. ON DISEASES OF THE PUERPERAL STATE. By J. T. INGLEBY, Edinburgh. 1 vol. 8vo. sheep. " We can very cordiallyrecommend them as affording a concise and practical exposition of the path '1 igy and tre;i ment of a must impjrtaut class of diseases, and which cannot be too attentively studied.''—A'. Y. Law et. '•'] be present volume contains a short and succinct practical account of the principal morbid states either ofthe functi >ns ur the s.ruciure ofthe womb, the best methods of distinguishing them, and the means which experience has sh >wn m be the most effectual in removing them. The reader will find that he obtains, in a small compass, a distinct view of the nature and treatment of each disorder."—Edinb. Med. and Surg. Journ. DISEASES OF CHILDREN. Evanson and Maunsell. A PRACTICAL TREATISE ON THE DISEASES AND MANAGEMENT OF CHILDREN. Br KICHARD T. EVANSON, M.D., Professor of Medicine, — and HENRY MAUNSELL, M.D., Professor of Midwifery in the College of Surgeons, Ireland. Edited by D. F. CONDIE, M.D. From the Fourth Dublin Edition. 1 vol. 8vo. sheep. "The second chapter embraces the Manngpmnnt and Physical Education of Chil- dren. This chapter ought to be printed in jjold letters, and hung up in the^ nursery of every family. It would save many lives, and prevent much suffering.'" Medico- Chirurg. Rev. " As this Practical Treatise on the Diseases of Children has before been made known to the medical public, we dare not suppose it a new thing to any intelligent practi- tioner in this country ; still, there may be those who do not own a copy—and to such there is nothing ungenerous in saying we wish that they may always have it in their power to consult such authority."— Boston Med. and Surg. Journ. " The present edition is enlarged, and in its present form constitutes one of the best works on the subject in our language. We do not intend to say that it is by no means unexceptionable/but that at this time we know of no English production on the same subject which is superior, or perhaps, on the whole, as good."—Philad. .Med. Exam. Michael Underwood, M.D. A TREATISE ON THE DISEASES OF CHILDREN. WITH DIRECTIONS FOR TUB MANAGEM1NT OF IKFANTS. By the late MICHAEL UNDERWOOD, M.D. From the Ninth English Edition, with Notes, By S. Merriman, M.D., and Marshall Hall, M.D., F.R.S., Etc with hotes, by joh> ekll, M.n.,etc, of Philadelphia. 1 vol. 8vo. sheep. —-=tfg 1 HB=—-- BARRINGTON 8c HASWELL'S MISCELLANEOUS. J. L. Ludlow, M.D. A MANUAL OF EXAMINATIONS UPON ANATOMY AND PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, CHEMISTRY, MATERIA MEDICA, OBSTETRICS. ETC. Designed for the Use of Students of Medicine throughout the United States. By J. L. LUDLOW, M.D. 1 vol. I2mo. " We have no hesitation in saying, that Dr. Ludlow's Manual is decidedly the best, both in rela- tion to comprehensiveness and general accuracy, that has yet been published in this country."— West. Lancet. " In this ' Manual of Examinations' the questions are clearly put, and, with few exceptions, well and distinctly answered." " The Manual will be found to be equally available at the three schools in Philadelphia, as at the two iu New York, or those of Louisville, Lexington, and Cincinnati, or of Charleston, Augusta, and New Orleans, not to mention the numerous confreries for teaching down East." —Bull. Med. Science. " We have no hesitation in saying, that Dr. Ludlow's Manual is decidedly the best, both in relation to comprehensiveness and general accuracy, that has yet been published in this country."—Western Lancet. "There is nothing particularly new in this method of imparting instruction ; it is an old, but long approved system, which commends itself to the good sense of all well regulated minds. Dr. Ludlow discovers a minute knowledge with all the leading departments of professional lore, which he imparts agreeably. He is careful to be exact, without being redundant in any paragraph."—Boston.Md. and Surg. Jour. " Between all the classes whose comfort the Student's Manual is designed to pro- mote, we should think it would obtain not a little currency."—West. Journ. Thomas Henderson, M.D., U.S.A., HINTS ON THE MEDICAL EXAMINATION OF RECRUITS FOR THE ARMYi AND ON THE DISCHARGE OF SOLDIERS FROM THE SERVICE ON THE SURGEON'S CERTIFICATE. Adapted to the Service of the United States. By THOMAS HENDERSON, M.D., Assistant Surgeon United States' Army, etc., etc. Prof. XV. E. Horner, M.D. NECROLOGICAL NOTICE OF DR. P. S. PHYSICK. Delivered before the American Philosophical Society, May 4, 1838. Br PROF. W. E. HORNER, M.D. Pamphlet. Drewry Ottley. THE LIFE OF JOHN HUNTER, F.R.S. By DREWRY OTTLEY. 1 small vol. 8vo. ",In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judg- ment and candour."—British and Foreign Medical Review. M 26 "" «=tfi MEDICAL PUBLICATIONS. Thomas J. Pettigrew ON SUPERSTITIONS CONNECTED WITH THE HISTORY AND PRACTICE OF MEDICINE AND SURGERY. By TIIOS. JOSEPH PETTIGREW, F.R.S., F.S.A., Doctor of Philosophy to the University of Gdttingen, &c, &c. 1 vol, 12mo. •' The book will prove instructive, not only on account of th» extensive learning which it display?, but the numerous and curious facts which it develops."—JV. Orleans Med. Jour. "Mr. Pettierew's book is amusing to such as are inclined to smile, and instructive to those who are willing to reflect."—Med. Chir. Rci\ " From the follies ofthe past we may derive wisdom for thefuture, and there is much in the volume before us that may be profitably used for this purpose.—Med. Exam. " It is the common-place book of a literary physician with a running commentary, giving a unity and continuity to the mosaic."—Brit, and For. Med. Rev. " We do not know of pleasanter reading, either for the physician in the between- whiles of professional labour, or for the guneral reader who loves to study human nature in its external and often eccentric workings."—Bull. Med. Science. " We heartily commend this little work to the curious of all classes of readers."— N. Y. Journ. Med. and Collat. Sciences. " We take leave of his book, from which we have derived not only entertainment but instruction."—West. Journ. Edwin Lee. OBSERVATIONS ON THE PRINCIPAL MEDICAL INSTITUTIONS PRACTICE OF FRANCE, ITALY, AND GERMANY. WITH NOTICES OF THE UNIVERSITIES, AND CASES FROM HOSPITAL PRACTICE : With an appendix on By EDWIN LEE, Member of the Royal College of Surgeons, &c. 1 vol.8vo. muslin. " Mr Lee has judiciously selected some clinical cases, illustrating the practice pursued at the different hosoitals and he has wound up the volume with an amusing account of animal1 mag- neUsm and Copathy-those precious effusions of German ideally, for which we refer to the work itself."—Medico-Chirurg. Rev. Jas. W. Dale, M.D. IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM! By JAMES W. DALE, M.D. of Newcastle, Del. Pamphlet. G. R. B. Horner. M.D., U.S.N. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS UPON THE MEDITERRANEAN AND UPON PORTUGAL, SPAIN, AND OTHER COUNTRIES. ByG. R. B. HORNER, M.D., Sur»eon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. WitfViEngravings. 1 vo1- 8v0- muslin. ..An ..n.-nmrnonlvinterestfrig' book is presented to those who have any disposition to know " An uncommoi 'Y ,"'er^"| eg in a'nd otner countries," and " will doubtless be read, also, with^V^sa^ZLV^hlZ have a taste for travels."-*^. Med. and Sur£. Jour. MEDICAL PUBLICATIONS. Wm. C. Wells, M.D. AN ESSAY ON DEW, And several appearances connected wilh it. Br WILLIAM CHARLES WELLS, M.D..F.R.S. LIVER AND SFLESN. Thomson and Twining. DISEASES OF THE LIVER AND BILIARY PASSAGES. Bv WILLIAM THOMSON, One ofthe Physicians ofthe Royal Infirmary of Edinburgh ; AND CLINICAL ILLUSTRATIONS OF THE LIVER AND SPLEEN. By WILLIAM TWINING, Surgeon of General Hospital of Calcutta, &c, &c. 1 vol. 8vo. sheep. " The work before us is an excellent compilation of the subject of hepatic affections, functional and structural: ami, as such, it is infinitely more valuable to practitioners and students, than any original essay, however ably executed. We cannot do better, therefore, than stronaly recommend the work as the best in the English language, ou the iinpunani suLjects of which it treats. '— Medico-Chirurg. Rev. John G. Malcolmson, M.D. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. Bv JOHN G. MALCOLMSON, M.D., Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London. 1 vol. 8vo. JOHN HUNTER'S WORKS. Comjirising his Lectures on the Principles of Surgery; A Treatise on the Teeth ; Treatise on the Venereal Diseases ; Treutise on Inflammation and Gunshot Wounds ; Observations on Certain Parts of the Animal (Economy; and a full and comprehensive Memoir. Each of the Works is edited by men of celebrity in the Medical Science, and the whole under the superintendence of JAMES F. PALMER, Of the St. George's and St. James's Dispensary. 4 vols. 8vo. This is the only complete edition of the works of the distinguished physiologist ever published in this country. " One distinctive feature ofthe present edition of Hunter's works has been already mentioned, viz.: in the addition of illustrative notes, which are not thrown in at hazard, hut are written by men who are already eminent lor their skill and attainments on the particular subjects which they have thus illustrated. By this means, whilst we have the views entire ol John Hunter in the text, we are enabled byrelerence to the accompanying notes, to see wherein the author is borne out by the positive knowledge ofthe present day, or tojrfcat extent his views require modification and correction. The names of the gentlemen wT»have in this manner assisted Mr. Palmer, are guarantees ofthe successful performance of their task."—Med. Gaz. f Any person ordering Books to the value of Ten Dollars from the following list, and remitting the amount free of postage, will be entitled to the Bulletin of Medical Science for one year, gratis. LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY EXTRAS, —BY 31 AIL. 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Their fine edition is of superior workmanship, and the paper on which it is printed \ has all ofthe firmness, consistency, and colour of the best European. They are in all j styles of binding AN EXPOSITION OLD A1VD NEW TESTAMENT. Wherein each chapter is summed up in its contenN ; the sacred text inserted at large, in distinct paragraphs; each passage reduced to its proper heads; the sense given, and largely illustrated. WITH PRACTICAL IlEMARKS ASB OBSERVATIONS, By MATTHEW HENRY. Edited by the Rev;. Geo. Burder, and the Rev. Joseph Hughes, A.M.; with the Life ofthe author by the Rev. Samuel Palmer. TO WHICH IS PREFIXED A PREFACE, Bv ARCHIBALD ALEXANDER, D.D., Professor of Theology in the Seminary at Princeton, New Jersey. First American edition, 6 vols, super 8vo. This work has elicited so decidedly the approbation of the most judicious men of the principal denomination of Christians in the United States, that the publishers deem it unnecessary to offer now many ofthe numerous recommendations they have received from various quarters. The following will serve to show the universal opinion with regard to this work : From the Rev. S. H. Cone, Pastor of the Oliver Street Baptist Church, New York. " I have examined the stereotype edition of Matthew Henry's Exposition of the Old and J\ew Testament, and take pleasure in bearing testimony to its typographical Y THEOLOGICAL PUBLICATIONS. neatness and accuracy, and the comparative cheapness of price at which it is now offered to the American public. " With reference to the intrinsic excellence ofthe work itself, it needs not my feeble commendation. The wise and good unite in saying, that it is calculated to render those who read it wiser and better; and having frequently derived from it edification and comfort mysslf, I do sincerely hope you may succeed in circulating it extensively among my fellow-citizens." The following vivid delineation of its characteristic qualities is from the pen of the Rev. Dr. Alexander, of Princeton ; " A characteristic of this Exposition of a more important kind than any that have been mentioned, is, the fertility and variety of good sentiment manifest throughout the work. The mind ofthe author seems not only to have been imbued wilh excellent spiritual ideas, but to have teemed with them. It is comparable to a perennial foun- tain, which continually sends forth streams of living water. In deriving rich instruc- tion and consolation from the sacred oracles, adapted to all the various conditions and characters of men, the author displays a fecundity of thought, and an ingenuity in making the application of divine truth, which strikes us with admiration. The resources of most men would have been exhausted in expounding a few books ofthe Bible; after which little more could have been expected than common-place matter, or a continual recurrence ofthe same ideas ; but the riches of our Expositor's mind seem to have been inexhaustible. He comes to every successive portion ofthe sacred Scriptures with a fulness and freshness of matter, and with a variety iu his remarks, which, while it instructs, at the same time refreshes us. Even in his Impo- sition of those books which are very similar in their contents, as the gospels for ex- ample, we still fine a pleasing variety in the notes of the commentator. It is difficult to conceive how one man should have been able to accomplish such a work, without any falling off in the style of execution." The Rev. Edward Bickersteth says,—"There is in Matthew Henry a glow of love, a full exhibition of the sense, a happy reference to the passage expounded, and a lively cheerfulness, which will ever make his work popular, useful, and indis- pensable." Dr. Doddridge says,— " Henry is, perhaps, the only commentator so large that deserves to be entirely and attentively read through. The remarkable passages, I think, should be remarked. There is much to be learned from this work in a specu- lative, and still more in a practical way." Dr. Edward Williams says, — " It is an incomparable work, and too well known to need a discriminating character." " The Rev. Dr. Thomas Hartwell Home, in his valuable Introduction to the Study ofthe Scriptures, says, that ils high and generally known value is so just and exten- sive, thatft ue^ds no recommendation. The Rev. Adam Clarke, the Commentator, says, — " The Rev. Matthew Henry, a v