.tp£ "3fc£V. :.v.afc - i ■-*»»■ It — *^» *»!__. &>...' H^C UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D.C. GPO 16—67244-1 A TREATISE PRACTICE OF MEDICINE. BY JOHN EBERLE, M.D., PROFESSOR OP MATERIA MEDIC A AND BOTANY IN THE OHIO MEDICAL COLLEGE ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; AND CORRESPONDING MEMBER OF THE MEDICO-CHIRDRGICAL SOCIETY OF BERLIN IN PRUSSIA, &C, &C. / SECOND EDITION.—REVISED AND ENLARGED. ^G.GtH$ *iJ* "^)i I]V TWO VOLS.—VOL. II. PHILADELPHIA: JOHN GRIGG, No. 9, NORTH FOURTH STREET. LYDIA R. BAILEY, PRINTER. 1831. ';>'&ffii we l?3l v. 2. Entered according to the J3ct of Congress, in the year 1831, by John Eberle, M. D., in the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsylvania. t CONTENTS OF VOLUME II. CHRONIC DISEASES. CHAPTER I. Of Chronic Nervous Diseases. General Observations, ... _ Page. 1 Sect. I. Apoplexy, -Sect. 11. Paralysis, - - 4 - 25 1. Hemiplegia, - - 27 2. Paraplegia, - - 29 3. Paralysis Partialis, - - 30 Sect. III. Epilepsy, ... - - 42 Sect. IV. Catalepsy, . - - - 66 Sect. V. Chorea, - . - 73 Sect. VI. Convulsive Affections of Infants, - - 86 Sect. VII. Hysteria, -Sect. VIII. Puerperal Convulsions, > . - 98 . - 113 Sect. IX. Tetanus, ... . - 117 Sect. X. Hydrophobia, ... - - 133 CHAPTER II. Chronic Nervous Affections, in which Intellectual and Moral Faculties are Disordered. Sect. I. Mental Derangement, .... 147 1. Mania, - - - - - 159 2. Monomania, .... 160 3. Dementia, - - - - - 163 4. Idiotism, - - - - ib. Sect. II. Delirium Tremens, - - - - 172 CHAPTER III. Local, Chronic Nervous Affections. Sect. I. Neuralgia, - - - - - 181 Sect. II. Amaurosis, - 198 CHAPTER IV. Chronic Affectums of the Respiratory Organs. Sect. I. Asthma, - - - - - - 208 Sect. II. Whooping-Cough, - 221 Sect. III. Asphyxia, ..... 235 Sect. IV. Pneumo-Thorax, - - - - 247 IV CONTENTS. CHAPTER V. Page. Chronic Diseases of the Heart. Sect. I. Of the Diseases of the Heart, - 25^ 1. Hypertrophy of the Heart, - 260 2. Dilatation of the Ventricles, - - 262 3. Aneurism of the Aorta, - 263 Sympathetic Affections of the Heart, - 270 Sect. II. Angina Pectoris, ----- 273 CHAPTER VI. Chronic Diseases of the Alimentary Canal. Sect. I. Indigestion, - 280 Sect. II. Diarrhoea, - 296 Sect. III. Cholera, ------ 306 Cholera Infantum, - 309 Sect. IV. Colic, - - - - - - 320 1. Flatulent Colic, - - - - 321 2. Bilious Colic, - 324 3. Colica Pictonum, - 329 Sect. V. Ileus, ...... 336 Sect. VI. Constipation, ..... 342 Sect. VII. Intestinal Worms, .... 344 Sect. VIII. Hemorrhoids, ..... 355 Sect. IX. Jaundice, ------ 367 CHAPTER VII. Chronic Diseases of the Urinary Organs. Sect. I. Diabetes Mellitus, - - . . - 381 Sect. II. Diabetes Insipidus, - 395 Sect. III. Lithiasis, ----.. 401 1. Lithic Acid Diathesis, ... 400 2. Phosphatic Diathesis, ... 405 Sect. IV. Ischuria Renalis, - - . . -411 Sbot. V. Retention of Urine, . . _ - 416 Sect. VI. Dysury, - - - . . - 427 Sect. VII. Enuresis, - ,„Q CHAPTER VIII. Chronic Diseases of the. Serous Exhalent Vessels Hydrops, - . . . . * 1. Ascites, . 4 2. Hydrothorax, "m ^j" 3. Anasarca, - . 'f43 - 445 contents. V CHAPTER IX. Page. Chronic Affections of the Lymphatic System. Sect. I. Scrofula, - - - - - - 463 Sect. II. Bronchocele, ..... 480 CHAPTER X. Chronic Disorders of the Assimilative Functions. Sect. I. Scorbutus, - - - - - -491 Sect. II. Chlorosis, ------ 497 CHAPTER XI. Chronic Diseases of the Sexual Organs. Sect. I. Gonorrhoea, .... - 503 Sect. II. Syphilis, - - - - - - 514 Buboes, ------ 536 Sect. III. Amenorrfwea, ----- 539 Sect. IV. Dysmenorrhea, ----- 546 Sect. V. Leucorrliosa, y • 552 VALUABLE MEDICAL BOOKS PUBLISHED BY J. GRIGG, NO. 9, NORTH FOURTH STREET, PHILADELPHIA, And for Sale by the principal Booksellers in the United Slates., VELPEAU'S ELEMENTARY TREATISE ON THE ART OF MIDWIFE- RY, or the Principles of Toxicology and Embryology, in 1 vol. 8vo. Trans- lated from the French, by Charles D. Meigs, M. D. Member of the College of Physicians, &c. &c. The distinguished editors of the North American Medical and Surgical Jour- nal, after noticing the various works on the subject of the obstetric art, ob- serve : " We have chosen this, because it appears to us to be one of the very best. It is a model for such a work. The several parts being duly connected, and related and managed with a beautiful simplicity and dexteri- ty, like that used by the naturalist. A sort of nomenclatural neatness and conciseness reigns throughout." It is a book that no physician should be without. PHARMACOPOEIA OF THE UNITED STATES, revised edition, by autho- rity of the NationaV Medical Convention of 1830, in 1 vol. 8vo. 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This work is highly esteemed by all the distinguished of the medical profes- sion ; and in many of our medical schools is used as a text book. HUFELAND ON SCROFULOUS DISEASES. MANUAL OF GENERAL ANATOMY: containing a concise description of the Elementary Tissues of the Human Body. From the French of A. L. Bayle and H. Hollard. By S. D. Gross, M. D. Until the publication of the translation of the Manual of Bayle and Hollard, there was no work on general anatomy in this country, except that of the illustrious Bichat, a work which, although replete with useful information, is entirely too voluminous and expensive for most medical students. The above Manual, therefore, is calculated to remedy these inconveniences; and cannot fail of proving useful to the medical practitioners of this country. MANUAL OF PRACTICAL OBSTETRICS : Arranged so as to afford a con- cise and accurate Description of the Management of Preternatural Labours; preceded by an Account of the Mechanism of Natural Labour. From the French of Julius Hatin, Doctor of Medicine of the Faculty of Paris, Profes- sor of Obstetrics, and of the Diseases of Women and Children, &c. &c. &c. By S. D. Gross, M. D. M. Hatin at present is one of the most successful and eminent practitioners in Paris, and the Manual will be found peculiarly useful to those who wish to MEDICAL BOOKS. extend their knowledge on this most important subject. Both ^^se Ma- nuals have already been adopted as text books in several ot tne mosi re- spectable medical schools in the United States. MANUAL OF THE ELEMENTS OF OPERATIVE SURGERY: Arranged so as to afford a concise and accurate Description of the present Ma« oiine Science in Paris. From the French of A. Tavernier, Doctor of Medicine ot the Faculty of Paris, late Surgeon to the Third Regiment ot Artillery, &c. «c. &c. By S. D. Gross, M. D. . . . , , The original of the present work was published in Pans, in 1828, and has been already translated into the Italian, the Spanish and the German. It contains an abstract of the writings of the most eminent American and Eu- ropean Surgeons, especially of those of Abernethy, Barton, Beer, Bell, Boyer, Cloquet, Cooper, Delpech, Dubois, Dupuytren, Gibson, Grade, Guthrie, Henden, Lallemand, Larrey, Lawrence, Lisfranc, Marjolm, M Clel- lan, Mott, Physick, Richerand, Roux, Scarpa, Travers, and Berlinghien; men who are at once an honour to their countries and ornaments to Modern Surgery. RUSH ON THE MIND, new fine edition. This work is valuable and highly interesting for intelligent readers of every profession: it is replete with curious and acute remarks, both medical and metaphysical, and deserves particular praise for the terseness of its diction. EBERLE'S THERAPEUTICS, new edition: A Treatise on the Materia Me- dica and Therapeutics : in 2 vols. 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Professor of Anatomy and Surgery in the Jefferson Medical Colleee! in 2 vols. 8vo. 6 %* All the new Medical Works received and for sale us soon as published, on the most reasonable terms. A TREATISE OX TUB PRACTICE OF MEDICINE. C. CHRONIC DISEASES. CHAPTER I. OP CHRONIC NERVOUS DISEASES. General Observations. The nervous system gives to organized matter all the peculiar functions of animal life, and in its higher states of development, renders it a fit recipient for the powers of reason and moral feel- ing. In a state of health, or freedom from irritation, it qualifies man for the enjoyment and communication of happiness—when disordered, it may render him the most deplorable and abject of created beings. Exalted mental endowments, equanimity, and benevolence, may be converted into imbecility, waywardness, and misanthropy; meek piety into the wildness and' intolerance of fanaticism; confidence into universal mistrust, and friendship into hatred, by morbid conditions of this component of the hu- man organization. The chronic diseases of the nervous system may be divided into two classes—viz : 1. Those in which the sensorial or mus- cular functions are morbidly affected, either separately or con- jointly ; 2. Those in which the intellectual and moral powers are disordered. The first of these classes comprehends a great variety of af- fections—characterized either by a perversion, or a morbid acti- vity, or abolition of one or more of the sensorial functions ; or by spasm, or convulsion, or paralysis, of a greater or less portion of the muscular system. The examples of singularly perverted sensorial function are numerous. Reil mentions a case in which the whole surface of the body was insensible to heat or cold, and incapable by the Vol. II. 1 o GENERAL OBSERVATIONS. touch of distinguishing hardness from softness in bodies. Dufour gives an account of a similar case.* Sauvages relates the case of an individual who always heard two voices, one an octave higher than the other, when any one spoke to him. Individuals have lost the power of distinguishing colours ; and some have been much harassed by various visual illusions. Instances of very distressing morbid increase of sensorial power are frequently met with. The sense of hearing has become so exceedingly acute, that the weakest sounds gave rise to pain and uneasiness, and the same has been observed with regard to the other sensorial powers. In some cases, nervous disorder mani- fests itself by excruciating pain in some part of the body, as in the various forms of neuralgia. The sensorial functions may also be weakened or entirely de- stroyed, by affections seated in the nervous system. When such affections are local, one sense alone may be obliterated ; but when the disorder implicates the whole of the sensorium commune— the brain—all the sensorial powers wil] be suspended. This ge- neral state of nervous oppression or inactivity is attended with manifest respiration and arterial action, and constitutes what is termed coma ; a condition which must not be confounded with syncope, or asphyxia. These latter affections are not accompa- nied by any perceptible respiratory and arterial actions, and although like coma, the immediate consequence of impeded cere- bral function, yet they are manifestly dependent on different conditions of the encephalic circulation. The pathology in rela- tion to this subject, however, will be illustrated hereafter. When the nervous irritation passes upon the muscular system, it gives rise to irregular, spasmodic, or convulsive actions, either in one, or jn several, or in the majority of the muscles of the body. These convulsive or spasmodic muscular contractions, are divided by authors into tonic and clonic. In the former the con- tractions are permanent, as in tetanus; in the latter they occur in quick alternation, with relaxations, as in hysteria and epilepsy. There exists, however, no essential difference between these va- rieties of convulsive muscular action. They indeed often occur at the same time in the same individual, some muscles remain- ing in a state of firm contraction, whilst others are alternately relaxed and contracted. In general, however, convulsions of the clonic form are attended with less danger than those of the rigid or tonic spasmodic affections. The former are frequently the result of a mere temporary sympathetic irritation of the brain, from causes of a transitory character, or susceptible of being re- moved; whilst the latter usually depend on a more intimate affection of the nervous system, from causes over which we have * Reil, Fieberlehre, bd. iv. p. 64. GENERAL OBSERVATIONS. little or no control. Convulsions, or general spasmodic affections of the voluntary muscles, must, therefore, be regarded as the external manifestations of certain morbid actions or conditions of the brain and nerves. The brain, or spinal marrow, is the imme- diate source of the muscular irritation ; and the violence, dura- tion, character, and extent of the convulsive affection, depends on the nature of the cause, and the constitutional habit of the patient. In some instances, the cerebral affection which gives rise to the convulsive muscular contractions, is so great as to produce a tem- porary suspension of consciousness, and of the sensorial functions. In others, as in tetanus and chorea, the mind and sensorial pow- ers remain unaffected until the disease becomes inveterate. Spasmodic contractions are often confined to one part, and indeed frequently to a single muscle. Of this kind are, tonic spasm of the muscles of the eyes, producing strabismus; or convulsive action of these muscles, giving rise to rolling of the eyes, (hippus); spasm of the muscles of the lips and face, (sar- drosis, risus sardonicus,) giving an expression of malignant laughter to the countenance; tonic contraction of the muscles of the jaws (trismus); spasmodic affection of the oesophagus; con- vulsive action of the diaphragm, producing hiccough (singultus); tonic spasm of the erector muscles of the penis, giving rise to painful, and sometimes protracted priapism; tonic or clonic spas- modic contractions of the abdominal muscles ;* and other local spasms or cramps of the voluntary muscles, are among the most common affections. The involuntary muscles also are subject to spasmodic affec- tions ; but these appear to depend more frequently on some local irritation than upon a reflected cerebral impression. The whole arterial system is sometimes affected with clonic convulsive ac- tion. This is particularly apt to occur from sudden* and violent mental agitation; from gastric irritation ; and from organic affec- tions of the heart, (anginapectoris, palpitation.) The stomach, the intestinal tube, the common gall duct, the urethra, uterus, &c. are all particularly liable to painful spasm. The second class of nervous diseases, those in which the cere- bral irritation produces mental derangement, presents a variety of modifications, both in relation to the degree, and the particular character of the hallucination. In some instances, there is a ge- neral derangement of all the intellectual faculties, with violent excitement of the passions; occasional exacerbations of raving delirium and agitation, (mania.) In other cases, the insanity is only partial—the patient retaining the regular powers of his un- * Whytt mentions the case of a young woman who was affected with constant convulsive action of the abdominal muscles during the day, though free from them at night when in bed. 4 GENERAL OBSERVATIONS. derstanding on all but a few, or a single subject, (monomania.) Sometimes the reasoning powers become defective or imbecile, and the memory weak or obliterated, (dementia,) a state of mind which is most frequently met with in very old people, and in such as have suffered frequently from convulsive affections, as epilepsy, chorea, or apoplexy. In some instances, almost every trace of intellectual power is wanting, either from a congenital defect in the cerebral organization, or from diseases or accidental causes affecting the brain. These varieties of mental disorder sometimes pass into each other, and present an almost infinite diversity in their particular phenomena. They may arise from causes acting directly on the brain, and from impressions con- veyed sympathetically to this organ from remote visceral af- fections. Whatever be the nature of the remote cause, however, insanity of every variety is always the immediate consequence of some peculiar dynamic or organic disorder of the senso- rium commune. Under the particular head of these affections, I shall enter more fully into the etiological consideration of this subject. Sect. I.—dlpoplexy. Apoplexy may be defined, a sudden loss or suspension of the animal functions, with a slow and full pulse, laborious breathing, generally attended with stertor; whilst the organic or vital func- tions continue with little or no perceptible disturbance. In some instances, the apoplectic attack comes on suddenly without any precursory indications of its approach. Occasionally, indeed, patients feel unusually well for some time previous to an attack of this affection, and this is most apt to be the case in indi- viduals of a gouty habit. (Richter.) Much more frequently, however, various premonitory symptoms, indicative of cerebral disturbance, precede the attack ; and amongst these the following are the most common: vertigo; a dull and deep-seated pain, or sense of weight in the head, particularly on stooping or suddenly turning the head round ; a turgid state of the veins of the head; throbbing of the temporal arteries; ringing in the ears ; inability to articulate distinctly; dimness of sight; transient obtuseness of hearing; sparks and flashes of light before the eyes ; bleeding of the nose; drowsiness; confusion of ideas, manifested by inco- herent talking; disturbed and heavy sleep; loss or unusual weak- ness of the memory ; general sluggishness, both of body and mind; irregular spasmodic contraction of the muscles of the face- and, occasionally, transient pains in the pit of the stomach and' nausea. In some instances, a numbness is felt in the fingers or in one side of the body shortly before the attack supervenes In APOPLEXY. general, the symptoms which announce the approach of an apo- plectic attack, indicate an unusual determination of blood to the head. Of these symptoms, however, vertigo, ringing in the ears, dimness of sight, and pain and heaviness in the head, are by far the most common precursors of an attack of this disease. The duration of these symptoms is extremely various. In some cases, they do not continue more than a few hours before the at- tack ensues; in others, they occur with occasional remissions or intermissions, for several weeks, or months, and even years. Oc- casionally, the most alarming of the foregoing symptoms occur and continue for a longer or shorter time, without terminating in an attack of this disease. The premonitory symptoms often be- come considerably aggravated immediately before the apoplectic attack supervenes. The fulness, weight, and pain in the head, become suddenly very severe; a sense of tension and drawing is felt in the muscles of the back of the neck; and, in some in- stances, pain in the epigastrium, with nausea, occurs just before the attack. In some cases the apoplectic attack comes on by a Sudden de- privation of all sensorial power and motion; the patient sinking almost instantaneously into a state of profound stupor, resembling deep and heavy sleep, from which it is impossible to rouse him in the slightest degree. This mode of seizure constitutes what authors term perfect or strong apoplexy, (apoplexia perfecta, apilepsis, sideratio;) and generally terminates fatally in a very few hours, and sometimes in less than an hour. In other cases, the patient is seized with sudden deep-seated pain in the head; tremor of the extremities; confusion of ideas; nausea or vomiting; and vertigo. He then becomes insensible, and sinks down as from syncope; in a short time, however, he recovers sufficiently to converse, and, perhaps, to wal* about, but still complains of pain and other unpleasant sensations in the head, with confusion of the mind and giddiness. In the course of a few hours after this temporary recovery, the brain becomes gradually more and more oppressed, until complete insensibility is induced, and the patient lies in a state of deep coma. Sometimes paralysis of one side suddenly occurs, with loss of speech; pain in some part of the head; slowness and confusion of the mind; and vertigo;—the sensorial functions and conscious- ness remaining. By degrees, however, the brain becomes more oppressed, and the sensorial powers gradually decline, until pro- found apoplectic stupor ensues.* In whatever way the apoplectic attack comes on, the following phenomena attend its course, and serve to distinguish it from the other forms of soporose affections. Immediately after the acces- • Abercrombie. Edin. Med. and Surg. Journ. vol. xiv. p. 554. 6 APOPLEXY. sion of the fit, the pulse and respiration are weak and often scarcely perceptible. Both, however, soon recover from the first shock; the pulse becomes full, slow, regular, and often hard; and the respiration slow, oppressed, interrupted or irregular, and ge- nerally stertorous. Some writers contend, that in true apoplexy, stertorous breathing is invariably present; but this is not confirm- ed by general experience.* In violent instances, expiration is attended with a puffing motion of the lips, and a frothy saliva is blown out with a sputtering noise. The face is sometimes livid and of a turgid appearance; more frequently, however, it is pale and somewhat bloated. In some instances, the eyes are blood- shot ; in others, they are dull, glassy, and fixed, or rolling about in their sockets. In general, the pupils are considerably dilated; and in some cases they are permanently contracted. Dr. Cook states, that he has seen instances in which the pupils were almost entirely closed. The extremities are usually below the natural standard of tem- perature, but the skin about the body, and particularly of the head, is warm. The jaws are generally spasmodically closed; some- times they remain widely open. The power of swallowing is occasionally, in very violent cases, entirely destroyed; but in most instances, though greatly impeded, it remains to a degree suffi- cient to enable the patient to swallow small portions of fluids. In all instances, very considerable torpor of the bowels exists; and this is sometimes so great as to resist every effort to evacuate them by cathartic remedies. Clammy sweats usually break out about the head and neck, and the same sometimes occurs on the extremities. In moderate cases, the temperature of the skin, and appearance of the countenance, do not differ from their natural condition: and in such cases, the power of deglutition is gene- rally sufficiently strong to permit the easy administration of me- dicines by the mouth. This is most apt to be the case in what is termed apoplexia hydrocephalica, or the apoplectic stage of hy- drocephalus. Towards the termination of fatal cases, the pulse becomes small, irregular, and frequent; and the respiration slow, short, and interrupted by long intervals. If the disease does not end in death, it may terminate:— 1. In the perfect restoration of all the suspended functions, and the enjoyment of good health. This favourable issue may be ex- pected when the various organs gradually resume their respective functions, more especially if consciousness and a command over the voluntary muscles gradually return. The tongue is often the first organ that obeys the commands of volition; after this the • I have seen a case of fatal apoplexy, in which the breathing was throughout free from stertor. On post mortem examination, a coagulum of extravasated blood was found in the centre of the right anterior lobe of the brain, and blood was also effused into the lateral ventricle of that side. APOPLEXY. 7 upper extremities, then the inferior ones, resume their power of motion; the muscles of the face being in general the last to return to their regular action. Not unfrequently, during the progress of recovery from an attack of apoplexy, general and pretty free perspiration, or diarrhoea, and in some instances active vomiting, occurs. Sometimes sanguineous evacuations attend the favourable termination of the disease; such as epistaxis or hemorrhoidal and menstrual discharges. * 2. In paralysis of certain parts of the body, with a restoration of health in all other respects. More or less paralysis, indeed, remains after the majority of apoplectic attacks. In some in- stances, the palsied muscles soon resume their natural power; in others, they slowly recover a certain degree of power, without, however, ever regaining their natural state of activity; whilst in some cases little or no perceptible diminution of the paralytic affection ensues—the affected muscles remaining permanently palsied. In most cases in which permanent paralysis is left by an attack of apoplexy, the mind becomes very perceptibly weaken- ed. The power of comprehending complex ideas and the memory are often almost entirely obliterated in persons who recover from a severe apoplectic seizure. Paralysis from apoplexy is usually of the hemiplegiac variety; but in some instances, the palsy is confined to a single member or to certain muscles, more especially to such as derive their nerves immediately from the brain, as those of the face. 3. The apoplectic fit may terminate in a general febrile condi- tion after the sensorial oppression has passed off. In some in- stances, strong synochal fever is developed in proportion as the nervous functions are restored; in others, fever of a typhoid cha- racter, with manifest gastric irritation, ensues. Several years ago, I was called to a gentleman who a few minutes before had been seized with a fit of strong apoplexy. Under the usual treatment he gradually recovered so as to be able at the end of the fourth day to sit up and converse without difficulty. On the next day strong febrile reaction, with a hot and dry skin supervened, and notwithstanding the most vigorous antiphlogistic measures, violent delirium ensued, and continued for several days before it subsid- ed. The patient eventually recovered. Diagnosis.—The diagnosis of apoplexy is not, in general, attended with difficulty. Where a loss of consciousness of the sensorial functions and voluntary motion suddenly come on, and continue with an active state of the pulse and full respiration, the case must be regarded as apoplexy. From syncope and as- phyxia, this form of soporose disease is distinguished by the ab- sence or almost imperceptible action of the pulse and respiration • Richter's Specielle Therapie, Bd. viii. p. 711. 8 APOPLEXY. in the two former affectfcms. It is sometimes difficult, however, to distinguish apoplexy from deep intoxication. The habits of the individual, the smell of his breath, and the general relaxation of all the muscles, particularly those of the jaws and the sphinc- ters, will generally lead to a correct diagnosis on this point. Dr. Cook observes, that " as the treatment for true apoplexy would not be improper for intoxication, a mistake respecting the cause would not be hurtful to the patient." This is no doubt correct in reference to mistaking intoxication for apoplexy; but if a case of apoplexy were mistaken for intoxication, the consequence might be very injurious to the patient; for under this mistake the case would probably not be subjected to any efficient medi- cal treatment whatever. Prognosis.—Apoplexy is always to be regarded as a highly dangerous affection. When the sensorial functions are completely abolished, and the respiration is strongly stertorous, intermitting, and attended with a sputtering discharge of saliva from the lips, distortion of the mouth, immobility of the pupils, and an entire loss of the power of swallowing, no reasonable hope can be enter- tained of a recovery. Nevertheless, patients do sometimes, though indeed extremely seldom, recover from this affection, after the most profound coma, stertorous respiration, and foam- ing of the mouth have supervened.* In general, however, if an appropriate and energetic treatment do not soon make a favour- able impression upon the disease in its violent form, the case may be regarded as hopeless, t The duration of the apoplectic attack varies from a few minutes to two or three days. In some instances, death almost immedi- ately follows the apoplectic seizure. This indeed has been doubted by some. Dr. Cook thinks that the cases of sudden death which have been ascribed to apoplexy, depended, probably, on some affection of the heart or large vascular trunks within the chest. There is good reason for believing that this has sometimes been the case; but it is by no means improbable, that sudden and extensive extravasations of blood into the substance of the brain, particularly in that part of this organ which gives rise to the re- spiratory nerves, may suddenly abolish, not only the sensorial powers and voluntary motion, but also the action of respiration, and thus produce speedy death.:}: Death from this affection, how- • Portal, Observations sur la Nature et le Traitement de l'Apoplexie, p. 404. | Cook on Nervous Diseases, p. 113. Boston edition. % A case is related by Dr. Abercrombie, in which death from apoplexy occur- red in the space of five minutes. The patient had long complained of headach. While sitting in a crowded meeting, apparently in good health, she suddenly fell down in a state of insensibility, and expired in a few minutes after. On dissec- tion, a thin but extensive layer of extmvasated blood was found on the surface of the brain ; and small coagula were found also in the substance of the anterior right lobe. APOPLEXY. 9 ever, seldom takes place before the second or third hour from the attack. In most instances, indeed, from twenty to thirty hours, and in some cases five or six days pass, before the fatal termination occurs. Besides the unfavourable symptoms mentioned above, there are various others which are said to indicate especial danger. When the attack commences with sudden severe pain in the head,* or with vomiting,t or a general spasmodic rigidity of the muscles, the utmost degree of danger is to be apprehended. General, clammy, and profuse perspiration, with a small and fre- quent pulse, is also a peculiarly unfavourable sign. Hippocrates says that the supervention of fever in apoplexy is favourable ; but Richter observes that this observation can only be regarded as generally correct when the fever is of the synochal grade and commences early, for when it supervenes at a late period, and assumes a typhoid character, it never fails to increase the danger. (Loc. cit. 774.) The prognosis is also influenced by the character of the excit- ing cause, and still more by the presence or absence of that cor- poreal habit, which experience has shown to predispose especially to this affection. When there are evident manifestations of some degree of sen- sibility remaining; such as contraction of the pupils from the stimulus of light; some power of swallowing, &c, together with free and regular respiration, without stertor or discharge of sali- va from the lips; a warm and general perspiration; the occur- rence of sanguineous discharges, particularly from the nose or hemorrhoidal vessels; diarrhoea, or a copious flow of urine; rea- sonable hopes may be entertained of a favourable issue of the case. It was formerly supposed that apoplexy from the rupture of a vessel, and extravasation of blood into the substance of the brain, is always necessarily fatal. This opinion has, however, been satisfactorily controverted by the experience of many of the ablest pathologists of the present day.f The observations and dissections of Riobe, Rochoux,§ Cruvelhier, Bricheteau, and Serres ;|| and we may add, of Baillie and Sir Astley Cooper,f place the occasional recovery from strong apoplexy beyond all doubt. From the numerous dissections made in the Parisian hospitals by the French pathologists just mentioned, we learn, that when sanguineous extravasation into the substance of the • Cheyne. f Richter, Specielle Therapie, Bd. viii. p. 773. t Recherches sur l'Apoplexie. § Considerations et Observations sur l'Apoplexie. H Nouvelle Division des Apoplexies. Annuaire Medico-Chirurg. vol. i. 1 Cook, loc. cit. p. 129. Vol. II. 2 10 APOPLEXY. brain does not soon terminate in death, a membranous, vascular structure is formed around the coagulum, and that the coagulum is afterwards absorbed by the vessels of this membrane or cyst. In the progress of time, this cyst itself becomes absorbed, and leaves a yellowish cicatrix, or laminated, cellular structure, which in some instances is found to contain a small portion of reddish serum. (Rochoux.)* Sir Astley Cooper thinks, that in apoplexy from sanguineous extravasation, " the blood never becomes absorbed, but that the brain gradually acquires the power of bearing its pressure, and that thus the general symptoms which are produced at the first moments of extravasation gradually diminish, "t That the brain is capable of accommodating itself in some degree to unnatural pressure from extravasation, or other causes, cannot be doubted. I knew an instance of considerable depression of a small portion of the superior and lateral part of the os frontis from a fall. The child remained in a state of apoplectic insensibility for about twelve hours, and very gradually recovered a state of perfect consciousness in about three days. The depression still continues, and, with the exception of occasional headach, no inconvenience appears to remain from the accident. The numerous and well- attested facts that have been brought to light by the authorities already mentioned, are nevertheless sufficient testimony to esta- blish the truth of the occasional absorption of sanguineous effu- sions in the brain. Bricheteau and Riobe have reported numerous dissections, "all proving, not only the resorbtion of the effused fluid, but a reunion of the lacerated surfaces afterwards by a kind of cicatrization. J Causes.—A variety of circumstances, both in relation to the constitutional habit of individuals, and extraneous influences, appear to predispose to this affection. Of these predisposing causes, the following are the principal:— 1. Jl peculiar conformation of the body; consisting in a large head; thick, short neck; broad shoulders; ample chest; florid, and full face; short stature; globular abdomen, with a tendency to plethora and obesity. Such individuals are often subject to hemorrhage from the nose, as well as to sensations of weight and fulness in the head, particularly on stooping, or making strong • " After the absorption of the extravasated coagulum," says Rochoux, "the sides of the cavities approximate, and unite into a kind of cicatrix by the inter- vention of a cellular and vascular structure, forming various areolx, between which a reddish, serous fluid is found. These parietes are much more dense than the rest of the brain, about a line or two in thickness, and of a yellowish brown colour. He asserts that these caverns are invariably found after apoplexy terminating in paralysis, and that their number constantly corresponds with the number of previous attacks." f Cook on Nervous Diseases, p. 129. * Med. Chir. Rev. June, 1820. APOPLEXY. 11 corporeal exertions. When they sleep with the head lying low, they are restless, disturbed with dreams, and the respiration is heavy and sonorous. Such a corporeal structure constitutes, no doubt, in many instances, the hereditary predisposition to this dis- ease, noticed occasionally in particular families.* It is to be pre- sumed also that a peculiar condition of the intimate organization may, in some cases, establish a constitutional tendency to inordi- nate determinations to the head, and to the consequent occurrence of apoplexy and other cerebral affections. 2. Age. The observations of Hippocrates, that apoplexy occurs chiefly between the fortieth and sixtieth years of age, (Jlphor. sect. vi. Aphor. 21.) still holds good at the present day. Instances of apoplexy occur indeed at a much earlier period of life, parti- cularly between the thirtieth and fortieth years; but in a general estimate, it will be found that a very large majority of cases hap- pen after the age of forty. Rochoux states, that out of sixty- three cases of this disease, two occurred between the ages of twenty and thirty—eight between thirty and forty—seven be- tween forty and fifty—ten between fifty and sixty—twenty be- tween sixty and seventy—twenty-three between seventy and eighty—and one between eighty and ninety years of age. It would appear from this statement, that apoplexies occur more frequently after the age of sixty than at any previous period; and this corresponds with the sentiments of Cullen and Portal. The greater liability to apoplexy at an advanced period of life, cannot be referred to a mere increased tendency to a preternatural deter- mination of blood to the head; for in infancy this tendency is acknowledged to be generally greater than at any subsequent period of life; and yet apoplexy at this early age is an extremely rare occurrence. Some other circumstance, therefore, connected with advanced age, must be the cause of this greater aptitude to the disease. Many pathologists have ascribed this increased tend- ency to apoplexy in old people, to an ossified state of the cere- bral vessels; but this opinion is not verified by post mortem ex- aminations. Others, with more plausibility, have supposed that it may depend on a weakened state of these vessels, similar to that morbid condition of the arterial coats which favours the occurrence of aneurism. It is probable, however, that this pre- disposition depends on various circumstances of a general character connected with old age, independent of a morbid condition of the cerebral vessels. 3. Whatever tends to produce general plethora, or to keep up a preternatural determination of blood to the brain, increases the liability to apoplexy. A full and nourishing diet; the habitual • Dreysig, (Handworterbuch der Med. Klinik. B. i. p. 450,) mentions some remarkable cases of this kind. Portal and Van Hoven also state that they have known families in which a hereditary predisposition to this disease was manifested. 12 APOPLEXY. use of stimulating drinks, particularly in connexion with an in- active and sedentary course of life, are especially calculated to increase the predisposition to this disease. Immoderate venereal indulgences.at an advanced age; frequent, and long-continued warm bathing; a sudden change from an active or laborious to a quiet or indolent course of life; intense and protracted study; and the free use of strong coffee, are mentioned among the pre- disposing causes of this disease. 4. Various organic affections, such as aneurism of the aorta ; hypertrophy of the heart; visceral indurations; and tumours about the neck, increase the liability to apoplexy. The exciting causes of apoplexy are very numerous. In ge- neral, whatever produces inordinate determinations of blood to the head, or impedes its free return from the brain to the heart, may give rise to this disease. Over-distention of the stomach by immoderate eating, more especially if the ingesta are stimulating and of difficult digestion, and the digestive powers weak, is one of the most common and powerful exciting causes of apoplexy. The intemperate use of spirituous liquors, violent exertions in lifting, much straining in evacuating the feces, strong fits of coughing, sneezing, and great exertions in declaiming, playing on wind instruments, singing, laughing, or speaking, by causing sudden and strong determina- tions of blood to the head, may produce this disease in individu- als predisposed to it. Exposure to the direct rays of the sun in warm climates, gives rise to that sudden and fatal affection called stroke of the sun, and which is generally regarded as apoplexy. Extreme cold also is capable of producing this affection, by di- minishing the circulation in the external vessels, and causing strong internal congestions. Violent and sudden mental excite- ment, rage, excessive joy, terror, and deep sorrow, have been known to produce this disease. The suppression of habitual dis- charges, whether sanguineous or serous, may give rise to apoplexy. This is particularly the case with habitual hemorrhoidal discharge or epistaxis in plethoric subjects. The healing up of old ulcers has a tendency also to produce this disease in persons otherwise predisposed to it, (Schmucker's Vermisch. Schriften. B. iii. p. 149 ;) and the neglect of customary venesection in full habits may tend to the same effect. * Stoll mentions the sudden disap- pearance of oedema of the feet as an exciting cause of apoplexy (Ratio. Medend. Pars. iii. p. 305.) Women in the puerperal state, "are in some degree liable to apoplexy." Dr. Davis of London, states that he has met with four or five apoplectic sei- zures and consequent hemiplegia in puerperal women. In all these cases, the habitus apoplecticus mentioned above, was pre- • Vogel. Pnelectiones Academ. § 558. APOPLEXY. ID sent.* Tumours or visceral indurations In the abdomen, by press- ing on the aorta, may give rise to this disease. Morgagni relates an instance which was produced apparently by an enlarged spleen pressing on the aorta. Apoplexy may also occur in consequence of the repulsion of chronic cutaneous diseases ; and it is frequently the result of me- tastasis of gout. Authors mention also translations of rheuma- tism, erysipelas, and of other exanthematous affections among the exciting causes of this disease. I knew an instance in which it appeared to be brought on by a very severe attack of mumps. Violent rigors or chills, particularly the severe and protracted chills of intermittents, sometimes give rise to apoplexy. 1 have known several fatal instances of this kind. In one case, I stood by the patient when he was seized with the chills ; in about ten minutes after they commenced he became insensible ; fell into convulsions, and quickly passed into a profound apoplectic stu- por, from which he did not recover. The patient was an old, corpulent, and very plethoric man. Intestinal irritation may also cause so strong a determination of blood to the brain as to give rise to this affection, t Besides the foregoing causes, which operate apparently by causing undue determinations to the vessels of the brain, apo- plexy may also be produced by causes that impede the free re- turn of the veinous blood from the head to the heart. Stooping, or other situations in which the head remains in a depending position ; wearing tight cravats, and turning the head round to look back, by which the jugular veins are in some degree com- pressed ; impeded circulation through the lungs ; organic diseases of the heart;% tumours on the neck, or in situations where they may press upon the veins which convey the blood from the head, are the principal of these causes. Authors mention also excessive evacuations among the occa- sional causes of this disease. Boerhaave states, that he knew an instance of apoplexy apparently produced by an excessive hemor- rhage from the nose. The tendency of excessive sanguineous evacuations to produce soporose or cerebral oppression very simi- lar to apoplexy, has already been adverted to under the general head of hemorrhages. The work of Marschall Hall, referred to in that place, gives some very interesting observations on this subject. It is certainly a very remarkable circumstance, and not * Dr. Davis. Medico-Chirurg. Rev. April, 1825. \ There is, indeed, much reason to believe that gastro-intestinal irritation is a very common exciting cause of apoplexy. Thilenius, (Medicin. Chirurg. Be- merkungen, p. 66.) Also Schroeder, (De Apoplexiae ex praecordior. viiiis Origine. Analecta in Opusc. vol. ii. p. 388.)—as quoted in Jahn's Klinik der Chronischen Krankheiten. Bd. i. p. S40. t See Medico-Chirurg. Rev. January, 1820. pp. 343 and 345. 14 APOTLEXY. accordant, with the presently received pathology of apoplexy, that entire insensibility, with stertorous breathing, sometimes results from profuse hemorrhage." Diabetes sometimes termi- nates fatally, under symptoms strongly resembling apoplexy ; and the same termination has been noticed in excessive diarrhea and cholera. (Richter.) Peculiar atmospheric constitutions have also been ranked among the exciting causes of apoplexy ; and from causes of this kind, this disease has at times prevailed epi- demically, t Besides the authorities referred to below, we have also the more recent testimony of Weikard, ( Vermisch. Schrif- ten, st. i. p. 292. st. ii. p. 65,) and of Jahn, (Klinik d. Chronish. Krankheit. B. i. p. 333,) in confirmation of this fact; and Bag- livi mentions the epidemic occurrence of this affection. Richter states, that a humid, cold, and variable state of the atmosphere, appears to be most favourable to the occurrence of apoplexy. It is not improbable, however, that such a condition of the atmo- sphere depends more upon its electrical and barometrical state, than on its relative degrees of humidity and temperature. ^ This atmospheric tendency to produce or favour the production of apoplexy, is sometimes limited to a few days of continuance. Thus Thilenius states, that in the course of a few days, nine per- sons were seized with apoplexy in one district. (Bemerk. B. i. p. 61—Richter.) Various organic affections of the brain and its meninges, and the narcotic poisons, are also enumerated among the exciting causes of this disease. Gregory doubts whether these latter can, with propriety, be considered as exciting causes of apoplexy. As they tend, however, to cause strong congestion in the vessels of the brain, they may, no doubt, excite this affection in persons otherwise predisposed to it, as other causes do that strongly de- termine the circulation to the head. Pathology.—What is the immediate cause of the abolition of sensorial power and voluntary motion in apoplexy? Pathologists are far from being unanimous in their answers to this question. Some maintain, that pressure on the cerebral mass is always the immediate cause of the characteristic phenomena of this disease; others suppose that they depend not on pressure, but simply upon interrupted circulation in the brain;% whilst some believe that the encephalic effusions are the consequence of a previous morbid change in the brain, (Rochoux,) upon which the loss of sense and • For an interesting example of this kind, see Mr. Brown's case of uterine haemorrhage, reported in the London Medical and Physical Journal—1827. f Agathias. De Bello Gothico, in Hugo Grotii. Histor. Gothorum. p. 568. See also, Lepecq. de Clotiere. Anleit. f. Aerzte, Epidem. Krankh. Zubeobacht. p. 412. Fr. Hoffman. Medic. Ration. System, torn. ii. p. 11. 9. 11. p. 529— as quoted by Richter, Specielle Therapie, vol. viii. p. 755. t Abercrombie. Researches on the Pathology of the Drain in Apoplexy. APOPLEXY. 15 motion depends. Some pathologists confine the term apoplexy strictly to sanguineous extravasation within the brain; others in- clude serous effusions among the immediate causes of the diseasej and many believe, and correctly too, that mere vascular tumes- cence, without effusions of any kind, frequently produces apo- plexy. From a careful examination of much that has been written on this subject, as well as from my own observations, it appears to me clear that the opinion which assigns the characteristic pheno- mena of apoplexy to pressure of the brain, is the correct doctrine on this point. Post mortem examination detects in those who die of apoplexy one or more of the following phenomena:—1, vascular tumes- cence of the brain; 2, sanguineous extravasation into the substance of the brain; 3, serum effused into the ventricles or upon the surface of the brain; and 4, no cognizable cerebral disorder what- ever. Of these four conditions, the first only ought, I think, to be considered as primary or essential; the others being consecu- tive, and not immediately concerned as a cause in the apoplectic seizure. When the blood flows more rapidly into the arteries of the brain than it can be returned by the veins, preternatural disten- tion of the cerebral vessels must be the consequence; and this ge- neral vascular turgescence must exert an unusual degree of pres- sure on the cerebral mass. That such vascular engorgement and consequent pressure on the brain is capable of producing all the peculiar symptoms of apoplexy, admits of no doubt. In some instances of fatal apoplexy, the vessels of the brain are found so much engorged with blood, as to render even the smallest branches very conspicuous, and to give a more or less deep red tint to certain portions of the cere- bral mass without any sanguineous or serous effusions. * Richter says that an extremely congested state of the cerebral vessels is sometimes the only morbid condition visible within the head.t Bricheteau also observes, "that we often find a general turges- cence of the cerebral vessels, which congestion causes a general pressure on the encephalic mass, sufficient to extinguish the ner- vous influence, and destroy life."J Morgagni has related a case in which he found, on dissection, the whole vascular system of the brain extremely engorged with fluid blood. Dr. James John- son, in commenting on this case, observes,—" that apoplexy is frequently produced by turgescence of the vessels alone, was believed in ancient times as well as in modern. It is, indeed, • Portal. Resultats de l'Ouverture des Corps. f Specielle Therapie, Bd. viii. p. 718. i Journal Complimentaire du Diet, des Scicn. Med. p. 296. 16 APOPLEXY. reasonable to suppose, that in the majority of apoplectic recove- ries, congestion only had taken place in the vessels of the brain. But if congestion gives rise to the most favourable cases, it appears capable of producing the most desperate and instantaneously fatal ones also."* Dr. Fouquier, also, has reported a case of fatal apoplexy, which was manifestly the result of mere sanguineous engorgement of the brain. "The exterior vessels of the brain and those of the choroid plexus were much engorged with blood;" and the interior of the cerebral mass, when sliced off, presented a multitude of red points. Neither serous nor sanguineous effusion was present.! Strong and sudden sanguineous engorgement of the cerebral vessels is, probably, always one of the first morbid conditions in the occurrence of apoplexy—the immediate result of diminished vital resistance in the vessels of the brain, and a preternatural afflux of blood to these vessels. (Johnson.) This vascular turges- cence may pass off again under proper remediate measures; or it may terminate speedily in sanguineous extravasation into the brain; or continue, finally, without any effusions, until it termi- nates the patient's life. What is usually termed serous apoplexy, is perhaps only one of the terminations of apoplexy from vascu- lar turgescence. A sudden violent determination of blood to the brain, and consequent cerebral compression, may immediately destroy all sense and voluntary motion. If the vessels be not relieved by extravasation or by remediate applications, they may, in the course of some hours, relieve themselves by serous effusion, as they do in hydrocephalus acutus ; and this effusion must then become a secondary but permanent cause of cerebral compression. It is unnecessary here to adduce any arguments in support of this pathology of serous apoplexy. We often meet with striking ex- amples of sudden serous or lymphatic effusions from vascular engorgement. Every one has heard of the affection usually call- ed apoplexy of the lungs. Sudden and often fatal effusions of this kind occur into the substance of the lungs from violent en- gorgement of its blood-vessels. It appears highly probable, therefore, that strong vascular tur- gescence of the encephalic mass, constitutes the primary patholo- gical condition of apoplexy. This state often terminates almost immediately in sanguineous extravasation, or at a later period in serous effusion; and both these consequences constitute, of course, additional causes of cerebral compression.^ • Medico-Chir. Rev. June, 1820, p. 9. \ Annuaire Medico-Chirurgicale, vol. i. p. 376. \ M. Serres contends that both sanguineous and serous effusions are always the effect, and not the cause of apoplexy. He denies that pressure, in any case, is capable of producing either this disease or hemiplegia. He thinks, that what is usually termed serous apoplexy depends on disease of the meninges j apoplexy APOPLEXY. 17 To this view of the pathology of apoplexy, it has been object- ed, that cases sometimes occur in which the brain on dissection exhibits no traces whatever of vascular congestion, nor any other obvious lesions. Petzold has related instances of this kind, which he ascribes to inanition of the cerebral vessels, and in which not the slightest unnatural appearances were discovered on dis- section, except an empty and collapsed state of the vessels of the brain.* Such cases are, however, extremely uncommon ; and do not, upon proper inquiry, militate against the doctrine advocated above. Upon this point Dr. Johnson observes, "that there is nothing more certain than that the vascular turgescence in the brain may so far subside, in the interval between death and dis- section, as to leave no trace of its previous existence. This, in fact," he continues, "we consider to be the natural and true so- lution of the difficulty respecting the cause of apoplexy in those cases where the scalpel cannot detect deviations from the healthy structure."! There is, however, another objection that has been urged against the doctrine of cerebral compression as the exclu- sive cause of apoplexy, which, though plausible, possesses no real weight. It is stated, and correctly, that all the external ma- nifestations of strong apoplexy are sometimes the immediate re- sult of excessive hemorrhage. I have already referred to the case reported by Mr. Brown, in which entire insensibility and stertorous breathing were the immediate consequences of exces- sive uterine hemorrhage, and which were removed by transfus- ing blood from another person into the patient's veins. J Dr. Denman has also related an instance of apoplectic symptoms su- pervening on very profuse hemorrhage, § and many more cases with paralysis, he says, is the immediate consequence of an altered state of the cerebral structure, attended generally with sanguineous extravasation as a secon- dary result. His reasons for denying the agency of pressure in the causation of this affection, are derived from the fact, that fatal apoplexy sometimes occurs without any effusion or extravasation, or even vascular turgescence appearing on dissection; and from some experiments which he made on animals,in which the cranium was opened, and a vessel wounded, and the blood carefully confined within the head by closing up the external opening. Although much blood was thus extravasated and lodged into the great interlobular scissure and upon the surface of the brain, no comatose or paralytic affections ensued. These views, so far as cerebral pressure is concerned in the production of the disease, are, however, directly contradicted by the results of some experiments made in rela- tion to this subject by Portal. This pathologist trepanned the cranium of a dog. By different degrees of pressure made on the brain through the opening with the finger or a piece of wood, he could at pleasure produce convulsions, or coma, and apoplectic stertor; and Sir Astley Cooper obtained the same results from similar experiments made on a dog. (a) • Dissert, de apoplexia ex inanitione vasorum cerebri, Goett. 1785. f Med. Chir. Rev. June, 1820, p. 8. * Lond. Med. and Physical Journal, 1827. § Trans, of a Soc. for the Improv. of Med. and Surg. Knowledge, vol. iii. p. 315. (a) Cook on Nervous Diseases. Vol. II. 3 18 APOPLEXY. of this kind might be collected. In relation to such cases it is to be observed, that great losses of blood are peculiarly w™™\e to extraordinary determinations to the brain, or as Marshall riatl expresses it, " to increased action and fulness of the cerebral ves- sels."* The experiments of Kellie, on animals, show that serous effusion within the head, is a pretty constant concomitant or con- sequence of excessive sanguineous depletion; and the experi- ments of Dr. Seeds go to establish fhe same fact.t ^ The sanguineous extravasations are usually found in the corpus striatum, or in the thalami nervorum opticorum. Out of forty- one dissections, Rochoux met with but five or six instances of extravasation in other parts of the brain; and the observations of Morgagni give nearly the same result. $ Extravasation of blood into the cerebellum is an extremely rare occurrence. According to Rochoux it hardly happens once in fifty cases; and Morgagni reports only one instance of this kind. " Blood is rarely effused, in the first instance, into the ventricles. During ten years ob- servation in the different hospitals, M. Bricheteau saw only two cases of this kind. The fluid is generally extravasated in the neighbourhood of the ventricles, and bursts into them by a rag- ged opening." (Med. Chir. Rev. loc. cit.) Occasionally blood has been found effused on the surface of the brain. Rochoux relates a case of this kind; and Richter states that sometimes the brain, on removing the cranium, appears dark, brown, or blackish, through the membranes, from extravasated blood underneath, (loc. cit. B. viii. p. 719.) The old division of apoplexy into sangui- neous and serous, possesses no importance in a practical point of view. I have already stated that the effused serum sometimes found within the head on dissection, is very probably not the immediate cause of the apoplectic seizure, but one of the results of the vascular engorgement, upon which the apoplexy depends. There are, nevertheless, some circumstances connected with this distinction which it may be proper to notice. Thus, it appears, from the observations of M. Serres, that when the apoplectic attack is complicated with hemiplegia, we may infer that there is extra- vasation into the cerebral substance. When, on the other hand, * Medical Essays, p. 68. | M. Seeds, in six experiments performed on animals which he bled to death, found the contents of the cranium and spinal canal so engorged with blood, that it might at first sight have been thought that blood-letting would have saved the animals."—Medico-Chirurg. Jour, and Review, vol. i. \ In explanation of this fact, M. Bricheteau observes, "an attentive study of the vascular system of the brain shows us that a number of arteries penetrate directly into these parts—the corpus striatum, &c. without dividing themselves in the pia mater, as the other vessels do which serve to nourish the brain. In consequence of this they are without any additional membranous support in the middle of the cerebral mass, the consistence of which is but illy calculated to support them against the impulse of the blood.—Loc. cit. APOPLEXY. 19 the disease is unaccompanied with paralysis, we may presume that the substance of the brain remains uninjured, and that more or less serum, or sero-sanguineous fluid, is effused by the congested and irritated meninges upon the surface, or into the natural cavi- ties of the brain. The former variety—that is, the complicated or paralytic form of the disease, M. Serres calls cerebral apo- plexy, from the cerebral mass itself being the principal seat of the morbid changes. The latter, or uncomplicated variety, he denominates meningeal apoplexy, on account of the manifest traces of vascular irritation and congestion, discovered by dis- section, in the meninges. It appears from the observations made in the Parisian hospitals, that meningeal or serous apoplexy oc- curs chiefly before the fifteenth and after the sixtieth years of age; and that females are more liable to this variety of the disease than males. When blood is extravasated into one hemisphere of the brain, the consequent paralysis occurs almost universally on the oppo- site side of the body. The paralysis is occasionally general— both sides of the body being equally affected. In such cases the mouth is not drawn to either side, and the patient dies as from asphyxia; or as animals do who have the pneumo-gastric nerves of both sides divided. The extravasation, in cases of this violent character, takes place into the substance of the tuber annulare, or bursts from thence and spreads along the basis of the skull. (Ser- res. ) The existence of hemiplegia may, in general, be readily detected by the distortion of the mouth; for however profound the apoplectic stupor may be, more or less deviation from the natural position of the mouth is almost universally present. Treatment.—The main object to be kept in view in the treat- ment of apoplexy, is the removal of the vascular turgescence within the head. This fundamental indication is to be answered by a prompt reduction of the general mass and momentum of the blood; and by the employment of means calculated to lessen the determination of the blood to the brain, and to derive it from the cerebral vessels. In the actual paroxysm of apoplexy, the patient should be im- mediately removed to an airy and cool situation, and placed in a position which least favours the flow of blood to the head. All ligatures, particularly those about the neck, should be speedily removed, and his head and shoulders supported in an elevated position. In this posture, a large orifice should be made into a vein, and the blood suffered to flow until a very decided impres- sion is made on the pulse, at the same time that cloths, wet with cold water, are applied to the shaven scalp, and warm or stimu- lating applications—such as fomentations, sinapisms, or frictions with tincture of capsicum, made to the legs and feet. Cups may also be very beneficially applied to the temples and back of the 20 APOPLEXY. neck, conjointly with the means just mentioned. Some advise bleeding from the temporal artery or the jugular vein in prefer- ence to brachial venesection ; but others do not regard this pre- ference as founded on good grounds. It is nevertheless very probable that blood promptly drawn from the jugular veins or temporal arteries, will have a more direct and speedy effect in diminishing the sanguineous congestion in the brain, than if it be taken from the arm; and as the accomplishment of this effect constitutes our chief purpose in the employment of blood-letting, we may with propriety adopt this mode of depletion. In what- ever way the blood is drawn, little or no advantage will be ob- tained, unless a sufficient quantity is abstracted to produce a very obvious impression on the action of the pulse; and this effect can seldom be produced without the loss of from thirty to forty ounces of blood at once. If in the course of an hour the pulse resumes its activity, a second venesection should be practised, and repeated afterwards at longer or shorter intervals, as long as the pulse indicates the propriety of further depletion. It is some- times necessary to abstract a vast quantity of blood before the disease begins to subside. " From six to eight pounds of blood have been taken from a person by no means robust, before the disease began to yield."* I have myself drawn five pounds of blood from an apoplectic patient in the course of six hours after the seizure with entire success. In the employment of blood- letting we may suffer ourselves to be guided by the pulse, as has just been stated. Nevertheless, the judicious practitioner will regulate the extent to which this evacuation is carried, not only by its effects on the pulse, but by an attention also to the age and constitutional habit of the patient. I have met with a case of apoplexy which ultimately proved fatal, in which the loss of thirty ounces of blood produced, almost immediately, much fee- bleness of the pulse. The patient was a female, beyond the seventieth year of age. Leeching is of no service beyond what may result from the general diminution of the circulation. Cupping, however, is a most important auxiliary.t After an efficient venesection, the * Cheyne. f I very much admire the mode of cupping recommended by Mr. Wallace, (a) It is as follows : A cupping glass having been exhausted in the usual way, is ap- phed to the surface until the skin is sufficiently raised. A very sharp gum lancet is then to be lightly and rapidly drawn over the skin, so as to make superficial incisions about the sixth of an inch from each other, over the whole surface raised by the exhausted cup. These incisions should be so slight as to be scarcely visible. The moment the cupping-glasses are reapplied, the blood will be found to stream trom them with surprising rapidity. (a) A Physiological Inquiry into the Action of Moxa, &c. By Mr. William Walhce, M. R. I. A. Surgeon of the Charitable Infirmary of Dublin, &c. &c. APOPLEXY/. 21 application of cups along the temples and back of the neck, or to the shaven scalp, will sometimes speedily rouse the patient from his stupor. * The application of ice, or very cold water to the scalp, is one of the most useful remedies in this disease. This was a favourite measure with Thilenius,t and his praise of its powers, though great, can scarcely be deemed extravagant. Its efficacy will be much enhanced by the simultaneous application of warmth, or stimulating frictions to the legs and feet. Of course, where the pulse is feeble, and the countenance pale, cold must be cautiously applied, but stimulating and warming applications to the lower extremities are always proper. Formerly, blood-letting was re- garded as of very doubtful propriety in this affection; but at the present day its usefulness, or rather its indispensableness, in every case of genuine apoplexy, is universally acknowledged. Active purgatives also are among our most efficient remedies in this affection. As the advantages derived from them depend, no doubt, in most instances, chiefly on the tendency they have to direct the circulation more particularly to the intestines, and to excite a free secretion from their internal surface, and conse- quently to diminish the afflux of blood to the head, it is evident that the more rapidly they operate, the more beneficial will be their influence. On this account, as well as from the great intes- tinal torpor which prevails in this affection, it is necessary to em- ploy the most active articles of this class of medicines. It is, however, often extremely difficult, and in violent instances, some- times impossible to administer cathartics by the mouth, from the paralysed state of the organs of deglutition. Where the power of swallowing is wholly destroyed, we may introduce a purga- tive fluid into the stomach through an elastic stomach tube. Ca- lomel and extract of jalap are recommended by Sir Gilbert Blane as the best purgative in this affection. Calomel and colocynth form also a suitable purgative. I have used the oil of croton, rubbed up with a little gum arabic and water, with excellent effect in two instances of apoplexy. This article generally acts with much energy, and from its small bulk and fluidity, is more easily introduced into the stomach than other remedies of this kind. Castor oil with turpentine, also forms an excellent purga- tive in this disease. At the same time that cathartics are given by the mouth, active purgative enemata should be repeatedly ad- ministered. For this purpose we may use a solution of aloes in warm water, in the proportion of from thirty to forty grains to the pint of water ; or a strong infusion of senna. Richter ad- vises a solution of tartar emetic for this purpose. Where the * Dreysig, loc. cit. p. 481. f Medicinische und Chirurgische Bemerkungen, p. 62. et seq. 22 APOPLEXY. vascular reaction is vigorous, this solution may be peculiarly ser- viceable, by the nausea and consequent reduction of arterial ex- citement which it is apt to produce, as well as by its evacuant effects on the bowels. Purgatives are particularly useful where the bowels are in a loaded condition. Dr. Abercrombie relates some instances of this disease, in which blood-letting afforded but very little advantage. As soon, however, as the bowels were freely eva- cuated, a very obvious improvement.took place. Where the inordinate flow of blood to the brain is caused or supported by intestinal irritation from accumulation of feculent matter, or the presence of vitiated secretions, it would seem in vain to expect decided benefit from bleeding or any other remedy, unless the bowels are freely moved ; and it is in such cases especially, that cathartics are of primary importance. Formerly emetics were much extolled for their remediate powers in apoplexy. Van Helmont, Riverius, Stoll, and Burse- rius, placed much dependence on them in the treatment of this disease.* Since the time of Cullen, however, they have been generally abandoned, as much more calculated to do mischief than good.t Unquestionably, as a general rule, emetics must be regarded as hazardous remedies in apoplexy ; for the tendency of vomiting to propel the blood to the head is always very con- siderable. Nevertheless, this disease may occur under circum- stances of gastric irritation, which may not only render emesis useful, but absolutely indispensable to success. When the apo- plectic seizure occurs soon after taking a very full meal of stimu- lating food, an emetic ought undoubtedly to be given. But even under the most urgent indications for the exhibition of an emetic, a copious and efficient abstraction of blood should always be pre- mised. A few years ago, 1 met with a striking instance of the usefulness of emetics in apoplexy, under the circumstances just mentioned. A robust man, about fifty years of age, fell down in a fit of apoplexy about an hour after he had taken a very full meal of animal food, with several glasses of brandy and water. The coma was profound, and the respiration stertorous and sputter- ing. He was immediately bled to the extent of about forty-eight ounces, but although the pulse was considerably reduced, no per- ceptible improvement ensued. Twenty grains of sulphate of zinc were with difficulty introduced into his stomach, and free vo- miting ensued in about ten minutes after. Almost immediately after the contents of the stomach were thrown off, he became bet- ter ; and by the use of purgatives, enemata, and cups to the head, he recovered without any further difficulty. Dr. Gregory says, * Burserius. Inst. Med. Pract. vol. iii. § 131, p. 106. f See Lond. Med. and Phys. Jour. vol. v. and vi. for an ample discussion on this subject. APOPLEXY. 23 " in certain cases vomits are proper ; but they should nefver be given till after large evacuations by blood-letting. They are most proper where the disease proceeds from a surfeit; and in serous habits vomits are very efficacious."* Authors generally advise the mildest emetics in cases where they are indicated. Heberden gave a weak infusion of chamomile ; Cheyne used lukewarm water with hartshorn ; and others recommend warm water with mustard. It is very questionable, however, whether any peculiar advantages attend the use of these milder emetics. Indeed, the system is almost always so insensible to the impres- sions of medicines, that nothing but the most active articles in large doses, will procure emesis. Where there are indications present to justify the exhibition of an emetic, the more promptly the stomach is evacuated the better. Richter;, who speaks very favourably of the employment of emetics in cases of this kind, advises the most active articles of this class, t Blisters do not appear to afford any advantage in apoplexy, un- less the pulse is weak, small, and quick, which, though rarely, is sometimes the case, in old and enfeebled persons of leucophleg- matic habits. At all times, however, it is better to apply them to the ankles and wrists than to the head or back of the neck. It is scarcely necessary to say, that stimulants are decidedly improper in the early period of apoplexy. Where, after copious evacuations, some degree of consciousness and a power of volun- tary motion returns, with much prostration and a feeble pulse, some benefit may perhaps be obtained from the cautious exhibi- tion of the carbonate of ammonia or camphor, (Richter,) in the form of a mucilaginous mixture. The prompt and judicious employment of the foregoing means, embraces every thing that may be deemed efficient in the reme- diate management of apoplexy. From whatever cause the disease may arise, our whole efforts should be directed to the removal of the inordinate vascular action or turgescence within the head. Some modifications in the mode of employing the measures men- tioned, according to the general constitutional habit, the age, and the character of the exciting causes, will of course be necessary. Thus, in cases which succeed the sudden suppression of habitual hemorrhoidal discharge, some peculiar advantage may perhaps be gained from the application of leeches to the anus ; if the heal- ing up of old ulcers on the lower extremities appears to have given occasion to the apoplectic seizure, blisters, issues, or sina- pisms to these parts will be proper ; and I have already adverted to the usefulness of emetics when the attack takes place soon after • MS. Lecture as quoted in the Med. Chirurg. Rev. June, 1820. p. 26. f Med. Chir. Bemerkungen. B. ii. p. 109. 24 APOPLEXY. a surfeit, and the lndispensableness of cathartics when the bowels are loaded with feculent and other irritating matters. During convalescence from apoplexy, nothing but the lightest unirritating diet should be allowed ; and unless great prostration exists, all kinds of vinous liquors should be interdicted. The prophylactic management, in persons labouring under the usual premonitory symptoms of apoplexy, or constitutionally predisposed to this affection, constitutes a very important point of medical attention. A simple, abstemious diet, exercise in the open air, and the avoidance of all kinds of stimulating drinks, as well as of sudden and violent mental excitement, are among the most important precautionary measures in cases of impending apoplexy. If the bowels are torpid, and cannot be brought to a regular state by vegetable diet, it will be necessary to use an occasional dose of some mild laxative, as castor oil, or small por- tions of rhubarb ; and where there is reason to suspect hepatic torpor or derangement, three or four grains of blue pill with a few grains of pulvis antimonialis, taken occasionally at night on going to bed, will be useful. When alarming premonitory symp- toms come on, with an active, full, and hard pulse, blood should be immediately drawn to an extent sufficient to reduce considera- bly the momentum of the circulation, and a brisk cathartic ad- ministered. It should be recollected, however, that blood-letting affords only temporary benefit. A copious abstraction of blood may obviate an approaching attack of this disease, but frequent venesection will do little or no good in preventing that general plethoric habit which is so favourable to the occurrence of this affection. This must be done by abstemious living ; and above all, by an active course of life. Persons predisposed to apoplexy from corporeal conformation, should be particularly careful not to interfere with, or check he- morrhoidal discharges, unless they become excessive. The same precaution is necessary with regard to epistaxis in individuals of the apoplectic habit, as well as with other habitual evacuations. Drs. Cheyne* and Stokert recommend the internal use of small doses of James's powders, or pulvis antimonialis, where there is an habitual tendency to inordinate sanguineous determinations to the head. In one instance of this kind, I have known the daily use of two grains of James's powder, mornings and evenings, of unequivocal benefit. Green tea also is said to possess the power of diminishing or obviating,cephalic congestions. Drs. E. Per- civalj and Stoker strongly recommend it for this purpose in co- matose affections ; and my own experience leads me to think that * Dublin Hospital Reports, vol. \. p. 315. \ Dublin Medical Essays, anno. 1806. Transactions of the Association of Fellows and Licentiates of the Queen's College of Physic. Dublin, vol. ii. \ Dublin Medical Essays, vol. ii. p. 44. APOPLEXY. 25 it possesses considerable powers in this way. Coffee, however, is decidedly injurious where there is an apoplectic tendency. Some eight years ago, a gentleman in this city, of a strongly developed apoplectic habit, was seized with an attack of this af- fection. He was in the habit of taking large quantities of very strong coffee twice daily. I advised him to leave off taking this beverage entirely. He did so ; and has not since experienced even the ordinary premonitory symptoms of the complaint. Apoplectic subjects should be very careful not to bathe their feet in very cold water—more especially when they are subject to habitual perspiration from these parts. The frequent use of the warm bath also is hazardous in persons of this habit; and exces- sive venereal indulgence is equally apt to do injury. Sect. II.—Paralysis.—Palsy. Palsy consists in impaired or abolished power of voluntary motion, or of sensation, or of both, in certain parts of the body, without coma, or a loss of consciousness. Cases in which both sensibility and the power of motion are at once destroyed, are however extremely rare. Instances even occur in which the sensibility of the palsied part is morbidly increased. I have met with a case of this kind. The patient had lost all command over the muscles of the lower extremities ; but the sensibility of the skin from the knees downwards was so great, that even moderate pressure with the fingers gave rise to considerable pain. An in- stance is related in a recent French journal, in which the surface of the paralysed limb was entirely insensible, but the muscles beneath were the seat of acute pain, which was always much in- creased by pressure.* In general the paralysed parts become soft and flaccid, and at last usually emaciated, or occasionally cedematous. Sometimes a peculiar tingling, or creeping sensa- tion (formicatio) is felt in the affected parts, "as if small insects were creeping over them." The opinion generally entertained, that the temperature of the palsied parts is lower than natural, does not appear to be founded on correct observation. It is true, we frequently find such parts cooler than the rest of the body ; but this would seem to depend on the loss of power in the para- lytic part to maintain its specific temperature; in other words, to resist the physical laws of the distribution of heat, in conse- quence of which, such part becomes cooler when exposed to a temperature below that of the human body, and warmer than natural, when exposed to a temperature above this point.t Pa- • Med. Chir. Rev. October, 1829, p. 168. f Dr. Abercrombie—See Cook on Nervous Diseases, p. 227. Boston, 1824. Vol. II. 4 26 PARALYSIS. tients sometimes complain of a severe, sense of cold In the affect- ed parts, although to the touch the temperature does not appear to be materially diminished. In some instances the pulse is smaller and weaker in the paralysed limb, than in the healthy one ; sometimes, however, it is fuller and stronger in the affect- ed than in the sound side; and frequently no difference whatever can be perceived in this respect. When palsy arises from disease of the encephalon, it is gene- rally attended with an evident impairment of the mental pow- ers—amounting, in some instances, to complete imbecility. The memory, especially, is apt to suffer in this affection ; and some- times in a very singular manner. Individuals affected with cere- bral palsy, have lost the power of recollecting particular words* numbers, letters, localities, or even their own names ; whilst in other respects no material defect was manifested in this faculty. The natural temperament and disposition also sometimes suffer a total change from a stroke of palsy. Individuals of amiable and placid dispositions have become sullen, peevish, irascible ; and persons of an irritable and passionate temperament have been rendered mild and simpering by a paralytic seizure. (Cook.) Paralysis has been known to occur periodically. A case of palsy is related by Musgrave, (Philosoph. Transact.) which regularly returned every eight days, and continued each time to the fourth day. The duration of palsy is very various. Occa- sionally the affected muscles recover almost entirely their healthy powers in a few days; but the progress of amendment is much more commonly very gradual and slow. It is a singular fact, that the extreme parts of a paralysed limb are often the first that manifest any degree of returning muscular power. I attended a hemiplegiac patient about two years ago, for three weeks, without any apparent amendment; at last, however, he found that he could move his toes ; by degrees he regained the power of moving the foot, then the leg, and finally the thigh. The same progress of amendment occurred in the paralysed arm. The power of motion began in the fingers, and gradually extended upwards. When palsy occurs in the whole of one side of the body, it is termed hemiplegia; if both the inferior extremities, from the hips downwards, are paralysed, it is called paraplegia ; and when only some one particular part is affected, it constitutes the paralysis partialis of authors. Paralysis, without coma, affecting the whole body, is an extremely rare occurrence. Cases of this kind, however, have been recorded. A very curious instance of general palsy occurred lately in one of the Parisian hospitals. The paralysis in this case commenced in the feet, and gradually ascended towards the body ; when it had arrived at the knees, the palsy seized also upon the hands, and slowly passed upwards PARALYSIS. 27 to the trunk ; finally, every voluntary muscle, excepting those of the face, neck, and tongue, became paralysed. The patient's general health was good, and his intellect perfect* Tissot relates an instance of a boy, who, apparently in consequence of a repelled scabby affection of the head, became paralytic throughout nearly the whole of the muscular system, attended with much torpor of the sensorial functions, and mental weakness, though wholly free from coma or somnolency, t M. Bretonneau has related a some what similar case. "A lady was seized with paralysis of the little finger of the left hand, which gradually extended to the whole of that side ; the right became similarly affected, with the exception of the thumb and two fingers. The whole body was thus palsied—the tongue was motionless, and deglutition extreme- ly difficult; but her intellectual faculties remained unimpaired." J Cook mentions a ease, from a publication of M. Keratry, in which there was paralysis of the "arms, thighs, and of the whole exte- rior surface of the body, with the exception of the face." I*. Hemiplegia. This is by far the most common of those forms of palsy which depend on oppressed function of the sensorium commune. In its essential pathological character, it does not appear to differ mate- rially from apoplexy ; and it occurs frequently as an immediate concomitant of this disease. Hemiplegia is almost always ush- ered in with more or less distinctly marked apoplectic symptoms. Occasionally the hemiplegiac attack occurs suddenly, without any distinct manifestations of its approach. Much more frequent- ly, however, some of the ordinary premonitory symptoms of apoplexy precede the attack for several days; and just before the seizure, strong symptoms of sanguineous determination to the head, and cerebral disturbance, are particularly apt to occur— such as flushed face; distention of the veins about the head and neck; vertigo; a sense of fulness, weight, and sometimes pain in the head; ringing in the ears; drowsiness; impeded articulation of words, or loss of speech; slight delirium, or confusion of the mind; loss of memory, and a change of habitual disposition. M. Serres states that he has noticed in cases that came on gradually, distortion of the mouth for several hours before the hemiplegia supervened; and immediately before the seizure, he has some- times remarked, that in the act of respiration, one side of the chest * Medico-Chirurg. Rev. Oct. 1829, p. 168. f Medical Works, vol. iv. p. 552. i Med. Chir. Rev. Oct. 1826, p. 604. Clinical Report of the Hospice de Peifeclionncment, Rev. Medicale, 1826. 2S HEMIPLEGIA. was quiescent, whilst the other was very conspicuously dilated and contracted. The reproductive or vital functions are seldom much disturbed in the ordinary cases of hemiplegia. In some instances, however, the whole track of the alimentary canal is extremely torpid, and it would appear that the liver is sometimes affected.* The coun- tenance generally acquires a vague or fatuous expression ; the mouth is drawn to one side; the lower lip on the palsied side hangs down, and suffers the saliva to dribble away. Articulation is always more or less difficult and indistinct, and deglutition is generally somewhat impeded and difficult—more especially on attempting to swallow liquids. It is in this form of paralysis, particularly, that the mind is apt to suffer from the long con- tinuance of the disease. General impairment of the intellectual powers usually occurs; but the memory is most apt to become . conspicuously enfeebled, and even wholly effaced. Very remarkable anomalous circumstances are sometimes con- nected with hemiplegiac affections. Cook has collected a great variety of curious cases of this kind. An instance is related, in which the arm of one side and the leg of the opposite one were palsied, (Fahricius;) another, where the sensibility, but not the power of voluntary motion, was destroyed in one leg, whilst in the other the power of motion was lost, with the sensibility unimpaired. (Ramazzini.) Cases are reported in the Memoirs of the Royal Academy of Sciences, in which there was an entire loss of sensibility, without any impairment of voluntary motion. In some instances the sensibility is morbidly increased. Falconer mentions a case in which cold bodies communicated the sensation of heat to the palsied parts; and in the case Dr. Vieusseux, (Med. Chir. Trans, vol. ii. pp. 216, 217,) the right side was at first so insensible that it could be pinched or pricked without giving him pain ; afterwards this insensibility seized on the left side. In the right side cold bodies excited the sensation of heat, and hot bodies that of cold, or only coolness. Dr. Cook has seen a case of hemi- plegia, in which the muscles of the left arm, from the shoulder to the elbow, were much emaciated, and greatly impaired in ac- tivity ; whilst those of the fore-arm were in a perfectly natural state, both as to fulness and power. The condition of the right arm was directly the reverse, the muscles of the part above the elbow were natural in size and energy, but those of the fore-arm were wasted and powerless. In some instances little or no improvement takes place, and the patient remains helpless, often for a long time, and at last dies, either from gradual exhaustion, or suddenly from apoplexy. More commonly, however, more or less amendment slowly oc- * Morgagni. Epist. xi. art. xiv. HEMIPLEGIA- 29 curs, until the patient is perhaps able to support himself with but little aid in a sitting posture, or even to walk about, with some assistance, without any further improvement. Occasionally the paralysis passes off almost entirely in a few days; but the progress of improvement is usually very slow and gradual, and rarely goes on at once equally throughout the whole of the paralysed part. 2.—Paraplegia. The palsy, in this form of the disease, is confined to the lower half of the body—that is, to the pelvis and the inferior extremi- ties. When the immediate cause of abolished nervous function is seated in the upper parts of the spine, the paralysis will affect the superior parts of the body; but the term paraplegia is gene- rally restricted to palsy of the inferior extremities, and parts about the pelvis. Paraplegia generally comes on gradually, and when it arises from an affection of the brain, is often preceded and accompanied in its course by pain in the head, giddiness, drowsiness, dimness of sight, and impaired memory. Sometimes a feeling of heavi- ness and numbness is felt in the upper extremities, as a precurso- ry symptom of this form of palsy. At first the patient usually experiences a slight stiffness and awkwardness in the motions of the lower extremities, which gradually increase until the patient finds himself unable to maintain the due balance of the body with- out the aid of a cane. As the disease advances, " the stream of urine becomes more and more feeble, and at length dribbles off involuntarily." The bowels are generally constipated; but when the sphincter muscles of the anus become paralysed, the feces are evacuated without the consent of the will. I have met with an instance of paraplegia, in which retention of the urine took place, requiring the use of the catheter five or six days before any para- lytic affection was experienced in the lower extremities. Some- times the palsy is complete, the patient being unable to maintain even a sitting posture; in other cases the power of motion is not wholly destroyed, so that with a little assistance, the patient may support himself in a sitting position. (Baillie.)* When paraple- gia depends on disease or lesion of the spinal marrow, it usually approaches very gradually, unless it occurs as the immediate con- sequence of some mechanical injury of the spine. The patient at first feels a languor and weakness in the knees; after some time a difficulty in directing the feet occurs, and the legs in walking are involuntarily thrown across each other, causing frequent trip- * Observations upon Paraplegia in Adults. By Matthew Baillie, M. D., in the sixth volume of the Medical Transactions of the London College of Physicians. 30 PARAPLEGIA. ping or stumbling. By degrees the insensibility and loss of mus- cular power in the legs and thighs become more and more con- spicuous, until, at length, a total paralysis of these parts occurs. The loss of vitality is sometimes so great, that gangrene and sloughing of the legs ensue from the mere pressure of the parts against the bed. About six years ago, I met with a case of para- plegia in an adult, w*hich, from the attending symptoms of cere- bral disturbance, depended, I presume, on some affection of the brain. In the course of about ten days after the accession of the paralysis, the heel first, and then rapidly all the soft parts of the right leg, from the ankle to near the knee, became gangrenous, and sloughed off to the bones. Paraplegia from cerebral affection most commonly occurs after the forty-fifth year of age, and, according to the observations of some, more frequently in males than in females. That variety of paraplegia which depends on disease or injury of the spine, is most common in childhood, and seldom comes on spontaneously after the age of puberty. Contrary to cerebral paraplegia, it occurs more frequently in females thau in males. 3.—Paralysis Partialis*. Every sensitive and motive part of the animal system may lose either its power of feeling, or of motion, or of both. In some instances the palsy is confined to a particular organ, but when the muscles are the seat of the affection, it generally em- braces either all the flexors or extensors, or both, of a part or the whole of a limb. Some cases of partial paralysis are attended with loss only of sensorial power. Of this kind are the paralytic affections of the olfactory nerves; of the retina; of the gustatory nerves; of the auditory nerves; and of the nerves of general feel- ing or touch. In other cases the palsy is confined to a depriva- tion of the power of motion, with or without the loss of sensibil- ity, in a particular part. In some instances a Single muscle alone is paralysed. Abercrombie mentions a case of this kind, which continued for a long time without either extending to other mus- cles or becoming better. Paralysis of the muscles of one side of the face is by no means uncommon, and in some cases the under lip only becomes thus affected. The eyelids also sometimes be- come palsied; and a los3 of the power of voluntary motion in the muscles of the hands, feet, fingers, wrists, legs, and thighs, is of frequent occurrence. The bowels, the oesophagus, the pharynx, the bladder, the different sphincters, and the erector muscles of the penis, are occasionally affected with palsy; and it is not im- probable that some of the secretory organs—particularly the kidneys and liver, may sometimes be thus affected. PARALYSIS PARTIALIS. 31 Of the Causes of Paralysis.—The predisposing and exciting causes of those forms of palsy which arise from an affection of the common nervous centre, so far as they can be ascertained, do not differ from those which have already been mentioned under the head of apoplexy. In relation to the immediate cause of palsy, it would seem that so far as it is dependent on the state of the brain, it may be the consequence of a great variety of morbid conditions of this organ. It has been generally supposed that pressure on the brain is the chief immediate cause of hemiplegia. That sanguineous or serous effusions, and other causes producing pressure on the brain, often give rise to paralysis, appears to be well established. " When the causes which produce cerebral pressure act generally and powerfully," says Dr. Cook, " they seem to produce apoplexy, and to give occasion to palsy when they act partially or with less violence; so that by an increase of power of the cause, palsy may terminate in apoplexy; and by a diminution of it, apoplexy may terminate in palsy." Hemiplegia is, indeed, a very frequent consequence of apoplexy; and, on the contrary, paralysis very often terminates at last in an apoplectic attack. It is, neverthe- less, equally well ascertained, that both general and partial palsy may arise from cerebral affections wholly unconnected with any circumstances that might be supposed capable of exerting any pressure on the encephalon. Reasoning, indeed, upon the gene- ral nature of palsy, we would be led, h, priori, to suppose that. every thing which is capable of greatly disordering the source of nervous power, might give rise to this affection. Dr. Powel, in an interesting paper on the subject of paralysis from sudden ex- posure to cold, has adduced some cases which would seem to- show that both general and local palsy sometimes depend on a morbid condition of the nerves alone, independent of any affec- tion of the encephalic mass. So far, however, as post mortem examinations can throw any light upon the nature of the rjrox- imate cause of general paralysis, we have direct evidence that almost every variety of cerebral lesion and disorder may produce hemiplegia and other forms of palsy. We not only find this af- fection connected with sanguineous extravasation into the brain, but also sometimes with serous effusion; or with traces of recent inflammation and vascular turgescence; with encysted suppura- tion ; with induration of some portions of the cerebral mass; with softening of the brain, or with destruction and entire loss of a portion of it; and with other morbid conditions of this organ. (Abercrombie.) Willis states, that in cases of protracted palsy, he found the corpora striata in a diseased condition; and Peyrouse, in one instance, found a firm tubercle, about the size of a bean, in the middle of the corpus striatum. (Cook.) But the most frequent morbid appearance, discovered on dissection, is organic lesion or 32 PARALYSPS PARTIALIS. injury of the cerebral substance, particularly about the corpora striata, thalami nervorum opticorum, and in the medulla oblon- gata or its immediate vicinity. M. Serres mentions a case of apoplexy attended with palsy, in which every part of the brain was perfectly sound, except the tubar annulare, which was com- pletely destroyed by a central cavity containing a clot of blood. Although some of these phenomena usually present themselves on the dissection of paralytic subjects, yet each of these morbid conditions of the brain not unfrequently exists without any, or with but very slight manifestations of palsy. There exists also much diversity in the extent and particular form of the paralytic affections connected with apparently similar morbid states with- in the brain. In one patient, a particular lesion or diseased con- dition of the brain will be attended with almost universal palsy; in another, a similar state of cerebral affection, with regard to its location and general character, will be accompanied with hemi- plegia; in a third patient, perhaps with paraplegia; and in a fourth one, with partial paralysis. It would appear, also, that in hemiplegia the immediate cause of the paralysis may be in the spine. Dr. Prichard has published some observations which render this opinion at least highly probable.* Notwithstanding, therefore, the light which dissection has thrown on the etiology of palsy, we are yet far from possessing any very satisfactory or precise information on this interesting subject. The general fact, that pressure or organic lesion of the brain is often attended with paralysis, and apparently its direct cause, is indeed sufficiently established; but the various and opposite results or phenomena just mentioned, assure us that our knowledge upon this subject, as in truth upon most other points of pathology, is but general and vague. What has been hitherto said relates chiefly to hemiplegia. It would appear that paraplegia also is frequently dependant on cerebral disease. Paraplegia in adults, says Dr. Baillie, is by most pathologists considered as the result of some disease, "either in the bones or ligaments of the spine, or in the cavity of the spine, most commonly at the loins, independently of any disease of the brain, "t He denies the correctness of this opinion, and expresses his conviction that, like hemiplegia, this form of palsy " depends most commonly in adults, in a great measure, upon disease affecting the brain itself." The same sentiments appear to be entertained by Mr. Earle, Mr. Halford, and Mr. Copeland ;% and several recent French writers have expressed similar views. Dr. Baillie and Dr. Abercrombie relate cases of paraplegia, in which, on dissection, the cause of the disease was discovered in * Med. Repository, No. I. New Series. | Loc. cit. p. 17. $ Med. Chir. Rev. December, 1820, p. 392. PARALYSIS PARTIALIS. 33 the bjain. In a strongly marked case, the arachnoid was much thickened and opaque; the substance of the brain was considera- bly softer than natural, attended with vascular congestion of the pia mater, a large quantity of serum in the lateral ventricles, as well as in the theca vertebralis, and between the membranes of the hjain. Dr. Baillie thinks that the serum which is sometimes found in the theca vertebralis in this affection, descends into it from the brain. We cannot doubt that paraplegia may sometimes be entirely dependant on perebral disease f yet observation ren- ders it equally certain that disorder, lesion, or pressure upon the spinal cord, is even in adults very frequently the immediate cause of the paraplegiac affection; and in children this is unquestionably by far the most common source of the disease. In relation to the disease in\dujts, a great number of well authenticated dis- sections might be adduced, presenting unequivocal evidence of its spinal origin; and facts illustrative of this point, in reference to the disease in children, must be familiar to every one. It has already been observed, that paralysis depending on disease of the brain, occurs almost universally on the side opposite to that in which the cerebral affection exists. Some exceptions indeed to this fact have been noticed by pathologists, but these are ex- tremely rare. Mr. Bayle has collected, from different authorities, eight cases in which palsy took place on the same side of the cerebral affection. * When paraplegia depends on disease seated within the head, the primary affection extends probably to both sides of the brain. This opyiion is at least strongly countenanced by the phenomena developed on post mortem examination. (Bail- lie.) ^ » Partial paralysis depends on a great variety of causes, both of a general and local character. It may depend on disease within the head, on spinal affections, and disease or local injury of a particular ne/ve. The latter source of this form of palsy is pro- bably the most common. Local paralysis is sometimes excited apparently by intestinal irritation in children. In cases of this kind, the palsy is usually confined to one of the arms.t I have seen cases of palsy of the arm in young children, which appear- ed'to have been, occasioned by th.e irritation of worms in the bowels.* Much attention has, within a few years past, been bestowed on local paralysis of the muscles of one side of the face. It ap- pears from the researches of Shaw and Bell, that this variety of palsy depends most commonly on some injury of the portio dura of the seventh pair; and in some instances, also on a diseased condition of that part of the brain which gives origin to this nervcj • Revue Medicale, Janvier, 1824. | C. Bell. See Cook's Treatise on Nervous Diseases, p. 268. t On Partial Paralysis. By John Shaw. Med. Chirurg. Transact, vol. xii. p. 1. Vol. II. 5 34 PARALYSIS PARTIALIS. The occasional causes of this variety of palsy are, inflammation of the ear spreading to the portio dura; surgical operations about the ear ajid consequent injury of this nerve; disease of the tem- poral bone; tumours pressing on this nerve; sudden exposure to cold;* injuries inflicted on the head; and disorganization and other morbid conditions within the brain, implicating the portio dura. The paralysis in cases of this kind is not complete'-'-the muscles of the face being deprived only of " the power of those actions which are to a certain degree involuntary, and to perform which it is necessary there should be a combination with the organs of respiration;" sensibility, and those actions which are derived from the trigeminus, namely, the action of the orbicula- ris oris, of the eyelids, of the buccinators, and of the muscles sub- servient to mastication remaining undiminished. ^Mr. Shaw re- marks, that in the paraly^js of the face after an attack of apoplexy, just the reverse condition in this respect obtains—the actions just enumerated as depending on the fifth pair of nerves being abolish- ed ; whilst those which are influenced !ry the portio dura remain unimpaired. Among the exciting causes of partial paralysis, the poisonous * influence of lead is the, most remarkable. The tendency of this article, in whatever way it may be brought to act on the system, to produce paralysis of the muscles of the fore-arm and wrists, is peculiarly strong, as is evident from the frequency of this affec- tion in persons who work in lead mines, in plumbers, manufac- turers of white lead, painters and glaziers. There exists^ however, much diversity, with regard to the constitutional predisposition of different individuals, to become thus affected by this article. Some persons appear to enjoy almost an entire immunity from its poisonous influence, although much exposed to its operation; whilst others are peculiarly liable to its effects. Paralysis of the extensor muscles of the hands and wrists some- times occurs, apparently from pressure of the nerves which go to these muscles. Cases of this kind generally come on during sleep, and seem to be occasioned by a particular position of the arm, while the head is resting upon it and compressing perhaps its principal arteries and nerves. I met with, a case lately in a young gentleman who fell asleep while sitting at his desk. O'n awaking, he found that he could not extend the hand nor use the fingers; the palsy continued for four weeks before it yielded. Dr. Healy has published an interesting paper on this variety of palsy, in the third volume of the Dublin Hospital Reports. The question why the power of motion is often entirely de- stroyed whilst that of sensation remains undiminished, has at all times greatly perplexed physiologists. Galen supposed that two * Dr. Powell. Transactions of the College of Physicians, vol. v. PARALYSIS PARTIALIS. 35 sets of nerves were distributed to every part of the body—one to endow them with sensibility, and the other to give to the mus- cles the power of voluntary motion. What was thus alleged from mere theoretical views by this very sagaciousjmysician, has been recently demonstrated by M. Magendie and Mr. C. Bell. The nerves which originate from the spinal prolongation of the brain, and which supply the power of voluntary motion and sensibility, are composed of two packets of fibres, proceeding from distinct parts of the spinal marrow. It has been ascertained that, by di- viding or compressing the posterior of the two fasciculi by which the spinal nerves originate, the sensibility of the part to which the nerves go is greatly diminished, whilst the power of motion remains unimpaired; and, on the contrary, if the anterior of these heads of the nerve be* divided or materially injured, the power of voluntary motion is destroyed in the parts to which it is dis- tributed, but the sensibility remains unaffected. This physio- logical fact throws much light on the curious phenomenon in question, and may be regarded as full an explanation of it as ana- tomical investigations are capable of furnishing on any subject. Treatment.—The prophylactic treatment of approaching he- miplegia does not differ from that which is proper for warding off an attack of apoplexy. In the apprehension of a stroke of palsy, a low "diet, gentle exercise in the open air, and the avoid- ance of all kinds of stimulating liquors, as well as of full and heavy meals, should be enjoined ; and the bowels kept in regular motion by gentle laxative medicines. Where predisposition to apoplexy exists, and particularly when the ordinary premonitory symptoms of this affection occur "frequently, a drain, by means of setons or issues established in the neighbourhood of the head, will contribute materially in ob- viating the paralytic seizure. Much discrepancy of opinion has been expressed with regard to the value of blood-letting in hemiplegia. Some speak strong- ly in praise of its powers ; whilst others condemn its use as often decidedly injurious. An attention to the various pathological conditions of the brain in cases of this disease, must at once show the folly of sweeping declarations either in favour or against this measure. We meet with cases, for instance, in which there are unequivocal manifestations of sanguineous engorgement in the vessels of the head ; and with others, in which the face is pale and shrunken, and the pulse small, weak, and irregular. The immediate cause may consist in vascular turgescence with san- guineous extravasation into the brain; or in a slow disorganiza- tion of a portion of this organ, with little or no engorgement or inordinate action of the cerebral vessels. The pulse must be our guide in the employment of this evacuation. If the artery beats strongly and is full and hard under the finger, blood should 36 PARALYSIS PARTIALIS. be drawn freely and promptly as in apoplexy,until the momen- tum of the circulation is adequately moderated. When, on the other hand, the pulse is weak, the extremities cold, and the face pale and contracted, as it sometimes is in old, weak, and nervous individuals, blood-letting to any considerable extent is just as obviously contra-indicated. In a few cases, I have abstracted from forty to fifty ounces of blood in the course of twelve hours after the hemiplegiac attack with decided benefit; but I have met with cases also, in which even a moderate bleeding brought on faintness and alarming weakness, without any favourable inqg- pression on the paralytic affection. Of course, even where ' the state of the circulation indicates the propriety of this evacuation, regard must be had to the age of the patient, his constitutional habit, and the nature of the exciting cause. Purgatives are as useful here as in apoplexy, in no instance, whether the action of the pulse be strong or weak, can evacuants of this kind be properly omitted. "All writers," says Dr. Cook, "agree as to the propriety of ^keeping the body open in hemi- plegia. The neutral salts and other purgatives of4he refrigerant kind, may be given where there is much determination of blood j to the head, and in full habits ; but in debilitated, leucophlegrna- tic, and dropsical cases, the more stimulating purgatives, such as aloes, calomel, scammony, colocynth, jalap, &c. may with more propriety be administered." An excellent mode of giving pur- gatives in habits of this latter kind, is to administer them in com- bination with powdered mustard. From ten to twelve grains of calomel, mixed with about twenty grains of mustard, and succeed- ed in about three hours by a dose of infusion of senna, will rarely fail in such cases to procure free and copious evacuations. In relaxed and sluggish habits, cathartics will almost always operate with more certainty #hd force when given with a stimulant of this kind. I have frequently, under such circumstances, admin- istered a small portion of Cayenne pepper with purgatives, with excellent effect. v- Emetics also are much recommended by some writers in tne treatment of hemiplegia. In recent instances, ushered in by apoplectic symptoms, and particularly in robust and plethoric subjects, they are of doubtful propriety. When hemiplegia comes on during a dyspeptic condition of the stomach, or soon after taking food of difficult digestion, an emetic may, no doubt, prove very serviceable. At a more advanced period of the disease, when the momentum of the circulation is moderate, and no symp- toms of cerebral congestion exist, emetics will occasionally do much good, and may be freely employed without risk of doing mischief. In addition to the general remedies already mentioned, revul- sive applications constitute important auxiliaries in the treatment PARALYSIS PARTIALIS. 37 of this affection. In recent cases, blistering or cupping the nape of the neck and sinapisms to the ankles, will sometimes contri- bute considerably to the removal of the disease. Stimulating enemata also are highly recommended in this va- riety of palsy ; and I have myself witnessed several instances of their good effects. In paraplegia, attended with symptoms of cephalic disorder, besides the local applications just mentioned, Dr. Baillie recom- mends the use of calomel, or the blue pill in union with squills, together with purgatives. He directs a grain of calomel, or five grainspf the blue mercurial mass with one grain of dried squills, every night for several weeks, with an occasional dose of one of the neutral purgative salts. When all the symptoms of undue determination to the head have disappeared, or the disease has assumed a strictly chronic character, antiphlogistic and depletory remedies are no longer appropriate means. Exciting remedies must now be resorted to. Frictions, stimulating liniments, sinapisms, blisters, stimu- lating baths, cold affusions, electricity and galvanism, are the principal external exciting applications ; and, under proper man- agement, they often prov^j decidedly beneficial. Frictions with the flesh-brusJ? or a piece of dry flannel, will sometimes answer better than the more irritating or rubefacient applications. The frictions should be made twice or thrice daily, and continued each time at leSst half an'hour. Along with dry frictions, the occasional application of blisters to the leg and wrist of the affect- ed side may prove beneficial. Where the palsy is complete, however, the sinapisms or blisters should not be left on too long, lest gangrene and sloughing be produced. A moderate rubefacient effect is all that it will, in general, be prudent to excite in cases of this kind. Cullen indeed observes, that when external stimu- lants produce violent inflammation, they are apt to do less good than when they act merely as rubefacients, or at most, create but a moderate degree of superficial inflammation. Anciently, the application of nettles was much recommended ; and from the very pungent irritation they produce in the skin, they may, no doubt, be serviceable. I have known the application of dolichos pruriens to a paralytic limb to be of manifest advantage. Electricity, being peculiarly adapted to excite the nervous system, has been much employed in the treatment of paralytic affections; and, under judicious management, it will sometimes do much good. I have known several cases of local palsy com- pletely cured by this agent; and the records of medicine furnish, us with no small number of instances in which it was successful- ly employed. It would appear, however, that it has sometimes proved injurious. Mr. Cavallo observes, that electricity has often proved wholly inefficacious in paralysis, and in some instances, 38 PARALYSIS PARTIALIS, pernicious and even fatal. It seems probable, however, that where it has been followed by unfavourable or fatal consequences, it was applied in too powerful^a manner ; for it is admitted, on all hands, that it proves most beneficial when it is moderately and repeatedly applied. Shocks should never be given. The electric flaid must be passed through the affected part, ivithout sparks, by means of wooden points ; or, at most, by discharging very weak sparks into it from the prime conductor. Dr. Cook remarks, that this agent " is only to be consideted safe when its operation is confined to parts somewhat remote from the head ;" and that it is most apt to prove injurious when the disease de- pends upon disease or compression of the brain. Galvanism, also, has been recommended for the cure of this affection ; and it is said to be safer, and in general, more effectual than electricity. Dr. Bardsly, from considerable experience with the use of galvanism in paralysis, concludes, that if no sensible benefit arise from a steady and well-regulated application of this influence, after a trial of a week or ten days, its use ought to be discontinued; that when the brain forms a part of the galvanic circle, it is to be very cautiously employed ; and that when the activity and firmness of the pulse, asjvell as the temperature of the affected part are increased—the corporgal and fhental feelings somewhat enlivened, and the secretions improved, we may per- sist in the application of this agent, with a prospect of ultimate and permanent advantage. When the affected "parts are so tor- pid as to render them insusceptible of the galvanic stimulus, the cuticle ought to be removed by a small blister*, and the metallic points applied to the raw skin. (Bardsly.*) ? Moxa has been used with success in paralysis. Dupuytren has reported a case of general paralysis, in which moxa applied M on each side of the spine, near the first and second dorsal verte- bra, procured immediate benefit. Larrey mentions a case of palsy from disease of the spine, which was cured by thirty-two applications of moxa; and two oth§r cases of paralysis of the fore-arm from gun-shot wounds yielded completely to this reme- dy. He also states, that he cured several cases of paralysis of the muscles of one side of the face from cold, by the application of moxa ; but he observes that the application of moxa to this part is dangerous, unless the cones of cotton are small, and sup- puration be prevented by the application of ammonia, t The in- stances on record of the successful application of moxa in paraly- sis are, indeed, sufficiently numerous to entitle this remedy to' particular attention in the treatment of this affection. Internally, a variety of remedies have been recommended for * Medical Reports, p. 183. Cook, 1. c. p. 296. t Recueil de Memoires de Chirurgie. par le Baron D. L. Larrey, p. 94. PARALYSIS PARTIALIS. 39 the cure of this disease. Among these the nux vomica, or its preparation strichnine, has of late years been a good deal used in palsy, and occasionally with decided benefit.* Mr. Purcell has recently reported a case of paraplegia, in which this article, in conjunction with the application of moxa, was successfully used.t My own experience with this remedy in paralysis has hf no means been encouraging"; but there, can be no question of its occasional usefulness, although it seems now to be generally ad- mitted that it is also frequently pernicious. When the peculiar convulsive motions which result from the operation of this nar- cotic, appear early in the palsied limb, in connexion with tran- sient tremours, formication, and free perspiration in this part, and particularly if these affections do not directly pass to the sound parts, the prospect of benefit from this remedy is said to be considerable. In paralytic affections connected with an inflam- matory or congested condition of the brain or spinal marrow—and in hemiplegia from sanguineous extravasation into the cerebrum, this remedy cannot be employed without considerable risk of Injurious -consequences. From two to four grains of the nut may be administered three or four times daily, until spasmodic mo- tions of the extremities ensue, or gastric distress is experienced. The extract is given in doses of from two to three grains; and of the strichnine, which has latterly been used, one-sixth of a grain may be exhibited thrice daily. Somewhat analogous to the nux vomica is the rhus toxicoden- dron in its occasional effects in paralytic disorders. This article was formerly highly extolled for its remediate powers in affec- tions of this kind, and in Germany it has lately again attracted considerable attention in this respect. J In two instances of * Decandolle, Husson, Dumeril, Lescure, A%selin, Magendie, Bricheteau, and Fouquier, have reported cases of palsy in which the happiest effects were pro- duced by the use of this remedy. M. Fouquier gave the nux vomica to the ex- tent of from four to twenty-four grains of the powder daily to an habitual drunk- aid affected with hemiplegia from apoplexy ; and in the course of one month he was entirely cure/1. f Medico-Chirurg. Rev. November, 1829, p. 203.—Prov. Med. Gazette, No. XI. July, 1829. * i M. Dufresnoy, Professor of Botany at Valencia, was, I believe, the first who used the rhus toxicodendron in palsy. Mr. Alderson, an English physician, next published a small work on the medical effects of this article, in which he relates seventeen cases which were more or less benefited by its use. Dr. Horse- field, in his inaugural dissertation on different species of rhus, published in this city in 1798, testifies to its usefulness in paralytic affections. Mangrat, (Journ. de Phys. Chim. d'Histoir. Nat. vol. Ii. p. 370.) Elz. (Dissert, de Toxicodend., 1800.) Hunbld, (Piepenbrings' Archiv. f. Pharmacie. Bd. i. st. iii. p. 276.) Kok. Van Mons. Augustin, (Asklepeion, 1811, No. IV. s. 57.) Sybel, (Asklepeion, 1811, No. XXXII. p. 497.) Gisovious, (Rust's Magazine, Bd. xiv. s. 386.) D'Al- quen, (Harles Rhein-Westphal. Jahrb. ect. Bd. x. st. i. s. 135.) Osann, (Hufe- land's Biblioth. d. Heilkund, 1823, Mai. s. 324.) Buchheim, (Allgem. Med. Annal. 1825.) Hennin, (Archiv. fur Med. Erfahr. V. Horn., ect. 1823, Nov. and Dec. s. 393,) have all published cases illustrative of the remediate powers of this article in different forms of palsy. 40 PARALYSIS PARTIALIS. hemiplegia, I prescribed the saturated tincture of the leaves of the rhus with unequivocal benefit. In a letter to me from professor Osann of Berlin, I am Informed that the following mixture has been used with decided benefit at the Polyclinic Institute, in paralysis of the lower extremities: n ' ** . .' R. Tinct. rhois. toxicoder^d. ^fss. ---- atoniti------' ---- guaiaci. volat. aa^ii. M. S. Take forty drops every three hours. The effects of this article are often very similar to those which result from the full operation of the nux vomica. In one of the cases in which I used it, the patient experienced occasional con- vulsive actions in the muscles of the palsied limb, with a sensation of tingling or prickling in the affected part. The powdered leaves may be used, commencing vvith half a grain, and gradually in- creasing it to four grains, three times daily. The effects of this article when given in large doses, are headach, vertigo, n*usea, and sometimes profuse ^diarrhoea, and when these manifestations of its operation ensue, its use must be discontinued. The oil of turpentine is strongly recommended by Dr. Prich- ard, (Med. Repos. No. 1, new series,) in paralytic affections, after depletory measures have been adequately pursued. He gives it in doses of from one to two drachms, three times daily. Mr. Manson has related several striking instances of the success- ful use of iodine in paralytic affections.* The fores arnicas appear to have been frequently used with entire success in cases of this kind. They are said to be particu- larly useful in paralysis of the bladder,t and in local palsies of the organs of sense. Richter indeed says that they may be used with occasional success in almost every variety of palsy. Hufe- land states that he cured a case of scrofulous deafness with* this article, in conjunction with antimonials.J Within the present year I prescribed this remedy in an instance of hemiplegia* which came on very gradually in an elderly female, and its ef- fects were very manifestly beneficial. § The internal, use of mustard seed, and of horse-radish, hare also been recommended in paralysis; and I have known the form- er of these articles prescribed by the late Dr. Barton in the Penn- sylvania Hospital with much advantage. A number of other re- medies are said to have been employed with success in various forms of palsy. Cantharides in substance, "in the dose of one grain to a scruple of volatile salt, and gradually increased to two * Medical Researches on the Effects of Iodine, &c—Lond. 1825. nn 87—90 f Hufeland's Journal. Bd. ix. st. iii. p. 95. M1' I Ibid. Bd. xxxiv. st. v. s. 33. § The arnica is highly extolled for its virtues in paralytic affections by Junker, Colin, Plenk, and others. (Cook.) * ««»•»*», PARALYSIS PARTIALIS. 41 grains of the former and forty of the latter, every three hours," have been employed with great benefit. (Cook, Med. Comment. vol. xiii. p. 96.) Dahlbcrg and Kolpin speak highly of the effects of the tincture of colocy?ith,* in doses of ten drops every two hours, and gradually increased to sixty or seventy drops. This tincture is said to be particularly useful in paralysis of the infe- rior extremities, and of the bladder. Kolpin declares that he has used this remedy with extraordinary success; and many other authorities of respectability might be cited, in favour of its occa- sional efficacy in this affection. (Horn's Archiv. 1804.) The chenopodium ambrosioides is said to have produced excellent effects in aphonia from paralysis of the muscles of the larynx, t It is given in substance, in doses of from a scruple to half a drachm, twice or thrice daily. Jahn (Klinik. der Chron. Krank. B. i. p. 365,) says the belladonna is one of the most efficacious remedies in paralysis. Besides the foregoing remedies, almost every ac- tive tonic and stimulant has been recommended in such affections —phosphorus, camphor, volatile salts, valerian, bitters, chaly- beates, the essential oils, savin, &c. have all found advocates as remedies in paralytic affections, but they deserve little or no at- tention in this respect. In that variety of local palsy which arises from the poisonous influence of lead; the use of mercury, so as to produce moderate ptyalism ; in conjunction with the repeated application of blisters, or other active, irritating substances to the wrist; and the use of the splint or battledore, recommended by Dr. Pemberton; J with mild aperients, and occasional warm bathing, constitute our most useful remediate means. Dr. Gregory is not willing to attribute any powers to mercury against this affection, notwithstanding the authority of Dr. Clutterbuck in its favour. I have met with one case in which gentle salivation, with local stimulants to the pal- sied parts, succeeded in removing the disease. It is not impro- bable, however, that the chief advantage in this instance was de- rived from the local irritating applications. § In paralysis of the tongue, we may direct the patient to chew the rootpyrethrum, or other irritating and pungent substances; such as cloves, senega, squills, pepper, calamus aromaticus, &c. The oil of cajeput has also been recommended in this variety of local palsy. A few drops of it are to be put on the tongue three or four times daily. Blisters, or frictions with tartar emetic oint- ment under the chin and ears, may also be used; and a very mo- • Hufeland's Journal. Bd. ii. st. iv. p. 570. f Homes— Ibid. Bd. xiv. st. ii. p. 201. i This consists simply in applying a carved splint to the inner side of the arm, so that the broad surface supports the hand. § A gentle mercurial action is recommended for the cure of this variety of palsy by Hunter and Br. Clarke. Dr. Clutterbuck regards it as the mobt effec- tual means we possess in this affection. Vol. II. 6 42 PARALYSIS PARTIALIS. derate excftatfon of the tongue by the galvante mfluence; which may be done by two flat pieces of silver and copper, the one ap- plied to the upper, and the other to the under surface—the parts projecting from the mouth being brought in frequent contact. In partial paralysis of the face, cupping, leeching, and blistering over the origin of the portio dura, mercurial purgatives, and a seton in the neck, may be accounted the most efficient remediate measures. Dr. Delafield, of New-York, has related several in- stances of this affection, which yielded under the employment of these remedies.* I have known a case of this kind, produced, or at least accompanied, with indurated swelling of the parotid gland; cured by the use of iodine* Sect. III.—Epilepsy. Epilepsy, whether considered in its immediate phenomena or in its remote consequences, is unquestionably one .of the most distressing and deplorable of human maladies. Its tendency to impair the understanding, to produce hebetude, and even total abolition of the rational powers, leads often to a condition infi- nitely more lamentable than death itself. So frightful and dis- tressing a disease could not fail to attract the particular attention of the physicians of every age; and we accordingly find it mi- nutely described, and its nature and treatment extensively dis- cussed, in the works of the Greek and Roman physicians, t The soporose and convulsive affections are so closely allied to each other, both in relation to their general phenomena and their pathological character, that it is extremely difficult to give an unexceptionable definition of any one of them. Epilepsy may, perhaps, be defined a disease primarily seated in the nervous sys- tem, manifested by convulsions recurring at uncertain periods in paroxysms, accompanied by a temporary loss of consciousness, sense, and voluntary motion, and terminating in somnolency. The epileptic attack sometimes comes on suddenly without any manifestations of its approach. More frequently, however, certain symptoms precede the occurrence of the paroxysm, and • New-York Med. and Phys. Jour. Dec. 1824. ■j- Hippocrates describes epilepsy under the name of morbus sacer—a name which was given to it from its supposed origin ; it being generally regarded a» his day, as an infliction of the Gods, or of demoniac influence. Aristotle treats of it under the name of morbus herculius, because Hercules is said to have been afflicted with this disease. The most common appellation of this affection among the Roman physicians, however, was morbus comitialis. We nevertheless find it mentioned also under various other names in their writings—such as morbus son- ticus, morbus caducus, morbus pueriles, morbus insputatus, seleniacus, major, magnus, vitriolatus, mensalis, &c. In the sacred writings, epileptic persons are called lunaticos. EPILEPST. 43 of these the following are the most common :—A peculiar con- fusion and distressing feeling in the head ; an absent, wandering, and confused state of the mind ; giddiness ; dimness of sight; ringing and loud sounds in the ears; sparks and flashes of light before the eyes; distention of the veins of the head and neck ; a trembling and feeling of restlessness in the extremities ; an anx- ious feeling in the precordial region; restlessness and starting during sleep ; loss of the power of distinct articulation ; complete temporary deafness ; and drowsiness. In some instances, there is a manifest change in the moral disposition a short time before the accession of the attack. Sullen gloominess with an irritable temper is manifested by some patients. In some cases, the mind falls into a kind of revery from which it cannot be drawn, which terminates often speedily in total insensibility. Some epileptics evince an unusually timid disposition ; others are spiteful, resent- ful, and mischievous, shortly before the accession of the parox- ysm. Occasionally, spasmodic twitches of particular muscles, especially in those of the face, precede the attack. Richter states, that painful sensations in certain parts of the body, parti- cularly spasmodic pains in the stomach, with a rumbling noise in the bowels, occur as the precursors of the epileptic paroxysm. The most remarkable of the premonitory symptoms of epilep- sy, however, is that which is technically called aura. The sen- sation to which this term is applied, and which, I believe, occurs in no other disease, is compared by patients to the feeling which is communicated by a gentle stream of cool air directed on the part. This sensation generally commences in the feet or legs, and gradually ascends until it reaches the head, when the patient instantly becomes insensible and epileptic. Some patients are enabled by this symptom to tell with accuracy the nearness of the attack, and to avail themselves of this intimation to place themselves in a situation in which they will be less liable to sus- tain injury during the attack. Spiculae of bones, tumours, and foreign bodies pressing upon and irritating some nerve, have been found to exist at the starting point of this singular sensation. * The primary irritation is, however, almost invariably seated elsewhere, and transferred sympathetically to the part in which the aura commences. In many instances, the attack always occurs at night while the patient is sleeping. In this respect epilepsy differs conspicuously from chorea, the convulsive motions of which, however violent during the day, are almost always wholly suspended during sound sle,ep. When the epileptic seizure occurs while the patient is sitting • Van Syieten's Commentaries, vol. iii. p. 419.—See also Medical Experi- ments and Observations by a Society, &c. at Edinbuigh, vol. iv. p. 334. 44 EPILEPSY. or standing, he suddenly falls down in a state of insensibility, and immediately becomes more or less violently convulsed. In some cases, the convulsive actions of the muscles, particularly those of the face, are frightfully violent; the whole frame is vio- lently agitated; the eyes roll about; the lips and eyelids are con- vulsed ; the tongue often spasmodically thrust from the mouth, which, with "the gnashing of the teeth, and the foaming at the mouth, give the countenance a horridly wild expression." Some- times the teeth are firmly pressed together ; at others, the jaws are widely and fixedly distended ; the thumbs are almost invaria- bly firmly pressed in upon the palms of the hands. The spasms are generally of the clonic kind; but in some instances, the mus- cles remain for a time rigidly contracted, the body being bent either backwards, forwards, or to one side, as in tetanus. Occa- sionally, the abdominal muscles are violently drawn in towards the spine. In many instances, there are strong erections of the penis, with spasmodic retraction of the testicles, and occasional seminal discharge. (Richter.) The face is occasionally pale, but more commonly livid, with a turgid state of the veins of the head and neck. The heart palpitates rapidly; the pulse is usually con- tracted, irregular, and frequent;* and respiration oppressed, la- borious, and in violent cases, sonorous. About the termination of the paroxysm, a considerable quantity of frothy saliva usually flows from the mouth ; and in some cases, the feces and urine pass off involuntarily. Sooner or later these spasmodic symptoms abate—generally gradually, but sometimes abruptly. The respi- ration becomes freer; the pulse fuller and more regular; the coun- tenance more composed; and the patient finally falls into a state of stupor or deep sleep, out of which he awakens with a feeling of languor, and confusion and torpor of mind, which generally continues for ten or twelve hours. The countenance exhibits a vacant and stupid expression, and the eyes are dull, staring, and wandering. In violent attacks the mind remains obtuse and fa- tuous, and the temper irritable and morose, for several days after the paroxysm. During this somnolent state, the patient usually perspires freely, particularly about the head, neck, and breast; and the perspiration has frequently a very peculiarly offensive smell, t The sweating has been known to be distinctly confined to one side of the body only. J Epilepsy does not, however, always assume the violent grade just described. Sometimes the attack supervenes suddenly, and after a few moments of partial convulsions of the muscles of the • Dr. Burnett relates a singular case of epilepsy, in which the pulse became so slow at times, as to beat only fourteen strokes in a minute.—(Med. Chir. Trans- act, vol. xiii. part i. p. 202.) Morgagni relates two similar cases. f De Haen, Ratio Medcnd. torn. v. p. 123. * Voigtel's Handbuch der Patholog. Anatom. B. i. p. 70. EPILEPSY. 45 face and neck, quickly subsides, and restores the patient to con- sciousness. I once attended a girl affected with this disease, in so light a manner, that the convulsions seldom lasted longer than a few minutes. In relation to the duration of the epileptic paroxysm, there exists great diversity. The convulsive stage generally continues from ten to fifteen minutes, sometimes for half an hour, and oc- casionally for several hours. The paroxysm is most apt to become protracted in children. In most instances one paroxysm only occurs at a time. Sometimes, however, they recur several times —the patient passing from one into another, with but a very short interval between them. In general, the first attacks are shorter than those which occur after the disease has continued for somo time. The contrary, however, generally takes place when the first attack is caused by some sudden and violent mental impres- sion, as terror. With regard to the interval between the epileptic seizures, also, there exists the greatest diversity. In some cases the paroxysm returns almost daily; in others at various intervals, from a few days to a whole year. Many instances observe a more or less perfect periodicity in the recurrence of the fits; whilst others are quite irregular in this respect. Richter observes, that cases arising from gastric or intestinal irritation, and from catamenial irregu- larities, are most apt to assume a periodical character.* Occasion- ally the paroxysms recur regularly at the periods of new or full moon. Nearly twenty years ago I treated a case successfully, in which for several years previously the paroxysms had return- ed regularly on the night of each full moon. Examples of this kind may, however, occur as mere coincidences, without any re- lation, as cause and effect, between the two phenomena, t Epilepsy seldom proves fatal, except through the intervention of apoplexy. When it recurs very frequently, however, the mental powers gradually fail, until at last a total imbecility or idiotism is induced. The most complete state of idiotism I have ever seen, was produced in less than two years, in a fine, intelli- gent boy, by the ferocious attacks of this malady. Post mortem appearances.—The morbid appearances disco- vered on dissecting subjects who die of epilepsy, are often simi- lar to those which occur in apoplexy and palsy. No man has, perhaps, dissected so great a number of bodies that had died of epilepsy as M. Wentzel. Previous to the dissections of this * Specielle Therapie. Bd. vii. p. 570. f For a full discussion of this point, the reader may consult Mead, de Imperio Solis et Linis in Corpus Humanum; also, Balfour on Sol-lunar influence. That the moon governs the epileptic paroxysm, appears indeed to be a very ancient opinion. Galen, Aretacus, and Alexander Trallianus entertained this opinion. (Cook on Nervous Diseases.; 46 EPILEPSY. indefatigable anatomist, it was generally thought that the cere- brum is the chief seat of the proximate cause of epilepsy. M. Wentzel, however, in a very great proportion of heads he ex- amined, found the cerebrum perfectly sound, whilst the cerebel- lum was uniformly in a diseased condition. The part of the cerebrum which he found most frequently affected, was the pineal gland. The cerebellum was generally of a dusky red, approach- ing to a blackish colour; in some cases it exhibited a whitish or yellow hue, and in a few instances the posterior lobe was of a grey colour. This portion of the encephalon was sometimes very soft; more frequently it presented a preternaturally hard and compact structure. In ten out of twenty-one cases, a morbid, yellow, friable matter, was found between the lobes of the cere- bellum, which in some instances not only separated the lobes, but caused also the destruction of a portion of their substance. Notwithstanding these observations of Wentzel, dissections made by other pathologists render it certain that the substance of the cerebrum is often materially diseased in epilepsy. This indeed Wentzel does not deny, but his observations convinced him that this is much less frequently the case than we might be led to believe from the observations previously published on this sub- ject* Both Greding,t and Roederer relate cases in which the cerebrum was disorganized to a greater or less extent Some French pathologists have pointed out various morbid appearances of the mucous membrane of the intestinal canal as being intimate- ly concerned in the causation of this disease. Causes.—Observation has informed us that in some cases of this disease the original exciting cause is seated within the head, or acts directly on the cerebral mass; whilst in others the cause is located in some other part of the system, and affects the ence- phalon secondarily, through the medium of the nerves. It is evident, therefore, that we may with propriety divide this mala- dy into two general varieties—namely, into idiopathic and symp- tomatic. Experience has shown that the latter is in general much more apt to yield to remediate treatment than the former. In some individuals there appears to exist a constitutional pre- disposition to epilepsy; and it is, without doubt, in some instan- ces, of hereditary origin. Boerhaave mentions an instance in which all the children of an epileptic father died of this disease ;| and Stahl has related a similar occurrence. § Tissot also mentions a remarkable instance of this kind. An epileptic man had eight • Cook on Nervous Diseases, &c. p. 342. f Sammtliche Medic. Schriften. ii. Theil. * Praelectiones in Prax. Med. torn. v. p. 30. § De Hereditar. Dispos. ad Varios. Affectus. Halle, 1706, p. 48. Also in his Dissertatio de Epilepsia Hsereditarui Casutn Exhibens, as quoted in Uicbter's Specielle Theropic* Bd. vii. p. 594. EPILEPSY. 47 sons and three grandsons, all of whom, he says, became affected with this disease. (Cook.) Children, it has Jieen observed, are much more liable to this disease than adults; but the age at which there appears to exist the strongest predisposition to epilepsy is the period of puberty. Some writers assert that females are more subject to this affection than males; others, however, contradict this assertion. Probably hysteria has been frequently mistaken for epilepsy, which may have given rise to this opinion. Those who have once had this disease, and have been freed from it by remediate treatment, generally retain a particular predisposition to its recurrence. The exciting causes of epilepsy are exceedingly various. Of these causes some act immediately on the brain, and others make their impressions on distant parts, and affect the sensorium com- mune secondarily through the medium of the nerves. The most common of the former variety of causes are: injuries and mal- formation of the cranium; exostosis from the internal surface of the bones of the skull; spiculae of bones driven in upon the brain ; preternatural distention of the cerebral vessels; various organic affections of the brain, and effusions of different kinds within the cranium. (Cook.) Sudden and violent mental emotions frequently produce this disease by a morbid excitement originating in the brain. Fear, terror, grief, and other disagreeable sensorial and mental impres- sions, have been known to give rise to epilepsy. I have met with three instances that were excited by terror. Locker states that six out of fourteen cases of this disease, which came under his care in the Hospital St. Mark at Vienna, were produced by terror. Many remarkable instances of epilepsy, excited by disagreeable and strong impressions on the senses, have been reported. Strong odours, sudden and vivid light, loud and peculiar sounds, and certain colours, have produced this disease in weak and irritable habits. Weikart relates the case of an individual in whom the smell of red beets excited epileptic paroxysms.* The odour of the garden ranunculus has also given rise to the disease; f and Cook quotes from Buchner an instance of an epileptic child in whom the sight of a vivid red colour seldom failed to excite a paroxysm of the disease. Cases of this kind are of course con- nected with idiosyncracies by which the influence of these excit- ing causes is peculiarly favoured. This disease has frequently been excited by the sight of a per- son affected with the epileptic paroxysm. Dr. Rush mentions several instances of this kind. The principle of association ex- erts indeed a powerful influence over the actions of the animal economy ; and in no disease has this been more strikingly exem- * Hufeland's Journal, Bd. xii. st. i. s. 174. f Acta. Natur. Curios. Dec. iii. Ann. ix. x. Obs. 92, p. 170. 48 EPILEPSY. plified than in the present one. The mere recollection, or sight of the causes or circumstances which attended the first attack of the disease, has re-excited the paroxysm.* • Among the causes of this disease that act upon the brain through the general system, gastric or intestinal irritation is perhaps the most common. Epilepsy from this cause is most frequently met with in children. Worms, and indeed every other substance which is capable of producing an irritation in the nervous extre- mities of the mucous membrane of the alimentary canal, may give rise to this affection in weak and irritable subjects. A pro- tracted case is related, which ceased entirely after the expulsion of a tape-worm.t Leeches swallowed into the stomach have produced epilepsy. (Gudenklee.) The suppression of habitual evacuations, whether sanguineous or serous, is another powerful exciting cause of epilepsy. Sup- pressed or morbidly postponed catamenial discharge soon after the age of puberty, is particularly apt to give rise to this affec- tion in individuals otherwise predisposed to it.J The healing up of old ulcers, setons, issues, &c. may give rise to epilepsy. Rich- ter mentions the suppression of habitual sweating of the feet as a strong exciting cause of this and other convulsive affections. The repulsion or sudden drying up of chronic cutaneous eruptions, particularly the itch and tinea capitis, also may produce epilep- sy ; and in the exanthemata, either just before the eruption is about coming out, or from its sudden retrocession, this form of convulsive disease is by no means uncommon. Excessive evacuations are also among the exciting causes of epilepsy ; and this is particularly the case with inordinate semi- nalevacuations, either from excessive venery or masturbation.§ Various poisons, more especially of the narcotic kind, some- times produce this disease. It is said that in Kamtschatka, epi- lepsy is frequently occasioned by the use of an indigenous species of toad-stool, which the inhabitants of that country are much in the habit of eating on account of its exhilarating effects. || The abuse of opium in children has a tendency to produce this mala- dy ; and among the mineral poisons, lead and arsenic are said to be most apt to excite it. Wendt mentions a case produced by lead, and Dr. Warren relates a fatal case produced by this poi- son. (Cook.) In the second volume of the Medico-Chirurg. Transactions, five cases are reported which arose from the recep- tion of arsenic into the stomach. * Van Swieten. Commentar. Tom. Hi. p. 414. •j-Mursinna's Journal, f. Chirurg. Arzneik. u. Geburthshuife. B. i. st. ii. p. 306. (Richter.) l t Falk, Dissert, de Epilepsia, s. Motib. Convtils. Virgin. See also the interest- ing observations of Prichard on this subject in his Treatise on Nervous Diseases. § Zimmerman on Experience, vol. iv. chap. 10. | Langsdarf in d. Weterauschen Annalen. Bd. ii. hft. 2. (Richter, Spec. Ther.) EPILEPSY. 49 The habitual Intemperate use of alcoholic liquors is a very com- mon cause of epilepsy. It is probable that epilepsy from this cause proceeds from the combined influence of hepatic disorder, and a constant preternatural determination of blood to the brain. Painful dentition, pregnancy, and parturition, occasionally excite the disease. Tissot relates three cases which arose evidently from pregnancy. In one case, the patient was affected with epi- leptic paroxysms almost every week, in three of her pregnancies, until quickening commenced. Irritation from biliary concre- tions, as well as from urinary calculi, has sometimes given rise to this affection. Dr. Cook refers to the works of Bertholini for examples of this kind. Habitual tendency to congestion or plethora of the vessels of the brain is perhaps one of the most frequent exciting causes of the epileptic paroxysm. This may be the result either of a con- stitutional habit, or of the operation of some one of the foregoing exciting causes, particularly intestinal irritation, and suppressed sanguineous and serous discharges. Atmospheric influences also have been supposed capable of exciting this disease. Great heat or cold, and sudden vicissitudes of temperature, are mentioned as exciting causes ; but their influence in the production of this affec- tion is perhaps rather predisposing than exciting. On the subject of the proximate cause of epilepsy, a very great diversity of opinion has been expressed. Without entering into a detail of these opinions, all of which are hypothetical, and many of them absurd, I shall content myself with a statement of those circumstances, which experience and observation appear to sanc- tion in relation to the pathology of this affection.* 1. The immediate cause of the epileptic paroxysm, whatever its essential character may be, is always seated in the brain. 2. In the majority of fatal cases, organic and other obvious affections of the brain, particularly of the cerebellum, or of the meninges, are found on dissection, and which, we may infer, contributed to the excitation of the epileptic paroxysms. 3. The cerebral affection is in some instances primary, and the result of causes that act directly upon the brain. In others, probably in the majority of cases, it is secondary, depending on primary irritations located remotely from the brain. 4. Immediately before the accession of the epileptic attack, it would seem that vascular turgescence takes place in the encepha- lon ; and the pressure thus created, in co-operation with the ge- neral predisposition to the disease and the organic cerebral affec- * Mr. Mansford, in a work published on Epilepsy a few years ago, gives it as his opinion, that the proximate cause of this disease consists in an accumulation of the electric matter in the brain, or what he considers the same thing, a supera- bundance of the nervous power in the sensorium commune. Vol. II. 7 50 EPILEPSY. tion, where such disorder exists, is probably the Immediate excit- ing cause of the paroxysm. It would be useless to enter into any discussion concerning the causes of the paroxysmal character of this affection, or of the oc- casional strict periodicity of its recurrence. The influence of habit has been adduced in explanation of these mysterious points of pathology. The term habit, however, in a physiological sense, can mean nothing else than a tendency to repeat an action, whe- ther morbid or healthy, that has been produced by some exciting cause, without the presence or further co-operation of such cause. This, however, is merely expressing the general fact, and offers no explanation of it whatever. Diagnosis.—The affection with which epilepsy is most liable to be confounded, is hysteria, when this disease assumes the con- vulsive form. They may be distinguished from each other, how- ever, by the following circumstances. In hysteric convulsions, the countenance is less livid and distorted than in epilepsy ; and there is seldom any foaming at the mouth, or profuse discharge of saliva, nor does it terminate in heavy sleep, or in a confused and torpid state of the mind, so general at the conclusion of the epi- leptic paroxysm. In hysteria too, there are always some concom- itant phenomena which indicate its character, such as the globus hystericus, involuntary laughing or weeping, and in many instan- ces a continuation of some degree of consciousness, &c. Prognosis.—Although the immediate danger of the epileptic paroxysm is not in general very great, yet in relation to its sana- bility, the prognosis is always highly unfavourable. Even where a cure or suspension of the disease has been effected, the liability to a relapse is always considerable. When epilepsy depends on organic disorder within the head, no remediate management can effect a cure. Epilepsy, however, unconnected with cerebral lesion, may sometimes be cured. * That variety of the disease which occurs in young females about the age of puberty, from menstrual irregularities, is not unfrequently curable, and indeed sometimes passes off spontaneously after the catamenia begin to flow regularly. The longer the disease has continued, or rather, • Dr. Dewees, in his work on the " Practice of Physic," has inadvertently ex- pressed contradictory sentiments in relation to the curableness of this disease. Under the head of treatment, he asks, " What plan of treatment has ever suc- ceeded in curing epilepsy ? Has epilepsy ever been cured?" Under the head of diagnosis, however, he says, ''When the disease is symptomatic, it is occasion- ally curable;" again, "those attacked between the fourth and tenth year may be cured by proper treatment." Most assuredly this latter sentiment accords with the experience of the ablest of the profession of all ages. However appalling and really intractable this disease may 1n general be, perfect cures are by no means so uncommon as the Doctor's interrogatories might lead one to suspect. I have known at least five distinctly marked cases cured under my own observa- tion, two of which were of more than two years standing, and one above six years. EPILEPSY. 51 the more frequently its attacks have been repeated, the greater will be the difficulty, in general, of effecting a cure ; and when the mind has once become obviously affected or impaired by its attacks, all hopes of a cure may be abandoned. Experience, too, has shown that those epilepsies which commence soon after birth, or during early infancy, rarely, if ever, yield to remediate treat- ment. From the period of dentition to that of puberty, is the most favourable age for the cure of this affection. Hippocrates observes, that those who are attacked with epilepsy after the twenty-fifth year of age, will continue to have it as long as they live—an observation which, though very generally correct, is not confirmed by the experience of subsequent practitioners.* When the disease is the consequence of excessive venereal indul- gence or masturbation, it may sometimes be removed, provided the mental powers have not as yet suffered considerably from its repeated attacks, or from the influence of its cause. The epileptic paroxysms, which sometimes occur in the exanthematous diseases, are seldom followed by serious consequences, and very rarely recur afterwards. When the premonitory symptoms consist of some affections in the head, it may be regarded as more unfavourable than if they manifest themselves in remote parts of the body, particularly in the extremities. Richter observes, that a long continuance of the sleep, and subsequent mental stupor and confusion after the subsidence of the paroxysm, is a very unfavourable sign. Epilepsy from moral causes, particularly from violent anger or grief, is said to be very rarely cured. (Jahn. Klinik d. Chro- nisch. Krankh. Bd. i. p. 267.) It is also asserted, that those cases which come on at night during sleep, are in general more intract- able than such as occur during the day, and are preceded by premonitory symptoms. (Richter.) It has been affirmed by men of great experience, ihat epilepsy occasionally ceases spontane- ously on a change of climate, t Treatment.—There is perhaps no disease in which medical treatment is so frequently purely empirical as the one now under consideration. The causes are so multifarious, and generally so obscure, or so wholly beyond our cognizance, that we arc seldom enabled to prescribe with any degree of reliance upon general and rational therapeutic principles. In this state of perplexity and uncertainty, we have often no other alternative left us, than to administer remedies, without being able to give any other reason for their use than that they have been occasionally suc- • He says, moreover, that when epilepsy commences before the fourteenth year, and is not connected with an hereditary predisposition to the disease, it frequently terminates spontaneously in after-life.—Aphor. xv. s. 7.—Aphor. vii. s. 5.—Aphor. xlv. s. 2. t Lcutin, in Hufeland's Journal. Bd. xiv. s. iii. p. 17. 52 EPILEPSY. cessfully employed. True as this observation unquestionably is, we have nevertheless in some instances, at least sufficient lights in the symptoms and causes to lead us to a consistent and rational plan of treatment. When called to a case of epilepsy, the first object of the practitioner should be to inquire into the nature of its exciting cause, its duration, the time and manner of the first attack, the general constitutional habit of the patient, his age, previous or concomitant diseases, his habitual temper and dispo- sition of mind, his manner of living, his probable hereditary predisposition, in short, into every thing which can throw light on the particular character of the disease, and on the constitutional or acquired habits of the patient. Authors assert, that when the premonitory sensation, termed aura, commences in one of the lower extremities, the epileptic paroxysm may sometimes be effectually prevented when it is approaching, by compressing the limb firmly with a tourniquet or ligature above the part at which the aura may have reached. Dr. Cullen observes, " that a ligature upon the limb above the part from which the aura arises, should always in those cases be applied, both because the prevention of a fit breaks the habit of the disease, and because the frequent compression renders the nerves less fit to propagate the aura." Dr. Cook mentions an in- stance from the London Medical and Physical Journal, in which pressure made in this way prevented the paroxysm. Richter states, that when compression is thus made on a limb, above the ascending aura, the patient generally experiences great anxiety of feeling in the prsecordia, with extremely painful twitches in the compressed limb, accompanied sometimes with a sensation as if a heavy stone were thrown upon it. Brechstedt and Michaelis assert that the application of the tourniquet upon a leg has been known to put a speedy stop to the epileptic paroxysm after it had actually supervened.* In persons of robust and plethoric habits, prompt and efficient bleeding on the occurrence of the premonitory symptoms, has been known to keep off the epileptic attack. Active purgatives have also been recommended with the view of obviating or palliating the impending paroxysm, where the premonitory stage is protracted; but their tendency in this respect deserves little or no attention. Richter and other of the earlier German writers speak favourably of the employ- ment of emetics with this intention. They cannot, however, be used without considerable risk in cases attended with strong con- gestion in the vessels of the head. Richter states that they are only adapted to those cases which continue to recur from habit, after the original exciting cause has ceased to act. It even ap- * De artuum ligaturis ad nonnullos morbos internos. Michaelis—in Medizin. Pract. Bibliothek. Bd. i. st. iii. p. 397—as quoted by Richter. EPILEPSY. 53 pears from the observations of this writer, that a radical cure may be effected in this way. He states, that he cured a woman of this disease, by frequently suspending the paroxysms by the administration of emetics a short time before the expected occur- rence of the epileptic attack.* It must be observed, however, that many highly respectable authorities might be adduced against the use of emetics in this affection; and as a general rule, they are indeed to be regarded as of very doubtful propriety. Jahn, in his excellent work on chronic diseases, says that a draught of cold water will occasionally do more towards keeping off an impending attack of epilepsy than any other means; and Dr. Busmann has published some cases tending to confirm this obser- vation.! Some fifteen years ago, while practising in Lancaster, 1 knew an old epileptic patient who could generally keep off the paroxysm for some months by taking a large draught of cold water as soon as the premonitory symptoms came on. Without this precaution he seldom escaped having one or two fits a week. In the epileptic paroxysm, our principal object should be to diminish the preternatural congestion of the cerebral vessels. The immediate danger of an epileptic fit arises chiefly from this con- dition of the cephalic circulation ; for when death occurs during the paroxysm of this disease, it is almost invariably by apoplexy, from vascular turgescence, or sanguineous extravasation. When the patient is plethoric, and the signs of inordinate sanguineous congestion in the head are considerable, it will be prudent to abstract blood, and to remove every thing which may compress the veins of the neck, or impede the free return of blood from the brain to the heart. It is very doubtful, however, whether any treatment, during the epileptic paroxysm, can materially mitigate its violence, or shorten its duration. It is almost exclu- sively with the view of protecting the brain, that remediate mea- sures can be resorted to during the fit with a prospect of advan- tage. The most important part of the treatment of epilepsy, however, is that which is proper during the intervals of the paroxysms, for the purpose of effecting a permanent removal of the disease. I have already adverted to the importance of attending to the nature of the exciting cause in instituting a course of treatment for its radical cure. If our inquiries in this respect are success- ful, it will not be difficult to lay down an appropriate plan of treatment. Thus, if on a careful examination, it appears that the bowels are in a loaded and irritated state, and particularly if signs of intestinal irritation existed, in a very obvious manner, previous to the occurrence of the disease, it would be exceeding- * Specielle Therapie, Bd. vii. p. 630. f Hufeland's Journal. Bd. x. st. ii. p. 133. 54 EPILEPSY. ly unwise to neglect the state of the bowels, and to resort at once to some one of the numberless remedies usually recommended in the disease. Epilepsy from this cause is principally confined to infancy and childhood. It is in this variety of the disease that emetics have most frequently been found useful. When symptoms of gastric irritation—such as nausea, flatulency, dis- turbed sleep, and other manifestations of indigestion are present, in children affected with this disease, a course of emetics has been used with decided success. (Richter.) In a child which had been affected with occasional epileptic paroxysms for upwards of eigh- teen months, I succeeded in removing the disease entirely by a course of emetics, (ipecac.) administered every third day. * Dr. Clark recommends a solution of sulphate of zinc, in an aqueous infusion of ipecacuanha, to be given every six, eight, or ten days. Absorbents also have been recommended in the epilepsies of infants, attended with gastric disturbance; and when used in con- junction with mild tonics, and an occasional aperient, they are sometimes beneficial, particularly where there is much acidity in the primac viae.t Richter observes, that we have reason to presume that the re- mote cause of the disease is seated in the stomach when vomiting occurs at the close of the paroxysm. He mentions also a pecu- liar tremulous motion of the under lip, as a sign of gastric irrita- tion, from vitiated secretions or other offensive matters. Van Swieten relates a case of epilepsy, the fits of which were always preceded by a remarkable tremour of the under lip. The case was treated by emetics and purgatives, and thereby permanently removed.! If symptoms of intestinal worms are present, anthel- mintic remedies are decidedly indicated. Small and repeated doses of calomel, with an occasional dose of castor oil in union with a small portion of spirits of turpentine ; or infusion of spi- gelia, followed with a full dose of calomel and jalap, will some- times answer in such cases. In verminous epilepsy, full doses of powdered valerian with the elutriated oxyde of tin, has been successfully used. From one to two drachms of the former, with thirty to forty grains of the latter, may be taken three times daily. Should it appear that the disease arose in the first instance from sudden suppression of the perspiration, a course of diapho- • This case came on after an attack of ague, which was cured by Fowler's solution. f The famous powder of Margrave, which is still a good deal used by some of the German practitioners in infantile epilepsy, owes whatever powers it possesses to its absorbent, tonic, and aperient virtues. It is composed of one ounce of powdered misletoe, the same quantity of sugar, and half an ounce of the car- bonate of magnesia. The dose is a tea-spoonful two or three times daily for a child under five years old—Richter'a Spec. Therap. Bd. vii. p. 645. t Comment. T. iii. p. 439. EPILEPSY. 55 retics, and whatever else may have a tendency to keep up a re- gular action of the cutaneous exhalents, should be resorted to. Frictions with dry flannel; the occasional use of the warm bath, rendered more stimulating by the addition of common salt; flan- nel worn next the skin ; active exercise when the weather is dry ; the internal use of diaphoretic remedies—such as the pulvis anti- monialis ; camphor in union with tartar emetic ; the tincture of guaiacum ; and sulphur, are appropriate and occasionally benefi- cial remedies in such cases. When epilepsy arises from the repulsion of cutaneous erup- tions, or the drying up of old ulcers, the manifest indication is to restore these affections ; or, if this cannot be done, to establish others artificially in their stead. For this purpose we may em- ploy issues, setons, blisters, and particularly frictions with tartar emetic ointment, together with diaphoretics, warm bathing, and stimulating frictions. Richter says, that in such cases, vomits are occasionally very useful; he also speaks favourably of the use of musk and camphor in epilepsy arising from causes of this kind. Prichard recommends mercury, given to the extent of producing ptyalism, in this variety of the disease. One of his patients was perfectly cured by a copious salivation. In those cases which occur in young females, in consequence of an unsuccessful or imperfect menstrual effort, the indications are, to remove the preternatural determination to the head, and to establish or restore the natural determination to the uterine system, and thereby promote the regular performance of the men- strual function. This variety of the disease occurs chiefly in young females of sanguine temperament; and bleeding, therefore, can seldom be dispensed with. Indeed, in all cases of this kind I have met with, bleeding was decidedly indicated by the condi- tion of the pulse, the occasionally flushed countenance, and sense of fulness in the head. Dr. Prichard, speaking of this variety of the disease, which he calls uterine, observes—"The immedi- ate effects of blood-letting are generally relief of the pain and oppression of the head, and a subsidence of the carotid and tem- poral pulsations. Sometimes the use of the lancet is speedily followed by a restoration of the catamenia." He advises that the blood be taken while the patient is sitting up, and that it be suffered to flow until syncope begins to come on. In addition to bleeding in cases of this kind, the warm semicupium is a valua- ble remedy.* We may also employ frictions about the loins, back, and pubic region, and stimulating enemata, with advantage. Prichard recommends clysters composed of spirits of turpentine and castor oil, in such cases. An ounce of each may be occa- * The bath, says Prichard, should be about the temperature of 96° or 98° of Fahrenheit's scale.—Treatise on Diseases of the Nervous System. Lond. 1822. 56 epilepsit. sionally thrown tnto the rectum. After the plethoric or phlogis- tic state of the system has been reduced by the foregoing measures, it will be proper to resort to emmenagogue remedies, if the men- strual evacuation has not already been restored. The following pill may be employed for this purpose.* According to the expe- rience of Dr. Prichard, the best emmenagogue we possess in uterine epilepsy is the oil of turpentine. It should be given in doses of from a half to two drachms once or twice daily. I used the turpentine in a case, about eighteen months ago, with complete success. Setons in the nape of the neck, or on the arms, or on the sacrum, have also been recommended. This variety of epilepsy is almost invariably suspended by pregnancy. In epilepsy from onanism, besides the proper moral influences, Richter strongly recommends the use of camphor in regular and full doses. That this article possesses the power of lessening the venereal propensity I am fully persuaded, and its general influ- ence, independent of this particular effect, renders it a suitable remedy in cases of this kind. Patients affected with epilepsy from this cause, should sleep on a hard mattress, rise early, take exercise in the open air, and use a mild and unirritating diet. The tepid shower-bath, and laborious occupations, will sometimes assist materially in removing the habit upon which the disease depends, and without the discontinuance of this habit, nothing useful can be expected from remediate treatment. Epilepsy from local injuries of the head has been cured by surgical operations. Boerhaave, Thenier, Stalpart, and Van der Weil, relate instances in which trepanning succeeded in remov- ing the disease. Tissot also mentions several instances of this kind. Dr. Massie gives an account of a case of epilepsy which was produced by a blow on the head, and consequent depression of a portion of the cranial bones. After the disease had continued about four years, the patient was trepanned, and a spicula of the bone removed, after which the paroxysms returned no more.t Instances have also occurred in which epilepsy was cured by surgical operations on other parts of the body than the head. Portal relates a case, where the paroxysms always commenced with violent pain in the index finger. This patient was cured by dividing the radial nerves. % The disease has sometimes termi- nated spontaneously after the removal of spiculae of bones, balls, tumours, or other foreign bodies pressing upon particular nerves.§ • R. Extract, sabinae ^ii. G. aloes lace. gi. Sulphat. ferri. gr. x. M. Fiant. pil. No. 40. Take one every six hours. f Philadelphia Med. and Phys. Jour. 1809. No 35. i Cours d'Anatomie Medicale. T. iv. pp. 247. 272. § Memoires sur la Nature et le Traitement de Plusieurs Maladies. Par Ant Portal, vol. xi. p. 229. (Richter.) EPILEPSY. 57 Dr. Dudly of Lexington succeeded in curing a case of epilepsy by removing a spicula of bone which had penetrated the sub- stance of the brain to a considerable distance. Dr. Rogers of New-York succeeded in a case by a similar operation ; and an in- stance is related by Dr. Guild of Alabama which was cured by the operation of trephining. This case is an extremely interest- ing one, and deserves to be consulted as a remarkable instance of successful trephining for this disease.* Where we can ascertain the remote cause of the disease, we should always found the plan of treatment on the general indi- cations which such a knowledge is capable of affording. In the majority of instances, however, we are wholly left in the dark with regard to this point, and very frequently indeed, all our efforts to cure the disease, under the guidance of what we may deem the most unequivocal curative indications, are unsuccessful. In this case we are obliged, if we wish to pursue our endeavours to effect a cure, to resort to some one, or many, by turns, of that long list of remedies which, according to the reports of eminent practitioners, or our own experience, have occasionally succeeded in removing the disease, without our being able to give any other satisfactory reason why they are resorted to. The follow- ing are the most celebrated of these anti-epileptic remedies. Valerian.—This is one of the most ancient remedies employ- ed in this disease. Aretaeus and Dioscorides recommend it as a valuable medicine in this affection ; and it is favourably mention- ed by many of the most celebrated of modern writers, t It should be given in as large doses as the stomach will bear. From one to two drachms may be taken thcee times daily. This article is said to be most apt to do good in epilepsies from verminous irri- tation, suppressed catamenia, terror, and repelled cutaneous erup- tions. Quarin used it with success in epilepsy of infants. (Rich- ter.):!: Biett generally employs the oil of valerian in this affection * American Journal of Medical Science. October, 1829. \ Hoffman, De Haen, Burserius, Haller, Murray, Selle, Tissot, Thilenius, Vo- gel, Hanneman, Horn, Quarin, and others, recommend it as a valuable remedy in epilepsy. On the other hand, Cullen, Home, Heberden, and Woodville, regard it as of but little value in this disease. j The famous anti-epileptic powder of Ragolai contains a large proportion of valerian. According to Knopf's analysis, this nostrum is composed of one drachm of valerian, one scruple of orange leaves, two grains of muriate of ammonia, and a few drops of cajeput oil. Jahn thinks that it contains a portion of the powder- ed root of the convallaria majalis; and some assert that it consists of a mixture of valerian, agaric, and an ethereal oil. This remedy, according to the testimony of Richter and others, has cured obstinate and even inveterate cases of epilepsy. Richter succeeded in curing a case ot" four years standing, by a powder composed of one drachm of valerian, with three drops of cajeput oil, taken four times daily for six weeks. (Therap. Speciel. vol. vii. p. 672.) In this city the follow- ing composition has been used with complete success in some instances, and frequently with the effect of postponing the paroxysm for manv months.— Vol. II. 8 58 EPILEPSY. in doses of from 40 to 50 drops three times daily. (Casper. Cha- raktcr. d. Fanz. Med. p. 192.) The misletoe also is a very old remedy in epilepsy ; and it we are to place any reliance on the testimony of Boerhaave, De Haen, Van Swieten, Hufeland, Stark, and Richter, we cannot doubt of its having proved effectual in removing this affection. Cullen admits that in large doses it may perhaps be useful ; but he thinks it probable, and with justice, that the reputation it once had arose in a great measure from its having been an object of superstition, and thus calling in the powerful aid of the imagina- tion to whatever powers it may really possess of itself. Frazer, in a small work published on the powers of this article, asserts that he cured nine cases out of eleven with this medicine. He gave it in powder, in doses of from two scruples to two drachms, twice daily in a draught of camphorated emulsion. (Cook.) We have moreover the testimony of Fothergill and Dr. Willan in favour of this article as a remedy in epilepsy. Of late years, however, it has fallen into total neglect. I knew an empiric who succeeded in curing several old cases with this article. The animal oil of Dippel* also was formerly a good deal em- ployed in the treatment of this disease ; and we have the testi- mony of Hoffman, Cullen, Bang,t Kortrum, Quarin, Werlhof, Thouvenel, Van Hoven, and others, in its favour. It is given in doses of from 20 to 50 drops three times daily. It is said by Richter to be most useful in epilepsies originating from metastas- tic gout, rheumatism, and from repelled cutaneous eruptions. The oil of turpentine has* at present no inconsiderable reputa- tion as a remedy in this disease. I have already mentioned its usefulness in epilepsy from menstrual disorder, on the authority of Dr. Prichard. It has also been successfully used in other varieties, particularly in cases depending on intestinal irritation from worms and other offensive matters. Dr. Latham cured several cases of epilepsy with this remedy. Dr. Young has giv- en an account of two cases which yielded under the use of this remedy ;J and Dr. E. Percival relates three instances of its suc- cessful employment § Dr. W. Money also testifies to the useful- ness of this article in epilepsy ; and Dr. Prichard assures us that of all other remedies which he has tried in this disease, he has found none so frequently useful as the oil of turpentine, (loc. cit) R. Pulv. zingeberis. ----fol. salvia?. ----sem. sinapi aa gi. Dose. A tea-spoonful three times daily. I have myself employed this powder with advantage in a few cases, though never with complete success. * Dippel. Disquisitio de Vita Animalis Morbis. p. 89. f Acta Societ. Med. Hav. vol. i. p. 500. t Transactions of the College of Phvsicians. Lond. vol. v. § Edinb. Med. and Surg. Jour. vol. ix. rj. 271. EPILEPSY. 59 Biett is said to employ this oil frequently for the cure of epilep- sy in the Hospital St. Louis. This article should be given in doses varying from a half to two drachms three times daily. Fresh milk is perhaps the best vehicle for administering it. The root of the paeony was anciently highly esteemed for its powers in this disease. It was a favourite remedy with Stark ; and it is particularly recommended by Hufeland, Jahn,* and Thom. Hufeland says, it is especially useful in the epileptic affections of children. The powder is given in doses of half a drachm three times daily, or an infusion of one ounce of the root to eight ounces of water, given in table-spoonful doses every two hours. Agaricus muscarius was first employed in this disease by Bernhard. Wistling and Gruner afterwards published statements illustrative of its powers in this affection. (Richter.) It is said to be most useful in cases originating from repelled cutaneous eruptions. The dose is from a scruple to a drachm three times daily. Artemisia vulgaris, or mugwort, has been lately much com- mended for its virtues in this disease by several eminent German practitioners. About eight years ago, Dr. Burdach, an eminent physician and writer, published an account of the successful treat- ment of several cases of epilepsy by this root; and in a recent number of Hufeland's Journal, he has adduced further evidence of its usefulness in this disease. It is a remarkable circumstance, he says, that in nearly every case in which this article proved successful, an evident amendment of the disease took place from the first dose. It appears further, from the experience of this physician, that in cases of epilepsy occurring in male subjects about the age of puberty, this remedy very seldom does any good. In young females about the same age, " its beneficial effects are often prompt and decisive." He occasionally found it very speedily successful in apparently very obstinate cases, while in others, seemingly quite similar, it was wholly inefficient. An interesting instance of the successful employment of this remedy, is related by Dr. Wagner, in Hufeland's Journal, (vol. for 1824.) And in the 12th Annual Report of the Berlin Polyclynic Institute, there is another case related which yielded under the use of the artemisia. It is usually given according to the following formula.t This is not a new remedy. Ettmuiller mentions its use in epilep- sy ; and Zwinger, speaking of this plant says, mire in epilepsia valet. The internal ligneous part of the root is inert The cor- * Klinik. d. Chron. Krankh. Bd. i. p. 282. f R Pulv. rad. artem. vulg. gss. Pulv. sacch. albi. gi. M. Of this, about a tea-spoonful is to be taken four times daily; the dose being gradually increased. 60 EPILEPSY. tical portion alone is said to possess medicinal powers. The artemisia is indigenous to this country, particularly to Pennsyl- vania.* Of the narcotics, belladonna,! opium, J camphor, § and stramo- nium, || have been most recommended in this affection. Some of the antispasmodics also have been employed with benefit in epilepsy. Among these, musk, castor, and assafoctida, are gene- rally supposed to be the most useful. Very commonly, how- ever, no advantage whatever is to be derived from remedies of this kind ; and they are often manifestly injurious, by their ten- dency of increasing preternatural determination to the head. Of late years, phosphorus has been strongly recommended by some as a remedy in this affection. I gave it in one case about two years ago, and although it did not perform a cure, it suspend- ed the paroxysm above three months beyond its usual period of recurrence. Four grains may be dissolved in half an ounce of sulphuric sether. Of this, from eight to ten drops should be giv- en three times daily in some mucilaginous fluid.IF This article cannot, however, be employed with propriety, in cases attended * Besides the foregoing remedies, a great many others of a similar character have been recommended in this affection. Veratrum Album, (Stark, Schulze, Greding.) The roots of the white lily, (Hufeland's Jour. B. xxxi. p. 30,) Phe- landrium aquaticum ,• faba St. Ignatii; the fresh juice of white onions, (Hufeland's Annalem;) Radix mcu (Jahn;) the juice of unripe grapes, (L. Frank, Loebstein- Loebel;) sedum acre (Zachorn, Hufeland's Jour. Bd. xl. p. 19;) folia auran- tiorum, (Van Swieten, De Haen, Stoerk, Werlhof, Stark, Hufeland, Thilenius.) The carbonate of potash in large doses, is recommended in recent cases. (Hufe- land's Jour. Bd. viii. p. 170.) f Stoll, (Ratio Medend. vol. iii. p. 406,) Hufeland, (Journal d. Prack. Heilk. Bd. ix.) Greding, (Vermischte Shriften,) and Jahn, (Klinik d. Chron. Krank. B. i. p. 282,) speak favourably of this narcotic as a remedy in epilepsy. Richter says, it should never be given to children—or in cases attended with habitual congestion of the cerebral vessels. * Tralles, (Usu Opii Salubriset Noxius, &c. p. 16.) Fothergill, (Med. Observ. and Inquir. vol. vi. p. 80,) asserts that opium may be very beneficially used in cases attended with a weak, irritable, and nervous habit of body; and in cases that arise from violent pain or mental excitement. Dr. Huxy relates an instance of the successful employment of opium in epilepsy; and Dr. Darwin tells us that in two cases in which the fit always occurred at night during sleep—a grain of opium given at bed time removed the disease completely. § Richter says, that camphor is sometimes particularly useful in cases that de- pend on onanism, or on the repulsion of chronic cutaneous eruptions. (Loc. cit. B. vii. p. 682.) v || This article is much praised as a remedy for epilepsy by some of the Swedish writers. Ohdelius speaks favourably of it; and Greding cured a few cases with its use. Hufeland asserts, that he has used the tinct. sem. stramon. with decided benefit in this disease. (Journal, Bd. ix. st. 3.) 1 In Horn's Archives of Medicine (Bd. x. lift. ii. p. 270,) the following fofmu- la is given for the administration of this article. R. 01. tereb. |ss. Ol. olivar giii. Phosphor, gr. ii.; put them into a half ounce phial, and digest it in warm water until the phosphorus is dissolved; then add mucilage of gum arabic jf iv. Syrup of cinnamon .^ss. M. Dose, a desert- spoonful every 3 or 4 hours.—(Richter, 1. c.) EPILEPSY. 61 with general plethora, or habitual congestions in the cephalic vessels. Where symptomatic epilepsy is connected with torpor of the vascular and nervous systems, or general debility and re- laxation, advantage may be expected from it. Loebstein-Loebel, Van Hoven, and Horn, relate instances of its successful employ- ment. The oxyde of zinc is generally regarded as one of our most efficient remedies in epilepsy ; and from the testimony extant in relation to its powers, as well as from facts which have come un- der my own notice, I am inclined to regard it as a medicine of considerable value in this affection.* This article is generally given in much too small doses to do any good in epilepsy. It may be commenced with in doses of three grains thrice daily, and gradually increased to the amount of forty or fifty grains a day. Dr. Gutherie cured a case in which the paroxysms return- ed three or four times daily, with this article, given to the extent of eight grains on the first day, and gradually increased to forty grains in twenty-four hours. (Duncan's Annals of Med. v. iv. p. 473.) It is generally given by itself; but it would seem that its powers may at times be enhanced by combining it with bitter and laxative remedies. Lentin (Hufeland's Jour. Bd. xiv. st iii. p. 13.) cured an inveterate case with a powder composed of fifteen grains of magnesia, from two to eight grains of oxyde of zinc, two grains of the extract of quassia, and two drops of caje- put oil, twice daily. Stroubel (Hufeland's Jour. Bd. 52. st. i. p. 40,) used this metallic preparation, in union with misletoe, with complete success, in a case attended with much nervous irrita- bility. The sulphate of zinc has also been occasionally used with success in this affection. It is favourably mentioned, in this re- spect, by Lettsom, Weikart, Cullen, Ideler, (Hufeland's Jour. Bd. iv. p. 114.) Cuprum ammoniacum. This was the favourite remedy in epilepsy with Cullen. I have given it in ten or twelve cases, one of which only derived any decided benefit from its use. This article is indeed a very old remedy in this affection. Aretaeus mentions it as a valuable anti-epileptic. Richter observes, that the cuprum ammoniacum is only calculated to do good in cases attended with a torpid, unirritable, and phlegmatic constitution, and a healthy state of the digestive functions, and when it is con- * This remedy has been used with success by Bell and Percival, (Edinb. Med. Comment, v. i. p. 229, and v. ii. p. 316;) Beireis, Home, (Clinical Experiments, p. 223 ;) Ranoe, (Acta. Societ. Med. Hafn. vol. i. p. 451, 457;) Metzcher, (Ad- versar. Med. v. ii. p. 98;) Osiander, (Denkwuirdigk. Bd. ii. p. 188;) Hirschel, Richter, (Med. Chir. Nebenst.?pp. 161, 190;) Shearman, (Lond. Med. andPhys. Repos. Sept. 1822;) P. Frank, (Prax. Med. Univ. Praec. P. II. torn. i. p. 409;) Dr. Haygarth, Dr. White, (Cook on Nervous Diseases, p. 398;) Van Hoven, (Handbuch, Bd. ii. p. 131.) 62 EPILEPSY. tinued from habit* According to Stark, it is especially benefi- cial in cases depending on verminous irritation, or on repelled herpetic eruptions. Haase, an eminent German writer, asserts that it is much better adapted to the cure of epilepsy in adults than in children ; and he agrees with Richter in regarding unirri- table and phlegmatic subjects as most apt to derive benefit from its use. The dose at first is from a quarter to half a grain, and gradually increased to one or one and a half grain three times daily, or until it creates considerable nausea and gastric disturb- ance. Dippel refers to a preparation of copper, consisting of a union of this metal with potash, ammonia, and oil of turpentine, which, he avers, has been used with the most decided benefit in epilepsy. (Richter, Specielle Therapie. Bd. vii. p. 701.) The mode of preparing this mixture is given by Durr (in Hufeland's Journal, Bd. xxviii. st. iv. p. 117.) Richter says, that when giv- en in union with valerian, its effects are generally more beneficial. The nitrate of silver possesses at present more reputation as a remedy in epilepsy than perhaps any other remediate article. It would be an easy matter to collect a very considerable number of instances of its successful employment in this disease, t From the various and highly respectable testimonies we have in rela- tion to its powers, it is, without doubt, entitled to much attention as a remedy in this affection. In order to obtain its beneficial effects as an anti-epileptic, this preparation should be given in as large doses as the stomach will bear. Dr. Powel observes, that the ni- trate of silver may be taken into the stomach in much larger quan- tities without inconvenience in the form of pills than in solution. We may commence with one grain, and gradually increase the dose to three or four grains or more three times daily. Richter * Numerous authorities may be quoted in favour of the anti-epileptic powers of this preparation. The most celebrated are, Burserius, (Instit. Pract. vol. iii. p. 11. §289;) Loebstein-Loebel, (Wesen, u. Heilungd. Epilepsie, p. 234;) Dun- can, Harks, (Jour. d. Auslaend Med. Liter. Bd. iv. st. 2;) Bland, (Medical Com- mentaries, vol. vii. p. 300;) Greding. (Vermischte Schriften, Bd. i. p. 103;) Michaelis, (Med. Pr. Bibl. 1785. B. i. st. 3;) Stark, (Handbuch Z. Erkennt. &c.;) /. Frank, (Praxeos Med. Univ. Praec. P. II. vol. i. p. 412,) Haase, (Chron. Krankh. Bd. ii. s. 103;) Thilenius, (Med. u. Chir. Bemerk. Bd. i. p. 103;) Bally, (Duncan, Medical Annals, vol. i. Lust. p. 377.) f It has been used with success, in well marked and often long standing cases of epilepsy, by Sims, (Mem. of the Med. Societ. of Lond. vol. vi. p. 397;) Cappe, (Duncan's Annals, for 1798, p. 56;) Bostock, Hull, Heberden, (Commentaries;) Sauchier, (Annal. de la Societ. de M£d. de Montpell. T. vii. pp. 369, 384;) Valentin, (Ibid. T. viii. p. 182;) Heim, Nord, (Med. Nationalzeit. 1798;) Born, (Hufeland's Journal, Bd. xlv. st. i. p. 93;) Shaeffer, (Ibid. Bd. xlviii. p. 43;) Pitschaft, (Ibid. Bd. Ii. st. 3. p. 54;) Loebstein-Loebel, (Wesen u. Heil. d. Epi- lepsie, p. 243;) Portal, Fouquier, (Diet, des Sciences Med. T. xxxvii. p. 120;) Harrison, Baillie, Roget, Johnson, (Cook on Nervous Diseases, p. 394;) Barladi- ni, (Omodei. Annal. di. Medic. 1826. p. 41;) Jahn, (Arzneinuttell, Bd. i. and Klinik el. Chron. Krankh. B. i. p. 283;) Kruiger, (Archiv. f. Med. Erfahr. v. Horn, Maeitz, April, 1823;) Toel, (Ibid. 1824, Nov. and Decemb.;) Biett, (Casper. Charakt. d. Franzoesish. Med. p. 191.) EPILEPSY. 63 states, that this article seldom does any good unless the digestive organs are in a healthy and vigorous condition ; and Dr. Harri- son considers it particularly adapted to those cases which are con- nected with a morbid irritability of the nervous system. I have given it in a number of cases—in one case only, however, did it prove permanently successful. Kruiger employed this article with success according to the following formula.* The nitrate of silver will sometimes manifest no beneficial effects until its use has been continued for many months. Toel (Horn's Archives, 1824,) relates a case in which the paroxysms recurred regularly every month, at night during sleep, which yielded at last to this remedy after it had been regularly taken for more than a year and a half. It is a common practice to discontinue the use of this and other similar remedies, if no perceptible advantage is deriv- ed from it in the course of six or eight weeks. This, I am per- suaded, is not unfrequently the source of defeat in our attempts to subdue this complaint. I once succeeded in curing a case of seven years' continuance, by persisting with the same remedy for nine months. Tin.—This article has recently been strongly recommended in the cure of epilepsy. Dr. Shearman states, that in his hands the elutriated oxyde of tin has more frequently succeeded in curing this affection than any other remedy he has ever employed. He gave it in doses of from two scruples to one drachm, night and morning, for about four days. At the end of that time he ordered a purgative, and again gave this preparation, or not, ac- cording to its effects on the system.t The filings of tin, given in large doses, have been used with success in epilepsy from ver- minous irritation by Richter, (Asklepeion, 1811. st. 67. s. 1060,) and Monro, (A Treatise on Med. and Pharm. Chem. vol. i. p. 289.) From the acknowledged anthelmintic properties of this article, it is manifestly peculiarly adapted to cases which depend _ on irritation from worms. Lead.—The acetate of lead has been employed with entire success in a few instances of this disease. About sixteen years ago, I succeeded in curing a case with this remedy which had continued for upwards of seven years. The patient was a young man about 22 years old; and the disease was excited, in the first instance, by violent terror. The paroxysms returned regularly at each period of full moon. I prescribed three grains of sugar of lead mornings and evenings, commencing three days before * R. Nitrat. argenti. gr. vi. G. opii. gr. x. Extract, gentian, gi. Extract, aloes, >)i. M. Divide into two grain pills. Take one three times daily, in- creasing the number from time to timer f London Meuical Repositoiy. 64 EPILEPSY. the time of full moon, and continuing two or three days after this period. He took the medicine in this manner for nine suc- cessive lunar periods; but the disease did not return alter the fifth period from the time the treatment was commenced. Dr. Rush gave this remedy in two grain doses with complete success in a case of this disease ;t and Drs. Spence and Agnew employed it, in some instances, with decided benefit. Saxdorph also gave it with marked advantage. J Quarin (Animadv. Pract.) and Por- tal condemn its use in epilepsy, as being inefficacious in small doses and dangerous in large ones. Besides the foregoing remedies, many others have been used with advantage. Dr. Johnson speaks favourably of the internal use of cantharides; Dr. Kirkhoff has used the prussiate of iron with success; and Underwood has derived advantage from the use of savin. Mercury, with a view to its salivant effects, was formerly much recommended. Burserius speaks highly of the powers of cinnabar in this affection. Mercurials, particularly mercurial frictions, were used with success by Bang, Willis, Ettmuiller, J. Frank, Tissot, Locher, and others. Richter states, that the sulphuric acid sometimes produced the happiest effects in epilepsy. Advantage, however, is to be expected from its use only in cases attended with a general ner- vous irritability, and erethism of the vascular system. In such cases, from two to four drachms of the acid should be taken during the day. Zimmerman, Tissot, and Hildebrand, (Hufe- land's Jour. Bd. ix. p. 34,) commend the anti-epileptic powers of this acid. Various external remediate applications also have been recom- mended, and occasionally used with advantage in this affection. Statements have been published which go to show that galva- nism may occasionally be employed with benefit. It is said to be most efficacious in this disease when its influence is applied some time before the accession of the expected paroxysm; and (when the case is preceded by the aura,) if the positive current of the galvanic fluid is passed through the part where the aura commences. § According to the experience of Mansford, little or no advantage is gained from galvanism in epilepsy, unless it be applied steadily and constantly, and only with a weak power. He thinks that the negative point should be as near the brain as possible, and the positive one in some distant part of the body.|| * New-York Medical Repository, vol. ii. No. I. 1815. ■j- New-York Med. Repos. vol. ii. No. I. new series, 1813. $ Osann. Dissertatio de Saturni Usu .Medico, &c. 1809. § Walther. Uber d. Therapeutisch lndic. d. Galvanism. Richter, Specielle Therap'12, Bd. yii. p. 716. H Galvanism is favourably mentioned ?.s * remedy by Martens, (Answeis. Zut EPILEPSY. 65 Electricity has also been recommended for the cure of epilep- sy. Richter states, that this agent has been employed in several obstinate cases with great advantage. Both galvanism and elec- tricity, however, may, and have done unequivocal harm, particu- larly when applied with much force. It is only in cases attended with a torpid and unirritable state of the nervous system, that these powers appear to be applicable with a prospect of benefit* Setons and issues were at one time much used in epilepsy. Hippocrates cured a case by an issue on the crown of the head, (De Morb. Sacro. § vii.;) and Tulpius relates a case cured in the same way. Mead used blisters on the back of the neck with success, (De Imperio Solis et Lunse, cap. xi.) Fabricius cured an obstinate case with a seton in the nape of the neck, (Observ. et Epistol. Franc, cent i. ob. 41.) The actual cautery has also been successfully applied in this disease. Van Swieten, Heister, Willis, De Haen, Larrey, and others, have related cases cured by this severe application. Thia remedy is mentioned by the anci- ents as a cure for epilepsy, ^particularly by Caelius Aurilianus. (Richter.) Larrey has published an account of some cases of epilepsy, in which local bleeding from the vessels of the head, and the subse- quent application of moxas, blisters, and other counter-irritants, proved completely effectual. (Revue Medicale.) Of late years a good deal has been said in favour of pustulation with tartar emetic ointment, as a remedy in this affection. Mr. John Creighton has related six cases treated by frictions with this ointment, along the course of the spine, with very obvious benefit, though not with entire success in any one.t More re- cently, Dr. Carter has given an account of five cases of epilepsy, which go to show the usefulness of this application.^ Music has been employed to overcome this distressing mala- dy. Quarin states, by means of this delicious power he succeeded in gradually weakening and finally subduing the epileptic parox- ysms in one case. Whatever mode of treatment or remedies be employed, particu- lar attention should always be" paid to proper regulations in relation to the diet, exercise, and the action of the bowels. Therapeut. Anwend. d. Galvanismus, p. 333;) Whitlam, (Med. and Phys. Jour. vol. xiv.) Burdach. * Electricity is particularly recommended in this disease by Albans, Stoll, Kuihn, Spengler, Wilhelm, and others. | Dublin Transactions, vol. iv. i Med. Chir. Rev. vol. ix. July, 1826. Vol. II. 0 66 CATALEPSY. Sect. IV.—Catalepsy. We find this very remarkable and rare disease described in the books under a variety of names—such as stupor vigilans, congelatio, extasis, catoche, or catochus, lethargus, cams cata- lepsia, &c. Catalepsy consists in a temporary suspension of consciousness, sensorial power, and volition—the body remaining in the pre- cise position in which it was when the attack came on, without coma, muscular rigidity, or spasm; the respiration and circulation continuing. The attack generally comes on without any warning of its approach. In some instances, however, symptoms, premonitory of the cataleptic seizure, occur, such as vertigo, cephalalgia, flushed face, a certain inactivity of mind and body, pain in the praecordium, a feeling of heaviness or tremor in the extremities, forgetfulness, flatulent pains in the bowels, yawning, sensorial obtuseness, depressed spirits; and in some instances a sensation similar to the aura epileptica. When the attack occurs, every part of the body remains in precisely the same position in which it was at the moment of the seizure. If the paroxysm comes on while the person is in the act of doing any thing, as, for instance, drinking, the hand will be suddenly arrested with, perhaps, the glass near the lips and the mouth open. Even the expression of the countenance continues fixed during the cataleptic state, as at the moment of the attack.* The eyes are generally open, fixed, and slightly turned up. Sometimes they are spasmodically closed. One of the most re- markable circumstances of this affection is the wax-like flexibil- ity (flexibilitas cerea) of all the members of the body, with suf- ficient tonic muscular action to cause an extremity, or the whole of the body, to remain in the exact position in which it is put by another person. Thus, if during the cataleptic state, the arm be raised up, or in any way extended or flexed, it will remain so until the paroxysm is over. To this, however, the eyelids some- times form an exception. When they are closed, they will not remain open when separated with the fingers; and when open, they immediately separate again, if forcibly closed, as soon as the force is removed. Van Swieten mentions an instance of the for- mer,! and Heberden one of the latter. J In complete catalepsy, * Richter's Specielle Therap. Bd. viii. p. 471. f Comment, vol. x. p. 183. * Comment, on the History and Cure of Diseases, p. 291. CATALEPSY. 67 all the sensorial functions are entirely suspended, and the patient, on recovering, remembers nothing either of his own internal sensations, or of what is done about him during the paroxysm. The period occupied by the attack is a perfect blank in the pati- ent's existence; and if the paroxysm comes on while he is con- versing, or in the performance of any other continuous act, he will resume the thread of the conversation, or even finish the half-pronounced word, or continue his acts, as soon as the parox- ysm is over, as if no interruption had taken place. Although voluntary motion is almost universally suspended during the cataleptic attack, cases have occurred in which locomotion con- tinued, without, however, the least consciousness in the patient of its performance. Dr. Stearns* relates a case, in which if the pa- roxysm came on while the patient was walking, the same pace was unconsciously continued. Dr. Good also relates a similar instance, in which the involuntary walking continued during the attack, t Fernelius states, that he saw a cataleptic patient, who, when pushed forwards, walked with a regular and firm step. % In cases less perfect, some degree of sensorial power remains, and the patient retains an indistinct recollection of what occurred during the paroxysm, on emerging out of it. But even in cases of this kind, all power of voluntary motion, or of manifesting, in any manner, a consciousness of their situation, or a desire for any thing, is wholly suspended. A case is mentioned by Galen, § in which the patient, one of his fellow-students, lay motionless like a log, with his eyes open ; but he heard and remembered what occurred during the paroxysm. A remarkable case is related by M. M. Lenormand, seen also by Laennec and Recamier, in which there was complete immobility, rigidity of the whole body, pulse weak, expression of the countenance natural, and abolition of all the senses, except that of hearing ; the patient (a young female) heard every thing that was said in her presence", but was totally unable to make the least sign, or utter the weakest sound. In the course of the third week, her hearing also failed, and her limbs became flexible, and readily assumed any position in which her attendants placed them. During the intervals of the attacks, she suffered much anxiety and pain in the pit of the stomach.|| It is even stated that instances havo occurred of catalepsy on one side only. IT In some cases the respiration and pulse become so feeble as to • American Medical Register, vol. i, art. viii, . f Study of Medicine, vol. iii. p. 387. t Patholog. lib. v. cap. xi. p. TO. § Liber i. Prorrhetic. p. 756. U Rev. Medicale Juillet. 1825. 1 De la Metric, Abregpe de la Theorie Chymique, &c. p. 278 (Van Swieten.) 68 CATALEPSY. be imperceptible, and the whole surface is cold and contracted, as in death. The flexibility of the limbs, however, remains throughout—a circumstance which is never observed in dead subjects.* the duration of the cataleptic attack varies from a few minutes to several days. A deep inspiration generally announces the return of consciousness, sensation, and voluntary motion. In many cases the paroxysm passes off suddenly, the patient recovering in an instant all his mental and physical powers. I saw a case late- ly with my friend Dr. Stadiger, which regularly recurred three or four times daily, and in which the paroxysms never continued longer than between one and two minutes, and always came on and passed off suddenly. In other instances, particularly in those of protracted duration, the attack goes off gradually, the power of feeling and motion generally returning first in the fingers, then in the arms, and finally in the whole of the body. In transient cases, the patient experiences no unpleasant feelings, or sensible diminution either of the mental or corporeal powers, after the paroxysm ; in others, a feeling of weight and fulness in the head, with slight cephalalgia, lassitude, and some degree of sensorial obtuseness, remain for some time after the attack has passed off. The cataleptic attacks in some instances recur with more or less frequency for months or even years ; but it has very rarely been found to assume a strictly periodical character. Sometimes se- veral attacks may occur in the course of one hour.t F. Hoffman mentions the case of a woman in which upwards of one hundred paroxysms occurred during the period of forty days.f Occasion- ally individuals will suffer a cataleptic attack, without ever after- wards becoming affected with it again.§ Catalepsy sometimes succeeds, terminates in, or alternates or becomes complicated with other affections. Dr. Lenormand's case, already referred to, was a most remarkable instance of this kind. The patient, a young girl labouring under pains in the stomach and menstrual irregularities, passed successively through nostalgia, fever, obstinate constipation, chorea, trismus, trismal catalepsy, complete catalepsy, chorea, a species of somnambulism, and finally hysteric symptoms, during the period of about eleven months. The disease has been known to alternate or terminate in epilepsy, anomalous convulsive disorders, soporose affections, and mental derangement || It is sometimes modified by a very peculiar morbid excitability of the nervous system, giving it the • Fitzpatrick. Medical Commentaries of a Society 8tc. of Edin. v. x. \ Behreus.—Baldinger's Neu Magazin. B. ix. p. 207. t Medic. Ration. System. T. iv. part iii. cap. iv. § Vogel. Praelectiones de Cognosc. et Curand. Morb. p. 569. | Hirschel Gedanken von der Starrsucht. p. 13. CATALEPSY. G9 character of cataleptic hysteria. In such cases, the patient will remain in a completely cataleptic state for some time, and then suddenly, without a recovery of consciousness, begin either to talk incessantlv, or sing, or whistle, or declaim.* Flcisch calls this modification of the disease, catalepsis loquax. (Richter.) Sometimes catalepsy is connected with a species of somnambu- lism, the patient lying in what is familiarly called a trance. The diagnosis of catalepsy depends chiefly, if not wholly, on the wax-like pliability of the extremities, and their maintenance of the position into which they are placed by extraneous force, together with the* entire impossibility of the least voluntary mo- tion. (Richter.) The affection described in the books under the name of ecsta- cy, though differing in some respects from catalepsy, as described above, appears to be only a modification of this latter disease, or at least not essentially diverse from it. In its general phenome- na, ecstacy partakes both of the character of tetanus and catalep- sy. In ecstacy, the whole mind is concentrated, and as it were, fixed upon some particular object, and the motific nervous influx is strongly and regularly determined upon the extensor and flex- or muscles ; so that no other impression can affect the mind, and the whole body remains rigid. Authors, however, differ in their statements with regard to the state of the muscular system. Good says, that in ecstacy "the muscles are thrown into a rigid and permanent spasm, not incurvating the body as in the differ- ent modifications of tenanus, but maintaining it erect from an equal excess of supply (of nervous power) to the extensor and flexor muscles." Richter, on the contrary, states that the limbs may be bent by extraneous force as in catalepsy ; but they do not, as in this latter affection, continue in the position they are placed, but obey the laws of gravity.! The higher grades of ecstacy are sometimes attended with visions, apparitions, &c. and may continue for many hours. { Osiander speaks of a variety of partial cataleptic affections, which sometimes attacks a single ex- tremity in young females about the age of puberty. The limb swells suddenly, becomes insensible, incapable of voluntary mo- tion, but remains pliable as in true catalepsy. § Causes.—This affection occurs much more frequently in fe- males than in males. The period of life at which there appears to exist the greatest aptitude to catalepsy, is about the age of pu- berty. Persons of a nervous temperament, more especially when • Sauvages. Nosolog. T. ii. P. ii. p. 418. Richter, Spccielle Therapie, B. viii. p. 477. ■j- Loc. cit. Bd. viii. p. 481; i Braumer. de Differentia Ecstaseos et Catalepseos—as quoted by Richter. § Osiander, Denkwuirdigk, Sec. B. i. 70 CATALEPSY. addicted to long and Instcnse mental application, arc said to be most subject to this affection. The exciting causes of catalepsy appear to be ns various as those of epilepsv. The disease not unfrequently arises from the influence of mental affections, especially from disappointed love. Tulpius relates a case of this kind ;* and Schilling has collected similar instances.! Violent anger, protracted grief, hatred, and sudden terror, have produced this affection. £ Long continued and intense mental application has excited the disease.§ Wepfer knew a young man who always became cataleptic when he ap- plied himself to mathematical studies. || FerTielius saw a case brought on by close study. Repelled cutaneous eruptions, par- ticularly itch and tinea capitis, have been known to give rise to this affection.1 Suppression or irregularities of the menstrual evacuation appears to be one of the most common causes of cata- lepsy ; yet the catamenial disorder, as Richter observes, is pro- bably itself often only a concomitant occurrence, depending, as well as the cataleptic affection, upon some other morbid condition, particularly on intestinal irritation. That irritation in the sto- mach and bowels is often the direct exciting cause of the disease, is abundantly demonstrated by the cases that have been publish- ed. Van Swieten mentions the case of a woman seized with " true catalepsy," to whom he was called. While standing by her "she suddenly vomited up two live round worms/' and im- mediately the cataleptic affection ceased.** Similar cases are re- lated by Thom, Jawandt,!! Bchrens, and others. A constipated and loaded state of the bowels also has been known to give rise to this affection. (Hirschel.) Catalepsy has been frequently found to occur in intermitting fever. Cases are related in which each paroxysm of this fever commenced with a cataleptic state. Jf Van Swieten quotes a case of this kind from Dodonceus ; and Richter refers to Flcisch and Hirschel for similar instances. Tissot has seen catalepsy produced by carbonic gas. It is said to have been excited by pregnancy. §§ General plethora ; organic affections within the head ; masturbation, &c. are also enumerated among the exciting causes of this disease. It would be in vain to enter into any speculations concerning • Observ. Medicar. lib. i. cap. xxii—a9 quoted by Van Swieten. | Disser. JEgrum ex Amore Catalepticum Factum Exhibens. (Richter.) * Richter, Speciell. Therap. B. ix. p. 488. § The case already quoted from Galen was produced " by too much studv," Van Swieten, 1. c. T. x. p. 193. 0 Observ. Med. Pract. de Affect. Capites.-obs. 66. 1 BurseriuB Instit. vol. iii. p. 137. Dufotir. Jour, de Med. T. lxx n 418 *• Loc. cit. T. x. p. 191. ' ' ft Hufeland's Journal, II. iv. st. iv. p. 784. U Medicus Samml. u. Beobacht. B. ii. p. 372. (Richter.) §§ Osiander, Entwicklungs Krankhciten, &c. B. i. p. 182. CATALEPSY. 71 the proximate cause of this affection. We may indeed observe, that there appears to be a complete dissociation between the moral and corporeal elements of the human system, so that the former can no longer be affected through the latter, or vice versa. At the same time, however, that the mind is thus incapable of being excited, or of exciting the body, the brain continues to secrete and transmit the motific influence to the muscular system, al- though its distribution is wholly beyond the control of volition. That the muscles are furnished with a regular influx of the ner- vous power, is evident from the fact, that the cataleptic patient, though entirely without consciousness and sensorial power, will maintain not only an erect and firm posture, but support the ex- tremities in positions in which they can be kept only by a regu- lar and equilibrious action of the flexor and extensor muscles. The metaphysician might draw interesting inferences from the phenomena of this disease, concerning the essential distinction between mind and the mere physiological functions of the senso- rium commune. This, however, is not the place to indulge in speculations of this kind. The prognosis in this affection cannot, in general, be regarded as very unfavourable. Van Swieten observes, " I have both seen from practical observations myself, and it appears from undoubted observations' of celebrated physicians, that a great many have re- covered from this disease, and afterwards enjoyed a perfect state of health."* Tissot makes the same remarks from his own ex- perience. It may, nevertheless, terminate in fatal apoplexy, or in epilepsy, coma, melancholy or mania, and occasionally, though very rarely, the cataleptic paroxysm has been known to termi- nate fatally without the supervention of any other affection. (Richter.) In protracted cases of catalepsy, the mind generally at last suffers more or less impairment of its powers; and in some instances, atrophy, emaciation, or dropsy, are its consequences. When the cataleptic paroxysm is succeeded by weakness and numbness in some part of the body—particularly of one or more of the sensorial organs, together with a sense of weight, fulness, and confusion in the head, or inactivity and absence of mind, the prognosis is particularly unfavourable with regard to its sanability; and the same remark applies to those cases which alternate with chorea, mania, or epilepsy. The occurrence of spontaneous san- guineous discharges—as hsemorrhois, epistaxis, or the catamenia, has been known to put a stop to the further recurrence of the dis- ease. Those cases which come on about the period of puberty, often cease spontaneously after this stage of physical development has been fully passed over. Instances that depend on gastric irri- tating causes—such as worms, accumulated fecal matter, acrid ' Cuimuciiuii...-, \oi x. p. iy/. 72 CATALEPSY. secretions, or other moveable, offensive substances, are in general most easily cured. Treatment.—-In general the treatment of catalepsy does not differ materially, either in its particular indications, or remediate measures, from that which has already been described under the head of epilepsy. When the paroxysm is protracted, small doses of sulphuric or acetic aether may be administered, if the power of deglutition remains, and there are no signs of cephalic conges- tion present. Great caution, however, is to be practised in the use of internal stimulants. Frictions along the course of the spine, fomentations or stimulating applications to the feet, and enemata, may sometimes contribute to the removal of the paroxysm. When evident signs of vascular congestion of the head are present, and the pulse is not very feeble, blood should be taken from the arm, or by means of cups from the temples or back of the neck, and sinapisms or warm applications made to the feet, together with the use of purgative enemata. If a purgative can be introduced into the stomach, it ought, by all means, to be done,—more es- pecially when there is reason to apprehend the presence of irri- tating matters in the intestinal canal. Reil states, that he once saw a girl affected alternately with mania and epilepsy, which instantly went off, on the expulsion of a number of lumbrici, by anthelmintics and enemata.* Galvanism and electricity, also, have been recommended in the cataleptic paroxysm; but they must not be applied in a strong degree. Richter refers to an in- stance, related by Thom, in which a young lady who was pas- sionately fond of music, was roused from the cataleptic state by this delicious influence. Hard tones produced no effect on her, but soft and melodious ones brought tears from her eyes, and rous- ed her as from a dream. The treatment proper during the intervals of the cataleptic paroxysms, with the view of preventing their recurrence, should accord with the character of the occasional cause, the patient's constitutional temperament, and the state of the vascular system. In the cases that occur about the period of puberty in females, active or exciting remedies will seldom do any good, but on the contrary, often prove decidedly prejudicial; and when such in- stances are connected with suppressed or irregular menstrual function, the active emmenagogues should be particularly avoided, (Richter). A proper regulation of diet, country air, regular ex- ercise, tepid bathing, sea-bathing, chalybeate, and laxative mineral waters, will often do more in cases of this kind than any other course of remediate management. Where symptoms of gastric and hepatic derangement are present, the occasional use of four or five grains of blue pill, with a course of gentle laxative and * Fieberlehie. Bd. iv. p. 72. CATALEPSY. 73 tonic medicines, will often prove beneficial. A state of general plethora will require an abstemious mode of living, and abstrac- tions of blood; verminous irritation demands anthelmintics; re- pelled cutaneous diseases call for external vesicating, pustulating, or irritating applications, with a gentle course of alterative and diaphoretic remedies; and a general excitable and weakened state of the nervous system, requires tonics, with antispasmodics, the narcotic extracts, or camphor, exercise in the open air, and the use of the tepid shower bath. Stark cured a case of catalepsy by assafoetida, galbanum, and infusion of the bulb of paeony; the ex- tract of hyoscyamus, oxyde of zinc, valerian, musk, castor, and opium, (Greiner) have been successfully employed. Marx speaks very favourably of the powers of acorns in this affection. The sulphuret of iron, and belladonna, with the fetid gums, has been used with success; and Loebstein-Loebel recommends the use of phosphorus. In short, nearly every remedy that has already been mentioned, under the head of epilepsy, has been advised, and may perhaps be beneficial in certain varieties of this disease. The nitrate of silver, the elutriated oxyde of tin, flowers of zinc, mer- cury, cuprum ammoniacum, and the various antispasmodic and narcotic remedies have all been used, and sometimes, it is said, with success. Sect. V.—Chorea.—St. Vitus's Dance. The first distinct account which was given of this disease is to be found in the writings of Plater and Senertus, both of whom lived about the cjose of the sixteenth century. * Since that pe- riod it has been described under a variety of names, expressive of that peculiar saltant action of the extremities which character- izes the disease, such as chorea St. Modesti; saltus viti; choreo- mania; ballismus; orchestromania; epilepsia saltatoria; dance de St. Guy. The name St. Vitus's dance, by which it is now familiarly known, was derived, according to Horst, from the chapel of St. Vitus near Ulm, to which women labouring under a certain ner- vous affection were in the habit of resorting every spring, where they danced violently and unremittingly from morning to night, until they sunk down, completely exhausted, into a swoon, or kind of ecstacy, by which exercise they fancied themselves cured for one year. Some writers place its origin at a much earlier date, deducing it from the very remarkable dancing mania which * It has been supposed that Hippocrates alludes to chorea in the following passage, according to the version of Foesius. " Medulla spina affecta homo nee crurum aut ventris officio potens est, nisi urgente necessitate ; si vero morbus invaluerit turn aliquando nrjeter voluntatem mejit et egerit." Vol. II. 10 74 CHOREA. prevailed throughout Germany in 1374, and which, as it was thought to be the malicious doings of Satan, was generally treat- ed by exorcism ; and it is said that the monks of the convent of Korbey were particularly fortunate in casting out the fiend under the holy influence of their patron, Saint Veil. Chorea rarely, if ever, comes on suddenly. Its approaches arc always gradual under a variety of premonitory symptoms, varying in duration from a few days to several months, indicative of a deranged state of the digestive organs and nervous system. The most common of these symptoms are slight flatulent pains in the stomach or bowels, variable appetite, constipation, tumid and hard abdomen, occasional vertigo, anxiety and a feeling of oppression in the precordial region, slight tremours and heavi- ness of the extremities, oppression in the chest, frequent palpi- tations, visual illusions, fulness in the head with temporary con- fusion of mind, a feeling of tension in the forehead, itching in the nose, cold feet, variableness of disposition fluctuating between gloom and cheerfulness, and in some instances a remarkable proneness to mischievous and unruly conduct. After some or perhaps the majority of these manifestations of deranged health have continued for a longer or shorter time, irregular muscular twitches or spasmodic contractions are observ- ed in the face or one of the extremities. These spasmodic ac- tions are, at first, slight and only occasional, and are particularly noticed on the sudden occurrence of any thing that flurries the mind. With more or less rapidity, however, they become strong- er and more constant, until, at times, almost every muscle of the body is in a state of continued involuntary action. Not un- frequently, the morbid muscular action is almost entirely confin- ed to one side of the body ; and this is generally the left side. (Richter.)* From the imperfect command of the will over the voluntary muscles, the patient, when he attempts to walk, has a starting, hobbling, and irregular gait, with an awkward dragging of one of the legs. Sometimes the involuntary muscular actions arc so violent, and the empire of volition over them so complete- ly lost, that progression, and even an erect posture, are rendered wholly impossible.! The hands and arms too are in constant motion ; the patient is often entirely unable to direct them ; and in all cases, various ineffectual efforts arc made before the hand * Cases have been related, in which one leg and the arm of the opposite side alone were affected, (Woeltche, Qbservationes Medicin. Fascicul. Richter.) -j- Occasionally all the muscles suddenly become completely relaxed; and in- stances have been known where the extremities have been so violently distort- ed as to dislocate some of the joints. {Bruickman. Enerratio Choreas St. Viti et Epilepsia per Fontis Medicatos Emenses Curatse. Hufeland's Journal. Bd. iii. st. iv. p. 612. Richie); Specielle Therapie, B. vii. p. 735.) A case is mentioned in Baldinger's Magazine, st. xii. p. 1095, in which the elbow-joint was dislocated, and in a few minutes again replaced by the violent contortions of this disease. CHOREA. 75 can be brought to the desired point. Thus, in conveying food or drink to the mouth, the hand is generally forced in almost every direction except the intended one, and is at last brought to the lips only after a number of unsuccessful efforts. The contractions of the muscles of the face are sometimes extremely severe and irregular, giving a continually varying expression to the countenance, often of the most ludicrous cast, and occasionally truly frightful. The head is sometimes thrown from side to side, or backwards and forwards, the mouth sudden- ly widely opened and again forcibly closed, the tongue rapidly thrust out of the mouth and retracted, and the eyelids are in con- tinued irregular motion. In violent cases, deglutition is much impeded, and, occasionally, for a short time entirely prevented, by the spasmodic action of the pharynx and oesophagus. Respi- ration also is often anxious and irregular; the voice is altered, and articulation is indistinct and stuttering. Almost every voluntary muscle, in short, is at times in a state of uncontroulable and dis- sociated action. The authority and commands of volition are disregarded, and the whole muscular system is thrown into a state of revolt, its actions being irregular, lawless, and destructive to the welfare of the general constitution. At first the expression of the countenance, in the intervals of the spasmodic motions, " is that of good humour and content- ment;" as the disease advances, however, the eyes lose their wonted lustre and intelligence, the face becomes pale, expressive of languor, and at last acquires a fatuous expression. Fleisch ob- serves, that in many instances patients affected with this disease evince a peculiar and apparently irresistible propensity to creep into holes, boxes, or closets, so narrow that it is sometimes diffi- cult to extricate them from their confined situations. * The temper and mind almost always become more or less af- fected in cases of a protracted character, more especially in very- young subjects. I have seen several cases in which complete and permanent weakness of intellect was the consequence of this disease. In some instances, the patient occasionally lapses into a kind of ecstacy or somnambulism. (Richter.) Slight paralysis sometimes occurs on one side of the body. Nearly three years ago, I attended a child affected with this disease, in which incom- plete hemiplegia and amaurosis in both eyes took place; and it is only within the last ten months that these paralytic affections have wholly gone off. Sometimes chorea assumes very extraordinary forms. In some cases the patient is seized with paroxysms of violent dancing, leap- ing, or stamping, accompanied with various antic contortions of the • Handbuch der Krankheiten der Kinder, &c. B. iv. p. 419. Richter 1. c. p. 734. Wichmann, Ideen zur Diagnostick. B. i. p. 137. 76 CHOREA. body; at others there is a rapid and forcible beating with the hands against some part of the body, particularly the knees; occasion- ally an irresistible propensity to leap upon chairs, tables, and to clamber up the walls of the room is manifested; and patients have been known to stand erect and turn round like a top on the toes. Fever is not a necessary attendant on chorea, but when the disease continues long, the muscles become wasted and flac- cid, and in cases of a very obstinate and protracted character, slow febrile irritation ensues. During sound sleep, when volition is in a state of temporary suspension, (with regard to its influence over the voluntary mus- cles) all the spasmodic motions which characterize this affection cease entirely. Indeed the efforts of volition during the waking state, often manifestly aggravate the involuntary action of the muscles. It would seem that the stimulus of the will is in some degree essential to the production of the irregular muscular mo- tions. Chorea is a paroxysmal affection. In most instances several distinct paroxysms occur daily at irregular periods, with little or no spasmodic action during the intervals. Sometimes, how- ever, violent exacerbations take place once, twice, or oftener daily, with more or less of choreal action throughout the inter- vals. Occasionally, though indeed very rarely, the recurrence of the paroxvsms is strictly periodical.* There is much diver- sity also in relation to the duration of the paroxysms. Sometimes they do not last more than ten or fifteen minutes ; more frequent- ly they continue for an hour or two, and occasionally they com- mence in the morning and do not cease until the patient sleeps at night Cases have occurred in Which the paroxysms continued with no obvious remissions for six or seven days.! The touch of iron is said sometimes to have a very extraordi- nary effect upon this disease. Wichmann,J Richter, and others, assert that the peculiar spasmodic actions of this affection either cease instantly7, or become greatly aggravated, if the patient pla- ces his hands on a piece of cold iron during the paroxysm ; and Stark says that he has often known the same effect produced by sprinkling cold water on the patient, or merely by touching him with a cold hand.§ Chorea appears to be very closely allied to the tarantismus of Apulia, an affection which has, indeed, by some, been regard- ed as a mere modification of this disease. || The berberie of India, also, would seem to be somewhat similar to chorea; and that • Mead. Opera. Tom.i. p. 32. \ Vogel, Stark, Richter. $ Ideen zur Diagnostick. Bd. i. p. 153. 4 Handbuch zur Kentniss u. Heilung innerer Krankheiten & Th. iii. p. 164. U Swartz Dissert, de Tarantismo, &c. Richter. CHOREA. 77 singular convulsive affection, described under the name of rapha- nia, which, from the latter part of the 16th to the middle of the ISth century, appeared in frequent and extensive epidemics in various parts of Germany and France, bore, in many respects, a close resemblance, in its chronic form, to the present disease. Whether those remarkable nervous and spasmodic affections, which have been known to result from religious enthusiasm or frenzy, are to be regarded as instances of chorea, is very doubt- ful. Many very extraordinary examples of this kind have been related. Wierus gives an account of a choreal affection which occurred among the nuns of the convent of St. Brigitta. They were seized with occasional paroxysms of screaming, dancing, leaping upon chairs and tables, and various other ludicrous con- tortions and motions of the body.* The same writer gives the history of a somewhat similar affection, which prevailed in 1564, among the nuns of the convent Nazareth, near Koelln ; the pa- roxysms of which were attended with very un-nun-like actions. " Infima corporis parte," says Wierus, " succusata ad eum mo- dum qui veneri solet ascribi, occulis interim clausis," and it was concluded that nothing but the malicious workings of Satan could produce such mortifying and uncongenial phenomena. Dr. Robertson, in his inaugural dissertation, states, that some years ago, an affection, resembling chorea, appeared among a re- ligious sect in Tennessee, in consequence of an enthusiastic and noisyr mode of worship, and was extensively propagated by the influence of imagination, or moral sympathy1.! Causes.—Chorea very rarely attacks persons beyond the 20th year of age;% and its occurrence before the 8th year is equally uncommon. Sydenham, Wichmann, and Thilenius, never met with this disease in children under ten years of age ; but its oc- currence even in early infancy is unquestionable. About three years ago I met with an instance of well-marked chorea in an infant less than nine months old. This case was seen also by Dr. Parrish. Hamilton, § Gregory, and other writers, assert that the disease attacks girls and boys indiscriminately. Judging from my own observations, I should infer that females are by • J. Wieri. Lib. de Prsestigiis. p. 378. \ The Rev. Mr. Hoge, in a letter to the Rev. Ashbel Green, of this city, dated September 10, 1801, speaking of the Methodist revivals, says: During worship the members of the meetings "drop down on every hand, shrieking, groaning, crying for mercy, convulsed,- professors praying, agonizing, fainting, falling down in distress for sinners, or in raptures for joy ! No spectacle can excite a strong- er sensation. 1 am told by the subjects of it, that a tremulous benumbing sen- sation seizes the extremities, particularly the fingers, which rapidly spreads through the system, the knees become feeble, the heart violently compressed, and the person drops to the ground." $ Dr. Powell knew an instance in which this disease occurred in a person in the 50th year of age. § On Purgatives, &c. 73 CHOREA. far more liable to it than males ; and this inference is supported by the observations of several eminent writers. Van Hoven makes the relative proportion of males and females affected with chorea, as about two to twentw The constitutional habit, most favourable to the occurrence of this disease, is that peculiar excitable state of the common senso- rium, constituting what is usually called the nervous tempera- ment It is said that a predisposition to chorea is sometimes hereditary ; but this depends probably simply on the hereditary transmission of the general constitutional temperament. Cullen, Wichmann, and Jahn* state, that this otherwise not very com- mon disease, has been known to occur with unusual frequency during particular years or seasons ; and it has been supposed, from this circumstance, that certain atmospheric constitutions may create a predisposition to its attacks. The following are the principal exciting causes of chorea: 1. Mental emotions, particularly terror, fear, disappointed love, and religious enthusiasm. 2. Gastro-intestinal irritation from worms, accumulation of fecal matter, and other irritating sub- stances lodged in the intestinal canal. Hamilton and other late writers consider this as by far the most common source of chorea. That the disease very frequently arises from causes of this kind admits of no doubt. Its origin from intestinal irritation is not, however, so common, I think, as is alleged by Dr. Hamilton. Certain I am, that in the majority of instances that have come under my notice, the exciting cause did not appear to be located in the alimentary canal, and little or no advantage was derived from the remedies usually found beneficial in cases unequivocally dependant upon causes of this kind. Cases of chorea have been reported, which ceased almost immediately on the expulsion of worms—particularly the tape-worm.! 3. Repelled chronic and acute cutaneous eruptions. Bisset, an English physician, relates a case which came on in consequence of the repulsion of itch. Wendt saw an instance produced by the imprudent drying up of tinea capitis; and other authors mention cases excited by repelled small-pox, and miliaria, (Richter.) 4. The suppression of habi- tual discharges, more especially of the menses. A case of chorea, in a girl about fourteen years of age, terminated fatally in less than three weeks. On dissection, the whole body of the uterus was found as hard as cartilage, and completely scirrhous. J 5. Unsatisfied or over-excited sexual propensities. Richter states that chorea has been frequently cured by marriage. 6. Vegetable • Klinik. der Chronish. Krankheit. Bd. i. p. 245. f Albers. Hufeland's Journal. Bd. i. p. 152.—Baldinger's Neues Marazin. Bd. ix. p. 189. * Richter's Specielle Therapie, Bd. vii. p. 749, quoted from Wiegand'g Maea- zin. fur Geburtsh. 1808. st. ii: ° B CHOREA, 79 and mineral poisons have also been known to produce this affec- tion. Stramonium, (Comment. Litter. Norimburg. An. 1774); mercury, (De Haen Ratio Medend. torn iii. p. 202) and lead, have excited paroxysms of chorea. Dentition, pregnancy, par- turition, and cold, arc also mentioned among the exciting causes of this affection; and it appears frequently to depend upon rapid corporeal evolution, or that peculiar change of constitutional habit which occurs at the age of puberty. The pathology of chorea derives little or no light from anato- mical examinations. There are good reasons, however, for be- lieving that it is essentially a cerebral affection. Its frequent oc- currence from mental excitement; the intellectual weakness which almost invariably results from its protracted continuance; the suspension of the convulsive motions during sound sleep; and its exclusive confinement to the voluntary muscles, point directly to the sensorium commune, as the immediate source of the irritation upon which the spasmodic actions of the disease depend. Un- questionably, however, the cerebral irritation is itself very fre- quently secondary, depending on a primary irritation, located in some remote part of the system, and frequently, perhaps, in the alimentary canal. In some cases which I have seen, it appeared to me that the irregular muscular motions were not so much the result of involuntary muscular actions, as of an irresistible voli- tion to perform these peculiar motions. In those instances of the disease, at least, that are characterized by leaping on tables, chairs, dancing, clambering up walls, and other similar actions, the propensity or will to do so appears to be irresistibly exerted; and we might, with some plausibility, ascribe the characteristic phenomena of the. disease to a morbid action of the faculty of volition, depending generally on a sympathetic, and sometimes an idiopathic irregular excitement of the brain. Richter thinks that the proximate cause of chorea is seated in the system of ganglionic nerves, and particularly in the abdomi- nal plexus. It is from this location of the primary irritation, he says, that the first manifestations of the disease generally occur in the feet; that gastric and uterine irritation so frequently con- stitute its exciting cause; and finally, that those remedies which act more especially upon the abdominal viscera, are usually the most beneficial. All these circumstances may, however, be ad- duced with equal plausibility in favour of the cerebral pathology of this affection. Prognosis.—Chorea very rarely proves fatal, but it cannot be said to be entirely free from danger, as some writers have assert- ed.* I have known one instance to terminate fatally, by the supervention of a slow and wasting irritative fever. Occasionally * YYichmann, Baumcs. 80 CHOREA. it is converted into epilepsy, and may prove fatal through the intervention of this affection.* The duration of chorea varies greatly. It may continue only a few days, or several weeks, months, or even years. The more violent and protracted the paroxysms are, and the more the mind has become affected by its attacks, the more difficult, in general, will it be to effect a cure. When the disease becomes very protracted in its course, it rarely fails to weaken the intellect; and it has occasionally terminated in mental derangement, particularly in melancholy. Richter ob- serves, that when chorea is complicated with other affections—as chronic pectoral diseases, scrofula, fluor albus, and in general with a debilitated and shattered state of the nervous system, the prognosis is unfavourable. When it arises from the irritation of worms, or other substances in the alimentary canal, it is generally readily cured by proper remediate measures. It appears to be less apt to yield, when it has been excited by terror or other violent emotions of the mind. Instances that occur about the thirteenth or fourteenth year of age in girls, generally continue until the sexual development is completely accomplished. Cases of this kind, if left to themselves, almost universally terminate spontaneously after the regular establishment of the catamenia. When the disease is arrested by remediate treatment before the changes of puberty have been accomplished, it is apt to return, and to manifest itself at intervals until the period of adolescence is passed. Treatment.—The principal indications in the treatment of chorea, are, 1. To remove or counteract the exciting cause ; 2. To invigorate the general system ; and 3. To break up the train of associated actions by which the paroxysms are repeated or continued. As the ordinary cases of chorea are almost always devoid of danger, and often terminate spontaneously, after having for a considerable time resisted remediate treatment, it is not in gene- ral advisable to resort at once to very energetic remedies or modes of treatment. This observation applies particularly to those ca- ses which depend on that peculiar constitutional metamorphosis which occurs during the period of puberty ; for we may calculate almost with certainty on the spontaneous termination of such cases as soon as this stage of corporeal development is fully com- pleted. ! Every one knows how strongly purgatives are recommended in the treatment of this affection, by Dr. Hamilton of Edinburg ; and this practice has since obtained pretty general approbation in • Weigand, Hamburg Magazin. Fuir die Geburtsh. st. 1808. T The importance of attending to these circumstances is particularly insisted on by Richter. Specielle Therapie, Bd. vii. p. 755. CHOREA. 81 England and in this country.* Where the bowels'are in a tor- pid state, with an accumulation of fecal matter, free and repeat- ed purgation is, without doubt, a highly important measure ; and in all cases, indeed, laxatives must be regarded as useful aux- iliaries. That the power of this class of remedies as a cura- tive measure, is, however, considerably overrated by Dr. Ham- ilton and others, I am much inclined to suspect. I have treat- ed twelve or thirteen cases according to the plan laid down by this highly respectable writer, but have not, in more than two instances, derived the advantage from it that I was led to expect from his statements. As a preparatory and auxiliary measure to tonic and other suitable remedies, moderate purging will rarely fail to do good ; but I question much whether any decisive impression can be made on this disease by purgatives alone, except in cases depending on intestinal irritation from fecal accumulations or other irritating substances lodged within the bowels. Where the signs of gastric impurities, or of a load- ed state of the bowels, are unequivocal, mercurial purgatives should be given daily, or every other day, until there is reason to believe that the offending matters are evacuated, and the bi- liary secretion improved.! After the bowels have been freely evacuated, tonics should be used in alternation with laxatives. The quinine, or any of the ordinary bitter infusions, will answer for this purpose.—Whytt says that he has known the superven- tion of diarrhoea to put a permanent stop to chorea ; and the ve- ry remarkable case, reported by Dr. Watt, after active purga- tives, and a great variety of other remediate means, had been ineffectually employed, terminated at last, on the occurrence of profuse spontaneous diarrhoea. (Med. Chir. Transact, vol. v.) In some instances, coming on from retained or suppressed menstrual evacuation, the general diathesis is manifestly phlo- gistic. Here, along with aloetic purges, it will be proper to bleed, and to put the patient on a mild vegetable diet, with an ' occasional dose of Dover's powder in the evening. About three years ago I attended a young lady, who was seized with chorea, * The employment of active purgatives for the cure of this disease, was strong- ly recommended long before the time of Dr. Hamilton. Stark speaks highly of the good effects of very active purgation in this disease, (Acten d. Kurfuirstl. Academie der Wissenshaften. 1776. p. 193.) Unzer also employed drastic purges with success in chorea. Sydenham treated this disease by purgatives and bleed- ing on alternate days, with an opiate at night. fSckedula Monitoria de Novas Fe- bris Ingressu, an. 1655. J | Hamilton recommends full doses of calomel and jalap. I have generally preferred using the following pills : IJ. Extract, colocynth. comp. gi. Calomel ^ss. Tart, antimonii gr. i. M. Divide into 20 pills. S. Take one, two, or three, according to the age of the patient, every other day. Vol. II. H 82 CHOREA. apparently in consequence of suppressed catamenia. Her pulse was small, sharp, and tense ; the skin generally dry and warm, and the bowels constipated. I directed her to be bled to the extent of twelve ounces, and to take one of the pills, mentioned below,* every night, and a small dose of sulphate of magnesia every fourth day. In the course of two weeks she was bled four times, and the disease disappeared during the third week. The menses did not reappear until five weeks afterwards. When the disease attacks persons of a highly excitable state of the nervous system—or of a strongly marked nervous tem- perament, peculiar benefit may often be derived from the cau- tious exhibition of antispasmodic and narcotic remedies. Valeri- an, assafcetida in union with quinine,} musk, hyoscyamus, cam- phor, and opium, under judicious management, will sometimes do much good in cases of this kind. In cases depending on suppressed catamenial discharge, atten- tion must, in the first place, be paid to the alimentary canal. Laxatives, a mild and simple diet, with a few grains of blue pill at night, must be employed until the bowels and liver are brought to a healthy condition. When this is effected, recourse may be had to remedies more directly calculated to promote the flow of the menses—particularly to turpentine, warm pediluvium, can- tharides, blisters over the sacrum ; small doses of aloes!—and, where the general habit and pulse are languid, savin, and black hellebore. Richter says that in one instance of this kind, he gave twelve grains of borax three times daily, with speedy and complete success. It should be recollected, however, that re- tained or suppressed menstruation may accompany chorea, without having any agency in the production of this affection— the catamenial disorder being itself only a concomitant effect of some previous general morbid condition of the system. It will, therefore, be more accordant with correct principles of practice, to endeavour rather to remove that general morbid condition upon which both the menstrual irregularity and the convulsive disorder depend, than to make vain, and too often injurious, ef- * R. Massz hydrarg. gi. G. aloes, gss. Tart, antimonii gr. ii. M. Divide into 20 pills. | Within the present year I have seen very decisive advantage obtained from the use of the following pill, taken every four hours, after proper evacuations had been premised: R. Sulphat. quinx ^i. G. assafcetid. ^ii. M. Divide into 20 pills. + The compound tincture of aloes, in doses of from 15 to 20 drops three times daily, is one of the best aloetic preparations for this purpose. Small doses of hiera-picra, also, frequently answer peculiarly well, where there is considerable weakness of the stomach present. CHOREA. 83 forts to restore the menses with active emmenagogue remedies. When, therefore, relaxation, debility, or a general leucophlegma- tic state is present, tonics, particularly iron, a regulated diet, ventilation, and exercise by gestation, should be chiefly depended on : and, on the contrary, where the diathesis is phlogistic, the body plethoric, and the skin dry and warm, recourse must be had to depletion, purgatives, a vegetable or farinaceous diet, leech- ing about the pelvis, &c. When chorea arises in consequence of suppressed perspiration from cold, or the retrocession of cutaneous eruptions, antimonials, Dover's powder, camphor, warm aromatic ptisans,* the warm bath, blistering, rubefacient frictions, the internal use of sulphur, issues or setons, and a warm and equable temperature, are ap- propriate remediate measures. It is scarcely necessary to say, that where verminous irritation is manifestly present, anthelmin- tics should be used. In instances that are excited by mental emotions, musk and opium are said to be particularly calculated to do good. Considerable advantage may sometimes be obtained in the treatment of chorea, whatever be its exciting cause, from exter- nal applications—such as dry frictions with flannel, or blistering, or rubefacients, along the course of the spine ; stimulating baths ; the cold shower-bath, and sea-bathing. The cold shower-bath, after a proper course of evacuants, and in connexion with the in- ternal use of tonics, will generally contribute materially to the re-establishment of health. If our endeavours to remove the disease, by a course of treat- ment founded on the indications furnished by the character of the exciting cause and the general state of the system, prove abortive, we may then resort to what the Germans, with strict propriety, call the empirical remedies, recommended in this affection. Among these, the flowers of zinc have perhaps been most frequently employed, and favourably mentioned, as a remedy in chorea. Burserius,! Hand, Richter,J Stark, and Alexander,§ relate instances of the successful employment of this article in chorea, and Dr. Beddingfield asserts that thirteen out of fourteen instances of this disease, in which he gave this remedy, yielded permanently to its influence. || In my own practice I have never obtained any decided benefit from this article. The sulphate of zinc, however, removed the disease speedily and permanently in * Infusions of elder blossoms, eupatorium perforatum, catnep, sage, marjoram, balm, &c. will answer well for this purpose. | | 183S ) .391-4 Sum for England. 3274< Jl220^ J l 0.372-5 156 MENTAL DERANGEMENT. drawn up by Dr. Casper from official reports, it appears as a general result, that in France 0.44T9T of maniacal patients are cured; whilst in England the proportion is not so great, being only 0.37| of the whole number. In looking over the foregoing table, we observe that the. an- nual number of cures effected in the Hospital Charenton has been pretty uniform during a period of fourteen years. At Bethlem, on the contrary, we perceive that the difference in the propor- tion of cures effected, in the forty-six years from 1748 to 1794, and the fifteen years from 1800 to 1815, is eleven per cent, in favour of the latter period—a strong evidence, says Dr. Casper, that in England the treatment of mental diseases, has, within the last twenty-five years, received great improvements. From the following summary of the cures effected by Esquirol in the Salpetriere, we perceive that the chances of recovery de- creased very rapidly after the second year; and that after the fourth year, not more than one out of about 225 were cured. There were treated in the years 1804 1805 1806 1807 1808 1809;1810 1811 1812 181S Total number. 209 212 206 204 188 209| 190 163 208 216 total Of which were cured 1 during the 1st year, 64 73 78 60 64 48 48 44 75 50 604 2d, 47 54 49 55 57 64 51 30 41 49 497 3d, 7 4 10 11 4 9 7 8 11 71 4th, 4 2 3 1 2 4 1 3 20 5th, 3 2 1 1 1 3 11 6th, 2 1 1 2 3 9 7th, 1 1 2 8th, 1 1 9th, 1 1 10th, 11th, 1 1 1 129 137 143 129 129 129, 110 85 127 99 1217 Veitch, in his report in 1816, states, that of twenty-eight cases of recent insanity, admitted into his private institution, he cured eighteen, but of one hundred and twenty-five inveterate cases, he succeeded only in five instances. In the Retreat at York, England, out of sixty-six patients cured of insanity, twenty-seven were effected during the first year, thirteen in the second, three in the third, one in the fourth, five in the fifth, three in the seventh, two in the ninth, one in the thirteenth, and one in the fifteenth, (Casper.) Pinel observes, that after three years' inef- fectual treatment, the chance of cure in insanity will be about as one to thirty. MENTAL DERANGEMENT. 157 Unfortunately, relapses are very common in mental diseases. In the Hospital Salpetriere, relapses, according to the observa- tions of Esquirol, have occurred in the proportion of about one in ten.* This agrees pretty well with the facts stated by other writers, on this point. Relapses are most apt to occur during the spring and summer months, and particularly at those seasons in which the disease had made its attack in the first instance. (Es- quirol.) Dr. Hallaran observes, that when a violent fit of mania subsides rapidly, it is particularly apt to return. If the patient, soon after recovery from an attack of mania, becomes corpulent, there is not, in general, much probability of a relapse.t According to the observations of Esquirol and Georget, the mortality is greatest during the autumn and winter. Of seven hundred and ninety insane females that died during ten years, (1804—14) in the Hospital Salpetriere, one hundred and seven- ty-five died in the months of March, April, and May ; one hun- dred and seventy-four in June, July, and August; in September, October, and November, the number of deaths amounted to two hundred and thirty-four, and in the three remaining winter months, to two hundred and seventy. With regard to age, it appears from the same observations, that the greatest number of deaths take place between the ages of forty and fifty in males, and between thirty and forty in females. Maniacal patients appear to be much less obnoxious to conta- gious and epidemic diseases than individuals who are of a sound mind. This fact has been particularly noticed by Rush, Dubuis- son, Mead, Willis, Reil, and Cox. Mania sometimes terminates spontaneously, in consequence, apparently, of some critical evacuation. Dubuisson saw it cured by the supervention of dysentery; Esquirol by epistaxis; Pinel and Hallaran through spontaneous salivation; and instances are mentioned, of the subsidence of mental derangement soon after the occurrence of profuse discharges of urine or tears, and, ac- cording to Buffon, of the semen. In general, the difficulty of curing monomania and melancholy, is greater than of the other forms of mental derangement. Has- lam observes, that when melancholy alternates with raving mad- ness, the chance of a cure is extremely small; and when mono- mania or melancholy is converted into madness, almost every hope of a fortunate issue may be abandoned. Casper states, that Esquirol in his lectures observes, that when maniacs are able to recollect recent occurrences, with an oblivion of events long passed, the prognosis is much better than when they have a recollection of remote occurrences, without being * Casper, 1. cit. p. 405. f Haslam, 1. cit. p. 79. 158 MENTAL DERANGEMENT. able to remember what has recently transpired about them. Ma- nia, connected with paralysis or epilepsy, may be regarded as absolutely hopeless. In general, acute and furious mania is much more under the control of remediate management, than low, tor- pid, and fatuous insanity. Mental derangement, from physical causes, generally yields more readily and permanently than when it arises from moral causes. A recovery of the general health of the system, without a corresponding melioration of the mental disease, is said to be an unfavourable sign. Puerperal mania appears to be more frequently treated with success than any other form of mental derangement. Post mortem phenomena.—Notwithstanding the zeal and in- dustry with which post mortem examinations have been pursued in relation to mental diseases, we have as yet derived but very little information from such researches concerning the nature and seat of insanity. Esquirol assured Dr. Casper that he had dissect- ed the brains of more than twelve hundred subjects who had died of mania, and that he did not in a single instance discover any morbid appearances which are not found also in subjects who had never suffered any mental diseases whatever. In almost every instance, however, he found the two hemispheres of the cranium of unequal size—and this, he says, " is the most constant pheno- mena, and perhaps the most worthy of attention."* Haslam, Reil, Esquirol, and others, state that in the majority of cases, the brain is found preternaturally soft. Esquirol found the brain very soft in twenty-nine instances out of forty-four sub- jects ; in fifteen it was of a firm consistence. According to Georget, however, softening of the brain is much more frequent than would appear from Esquirol's statement. Ossification of the dura mater is, according to the observations of Esquirol, no un- common occurrence in maniacal subjects. He observes, more- over, that he invariably found a very firm adhesion of the lining membrane of the lateral ventricles to the adjoining substance of the brain. In several instances, Georget found the cerebellum to- tally disorganized. (Casper.) Among the abnormal circumstances discovered in the thorax and abdomen, Esquirol mentions one in relation to the position of the transverse colon, .which is of a very remarkable character. This portion of the intestinal tube, he says, is sometimes found sunk down so low as to pass into the pelvis, and often placed in a perpendicular instead of a transverse position. The phenomenon occurs most commonly in persons who labour under melancholia. It must be observed, however, that Mr. Lawrence asserts that instead of having found this position of the colon in those who had laboured under insanity, he has seen it only in such as had • Diet, des Sciences Med. Art. Idiotism. MENTAL DERANGEMENT. 159 never been affected by any mental diseases whatever. We per- ceive, from these contradictory observations, how little reliance is, in'general, to be placed on the sweeping inferences which are so' frequently drawn from post mortem appearances, in relation to the proximate cause and essential location of diseases. The diseases of the mind maybe divided into four classes: viz. mania, monomania, dementia, and idiotism. I. Mania. General mental derangement is characterized by a rapid suc- cession of incoherent ideas, and violent excitement of the passions, expressed by great agitation, loud vociferation, singing, menaces, and fury. Mania is generally preceded by a marked change in the habits, tastes, attachments, and passions of the patient. He is usually animated, his sensibilities are keen, his ideas rapid, his temper irritable, jealous, and wayward. He is eccentric in his conversa- tion and conduct; often betrays an unusually vicious disposition; he sleeps but little; is harassed by frightful dreams; forms various and extravagant plans for the increase of his fortune, or the good of the public; enters into ruinous speculations, or squanders away his means in childish or extravagant amusements, or in the purchase of unnecessary or useless articles of furniture, clothing, &c. Costiveness, a craving appetite, vertigo, cephalalgia, a sense of throbbing and tension in the head, and a dull and wild expres- sion of the eyes, are among the common premonitory symptoms of mania. When the disease is once completely developed, the expression of the countenance is wild, and often ferocious ; the eyes are prominent, sparkling, and in constant motion ; the patient sings, whistles, vociferates, halloos, walks to and fro with rapidity, "or stands still with his hands and eyes often raised towards the heavens ;" he does not sleep for many nights, sometimes not for weeks ; he often manifests great muscular power ; the skin is dry, cool, and occasionally covered with profuse perspiration; the sensorial organs are extremely excitable; the appetite is some- times craving, at others wholly absent; the bowels constipated, and the urine small in quantity and high-coloured. The pulse is variable—sometimes full and strong, at> others small, irregular, and tense, or slow and intermitting, and occasionally morbidly natural. (Rush.) Perhaps the most constant and remarkable among the physical phenomena of mania, is continued watchful- ness, and a very peculiar disagreeable odour, which exhales from the patient's body and excretions, and impregnates his clothes and bedding. (Esquirol.)* Some patients are tortured • This peculiar smell issuing from the bodies of maniacal patients, is also par- ticularly noticed by Wagnor, Simes, and Reil.—Rett, Fieberlehre, B. iv. p. 348, 160 MENTAL DERANGEMENT. with a constant severe internal heat; and the majority experience pain in the head, or in some part or organ in the abdomen or thorax. In the violent grades of mania, the mind forms erroneous per- ceptions of the impressions of external objects on the senses, or the senses convey erroneous impressions to the mind. In this case the patient does not recognise the objects and persons around him; mistakes " friends for strangers, and common visiters for his relations," loses the consciousness of his individuality, and " is ignorant of the place he occupies, of his rank and condition in society, and of the lapse of time." The imagination is some- times so powerfully excited, that its representations prevail over those of the senses. The patient hears voices, holds conversations with persons who he imagines are present, and in some cases these voices pursue and harass him wherever he goes, by day and by night, in public and in private. (Esquirol.) Sometimes the em- pire of volition seems to be entirely suspended, and the patient is no longer master of his own determinations. An irresistible impulse leads him to injure himself, or to inflict injury on others, to tear the clothes from his body, run out naked into the streets, leap out of windows, and to commit various other acts of fury. The sense of modesty and delicacy is generally wholly obliterat- ed, and " people of the finest previous feelings will deliver them- selves up to the most indecent or culpable actions, without the consciousness of impropriety." Mania may be continued, intermittent, or remittent. A single paroxysm may continue from a few days to several months, be- fore it terminates in a remission, intermission, or in death. Some patients experience paroxysms of maniacal excitement at regular intervals of a day, a week, or months—the intervals being pass- ed in a state of quiet and inoffensive insanity.* Mania may also assume a chronic form, with little or no distinct exacerbations. This constitutes what Dr. Rush has called manalgia. It is usually characterized by "taciturnity, downcast looks, a total neglect of dress and person, long nails and beard, dishevelled or matted hair, indifference to all surrounding objects, and insensibility to heat and cold." II. Monomania. Monomania consists in a state of partial insanity—the patient being insane upon some one subject only, with a full and regular use of his intellectual faculties " upon all, or nearly all other * These remissions, says Esquirol, sometimes offer very remarkable anomalies. A patient will, for instance, remain in a state of profound melancholy for three months, the three following months will be passed in a state of high maniacal excitement, and to this three months of complete fatuity will succeed. MENTAL DERANGEMENT. 161 subjects." This class of mental diseases comprehends many va- rieties, as nostalgia, fanaticism, hypochondriasis, melancholia, misanthropy, satyriasis, &c. This is by far the most common form of mental derangement, and is always entirely free from delirium or paroxysmal raving. In that variety which is usually denominated hypochondriasis, the hallucination relates to the patient's own body, or to the cir- cumstances which he conceives have an especial sinister influence upon his own system, fortune, or happiness. The suggestions of his morbid imagination are taken for realities. He believes him- self afflicted with certain incurable and fatal diseases, "particu- larly with consumption, cancer, stone, and above all, with impo- tencyand the venereal disease." He fancies that some poison has been maliciously introduced into his system ;* or that he has a living animal, or some other very injurious substance in his sto- mach or bowels. Some patients believe themselves transformed into inferior animals, as dogs, cats, wo!ves,t oxen, J cocks,§ &c. Others imagine themselves converted into trees, plants, pots, clocks, candles, glass, butter, straw, wax, &c. The following lines, by Pope, give a sufficient enumeration of these singular hallucinations. Unnumbered throngs on every side are seen, Of bodies changed by various forms of spleen. Here living tea-pots stand, one arm held out, One bent; the handle this, and that the spout; A pipkin there, like Homer's tripod walks, Here sighs a jar, and there a goose-pie talks. Men prove with child, as powerful fancy works, And maids, turned bottles, cry aloud for corks. Tissot mentions an instance, in which the patient believed him- self to be a lump of butter, and would not suffer any fire near him, lest he should melt. An eminent painter imagined himself made of wax, and avoided all contact with hard substances. (Tul- pius.) Zacutus Lusitanus mentions a person who believed that • Some years ago there was a foreigner—a barber, in I.ancaster, who continued to occupy himself regularly and cheerfully with his customers, and to converse rationally upon all subjects except his own fortune, and the universal conspira- tion among his neighbours to poison him. He cooked his own victuals, and re- gularly every morning went about a mile to the river Conostoga to supply him- self with water, which he asserted could contain no poison, since the fish con- tinued to live in it. f Qui lyncanthropia detinentur, noctu, domo egressi, lupos in cunctis imitatur, et donee dies illucessat, circa defunctorum monumenta plerumque vaeantur.— P. Aegtneta. Dere Med. lib. iii. cap. 16. * This was the case with the daughter of the king of the Argives, whom Vir- gil mentions.—Prohdes implerunt falsis mugibus agros. Eclog. vi. The madness ot Nebuchadnezzar appears also to have been of this kind. § Alter gallos cantare audiens, ut hi alarum ante cantum, sic ille brachiorum piiusu latera quatiens, animantium sonum imitatus est—Galen, de locis affectis. 1. m. c. vi. as quoted in Rett's Fieberlehre. Vol. II. 21 162 MENTAL DERANGEMENT. his posteriors were composed of glass, and would on no account sit on any thing but the softest pillows. Some hypochondriacs have thought themselves dead ; others imagined that their souls formerly resided in some inferior animal, or in some fellow- creature ; in short, almost every imaginable hallucination of this kind has been known to occur in this variety of mental disease. In many instances of monomania, the hallucination is not of a distressing or sombre character. Some patients, though perfectly sane upon every other subject, have an unalterable belief, that they are destined to make some great discovery, as the perpetual motion, the philosopher's stone, the squaring of the circle, &c. Others imagine themselves the legal heirs of crowns, princely fortunes, and hereditary honours. Professor Titel of Jena, con- tinued to perform his professional duties for some time, although labouring under the fixed hallucination of believing himself to,be Emperor of Rome. * I knew a person who for more than twenty years was firmly persuaded that he was the President of the United States; and yet this individual would converse and think rationally upon all the ordinary concerns of life. Some believe themselves invested with a special commission from Heaven to perform certain pious acts, or to commit some deed, often cruel and horrid, under the persuasion that it is the command of Pro- vidence, and necessary for the general welfare of the world, t Others fancy they converse with spirits, angels, and messengers from heaven. Tasso, in the latter years of his life, obstinately maintained, that a spirit regularly visited, and held conversations with him.| Was not the celebrated Swedenborg a monomaniac?§ Some monomaniacs have believed themselves to be the Messiah. Dr. Rush informs us that he has seen two instances of this kind. "We see this form of mania," says Dr. Rush, "in the enthusi- astic votaries of all pursuits and arts of men. The alchymists, the searchers after perpetual motion, the metaphysicians, the po- liticians, the knight-errants, and the travellers, have all in their turns furnished cases of this form of derangement. "|| * Reil, Fieberlehre, b. iv. p. 39. f Pinel mentions the case of a monk, who imagined that the holy virgin had commanded him to murder a person whom he considered an unbeliever. * Hoole's Life of Tasso, p. 48. § Of this kind of hallucination was that of the man mentioned by Horace :— ------Fuit haud ignobilis Argis Qui se credebat miros audire tragcedos, In vacuo, lactus sessor, plausorque theatro. Cetera qui vitse servaret munia recto More; &c. || Boileau says :— Tous les hommes sont fous; et malgre' tous leur soins, Ne different entre eux, que du plus au du moins. Sat. iv. p. 27. MENTAL DERANGEMENT. 163 III. Dementia. This variety of mental disorder " consists not in false percep- tion, like the worst grades of madness, but of an association of unrelated perceptions, or ideas, from the inability of the mind to perform the operations of judgment and reason The judgments ^generally excited by sensible objects; but ideas, collected to- gether without order, frequently constitute a paroxysm of the disease. It is always accompanied with great volubility of speech, or with bodily gestures, performed with a kind of convulsive rapidity We rarely meet with this disease in hospitals ; but there is scarcely a city, a village, or a country place, that does not furnish one or more instances of it Persons who are afflicted with it are good-tempered and quarrelsome, malicious and kind, generous and miserly, all in the course of the same day.* Dementia is therefore directly opposed in its phenomena and character to monomania; for in this latter variety of insanity, the mind is fixed upon some particular subject, and upon which alone it hallucinates ; whilst in dementia, there is no leading idea, and "the mind," as Dr. Rush expresses it, "may be considered as floating in a balloon, and at the mercy of every object and thought that acts upon it." IV. Idiotism. This variety consists in a defective development, or impair- ment, of all the intellectual faculties, amounting sometimes to a total absence of mind; and, in some instances, even to a destitu- tion of the instinct which leads to the gratification of the animal appetites. Idiotism is frequently congenital. It may however be produced by various causes, as apoplexy, epilepsy, chorea, blows on the head, onanism, &c. It is the most hopeless form of mental disease ; and, when -congenital, or produced by the spasmodic affections just mentioned, it may be regarded as absolutely irre- mediable. Treatment of Mental Diseases. In France, England, and the United States, there is, in general, but little medicine employed in the treatment of mental diseases. In the year 1819, the expenses incurred for medicines at the Glasgow Lunatic Asylum was but eighteen pounds sterling, whilst the sum expended for food and beer amounted to £ 1225. At the Exeter Hospital £1162 was expended for food, and only • Rush, On the Diseases of the Mind, chap. ix. 164 MENTAL DERANGEMENT. j£33 for medicines and instruments during the year 1819 ; and in the Institution at Nottingham, the necessaries of life cost £ 920, whilst the expense for medicine was only seven pounds, during the same period. Fifty years ago, the amount of expenses for medicines for the same number of patients, during an equal period, would have been much greater, although the proportion of cures effected was then considerably smaller than at present. Even at the present day, much more medicine is employed, according to Dr. Casper, for the cure of insanity, in the German hospitals, than in those of England and France, although the success of the former appears to be considerably less than that obtained in the latter.* The truth is, medicines, properly so called, are by no means the most useful agents in the treatment of a majority of mental diseases. Much more is in general to be effected by appropriate moral influences—by kind and humane treatment, and comfortable se- clusion. The physician who looks for particular success in the management of lunatics, must enter into their feelings—take an interest in their real or imagined pleasures and pains, sooth and admonish them in a tone of kindness and affection, and appear among them, not as a stern ruler, but as a sympathizing friend and protector. It is by a moral treatment of this kind, more than by the materia medica, that the most good may in general he done in the management of patients labouring under mental dis- eases. The cruel and coercive measures that were formerly so generally adopted in the treatment of insane persons, are as inju- rious as they are repugnant to the best feelings of the heart. Hu- manity and reason combine against the employment of such re- mediate measures ; and the triumph of reason and good feeling over cruelty and error, is no where more delightfully illustrated than in the improvement that has of late years been effected in this respect. Instead of subduing the miserable maniac with im- plements of terror and torture, or keeping him in trembling sub- jection by threatening looks and menaces, or endeavouring to put reason right by drugs, chains, cells, and hand-cuffs, physicians now know that a kindlier mode of management will often call back the unsettled and wandering intellect, when a contrary course would only fix it the more firmly in its wild and distracted mood. One of the first measures in the treatment of mania, should be to remove the patient from his friends and home, and to place him in some quiet and secluded situation. Dr. Rush strongly in- sists upon the importance of separation and proper seclusion ; and • In Berlin, the proportion of cures effected has been estimated at about 0.28; at Vienna about 0.27—whereas in France it averages about 0.44. Casner. loc. cit. p. 413. ' MENTAL DERANGEMENT. 165 the most eminent of the English, German, and French writers, advise the adoption of this measure. " Confined to a regular life and discipline," says Esquirol, "the patient is naturally led to reflect on this change in his situation; while the necessity of Irv- ine among and submitting to the control of strangers "to him a powerful stimulus to regain his lost freedom and reason. When thus confined, the medical attendant must in the first place endea- vour to obtain the confidence and good will of the patient. Kind- ness, consolation, affability, and in some cases a moderate yield- ing to the hallucination, will in general soon acquire the patient s confidence. Having gained this point, he must " sooth the irri- table, repress the insolent, cheer the desponding, calm the excit- ed, check the forward, encourage the timid, resist the importu- nate and petulant,but carefully attend to all reasonable requests." (Knight.) Let it be observed, however, that in recommending separation and confinement, it is not intended to object to regular exercise in the open air, and the enjoyment of the society of suitable persons during the patient's intervals of comparative calmness. When- ever the weather is favourable, and the patient's condition will admit of it, free air and ample exercise should be allowed. The mutual association of patients similarly affected, and particularly during convalescence, has also a favourable tendency. "Nothing," says Georget, "contributes more to the recovery than the mutual association of convalescents ;" and for this purpose, it is particu- larly important that the institutions in which insane patients are placed, should have extensive gardens, well furnished with trees and flower-beds, and instruments of bodily amusements, such as swings, &c. Idleness in monomaniac patients should be discouraged. Va- rious amusing exercises—" as playing at quoits, the chase, shoot- ing, and even chess, checkers, cards, and push-pin, should be pre- ferred to idleness." (Rush.) Indeed, in cases of a moderate grade of maniacal excitement, travelling will sometimes do much good. Esquirol states, that he has always found the disease conspicuously moderated, after a long journey, particularly if it has been attend- ed with difficulties and privations, and performed through a strange country. It is on this account, perhaps, that foreigners are more apt to be cured in England, than natives, (Wills;) and that stran- gers sent to Paris are more readily restored to reason than the inhabitants of that city. I have stated above, that in order to obtain the patient's confi- dence, it may be proper, occasionally, to give way in some degree to his hallucinations. This, however, must be done with caution. In general, it is improper to encourage, in any degree, the particu- lar error, or false ideas under which the patient labours, and this is more especially to be observed with monomaniac patients. 166 MENTAL DERANGEMKNT. On the other hand, however, peremptory and absolute contradic- tion, is perhaps still more unfavourable than indulgence ; for it seldom fails to excite the anger and contempt of the unfortunate sufferer against the person who thus vehemently opposes the cur- rent of his hallucinated notions. "In the furious state, insane patients," says Dr. Rush, ''should never be contradicted,however absurd their opinions and assertions may be, nor should we deny their requests by our answers, when it is improper to grant them. In the second grade of the disease, we should divert them from the subjects upon which they are deranged, and introduce, as it were accidentally, subjects of another and of an agreeable nature. When theyT are upon the recovery, we may oppose their opinions and incoherent tales, by reasoning, contradiction, and even ridi- cule." . Where the insanity turns upon some prominent idea, or pas- sion, much benefit may sometimes be obtained by dexterously exciting- some counteracting emotion, or sentiment. Esquirol states, that a melancholic man, who was in a state of great despon- dency, had his intellectual energies restored, by having been told that he had a law-suit on hand. An insane soldier was informed that the campaign was about to open. He immediately requested permission to join the army; it was granted, and he arrived at his regiment perfectly sane. "The excitement of new turns of thought," says Georget," the rousing of inert faculties, form a third principle of moral treatment. For instance, endeavour to con- vince a king that he is without power, with the hope of reflecting that he may have been in error. Take the patient to the situation whence the subject of his hallucination proceeds; as, for instance, fancied voices, enemies, &c. and assure him of their non-reality. Awaken the passions, by reproaching them with indifference to parents, &c.; relate to them their past conduct, by telling them of their designs, as suicide, destruction of children, hatred to husbands, &c.; and by this management cures may sometimes be effected. In some instances it will be proper to substitute a real for an imaginary grievance." If a melancholic is harassed by en- nui, withdraw from him his usual sources of amusement, so as to inflict on him real privations. The real ennui which he will then suffer, will often prove a powerful means of diverting his mind from its hallucinations. If a patient, says Esquirol, imagine him- self abandoned by his friends, we may sometimes promote his recovery by depriving him of every testimony of their affection, and thus awakening him to a sense of his real loss. Dr. Rush relates some remarkable instances, in which sudden terror, excited by actual danger, had the effect of curing insanity. The attempt to laugh or ridicule hypochondriacs out of their erroneous conceptions, is, in general, as injurious as it is cruel. Upon this point Dr. Reid makes the following sensible and hu- MENTAL DERANGEMENT. 167 mane observations. "No one was ever laughed or scolded out of hypochondriasis. It is scarcely likely that we should elevate a person's spirit by insulting his understanding. The malady ot the nerves is, in general, of too obstinate a nature to yield to a sarcasm or a sneer. It would scarcely be more preposterous to think of dissipating a dropsy of the chest, than a distemper of the mind, by the force of ridicule or rebuke. The hypochondriac may feel, indeed, the edge of satire as keenly as he would that of a sword; but although its point should penetrate his bosom, it would not be likely to let out from it any portion of that nox- ious matter by which it is so painfully oppressed. By indirect and imperceptible means, the attention may, in many instances, be gently and insensibly enticed, but seldom can we safely attempt to force it from any habitual topic of painful contemplation."* During the exacerbations or periods of excitement, it sometimes becomes necessary to employ coercive measures. The only means employed for this purpose, in the hospitals of this country, and I believe also in those of Paris, is the strait jacket and Rush's tranquillizer. Haslam condemns the former mode of restraining patients, in strong terms. It is certainly an offensive and oppres- sive mode of coercion in a state of furious mania. Haslam em- ploys, instead of it, a belt from eight to ten inches wide. This is passed round the lower part of the body, above the arch of the pubis, and fastened on the back by strong buckles. On each side, leather bags are fastened. Into these the hands of the patient are thrust, and secured there by proper bandages. By this contrivance the respiration is not impeded, as is always the case, to a greater or less degree, with the strait waistcoat; nor is the perspiration suffered to become offensive and injurious by being absorbed and retained in the waistcoat. Patients too, may walk about with this belt without much inconvenience, and they are said to endure it with much more patience than the jacket. In Dubuisson's private institution, an arm-chair, resembling Dr. Rush's tranquillizer, is used as a mode of coercion. It consists of an arm-chair with a high back, and foot-board. The arms, legs, feet, and body, are fastened to this chair by strong and broad straps furnished with buckles. A simple and very excellent means for moderating the violence of a paroxysm of mania, is the total exclusion of light from the patient. This is daily practised in the Salpetriere. When a ma- niac begins to rave violently, a piece of thick cloth is quickly thrown over his head, and fastened over the eyes. This, it is said, generally immediately moderates the patient's fury, and he may then easily be conducted into his apartment and properly • Essays on Hypochondriacal and other Nervous Affections. By John Reid, 168 MENTAL DERANGEMENT. secured. Esquirol particularly lays great stress on the soothing influence of darkness on maniacs ; and Dr. Rush enjoins it as a measure of much importance during the first stage of the disease. Confinement, darkness, solitude, low diet, and cold affusipns, will rarely fail to subdue the most turbulent and furious maniacs. Medicinal Treatment.—Blood letting was formerly much more commonly resorted to in maniacal diseases, than is now done. Dr. Rush was a strenuous advocate for the employment of this evacuation in general mental derangement; and the old established traitement de V Hotel Dieu, says Pinel, consisted almost entirely of repeated blood-lettings. In the Parisian and English institutions, we are told that venesection is now but rarely employed in mental diseases. There can be no doubt, how- ever, that the abstraction of blood will often contribute considera- bly to the reduction and removal of acute mania ; and we may safely, and advantageously, resort to this measure in all instances in which the pulse is full and active, or tense, corded, and quick, in connexion with "great wakefulness, redness of the eyes, a ferocious countenance, and a noisy and refractory behaviour." When the disease assumes the grade of phrenitis, with raving delirium, a hard and bounding pulse, throbbing of the carotids, flushed face, red eyes, prompt and free venesection cannot with propriety be dispensed with. Georget* says, that in cases that occur about the pubertal period, accompanied, as they usually are, with general plethora, repeated small bleedings are particularly useful; and the same observation applies to cases that occur at the turn of life in females. When mental derangement is attend- ed with suppression of an habitual sanguineous evacuation, cup- ping or leeching near the parts from which such discharges occur- red, will sometimes contribute considerably to the removal of the mental malady.t In monomania, or generally in all those varieties of mental alienation that are unattended with paroxysms of high cerebral excitement, bleeding can do no good, and may prove permanently injurious. Purgatives arc often very useful auxiliaries in the remediate management of lunatics. Where there is reason to believe that the bowels are in a loaded condition, or irritated by vitiated se- cretions, that is, where the tongue is furred, with pain on pres- sure in the region of the liver, a hard abdomen, and constipation, active purgation is particularly proper. Dr. Prichard observes, that in cases of this kind (enteric mania,) the rectified oil of turpentine, in union with castor oil, is decidedly the most valuable purgative. Esquirol prefers mercurial purgatives, with the view of exciting the biliary secretion ; and in instances where tension • Da la Folie, p. 293. f D. Ratier. Formulaire Pratique des Hopitaux Civiles de Paris, Sic. Stc. MENTAL DERANGEMENT. 169 and tenderness exist in the right hypochondnum there can be lit- tle doubt of their superiority. "There are cases," says Dr. Rush, «in which purges should be given daily, so as to excite an artifi- cial Irrhcia," and calomel and jalap should be preferred for this nurnose Where there is reason to suspect the existence of ver- minous irritation, anthelmintics should be given, in conjunction or alternation with active purgatives. Infusion of the root of spigelia, followed by a full dose of turpentine and castor oil, generally answers this purpose better than any other articles of Emetics may occasionally be employed with manifest advan- tage, in the milder forms of mental derangement—more espe- cially in melancholia, and in recent cases of hypochondriasis. They are improper, however, where there is much cerebral irri- tation, or in cases attended with much febrile excitement. Es- quirol has found emetics useful in puerperal mania. Mercury is much recommended by some writers, whilst others condemn its use in maniacal affections. With Dr. Rush, it was a favourite remedy in mania. "Too much," he observes, "can- not be said in favour of salivation in general madness ;" and he strongly recommends it also in partial insanity. As an alterative, it may be used, occasionally, with very considerable advantage in chronic mania, particularly where the disease is attended with prominent functional disorder of the biliary organs. Dr. Knight states that he has found the blue pill a valuable medicine in cases of long standing, and that he never knew it to be productive of any injurious effects ; but he apprehends, that in recent cases of mania, the constitutional influence of mercury must be prejudi- cial in any form.* Narcotics and antispasmodics were formerly much employed in the various forms of mental derangement, and although by no means generally applicable, they may in some cases be used with advantage, after the general indications have been adequately attended to. Opium, when given in small doses, says Dr. Rush, may be useful, but it should never be given in large doses, with a view of procuring sleep in general mania. Regimen, exercise, purgatives, and the use of the warm bath, will commonly do more towards procuring sleep than any other remedies that can be em- ployed. Indeed, opium never fails to increase the wakefulness, and when given in strong doses, before the general and cerebral excitements have subsided, it rarely fails to aggravate the disease. In chronic mania from masturbation, camphor has been recom- mended ; but almost all recent writers agree, that it very rarely produces any good effects, but on the contrary often manifest in- • Observations on (he Cause?, Symptoms, and Treatment of Deraneremcnt of the Mind, &c. By Paul Knight, M. D. Vol. II. 22 170 MENTAL DERANGEMENT. jury. In puerperal mania, however, Dr. Gooch asserts that camphor, given in union with the extract of hyoscyamus, (ten grains of each) is the most useful anodyne we possess.* Dr. Knight also has found this combination very useful as a soporific in mania unattended with sanguineous congestion in the brain, or a general phlogistic habit.t In maniacal affections succeeding the sudden suppression of the catamenia from cold, or any powerful mental emotion, advantage may be expected, says Dr. Prichard, from stimulating emmena- gogues, in conjunction with efficient abstractions of blood, and warm semicupium. He considers the tincture of melampodium and the oil of turpentine, as decidedly the best emmenagogues in cases of this kind. Georget also recommends the use of em- menagogues, in conjunction with mustard, pediluvia, hip-baths, and leeches to the pudenda, in cases attended with suppressed menstruation and cephalalgia. The warm bath is a cardinal remedy in the treatment of in- sanity in the Parisian hospitals. In the Salpetriere, the women use the warm bath two or three times a week, unless an apoplec- tic tendency, or some other circumstance contra-indicating its use, be present. They remain in the bath from a half to two hours. (Casper.) Patients of a thin, nervous, and irritable habit of body, says Esquirol, may be kept in the warm bath a very considerable time with advantage. When the vessels of the head are strongly congested, and much cerebral irritation is present, cloths saturated with cold water should be applied to the head, while the patient is in the bath. The heat of the water should be about 99° or 100° of Fahrenheit. The cold bath, also, has been much employed in maniacal affections. In young, robust, and sanguineous patients, particu- larly when the skin is dry and preternaturally warm, considera- ble benefit will occasionally accrue from cold affusions. More advantage, however, may, in general, be obtained from the appli- cation of cold water or ice to the head, in young and excited maniacs with much sanguineous determination to the brain. In the early stages of mania, where there is much headach, redness of the face and eyes, and turgidity of the vessels of the head, cold affusions "from a cock, funnel, or pitcher," upon the top of the head, after leeching or cupping, with stimulating pediluvia and laxative enemata, often produce the most excellent effects.^ " The signal for removing the cold applications," says Dr. Rush, "should be, when they produce chilliness,and sobbing or weep- • Observations on Puerperal Insanity. Transact, of Lond. College of Phys. 1820, vol. vi. •j- Loc. cit. $ Esquirol, loc. cit. MENTAL DERANGEMENT. 171 ing in the patient." Dubuisson, in conformity with the recom- mendation of Hill and Cox, has applied ether to the head with much advantage.* Counter irritating applications may occasionally be employ- ed with benefit in insanity. Esquirol was formerly much in the habit of applying moxas to the back part of the head, in cases attended with much torpor ; but he has for some years past, in a great measure, discontinued this practice. " They augment," he says, "the erethysm, torment the patient, increase his irritability, and convince the insane that he is a victim to our cruelty, "t Georget, however, speaks strongly in favour of setons, moxa, and blisters to the neck, in monomania, and other varieties of mental derangement accompanied with stupor, insensibility, and cerebral inactivity. These, he says, in conjunction with the repeated ex- hibition of vomits, rouse the energies of the nervous system, in the most desperate cases of alienees stupides. Dr. Rush, also, speaks decidedly in favour of the use of blisters. " They have," he says, "been considered as remedies of doubtful efficacy; but it is only because they have not been employed in the manner, or at the precise time that was necessary to obtain benefit from them. In the first stage of tonic or violent madness, the disease is en- trenched as it were in the brain. It must be loosened, or weak- ened, by depleting remedies, before it can be dislodged, or trans- lated to another part of the body. When this is effected, blisters easily attract it to the lower limbs, and thus often convey it at once out of the body." The circular swing has been much used in the institution for lunatics at Glasgow, and "in some cases, with wonderful good effects." Dr. Knight also asserts that this agent possesses "im- mense power" in subduing general and cerebral excitement. "A patient, subjected to its action, is speedily affected with giddiness and sickness, and the peristaltic motion of the whole alimentary canal seems to be excited, and in some instances to such a degree that the patient vomits, and passes feces in rapid succession and great abundance, along with his urine. Apprehensions have been expressed, lest the use of the circular swing should induce apo- plexy : having attentively examined the sources of these fears, I conclude them to be groundless; nor have I ever seen the slightest reason to apprehend such result; nor do I believe it can occur, if the patient be not in a furious state when put into the swing." The best time, says Dr. Knight, for using the swing, " is a little before retiring to rest at night, as the unloading of the alimentary canal, the lowering, and the relaxation of the skin, very generally predispose to sound and refreshing sleep. J • Des Vesanies ou Maladies Mentales, p. 225, f Loc. citat. i Loc. cit. p. 63. 172 MENTAL DERANGEMENT. Music sometimes has a most soothing influence over the dis- tracted and raving minds of maniacal patients. Dr. Rush ob- serves, that "lively tunes are as offensive as comic representations in this disease." Tissot relates an instance of insanity which was permanently removed by music ;* and we read, that Saul's melancholy was dissipated by the harp of David—Tange lyrarn digitis, animi dolor omnis abibit dulcisonum, reficit tristia corda melos. Sect. II.—Delirium Tremens.—Mania il Potu. This very remarkable va:iety of mental disease, is characterized by general inquietude, tremor, continued watchfulness, cool skin, perspiration, delirious loquacity, and sensorial illusions. It occurs only in habitual drunkards, and in such as are addict- ed to the inordinate use of opium, and, perhaps, other narcotic stimulants. So long as the customary quantity of the stimulus is taken, the disease seldom, if ever, supervenes ; but, if from ne- cessity, sickness, or a temporary disgust, the ordinary stimulat- ing potations are suddenly left off, or greatly diminished, the activity of the brain becomes morbidly increased, and mental disorder, in many instances, speedily ensues. "It is important to bear in mind," says Dr. Coates, "that this disease is the result, not of the application, but of the sudden intermission of the use of these articles."! The disease usually commences with lassitude, general indis- position, a feeling of distress in the epigastrium, anorexia, nausea and vomiting, giddiness, a sense of confusion in the head, want of sleep, an anxious expression of the countenance, and tremor of the hands. After a day or two, the countenance exhibits an expression of alarm and suspicion, the eyes are cast about with quick and scrutinizing glances, or often fixed, apparently upon some object that attracts the attention for a moment, and then quickly withdrawn ; the tremor of the hands increases; the pa- tient becomes irritable, and sometimes irascible; he is extremely restless, walks continually to and fro, and is wholly unable to obtain a moment's sleep. He now begins to manifest mental dis- order, becomes loquacious, says he feels well, and is tormented with a more or less continued succession of various alarming, dis- gusting, and ludicrous apparitions. He fancies that he sees dogs, snakes, cats, mice, and other animals in his room, and disgusting vermin crawling over the bed, and on his clothes, or that various • Reil's Fieberlehre. ■j- See an able and highly interesting memoir on this disease, by Dr. Coates, of this city, published in the North American Med. and Surg. Jour. vol. vii. p. 34. DELIRIUM TREMENS. 173 persons have entered his room, for the purpose of robbing, kill- ing, or annoying him. To avoid these and other hornd illusions he often calls out loudly for assistance; runs to the door to make his escape, or to the window to leap out; is greatly agitated vo- ciferates, threatens, and sometimes raves violently. Sometimes he fancies that he hears loud and strange noises around him, oyer head, in an adjoining apartment, or loud and frequent knocking at the door. His mind and body are in a continued state ot action; he calculates, projects, walks hurriedly about the room, picks up money, runs up to the window, and calls out to some imaginary person in the street, starts with terror and agitation from the presence of frightful and disgusting apparitions, insists that he is well, and confined with some sinister intentions against him, and requests to be suffered to go out in pursuit of his usual occupations. If the patient is flatly contradicted, he usually becomes much exasperated, and insists with vehemence on the correctness of his notions ; but, when he is soothingly dealt with, he will now and then answer certain questions mildly and even distinctly, and by judicious management, may, in general, be restrained without any violent coercive measures. When the disease rises to a high grade, the patient becomes violently and often furiously delirious, talks incessantly, is restrained with difficulty, and is unable to recog- nise his friends and acquaintances. Patients affected with this disease do not appear to be suscep- tible of much bodily pain. " They never seem to experience any sufferings from fractures, though they may be at the time subjecting these to the most constant friction and concussion; and when the delirium supervenes upon a pleurisy, or other inflam- matory affection, accompanied with pain, the principal disease seems to disappear, even to the eye of the experienced practi- tioner, to be reproduced at a later period, when the brain and nerves regain their ordinary tranquillity." (Coates.) The pulse in this disease varies considerably in different cases. In some instances it is hard, full, and frequent, but much more commonly, soft, full, and quick, without strength or tension. The skin, generally, retains its natural temperature and moisture; the tongue is humid, and covered with a white fur; the bowels are torpid, and there is usually an entire loathing of food throughout the whole course of the disease, but the thirst for cold drinks is almost always considerable. The duration, and degree of violence of delirium tremens, vary much in different cases. Sometimes slight tremor of the hands, with occasional transient manifestations of delirium, sen- sorial illusions, and watchfulness, continue for a day or two, and then pass off. At others, the wakefulness, tremor of the hands, and general restlessness and agitation, continue for five or six days, with delirium and annoying apparitions at night, whilst during 174 DELIRIUM TREMENS. the day, but little mental hallucination is noticed. In some cases, the symptoms described above, continue, with but slight remis- sions, day and night, for one or two weeks and upwards, and in highly aggravated instances, the disease assumes the character of wild and ungovernable mania. Dr. Armstrong observes, that when convalescence is not restored within the first month, there will be a risk of long continued, if not permanent alienation of mind. Mild cases of this disease, when left to themselves, have been known to terminate spontaneously, (Stoughton,) on the super- vention of diarrhoea or vomiting. The occurrence of profuse dis- charges of this kind, however, often brings on a low and typhoid condition of the system ; and this is especially apt to be the case in persons who have been long and exceedingly intemperate, and in whom the disease is accompanied by some local inflammatory affection or general fever. In full and robust habits, the disease not unfrequently terminates in fatal convulsions or apoplexy. Pathology.—It appears to be generally admitted that this dis- ease has its primary and essential location in the sensorium com- mune, and that it is wholly independent of inflammation or vas- cular turgescence in this organ. It would seem to consist in a purely dynamic disorder—a morbid activity of the brain, from the sudden abstraction of an habitual stimulus by which its excit- ability had been long repressed or blunted. Dr. Coates considers it as consisting in "a heightened activity of the sensorium," from the generation, as it would seem, of an inordinate degree of vital activity in the brain ;* and similar views of the nature of this affection have been expressed by Dr. James Johnson, Dr. Ayre, and many other eminent British physicians.! Dr. Joseph Klapp, of this city, has published a series of cases, with observations, tending to show that the proximate or essential irritation of this disease is seated in the stomach, and it must be confessed that the arguments adduced in support of this opinion, possess considera- ble plausibility4 It is asserted in support of this opinion, that dissection almost uniformly discloses traces of previous inflamma- tion in the stomach; that, in nearly all instances, nausea, vomit- ing, and a foul tongue occur; and that the operation of an emetic, in many cases, brings off from the stomach a viscid, light-brown, or black coloured fluid, of the consistence of boiled tar; and, finally, that the disease yields more frequently and speedily under the employment of emetics, than under any other mode of reme- diate management that has hitherto been recommended. In reply to these arguments it may be observed, that post mor- * Loc. Citat. p. 225. f Med. Chir. Rev. Feb. 1828, p. 484. ± Eclectic Repertory, vol. vii. p. 259. DELIRIUM TREMENS. 175 tem signs of inflammation cannot be received as a valid proof that the inflammation was primary and causative, in relation to the peculiar train of phenomena which characterize the disease; for nothing appears to be more satisfactorily established, than that mucous inflammation of the alimentary canal very often super- venes during the latter period of all violent diseases ; and that the ordinary signs of inflammation—increased vascularity and sanguineous engorgement—are frequently produced in the last moments of life, or in articulo mortis. If the disease depended on mucous inflammation of the stomach, can it be conceived that emetics should in any. instance operate beneficially? Would any prudent physician prescribe an emetic in a case attended with unequivocal gastritis? Dr. Klapp, indeed, does not appear to consider the morbid condition of the stomach as a state of inflam- mation ; although Dr. Stoughton, who advocates the gastric pa- thology of this affection, lays particular stress on the post mortem signs of phlogosis in the stomach, as an evidence of the correct- ness of this pathology. Dr. Klapp seems to consider the gastric affection as rather the reverse of inflammation—as a state of tor- por, insensibility, and chronic irritation, or morbid excitement of the stomach. The argument drawn in favour of this opinion from the occasional good effects of emetics in this malady, affords it but little support. The post hoc, ergo propter hoc, is always a falla- cious mode of reasoning, We may admit, to the full extent, the beneficial influence of emesis, and yet consistently deny our assent to the doctrine which alleges that the stomach is the primary seat of the disease. With regard to the foul tongue, vomiting, &c. men- tioned in confirmation of this view of the nature of the disease, it may be observed, that the majority of writers do not bear testimony to the frequent occurrence of these phenomena. Dr. Coates found them " generally absent in the cases that came under his own in- spection." Dr. Sutten mentions them only as symptoms accom- panying the disease, where it occurred in connexion with typhus fever, scarlatina, or some other acute affection ; and Dr. Brown, of New-York, has noticed a foul tongue only in two out of eight cases. Within the last six years, I have seen about ten cases of this disease, and although I have paid particular attention to all the phenomena that might throw light on its pathology, I do not remember of having noticed a foul tongue in more than three instances, one of which was complicated with pneumonia, and another with dysenteric symptoms. Prognosis.—Delirium tremens, is not, in general, a very dan- gerous affection, when it occurs in a simple and uncomplicated form, and in systems not yet greatly broken down and depraved by a long course of excessive intemperance. When it supervenes during the course of violent forms of fever, and more especially during the existence of acute visceral inflammation, it almost in- 176 DELIRIUM TREMENS. variably terminates fatally. The disease is also attended with peculiar danger when it occurs in confirmed drunkards, who have previously laboured under chronic hepatitis, or some similar or- ganic affection. Subjects of this kind, generally rapidly sink under the disease, (Armstrong.) When the delirium becomes constant, the pulse rapid and very small, the extremities cold and covered with perspiration, the pupils small and contracted, with subsultus tendinum, and an agitated motion of the muscles of the face, death may be regarded as inevitable. It is also a particu- larly unfavourable sign, when coma, with sonorous respiration, or convulsions, ensue. The occurrence of .tranquil sleep, even of short duration, announces a favourable tendency in the disease ; and no symptoms can be regarded as indicative of declension of the malady, so long as the patient is unable to obtain some sleep. Treatment.—If delirium tremens depends—as I am well per- suaded it does—on a morbid activity of the sensorium, indepen- dent of inflammation or sanguineous congestion, the prominent indication is obviously to subdue this inordinate cerebral activity; and it remains only to inquire, by what remedies or course of treatment this object is best accomplished. If we attend to the circumstance that this peculiar condition of the brain is almost invariably the consequence, not of the appli- cation, but of the sudden abstraction of the customary stimulus, we are led, a priori, to infer, that the best mode of removing it, is to supply a stimulus, which may be capable at once of blunting and exhausting the morbid excitability of the sensorium. For this purpose, opium is decidedly the most valuable remedy we possess. Dr. Coates observes, and correctly too, that sleep must be produced coute qui coute—that the patient must sleep or die. Dr. Coates, however, goes too far, I think, when he expresses his conviction, that every case of simple delirium tremens- may be cured by the "opiate treatment." Satisfied as I am, that opium is the remedium magnum—the " sheet anchor" of our hopes, in this affection, there nevertheless exists no doubt in my mind, that important advantages may also be derived, in some instances, from other remedies, auxiliary to this potent narcotic. When the bowels are constipated, and there is reason to presume that they are in a loaded state, a purgative should be administered before recourse is had to the opium. This, like all other affections, may come on while the intestinal canal is charged with vitiated secre- tions and other irritating substances; and when it is considered, that intestinal irritation from sources of this kind, has a powerful tendency to originate and support morbid excitement in the brain, the propriety of administering one or two active purgatives pre- paratory and auxiliary to the employment of opium in this dis- ease, would appear to be very obvious. It has appeared to me, indeed, that without this precaution, the free use of opium has a DELIRIUM TREMENS. 177 tendency, in some instances, to cause dangerous determinations to the head, and to bring on coma instead of healthy sleep. About four years ago, I was called to a gentleman, a few miles from the city labouring under the ordinary symptoms of this disease. I found him sitting on his bed, busily engaged in driving away eels and snakes, which, he said, were annoying him ; and he requested me to turn out of the room several negro children, who had placed themselves, he thought, on the tops of the bed-posts. This was the second day of his illness ; his pulse was moderately full and compressible, and his tongue covered with a white fur. 1 at once directed two grains of opium to be given to him every hour, and to be continued until sleep should ensue. In the evening I visited him again. I found him lying on his back, apparently perfectly unconscious, his hands and arms, and muscles of the face, in continual motion, and uninterruptedly muttering indis- tinct words; the pupils contracted, and the whole frame in a state of tremulous agitation. The skin was moderately warm and moist, and the pulse frequent, small, and more firm than on the preceding day. With much difficulty I got him to swallow about an ounce of castor oil, with three drachms of ol. turpentine, and directed a laxative enema to be administered in two hours after- wards. Early next morning I saw him again, and found him much relieved. The purgative had acted four or five times, and brought away large and very offensive stools. He immediately recognised me when I entered the room; his pulse was frequent and feeble, and he was still much harassed by various disgusting and alarming apparitions. I now directed him a grain of opium every hour ; after the eighth dose was taken, he fell into a tran- quil sleep, which lasted several hours. He recovered under the use of this narcotic, without any other remedy. I cannot, indeed, assert with certainty that the comatose state mentioned above was the result of the influence of the opium ; but I am led io ascribe it to this cause, from having, in another instance, witnessed similar phenomena, after the use of large doses of this narcotic. Dr. Coates says: "I have never seen, read of, or heard of an instance in which opium was productive of harm." I must, in- deed, be greatly mistaken in the diagnosis, if I have not seen one unequivocal instance of this kind. In a case which I regarded as pure and uncomplicated delirium tremens, four grain doses of opium were given every two hours. In twelve hours the patient was comatose, became convulsed, and soon expired. I mention these facts, not to deter from the use of this valuable, and, I may say, indispensable remedy in this affection, but as a caution to the practitioner, to watch with assiduity its administration; "because we know not whether poisonous effects will be produced by an arithmetical or a geometrical increase—whether five grains, or Vol. II. 23 178 DELIRIUM TREMENS. thirty grains in addition, are sufficient to endanger the patient's life."* The quantity of opium which it is usually necessary to admi- nister, before the desired soporific effect is produced, is often truly enormous. In some instances, from twenty to thirty grains, in divided but frequent doses, are required, before the full advan- tages can be obtained, which it is capable of affording. My usual practice has been, to exhibit two grains every hour, (after free purgation) until sleep is induced. With regard to the employment of blood-letting in this affec- tion, the opinion of the profession seems to be pretty well settled as to its general impropriety and inefficacy. Dr. Sutton informs us, that where blood-letting " has been principally relied on, he has observed a fatal termination of the disease in almost every case."t Dr. Armstrong, who is not inclined to undervalue this measure, asserts, that he is "fully persuaded that there are not many instances where the lancet is requisite;" yet "in constitu- tions that have not been shaken by reiterated drunkenness, he has known early and moderate venesection of much use." The experience of Dr. Brown, of New'-York, coincides with the ob- servations of Dr. Armstrong on this point. Dr. Stewart "had seen the disease on a large scale. Almost all those patients who were treated on the antiphlogistic plan died, while those who were treated by opium and stimulants recovered."J The expe- rience of Dr. Gregory, Dr. Shiel, Mr. Lambert, Mr. Mackelan, Mr. Chinnock, and Dr. Ayre, is decidedly against the use of blood-letting, and in favour of the stimulating and narcotic treat- ment, in uncomplicated cases of the disease. § My own experience is entirely opposed to the employment of the lancet, under the ordinary circumstances of this malady. In very plethoric and robust subjects, it will, nevertheless, be proper to draw some blood, with the view of lessening the liability to dangerous san- guineous congestion in the brain; and thus enabling us to proceed with more confidence in the employment of opium. Cupping about the head may, under certain circumstances, prove very useful. Where the sanguineous determination to the brain is considerable, and the raving becomes constant and violent, cups may be applied to the temples, forehead, and neck, with much advantage. Dr. Coates informs us, that in the Pennsylvania Hospital, Dr. Parrish has resorted to cupping in delirium tremens, with great benefit. In an instance I attended about six months ago, where there was much vascular turgescence of the head, and a state of delirium approaching the raving of phrenitis, imme- * Coates, loc. cit. p. 214. f Tracts on Delirium Tremens, &c. p. 66. * Med. Chir. Rev. February, 1828, p. 484. § Ibid. p. 485. DELIRIUM TREMENS. 179 diate and very decided benefit was derived from cupping. Blis- ters also will sometimes act beneficially when applied to the legs or to the back of the neck, in cases attended with violent cerebral excitement. In one case, in which the disease seemed to verge into phrenitis, a large blister, laid between the shoulders, mitigated the symptoms very considerably. Dr. Coates, referring to the practice of Dr. Parrish in the Pennsylvania Hospital, ob- serves, that blisters appear of more service than cupping, "as they did not equally weaken the patient." Emetics, as has already been intimated, deserve more atten- tion as curative means in delirium tremens, than any other re- medies that have been employed, with the exception of opium. In my own practice, I have had unequivocal testimony of the occasional usefulness of emetics in this malady. In several in- stances, however, they failed, in my hands, of doing any good; and in two cases, within the last six years, they were unequivo- cally injurious. To one patient, who had been long a confirmed drunkard, I administered, in divided doses, fifteen grains of tar- tar emetic. It produced neither purging nor vomiting; but its sedative operation was immediate and powerful. In about an hour after taking the medicine, the pulse became small and ex- tremely feeble—the extremities ice-cold, and a profuse, cold, clammy sweat broke out over the whole body. The patient sunk rapidly, and expired in about four hours after the antimony was taken. In the other instance, the emetic brought on the most profuse and exhausting diarrhoea, and soon prostrated the patient below the point of reaction. Nevertheless, in moderate and uncomplicated instances of the disease, and in patients who have still considerable constitutional vigour left, we may with safety, and often with decisive advantage, resort to one or two emetics. As an auxiliary or preparatory measure to the employ- ment of opium, 1 am satisfied that the exhibition of an emetic is often peculiarly beneficial. I have known a few cases cured by emetics, with little or no other remediate applications; but ex- perience has convinced me, that they are much more worthy of attention as auxiliaries to opium, than as a principal curative means. Dr. Brown expresses the same opinion. " Although it has not been our practice," he says, "to depend exclusively upon emetics in the treatment of delirium tremens, we can bear testi- mony to the utility, in some cases, of premising an emetic to the use of opium. And, no doubt, this is often an important step in the treatment of this disease."* It is often extremely difficult in this disease to excite vomiting, without administering very large doses. Dr. Klapp gave one of his patients twenty grains of tartar emetic before vomiting was " Observations on Delirium Tremens, &c. by Dr. Stephen Brown, in the Med. Recorder, vol. v. p. 207. 180 DELIRTUM TREMENS. excited; and Dr. Brown mentions an instance in which thirty grains of this article were given before the desired effect was pro- duced. I have, in general, preferred giving the tartar emetic in combination with ipecacuanha, in the proportion of two grains of the former with fifteen of the latter, repeated every ten or fifteen minutes, until vomiting ensues. Cold and tepid affusions also, have been recommended in this affection. Dr. Armstrong speaks favourably of the effects of dashing two or three gallons of tepid water, strongly impreg- nated with salt, over the whole body, and then immediately dry- ing and rubbing the surface with warm flannel; and, having put the patient to bed, administering forty or fifty drops of tinct. opii in a little warm wine. He informs us, also, that in several cases he used cold affusions with decided benefit; but he never resort- ed to this measure except in patients possessing much apparent vigour of constitution, and he always administered stimulants— such as warm wine—immediately afterwards. Besides opium, various other stimulating remedies have been employed in delirium tremens. Dr. Coates considers camphor and assafoetida " as powerful agents in restoring the mind to its equilibrium." I have used camphor and opium in combination; but I cannot say that more benefit was derived from this mixture than is usually obtained from the latter article, when given by itself. In several instances, I gave the camphorated tincture of opium, during the declension of the disease, with the happiest effect. Two drachms of it may be given every three or four hours during convalescence. The carbonate of ammonia, also, may be given with more or less benefit in slight cases, or during the sub- sidence of the disease. I prescribed this article lately in a case of incipient delirium tremens, with marked advantage. With regard to the employment of ardent spirits, I can say nothing from my own experience, as I have never allowed my patients to take any thing of this kind, except warm wine, and, in a few instances, a little weak brandy toddy. The sentiment of the pro- fession appears now very generally and strongly opposed to the employment of spirituous liquors in the treatment of this affection. There is, indeed, something very revolting in the idea of exhi- biting copious draughts of the very agent whose destructive in- fluence has caused the w7reck of body and mind, which we are called on to remedy. There can be no doubt, that opium will, in general, do all that can be effected by remedies of this kind; and where it may be thought advisable to bring in the aid of a more diffusible stimulus, camphor, ammonia, assafoetida, and Hoffman's anodyne, may be resorted to with propriety. During the course of the disease, and particularly during con- valescence, the diet should be light, unirritating, and fluid. Ani- mal broths will, in general, answer better than any thing else. NEURALGIA. 181 CHAPTER III. LOCAL, CHRONIC NERVOUS AFFECTIONS. Sect. I.—Neuralgia.—Tic Douloureux. The first account of this affection was given in 1756, under the name of tic douloureux, by M. Andre of Versailles. Ten years after this short and rather indistinct description was given, Dr. Fothergill published a paper, in which this painful affection is clearly and very circumstantially described, under the name of facei morbus nervorum excrucians, and since that period, vari- ous interesting and elaborate essays, and a multitude of cases, illustrating the character and treatment of this disease, have been given to the public. The term neuralgia, which was, I believe, first given to the disease by Dr. Meglin of Strasburg, is now generally, and certainly with much propriety, preferred to the name tic douloureux. Neuralgia is usually divided into different species, according to the seat of this affection ; but the fact, now well ascertained, that its attacks are confined to no particular nerve or system of nerves, that it may occur in almost every sentient structure of the body, in the cerebro-spinal, the pneumo-gastric and phrenic nerves, and even in the ganglionic nerves arising from the solar plexus, renders the propriety of such divisions as specific distinc- tions very doubtful; and the more so, as they do not appear to in- volve any essential peculiarities, either in a pathological or thera- peutic point of view. Unquestionably, however, certain nerves are much more liable to become the seat of this affection than others ; and this is especially the case with the three grand divi- sions of the fifth, and the facial portion of the seventh pair of cerebral nerves. Symptoms.—The pain in neuralgic affections is very peculiar. It is extremely acute, and darts like lightning from its more fixed point along the course of the nerves. It comes on in sudden paroxysms, with longer or shorter intervals of more or less com- plete freedom from suffering. In general, much pain is expe- rienced throughout the whole paroxysm, with frequent transitory shocks of darting pain, so extremely agonizing as often to cause a temporary loss of reason and consciousness. Occasionally, the paroxysm consists of a succession of transient fits of pain, coming on with the suddenness of an electric shock, with short intervals of comparative ease. During the paroxysms, the surrounding parts are extremely sensitive or tender to the touch ; and it is a 182 NEURALGIA. remarkable circumstance, that the slightest touch, in many instan- ces, causes much more suffering than firm pressure ; the former, generally, instantaneously bringing on a shock of the piercing nervous pain. In general, the pain is attended with considerable turgescence of the blood-vessels in the immediate neighbourhood of the affected part; and this vascular engorgement, says Dr. Macculloch, sometimes "amounts to a species of inflammation, resembling that of rheumatism." Much general soreness in the part is usually left after the subsidence of the acute neuralgic pains ; but in some cases only a little tenderness remains, which gradually subsides, and leaves the patient in his ordinary state of health. In very violent attacks of the disease, we generally find the neighbouring muscles affected with spasms, and occasionally spasmodic twitches occur in* the muscles of parts distant from the place where the pain is located. When the disease occurs in the nerves of the face, the saliva is often secreted very copiously, and in nearly all instances of this kind, there is a profuse flow of tears from the eyes during the paroxysms. In individuals of a nervous temperament, it is not uncommon to observe sympathe- tic affections of other and distant nerves, with which those affect- ed have no other connexion than that which exists through the medium of the sensorium commune. In some cases, the paroxysms are strictly periodical in their recurrence, with regular intermissions of comparative health, the type being almost always quotidian. This periodicity of the paroxysms occurs only in what may be termed the acute or recent form of the disease ; and is particularly pointed out by Dr. Mac- culloch as an evidence of the affinity or rather identity of this affection with intermitting fever. Sometimes the disease assumes a chronic character, continuing in irregularly recurring parox- ysms for months or even years, with scarcely any intervals of entire freedom from uneasiness, ill-health, or suffering ; and this is especially apt to be the case, when the disease occurs in con- sequence of some mechanical injury of a nerve. This affection occurs much more frequently in the face than in any other part of the body. When the portio dura is affected, the pain usually commences on the side of the face, near the ear, and darts along the ramifications of the nerve, to the angle of the jaw, the alae of the nose, the angle of the mouth, external canthus of the eye, and along the temple to the forehead. Sometimes the pain radiates from a point on the cheek just below the orbit of the eye, and passes to the side of the nose, the upper lip, teeth, gums, and temple, in which case the disease is seated in the second branch of the fifth pair of nerves. When the principal pain is experienced in the internal canthus of the eye, forehead, eye-lids, and in the ball of the eye, we may presume that the first branch of the fifth pair is affected; and in cases where the tongue NEURALGIA. 183 and lower jaw are the seat of much pain, the neuralgic irritation extends to the third branch of the trigeminus. Sometimes the pain occurs in the scalp; and I have seen an instance of extreme violence, in which the pains were most severely felt behind the ear, and along the scalp of the occiput and the posterior portion of the temporal bone. The optic nerve, also, has been known to be affected with neuralgia. Dr. Macculloch mentions a case in which the pain in the eye was described by the patient as if a red-hot needle had been passed through its centre.* The decidedly neuralgic character of this pain was evident from its having occurred the moment after an attack of neuralgia in the upper jaw had ceased. Neuralgia in the nerves of the extremities is by no means uncommon. Dr. Macculloch mentions a severe case that occur- red in the radial nerve which runs along the metacarpal bone of the fore-finger. The pain was confined to a space " which a pea could have covered," and continued during a period of four months. Mr. Abernethy has related a striking instance of neu- ralgia, which affected the superficial nerves under and adjoining the inner edge of the nail of the ring-finger of the hand ;t and Dr. Pearson has given an account of a remarkable case affecting the extremity of the left thumb.J The occurrence of this affection in the nerves of the feet and legs has been frequently noticed. I have lately seen an instance of this kind, which had already lasted upwards of six months. Dr. Good, who makes a distinct species of such cases, under the term neuralgia pedis, describes an instance of this kind, which continued for several years. The paroxysms were transient, of uncertain recurrence, and so severe as nearly to cause faintino- darting up the calf of the leg towards the knee, and downwards into the toes. Dr. Macculloch relates instances of neuralgia of the knee. In two extremely violent cases, the pain was situated im- mediately over the margin of the head of the tibia, and the affected part was not more than an inch in area. In another case imitating the double tertian type, " there was on one day pain in both knees, and on the alternating day a pain in one arm •» and in this way the disease continued a long time. Neuralgic pains in this joint, says this writer, have been mistaken for scrofulous affections, "and in some cases that had lasted five years, as the pain was very severe, the surprise had long been that no swelling could be discovered by the touch." This affec! .on is what Mr. Brodie has described under the name of hys- terical white swelling; and he appears to think, " that nine out T Surgical Works, vol. n. p. 18. t. Med. Chir. Transact, vol. viii. part. i. 184 NEURALGIA. of ten of those unfortunate young women who have been doc- tored of late years for spinal diseases, have really laboured under nothing but hysterical pains of the back."* The tibia has been frequently the seat of extremely violent neuralgia ; and it has also occurred in the thigh, particularly in the anterior crural nerve, shooting down with great severity, from near the groin to the foot or toes. The occurrence of neuralgia in the breasts of females has of late years been noticed by several writers. The third species of Dr. Good's subdivision of this affection, (neuralgise mammse) is founded upon this location of the disease. He describes an in- teresting case of this kind. "The breast," he says, was "full- formed and soft, without the slightest degree of inflammation or hardness. When the paroxysm of pain was not present, it would bear pressure without inconvenience, but during the pain the whole breast was acutely sensible. The paroxysms returned at first five or six times a day, and were transient, but as the disease became more fixed it became also more severe and extensive, for the agonizing fits at length recurred as often as once an hour, and sometimes more frequently." Dr. Addison says, that neuralgic pain under the mammse, or under the margin of the ribs of the left side, is far from being uncommon in females. This pain, he observes, is " very circumscribed, and will often last for weeks, or even months, with but little intermission. It is often associated with palpitation of the heart, or what is much more usual, with unnatural pulsation of the organ, i. e. the patient is conscious of the heart's action, or she feels as if its impulse were communicated to a part so sensitive as to excite distinct sensa- tion, "t The internal organs, as was observed above, are no less liable to neuralgic affections than the external parts. Of the neuralgia of the heart, I shall speak more particularly under the head of angina pectoris ; for it will scarcely admit of a doubt, that, in some instances at least, this appalling affection is strictly of a neu- ralgic character. The occurrence of neuralgia in the abdominal viscera appears also to be much more common than is generally suspected. Dr. Macculloch has met with a well marked instance of neuralgia in the rectum. There is an affection of this kind which occasionally occurs at the extremity of the rectum or coccygis, immediately after parturition, causing indescribable suffering to the patient, and which scarcely any dose of lauda- num is adequate to allay. Dr. Dewees, in his Midwifery, men- tions a remarkable instance of this kind, and I have not long » Med. Chir. Rev. Nov. 1828, p. 58. f Observations on the Disorders of Females; connected with Uterine Irritation. By Thomas Addison, M. D. &c. Lond. 1830. NEURALGIA. 185 since met with one equally striking. The pain continued for two hours before it began to decline. The painful affection usually termed gastralgia, is probably purely neuralgic in its nature. In this variety of the disease, the pain is paroxysmal, sometimes quotidian, and usually radiates from the epigastrium to the thoracic parietes, the back, and to the shoulders. The tongue is white, the saliva abundant, without thirst, and epigastric tenderness on pressure. Immediately after eating, the pain generally abates for some time, but in the course of one, two, or even three hours afterwards, it is renewed with a feeling of weight and distress in the epigastrium, as if there was a foreign body in the stomach. Nausea, borborygmi, flatulent colic, and eructations of air, are usually experienced some hours after eating. There is generally much constipation, and the urine is usually pale, and small in quantity. In violent and protracted cases, difficulty of breathing, palpitation of the heart, wandering pains, and a peculiar sensation of coldness in the arms, loins, and lower extremities, are wont to occur. In the morning the patient commonly gets up refreshed, and feels quite well until breakfast renews the gastric pains.* Dr. Prus has recently reported a very interesting case of neuralgia of the stomach, which was brought on by violent mental emotion. The patient, a female, was affected with excruciating pains in the epigastrium, which came on daily in paroxysms, between the hours of three and half-past seven, P. M. Fourteen years after the commencement of her sufferings, the patient consulted Dr. P. The epigastric pain was removed in five days by full doses of quinine, given during the intermission, and the patient appeared to be entirely cured. On the twenty- second day afterwards, however, intense pain occurred in the course of the infra-orbital nerve ; soon afterwards it seated itself in the cubital nerve of one arm, where it remained but a very short time. It then returned to the face. A blister was now ap- plied beneath each trochanter. After this the sciatic nerves of the right side became violently painful. Blisters were applied along the course of the nerve, and in a few days more the pain suddenly shifted to the left sciatic nerve, and soon afterwards disappeared altogether, t The kidneys, also, may become the seat of this affection. Dr. Macculloch states, that he has met with an unequivocal instance of this kind. There is an exceed- ingly painful affection which occurs in the right iliac region, usually confined to a very circumscribed space, and which has been generally regarded as the result of calculous irritation in the ureters, but which appears, very manifestly, I think, to be purely • For a detailed account of the diagnosis between gastralgia, and chronic gastritis, see the section on gastritis, in the first volume of this work. f Med. Chir. Rev. March, 1829, p. 553. Vol. II. 24 186 NEURALGIA. neuralgic. I have met with five or six cases of this kind, several of which continued to recur daily for two or three months. Its mere nervous character seems to be demonstrated by the strict periodicity which it observes in its recurrence; although in most instances there is retraction of the testicle on the affected side, as in calculous irritation, without, however, any difficulty, or diminution, of the discharge of urine. The uterus also is liable to become the seat of extremely pain- ful affections of this kind, in females of a nervous or hysterical temperament. Dr. Jolly, in the second part of his Memoir on Visceral Neuralgia, has reported some severe and well marked cases of neuralgia of the uterus. In one instance, the affection assumed a strictly quotidian intermittent type. After some mani- festations of catamenial irregularity, the patient became affected with violent pains in the right iliac region, shooting into the pel- vis, and extending to the left iliac region. These pains were acute, lancinating, recurring every three or four minutes, and soon ac- quired such a degree of violence, as to cause some delirium, and even convulsions. The attacks came on about noon, and continued until the evening. On the following morning, the patient appear- ed in good health, and without any pain, but about mid-day the paroxysm returned. After trying a variety of means ineffectually, eight grains of quinine were given during the remission, and the paroxysms were arrested. Mr. Jolly relates another highly in- teresting case of neuralgic affection of the trisplanchnic nerves, which assumed the tertian type. The patient, a lady, aged thirty, soon after accouchement, experienced most violent attacks, which resembled gastritis, nephritis, hepatitis, hysteritis, &c. according to the organ principally invaded. Active depletory measures were employed, until the patient was reduced to a very low state, with- out any permanent favourable impression being made on the dis- ease. At last, recourse was had to quinine and opium, during the intermissions, and under the use of these remedies the disease yielded speedily. * Mr. Shaw has related a case, where the neu- ralgic affection was seated in the ulnar nerve, from the elbow to the little finger. After some local rubefacient applications, and the internal use of blue pill, and the volatile tincture of valerian, the pain abated in the arm; but the patient (a female) was attack- ed with severe pains in the uterus. It would seem, too, that neuralgia sometimes invades the bladder. In a conversation which I lately had with Dr. Parrish, he mentioned an instance that occurred in his practice, which he called tic douloureux of the bladder. M. Martinet has related some singular instances of neuralgia,! * Bib. Med. Juin, 1828. See also, Med. Chir. Rev. Sept. 1828. f Rev. Medicale, Janvier, 1824. NEURALGIA. 187 which assumed the general appearances of cerebral disease. One case commenced suddenly with incomplete paralysis of the right lower extremity, attended with pain running along the sciatic nerve ; next a dull pain, with formication, occurred in the re- gion of the loins—in a few days afterwards pains radiating along the temples, forehead, and upper eye-lid of the right side came on—then distortion of-the mouth to the left side, embarrass- ment of speech, with pain in the facial nerves; darting pains along the scalp, deep-seated cephalalgia in the right side of the head, and finally uneasiness in the epigastrium, coated tongue, &c. The case was cured by leeching and purgatives. He men- tions another instance still more closely similating disease of the brain. A very singular case is related by M. Hellis, of Rouen. The patient, a young man aged about 15, at first felt a dull pain near the last dorsal vertebrae, which soon extended itself to the epigastrium, attended with hiccup. In this situation he continued, with occasional intervals of weeks or months, for several years : at last the pains did not confine themselves to the back and epigastrium, but darted through the chest, abdomen, and down the legs to the toes. It also affected the upper extre- mities, and passed along the course of the nerves to the extremi- ties of the fingers. On closing the hand, the hiccup and the pain would cease, but "on extending a single finger it would appear, and quick as lightning traverse the parts just mentioned."* From the foregoing facts, we perceive that neuralgic irritation is by no means confined to a few points of attack ; and we shall presently make it appear that its causes are scarcely less various than the parts which are susceptible of becoming its seat. Causes and Pathology.—Dr. Macculloch strenuously insists on the malarious origin of neuralgia, and there can scarcely exist a doubt, indeed, that in many instances, neuralgic affections are nothing more than masked agues from the influence of koino- miasmata. In miasmatic districts, the occurrence of affections of this kindJs far from being uncommon; and their close affinity to intermitting fever seems to be sufficiently demonstrated by the strict periodicity of their character ; and the remedies most successful in removing them, being the same that are most effec- tual also for the cure of fully developed intermittents. The symp- toms too, which on a careful examination may be detected in many instances of periodical neuralgia just before the accession of the paroxysms, indicate the close alliance between them and intermittents. "Immediately before the attack," says Dr. M., " if the pulse be examined, it will be found to put on that cha- racter which it possesses in the cold stage of intermittents, while through the progress of the paroxysm it passes through the other * M:J. chir. R;v, Oct'r. 1816. Journal General de Med. April, 1826. 188 NEURALGIA. analogous changes." There are also, most commonly, "some indications of a cold 6tage, generally obscure, it is true, as is the case in most of the anomalous and chronic intermittents, but still discernible." There is much reason to believe that indivi- duals who have laboured nnder intermittents, may afterwards, even at remote periods, have relapses of the disease in the form of periodical neuralgia. I have seen two instances of this kind, of great severity, which yielded readily to the powers of arsenic given during the intermissions. True as it undoubtedly is, that many cases of this affection arise from the influence of koino- miasmata, and partake of the nature of intermitting fever, it is nevertheless far from being so generally dependent on this cause as is alleged by Dr. Macculloch. It is manifest, indeed, from the many cases that have been published of late years, that this painful affection may be originated by a variety of very distinct causes, some of them of a general, and others of a strictly local character. Sometimes it appears to be dependent on a morbid irritability and irritation in the intestinal canal ; and this is pro- bably most commonly the case when the affection occurs in the nerves of the mammae, on the side of the head, and in the heart, producing angina pectoris. I have seen an instance of excruciat- ing pain and tenderness in the left breast, between the nipple and the axilla, without inflammation, swelling, or redness, in a lady habitually affected with gastric disturbance. It was remov- ed by a course of simple diet, mild tonics, blue pill, aperients, and laxative enemata. The occurrence of neuralgia from mechanical injury of the nerves, is by no means uncommon. In many instances of this kind, the neuralgic pains are seated at a distance from the part where the primary irritation or injury exists; but in others, the affection is located immediately in the injured nervous ramifica- tions. Sir Henry Halford has lately adduced some observations, which would seem to show that facial neuralgia is occasionally excited by lesion of bone. In one of the cases he relates, "there was an exostosis of the alveolar process—in another .there was disease of the antrum highmorianum, and in a third, and the most remarkable of all, there was a prodigious deposit on the internal surface of the skull, like frost-work, which must have caused great pressure on the brain. Dr. Pemberton, previously to the development of the neuralgia of which he died, was twice affect- ed with abscess in the frontal sinuses."* In a case of neuralgia of the face, Dessault found the foramen through which the nerve passed in a diseased state. Many cases are on record where neuralgia was produced by accidental injuries, such as wounds, bruises, &c. M. Feron has • Med. Chir. Rev. April, 1828. NEURALGIA. 1S9 related an interesting Instance of this affection, which was pro- duced by a bite from a little girl in a state of delirium, inflicted on the back of the second phalanx of the little finger of the left hand in an old lady. In a few days, excruciating pain was expe- rienced in the little finger, spreading successively to the hand, fore-arm, and elbow, along the track of the cubital nerve. After cauterizing the wound, the pain extended to the axilla, and in- creased in severity; at last a sense of stricture and fulness or stuff- ing in the chest ensued, which was soon succeeded by violent cardialgia and vomiting. These symptoms, recurring in parox- ysms, lasted six months.* A most distressing case is related, which was caused by a wound of the hand from the explosion of gun- powder. Amputation of the arm was twice performed, but the disease always returned in the stump as soon as it was cicatrized. The patient visited Paris, London, and Edinburgh, where he consulted the most eminent of the faculty, but he derived no permanent advantage from the measures that were recommended. I once saw a case of great violence, which was produced by a fracture of the fore-arm. I have not heard whether the disease was ultimately removed or not. Dr. Jeffrey has recorded a very aggravated case, which was caused by a wound in the cheek by a piece of chinaware, a small portion of which remained imbed- ded in the wound. It may also arise from the irritation of a ca- rious tooth. Mr. Swan has given the history of a case of facial neuralgia, which was produced by a blow on the right eye. With regard to the proximate cause of neuralgic affections, pathologists have expressed a diversity of opinions. Dr. Parry attributed the pain to "increased vascularity or determination of blood—perhaps amounting to inflammation—of the neurilema or vascular membranous envelope of the affected nerves." M. Vaidy, who has published a valuable memoir on this disease, en- tertains a similar view of its pathology. He considers all neural- gic affections as consisting in inflammation of the nervous tissues.t The affected nerve, or its neurileme, has indeed sometimes been found preternaturally vascular and injected; yet these conditions may be the consequence, and not the cause of the neuralgic irri- tation. The nerves, says Mr. Swan, are liable "to become en- larged and inflamed from irritation, just as muscles are from con- tinued action; but dissection, he says, has not shown those depo- sitions of coagulable lymph and structural changes which are produced by continued inflammations of the other parts of the body, and of the nerves themselves in stumps and portions along the seat of inflammatory action." J The general opinion at present • Med. Chir. Rev. Sept. 1821—from the Journal Complement, Mai, 1820. t Journ. Complement, Dec. 1820. \ Dissertation on the Treatment of Morbid Local Affections of the Nerves. By Joseph Swan, &c. 190 NEURALGIA. is, that this painful affection is frequently the result of mere ner- vous irritation, without any necessary connexion with vascular congestion or inflammation. Without doubt, however, inflamma- tion or increased vascularity of the neurileme may give rise to the disease; and it may, I think, be assumed as a fact, that neu- ralgia may depend on different causes—on local inflammation or congestion of the affected nerve—on organic disease of the brain —and most commonly on a sympathetic irritation, from latent irritation in other parts or organs. Diagnosis.—The diagnosis of neuralgia is not, in general, attended with difficulty, unless it be seated in the internal organs. The pain, as has been stated, is darting, extremely acute, parox- ysmal, and usually transient, coming on with the suddenness of an electric shock, and ceasing as instantaneously. These circum- stances, together with the exceeding aptitude of the slightest touch or motion of the affected part to renew the paroxysm of pain, and the entire absence of swelling or inflammation, and usually of heat in the part, and finally, the transient radiations of the pain along the course of the nerves, are sufficient to distinguish this disease from other painful affections. Treatment.—The mode of treatment must of course be di- versified, according to the nature of the exciting cause, and the extent and situation of the neuralgic affection. A case produced by local injury of the nerve, will scarcely yield to the same treat- ment that will be required for one which arises from the influence of miasmata; and an instance depending on this latter cause, will probably yield to remedies that would fail in one which originates from gastric irritation, and a general morbid irritability of the system. Formerly, considerable reliance was placed on dividing the affected nerve ; but although no inconsiderable number of cases have been related, where this operation effected a cure, it is but seldom that it can be resorted to, on account of the number and situation of the affected nervous ramifications ; and where the disease depends on a sympathetic irritation, or a local injury nearer the origin of the nerve than can be reached with the scal- pel, there would appear to be but very little or no chance of ad- vantage from this measure. Mr. Swan, in speaking of this ope- ration when the portio dura is affected, says, that the attempt to divide the trunk of this nerve is not only attended with much difficulty, but also with danger ; and "to divide all the branches that go to the face, requires an incision from the zygoma to the angle of the jaw. The greatest portion may be divided by making an incision down to the jaw, a little below the zygoma, and thus the main branches of the nerve will be cut through ; and if the patient is not relieved by the operation, another incision may be made quite to the angle of the jaw, by which nearly all the prin- cipal branches will be divided." When the disease is located in NEURALGIA. 191 the third branch of the trigeminus, in which case the pain is felt in the side of the tongue and the teeth, the attempt to divide the nerve would be dangerous. When, however, the pain occurs in the lower lip, the nerve may be divided as it passes out of the lower jaw, by passing the point of a knife between the lip and the bone at the first bicuspid, down to the foramen, and moving it a little from side to side.* Notwithstanding the difficulty and hazard of dividing the trunk of the portio dura, a very interest- ing example of the performance of this operation, by Dr. Warren, of Boston, is related in the sixth volume of the Medical Recorder. The patient had laboured under the disease for fourteen years, and had already undergone the operation of dividing the infra- orbital nerve, and the first branch of the trigeminus. The pain passed from a point near the ear over the side of the face. " A dissection was made between the back part of the parotid gland, and the mastoid process," the nerve exposed, and a portion re- moved. The pain nevertheless returned. He now cut down over the side of the jaw, through the parotid gland and masseter muscle, removed a portion of the bone with the trephine, and exposed the nerve where it enters the lower jaw, and removed a piece half an inch long. This completed the cure. In cases of neuralgia in the nerves of the extremities, the re- moval of a portion of the affected nerve has been practised with success in no inconsiderable number of instances. Mr. Earle has reported a case,t where the complaint was cured by cutting out a portion of the nerve ; and Mr. Abernethy cured a case seated in the integuments of a finger, by removing about half an inch of the digital nerve. The propriety of removing, instead of merely dividing the nerve, is founded, in part, on experience, and on the fact ascertained by Sir Everard Home and others, that when a nerve is merely divided, and the extremities left close together, they regain the power of transmitting the nervous influence in a few days. M. Lisfranc cured a case of neuralgia of the scalp, caused by an external injury, "by removing an oval piece of scalp, including the seat of the pain, three inches in length, and two in breadth."f The practice of dividing the neuralgic nerve, has, however, so frequently, we may say, so generally, failed, than it is now almost entirely abandoned by practitioners. Where the disease is confined to a single branch, and arises from local irritation, it may, nevertheless, be resorted to with some prospect of success ; and ought most assuredly to be employed, where all other remediate measures are ineffectual. In recent cases, depending on a constitutional cause, where the * Loc. citat. p. 56. f Med. Chir. Transact, vol. vii. t Med. Chir. Rev. July, 1826. 192 NEURALGIA. paroxysms recur periodically, tonics, particularly quinine and arsenic, will most frequently remove the disease. Instances of this kind, as has been stated, are generally of malarious origin, and will commonly yield to the same mode of treatment that is usually adopted for the removal of intermitting fever. Indeed, neuralgia of this kind sometimes disappears spontaneously, just as intermittents are known to do, without any medicine. About two years ago, I attended a lady labouring under quotidian pa- roxysms of the most excruciating neuralgic pains in the portio dura. The autumn previous she had been affected with protracted intermittent, and as she had taken a great deal of quinine, which always affected her head very disagreeably, she now obstinately refused to take it. I therefore directed a blister to be laid on the epigastrium, and put her on a very simple farinaceous diet. In three days the neuralgia ceased, and has not troubled her since. Dr. Macculloch, whose experience in cases of this kind appears to have been very extensive, says that the Peruvian bark and arsenic are decidedly the most efficacious remedies in intermit- tent neuralgia ; and this observation is confirmed by the expe- rience of others. Mr. Shaw has used bark with marked success in neuralgic complaints; and Dr. Kerrison asserts, that, according to his experience, cinchona is the most useful medicine we pos- sess in cases of this kind. M. Vaidy also cured an instance of facial neuralgia, which came on with extreme violence every day at 12 o'clock, and lasted four or five hours, by means of the cin- chona.* Five or six years ago, I met with a few cases of well marked intermitting facial neuralgia, which yielded readily to large doses of quinine; but in one instance, of a strictly quotidian type, which more recently came under my care, neither this re- medy, nor arsenic, made the slightest impression on the disease. Many cases might be collected from recent medical publications, illustrative of the good effects of tonics in periodical neuralgia. MM. Ribes and Dupre have reported an interesting case, which was speedily removed by the quinine ;\ and M. Piedagnel, suc- ceeded in a very short time in curing this affection with this tonic. \ Dr. Lalaurie, physician to the Central House of Correc- tion at Eysson, has related an instance of neuralgia which origi- nated from a puncture of a ramification of the frontal nerve, and which had continued for ten years. The attacks came on peri- odically. The patient was ordered to take every morning the sixteenth part of a mass, composed of a drachm of white soap and a grain of arsenious acid; drinking immediately afterwards three cups of water containing mucilage and honey. This was * Journal Complement, December, 1820. f Magendie's Journal de Physiologie—1822. % Lond. Med. Repository—1821. NEURALGIA. 193 repeated every other day, and in two weeks the disease was en- tirely removed. From the observations that have been published, it appears, therefore, that in intermittent, quotidian, or tertian neuralgia,—and in these only, do the tonics just mentioned mani- fest any particular curative powers; and in all such cases, whether originating from general or local causes, they ought certainly to be fully tried before recourse is had to other modes of treatment. No article of late years has attracted more attention as a re- medy in neuralgia, than the carbonate of iron. Mr. Hutchinson has published a small work on tic douloureux, in which he relates a considerable number of well marked cases, that yielded to the powers of this remedy.* It has also been used with success in this affection, by Mr. Richmond,t Dr. Crawford,% Dr. Evans, § Dr. Brothwick,|| Dr. Davis, Dr. Yeates, Dr. Ay re, Dr. Marsden, Dr. Payne, Dr. Marshall Hall, and others. The cases related by Dr. Evans furnish very striking testimony of the sanative powers of this article, even in very protracted instances, and of great severity. It should be given in large doses—from one to two drachms, three times daily. This remedy appears to be best adapt- ed to intermittent cases, attended with debility of the digestive powers. It is not, however, superior to the quinine or arsenic in such cases. I have in several instances resorted to it, but only with partial advantage. In one of these cases the disease was afterwards removed with the quinine. Some of the narcotics, also, have been strongly recommended for the cure of neuralgic affections. The stramonium, especially, possesses very considerable powers against such pains. It was some years ago recommended by Dr. Marcet, as a highly valuable medicine in these and other painful affections unattended with an inflammatory diathesis, and it is unquestionably entitled to much attention as a remedy in cases of this kind. Dr. BigbeelT has pub- lished a paper, illustrative of the valuable powers of this article in painful affections of the nerves, and we have also the testimony of Dr. Elliottson, among others, in favour of its virtues in neu- ralgic complaints.' * I have employed it in four cases of recent neuralgia, in two of which I succeeded, in the course of three or four days, in completely removing the disease. One fourth of a grain may be given every four hours, until vertigo is produced, when its use must be omitted, and resumed as soon as the vertigo * Cases of Tic Douloureux successfully treated. By B. Hutchinson. London. 1820. f Lond. Med. and Phys. Journ. No. cclxxi. p. 271 * Ibid. 1823. § Edin. Med. and Surg. Jour. Jan. 1824. 1 Ibid. 1 Edin. Med. Chir Tians. vol. i. p. JSJ " Med. Chir. Rev. June, 1828. Vol. II 25 194 NEURALGIA. subsides. It has appeared to me most effectual in cases attended with, and probably mainly dependent on, a general irritable con- dition of the nervous system, or in what may be termed hysteric neuralgic pains. It must not be forgotten, however, that when given in repeated and active doses, it is very apt to produce a species of maniacal delirium, strongly resembling delirium tre- mens. In two instances, in which I prescribed it for chronic rheu- matism, it had this effect. The belladonna, too, has had its advo- cates as a remedy in neuralgic complaints; but its powers arc certainly much inferior to those of stramonium in this respect. Mr. Todd states that he has cured several cases of painful affec- tions of the nerves, by the external application of a strong aque- ous solution of the extract of belladonna to the skin over the affected part. In one instance, where the pain was experienced along the course of the sciatic nerve, from the hip to the foot, almost immediate relief was procured by rubbing the track of the pain with a solution of two drachms of the extract of belladonna in an ounce of water. Another instance, of a similar character, was gradually removed in the same manner. * Mr. Baily speaks highly of the powers of this narcotic in affections of this kind. He has related nearly thirty cases in which this medicine was found more or less successful. Of the extract, he began with three grains, and repeated it in diminished doses until relief was procur- ed. In some instances he employed the tincture. The oil of turpentine, likewise, has been used with success in certain neuralgic affections. M. Sedillott cured several instances of sciatic neuralgia, by administering this article in drachm doses once or twice daily; and Dr. Wilson, in a communication to Dr. Johnson, states, that " in three cases of neuralgic disease which had lately come under his care, a cure was effected by the com- bination of calomel, opium, and the oil of turpentine." A pill, containing from two to four grains of calomel, and one or two grains of opium, was given each night at bed-time, and next morning, one or two drachms of oil of turpentine, mixed with a little honey. In each of the three cases, a complete and permanent cure was effected by this plan, and in a moderate space of time. It is more especially in sciatic neuralgia, however, that this arti- cle has been found particularly efficacious ; although it has also been used with success in other varieties of the disease. M. Mar- tinet has published a paper on the use of this remedy in neuralgic affections of the hip and extremities, in which he asserts, that of seventy cases, fifty-five were cured by the internal administration of turpentine ; and many of these cases had previously been sub- • Transactions of the Surgeons-Apothecaries, vol. i. article vi. On the Treat- ment of Painful Affections of the Nerves, arising from Local Injury. By George R. Todd, Esq. &c. f Medico-Chir. Review NEURALGIA. 195 jected to various other modes of treatment, without advantage.* M. Recamier, of tbe Hotel Dieu, also, speaks in high terms of the efficacy of the oil of turpentine in neuralgia. Leeching has of late years been employed in neuralgic affec- tions; and from some accounts that have been published, it would appear that benefit may be derived from this measure in certain cases of the disease. Without doubt, where the malady depends on an inflammatory condition of the nerve or its neurileme, the local abstraction of blood is well calculated to do good ; but it is by no means probable, I think, that any advantage can be derived from this measure in cases connected or dependent on constitu- tional causes, and there are instances on record where it did much harm, as in the remarkable case related by Dr. Yeates.t M. Vaidy has reported cases which were cured by the application of leeches along the course of the nerve, (loc. cit.) Of the local applications that have been employed in this affec- tion, moxa is, without doubt, the most efficacious. Larrey relates cases that were removed by this remedy; and Dr. Barras has given an account of a case of neuralgia of the spermatic cord, which yielded to this application. M. Feron has reported a highly interesting instance of neuralgia of the ulnar nerve, which was removed almost immediately by the application of moxa near the elbow. In four or five months, however, the disease returned ; but the moxa now procured only a temporary mitiga- tion of the patient's sufferings. Larrey advises that the moxa be applied repeatedly, if the first applications afford only partial re- lief. He has repeated the burning ten or twelve times, and fol- lowed the pain with the moxa wherever it fixed itself, before the disease was completely subdued. M. Vaidy has mentioned a case of neuralgia of the sciatic nerve, from the hip to the foot, which was speedily and permanently removed by a light bandage applied over the whole extremity. Acupunctural ion has also been resorted to with success in this painful affection. M. Pelletan relates a considerable number of neuralgic cases that were completely cured by one or two opera- tions of acupuncture. It does not appear, however, that it has yet been employed with success in facial neuralgia. In the cases mentioned by M. Pelletan, the crural, the sciatic, and the plantar nerves, and in one instance the superficial nerves of the chest, were affected. J A case of facial neuralgia is related by Mr. Beddingfield,§ in which the application of cerussa, with the view of paralysing the • Revue Mldicale, Nov. 1828, p. 222. f A History of a severe case of Neuralgia, occupying the nerves of the rieht thigh, It-g, :uid foot. * * K.vue Mfdicale, Janvier, 1825; and Archives Generates, Fevrier, 1825. $ Compendium of Medical Practice. 196 NEURALGIA. affected nerve, proved entirely successful. The case was under the direction of Sir Astley Cooper, and had previously resisted every other remedy. Two scruples of the cerussa, formed into an ointment, were rubbed on the affected cheek every morning, about an hour before the paroxysm was expected. By continuing this application daily for a month, the disease was completely removed. The application of a strong magnet, also, has, in a few instances, promptly removed the pain in neuralgia of the face. M. Alibert, in his treatise on materia medica, mentions some examples of this kind; and a remarkable case of this kind occurred in my own practice about eighteen months ago. A gentleman of this place daily experienced the most agonizing paroxysms of neuralgic pain in the ramifications of the portio dura. Quinine, the carbonate of iron, arsenic, and belladonna, were used, but without the least advantage. At last I sent him a strong horse-shoe magnet, and directed him to keep it applied on the side of the face, so as to bring the two poles opposite to the meatus auditorius. lie did so. In about two hours after the magnet was applied, the pain became more severe than ever, so as nearly to deprive the patient of his consciousness. Suddenly, however, the pain ceased entirely, and I found him calm and cheerful in the evening. On the fol- lowing day the magnet was again applied, and the paroxysm was very slight, and not more than one third the usual duration. In the course of five or six days further, the disease was wholly re- moved. Was this a mere coincidence, or did the magnet control the neuralgic irritation ? It is certain that intermitting neuralgia sometimes terminates spontaneously, and it is possible that this may have been the case in the present instance. Within a few years past, much attention has been directed to the origin of the spinal nerves, in neuralgic affections of the trunk and extremities of the body. From the interesting observations of Teale* and Tate,t it appears, that in many cases of neuralgic pains in the chest, abdomen, and extremities, much tenderness to pressure exists in the region of one or more of the vertebrae. They assert, that the application of leeches, or cups, or, as Teale particularly recommends, tartar emetic ointment, so as to cause pustulation over the tender part of the spine, will very generally speedily remove the painful affection. They report some striking cases of the value of this practice; and the recent periodical me- dical publications furnish interesting testimony from other sources, in confirmation of their experience. An attention to proper dietetic regulations, and to the restora- tion or maintenance of the regular action of the liver and bowels, * Teale, On Neuralgic Diseases. \ Tate, On Hysteria, &c. NEURALGIA. 197 is of much importance in affections of this kind—more especially where the disense is attended with manifest symptoms of gastric derangement. Gastralgia.*—For mitigating or removing this painful and distressing affection, which appears to be purely neuralgic, various remedies have been recommended; but they have seldom afford- ed more than temporary relief. Opium in full doses will indeed always procure perfect ease for a time ; and there are few who are much affected with this complaint, that do not find it neces- sary to resort to this narcotic. The misfortune, however, is, that those who have once experienced the delightful effects of this medicine when suffering under an attack of gastrodynia, will re- peat, it again and again, whenever the pain returns, and as the dose must be progressively augmented, the unfortunate sufferer will almost inevitably contract a habit of taking it in enormous and ruinous quantities. Dr. Dawsont observes, "it may be said that opium is a great evil; it is so; a most painful necessity; but it is a far greater evil to pass one half of life in excruciating pain, and the other half in miserable anticipation. The gastrodynic sufferer has a choice of evils; for him there is no middle path ; he must either contentedly endure a pain which makes life a burthen, and ren- ders talents useless, or take opium; for where is the man, who, racked with pain in his stomach night and day, can perform his duties in society, and enjoy life as it ought to be enjoyed?" Un- questionably the effects of large doses of opium in this distressing malady are delightful for a time; but I am by no means disposed to regard this drug as the only means in our power for procuring relief in cases of this kind. I have myself suffered much from this complaint, and have taken opium in large doses; but I have found another remedy, which is less ruinous in its consequences, and far more permanent in its good effects, than this narcotic. • Although I have already described this affection, I may add the following description of its symptoms, as given by Dr. Dawson. " The time and accession of the paroxysm, and the duration of it, are alike uncertain. A hearty meal, or a copious drink of a stimulating fluid, will sometimes bring temporary relief. The pain is aggravated by walking, and slightly mitigated by reclining on the left side and applying pressure by the hand. In some cases the pain is always in the stomach only ? but in others, it does, occasionally, for a short period, quit that organ, and, as it were, fancifully and indifferently affects the back, sides of the spine, or the integuments covering the sternum and ribs. The pain itself is of a peculiar and even of a varying nature. It is not acute, it is not lancinating, it is not spasmodic, it is neither sickening nor dragging. It is of an excruciating aching kind, and of the most soul depressing nature, fhave known a gentleman he on the floor in agony, and have three distinct attacks, of three, four, or six hours, during twenty-four hours. Sometimes the stomach feels empty; at others it seems distended, and gives rise to bitter or saltish eructations. Vet the patient, even on the rack of pain, is not ill; and the instant the pain ceases he is as well :is he could wish." t Nosological Practice of Physic, p. .300. 198 NEURALGIA. This remedy is the saturated tincture of lobelia inflata; a few table-spoonfuls of which has never failed to give me speedy re- lief, and to procure me long intervals of exemption from the dis- ease. I have also used it in the case of a gentleman in this city with the happiest effect, but further than this my experience with this article does not go. The oxyde of bismuth, the carbonate of ammonia in conjunction with magnesia and mint water, the tinc- ture of henbane, and the sulphate of quinine, with a diet consist- ing chiefly of animal food, have been recommended in this affec- tion, and in some instances considerable benefit may no doubt be derived from them. I have prescribed the oxyde of zinc in a number of cases, and occasionally with advantage. Would not the use of the magnet, in the manner recommended by Laennec for the cure of angina pectoris, be beneficial in this complaint? I have just mentioned animal food, as, according to the experience of some, (Dr. Johnson,) most proper in cases of this kind. This may be correct with regard to some instances ; but I have found it best to make as great a change of the customary diet of gastro- dynic patients as could be done. Thus, if a person has been in the habit of using much animal food, he should be put upon a simple vegetable diet; and where the accustomed diet has been vegetable, which is most commonly the case, it should be changed to one consisting chiefly of animal substances. It has appeared to me that this affection is often connected or dependent on an ineffectual hsemorrhoidal effort; and advantage might perhaps be obtained from leeches applied to the anus, and the internal use of small doses of aloes. I have been led to this conjecture by the case of a lady in this city, who, for six years, suffered from fre- quent extremely severe attacks of gastralgia, radiating along the muscles of the chest, into the left mamma. About a year ago, several large hemorrhoidal tumours appeared at the extremity of the rectum, and in a short time began to bleed freely. The discharge has recurred every three or four months, and she has not had an attack of the gastralgia since the haemorrhage first appeared. Sect. II.—Amaurosis. This disease consists in a diminution, or total loss of sight, from impaired or abolished sensibility of the retina to the impres- sions of light, or from decreased or lost power in the optic nerve to convey the visual impressions from the retina to the sensorium commune. This impairment, or loss of sensorial function of the optic nerve, and its expansion, may depend either on organic disease of the retina, optic nerve, and thalamus, or merely on functional torpor. AMAUROSIS. 199 or palsy of these parts, without any perceptible structural lesion. Among the organic affections of the optic apparatus, which give rise to this disease, the following are the principal. Extravasation of blood ; opacity; structural lesion, and deposition of lymph upon the surface of the retina; fungous, or other morbid growths; dropsy, and atrophy within the eye; and all such disorganizations as directly oppress or derange the texture of the retina; and, lastly, morbid conditions within the head, oppressing or disor- ganizing the optic nerve or its thalamus—as sanguineous or serous effusions, tumours, suppurative destruction in the vicinity of the optic nerve or its origin, and thickening, atrophy, absorption, or ossification of its sheath.'* The causes which are capable of suspending or destroying the functional powers of the retina and optic nerve, independent of perceptible organic change, are extremely various. Functional torpor of the optic apparatus may depend either on vascular tur- gescence of the retina of the sheath of the nerve, or of its tha- lamus, or on deficient arterial circulation in these parts; or finally, it may be the result of an idiopathic paralysis, or loss of senso- rial power of the retina and its nerve. When the organic disorder that produces the amaurosis is seat- ed in the eye-ball itself, several, or all of the following pheno- mena accompany the disease :—namely, dilated pupil, its con- tracting power being feeble or null; congestion of the veins of the conjunctiva ; a bluish grey tint of the sclerotica ; loss of re- gular shape of the globe of the eye, the sides either bulging out or appearing flattened ; a turbidity or milkiness in the posterior chamber of the eye, "resembling the humours in the eye of the horse." hi many instances of organic amaurosis, a small circu- lar spot of a pearly or greenish yellow colour may be seen at the fundus of the eye, a small distance from the visual axis.t When the disease is the consequence of inflammation of the retina or choroid coat, and the inflammatory action has entirely subsided, we usually find the conjunctival veins varicose, the iris discolour- ed, thick, very vascular, and inelastic; the bulk of the crystalline lens diminished, or liquefied and discoloured, with opacity and deep yellow colour of the vitreous humour. (Travers.) In such cases there is usually a feeling of tension, and, at times, of un- easiness, but rarely any distinct acute pains in the globe of the eye, and the sclerotica becomes thinner and semi-transparent, admitting the reflection of the vascular texture of the choroid • Travers. Synopsis of the Diseases of the Eye, p. 141. | " This appearance has been attributed to a circumscribed opacity of the re- tina, answering to the porus opticus. Others have supposed it to be the macula lutea of Soemmering. It is, however, with more propriety, ascribable to a dimi- nished secretion of the black pigment."—Stevenson on the Nature, Symptoms, and Treatment of Amaurosis. 200 AMAUROSIS. coat, which occasions the above-mentioned bluish grey tint of the sclerotica. (Stevenson.) In some cases of organic amaurosis, an opaque white spot, or projecting whitish substance, may be seen on some part of the concave surface of the retina, when the eye is examined in a good light. This constitutes the medullary fun- gus of the retina, which, in the progress of the disease, involves the eye in one undistinguishablc disorganized fungous mass. Functional amaurosis, as has just been said, sometimes depends on vascular turgescence of the optic apparatus. In such cases the pupil is dilated, sluggish in its motion, or immoveable; more or less strabismus, ptosis, or double vision of the affected eye, often exists ; the carotids beat strongly; the face is apt to be flushed ; a sense of fulness and tension in the globe of the eye is felt, with pain, and a feeling of pressure of the scalp ; occasional ringing in the ears ; disorder and irritability of the stomach; and somno- lency. Luminous sparks or flashes appear before the eyes, par- ticularly on stooping, straining, or on first lying down. (Travers.) These cases sometimes come on suddenly. Mr. Stevenson has known several instances, in which the patients went to bed appa- rently well, and awoke with more or less complete loss of sight in one or both eyes. Functional amaurosis from depiction occurs sometimes imme- diately after excessive haemorrhages, particularly uterine flood- ings. In this variety, as in that which arises from vascular con- gestion, the pupil is dilated and immoveable, and there is usually deep-seated pain in the head, and occasional vertigo. This pain is attended with a feeling of circumscribed pressure on some part of the brain, accompanied sometimes with a jarring noise, "like that of a mill or threshing floor." In cases resulting from this cause, there exists, in fact, strong vascular congestion in the head; for there is no pathological fact better established, than that strong determinations to the head often supervene as the immediate con- sequence of excessive sanguineous discharges.* It is of much im- portance to distinguish this from the former variety in a therapeu- tic point of view;—for, amaurosis from excessive sanguineous evacuations, is always increased by even small abstractions of blood ; whereas that which is attended with a plethoric state of the system, demands sanguineous evacuations. Symptoms.—Functional amaurosis usually comes on very gra- dually. The patient at first complains of some weakness of sight When he looks at small objects, as, for instance, the letters of a book, he finds that his vision is variable and irregular—the letters " being at one time more distinctly visible than at another, the * See the observations of Marshall Hall on this subject, in his " Medical Es- says." The experiments of Dr. Seeds on the effects of excessive abstractions of blood in animals.—Med. Chirurg. Jour. No. VI. p. 107. AMAUROSIS. 201 sight of which he alternately loses or regains by shutting or rub- bing his eyes, or by moving his head in different directions." Sometimes the approach of the disease is announced by a pecu- liar dimness of sight, as if a fine piece of gauze or spider's web were held before the eyes ; at others, by the perception of spots, threads, or other imaginary appearances floating in the air a short distance from the face ; and at a more advanced stage of the dis- ease, coloured spectra, or luminous impressions of objects remain- ing upon the retina, often occur. Sometimes the objects looked at appear to have a tremulous or wavering motion. Connected with these symptoms, there is generally more or less pain in the head and temples, diminishing in proportion as the dimness of vision increases, and ceasing altogether when the amaurosis is complete. When the pain continues severely, with but slight re- missions, and is readily aggravated by whatever excites the system, we may presume that it is connected with organic disease within the brain ; and such cases are almost invariably accompanied by torporof the bowels; gastric derangement; disposition to lethargy; occasional confusion of mind; indisposition to corporeal or mental exertion ; and paralysis in one or more of the muscles. In some cases, very severe spasmodic pains occasionally shoot through the eye into the head, coming on every night, or second night, about the same time, and continuing an hour or two, and "is accompanied with convulsive quivering of the muscles of the eye and eye-lids, and profuse lachrymation." Some patients affected with incomplete functional amaurosis, see more distinctly on first waking in the morning; and in others, the sight is clearest in the evening. (Travers.) When one eye only is affected, the iris, in functional amaurosis, will generally act in accordance with that of the sound organ, "provided both be allowed to remain open at the same time ; but if the latter lie closed, the pupil of the diseased eye will be found to have lost its power of motion on the admission of the usual degrees of light."* In the majority of cases, the pupil is dilated and immoveable ; and frequently misshapen or irregular. It is some- times smoky or clouded, or dark grey, or greenish grey, and occasionally of a reddish or yellowish white appearance. Diagnosis.—Immobility and dilatation of the pupil furnishes no certain evidence of amaurosis. In some cases of complete amaurosis, though indeed very rarely, the pupil acts regularly; in others, it retains its ordinary size, but is motionless;! and in others, it is fixed and contracted:X Moreover, the ciliary nerves • Loc. citat. p. 68. \ M. Travers is of opinion, that, in cases of complete amaurosis, where the pupil is of the natural shape, but motionless, the retina has, most probably, un- dergone some structural change. * When this is the case, says Mr. Stevenson, the disease is jrenerally the result Vol. II. 26 202 AMAUROSIS. may be paralysed, occasioning enlargement and immobility ol the pupil, without amaurosis. Among the symptoms which may aid us in distinguishing amaurosis from cataract, writers particularly mention the different appearances which the flame of a candle presents to persons labouring under one or the other of these dis- eases. To a person affected with the latter disease, the flame of a> candle appears as if it were surrounded with a uniform thin mist, or white semi-transparent cloud ; to one labouring under the former affection, an iridescent halo seems to encircle the flame, or to emanate from the mist. In imperfect amaurosis, the faculty of vision is occasionally increased or diminished, "under differ- ent states of the circulation, as influenced by a full and stimulant meal, by which some find their sight improved, others greatly deteriorated. Enlivening or distressing mental emotions, and other physical causes, that have a tendency to excite or depress the energy of the nervous system, have a correspondent effect in affording temporary benefit, or in causing diminution of vision, which does not occur in cases of incipient cataract.9' Prog?wsis.—Those cases which depend on organic lesion, may be regarded as incurable ; where, with total loss of sight, the iris is immoveably dilated, or preternaturally contracted, accompanied with violent pain in the head, or eye, or cranium; when the dis- ease occurs as a consequence of apoplexy, blows on the head or eye, syphilis, or protracted internal ophthalmia ; and in cases where the above-mentioned whitish projection appears at the bottom of the eye, little or no hopes of a cure can be entertained. Where, on the contrary, the amaurosis is not complete, and no severe and protracted pains in the head or eyes, or sense of con- striction in the eye-ball, accompanies the development of the dis- ease ; and where, at the same time, the pupil retains its natural shining black colour, and some degree of sight still remains, there is reason to expect relief from remediate management. Periodi- cal amaurosis, also, unless of very long standing, is of a favoura- ble character ; and, in general, all those instances of the disease which are purely functional, or symptomatic of visceral irritation, or metastasis of gout, rheumatism, &c. may be regarded as sus- ceptible of being cured. Causes.—When amaurosis is not the result of organic or struc- tural disease of the optic apparatus, it arises, probably, in most instances, from pressure on some portion of the visual nervous texture. Even in those cases which occur in consequence of ex- cessive losses of blood, vascular turgescence, and pressure of the retina, optic nerve, or its thalamus, is, perhaps, the immediate of inflammation of the internal ocular textures, and is usually attended "with an angular or irregular form of the pupillary border in one or more points of the circumference, and with an opacity of the capsule of the crystalline lens." AMAUROSIS 203 cause of the disease I have already adverted to the great ten- dency fo cephalic congestion in that exhausted state of the system which results from profuse haemorrhage, and in this state, vascular congestion of the capillary vessels of the retina, and consequent pressure of this structure, may, it is to be presumed, readily occur. It may, nevertheless, in some instances, depend also on mere functional torpor, from previous over-excitation of the retina and optic nerve, or from the vitality of the nerve being too much depressed. * It would appear, from the observations of pathologists, that persons who have dark-brown, blue, or black eyes, are, in gene- ral, much more liable to amaurotic affections, than such as have light-coloured, or grey eyes. It has been stated, that the propor- tion of instances of this disease in dark-eyed persons, is to that of the cases which occur in individuals with light, or grey eyes, as twenty-five to one.t The exciting causes of amaurosis are very various. It may depend on metastasis of other affections, particularly of gout, and from the sudden suppression of habitual sanguineous or serous evacuations ; as of the catamenial or hemorrhoidal discharges ; the healing up of old ulcers ; and the sudden retrocession of cu- taneous eruptions ; and of habitual perspiration of the feet. It is sometimes symptomatic of hysterical, epileptic, hypo- chondriacal, and other nervous affections, (Beer;) arises from the excessive use of narcotics, as well as from the poisonous influence of lead; is the result of abdominal irritation, from a loaded state of the bowels ;X suppressed, or deranged, or excessive secretions in the liver, kidneys, or uterus; intestinal worms; and dyspeptic affections. Sudden mental emotions, particularly rage, terror, and protracted grief, sometimes produce this disease. The sudden suppression of the secretion of milk in the puerperal state has produced it ; and it has arisen from rapid and copious salivation ; from excessive venereal indulgence, particularly habitual self- pollution ; from intoxication ; and from the sudden influence of cold. Anions |he most common external causes of amaurosis, is intense application of the eye to the inspection of minute and bright objects§—which, Mr. Stevenson thinks, tends to produce • Wcller. Manual of the Diseases of the Human Eye. \ Jahn's Klinik der Chronischcn Krankh. Bd. v. p. 295. t Dr. Wishart lias related an interesting case of amaurosis in the Edinburgh Medical Journal for July, 1825, which was manifestly the consequence of intes- tinal irritation from indurated fecal matter. § " Hence the frequency of weakness of sight among silk stocking weavers, milliners, embroiderers, and other mechanics and artists whose occupations oblige them to exercise their visual organ with too little intermission and variety, in looking intently tit their delicate, light-coloured, and highly illumined manipu lations. Persons addicted to read, write, or perform much fine needle-work by the aid of candles, and what i* much worse, by the brilliant and artificial light 204 AMAUROSIS. preternatural vascular turgescence in the retina and choroid coat. It may also be occasioned by falls or blows on the head; insola- tion ; straining in parturition; evacuating the feces; or lifting— in short, by whatever is capable of causing preternatural san- guineous determinations to the head. The occurrence of symp- tomatic amaurosis from excessive loss of blood, has already been mentioned. Mr. Travers, and Dr. Hall,* relate some remarkable examples of this kind. Treatment.—When amaurosis arises from organic disease of the visual organ, or the brain; or from epilepsy, or in consequence of violent forms of fever, and other acute constitutional diseases, nothing is to be expected from remediate treatment. The func- tional, or symptomatic varieties of the disease, however, will often yield under a proper course of management. The treatment of amaurosis must of course be modified accord- ing to the nature of the occasional cause ; and the removal of the primary irritating cause ought to be the first object in prescribing for this disease. Mr. Travers remarks, that the treatment of amaurosis is almost entirely constitutional; and he attaches no value to the external application of stimulating vapours, lotions, ointments, and etherial embrocations, &c. although setons, leech- ing, and blistering, are important auxiliaries. Upon this point, however, Mr. Stevenson, as well as many others, differ widely from Mr. Travers. The former agrees with Mr. Ware in regard- ing errhines as often particularly useful in chronic functional amaurosis ; and he thinks favourably of the use of stimulating applications to the eye, in cases unattended with fever, or local vascular irritation in the eye. When the momentum of the circulation is preternaturally in- creased, and the eye is somewhat tender and irritable, and par- ticularly when the habit is robust and plethoric, the treatment should be commenced by both general and local abstractions of blood. " Bleeding, in the early stage of acute amaurosis," says Dr. Stevenson, " is the sheet-anchor of our hopes. It should be repeated," he says, "at short intervals, until the^tiolence of the symptoms shall have been moderated." Immediate attention must also be paid to the bowels. So long as the general habit is phlogistic, free purging with calomel, succeeded by a portion of Epsom or Glauber's salts, should be practised every second or third day, and antimonials, in nauseat- ing doses, administered during the intermediate time. In relation to the employment of sanguineous evacuations in this affection, of lamps, rarely fail, if their organ of vision be constitutionally feeble, to dis- cover, sooner or later, the greater or less decay of sight."—Stevenson, Loc. cit. p. 121. • Researches, principally relative to the Morbid and Curative Effects of Loss of Blood, p. 71. AMAUROSIS. 205 Mr. Travers observes, that although obviously proper in cases attended with general plethora and cerebral compression; yet where the undue determination of blood to the eye is attended with diminished tone of the vessels of this organ—a circumstance very common, he says, after deep-seated inflammation, or irrita- tion and relaxation from over-excitement—depletion is always decidedly detrimental. In cases of recent imperfect amaurosis making rapid progress, and attended with signs of obscure inflammation, the employment of mercury, so as speedily to produce soreness of the gums, but not salivation, will sometimes suddenly arrest the disease. Mr. Travers asserts, that salivation does no good, and may readily prove hurtful. "When mercury is beneficial," he says, "its efficacy is perceived as soon as the mouth becomes sore." When the pupil shows a disposition to contract, or has actually formed adhesions with the capsule of the lens, the application of bella- donna, or stramonium in solution, to the eyes, says Mr. Steven- son, "must on no account be omitted," in order to prevent per- manent contraction and obliteration of the pupil. The light should be excluded from the eyes where there is ten- derness and irritability of the organ; and all kinds of compress- ing or tight bandages be carefully avoided. When the local and general excitement has been moderated, or where the disease from the beginning is free from manifest gene- ral vascular irritation, revulsive applications, particularly blister- ing, or a seton on the nape of the neck, and leeching at the tem- ples, and around the eye, may be resorted to with advantage. In conjunction with the occasional employment of these external means, alterative and aperient remedies should be regularly used, until there is reason to think that the healthy condition of the visceral functions is restored. For this purpose, a great variety of remedies has been recommended, but the use of four or five grains of blue pill, with two grains of ipecacuanha at night, on going to bed, and a dose of rhubarb, or of the compound extract of colocynth, every second or third day, will probably do all that can be effected in this respect* Benefit may also be derived with this view, from the frequent use of very minute portions of tart. antimony, dissolved in an infusion of sarsaparilla, or of the root • Schmucker's visceral pills were formerly much employed in Germany for the cure of this disease. They are made according to the following formula. R. G. Sagapen.—Galban.—Sapo. venet. aa 31. Pulv. Rhxi ^iss. Tart. Emetic gr. xvi. Succ. Glycyrrh. 31. Piant pill, singul. gr. v. Of these pills, three are to be taken every morning and evening for a month. Richter recommends the following pills: R. G. Ammon.—Assafoetid.—Sapo. venet.—-Rad. Valerian.—Sumitat Amicx.— aa z„ Tart. Emetic, gr. xviii. Fiant pill, sing. gr. v. Six to be taken thrice daily for three or four weeks. The following combination forms an excellent purgative for this purpose : R. Mass* Hydr. 31. G. Aloes Zss. Tart. Antim. gr. u. Fiant pill, No. xx. Take one every night on going to bed. 206 AMAUROSIS. of burdock (arctium lappa.) A grain of this antimonial may be dissolved in a pint of infusion, and drank in small portions throughout the day. If the visceral functions have been brought to a healthy state, and there is an entire absenco of general and local vascular irritation, recourse should be had to tonic remedies, such as arsenic, bark, iron, and the mineral acids. The eyes should be kept in a state of repose; and the patient be directed to take gentle exercise in the open air when the weather is dry; to use a nutritious but digestible diet, the cold bath, and regular rest When amaurosis is strictly chronic, or devoid of general or local irritated action, general depletion is not only useless, but frequently pernicious. Small abstractions of blood, however, by means of leeches, will sometimes be useful, by relieving the local congestion in the affected organ. In cases of this kind, much advantage may be derived from a seton in the back of the neck, or from the repeated application of blisters to that part. To lessen sanguineous congestion in the eye, some writers recommend the use of errhines, and there can be no doubt of their occasional beneficial influence, by the irritation they produce in the imme- diate vicinity of the affected organ, as well as the consequent in- creased discharge from the mucous membrane of the nose. Some advantage may also, at times, be derived, in cases of this kind, from stimulating applications directly to the eye ; such as the ungt. hydrarg. nitrat., the vapour of volatile alkali; weak in- fusion of eapsicum ; vinous tincture of opium, &c. Electricity does not appear to possess any particular remediate powers in this affection; and it is said to be even frequently injurious. Mr. Travers has not seen a single instanco of benefit derived from electricity. Emetics were formerly much recommended in the treatment of amaurosis, not only for the purpose of evacuating the stomach, but also with a view to their general influence upon the nervous and sanguiferous systems. Mr. Travers does not speak favourably of their effects in this disease. Richter, on the other hand, gives the most favourable account of their influence in amaurosis. That they have been employed with success in some instances, is un- questionable; and, under peculiar circumstances, may, no doubt, be again used with advantage ; although they arc certainly not so efficacious as they were formerly represented to be by physi- cians of high authority. In complete amaurosis, of a chronic or asthenic character, the German writers recommend exposing the eye to a bright light, and even to the direct rays of a meridian sun, with a view of stimulating the palsied retina. Mr. Stevenson says, that he has heard of an instance of the success of this practice; although his own experience does not furnish him with an example of its use- AMAUROSIS. 207 fulness. Mr. Stevenson recommends dry cupping applied to the ball of the eye and its appendages. " By carefully fixing a well adapted strong glass, fitted with an exhausting syringe upon the edges of the orbit, the instrument may be made capable of exert- ing a more or less powerful influence upon the organ of vision, in proportion to the extent to which the atmospheric air contain- ed in the cupping-glass is exhausted. The effect of this application is to occasion a great redness and tumefaction of the eye-lids ; an immediate distention of the conjunctiva; and a bulging for- ward, or protrusion of the whole globe of the eye, the obvious tendency of which must be to relieve the deep-seated vessels." He mentions a few cases, in which this practice was employed with the most decided advantage. Dr. Heathcote, of the Royal Infirmary of Edinburgh, has lately published some cases, illustrative of the good effects of strych- nine in amaurosis. The cases published by Dr. H., occurred in the practice of Dr. Short. The mode in which the strychnine was used in these cases, is as follows : A small blister, about the size of a crown piece, was applied upon the temple or forehead; when the part was vesicated, and the cuticle removed, one fourth of a grain of strychnia, finely levigated, was dusted over the exco- riated surface, and a piece of simple dressing placed over it. The quantity of strychnia applied is to be gradually increased, and the application made daily. Three cases, out of about sixteen, termi- nated successfully under this mode of management. In no in- stance did this remedy cause any injurious effects; although slight headach, giddiness, and twitching of the limbs, were experienced by some of the patients. "In one case, erysipelas of the face occurred, which immediately subsided upon the omission of the strychnia, and the use of opium, which is Us proper antidote." One patient, after about seven grains of the strychnia had been applied, was seized with numbness and immobility of the lower ex- tremities ; but these effects soon gave way to a few doses of opium and aperient remedies. We find, also, a statement in the London Medical Gazette, of five cases treated on this plan in the West- minster Ophthalmic Infirmary. In one case, "evident and con- siderable benefit ensued."* Some modification in the treatment will, of course, always be made by the judicious practitioner, according to the occasional cause of the disease. Thus, when the disease appears to be the consequence of suppressed haemorrhoidal discharge, aloetic pur- gatives, stimulating enemata, and leeching around the anus, are indicated. If it be the result of an arthritic or rheumatic diathesis, advantage may probably be obtained from the internal use of the tinctura guaiaci, or colchicum, and sinapisms or blisters to the • Med. Chir. Rev. July, ldJU, p. 412. 208 AMAUROSIS. ankles. In instances that arise from syphilitic irritation, a slow mercurial course, with infusion of sarsaparilla, &c. will be par- ticularly indicated, and the same remedies arc to be relied on where manifest hepatic disorder is present. If suppressed perspiration lie at the bottom of the disease, the warm bath, diaphoretics, par- ticularly antimonials, both in nauseating and emetic doses, will be appropriate means. In short, the practitioner should always en- deavour to ascertain the cause of the disease, and to counteract or remove this cause, if possible, by an appropriate course of reme- diate management. CHAPTER IV. CHRONIC AFFECTIONS OF THE RESPIRATORY ORGANS. Sect. I.—Asthma. Asthma is a paroxysmal affection of the respiratory organs, characterized by great difficulty of breathing, tightness across the breast, and a sense of impending suffocation, without fever or local inflammation. In the majority of cases, certain symptoms, indicative of gastric derangement, precede, often for several days, the paroxysms of the disease. Among these symptoms, a sense of weight and fulness in the epigastrium, acid eructations, inappetency or voraciousness, heart-burn, flatulency, weight over the eyes, anxiety in the praecordia, and an itching of the skin, are the most common. The paroxysm generally comes on at night during sleep. The patient is seized with great anxiety, difficulty of breathing, and stricture across the breast, and a short dry cough. These symptoms soon acquire a most appalling degree of violence. The breathing becomes wheezing, extremely laborious, gasping, and suffocative, the countenance expressive of intense anxiety and distress, and the heart generally palpitates violently. The desire for fresh and free air is inexpressibly urgent; the patient insists on the doors and windows being Ihrown open ; or he starts from his bed, and rushes to the window for fresh air, and is wholly unable to remain in the recumbent posture. The extremi- ties are generally cool, sometimes of the natural temperature, and moist; the face is bloated and livid or pale, and the veins of the neck and head are turgid. The pulse is often irregular, ASTHMA. 209 intermitting, accelerated, moderately full, and compressible ; sometimes it is nearly natural, and occasionally it is full, active, and firm. After these symptoms have continued for an uncertain time, the breathing gradually becomes less laborious and anxious, and towards morning a copious expectoration of viscid mucus very generally ensues, which always brings with it considerable relief. During the ensuing day, the patient usually experiences but little uneasiness or oppression in the chest. On the next night, however, the paroxysm of suffocative respiration returns; and in this way the disease proceeds, with remissions by day, and violent exacerbations at night, for three or four days in suc- cession, and in some instances much longer, before it finally subsides. During the paroxysm, the urine is almost always pale and copious, and the abdomen distended with flatus. Bree states that the temperature of the body is generally considerably below the healthy standard. He has found the thermometer placed under the tongue as low as 82° during the asthmatic fit He observes, also, that the violence and inconvenience of the paroxysm is equal, whether the stomach be full or empty; but that great distress is experienced immediately after the fit, if the stomach be completely empty. Patients often experience a sensation in the abdomen, about the commencement of the paroxysm, as if an evacuation from the bowels would certainly greatly relieve them ; but this feeling is almost invariably deceptive. No dis- tinct pain is felt, in the chest during the asthmatic paroxysm. Causes.—-Asthma rarely occurs before the age of puberty; yet Dr. Gregory states, that "the period of youth and manhood is most prone to it." If, indeed, we include the acute asthma of Millar, or as it is more commonly called in this country spasmodic croup, under the head of genuine asthmatic affections, as is done by most of the German writers, there can be no doubt of the correctness of this observation; but the spasmodic croup of children, and the true asthma of adults, are manifestly very distinct diseases. It is generally admitted, that a predisposition to this affection is sometimes hereditary. This predisposition would seem to consist in a peculiarly irritable state of the pul- monary system, or more correctly, perhaps, of the pneumo- gastric nerve. That this nerve is the seat of that peculiar con- dition which predisposes to asthma, seems probable from the circumstance, that in persons who are subject to this disease, almost all the organs to which this nerve is largely distributed are particularly liable, from slight causes, to functional derange- ment Thus, there are few asthmatic subjects, who are not especially liable to gastric disorders; as indigestion, flatulent colic, and gastralgic affections. These facts would appear to show that the pneumo-gastric nerve which presides over the Vol. II. 27 210 ASTHMA. functions of the stomach and lungs, is in a state peculiarly sus- ceptible of being thrown into morbid excitement in asthmatic individuals, and~that this condition, has probably an important share in the predisposition in question. Authors have divided asthma into various species, founded principallv on the different characters of the exciting or proxi- mate causes of the disease. Bree has subdivided the disease into four varieties, namely: 1, those cases that are excited by the irritation of effused serum in the lungs: 2, those arising from a gaseous acrimony in the pulmonary cells ; 3, those result ins; from gastric or abdominal irritation; and 4, those depending on habit This division is, however, altogether arbitrary, as it is manifestly founded on gratuitous principles: for its dependence on an aereal acrimony in the lungs, Is a mere hvpothesis: and the effused serum in the lungs, is an effect probably, and not the cause of the asthmatic paroxysm. It is certain at least, that the difficulty of breathing always commences and continues for some time before the effusion of mucus into the bronchial cells becomes copious. Richter describes no less than eleven species of asthma, founded on the character of its prominent exciting causes, namely: asthma hypochondricum et hystericum; .i. plethoricum ; A. urinosum: A. aereum: A. abdominale; A. nocturnum in- cubus; A. metallicum; A. d. causa specifica; A. ex debilitate; A. spasmodicum: and A. acutum periodicum miliari. Some writers assume only three varieties:—the spasmodic. the dry, and the asthma from abdominal irritation. Dr. Good has admitted of but two species, namely: the dry or nervous, and the humid asthma. Such divisions do not, however, appear to possess any essential practical usefulne^s; and the mere dryness or humidity of the cough, cannot, I think, be regarded as of sufficient importance to form the basis of a pathological distinction. As symptoms, they unquestionably deserve attention; and it is no less proper, in a practical point of view, to attend to the nature of the exciting causes. The judicious and careful physician will not, however, require the aid of classification, and subdivisions, to bring these circumstances to his attention; and it may be reasonably doubted whether any distinctions not founded on prominent and essential points of difference, can be usefully admitted into the description and pathology of diseases. The exciting causes of asthma, are— 1. Particular conditions of the atmosphere, in relation to its dryness or humidity, electricity, and temperature. In general, asthmatic individuals breathe easiest in a pure and un- connned air; but there are many who breathe better in the impure atmosphere of populous cities or crowded rooms, than in the fresh and uncontaminated air of the country. Most persons ASTHMA. 211 subject to asthma, bear a dry and warm air much better than a cold and humid atmosphere; but here too, the very reverse sometimes obtains in certain individuals liable to this affection. Some suffer most from this disease during the warm weather of summer; whilst others experience its attacks only in the winter, or about the autumnal and vernal equinoxes. 2. Various irritating matters inhaled into the lungs, are capable of exciting the disease in persons predisposed to it; such as dust, and the fumes of lead, arsenic, sulphur, nitric acid, tobacco, and other irritating and offensive vapours. 3. Gastro-intestinal irritation, from indigestible and irritat- ing articles of food, vitiated secretions, or a loaded state of the bowels, is one of the most common exciting causes of the asth- matic paroxysm. Almost all asthmatic subjects are peculiarly liable to gastric disorders from causes of this kind, and even slight irregularities in diet are apt to give rise to oppressed breathing in individuals of this habit. 4. The suppression of habitual sanguineous and serous dis- charges, frequently give rise to this affection. I have, during the last eight years, occasionally attended an old gentleman in whom the temporary drying up of a long standing superficial ulcer on the left leg has invariably been followed by violent paroxysms of asthma. I have seen an instance in which very distressing asthmatic symptoms alternated with the haemorrhoidal discharge. The suppression of the menses sometimes gives rise to nervous or hysterical asthma. 5. Metastasis of rheumatism and gout, and of various cuta- neous affections, sometimes gives rise to more or less violent asthmatic symptoms. One of my patients, a rheumatic subject, has had several violent fits of asthma during the remissions of his arthritic affection. Mr. Andral mentions an extremely violent case, which was produced by the sudden disappearance of a dartrous eruption. Leeches and blisters were applied to the part where the eruption had disappeared; and the asthma, by this measure, was completely removed in a few days.* 6. General plethora, in co-operation with causes that produce strong sanguineous determinations to the lungs, or increase the momentum of the circulation, is particularly favourable to the occurrence of asthma. Individuals of obese and robust habits, florid and full complexions, with large and turgid veins about the neck and head, are especially liable to asthmatic symptoms from over-exertion by exercise, loud speaking, singing, or violent mental emotions. 7. Cold, when the body is in a state of free perspiration, and particularly suppressed perspiration of the feet, may excite the • Med. Chir. Rev. vol. vi. p. 447. 212 ASTHMA. disease. I attended a lady about ten years ago, who suffered exceedingly from a protracted and regular paroxysm of asthma, which was brought on by bathing her feet in very cold water. She was subject to profuse sweating of the feet. 8. Mental emotions, particularly violent anger and terror, will sometimes excite asthma in those who are predisposed to it. 9. Particular odours and articles of diet, from peculiarity of habit, or idiosyncrasy, may give rise to asthmatic affections in certain individuals. Thus, the odour of ipecacuanha has ex- cited the disease in some persons; and instances are mentioned in which asthmatic paroxysms have been caused by the odour of musk, roses, red beets, fresh hay, and of sealing-wax. (Parry.) 10. But by far the most common exciting cause of asthmatic symptoms, is organic affections of the heart and aorta. Ossifica- tion of the cardiac valves, hypertrophy, aneurism of the large arterial trunks within the chest, and other organic causes that disturb the action of the heart, are rarely wholly free from symp- toms of asthma. It is, generally, in cases of this kind, that we find the disease to alternate with oedema of the extremities, both being merely symptomatic of the cardiac affection. 11. Finally, asthma, like all other paroxysmal, nervous, and spasmodic affections, may continue to recur under the influence of what Dr. Darwin calls association, or that tendency in the animal economy to repeat morbid actions, when once established in the system, without the renewed application of the original exciting cause. Pathology.—Various and very discrepant opinions have been expressed, with regard to the pathology or proximate cause of asthma. Of late years, several French writers* have denied, or at least greatly doubted the possibility of asthma, independent of organic disease within the cavity of the chest There can be no doubt, indeed, that the majority of cases usually called asthmatic affections, arise from causes of this kind, more espe- cially from organic cardiac diseases, aneurism of the large arte- rial trunks, and pulmonary hepatization. The occurrence of purely spasmodic asthma, wholly independent of obvious struc- tural disorder, is, nevertheless, equally unquestionable. In relation to the immediate cause of the dyspnoea in spasmodic asthma, there are two doctrines which at present divide the sen- timents of pathologists. According to some, the suffocative breathing is caused by a spasmodic constriction of the air-cells and smaller bronchial tubes, in consequence of which the free admission of air into the lungs is greatly impeded. Others be- lieve, that the oppressed respiration depends on vascular en- gorgement of the mucous membrane of the bronchia, giving rise, * Rostan. ASTHMA. 213 bv the tumefaction of this membrane, to a mechanical diminution of the bronchial tubes and cells, and consequent obstruction to the regular intromission of air to the lungs. Laennec, among many others, has adopted the former opinion, and has endeavour- ed to prove that the bronchial ramifications are furnished with a coat of circular fibres, beginning where the cartilaginous circles terminate. By the spasmodic contraction of these fibres, the air passages are obstructed, and the phenomena of asthma produced. He asserts, that he has " met with many cases, in which it was impossible, after the most minute examination, to find any organic lesion whatever, to which the asthma could be attributed. 1 am convinced," he says, "that the asthmatic paroxysm may be in- duced equally by the supervention of a fresh catarrh, and by a deranged state of the nervous influence, occasioning pulmonary spasm, or an increase of the necessity of respiration, and some- times by both causes at once. With the exception of the differ- ent kinds of catarrh, the occasional attacks of asthma and dysp- noea are almost always of a kind to give occasion to an immediate and evident disturbance of the nervous influence. Of this kind are strong mental emotion ; venereal excesses ; the influence of light and darkness; retrocession of gout, (a disease, which, from its mobility and various effects, can only be considered a nervous affection ;) certain odours, such as those of the tuberose, helio- trope, stored apples, &c.; changes of atmospheric air, electricity, and other less appreciable conditions of the atmosphere."* Mr. Abernethy appears to entertain a similar view of the nature of asthma. He contends, that one of the principal causes of this disease is a morbid irritability of the mucous membrane of the air-cells. "A man," he observes, "having irritable lungs, may be sitting comfortably enough at the fire-side, but a little smoke comes into the room, and he can breathe no more ; he gasps for breath, he cannot enlarge the chest, and he finds the utmost dif- ficulty in respiring ; but where is the difficulty ? Where is the sensation of pain and contraction ? Why in the lungs themselves; the hindrance is there; I believe it is all irritability, and which proceeds from the state of the stomach, "t Other writers of emi- nence have declared it as their opinions, that pure spasmodic asthma depends immediately on a constriction of the air-cells and smaller bronchial ramifications, by which the ingress of atmo- spheric air is impeded or prevented, and suffocative respiration produced. It has been objected to this doctrine, that we have no evidence of the existence of muscular fibres in the smaller branches of the bronchia and air-cells; but M. Laennec observes, that as such fibres do undoubtedly exist in the larger bronchial • On the Diseases of the Chest, last edition, p. 414. f Lectures, p. 375. 214 ASTHMA. tubes, analogy must lend us to admit their existence in the ulti- mate ramifications. "Besides, it is by no means demonstrated," he says, " that muscular fibre is the only contractible tissue; in- deed, the contrary is proved by the fact, that animals of almost a mucilaginous consistence are capable of evident contraction."* We are not, however, without direct evidence of the existence of contractile fibres in the minuter bronchial tubes. Professor Nasse, of Halle, has published some very interesting experiments on pulmonary contraction, t He asserts, that in the lungs of sheep, he was able, with a good lens, to trace the longitudinal fibres of the internal surface of the bronchia, described by Soemmering and Reiseisen.f into the smallest bronchial ramifications; and by means of the galvanic influence, he demonstrated the contraction of these fibres in the most unequivocal manner. Morgagni has very particularly noticed the fibres of the bronchia ;§ and although their apparent tendinous character would seem to oppose the idea of their possessing contractility, yet we perceive that the contractile fibres of the bladder and uterus, possess a somewhat analogous appearance and structure. From the experiments of Nasse, it appears, that the bronchial fibres possess considerable contractility; that by passing the galvanic influence through the pneumo-gastric nerves, these fibres, and consequently the whole lungs, are thrown into a state of contraction; and finally, that by dividing the par vaga, the power of pulmonary or bronchial con- traction is destroyed, and dyspnoea produced. It is highly probable, therefore, that asthma consists essentially in a peculiar irritation of the pneumo-gastric nerves, in conse- quence of which the smaller bronchial tubes and air-cells are thrown into a state of spasmodic constriction, by which the re- gular ingress of air to the lungs is prevented. When we advert to the almost invariable antecedent and concomitant manifesta- tions of functional disorder of the stomach in this affection, we have good reasons to conclude that the nerves which especially preside over the functions of this organ and the lungs, are in a state of irritation or morbid excitement. The suddenness with which the asthmatic paroxysm is sometimes excited by mental emotions and other causes that act directly through the nervous system, and above all, the rapidity with which it is often dissipated * Loc. cit. p. 408. ■j- Undersuchungen iiber die naechste ursache des hustens. Leipzig, 1829, p. 9. \ Ueber den Bau der Lungen. § Extant in tunica intimaceu lacerti quidam insignes ex albicantibus fibrillis compacti. Hi digitos aliquot supra aspene arterix divisionem initium capiunt, et secundum ejus longitudinem dispositi, interstitium illud, quod memorabam, tenentes, ubi ad secundam bronchiorum divisionem pervenerunt, ibi primum solent per omnem undique bronchiorum superficiem ad istorum extrema versus decurrere. Quorum lacertorum usus nunc non existimo.—Adversaria Anatom. Adver. I. § 25. ASTHMA. 215 by a few full doses of the lobelia inflata, are directly and strongly confirmatory of this view of the pathology of the disease. The existence of a constricted state of the ultimate branches of the bronchia, dependent, we may presume, on the functional derange- ment or irritation of the pneumo-gastric nerves, appears, more- over, to be confirmed by the good effects, which, according to Dr. Chiarenti, result from the artificial insufflation of atmospheric air into the lungs in this affection.* Dr. Parry, however, considers this opinion of the nature of asthma as being without the least foundation, and ascribes the dyspnoea to great vascular turgescence of the bronchial mucous membrane, by which the smaller respiratory passages are me- chanically diminished or closed, until the vessels relieve them- selves by a copious effusion of serum. If, however, vascular congestion be the only or principal morbid condition upon which the peculiar symptoms of the disease depend, it seems extremely improbable, that any impressions made on the stomach would be capable of speedily arresting the progress of the disease; and yet, in a considerable number of instances, I have known violent paroxysms of asthma greatly, and in one case completely, allayed, in less than thirty minutes, by the use of the lobelia. There can be no doubt, that congestion always takes place to a greater or less extent in the vessels of the bronchia and air-cells, after the development of the paroxysm; but if this congestion were as great as Dr. Parry and others seem to think, is it not very likely that effusions of blood would occasionally show themselves in the expectoration ? The mere circumstance of the frequent inordinate secretion of mucus into the bronchia, is no satisfactory evidence that great sanguineous congestion pre-existed in the mucous membrane of the lungs. It is well known, that the process of secretion is wholly under the influence of the nerves, and we do no violence to correct physiological data, in presuming that the redundant secretion of mucus, is determined by the irri* tation of the pneumo-gastric nerves. Prognosis.—An attack of spasmodic asthma seldom proves fatal; and although the frequent recurrence of the disease is apt, ultimately, to give rise to dangerous pulmonary congestions, effusions within the chest, and to general exhaustion, it is by no means uncommon to meet with persons of very advanced age who have been long subject to this disease. Where asthmatic symptoms are connected with, or sympto- matic of, organic pulmonary or cardiac disorder, the prognosis is of course always peculiarly unfavourable; for in such cas°es, fatal dropsical effusion into the cavity of the pleura or the pericardium is almost a never failing consequence of the disease. Spasmodic • Journal de Progress. Vide Med. Chir. Rev. Jan. 1828. 216 ASTHMA. asthma resulting from mental emotions, or some peculiar odour or vapour, is, in general, less obstinate and protracted than those cases that arise from gastric irritation, or recur from the influence of habit. Treatment.—The treatment of asthma is either merely pal- liative, or radical, according as we prescribe for the mitigation and removal of the paroxysm, or the prevention of its subsequent recurrence during the intervals of the fits. A great number of remedies and modes of treatment have been recommended for palliating or allaying the asthmatic paroxysm; but the effects of remedies of this kind are extremely variable in different cases. Some will do much good in one person, and fail altogether of procuring relief in an apparently similar case in another indi- vidual. Nay, the same remedy, will in one attack afford speedy relief, and fail entirely in another paroxysm in the same person. (Laennec.) According to the pathology advocated above, the principal indications of cure during the paroxysm are to diminish the pulmonary congestion, and especially to relax the spasm of the bronchial tubes and air-cells. Where the pulse is active, and the countenance livid, in young and vigorous subjects, blood should be freely drawn; for although venesection will rarely by itself make any decisive or permanent impression on the pa- roxysm, its employment is always proper in robust and san- guineous habits, to obviate any evil consequences that might result from the violent pulmonary and cardiac congestion, and as a preparatory measure to the employment of other remedies. Professor Potter of Baltimore, expresses much confidence in the efficacy of blood-letting in asthma—more than seems to be war- ranted by general experience. He considers bleeding "not only the most effectual remedy" in strong subjects, but in many in- stances capable of effecting a radical cure.* Laennec observes, that, "we must never omit blood-letting, whenever the lividity of the countenance, the strength of the patient's constitution, or the overaction of the heart, indicate pulmonary congestion; but we must be careful not to abuse this practice, which, in ge- neral, only produces a temporary advantage." In old persons who have suffered much from the disease, it is not in general prudent to abstract blood. It must be observed, however, that many writers regard this measure as always of very doubtful propriety, and often injurious in its effects. Judging from my own experience, I am not inclined to place much reliance on its palliative effects, although, for the reasons stated above, I have very generally resorted to it, in robust and full habits, without having ever known any ill consequences to result from its em- ployment. • Gregory's Practice, vol. i. p. 187, second edition. ASTHMA. 217 The narcotics have been a good deal employed with the view of allaying the asthmatic paroxysm. Laennec has found opium and colchicum the most powerful remedies for mitigating and curtailing the paroxysm. Articles of this kind, he says, may act beneficially, both by lessening the necessity of respiration, and by relaxing the pulmonary spasm. Hyoscyamus and stra- monium, also, may be used with occasional advantage. The latter article, in particular, has done much good in several in- stances of habitual asthma, under my own observation. In one case, a quarter of a grain of the extract given every four hours for two days, suspended the disease entirely for upwards of nine months. The leaves and root of this plant, smoked in a pipe, will sometimes give much ease to habitual asthmatics; and it is said, that when used in this way, it will sometimes promptly mitigate the paroxysms of the complaint. I have prescribed it in a few instances in this manner, but never with any particular advantage; and writers have mentioned instances in which it proved injurious. In cases attended with catarrhal irritation, and a very copious secretion of viscid mucus into the bronchia, emetics sometimes procure considerable relief. The production of emesis is par- ticularly proper, where the paroxysm comes on soon after taking a full meal. It is not necessary, nor, in general, proper, to excite strong vomiting. Dr. Akenside asserts that he has derived as much benefit from nauseating doses of ipecacuanha in this affec- tion, as from full emesis. It is generally admitted, that ipeca- cuanha is decidedly the best article for this purpose. It is said that the union of distilled vinegar and ipecacuanha forms a par- ticularly useful remedy in this disease. Three grains of the latter with three drachms of the former, may be taken every fifteen minutes, until nausea or gentle vomiting is excited. The vinegar of squills, too, has been highly extolled in asth- matic affections, both for its emetic and expectorant powers. Sir John Floyer considered this preparation as a specific in asthma. He asserts, that he has often prevented the paroxysm, by taking a dose of it at bed-time. Dr. Bree, also, places much reliance on the powers of this remedy; and he observes, that its efficacy is in proportion to its emetic operation. I have known much relief obtained from this remedy, taken in two drachm doses every half hour until nausea was induced; more frequently, however, no obvious advantage resulted from its use. Vinegar is much praised by Bree, as a palliative in the pa- roxysm of spasmodic asthma. He found it more frequently and decidedly beneficial, he says, than any other remedy he had tried. One of my patients, affected with occasional paroxysms of this disease, has in several attacks derived great relief from two or three table-spoonfuls of strong vinegar taken at intervals of half Vol. II. 28 218 "ASTHMA. an hour, and from inhaling its fumes. hi the last two attacks, however, he derived no benefit from its employment Bree speaks very favourably, also, of the union of acids and narcotics, as palliatives in the asthmatic paroxysm. He recom- mends the following formula as an excellent combination of this kind.* In the asthma of old people, attended with deficient urinary secretion, and oedema of the feet, diuretics sometimes answer an excellent purpose. It is in cases of this kind especially, that the squill may be used with benefit. In general, a good deal of advantage may be derived from diuretics in habitual asthmatic affections. Dr. Ferriar speaks well of the powers of digitalis combined with small doses of opium in such cases; and Dr. Percival asserts, that he has known this combination to produce very favourable effects. A copious flow of urino is always a favourable symptom in this affection. Some writers (Pringle, Percival) speak favourably of the use of strong coffee in this affection. I have met with a few indi- viduals who derived advantage from its use during the paroxysm. In another person, however, subject to habitual difficulty of breathing, with occasional violent fits of dyspnoea, the use of coffee has, of late years, invariably aggravated the difficulty of respiration. Expectorants also may occasionally be employed with some benefit in this disease; and for this purpose, the different pre- parations of the squill appear to be the best remedy. 1 have known the following mixture to give much relief towards the termination of an asthmatic paroxysm, t Antispasmodics do not often produce any good effects; yet, in slight cases, considerable relief may be obtained from inhaling the vapour of ether; and in old and habitual cases, the aqueous solution of assafoetida has afforded temporary benefit. The only article of this kind which I have found to manifest any particular powers, in allaying the violence of the asthmatic paroxysms, is the root of the skunk-cabbage. (Symplocurpus foetida.) I have occasionally employed this article in attacks of spasmodic asthma, and in several instances, with much temporary benefit. From thirty to fifty grains of the powdered root may be taken every • R. Tinct. scill. gtt. *. Acid, nitric, gr. vi. Extract, hyoscyam. gr. iii. Aqua: fonlanx ^iss. M. This draught is to be repeated thrice daily. | ft. G. Ammoniac aji. solve in Acid, scillae f, iss. Tinct. opii. camph. ^ss. M. Take a tea-spoonful every hour, in a little clear and strong coflee. ASTHMA. 219 two or three hours during the paroxysm, according to the urgency and obstinacy of the symptoms. Of all the remedies we possess, however, the lobelia in flat a is I think, decidedly the most valuable in this affection. With- in the last five years, I have had an opportunity of witnessing its good effects in four cases, and I can truly say, that in two of these, it acted like a charm. I have known the most violent paroxysm of spasmodic asthma completely subdued in less than thirty minutes by this medicine. It appears to me that ergot does not more certainly act upon the gravid uterus during par- turition, than the lobelia upon the pulmonary organs in asthma. I have even found it to mitigate the dyspnoea, which occurs in consequence of organic affections of the heart. Since the publi- cation of the first edition of this work, I have had occasion to prescribe this article in a violent and inveterate case of this malady. The good effects, in this instance, were as prompt and decisive as in any case I had previously witnessed. In one hour after the exhibition of the remedy, the patient's respiration was entirely free from difficulty or oppression. The good effects of a full dose of this medicine are often ex- perienced in the course of ten or fifteen minutes after it is taken. The Rev. Dr. Cuttler, in a violent paroxysm of spasmodic asthma, took a table-spoonful of the saturated tincture. "In three or four minutes," he says, "my breathing was as free as it ever was. In ten minutes I took another spoonful, which occasioned sick- ness. After ten minutes, I took the third, which produced sensible effects on the stomach, and moderate puking, with a kind of prickly sensation through the whole system, even to the extremities of the fingers and toes. Since that time I have en- joyed as good health as perhaps before the first attack."* In a case of spasmodic asthma, in which I employed this tincture, during the present summer, the dyspnoea was almost entirely allayed in fifteen minutes after the first dose was taken. I have not found it necessary to give it to the extent of producing emesis, though some evidence of its influence on the stomach, as nausea, is desirable. A table-spoonful of the saturated tincture may be given every ten or fifteen minutes. A great variety of other remedies have been employed with more or less advantage in asthma. The prussic acid was suc- cessfully given by Dr. Oliver and Dr. Granville. Alkalies, particularly the carbonate of potash, will be proper where there is reason to suspect acidity of the stomach. Dr. Bree strongly recommends the use of prepared chalk and rhubarb, in combina- tion, in cases of this kind—more especially after the operation of a gentle emetic. The use of laxatives, with some absorbent, • Thacher's Dispensatory. 220 ASTHMA. will, in general, afford some advantage in habitual cases, attended with dyspeptic symptoms, and torpor of the bowels. Tonics also, are said occasionally to produce very good effects in protracted cases, attended with much debility and general relaxation. The bark is especially recommended by Sir John Floyer. During the intervals of the paroxysms, much benefit may, no doubt, be derived from this tonic, in individuals of exhausted and relaxed habits; but there are few physicians, I presume, who would venture on the exhibition of this remedy during the paroxysm, except under circumstances especially in- dicating its employment. Dr. Chiarenti, an Italian physician, has lately published a statement, from which it appears, that the artificial insufflation of atmospheric air, by means of a common bellows, is capable of speedily removing the asthmatic paroxysm. " He introduced the pipe of the bellows into his mouth, (he was himself affected with the disease) and, closing the nostrils, he pushed the air forcibly into his lungs, and with instant relief." He afterwards tried the same means in other cases of this disease, and always with the same happy result* Galvanism has of late years been employed with advantage in chronic asthmatic affections, by Dr. Philip and others. The gal- vanic influence must not, however, be communicated with much force. The two wires of a weak trough are to be attached, one to a piece of metal placed on the pit of the stomach, and the other on the side of the neck, over the par vagum. With the view of preventing the recurrence of the asthmatic paroxysms, recourse must be had to tonics, a regulated diet, a change of air or climate, and regular exercise ; and the usual ex- citing causes of the disea.se must be carefully avoided. The tonics usually employed, are bark, quina, arsenic, and the carbonate of iron. Laennec states, that he has derived much advantage from the latter article, during the intermissions of the disease. Whilst tonics are employed, attention must also be paid to the state of the bowels, and the hepatic functions. An occasional blue pill at night, followed by a gentle aperient in the morning, the use of the tepid shower-bath,' where the system is relaxed or exhausted, or cold bathing in robust and full habits, together with regular exercise out of doors, change of air or climate, agreeable occupa- tion of the mind, a light and simple diet, and the careful avoid- ance of the usual exciting causes of the disease, are the most effectual measures for preventing, or postponing and moderating the violence of the attacks. Attention must, of course, be paid to the character of the exciting cause in prescribing for asthma, both with a view to its palliation and radical cure. When the * Med, Chir. Rev. January, 1828, p 221 ASTHMA. 221 disease is attended with a rheumatic or gouty diathesis, colchicum diuretics, and opium, are especia ly indicated. When it succeeds the healincr up of an old discharging ulcer, blisters and sinapisms to the nartVe proper. Andral succeeded in curing a violent case, bv means of this kind. Here diuretics, also, are generally pecu- liarly beneficial. Where catarrhal irritation has excited the dis- easef emetics, the warm bath, squills, and opiates, may be resorted to with a good prospect of success ; and in cases that depend on gastric irritation, alteratives, the warm bath, mild aperients, tonics, Jnd regular exercise, are particularly proper. "Among the reme- dies best deserving notice in asthma," says Laennec, " 1 would mention a mild and spare diet, residence in a more temperate climate, and warm bathing. The first of these measures will be found very beneficial in cases complicated with gastric irritation ; the two last are especially indicated in that class of cases which date from the disappearance of cutaneous eruptions, under the use of powerful external applications."" Sect. II.—Whooping-Cough, This is unquestionably one of the most remarkable diseases with which we are acquainted. A cough, which is highly conta- gious in its nature—which has its regular rise, progress, and de- clension—and which completely destroys the susceptibility of the system to a subsequent or second invasion of the disease, is a phe- nomenon truly mysterious and striking. It is maintained by some writers, that whooping-cough is com- paratively a modern disease ; and some assert that it was first brought into Europe out of Africa, in the thirteenth century. By consulting the works of the ancients, however, it. would seem that this disease was known at a very early period of our science. Hippocrates, in the 6th book on Epidemics, and also in the 6th section of his Aphorisms, speaks of a cough, which, from the short description he gives of it, may, I think, be regarded as the same affection which is now known under the name of whooping- cough. The first distinct and comprehensive description of this malady, however, was given by Mezeray, in the year 1414, in his Chronological History of France. Since that time, a great many epidemics of this disease have been circumstantially record- ed ; and medical literature furnishes us with no inconsiderable number of elaborate monographs on its nature and treatment. Whooping-cough usually commences with the symptoms of ordinary catarrh. The patient at first experiences some degree of lassitude, headach and sneezing, with a slight hoarseness, and • Loc. cit. p, 419. 222 WHOOPING-COUGH. occasional oppression of breathing. The sleep is generally dis- turbed by dreams and sudden starts; the appetite becomes weak, the bowels torpid, and the pulse slightly febrile towards evening. For the first two or three weeks the cough is almost always dry and ringing ; and the paroxysms are short, and free from that peculiar sound which is called whooping. At the end of this time the disease begins to assume more of a convulsive or spasmodic character, so far, at least, as the mere cough is concerned. The paroxysms of coughing now come on more frequently, and are of longer duration than previously. The inspirations during the fits of coughing are extremely difficult, slow, and stridulous, and attended with a sense of obstruction or spasmodic stricture of the glottis, rendering the paroxysms distressingly suffocative, and, in a manner, convulsive. The approach of a fit of coughing is generally announced by a peculiar sensation of tightness in the breast, and of titillation in the larynx and praecordia. These circumstances should be borne in mind, for they throw considerable light on the pathology of this remarkable affection. The duration of the fits of coughing is very various. In some instances, the paroxysms are generally over in less than half a minute ; in others, they last from five to six minutes, and often longer. The spell of coughing at this stage of the disease, is always terminated by the discharge of a large quantity of a viscid mucus; and the patient frequently ex- periences some pain in the chest, immediately after the cough has subsided. In many cases, the cough continues until vomiting comes on, when it is immediately arrested, and the patient is greatly relieved. So violent, in some instances, is the fit of coughing, that it induces a state of partial insensibility, and a most distress- ing sense of impending suffocation. Occasionally, the determina- tion of blood to the head is so great, during the paroxysm of coughing, that it bursts out from the nose and mouth ; and it is not uncommon for children to become convulsed, in consequence of the cerebral compression from this cause. In this aggravated state, the disease usually continues from four to six weeks, before it begins to abate. The declension is always very gradual, con- tinuing commonly from two to four weeks. Fever is not essen- tially connected with the disease, although in many instances there is a manifest febrile irritation present during some period of the complaint Whooping-cough occurs almost exclusively during childhood. I have nevertheless met with two instances of the disease in sub- jects beyond the fiftieth year of age, and several in persons be- yond the thirtieth and fortieth year. It is highly contagious, and occurs almost universally in an epidemic form. I have never yet met with a sporadic case of this affection, although it cannot be doubted that such instances do occasionally occur. It would f f WHOOPING-COUGH. 223 seem as if there existed some latent connexion between the con- tagions of whooping-cough and measles ; for the former fre- quently prevails most extensively, either immediately previous, or in alternation, or directly after the occurrence of epidemic measles.* Spring and autumn appear to be most favourable to the occurrence of whooping-cough, and it is during the wet and variable periods of these seasons, that the disease is most liable to become dangerous, from the pneumonic affections which atmo- spheric vicissitudes are so apt to produce. As is the case with all other epidemic diseases, considerable diversity occurs in the grade of violence which different epidemics of this affection assume. Some epidemics are so mild, that the disease is attended with but little difficulty, and passes by numbers who are still susceptible of it. At other times the disease manifests a violent and danger- ous character; and seizes on almost every individual, whether old or young, who has not yet had the disease. Prognosis.—Whooping-cough rarely terminates fatally, unless by the supervention of bronchitis, hydrocephalus, pneumonia, cynanche trachealis, apoplexy, or marasmus. As these secondary and superadded affections are, however, by no means uncommon —especially in variable and humid seasons—the disease, upon the whole, deserves to be regarded as one of considerable danger. It would appear to be a vastly more dangerous affection in northern or cold climates, than in the mild and equable regions of the middle and southern latitudes. Rosenstein states, that in Sweden there were 43,393 deaths from this disease, between the years 1749 and 1764—and of these, 5832 deaths occurred in the year 1755 alone. (Richter.) In general, the younger the patient, the more apt is the dis- ease to terminate fatally. Cullen observes, that by far the greater number of those who die of this disease, are children under three years of age. When it attacks weak and delicate infants within the first few months after birth, it is always attended with great danger; yet robust and healthy infants, even at this early age, generally pass through the disease without much difficulty or danger. In children bom with a scrofulous diathesis, whooping-cough is exceedingly apt to call the strumous affection into action. Scrofulous ophthalmia, and glandular tumours in the neck, fre- quently succeed whooping-cough. I know of no disease which is more to be dreaded than whooping-cough, in subjects of an hereditary consumptive habit. Where there is a predisposition to the formation of tubercles, or where these exist in an incipient and dormant state, an attack of whooping-cough will rarely fail to develop phthisis pulmonalis. • Richter, Specielle Therapie. 224 WHOOPING-COUGH. In many instances, the disease terminates in chronic bronchitis, in which case the expectoration becomes purulent, and symptoms of hectic supervene. This is especially apt to occur when the patient takes cold from exposure to a damp and variable atmo- sphere—a circumstance which always greatly aggravates the vio- lence and danger of the disease. I- have seen but few deaths from whooping-cough, which were not attended with bronchitis, puru- lent expectoration, and hectic symptoms, from having taken cold. The matter expectorated in these cases has generally a very pecu- liar appearance, resembling more a mixture of cream and mucus, than any thing else 1 know. In some instances, an accidental cold will renew the cough, and protract it for several months, in a state of great violence, after it had nearly disappeared. Cases aro often thus protracted for five or six months. When the disease assumes a chronic charac- ter, from cold or some other casual circumstance, it sometimes ultimately terminates in hydrocephalus—more especially if the patient labours under the irritation of difficult dentition, and in children habitually subject to disordered bowels. Cynanche trachealis, also, frequently supervenes during whooping-cough, and this is most apt to happen in children of robust and full habits, during the early stages of the disease, and is almost always the consequence of cold. The occurrence of cynanche in this affection is attended with the greatest danger. It is observed by Richter, that a profuse watery diarrhoea coming on suddenly in this disease, when pneumonic symptoms attend, is always to be regarded as one of the most dangerous occurrences. Death, he says, often follows such a discharge very speedily. The appearance of aphthae in the mouth and fauces, in the latter period of the disease, is also a very unfavourable sign. Ede- matous swelling of the feet and face is not an uncommon occur- rence in this affection, and when it takes place towards the con- clusion of the complaint, it is rarely followed by unfavourable consequences. When such swellings supervene in the com- mencement of the disease, however, they portend much danger— more especially if they are accompanied with a turbid, milky urine. (Richter.) Hufeland observes, that the occurrence of some degree of strangury in the advanced stage of the complaint, is generally soon followed by a manifest mitigation of the symp- toms of the disease. A sudden cessation of the cough, it has been remarked, is an unfavourable occurrence, and is frequently followed by pulmonary inflammation. In general, the more fever there exists in this affection, the more violent and danger- ous it may be considered. It is asserted by some writers, (Hufeland, 1. c. p. 420: Lentin, Memorabilia, p. 36: Jahn, Kinderkankn. p.-399,) that children affected with some chronic cutaneous affection, as tinea, itch, &c, WHOOPING-COUGH. 235 very rarely take this disease; and if they do become affected with it, they almost invariably pass through it in the lightest manner. This, however, is contradicted by others—particularly by Hoffman and Haase. Among the affections which are properly called sequela of this disease, the following are the principal. Strumous swellings, dropsy, epilepsv, ophthalmia, rickets, general cachexy, aneurism, deafness, dementia, paralysis, and phthisis pulmonalis. I have known most of these affections to occur as consequences of whooping-cough; and of these, epilepsy, struma, phthisis pul- monalis, and ophthalmia, appear to be the most common. When these and other consequences are taken into view—and they are by no means uncommon—we cannot but regard this disease as always one of very serious import. Whooping-cough is indeed as much to be dreaded on account of the many affections which are apt to supervene during its course, or to remain after its dis- appearance, as for its own proper power, however violent it may be. When perfectly free from any adventitious complications, it cannot be regarded as a disease of much danger, unless in very young and feeble subjects. Cause.—There exists no other cause,- so far as we know, capable of producing this affection, than the peculiar contagion which is generated by the disease itself. Richter observes, that besides this contagion, cold in conjunction with humidity, may give rise to this affection. For this opinion, it does not appear that there exist sufficient grounds; and it seems to me just as improbable, as that small-pox or measles should arise from acci- dental causes. It may be said that all these diseases must have primitively originated from accidental causes—for the first case could not have arisen from a contagion generated by the disease itself. Nothing, in truth, is more mysterious and incomprehen- sible, than the origin of those diseases which we now find to be engendered and propagated by a specific agent alone, elaborated by the living body actually suffering under the disease. The only solution we can offer, and it is indeed vague enough, is, that in the infinite combinations of which the material elements of the universe are capable, agents may have been evolved by a peculiar concurrence of circumstances, which had the-power of originating these affections in the human system. It is in this way alone that we can give any plausible explanation of the occasional rise of new diseases—which, when once originated, propagate them- selves by elaborating their own specific causes. Whatever may be our speculations in relation to this curious and interesting subject, the cause of whooping-cough, so far as we can ascertain, is in all instances a specific contagion. Riverius, Linnaeus, Dessault, Rosenstein, and more recently Vol. II 29 226 WHOOPING-COUGH. Clesius, maintain that whooping-cough is produced by the inhala- tion of microscopic animalcula. Whooping-cough does not appear to possess a contagious cha- racter until it has made considerable progress, (Richter;) or until the second or convulsive stage has supervened. The contagion of this disease, although very active, does not extend far from the body of the affected person. It is accordingly almost always prevented by separating the healthy from the affected portion of families. Autopsic phenomena.—The appearances discovered on post mortem examination are various, and often quite contradictory. Much diversity must necessarily result in this respect from the various accessory affections which are so common in this com- plaint, and the different periods of the disease at which death occurs. We cannot, for instance; expect to find the same post mortem appearances in a case which terminates fatally in conse- quence of pneumonia, as in one in which death occurs from apoplexy; nor is it reasonable to presume that there should be much uniformity in the autopsic phenomena, where the imme- diate cause of death is so various, or dependent on such a diversity of accidental affections. As the respiratory organs are the parts most obviously implicated in the disease, the principal attention of pathologists has of course been always directed to them, for a solution of the pathological character of this affection. Many writers speak particularly of the frequency of traces of inflam- mation in the mucous membrane of the bronchia and larynx. Strong, Cullen, Astruc, Lettson, and Danz, mention these ap- pearances as by far the most common; and more recently, Whatt and Marcus have adduced striking instances of this kind. The former lost three of his own children by this disease, and in each, the marks of previous inflammation in the mucous membrane of the bronchia, were very conspicuous throughout its whole extent. Marcus gives but two dissections in which bronchial inflammation was discovered; and in one of these a considerable quantity of pus was found in the air-passages, the smaller branches of which were in the most intense state of inflammation, approaching, in some parts, to gangrene. In some instances, the lungs have been found exceedingly congested, and the air-cells choked up with an extremely viscid mucus, without any traces of bronchitis whatever. Lobenstein- Loebel relates an instance in which a considerable portion of the diaphragm was covered with a number of small pustules contain- ing a purulent fluid.* After all, it is incontestable, that in many cases of death from this disease, no morbid appearances whatever are discovered on * Richter's Specielle Therapie. WHOOPING-COUGH. 227 dissection, and there are good grounds for believing, that the inflammation and other phenomena which have been detected on post mortem examination, have no essential connexion with the disease, but are altogether adventitious or secondary. Proximate cause.—The opinions that have been advanced, concerning the nature or proximate cause of this disease, are extremely various and Contradictory. Hoffman considered it as depending on an acrid serum in the lungs. Sydenham ascribed it to the effects of irritating effluvia, cast off from the blood into the lungs, in consequence of the suppression of the insensible transpiration by the skin, from cold and damp air. Huxham and others placed the primary seat of the disease in some morbid condition of the intestinal canal; Butler, in the liver; and some have considered it, as the consequence of gastric irritation, or, according to Stoll, of crude and bilious matters in the stomach. The opinion which appears to be most prevalent, at the present day, is, that the disease depends on a peculiar bronchial inflam- mation ; and this doctrine would seem to receive much support from the appearances which are occasionally detected in the mucous membrane of the bronchia and trachea on post mortem examination, as well as from the febrile movements which, in most instances, attend the disease. As, however, ordinary bronchial inflammation does not excite the train of symptoms which characterize this disease, the advocates of this doctrine are forced to assume the position, that the inflammation in ques- tion is of a specific kind, capable of exciting the peculiar convul- sive cough which distinguishes the disease. Whatever plausibility this doctrine may seem to possess on a superficial view of the subject, strong, and in my opinion, insurmountable objections, may be urged against its validity. It is true indeed, that fever is no uncommon attendant of this disease, and that unequivocal traces of inflammation are sometimes manifested on post mortem examination. It is, nevertheless, equally true, that in many instances no febrile symptoms whatever occur during the early period, and occasionally none during the whole course of the disease; nor are the signs of previous inflammation in the respira- tory passages always manifested on autopsic examination. That inflammation must frequently supervene in the trachea and bron- chia in a disease in which the lungs are so violently and fre- quently agitated as they are in the present one, is indeed to be expected. Besides this accidental source of pulmonary inflam- mation in whooping-cough, there can be no doubt, that the lungs are especially predisposed, by the same circumstance, to the injurious influence of atmospheric vicissitudes, and consequently to the supervention of pulmonary catarrh, or bronchial inflam- mation. From these circumstances, we have the strongest grounds for 228 WHOOPING-COUGH. believing that the inflammation which is frequently detected on dissection in the mucous membrane of the respiratory passages, is always accidental, and by no means essential to the perfect development of the disease. It may be observed, moreover, that bronchial inflammation is probably far from being so common in this disease, as one might be led to think from the appearances discovered on dissection; for it must be recollected, that death occurs chiefly in such instances only as are attended by unequivo- cal symptoms of inflammation, and we may, therefore, reasona- bly expect to find traces of inflammation in such cases, although in the milder instances no such inflammatory condition may exist If, however, bronchial inflammation be the proximate cause of the disease, it must, necessarily, be present in all cases, in the mild as well as in the violent instances of the malady, a circum- stance which is decidedly contradicted by almost universal obser- vation. The only dissection I ever witnessed of a subject that had died of this disease, presented no evidence of the existence of previous inflammation in the bronchia. This patient died suddenly of convulsions during a violent paroxysm of coughing. That inflammation of the mucous membrane of the bronchia, is not essential to this disease, or its proximate cause, is proved moreover by the fact, that bronchitis is rarely, if ever, attended with a violent cough, much less with that peculiar cough, which distinguishes this disease. Bronchitis, too, in its acute form, is always rapid in its course, and is attended with strong fever and a continued sense of tightness and oppression in the breast. In the chronic form, the expectoration is invariably purulent, and entirely distinct in its character from the ropy and transparent mucus which is expectorated in whooping-cough. It is also almost invariably attended with the usual symptoms of hectic fever. When cough depends on acute inflammation of the respira- tory passages, it almost always begins to decline as soon as the secretion of the bronchial mucus becomes copious. In whooping- cough, however, the reverse very generally obtains. During the first few weeks, there is seldom much mucus secreted in the bronchia; but as soon as this secretion becomes more abundant, which occurs after the second or third week, the cough also acquires much more violence, and especially that convulsive character which distinguishes it from other varieties of cough. Very commonly, moreover, the slight symptoms of fever which accompany the development and first few weeks of the disease, vanish entirely in the second stage, when the cough becomes more spasmodic and violent in its paroxysms. (Richter.) This circumstance most assuredly does not favour the idea, that the disease is of an inflammatory character; for if this were the case, the cough, one should think, would decline with the fever; instead of which, it is always found to acquire much more violence. WHOOPING-COUGH. 229 It appears to me that, whooping-cough is essentially a spasmodic or nervous affection, the proximate cause of which consists pro- bably in a peculiar irritation of the eighth pair, or pneumo-gastric nerves. If we attend closely to the phenomena which immediately precede and accompany a paroxysm of whooping-cough, we can- not but perceive unequivocal manifestations of a purely spasmodic condition of the respiratory apparatus. The sense of stricture in the breast and of the glottis, which is felt immediately before the fit of coughing—the sudden and convulsive character of the cough—the peculiar constrictive feeling in the praecordia—the stridulous respiration, all point to a spasmodic state of the pul- monary system. That the irritation which calls forth the con- vulsive action of the diaphragm, and the other parts immediately concerned in the act of coughing, is seated in the eighth pair of nerves, may, I think, be inferred from the known agency which these nerves have in the production of the various phenomena manifested by the respiratory apparatus. The interesting experi- ments of Professor Nasse, also afford strong support to this opinion. In a series of experiments, instituted for the purpose of elucidating the pathology of cough, this experimenter found, that on bruising or strongly pinching the par vagum so as to break down its structure, a violent convulsive cough was invaria- bly excited. By injuring in the same manner the diaphrag- matic nerve, no such effect ensued. According to these experi- ments, the act of coughing is performed almost wholly by the sudden spasmodic contractions of the diaphragm. By opening the abdomens of various animals, and exposing the lower surface of this muscle, he saw distinctly its violent convulsive contrac- tions during the cough, which was excited by bruising, with a pair of forceps, the pneumo-gastric nerves. The peculiar tone of the cough, and the sense of constriction which is felt at the glottis, may arise from the irritation extending to the recurrent branches of the vagus nerve; and that this irritation is peculiar or specific in its character, may be inferred from the nature of its exciting cause. Treatment.—It is very generally believed, that whooping- cough, though susceptible of much mitigation, is wholly uncon- troulable in its progress, and that no treatment is capableV mate- rially shortening its course. This, I am persuaded, is an unfound- ed opinion. Sydenham, Werlholf, Hufeland, and several later German, Italian, and French writers, admit that it may be arrest- ed in its course; but it is asserted, that this can never be done before the fourth week after its commencement (Richter.) Be this as it may, my own experience does not permit me to doubt of its susceptibility of being curtailed in its progress; and many 230 WHOOPING-COUGH. well authenticated observations in confirmation of this fact, might be collected from recent publications. Although inflammation and fever do not constitute essential conditions of this disease, yet blood-letting may often be employ- ed in the first stage of the disease with manifest advantage. An unusual or preternatural momentum of the circulation is not to be regarded as a harmless circumstance, even in diseases strictly spasmodic. Whatever may be the essential character of a dis- ease, if the pulse is full and active, blood-letting may be regarded as proper, and its employment will generally be productive of some benefit In the present disease, if the abstraction of blood should even afford no direct advantage over its characteristic symptoms, it tends materially to lessen the danger which may result from the violent cephalic congestions during the parox- ysms of coughing, as well as to diminish the liability to the acci- dental supervention of inflammation. In cases attended with bronchial or pneumonic inflammation, bleeding is obviously in- dispensable ; and should be employed promptly and decisively, both in a general and local way. To tamper with the ordinary remedies in cases of this kind, would be exposing the patient to great danger; for, when inflammation supervenes, it is this, and not the original disease, which claims our principal attention, since the danger and obstinacy of pulmonic inflammation must be especially great in an affection, which, like the one under consideration, keeps up so constant and violent an irritation of the respiratory organs, by the frequency and violence of the cough. Leeching on the breast, is particularly valuable in cases of this kind. The extensive sympathetic relations which subsist between the intestinal canal and the various organs of the body, cause it to participate, in a greater or less degree, in almost every form of disease to which the human system is liable. Whatever be the nature of the malady, and in whatever system of structure it may be principally located, the alimentary canal, sooner or later, suffers functional disturbance, giving rise either to a remora of its recrementitious contents, or to a vitiated secretion of the fluids which are poured into it. These latter consequences become in their turn sources of intestinal irritation, and I need not say how great a tendency such irritation has to aggravate and sustain dis- eases, whatever may be their original source or character. The bowels are almost always in an unnatural condition in whooping-cough. The evacuations are sometimes bilious, or al- most wholly mucous; and, in many instances, dark and exceed- ingly offensive stools are passed. In prescribing for whooping- cough, it is of much consequence, therefore, to attend to the condition of the bowels, and to keep them in a moderately loose state throughout the whole course of the disease. Very active WHOOPING-COUGH. 231 purging, however, is improper, as it tends to increase, rather than to moderate the intestinal irritation when frequently repeat- ed. A grain or two of calomel in the evening, with a small dose of rhubarb on the following morning, will in general answer very well for this purpose. Where there is considerable febrile irri- tation present, small doses of the sulphates of soda or magnesia may be preferable. Emetics constitute an important class of remedies in the ma- jority of pulmonary diseases. They are especially indicated in those affections of the respiratory organs, in which there is an abundant secretion of bronchial mucus. Much of the suffocative distress experienced by patients affected with whooping-cough, arises from the large quantity of viscid mucus which is lodged in the trachea and bronchia; and it is chiefly by effecting the discharge of this impediment to free respiration, that emetics prove serviceable in this disease. It is not improbable, however, that a part of their beneficial operation may depend also on the impression which they produce on the pneumo-gastric nerves in the stomach. They are particularly useful in the whooping-cough of infants; these are unable to throw off the viscid mucus that clogs the respiratory passages; and instances of death by suffoca- tion from this cause have frequently occurred. When, therefore, the cough in very young children is violent, and attended with symptoms of impending suffocation, an emetic should be imme- diately administered; or the fauces irritated with a feather, so as to bring on speedy vomiting. In cases of this kind, the sulphate of zinc will generally answer better than any other article, from the promptitude of its operation. It must nevertheless be ob- served, that the very frequent repetition of emetics, more espe- cially antimony, is apt to bring on much weakness and irritation of the stomach, which may have a permanent injurious influence on the future health of the patient. I have in general preferred the ipecacuanha to every other article of this kind. Dr. Fother- gill speaks very highly of the following combination as an emetic in this affection. ft. Pulv. chel. cancror. Jss. Tart, antimon. gr. ii. Misce. Of this 1, Ii, or 2 grains, may be given at a dose, according to the age of the patient. It has been supposed that the union of some absorbent with the emetic is peculiarly beneficial in this affection. The syrup of squills also forms an excellent emetic m very young patients. I have frequently prescribed this pre- paration, in union with a small portion of antimonial wine, with a very good effect. We may also prescribe the antimonial wine in union with an emulsion of assafoetida, with much advantage as a palliative. ° 232 WHOOPING-COUGH. The narcotics furnish us with several very valuable remedies for the treatment of this disease. Of these the belladonna is the most celebrated, and unquestionably by far the best article of this kind we possess. Professor Borda, who, I believe, was the first who employed this remedy in whooping-cough, speaks of its powers with unqualified praise. He asserts, that, in a number of instances, he has found it to remove every vestige of the dis- ease in ten or twelve days; and that where it did not remove the disease entirely, it rarely failed to mitigate it very considerably. He observes, moreover, that he has known cases, which appear- ed to be beyond the hope of recovery, restored by this remedy. The observations of Hufeland and Alibert, not to add the testi- mony of many other writers, speak in terms nearly equally fa- vourable, of the virtues of this narcotic in the present disease. A large mass of evidence might be adduced from the current me- dical publications, illustrative of the valuable powers of the bella- donna in this singular malady. From my own experience, I can testify with confidence to its virtues as a remedy in this affection. I have within the last six years prescribed it in perhaps twenty cases, and in the majority of them with manifest advantage. Since the publication of my work on the materia medica, my good opinion of the value of this remedy has been considerably increased. In two cases it arrested the complaint almost wholly in the course of eight days, although the disease was in both in- stances exceedingly violent. It does not appear, however, to answer any useful purpose in cases that are attended with fever and bronchial inflammation. In instances of this kind, the lancet with blisters, or tartar emetic ointment rubbed on the chest, are the means upon which our reliance must be almost entirely placed. In the purely spasmodic form of the disease, however, and where all symptoms of inflammation are absent, it is often singularly efficacious. The extract of conium, lactuca virosa, hyoscyamus, and opium, have also been favourably mentioned as palliatives in this disease. Dr. Butler states, that he has frequently used the following mix- ture with marked benefit* Opium is objectionable, both on ac- count of its constipating effect, and its tendency to determine the blood to the brain. Some writers recommend the tincture of cantharides A Dr. Sutcliff asserts, that when given to the extent of producing strangury, it will, sometimes, in a great measure, * ft. Extract, conii gr. iii. Magnes. sulphat. ^i. Aq. carui 3v. Syrup, rhaed. Ji. M. Take 30 drops three times daily. f Armstrong, Chambers, Millar, Ruchholtz, Loder, and others, speak much in favour of this remedy in whooping-cough. WHOOPING-COUGH. 233 remove the disease in four or five days. This practice has also been pursued with success by Hufeland; and Lettsom speaks very favourably of it Sutcliff used it according to this formula.* M. Fresnoi asserts, that he has used the extract of the rhus vernix with, much success in this disease. He gave half a grain, with half an ounce of syrup, every three hours. Antispasmodics are frequently prescribed in whooping-cough, and sometimes with temporary advantage. An aqueous solution of assafoetida will occasionally palliate the symptoms, in cases unattended with fever or strong pulmonary irritation. This arti- cle answers the double purpose of an expectorant and an anti- spasmodic. I have, in a few instances, known material relief obtained from a mixture of the vinegar of squills, and an emulsion of assafoetida. Expectorants also will occasionally mitigate the violence of the symptoms. Dr. Pearson strongly recommends the following mixture, and I have myself known it to give considerable tem- porary relief, t Tonics may, in some instances, be used with much benefit in whooping-cough. The Peruvian bark is particularly extolled by Dr. Cullen as a remedy in this disease; but its good effects are in a great degree confined to the latter stages of the disease. In some instances, the cough assumes a chronic character—continu- ing long after the usual period of its termination; and these cases are frequently connected with chronic bronchitis. If they are not subdued by efficient measures, they gradually undermine the constitution, until the system is worn down, and the patient dies in a state of marasmus, or under symptoms of phthisis pulmo- nalis. In such cases, strong doses of cinchona, or quinine, are often peculiarly serviceable. This tonic may also be very benefi- cially used in cases of a purely spasmodic character, where the disease becomes protracted, and kept up by habit. Among the mineral tonics, arsenic has been most commended for its powers in this affection. It is, however, wholly inadmis- sible in cases attended with febrile irritation or bronchial inflam- mation. Dr. Ferriar placed much reliance on this remedy in cases free from fever. He asserts, that according to his own experience, * R. Tinct. peruv. spirit. £i. Tinct. opii camphor, ^ii. Tinct. cantharid. J)ii. Two drachms of this mixture is to be taken thrice daily. f R. Aq. fontanae ^i. Syrup, jiii. Subcarbonat. soda gr. xxv. Vin. ipecac, ji. Tinct. opii gr. vi. M. The sixth part, every four or five hours, is the proper dose for a chiu be- tween one and two years old. Vol. II. 30 234 WHOOPING-COUGH. "arsenic is the only remedy which promises to shorten the dis- order effectually. I have," says he, "employed this article in several cases of infirmary patients, with tolerable success ; and I have occasionally given it in private practice with so much advan- tage, that I think it deserving of further trials." I formerly em- ployed this remedy frequently; and in some instances its good effects were very obvious. The proper dose for a child between one and two years old, is two drops of Fowler's solution, twice or thrice daily. I have usually given it in union with small doses of the extract of belladonna, or conium. The lobelia inflata has proved an excellent remedy in my hands, in whooping-cough. Within the last four years, I have prescribed this article in a very considerable number of cases, and very generally with some advantage, and in several instances with the most decided success. It not only often mitigates the violence of the cough, but it has appeared to me unequivocally to have shortened the course of the disease in several cases. I have usually given the saturated tincture in union with the syrup of squills, in doses of ten drops of each, four or five times daily, to a child about two years old. To several children about this age, I gave as much as twenty drops of the tincture of lobelia, and I have always found it strongly palliative when it excited sickness or slight vomiting. External rubefacient or revulsive applications, are particularly valuable in cases attended with bronchial inflammation, or strong and dangerous sanguineous congestions in the head. Dr. Gregory advises frictions with the following embrocation, along the whole track of the spine, and over the chest* Frictions with tartar emetic ointment over the praecordial region, will, in many cases, make a powerful impression on the disease. This practice origi- nated with Autenreith, and has been much employed by the Ger- man physicians. WThen the disease is complicated with pneumo- nic affections, blisters and rubefacients, in conjunction with vene- section, and especially leeching on the breast, are indispensable. When the disease becomes complicated with chronic bronchitis, in the advanced stage of its course, the balsam copaiva is a very valuable remedy. I have, in a few cases of this kind, prescribed this article with the most decided benefit; and I know, indeed, no other remedy that promises so much as this one, where chronic bronchitis attends. Various inhalations, also, have been extolled for their good effects in this disease. The nitrous acid vapour, and the fumes of tar, have been particularly recommended for this purpose. I • R.—Antimon. tart. Qii. Tinct. cantliarid. !|i. Aq. rosar. 3'ii. M.—The tartar emetic is to be dissolved in the ro*e water, and then the tincture of cantharides added to it. WHOOPING-COUGH. 235 have employed the nitrous acid vapour, in a few cases, with some benefit. Dr. Gregory states, that he has derived great advantage from small doses of calomel, (a grain twice a day) with a few grains of scammony in the latter stages of whooping-cough, attended with symptoms of marasmus. Change of air, and exercise by gestation, generally have an excellent influence in tedious and obstinate cases, attended with much exhaustion. In instances of this kind, a change of air, says Dr. Gregory, "is often the only thing that gives the patient a chance of life." I have seen one very remarkable recovery effected by removing the patient into the country, and the free use of a milk diet. In cases attended with bronchial inflamma- tion, this measure is inadmissible, as it rarely fails to aggravate the symptoms immediately. The diet should be light and digestible, and it is particularly important to guard the patient against the influence of a cold, va- riable, and damp atmosphere. Se ct. III. —Asphyxia.—Suspended Animation. The term asphyxia is here used to designate two varieties of suspended animation ; namely, those cases which result from the total suspension of the function of respiration, by preventing the ingress of atmospheric air to the lungs, or by breathing an air in- capable of converting venous into arterial blood; and those cases of apparent death which result from the temporary destruction of the sensibility and irritability of the system, by the influence of certain external causes. The first variety includes those cases that are produced by hanging, drowning, or strangulation, and by the inhalation of carbonic acid, or some other irrespirable gas. The second variety embraces the cases that are produced by a stroke of lightning or electricity, and by the protracted influence of intense cold.* 1. Asphyxia from drowning.—When a person who has been submersed in water until all manifestations of life are destroyed, is taken out, the face exhibits a turgid and livid appearance ; the eyes are open and staring ; the limbs somewhat stiff; the tongue usually thrust a little beyond the teeth ; and, in most instances, Ihe epigastrium is tense and tumid. Considerable controversy has existed concerning the mode in which drowning causes death. Many have contended that, suffo- cation is produced by the water rushing into and filling up the • Good's Study of Medicine, vol. iii. p. 367. 236 ASPHYXIA. cavity of the lungs. Haller, P. Frank," Louis, and Portalt men- tion cases in which the lungs were charged with an abundance of water, sometimes frothy and bloody. On the other hand, it has been satisfactorily ascertained, that in many instances of death from drowning, very little, or no water whatever, gains admis- sion into the lungs. Tissot,^ Goodwin,§ Kite,|| Roesler,1[ and many other later writers, have published numerous observations in illustration of this fact; and it is now, I believe, universally admitted, that so long as the larynx retains any degree of irrita- bility, no water can enter into the respiratory passages; and, consequently, that whenever water is found in the lungs, it must have entered into them after life was destroyed. Such is the peculiar sensibility of the respiratory passages, that the moment water or any other substance not in harmonious relation with them, comes in contact with the mucous membrane of the larynx, the glottis is instantly thrown into a state of spasmodic constric- tion, which wholly prevents the ingress of the irritating fluid into the trachea. When the sensibility and contractibility of these parts are extinguished, however, the water may gain ad- mission into the lungs, and hence it is not uncommon to find more or less of this fluid in the air passages of those who have lain a long time under water. Some have supposed that drowing destroys life by apoplexy —that the functions of the brain are at once destroyed by strong vascular congestion and extravasation. Portal,** who entertain- ed this opinion, states, that he found the vessels of the brain, as well as the right auricle and ventricle of the heart, jugulars, and descending cava, exceedingly turgid with blood in subjects that had died by drowning. This opinion is also advocated by Littre, Kite, Waltertt and Boerhaave. On the contrary, however, many observations have been published, which go to show that vascular congestion within the head, though an occasional, is by no means a common or general phenomenon. Champreaux and Faissole assert, that they found no marks whatever of unusual sanguine- ous congestion in the brains of persons who had died by submer- • System ein. Vollstandiger Med. Polizei, vol. i. p. 186. f Instruction sur le Traitment des Asphyxies. $ Avis au Peuple, p 426. § On the Connexion of Life with Respiration, &c. p. 14. | An Essay on the Recovery of apparent Death. ^ Diss. Inaug. &c. See Ed. Med. and Surg. Jour. No. Ixxxii. Dr. Roesler states, that in forty-five experiments he made on animals, he did not in a single instance find any thing more than a very small portion of frothy mucus about the bifurcation of the trachea. •• Loc. citat. See also Observ. sur les Effects des Vapeurs Mephytiques. f\ De Morbis Peritonei et Apoplexia. ASPHYXIA. 237 sion.* Schrage,t and Kuehn,t state that they even found the vessels of the brain almost entirely empty. Fothergill, in a num- ber of experiments made on animals with a view of illustrating this subject, fully confirms these observations^ and Dr. Curry states, that in every instance he examined, he found the vessels of the' brain entirely free from distention. In nearly all instances, however, the lungs are strongly engorged with blood, and the bronchial tubes generally contain more or less of a frothy and bloody mucus. Bichat has given a very interesting and satisfactory explanation of the mode in which death is brought on by submersion, and other analogous causes of asphyxia. When respiration is inter- rupted, the blood' ceases to undergo the necessary chemical changes in the lungs; and black or venous, instead of florid and arterial blood, is immediately sent to the left side of the heart, and thence throughout the system. Now it is well ascertained, that the regular transmission of arterial or red blood to the brain, is indispensable to the performance of its functions ; and there- fore, one of the first effects of interrupted respiration towards the destruction of vitality, is a cessation of cerebral action for want of red or arterial blood to excite the brain. The direct and in- stantaneous consequence of this cessation of cerebral action, is cessation of the animal functions, from want of excitement in the organs of these functions by the nervous influence and the red blood; and from the same causes the heart soon ceases to act, and the circulation stops. Death from asphyxia, by submersion, strangulation, or the inhalation of mephitic gases, commences therefore in the brain, and those vital actions that are immediate- ly dependent on the exercise of its functions,—namely, sensation, voluntary motion, thought, and the mechanical effort of respira- tion, cease a short time before those actions which constitute what are called the organic functions, that is, the circulation, absorption, exhalation, &c. are obliterated.|| Much difference of opinion has been expressed as to the time a person may remain under water, in a state of asphyxia, with sufficient vitality remaining to afford a chance of being resusci- tated by proper restorative measures. Mr. Brodie thinks it ex- tremely improbable that resuscitation can be effected after the heart has ceased to act; and this he supposes, always occurs with- in a few minutes after the cessation of the respiratory function. Dr. Paris, and other late writers, have expressed the same senti- • Erfahr u. Warneh iiber d. Ursach d. Todes bei Ertrunk. Dantzijr 1772— as quoted by Richter. b f Diss, de Submersi—179.-—Richter, Sp. Therap. * Diss, de Causa Mortis Submersorum.—Richter, Sp. Ther. h A New Inquiry into the Suspension of Vital Actions, &c. D Bichat on Life and Death, p. 136. 238 ASPHYXIA. ments on this point. Unless, however, we reject no small amount of evidence from sources of unquestionable credibility, we are forced to admit that there is in some instances a possibility of resuscitation after a much longer period of submersion, than Mr. Brodie and Dr. Paris arc willing to allow. The experiments that have been performed on animals in relation to this point, afford us no satisfactory results. Dr. Davy informs us that he has never been able to resuscitate dogs after they had been under water two minutes ; and Dr. Colhoun of this city states, that in some experiments he made on cats, "they invariably died after six minutes of submersion."* Dr. Roesler asserts, that he suc- ceeded in resuscitating two rabbits, one after 5%, and the other after 9\ minutes submersion; and a cat after having been sub- mersed 111 minutes. He observes, however, that he "several times failed when the animals were taken out of the water in- stantly after they seemed to have expired." Experiments on inferior animals cannot, however, furnish us with any certain data with regard to the human subject. We learn, nevertheless, from these experiments, that very considerable diversity occurs as to the time that animals may remain under water and still re- tain sufficient vitality to render resuscitation possible. We see it vary in the same species of animals, and in experiments con- ducted under precisely the same circumstances, from a few to ten or eleven minutes ; and we cannot doubt that a corresponding diversity occurs, in relation to this point, in the human subject. Instances of resuscitation after a period of submersion varying from fifteen to thirty minutes are on record ; and although doubts have been expressed as to the accuracy of these statements, we can scarcely, with propriety, permit our scepticism on this point, to carry us so far as to reject, positively, the testimony upon which they are made. That such instances of recovery are, how- ever, extremely rare, is sufficiently evident from the fact, that the possibility of resuscitation after such protracted periods of submersion, is now very generally doubted. Various circumstances may contribute to hasten or retard the complete destruction of vitality from drowning. Submersion in very cold water will no doubt destroy life sooner than when the water is warm or near the temperature of the body; for in the former case the animal temperature will be much more rapidly and completely abstracted than in the latter. Previous debility from disease, spasms and convulsions, injuries sustained in falling into the water, asthma, an apoplectic predisposition, intoxication, torpor from excessive cold, an overloaded stomach, &c. may all have a tendency to lessen the chance of resuscitation from asphyxia by submersion; and it is not improbable, moreover, * Gregory's Practice, second American edition, p. 247. ASPHYXIA. 239 that some diversity may exist in different individuals as to their respective powers of vital resistance under similar circumstances of submersion. The morbid appearances observed on dissection in persons who have died by drowning or strangulation, are: turgescence of the jugulars, vena cava, right auricle and ventricle of the heart, pulmonary arteries, and of the pulmonary vessels. The left auricle and ventricle are generally empty and flaccid; and in some instances there is considerable vascular congestion in the brain, but very rarely so much as to justify the belief that any apoplectic torpor proceeded from this cause. In nearly all instances, a considerable portion of water is found in the stomach, but the lungs very generally contain very little, or no water, whatever. Inquiries have been made to discover some mark by which we may decide whether dead bodies found in water have died by drowning, or whether they have been thrown into the water after they had been deprived of life. Mr. Orfila has paid par- ticular attention to this subject, and has examined in detail all the indications that have been mentioned as available guides in making up a judgment on this point. According to his obser- vations, more or less water always enters into the stomach when death occurs by drowning, but never when the dead body is thrown into water. The result, therefore, of his inquiries on this subject is, that the only certain sign of submersion during life, is the presence in the stomach and respiratory passages of water similar to that in which the submersion took place; pro- vided that it has not been injected into the stomach after death, and that the water in the lungs is found in the ultimate ramifi- cations of the bronchia; and provided, also, that the body was not found in a vertical position. The presence of a frothy fluid in the air-passages, he says, is only to be regarded as a pre- sumptive evidence of submersion during life, and this is strength- ened by the appearance of an unusual portion of water in the pulmonary tissue, since this fluid never penetrates so deeply after death, as during life, by the efforts of respiration. The absence of a frothy mucus in the respiratory tubes, does not, however, afford any proof that death did not occur by submersion.* Treatment.—When a person is taken out of water, and it may si ill be deemed proper to make attempts to effect resuscitation, he should be immediately well dried, wrapped in blankets, and convc) ed to a place convenient for the necessary applications. The principal object to be aimed at, is a restoration of the action of the lungs, at the same time that warmth is gradually commu- nicated to the body. • Revue Medicale, torn. xui. .p. 347. 240 ASPHYXIA. With this view, artificial inflation of the lungs has always been regarded as the most important resuscitating means we possess in cases of this kind. * The inflation may be made by blowing the air in the mouth through a tube, or by a common bellows, whilst the nostrils are held close, to prevent the return of the air by that channel. It is to be particularly recollected, however, that very forcible inflation is calculated to defeat our purpose, even in cases where the chances of resuscitation may be presumed to be considerable. M. Leroy d'Etiolles has recently paid particular attention to this subject, and has strongly set forth the injurious consequences of forcible insufflation into the lungs in asphyxia. Leroy, Dumeril, and Magendie, have ascertained by repeated experiments, that sheep, foxes, deer, rabbits, &c. may be speedily killed by rapid and strong inflation of the lungs, even when the insufflation is made with the mouth. When air is forcibly thrown into the lungs, it may lacerate the delicate structure of the air- cells and cellular texture of the lungs, and thus destroy all possi- bility of restoring the pulmonary functions ; for it appears from experiments performed by the same gentlemen on dead human subjects, that the pulmonary tissue may be readily ruptured by forcible inflation.* In endeavouring to restore the action of the lungs, the air should therefore be but moderately forced into the trachea—alternating the acts of inflation with compression of the thorax and abdomen, so as to imitate the mechanical process of respiration. M. Leroy proposes to introduce two fine needles, so as to penetrate the edge of the diaphragm, and to pass a gentle current of galvanism through this muscle. This has been prac- tised on inferior animals in a state of asphyxia, with complete success, after more than five minutes of submersion. The gal- vanic circle must be alternately interrupted and closed, so as to imitate the act of respiration. Whenever the circle is closed, the diaphragm contracts, and enlarges the thoracic cavity, and the air is drawn in; on taking off the communicating wires, the diaphragm resumes its former position, and expiration takes place. The practice of compressing the chest and abdominal parietes in alternation, with gentle insufflation, is particularly recommended. By this method the blood in the vessels of the abdomen and breast is put in motion, and propelled towards the heart and lungs, and the contractibility of the diaphragm is excited. At the same time that the efforts to carry on artificial respira- tion are made, heat should be gradually communicated to the body, by wrapping it in dry and warm flannel, and by applying heated cloths, or warm bricks wrapped in flannel, or bottles filled with warm water, to the lower extremities and body. Care must * Rapport sur un Mlmoire de M. Leroy d'Etiolles, relatif a lTnsufHation du Poumon, Sec.—Revue Medicate, vol. xiii. p. 328. ASPHYXIA. 241 be taken, however, that the warmth be communicated in a gra- dual manner, for the sudden application of a high degree of heat could not fail to do irreparable injury, by destroying the small degree of remaining excitability of the organization. Frictions with dry flannel or stimulating substances, such as powdered mustard or capsicum, will contribute to excite the circulation and impart warmth to the body. The injection of stimulating fluids into the rectum will be proper, more especially when some manifestations of returning life have been established by the foregoing measures. For this purpose, a solution of ammonia, with wine, or camphor, or warm diluted brandy, may be used; and where the abdomen is tense and tumid, we may inject a warm infusion of senna in wine, with the view of exciting the action of the bowels. Galvanism, also, has been employed as a resuscitating agent in cases of this kind. Wiedemann speaks highly of this influence, more especially when directed upon the external organs of genera- tion. He asserts that he has known the most excellent effects pro- duced by it when employed in this manner. It must be observed, however, that both electricity and galvanism can be employed with a prospect of advantage only when communicated in a very weak state, for when strongly applied, they tend to exhaust rather than to increase the vital energies. Various other modes of exciting the vital powers have been recommended; such as exposing the eyes to the direct rays of the sun; applying volatile and stimulating fluids to the sny- derian membrane; plucking the hairs; tickling the soles of the feet, sides, and arm-pits; acrid substances applied to the tongue ; burying the patient up to the head in warm ashes or sand, &c. Venesection has been much recommended in asphyxia from submersion; and some have particularly advised opening one of the jugulars. Some advantage may, perhaps, be occasionally obtained from this measure, where a flow of blood can be pro- cured, by its tendency to relieve the oppressive venous conges- tions of the lungs. In general, however, no blood can be obtained by opening a vein, except in cases of very transient submersion or where the action of the heart has been re-excited by the means already mentioned; and here there is much reason to apprehend hat injury rather than advantage would generally result from this operation. The return of the vital actions is at first manifested by transient and weak twitches of the muscles of the face, particularly of those IZl t8 i1PS;,SUCceeded ^ feeble, irregular, and convulsive efforts to breathe ; spasmodic tremor and agitation of the ex tremities ; a small and weak pulse, beating at very lon2 intervals • and^hscharge of a frothy fluid from thl moutn. 5 ™£w 242 ASPHYXIA. sensation and the power of motion return ; the lips assume a red hue, the skin becomes soft and warm, particularly about the scrobiculus cordis, and in some instances vomiting takes place. When recovery has been so far effected, the utmost degree of caution is necessary to prevent, on-the one hand, over-excitation by stimulants, and, on the other, sinking from deficient support of the vital energies by appropriate excitants. I knew an instance where a person after much exertion was so far resuscitated from a state of asphyxia by submersion as to breathe freely, and to manifest consciousness and the power of voluntary motion. The persons about him were directed to give him, from time to time, certain portions of warm wine whey. This was wholly neglect- ed, and in four or five hours he sunk and expired. Warm wine, or weak brandy toddy with warm aromatic ptisans, as infusion of balm, sage, or catnep, should be given from time to time, according to the state of the pulse, and the patient must be kept perfectly at rest in a dry and warm bed, with the air freely circulating through the room, if the weather be warm. Our efforts to effect a resuscitation in cases of this kind, where the period of submersion has not been so protracted as to pre- clude all reasonable hopes of ultimate success, should not be too readily abandoned. Instances have occurred in which the signs of returning life did not manifest themselves for more than an hour after commencing with the resuscitating measures. It has been said, and the observation appears to me very correct, that there is much reason to believe that some lives are lost in this way for want of duly continued exertions to re-establish the vital actions. In still-born infants, I have known two instances of ultimate resuscitation, where the signs of returning animation were not noticed for above forty minutes after the commencement of the usual measures. It should also be observed, that well- authenticated instances of recovery are on record, where the resuscitating means were not applied until many hours after the person had been taken out of the water ; and hence, where the time of submersion has been short, and, for want of assistance, means are not employed, it may still be proper to make suitable efforts to effect a resuscitation, although several hours have elaps- ed before this can be done. De Haen, whose authority cannot be questioned, asserts that he resuscitated a person seventeen hours after he had been taken out of the water ; and other similar instances might be adduced, which, though less remarkable, per- haps, are equally encouraging to late attempts of this kind. 2. Asphyxia from the inhalation of irrespirable gases.—The most common cause of this variety of asphyxia, is the inhalation of carbonic acid gas. When this aeriform poison is undiluted' with atmospheric air, it will destroy life almost instantaneously, by abolishing, at once, all the sensibility and irritability of the ASPHYXIA. 243 nervous system. When mixed with a portion of atmospheric air, its sedative effects on the brain are less vehement and sud- den ; giving rise to vertigo, faintings, insensibility, asphyxia, or death, according to the degree of its purity and the length of time during which persons are exposed to its influence. When life is suddenly destroyed by inhaling this gas in an undiluted state, the dead body is pale, collapsed, and flaccid. In instances, however, where death or asphyxia is caused by a gradual destruc- tion of the vital powers, from the gas being more or less mixed with atmospheric air, the face exhibits a tumid and livid appear- ance, the veins about the neck and head are turgid, the tongue somewhat swollen, the lips blue, with suggilations on different parts of the surface, and the body remains warm for many hours, or even for several days. On dissection, the sinuses of the brain, the jugulars, right side of the heart, pulmonary arteries, the lungs, and the cava?, are always strongly congested with black and generally fluid blood. The pulmonary veins, left side of the heart, and aorta, on the contrary, are empty, or contain but a small quantity of blood. The ventricles of the brain are com- monly charged with a considerable portion of bloody serum, and the cellular structure about the head and neck is often found infiltrated with the same kind of fluid. The bronchia are filled with a frothy mucus more or less tinged with blood ; and the mucous membrane of the stomach and intestines, usually exhibits a dark red, ecchymosed, and distended appearance. The epi- glottis is generally erect, and the glottis patulous.* Carbonic acid gas produces its fatal effects on the animal eco- nomy both by excluding the requisite portion of oxygen or respi- rable air from the lungs, and thereby preventing the conversion of venous into arterial blood, and by a peculiar and exceedingly powerful sedative principle independent of its mere irrespirable character. Animals die much more speedily when confined in this and other mephitic gases, than when placed in an exhausted receiver, or when the atmospheric air is otherwise excluded from the lungs ;t and frogs, worms, leeches, and snails, are killed in a few hours by being placed in carbonic acid gas, although capable of living a long time when simply deprived of atmospheric air.J These facts show conclusively, that in addition to the mere exclu- sion of respirable air, there is also a deleterious impression made on the vital powers by inhaling this gaseous poison ; and it acts therefore at once like submersion or strangulation, and as a pow- erful sedative poison. • Portal. Observations sur les Effets des Vapeurs Mephitiques t Fothergill. A New Inquiry into the Suspension of Vital Action, in Cases of Drowning and Suffocation. Cms"™"®' De Anima,ium ex meP1,itil>U3> etnoxiishalitibus interim ejusque 244 ASPHYXIA. There are several other gaseous substances, which, when in- haled in a concentrated form, produce immediate asphyxia or death. The fumes of sulphur, sulphurated hydrogenous gas, ni- trous gas, azote, hydrogene, and certain gaseous poisons, generat- ed by putrefying animal and vegetable substances, destroy life with more or less rapidity. Of these gases, azote, and pure hy- drogen, appear to destroy life simply by their not being respira- ble, or by preventing the chemical changes of the blood in the lungs, in the same manner that submersion or obstruction of the trachea produces this effect* Treatment.—When the asphyxia from this cause (carbonic acid gas) is incomplete, with some degree of sensibility remain- ing, the patient may be generally soon recovered by conveying him immediately into the open air, supporting him in a sitting posture, dashing a little cold water upon his face and breast, ap- plying dry frictions to the extremities, and, as soon as he can swallow, giving him small portions of cold wine and water. If the unfortunate individual is in a state of perfect asphyxia, without any manifestations whatever of life, we may sometimes succeed in effecting resuscitation by the following course of ma- nagement. He should be speedily carried into a free and cool air, divested of his clothes, and laid upon a sheet spread on the floor, or the ground, with his head and shoulders somewhat raised. Cold water must now be dashed upon his breast, and cloths dip- ped in cold water applied to the head ; or he may be supported in a sitting posture, and the water poured on the head. In some cases, the moment the cold affusion is made, a convulsive respi- ratory effort is excited. In an instance to which I was called about a year ago, I found the patient without the slightest indica- tions of vitality. Having stripped off his clothes, I dashed a bucket full of cold water over the head and breast, and almost at the same moment, I observed a short convulsive gasp. By con- tinuing the affusions at short intervals, the respiratory efforts were repeated, at first very weak, and at intervals of nearly a minute, and by the additional aid of stimulating frictions, the respiration was fully established in about an hour after the first symptoms of returning life. Frictions with the flesh-brush, or with stimulating embroca- tions, are important auxiliaries in re-exciting animation in cases of this kind. We may also derive advantage from volatile stimu- lating applications to the mucous membrane of the nose, by means of a feather—such as aqua ammonia, ether, and camphorated spirits. At the same time, also, stimulating enemata should be used, particularly a solution of the carbonate of ammonia in a mucilaginous fluid. Richter speaks favourably of the injection of * Bichat on Life and Death, p. 242. ASPHYXIA. 245 cold water and vinegar for this purpose. If the act of respiration be not soon excited by the cold affusions, artificial inflation of the lungs must be resorted to, in the way mentioned above. Upon these two means we must chiefly rely in our efforts to effect re- suscitation. When the respiration is partially established, but continues very laborious, and with a rattling noise in the bron- chia, considerable benefit will sometimes result from the abstrac- tion of from eight to ten ounces of blood from the arm. As soon as the respiration is fully established, the patient should be wiped dry, and laid in a comfortable bed, and small portions of warm wine, or wine-whey, or some other gentle stimulating beverage allowed. Galvanism has been employed, and, in some instances, with manifest advantage, in asphyxia from mephitic gases. The gal- vanic current should be weak, and passed along the course of the pneumo-gastric nerves, by placing the negative conjunctive wire in contact with the scrobiculus cordis, and the positive pole with the part immediately over the par vagum in the neck, just below the sterno-mastoid muscle. After the vital actions have been re-established, the arterial excitement, in some instances, becomes violent and tumultuous. The heart palpitates vehemently; the pulse is full, strong, and hard ; the vessels of the head turgid, and a disposition to heavy sleep ensues. Under these circumstances, venesection is indispen- sable, and the blood should be suffered to flow until the activity of the circulation is considerably moderated. In general, much caution is necessary after resuscitation is effected, neither to ex- cite the vital powers too much—which may readily be none__ nor to suffer them to languish for want of some gentle stimulus. 3. Asphyxia from electricity.—When electricity is passed through the animal system, in currents of moderate intensity, it excites and invigorates the vital energies; but when its intensity is great, it suddenly suspends, or entirely destroys the sensibility and irritability of the nervous system, and gives rise to more or less complete asphyxia, or immediate and irrecoverable loss of vitality. The appearances exhibited by persons who have been struck by lightning, vary considerably. In most instances, red streaks may be noticed on the breast and arms, of an ecchymosed and highly irritated appearance, and generally of a zigzag form. The hair is usually singed on some parts; and small blisters, like those produced by a scald, occur on different parts of the body Some- times blood is discharged from the ears, and suggilations of laree extent are frequently found on the trunk and extremities. Inter- nally structural lesions are but rarely detected in persons who are killed by lightning. In general, the heart is turgid with blood, but the lungs are usually collapsed, and entirely free from vascu- 246 ASPHYXIA. lar congestion. The blood is always deprived of its coagulability by a fatal stroke of electricity ; and the body commonly enters into putrefactive decomposition with extraordinary rapidity. When the electric stroke does not entirely destroy the vital pow- ers, the face is generally red and bloated; more or less blood often issues from the mouth and nose ; respiration is slow and very laborious; the pulse is extremely weak and irregular, or entirely absent; and spasmodic twitches of the muscles of the eye-lids, mouth, and throat, sometimes occur. Persons who are recovered from a state of asphyxia, caused by lightning, gene- rally suffer for a long time afterwards with tremors, painful sen- sation, swellings, and some degree of numbness in the extremi- ties, more especially in the legs. Such individuals usually retain a particular susceptibility to the electric influence, and are apt to feel a peculiarly uneasy feeling on the approach of a thunder- storm. The treatment of asphyxia from this cause, does not differ from that which is mentioned for asphyxia from mephitic gases. Cold affusions are particularly valuable to re-excite the latent vital energies in cases of this kind. Cold water should be copi- ously and frequently dashed over the whole body, and frictions diligently made with the flesh-brush or pieces of rough flannel. Galvanism and electricity also have been especially recommended in asphyxia from a stroke of lightning. Stoll asserts, that ani- mals in a state of asphyxia from an electric shock, have been speedily recovered by a second shock of this power ;* and Bernt assures us that in a case produced by a stroke of lightning, a se- cond shock effected a resuscitation.t M. Abilgaard also has relat- ed some instances of asphyxia from this cause, in inferior animals, in which resuscitation was effected by a second shock of electri- city, t 4. Asphyxia from cold.—-When the body is subjected to the influence of intense cold, the superficial blood-vessels shrink ; the surface becomes pale and contracted ; respiration oppressed ; the extremities benumbed and weak ; and finally, an irresistible desire to sleep comes on; and unless speedy aid be obtained, insensibility, asphyxia, and death, inevitably ensue. For the mode in which these effects are produced by low temperature, the reader is referred to the article cold, page 34, of the first vo- lume of this work. Instances of resuscitation from asphyxia, caused by intense cold, are by no means uncommon ; and cases are related in which re-animation was effected many hours, or even several days, after • Rettungsmittel in plotz. unf alien, p. 63. j- Vorlesungen iiber d. Rettungsmittel. beim Scheintode, p. 121; a9 quoted by Richter, Spec. Therap. vol. viii. p. 647. * Loc. Med. Havnien. Collectan. &c. T. ii.—Good. ASPHYXIA. 247 the asphyxia was produced.* The principal resuscitating means in cases of this kind is the gradual communication of warmth to the body. The introduction of warmth requires, however, the utmost degree of caution; for, if the heat be rapidly communicat- ed, it will inevitably destroy the remaining vitality, or should a partial recovery ensue, fatal gangrene would be the certain consequence. When a person is found in a state of insensibility from cold, he must on no account be immediately conveyed into a warm chamber, or placed near the fire. His body should be immersed in spring water, or water fresh drawn from a well. Burying the body in fresh snow has also been recommended for this purpose. Richter states, that the snow-bath is decidedly the most important resuscitating means we possess in cases of this kind. After the body has been suffered to lie in water or snow for forty or fifty minutes, it should be carefully dried with soft pieces of flannel, wrapped in blankets, and conveyed into an unheated chamber. Gentle frictions with flannel should now be resorted to, and if no manifestations of respiration occur, artificial inflation of the lungs should be practised. If these efforts suc- ceed in restoring symptoms of life, the temperature of the room should be very gradually increased, and bottles filled with luke- warm water laid to the feet, and about the body. When the power of deglutition is restored, moderately warm ptisans—such as balm, sage, or elder-blossom tea, and diluted warm wine, may be given with advantage; but the stronger stimulants must be rigidly interdicted. Sect. IV.—Pneumo- Thorax. The collection of aeriform fluids in the cavity of the pleura, is- termedpneumo-thorax. This is no very uncommon occurrence, and is always attended with the most distressing effects on the action of the lungs and heart In most cases the confined air is fetid, resembling the smell of sulphuretted hydrogen. This is always the case when the passage formed between the cavity of the pleura and the air cells is the result of a gangrenous eschar of the surface of the lungs, and where more or less purulent mat ter is effused into the cavity of the chest When such a com- munication is effected by ulceration, tuberculous softening, or otherwise, the air is forced into the cavity of the pleura during; the acts of respiration, and as its return into the lungs must al ways be very slow, and often wholly impossible from the valvu- lar form of the opening, it accumulates with more or less rapidi- ty, until the lungs are so greatly compressed as to render respira- :. Oekonom. Encyclopaedia, Th. xv. p. 261. Richter. Sp. Ther. 248 PNEUMO-THORAX. tion extremely difficult, and finally to arrest it entirely. The lung of the affected side becomes, at last, compressed into a very small and nearly solid mass; and when the disease occurs in the left cavity, the heart and mediastinum are usually forced completely into the right side of the chest. The affected side of the chest becomes manifestly bulged out, and the intercostal spaces wider and more raised or puffy than natural. The abdomen, also, usu- ally becomes more prominent in consequence of the depression of the diaphragm against the abdominal viscera by the distending force of the confined air. Patients affected with pneumo-thorax experience great pecto- ral oppression and difficulty of breathing, attended generally, with more or less palpitation of the heart, and often with severe pain under the sternum or the affected side of the chest. They are usually obliged to remain in the sitting posture, and can never rest even for a moment recumbent on the sound side. M. Rayer has related a case in which the patient was forced to remain day and night resting on his knees and elbows in bed. When the pneumo-thorax occurs in the left side of the chest, the palpitation of the heart is usually felt in the right side only; but this can take place only in very violent cases, where the confined air is so abundant as to force the heart completely into the right cavity of the thorax. The diagnosis of this affection is not attended with difficulty except to those who are not experienced in mediate auscultation and percussion. By these diagnostic means, the practised ear may arrive at certain conclusions as to the existence of air in the cavity of the chest. " Whenever we find one side of the chest sounding more distinctly than the other, and at the same time perceive the respiratory murmur distinctly in the least sono- rous side, and not at all in the other, we may be assured that there exists pneumo-thorax in the latter side of the chest." Even when, on percussion, we find both sides equally sonorous, the existence of this affection may be inferred, if auscultation do not enable us to perceive the respiration on one side whilst it is audible on the other. When the disease supervenes on pleuritic effusion into the cavity of the pleura, the affected side will yield a dull sound when percussion is made, before the pneumo-thorax commences. " As soon, however, as the air begins to accumu- late, the resonance of the chest returns in some degree, in the situation occupied by the air, without, however, being as distinct as in the sound side. Day after day, the extent and intensity of this resonance increase without any return of the sound of re- spiration ; and if there had previously been any remains of the respiratory murmur, even this now totally vanishes." But when the lung of the affected side is attached to the costal pleura by means of a very short cellular tissue, the diagnosis, even by aus- PNEUMO-THORAX. 249 cultation and percussion, is rendered more uncertain; for at the point of adhesion the respiration will still be audible (Laennec). When, on examining the chest with the stethoscope, that pecu- liar metallic sound is heard, which Laennec calls metallic tinkling, and which has been compared to the sound of a drop of water falling into a bottle half full, it indicates the existence, both of air and a puriform matter in the cavity of the pleura, with a fis- tulous opening between the cavity of the chest and the bronchia. This metallic sound, says Laennec, "exists only in that variety of pneumo-thorax which is complicated with empyema; and may be considered as a pathognomonic sign of this combination in con- junction with a fistulous opening into the bronchia." The me- tallic tinkling of pneumo-thorax may be distinguished from that which occurs from a large tuberculous excavation in the lungs partly filled with a purulent fluid, by the greater weakness of the sound, and the narrow space to which it is confined in cases of this latter kind. There is some risk in mistaking emphysema for pneumo-thorax in examining by percussion and auscultation ; particularly by those who are not accustomed to this mode of exploration. M. Laen- nec points out the following difference in the results obtained by the employment of these diagnostic means in these two affec- tions. " In pneumo-thorax, the respiratory murmur is wholly absent, except at the point between the scapula and spine, cor- responding to the roots of the lungs. In emphysema, the respi- ratory sound is never completely inaudible, and there is a slight rattle which never occurs in the former complaint. Pneumo- thorax comes on rapidly, and cannot continue long without giving rise to dangerous symptoms, or even proving fatal; emphysema, on the contrary, comes on slowly, and is never so severe as to confine the patient to bed, or incapacitate him for his ordinary occupations." Post mortem appearances.—On cutting into the cavity of the pleura, the air usually rushes out with very considerable force. In many cases there is a small portion of sero-purulent fluid found in the chest; and in nearly all instances, the surface of the pleura is more or less extensively covered with a thin layer of pseudo- membranous matter. Not unfrequently, slight adhesions occur between the costal and pulmonary pleura of the affected side. The lung of the side affected is usually compressed into a small irreguhu- and compact mass; and if the disease is in the left cavity, the heart and mediastinum are pushed completely within the right cavity of the thorax. Frequently, a fistulous opening may be detected between the cavity of the pleura and the bronchia. Causes.— Pneumo-thorax frequently occurs in consequence of tuberculous excavation near the surface of the lungs, and the formation of a fistulous opening into the bronchia. Chronic Vol. II 32 250 PNEUMO-THORAX. pleuritis, also, may give rise to this affection. Some of the cases related by M. Itard, originated from chronic pleurisy. When the disease arises from chronic inflammation of the pleura, it is always preceded by the effusion of sero-purulent matter into the cavity of the chest, and in such cases no opening into the bronchia, usually, occurs. It would appear that in cases of this kind, the air within the cavity of the pleura "is the product of a chemical decomposition of the effused albuminous and puriform fluid." In proportion as the gas is thus developed, the effused fluid becomes absorbed, until the disease has acquired the cha- racter of complete pneumo-thorax. The rupture of a vomica, giving rise to a communication between the bronchia and the cavity of the pleura, appears to be no uncommon cause of this affection. When the disease occurs in this way, the air in the thorax is generally associated with a purulent fluid. Pneumo- thorax may also arise from the extrication of fetid gas, by the decomposition of a gangrenous eschar dissolved and discharged into the cavity of the chest. (Laennec.) Treatment.—This is always an extremely dangerous affection; for although the mere accumulation of air in the cavity of the pleura, may not of itself be so formidable, yet the organic lesions with which it is almost invariably connected, are generally of such a nature as to admit of but slender hopes of cure, or even of a considerable prolongation of life. It would seem, neverthe- less, that spontaneous cures of this affection have taken place. Such a favourable termination is, however, an extremely rare occurrence, and is supposed to take place in the following manner. The lung being strongly compressed by the air that rushes into the cavity of the pleura, through the aperture made into the bronchia, gradually collapses, if no adhesions exist, until it remains quies- cent. In this state of collapse and rest, the lung is in the most favourable condition for the healing of the opening through which the air passed. "If the opening heals, the air will be absorbed, and the patient gradually recover." The general remedial management must, of course, be modified according to the nature of the lesion or primary affection, upon which the pneumo-thorax depends. When there is reason for believing that the air compressing the lungs is the result of chronic inflammation of the pleura, some advantage may be expected from counter-irritating applications to the chest:—such as blister- ing, pustulation with tartar emetic ointment, cupping, moxa, issues, setons, &c. Some benefit may also result from gentle courses of mercury, and from the internal exhibition of diuretic remedies. In cases manifestly connected with tuberculous soften- ing, and fistulous opening into the bronchia, little or no advantage can be looked for from any remedies of this kind. Different opinions have been expressed as to the propriety of PNEUMO-THORAX. 251 puncturing the thorax for the purpose of giving exit to the con- fined air in this affection. Laennec speaks favourably of this operation, although it does not appear that he has himself resorted to it with success in any case of this kind. The only instance m which he performed this operation, terminated fatally in a tew hours after the puncture was made. The opening was made between the fifth and sixth ribs, and very little air, and no puru- lent matter, escaped from the incision. This appears to have been a case of empyema conjoined with pneumo-thorax, for when after the death of the patient an incision was made about the middle of the fourth intercostal space, a considerable quantity of pus was discharged; and on making an opening into the chest near the junction of the third rib with its cartilage, much fetid gas rushed out. This case cannot, therefore, be regarded as a fair test of the value of this operation in pneumo-thorax. Riolan states, that he has seen several instances of the successful operation of paracentesis on patients who were supposed to labour under dropsy, without any thing having been evacuated from the chest but air. (Laennec.) These, doubtless, were cases of simple pneumo-thorax, and may be regarded as encouraging examples of the usefulness of this operation in the present affection, when uncombined with empyema. "Pneumo-thorax," says Laennec, "complicated with liquid effusion, and still more, with pulmonary fistula, is a case of a most serious nature, and leaves little hopes of a cure being effected. This, however, must not be regarded as quite impossible even in the severest cases. I formerly proved the possibility of the cicatrization of tuberculous excavations; and the observations of Bacqua, Jaymes, and Robin, (Jour. Gen. deMed. 1813,) to which I could add a more recent case of the same kind, sufficiently prove, that even in such cases, we may attempt this last resource with some prospect of success." That the operation in question is a proper one, in perhaps every variety of pneumo-thorax, can scarcely be doubted; for even where the prospects of an ultimate cure cannot be entertained, we may at least reasonably expect to prolong the patient's life, by giving exit to the confined air, and thereby preventing suffocation from the compression of the lungs. The object of the operation is to prevent the fatal compression of the lungs, by the confined gas, and to place this organ in a state of quiescence, so favourable to the healing of the aperture through which the air passes from the bronchia into the cavity of the pleura. Although the propriety of this operation seems to be obvious in this affection, yet we find but very few instances re- corded of its having been performed in pneumo-thorax. There is a highly interesting case reported in the Medico-Chirurgical Review, (January, 1829,) in which the chest was punctured; but although great relief was the immediate consequence of the 252 PNEUMO-THORAX. evacuation of the air, the patient in a few days sunk under the disease.* A case of pneumo-thorax is related by Dr. Davy, in which this operation was performed with entire success. The patient was affected with haemoptysis, which came on after "a severe fall on the left side of the chest, received eighteen months previously." While under treatment for this affection in the Military Hospital at Chatham, he was one morning seized with a violent fit of coughing, and symptoms of pneumo-thorax immediately suc- ceeded. The thorax was punctured with a trochar between the eighth and ninth ribs, "the integuments and intercostal muscles having been previously divided with a scalpel." As but little air escaped by this opening, it was "concluded that its escape had been pre- vented by adhesions of the pleura at the point where the puncture was made;" and on the following day the operation was repeated just below the left papilla. From this orifice a large quantity of air rushed out "as if from a blow-pipe." The relief obtained was immediate and great, and the patient continued to improve regularly. This and the preceding case, says Dr. Johnson, are the only instances in which this operation was performed for pneumo-thorax in England. CHAPTER V. CHRONIC DISEASES OP THE HEART Sect. I.—Of the Diseases of the Heart. There is scarcely a subject in pathology that has attracted so much attention of late years, as the chronic affections of the • The patient was a member of our profession, and was visited during his ill- ness by the majority of the most eminent physicians and surgeons of London. The incision was made between the sixth and seventh ribs, anteriorly. When the pleura was punctured, « a rush of air instantly issued forth with a loud hissing noise, and strong enough to extinguish several candles. The relief was almost ingbuitaneous. The patient turned on his back, and breathed with comparative freedom. On the fourth day after the operation, the patient was found to be sinking, and, after a strong paroxysm of convulsions, expired on the afternoon of tfus day. On dissection, an aperture was discovered at the division or cleft between the two lobes. This aperture was circular, about the size of a crow- quill, and evidently fistulous. It communicated with a small tuberculous ex- cavation. The right lung was much more tuberculous than the left, but the tubercles were m a quiescent state.—Med. Chir. Rev. Jan. 1T29, p 482 DISEASES OF THE HEART. 253 heart. The researches of Corvisart,* Kreys.g,t Testa,t Laennec,§ Burnsdl and Abercrombie^ have thrown great light on this im- portant class of diseases, and it is from these sources chiefly that the following observations are drawn. Symptoms.—-The general symptoms are nearly the same in every variety of structural disease of the heart. More or less habitual dyspnoea almost universally attends in affections of this kind; and a careful attention to the particular modifications of this symptom, is of great importance in a diagnostic point of view, (Corvisart.) The acts of inspiration are either very quick, and effected more by the action of the ribs than by the diaphragm, and somewhat wheezing; or the patient breathes as if he had been walking rapidly, and appears to make unusual efforts in filling the lungs; or "finally, the respiration is calm, and without any particular effort, but the air does not appear to enter into the lower portion of the lungs. Mental agitation, or corporeal exer- tions, particularly walking, or ascending acclivities or stairs, never fail to bring on more or less violent paroxysms of dyspnoea; and in the latter stages of the disease, the most trifling excitements of this kind give rise to extremely distressing spells of suffocative breathing, attended with great weight and constriction in the breast, inexpressible anxiety, a turgid and usually livid hue of the face, particularly of the lips, which are swollen and purple; distention of the veins in the neck and head, and an expression of extreme distress and suffering in the countenance. These pa- roxysms of dyspnoea often last but a few minutes, and rarely con- tinue beyond half an hour, and subside rapidly to the ordinary state of respiration. During the early period of the disease, or in cases of a less serious character, the patient is able to lie down, (tliough rarely with any degree of ease on the right side) but the sleep is much disturbed by alarming dreams, frequent startings, and spells of palpitation—obliging the patient suddenly to sit up in bed. In violent or inveterate cases, however, the patient is sometimes obliged to remain day and night in a sitting or half- sitting posture—every attempt to lie down being immediately followed by the most harassing paroxysm of palpitation of the heart and suffocative breathing. One of the most frequent symp- toms of cardiac diseases is irregular action of the heart. Some- times the heart beats tumultuously and indistinctly, which has • Kssai sur les Maladies et les Lesions Organiques du Cccur. t Die Krankbeiten des Herzens. Berlin, 1814-17. % lklle Malattie del Cuore. ed?tione*tiSe °" thC UiSCaSeS °f thC Ch6St: translated ^ J- F«rbes, M. D. : 3d Burntrsog!10"30" "^ °f ^ ™* ^^ Diseases °f Tart, potass, ^iss. Sulph. potass. Jss. Pulv. scillae gii. Tart, antimonii gr. ii.—M. 9. Take a tea-spoonful four or five times daily \ Clinique Chirurgicale. DISEA8ES OF THE HEART. 269 means of moxa. Against the supposed specific cause he employs mercurial remedies, and he avers that these are always highly beneficial when combined with counter-irritation. In active hypertrophy he uses local depletion over the cardiac region, after which he applies the moxas. He speaks also very favourably of cold in the form of ice applied to the region of the heart The moxas are to be applied first to the track of the intercostal nerves behind the left hypochondrium, and then gradually brought round and forwards to the anterior cardiac region. His favourite for- mula for administering the mercurial remedies is the following : R. Muriat. hydrarg. corros. Muriat. ammon. G. opii ia gr. v. Aq. distillat. Ifei. Misce. ft. solutio. Of this, a dessert-spoonful is to be taken, several times, we presume, daily, for he does not state the frequency of the dose. "One great principle,"says Dr. Forbes, "is always to be kept in view, in the treatment of diseases of the heart, namely, the removal of all disorders in other organs which can act as a source of irritation to the heart" It is particularly important to attend to the gastric and hepatic functions; and hence we find that patients almost always experience some relief when these functions are brought into a healthy condition. " I would lay it down," says the writer just quoted, " as a general rule in chro- nic affections of the heart, that previously to having recourse to any remedies intended to act directly on it, we ought to be as- sured that the digestive organs are in a healthy state—that their mucous surfaces are frse from irritation—their vascular system not morbidly distended, and that the liver is performing the secretory functions freely and regularly. When derangements of this kind are present—a few leeches to the praecordiaw anus, some small doses of oxide of mercury and castor oil, a mild and spare diet, and bodily and mental repose, will often do more to tranquillize the circulation than more active and rougher means. And indeed, in many cases, more especially in the earlier stages, when the stethoscope gives us but little information, it is not until we have restored the organs to a comparatively healthy condition, that we can know how far the disordered action of the heart depends on sympathy with these, or is the consequence of incipient organic lesion of the heart." * Con- comitantly with the employment of the above-mentioned tonics, very considerable advantage may in general be derived from an occasional dose of three or four grains of blue pill at night, and a mild laxative in the morning; and to keep up the regular action of the skin, the tepid shower-bath will generally be useful. * Laennec on the Chest. By Dr. Forbes. 270 DISEASES OF THE HEART. Sympathetic Affections of the Heart. Symptoms differing in no material circumstance from those which have already been mentioned as belonging to organic af- fections of the heart, are not unfrequently the result purely of a sympathetic irritation of this organ without any structural lesion whatever. I do not now allude to those cases of angina pectoris which arise from metastastic or sympathetic irritation, and which are probably always of a strictly neuralgic character. The heart is liable to be excited into vehement and tumultuous action, by a variety of causes not immediately connected with lesion or dis- order of its structure; and the most alarming instances of this kind often result from an irritation located in some remote part of the system. It is of much consequence, in a practical point of view, to keep this, indeed, well-known fact in mind, in pre- scribing for cardiac affections. I have, in several instances, been consulted by persons subject to extremely violent paroxysms of palpitation, who were supposed to be labouring under chro- nic affection of the heart, and who were completely relieved by a course of treatment calculated to restore the healthy condition of the digestive functions, and of the liver. When we find pa- roxysms of palpitation come on while the patient is quiet, perhaps lying down, without pain in the region of the heart, at the same time that there are symptoms of indigestion, particularly eructa- tions of flatus, there can be but little doubt that the cardiac affec- tion is symptomatic of gastric irritation. Habitual debility and irritation in the digestive organs are particularly apt to give rise to such affections in persons of a plethoric and nervous habit of body. I was consulted, about eighteen months ago, by a gentle- man of a very nervous temperament and weak digestive powers, for aid, in what he was led to regard as a local affection of the •heart. The slightest mental agitation, would, occasionally, im- mediately excite vehement palpitations ; and frequently similar paroxysms came on about two hours after taking his meals. He had paid little or no attention to the regulation of his diet, although often disturbed wTith flatulency, acidity, and other un- pleasant sensations in the stomach. He was directed to take four grains of blue pill every other evening, an occasional dose of rhubarb in the morning, and put on a light and digestible diet, with exercise on horseback. In four weeks his complaint left him, and he has not had any return of it since. Irritation located in other organs, as the kidneys, intestinal canal, uterus, liver, and probably the spleen, sometimes gives rise to severe fits of palpitation. They are particularly apt to occur about the age of puberty in young females, or just before the ir- ruption of the menses. Nervous females, more especially those DISEASES OF THE HEART. 271 who labour under chronic hysteric affections, are also especially subject to palpitations of the heart. These casesl are, in general, easilv distinguished from organic affections of he heart, but as structural disease of this organ may be associated with mere sym- pathetic irritation, it may be well to state more explicitly the signs by which nervous palpitation may be distinguished from hyper- trophy or dilatation of the heart. Violent and extremely alarming cases of cardiac disease, uncon- nected with organic lesion, sometimes result from the unnatural and enervating practice of onanism. I have met with a most deplorable instance of this kind, in a young man, which was finally removed by discontinuing this degrading habit, in con- junction with mild tonics, active exercise, and a regular, digesti- ble, and nourishing diet. Dr. Krimer has, within a few years past, published several remarkable cases, illustrating the injurious effects of self-pollution on the heart. The usual symptoms, in cases of this kind, are: pale and dejected countenance; eyes sunken and haggard ; taciturnity or pusillanimity; general languor of the body, and mental apathy; more or less tenderness in the epigastrium; and irregular action of the heart, with frequent paroxysms of tumultuous palpitation, dyspnoea, and precordial anxiety. * As this subject is one of great importance, I subjoin the fol- lowing observations from Dr. Krimer's paper, as diagnostic of cardiac affections arising from onanism. The hair is dry, not glossy, split at the extremities, and apt to fall off, especially from the fore part of the head. The eyes dull, sunken, watery, and apathetic; the edges of the lids are often red, and the lower mar- gin of the orbit surrounded with a bluish streak; the countenance is unsettled, timid, and the patient "cannot bear the steadfast gaze of another person." There is often headach, which returns, in most instances, at nearly the same time daily—the pain of which radiates from the occipital to the frontal region. Vision is, at times, confused or dim; the appetite weak and capricious; the tongue lightly covered with white fur; and the breathing is usually short. Pain in the stomach is almost continually present, and the epigastrium is extremely tender to pressure, " without any other symptoms of mucous inflammation of the stomach." Great lassitude, with pain in the loins and lower extremities, are very common symptoms. There is often a considerable drowsi- • The reviewer of Dr. Krimer's paper observes, "the disgusting nature of the subject has prevented English writers from any description or investigation of the phenomena; but we are well convinced, from many cases which have pre- sented themselves to our observation, and where the cause has been voluntarily confessed, or unexpectedly drawn forth, that a great number of cardiac affec- tions, as well as anomalous symptoms of disorder in other parts of the system, are owing to this destructive vice."—Med. Chir. Rev. April, 1828, p. 149. 272 DISEASES OF THE HEART. ness, and always a remarkable disinclination to mental and cor- poreal action.* "In nervous palpitation, the first impression conveyed by the stethoscope, is, that the heart is not enlarged. The sound, though clear, is not heard loudly over a great extent of the chest; and the impulse, although appearing considerable at first, is really not great, as it never sensibly elevates the head of the observer. This last sign seems to me the most important and certain of any, when taken in conjunction with the frequency of the pulsations. These are always quicker than natural, being most frequently from eighty-four to ninety-six in the minute. Nervous palpitations are rarely accompanied by any sign of determination of blood to the head or chest, except in old persons. A feeling of internal agita- tion, particularly in the head and abdomen, always accompanies nervous palpitation; and the urine is generally limpid and watery." (Laennec.) Treatment.—The treatment must of course be regulated ac- cording to the particular condition of the general system, and the local organic irritations that may exist. The digestive func- tions must be particularly attended to, and the sources of intes- tinal irritation obviated by gentle aperients. In relaxed and weak habits, the tepid bath; a mild, digestible, and nutritious diet; gentle tonics, especially bitters and iron; gentle exercise by gestation; and in young and plethoric subjects, small abstractions of blood; warm pediluvium; and digitalis, will, in general, prove beneficial. Antispasmodics very rarely procure any relief, and indeed much more frequently do injury. Although small por- tions of blood may sometimes be beneficially abstracted in robust and plethoric subjects, yet, blood-letting, to any considerable extent, is generally detrimental, in the sympathetic affections of the heart I have met with several instances, where repeated abstractions of blood had reduced the patients to the most de- plorable condition; and which were afterwards cured by tonics, gentle exercise by gestation, the tepid shower-bath, and a diges- tible and nourishing diet. One young man, of a dyspeptic habit, was affected at times with alarming palpitation, and dysp- noea. His physician; regarding it as active hypertrophy, bled him copiously. The disease, however, gradually became more distressing, and the blood-letting was repeated from time to time. Finally the patient was obliged to remain in his room, and could not walk across the floor without bringing on a violent paroxysm of palpitation and precordial distress. A consultation was called, and the plan of treatment changed. Mild tonics, dry frictions of the extremities, the tepid shower-bath, a nourishing, but light and digestible diet, were ordered. In a few weeks he could leave * Hufeland's Journal der Heilkunde, Jan. 1827. DISEASES OF THE HEART. 273 his room; soon was able to take exercise in a carriage, and in about three months had his health perfectly restored. Physicians are too apt to resort to the lancet when they find the heart in a state of tumultuous action. The minutest inquiry into the origin and character of the disease should always be instituted before this practice is adopted; and where there is reason to believe that the cardiac disorder is the result of a sympathetic irritation, blood should not be abstracted unless some especial indications exist for the reduction of the mass of the circulating fluid. When sympathetic disease of the heart is intimately connected with general plethora, which is indeed frequently the case, it may be proper to practice one bleeding in the commencement of the treatment; but even in cases of this kind I should prefer reducing the volume of the blood, by a more spare diet, and the encour- agement of the ordinary secretions, particularly those of the skin and kidneys. Sect. II.—Angina Pectoris.* Angina Pectoris was not noticed as a distinct disease, until the attention of the profession was directed to it by Dr. Heberden, in a very perspicuous and full account of its peculiar character, published in the second volume of the Medical Transactions of the London College of Physicians. Since that time, it has been frequently and minutely described, and of late years, especially, its phenomena and pathology have received much attention. This disease consists of sudden paroxysms of pain and pressure at the lower part of the sternum, or about the region of the heart, extending across the breast to the left shoulder, and to the arm as low as the insertion of the deltoid muscle, or the elbow, or even to the fingers; accompanied with some difficulty of breathing, great anxiety, and a sense of impending suffocation. The attack usually commences without any premonitions of its approach, by sudden pain and constriction in the left side of the chest, or near the scrobiculus cordis, and a peculiar numbness with more or less pain in the left arm, particularly on the inside, as low as the elbow. If the paroxysm comes on while the patient is walking, he is instantly obliged to stand still. The least ex- ertion gives rise to intense darting and constrictive pain in the cardiac region; and the patient feels as if an attempt to move i • This disease has been described under a great variety of names, as asthma tonvulsivum, by Eisner; arthritis diaphragmatica, by Butler; syncope anginosa, by Parry; asthma spastico arthriticum inconsluns, by Stoeller; sirenalgia, by Raumes ; sthenocardia, by Brera; asthma-dolorificum, by Darwin; slernodynia syncoplica et pa/pitunle, by Sluis; pnigophobia, by Swediaur; and cardodyne spasnwdicu, by llarlcs. Vol. II. 35 274 ANGINA PECTORIS. would inevitably cause.immediate death. During the paroxysm, the countenance is pale and expressive of great anguish, the extremities are cold, the heart palpitates violently, there is more or less dyspnoea, turgidity of the vessels of the head, and in some instances syncope and even convulsions ensue. Sometimes the pain passes up along the neck and face, or back, to the spine, with a sense of retraction at the lower end of the sternum; and occasionally it is felt in both arms at once. At first the parox- ysms last but a few minutes; and recur at remote intervals, generally in walking up hill, or rapidly ascending stairs soon after taking a full meal. By repetition, however, they become more and more violent and protracted, and return, in aggravated instances, on the slightest bodily exertion. When the attack has passed off, the patient usually feels only numbness of the left arm, with some degree of palpitation, and, occasionally, slight headach, hurried respiration, and anxiety of feeling in the precordia. Pathology.—This disease is very rarely met with in young people ; and it occurs indeed but seldom in individuals under forty years of age. I have, nevertheless, seen a well-marked case in a young man of an arthritic habit, who was not more than twenty-three years old; and 1 am now attending a girl under eleven years of age, who is occasionally seized with paroxysms which appear to me genuine instances of this affection. The majority of cases of angina pectoris occur in individuals of a gouty or rheumatic habit Jahn states, that in the summer of 1814, he met with several instances of this disease, which su- pervened apparently as sequelae of typhus fever. * In relation to the immediate or exciting causes of this affection, pathologists have expressed very different opinions. Heberden, Kreysig, t and Parry, % attributed the disease to ossification of the coronary arteries, and this opinion is still entertained by many physicians. Others have ascribed it to ossification of the semi- lunar valves of the heart; and various other organic affections of this organ and of the adjoining parts, have been mentioned as its cause, such as morbid dilatation and softening of its structure; ossification of the cartilaginous portion of the ribs; suppurative inflammation of the mediastinum, and disease of the pericardium. That no one of these morbid conditions, however, can be regarded as the proximate or essential cause of angina pectoris, is evident from the fact, that in many fatal instances of the disease, no such structural disorders are discovered on post mortem examination. M. Recamier, principal physician at the Hotel Dieu, has never witnessed an instance of ossification of the coronary arteries in • Klinic der Chronischen Krankheiten. Band iv. p. 406. \ Die Krankheiten des Herzens. 2 Th. 2. abhand. 5. Kap. i Treatise on Syncope, Anginosa, &c. ANGINA PECTORIS. 275 the bodies of those who have died of angina pectoris; and he wholly rejects the idea of its depending on organic cardiac dis- ease.* M. Laennec, also, denies the necessary connexion between organic affections of the heart and angina pectoris. "In a slight and middling degree," he says, "this disease is very common, and exists very frequently in persons who have no organic affec- tion of the heart or large vessels."! It must, moreover, be ob- served, that ossification of the coronary arteries, and other struc- tural diseases of the heart, are frequently met with in subjects who had never experienced any of the characteristic symptoms of angina pectoris. Mr. Cook says, "I have met with numerous instances of ossification in the coronary arteries, which had never been attended with symptoms of angina ;"X and Mr. Shaw observes, in relation to this subject, that he had often found the coronary arteries like tubes of bone in old people who never had the slightest symptoms of this disease. § The occasional spon- taneous removal of the disease, and its susceptibility, in some instances, of being cured, militate also directly against the doc- trine of its necessary dependence on organic affection of the heart. Laennec avers, that "he has known many individuals who had suffered a few very severe, but short attacks of angina pectoris, and had had no further return of it." Dr. Parry, who believed that the disease was always caused by ossification of the coronary arteries, nevertheless mentions a severe case, that was wholly or nearly cured by the use of the Bath waters. Dr. Baillie also met with two patients affected with symptoms "exactly resembling those of angina pectoris, who ultimately recovered entirely."! Unquestionably, however, ossification of the coronary arte- ries, and other organic cardiac affections, are very frequently connected with angina ; "but nothing proves, even in such ca- ses," says Laennec, "that the disease depends on affections of this kind, inasmuch as they are of various kinds, and as the an- gina exists without, them." A softened structure, or flabby and dilated state of the heart, is almost as common in this affection as ossification of the coro- naries. In a most severe case, which was seen by Dr. Latham, Dr. Bree, and Dr. Johnson, the heart on dissection was found " pale, flabby, and so lacerable as to be easily mashed between the fingers like wetted paper or putrid meat. "IF Dr. Johnson states, that in all the cases which occurred in his own practice, • Medico-Chir. Rev. March, 1829. p. 573. \ On the Diseases of the Chest, last edition; translated by Dr. Forbes, l Treatise on the Digestive Organs, p. 274. § Manual of Anatomy. I Lectures and Observations on Medicine, p. 185. 1 Med. Chir. Rev. April, 1826, p. 497. 27G ANGINA PECTORIS. where post mortem examination was made, there was a flabby and softened state of the muscular structure of the heart, connect- ed in a few instances with ossification of the coronary arteries.' Dr. Cook also mentions a peculiar flaccidity and softness of the structure of the heart, " as a phenomenon, usually found after this disease," sometimes with, and at others without ossification of the coronaries or cardiac valves.t Hypertrophy or dilatation of the heart, without any other organic disorder, is mentioned by Laennec as no uncommon condition in this affection. About six years ago I attended a gentleman, in consultation with Dr. M'Clellan, who was frequently affected with violent paroxysms of angina pectoris. In one of the attacks he suddenly expired. On dissection, the heart was found very large, and its structure so soft as to be easily broken down by pressure between the fin- gers. From these facts, it appears evident that organic affections of this kind are to be regarded rather as the exciting, than as the essential and proximate cause of the disease. It is now believed by many, that angina pectoris consists in a neuralgic affection of the heart, or of the cardiac plexus ; and there can, I think, scarcely exist a doubt of the correctness of this opinion. Laennec conceives that the location of the nervous irritation may vary according to circumstances. "For instance," he says, "when there exists at the same time pain in the heart and lungs, we may presume that the affection is principally seated in the pneumo- gastric nerves ; on the other hand, when there is simply a sense of stricture of the heart, without pulmonary pain or much diffi- culty of breathing, we may consider its seat to be in the nervous filaments which the heart receives from the grand sympathetic. Other nerves are also simultaneously affected, either by sympa- thy, or from direct anastomosis ;—for example, the branches of the brachial plexus, particularly the cubital, are almost, always so ; the anterior thoracic nerves originating in the superficial cer- vical plexus are also,frequently affected ; and it is also sometimes the case with the branches derived from the lumbar and sacral plexuses, as we find the thigh and leg now and then participating in the pain and numbness." M. Recamier also considers this disease as a species of neuralgia; and the same opinion is express- ed by Dr. Johnson,! Jahn,§ Jurin, Desportes, and other writers. Although this nervous irritation or neuralgia of the heart appears to be most frequently excited by some organic cardiac affection ; it may also be occasioned by other remote causes or irritations in the system. There are some well authenticated fads on record, ♦ Med. Chir. Rev. March, 1828, p. 430. ■J- Loc. citat. t Med. Chir. Rev. Nov. 1828, p. 197. § Loc. citat. Bd. v. p. 407. ANGINA PECTORIS. 077 exemplifying the occasional dependence of this disease on dys- peptic irritation. I have already adverted to the two cases men- tioned by Dr. Baillie, which ultimately recovered, and were evi- dently dependent "upon an imperfect digestion." Mr. Cooke, also, to whose excellent work on the diseases of the digestive organs I have referred above, thinks that angina pectoris is occa- sionally excited " by derangement of the digestive organs, espe- cially by dyspepsia." Several eminent writers have supposed that the disease depends on gouty irritation ;* and Lentint maintain- ed that it is always of rheumatic origin. From all that has been ascertained, therefore, in relation to this subject, it would seem that angina pectoris may be excited by various causes, both orga- nic and dynamic, and that it consists essentially in a peculiar irri- tation of the cardiac nerves, giving rise to pain, and more or less spastic action of the respiratory muscles. Treatment.—When once fully developed, angina pectoris is an extremely unmanageable affection, and almost always sooner or later terminates in death. It must not, however, be regarded as a hopeless affection, even in its most aggravated form ; for instances of complete recovery have occurred, after the disease had continued for several years, in occasional paroxysms of great severity. ° For the relief of the paroxysm, we may have recourse to small bleedings, anodynes, and antispasmodics. Ether, camphor opium, hyoscyamus, and the liquor ammonias succinate, have been most recommended for this purpose. I attended a patient some years ago, who was frequently seized with violent parox- ysms of this affection, and who generally obtained considerable relief from a draught of very cold water. This patient died sud- denly in one of the attacks ; and on dissection, the semilunar valves of the heart were completely ossified. Perfect rest need scarcely be enjoined, for patients are irresistibly constrained to remain quiet during the paroxysm. It would appear even that where the patient can summon up sufficient firmness of mind to continue walking when the attack comes on, the exertion has a z2: t cfr ?to itigat,e the pain and C—Id 1esp.rat.on4 Di-. Good advises that the patient be immediately placed in an inclined position, with the head raised huT and an emetic instantly administered. If tjie pain and dXitv of respiration continue after the vomiting, "opium intermixed with camphor, ether or other diffusible antispasmodicssSuhe free ly employed. Emetics were, I belief, first ^cSmmendidS rale l^^^S^T* "' * P" ^ "^ S*™™" ^S^ 278 ANGINA PECTORIS. the paroxysm of this disease by Percival." Richter admits, that much relief may sometimes be obtained from vomits ; but he asserts that they may also readily do a great deal of harm. Where the oppression in the chest is great, and the habit robust and plethoric, blood-letting will occasionally afford some relief. Ac- cording to Laennec, however, leeches applied to the epigastrium or region of the heart, sometimes prove more beneficial than ve- nesection. Indeed venesection may very readily prove injurious in this complaint, and it ought not to be used, unless the indica- tions for its employment are unequivocal. Dr. Parry, who par- ticularly advocates the practice of venesection in this complaint, advises that the blood " should be taken from a small orifice, the patient being placed in the horizontal position, while the physi- cian is to keep his finger on the pulse, to decide the limits to which venesection is carried." Advantage may also be obtained, during the paroxysm, from derivative applications, such as sina- pisms to the legs or soles of the feet, and over the epigastrium, and rubefacient frictions to the lower extremities. For preventing the return of the paroxysms, various remedies and modes of treatment have been recommended. As the car- diac irritation may be wholly symptomatic of gastric disorder, it will be proper, in all instances, to pay particular attention to the biliary and digestive functions. A mild diet, the occasional use of small portions of blue pill, chalybeate mineral waters, and tepid or cold bathing, are particularly indicated in cases attended with dyspeptic symptoms. In individuals of a gouty or rheumatic habit, much advantage, it is said, has been obtained from the protracted use of guaiacum.t Goodwin states'that he derived very great advantage from the frequent application of a strong solution of tartar emetic in spirits of camphor;X and cases have been published, which go to show that the establishment of a permanent drain from the region of the heart, by a seton or issue, may be resorted to with consider- able prospect of benefit. § Baumcs speaks highly of the internal use of phosphoric acid in this complaint; and thinks it capable of arresting the process of ossification ;|| an opinion which was also entertained by Richter. ^T It is given to the amount of a drachm and a half daily in the form of lemonade. In Hufeland's Journal, a writer speaks in the highest terms of praise of the extract of lactuca virosse. Sixteen grains of this extract is to be dissolved in two drachms of cinnamon water, of which fifteen drops must • Medical and Philosoph. Comment, vol. iii. p. 180. ■j- Berger. Loc. cit. Bd. p. 708. $ Annales de Litterature Medicale Etrangere, vol. iv. as quoted by Richter, § New-York Medical and Physical Journal, December, 1814. | A.nnales de la Societe Pratique de Montpellier, torn. xii. 1 Specielle Therapie, vol. v. p. 195. ANGINA PECTORIS. 279 be taken every two hours.* Arsenic has been used with con- siderable benefit by Richter; and Smith employed small doses of James's powder in union with castor and assafoetida, with very good effects in some cases of this complaintt The celebrated Odier of Geneva restricted his patients to an extremely spare and simple diet, as the best means, in his opinion, for preventing the return of the disease. Laennec asserts that the magnet is one of the best means for palliating or preventing the paroxysms of an- gina pectoris, that we possess. He uses it in the following man- ner : "I apply," he says, "two strongly magnetised steel plates, of a line in thickness, and of an oval shape, and bent so as to fit the part, one to the left precordial region, and the other exactly opposite on the back, in such a manner that the magnetic cur- rent shall traverse the affected part. This method has succeeded better in my hands in the case of angina than any other, as well in relieving the paroxysm as in keeping it off. After a certain time, the magnetism most commonly produces an eruption of small pimples, which are sometimes so painful as to oblige us to interrupt the process for some days. This eruption almost always takes place under the anterior plate, and cannot therefore be at- tributed to the action of the oxidized pieces of steel on the skin. By means of these plates, applied to the epigastrium and spine, I stopped at once a hiccup which had lasted three years. At the end of six months, the patient having one morning neglected to put on the plates, the hiccup returned, but was removed on their being replaced." When in angina the relief obtained from the magnet is but small, its good effects may be increased by pre- viously blistering the part to a small extent, to which the anterior plate is applied. Id the management of this affection, it is all important that the patient abstain from spirituous drinks, and avoid strong men- tal emotions of every kind. Inordinate venereal gratifications, too, are in general decidedly injurious; and strong corporeal ex- ertions, particularly walking up hill, or rapidly ascending stairs, as well as sudden atmospheric vicissitudes, indigestible and irri- tating articles of food, must be carefully avoided. • Journal, &c. 1809, st. i. p. 57. \ Medical Commentaries, Edin. vol. v. p. 78. 280 INDIGESTION. CHAPTER VI. CHRONIC DISEASES OF THE ALIMENTARY CANAL. Sect. I.—Indigestion. Indigestion occurs so frequently, and is attended with so dis- comforting a train of symptoms, that it has the strongest claims upon the attention and sympathy of the physician. The habitual dyspeptic is indeed truly miserable. His sallow and anxious countenance, his irritable and sullen taciturnity, his aversion to social enjoyments, and the occasional overwhelming despondency of his mind, show him to be the prey of deep and harassing suffer- ings, of which none but those who have experienced them can form an adequate idea. Common, however, as indigestion is, and serious as are its consequences upon the health and happiness of man, there is perhaps hardly any other malady which is so com- monly misunderstood, and consequently mismanaged. In order to obtain a correct view of the pathology of indiges- tion, and of the true indications for its remediate management, it is necessary to be acquainted with the physiology of the pro- cess of digestion. I can here, however, advert only to the pro- minent and essential circumstances in relation to this subject. It appears then to be satisfactorily demonstrated, that the two fol- lowing conditions are essential to the regular and healthy per- formance of the function of digestion. 1. A due tone and peristaltic action of the muscular coat of the stomach, in order that the food may be uniformly embraced by the parietes of this organ, and as it successively undergoes chy- mification, where it is in contact with the stomach, be pushed forwards towards the pylorus into the duodenum. 2. The regular secretion of a sufficient quantity of healthy gas- tric juice. That the fluid called gastric juice is really the solvent which converts the aliment into that pultaceous mass called chyme, and that, therefore, digestion, so far as chymification is concern- ed, is chiefly affected by the agency of this fluid, is, I think, es- tablished beyond all dispute. The experiments of Spallanzani, of Stevens, of Gosse, and those quite recently performed by Tie- demann and Gmelin of Hiedelberg, and by Leuret and Lassaigne of Paris, have placed this physiological fact beyond all reasonable doubt It does not appear, from some late experiments, that the bile has any material agency in the process of chymification. Ac- cording to the experiments performed in relation to this point INDIGESTION. 281 by Mayo, Brodie, Leuret, Lassaigne, Tiedemann, and Gmelin, chymification appears to go on perfectly in animals after the biliary duct has been tied. The principal agency of the bile in digestion, it would seem, is to render the fatty substances of the chyme soluble in the chyle. It is the fat or oil thus suspended, by means of the alkaline properties of the bile, that gives to the chyle its milky colour. When the common duct is tied, chymi- fication goes on regularly, but the chyle in the lacteals and tho- racic duct is transparent and of a yellowish hue. Causes of indigestion.—It has just been said that the imme- diate cause of indigestion consists in a vitiated or deficient secre- tion of the gastric juice, and in deficient or irregular action of the muscular coat of the stomach. Now as both muscular motion and secretion are under the immediate influence of the nervous power, it is obvious that whatever causes an irritation or morbid excitement in the nervous structure of this organ, must necessa- rily tend to derange the healthy performance of these two func- tions. Accordingly, every thing which is capable of causing in- digestion, does so either by interrupting the regular supply of nervous influence to the stomach, or by irritating the nervous extremities of the mucous membrane of this organ ; or by pro- ducing both these effects simultaneously. Of the former kind of causes, namely, those that interfere with the regular transmission of nervous influence to the stomach, are the mental emotions. It is surprising how suddenly any tem- porary mental agitation depresses, nay, often wholly suspends for a time the keenest appetite and powers of digestion. These tem- porary depressions of appetite and powers of digestion from sud- den emotions of the mind, are converted into protracted and exceedingly unmanageable cases of dyspepsia, when the mental perturbations are of a chronic and depressing character. Protract- ed grief and despondency seldom fail to weaken the digestive powers, and to bring on, ultimately, confirmed and unyielding indigestion. Protracted and intense application of the mind, especially when attended with a sedentary mode of life, is another of those causes which act through the medium of the general system. Such in- deed are the sympathetic relations of the stomach with the whole and every part of the organization, that its functions become dis- turbed by whatever causes either general debility or organic dis- order of any of the principal organs of the body. But by far the most common and powerful causes of indiges- tion are those that act directly upon the nervous extremities of the mucous membrane of the stomach. Whatever is calculated to cause permanent irritation in this membrane, has a direct ten- dency to produce this disease. I think it may be assumed as a pathological axiom, that the function of secretion can never be Vol. II. 36 282 INDIGESTION. deranged without the existence of irritation in the secreting or- gan. Irritation of the vascular extremities that secrete the gas- tric fluid, exists therefore in every case of indigestion. The causes which most frequently give rise to this irritation, consist of over-distention of the stomach and indigestible and irritating articles of food. The manner in which food of this kind produces the irritation in question, is easily to be understood. When the food resists the digestive powers too long, besides its direct irri- tating impressions upon the stomach, it enters more or less into the fermentative process, and evolves new combinations, such as gas, acidity, &c. which enhance the irritating qualities of the con- tents of the stomach. Besides these consequences of too long a retention of imperfectly digested food in the stomach, the mus- cular powers of this organ will be diminished by the long and continued exercise to which it is subjected, as well as by the over-distention and irritation caused by the gas. Portions, too, of the half-digested food, will pass into the duodenum, which, being altogether uncongenial to the sensibility of this organ, will give rise in it to irritation, spasm, and pain, and by sympathy, functional derangement of the liver. When this state of things is once produced by some error in diet, assisted perhaps by gene- ral causes, the slightest causes—even the ordinary digestible and plain diet taken in health, will not only sustain it, but often in- crease its violence, if favoured by other circumstances of a debili- tating character. Dr. Philip thinks that over-distention of the stomach, by eating too much, is one of the most common causes of dyspepsia, and there can be no doubt as to its decided tendency in this way. It is probable, however, I think, that it is not so much by an over- distention of the muscular coat of the stomach which a supera- bundance of ingesta produces, that indigestion is caused, as by the mere excess of food beyond what the stomach is capable of digesting. Suppose the utmost powers of the stomach to be capa- ble of digesting sixteen ounces of food at a time; it is manifest, that if twenty ounces are taken, some of it will remain either in a partially digested, or wholly undigested state in the stomach, a longer time than is compatible with the healthy condition of the organ. This portion will therefore irritate the gastric nerves, —enter more or less into a state of chemical decomposition, and give rise to deficient or vitiated secretions in the stomach, as well as debility of its muscular tunic. The effects which follow the reception into the stomach of an undue proportion of food, besides those of mere over-distention, do not differ from those which are caused by indigestible articles of diet. A small por- tion of food which resists the digestive powers, is capable of bringing on violent dyspepsia, by remaining in the stomach beyond the period which is allotted by nature to Ihe process of INMGEST10N. 283 digestion, and becoming thereby a source of irritation in the manner already mentioned. Just so does it happen when the portion of food, however digestible, is greater than the stomach is capable of digesting at a time: for the portion which remains in an undigested state, and which the stomach is no longer able to convert into chyme, will act like so much indigestible food, and give rise to the distressing consequences which often result from such articles of diet. The causes which most commonly occasion the reception of more aliment into the stomach than its powers are capable of con- verting into chyme, are: 1. Eating too fast.—Dr. Philip has satisfactorily explained the way in which rapid eating tends to cause persons to take more food than they are able easily to digest. "The appetite subsides only in proportion as the gastric juice becomes mixed, and as it were neutralized by the food. When we eat rapidly, time is not given to the gastric liquor to combine with that part of the food which is presented to it; the sensation of hunger therefore continues, and we continue to eat until so much food is taken that the whole gastric fluid which the stomach is capable of supplying during the digestive process, is not sufficient to effect the due chymification of it. Whereas, when we eat slowly, so that a proper time is given for the combination to take place, the appetite abates before the stomach is overcharged. Every one has occasionally observed, that if his meal is interrupted for ten or fifteen minutes after having eaten perhaps not one third of the usual quantity, he finds that he is satisfied. The gastric fluid which had accumulated has had time to combine with, and be neutralized by the food he had taken. It is for the same rea- son that a few mouthfuls of food taken a little before dinner, will often wholly destroy the appetite, especially in delicate people in whom the gastric fluid is secreted in small quantity, or of a less active quality." 2. Imperfect mastication acts in the same manner, and as it is always connected with rapid eating, contributes greatly to this latter cause. 3. The use of condiments, stimulating drinks, and high-sea- soned food. These excite an artificial appetite, and keep up the desire for food longer than it would be sustained by the impres- sions simply of the gastric fluid. The free use of very cold or warm drinks, particularly during meals, tends much to weaken the digestion, and to aid other causes in the production of dyspepsia. By drinking freely, the gastric fluid is so much diluted that its powers are weakened, and of course the process of digestion more or less retarded. A very mixed diet—especially if the articles are of unequal degrees of digestibility—is a frequent cause of indigestion. 284 INDIGESTION. I have stated above, that a tardy peristaltic action of the mus- cular coat of the stomach, by which the digested portions of food are too long retained in this organ, is very often concerned in the production of dyspeptic symptoms. I am persuaded, how- ever, that the reverse condition also very frequently obtains, in cases of painful and imperfect digestion—namely, that the food is too rapidly hurried through the stomach into the duodenum, before it has had time to undergo the full action of the gastric fluid. This appears most commonly to be the case in confirmed instances of the disease—or in such as are attended with a high degree of irritation, or a sub-inflammatory condition of the mucous membrane of the primae viae. That a morbid peristaltic activity of the stomach often exists in dyspepsia, may be inferred from the consequences which are known to result from high irritation or phlogosis of the mucous membrane of the intestinal tube. The phenomena of indigestion in aggravated cases, also confirm the correctness of this opinion. It is a common circumstance, for instance, to hear dyspeptics complain of a sense of fulness in the stomach after eating even a small portion of food. But notwithstanding this feeling of reple- tion, they soon complain again of the customary sense of empti- ness in the region of the stomach, and crave for more food. It is to be observed, likewise, that the chief distress or uneasiness in such cases, is not experienced in the stomach, but rather in the region of the duodenum. Many dyspeptics feel no particular uneasiness until an hour or two after eating, when they begin to experience pain and distention in the duodenum. In some cases the food is speedily hurried off by the bowels in an imperfectly digested condition, under very severe sufferings from tormina and flatulent distention of the intestines. Symptoms and course.—The symptoms of indigestion differ considerably according to the stage of the complaint, or the de- gree and extent of the irritation. In the commencement the appetite is variable, generally weak, and often entirely destroyed; the patient is troubled with flatulency, distention, acid eructa- tions, and colic pains; the mind is, at times, depressed and lan- guid; the tongue covered with a white fur; the bowels usually constipated; the whole system languid, particularly during the process of digestion ; and there is almost a constant uneasy feel- ing in the epigastrium. Sometimes the appetite is morbidly craving, but if the patient indulges freely in taking food, he becomes much oppressed, and generally suffers severe pains some hours after eating. After the disease has continued for some time, or has been aggravated by some- unusual irritating cause applied to the stomach, the pulse becomes tense and quick; the epigas- trium tender to the touch; the mind irritable, discontented, and gloomy. The colic pains, some time after taking food, are more INDIGESTION. 285 frequent and severe; the bowels become irregular—being some- times constipated; at others, affected with diarrhoea, during which, portions of food are occasionally passed off in an imperfectly di- gested state—the stools varying in colour, consistence, and cha- racter. The body now begins to waste, and the strength fails; the epigastric distress becomes severe and constant, the counte- nance assumes a haggard and sallow aspect, the patient complains of more or less difficulty of lying on the left side, the skin be- comes dry and shrivelled, and there is usually a morbid sensi- bility to low temperature. From the extensive sympathies which subsist between the stomach and every other part of the living body, dyspeptics are frequently much harassed by painful and other distressing affec- tions in parts situated remotely from the stomach. Among these sympathetic affections of indigestion, headach is the most com- mon and annoying. Dr. Warner observes, that there are two sorts of dyspeptic headach, the one occurring while the process of chymification is going on slowly and imperfectly in the sto- mach, and the other after the chyme has left the stomach and passed into the duodenum. The former is distinguished by a languid and feeble pulse, a slightly coated and whitish tongue, with very pale red edges, mistiness before the eyes, slight ver- tigo, and an apprehension of falling; slight nausea and uneasiness in the stomach; a sense of constriction about the fauces; and sometimes a coldness and numbness of the fingers; and gene- rally a feeling of weight in the brain. The second, or as Dr. Paris calls it, duodenal dyspeptic headach, is characterized by brilliant occular spectra which constantly distress the patient; by the chilliness of the body, and the coldness and dampness of the hands and feet. The pain in the head is very severe, and is attended with a sensation of coldness and tension of the scalp, and a sense of weight and distention in the eyeballs. The tongue is eommonly covered with a yellowish white fur, and is often much coated. The pulse is natural in frequency, but always languid. There is usually flatulency, and Dr. Paris states that a peculiar feeling of dryness and inactivity of the bowels, as if the intestines had lost their sensibility and were unable to propel their contents, giving rise to a peculiar sensation of weight and obstruction' may be regarded as pathognomonic of this variety of the affec- tion. These headachs rarely continue longer than two or three hours, and are usually diffused throughout the whole head In a practical point of view, it is of great importance to bear in mind that dyspepsia may depend on two distinct morbid conditions of the digestive organs: namely, 1. On functional debility of the stomach from deficient or vitiated secretion of the gastric fluid, and muscular inactivity, independent of vascular irritation or inflammation. 2. On deficient or vitiated secretion 286 INDIGESTION. of the gastric fluid, with vascular irritation or chronic inflam- mation of the mucous membrane of the stomach and duodenum, and a morbidly increased peristaltic action of these organs. The characteristic symptoms of the former grade of indiges- tion, are weak appetite ; tongue covered with white fur ; absence of epigastric tenderness, except after a paroxysm of colic from flatulent distention ; costiveness ; acid and fetid eructations ; ab- sense of habitual tension and febrile irritation of the pulse; and the ability of bearing lean and tender animal food better than vegetable and farinaceous articles of diet The phenomena which characterize the second or inflammatory grade of the disease, are tenderness to pressure of the epigastrium, and particularly about the region of the pylorus and duodenum ; a red, chopped, granulated or glossy appearance of the tongue ; a firm, tense, small, and somewhat accelerated pulse, with slight manifestations of febrile exacerbations towards evening ; emacia- tion ; irregular action of the bowels, with frequent attacks of mucous, bilious or watery diarrhoea ; violent and protracted pain in the lower part of the epigastrium during the process of diges- tion ; fulness about the edge of the false ribs on the right side ; an anxious and discontented expression of the countenance ; and inability, without great suffering, to endure animal food and stimulants. It appears, that the irritation or chronic inflamma- tion of such cases is seated in the mucous membrane of the pylo- ric extremity of the stomach and of the duodenum, connected usually with a congested state of the liver, and often with faecal accumulations in the colon. Hence the region of the duodenum and pylorus is almost invariably somewhat distended, and very tender to pressure in such cases; and these circumstances, to- gether with the tense and quick pulse, furnishes the most certain diagnosis of the existence of high mucous irritation or chronic inflammation in dyspeptic complaints. In some instances, the pain and tenderness extends across the epigastrium into the left side, and becomes fixed in the region of the spleen, or where the colon turns down to form the descend- ing arch. The pain and tenderness in the left side appear to depend on various causes, " all of which," says Dr. Philip, " are more unfavourable than the circumstances which cause its ex- istence in the region of the pylorus and duodenum."* It may depend on an inflamed and engorged condition of the spleen, in which case this viscus is generally found in an enlarged condi- tion. It arises also, sometimes, from enlargement of the left lobe of the liver, « which is always the part of this organi most.affect- ed in indigestion." According to the observations of Dr. Philip, • On the Treatment of the more Protracted Cases of Indigestion. London, 1827, p. 19. INDIGESTION. 287 however, the most common cause of the pain and tenderness in the left side, is the extension of the chronic inflammation from the pylorus to the other parts of the stomach. • There is generally much difficulty in distinguishing pain and tenderness seated in that part of the colon which lies over the pylorus, from the same affections in this portion of the stomach and duodenum. « The best means for distinguishing affections of the stomach from those of the colon, are the digestive process in the latter case being better performed ; the state of the bile being less disordered; the patient not experiencing the increase of uneasiness which often comes on after meals, for a considerable time after eating, and often experiencing more or less pain, or some other uneasiness in the region of the stomach a short time before the bowels are moved, and more or less relief soon after their action." (Philip.) Pain and tenderness on pressure, cannot, however, be regarded as an unequivocal sign of inflammation in the pylorus and duodenum. This part sometimes becomes mor- bidly sensitive, without capillary congestion or inflammation. Nevertheless, where we find this tenderness a little below and to the right of the pit of the stomach, at the same time that the sides and tip of the tongue are red, with a granulated surface and a dry streak in the middle, together with a tense and quick pulse, we may be assured that the parts just mentioned, are in a state of inflammation. Treatment.—One of the first things to be attended to when we are called to prescribe in a case of dyspepsia, is to obviate, as far as possible, the usual exciting causes of this distressing affection ; and with this view, we must direct our attention chiefly to the adoption of proper dietetic regulations. In all cases of dyspepsia, whether simple or complicated, mild or violent, an undeviating observance of suitable regulations in relation both to the quantity and quality of the aliment, and the manner of taking it, is absolutely indispensable to success in the management of the disease. The patient should be directed to masticate well and slowly; to take his meals at regular hours; to eat no more at a time than is just sufficient to sustain the powers of the system ; to drink but little during and for a short time after taking food • and he must avoid taking any active exercise during the first stage of the process of digestion. The presence or absence of symptoms indicative of high irritation or sub-inflammation in the mucous membrane of the stomach and duodenum, will enable us to say, almost with certainty, whether an animal or vegetable diet will procure most relief to the patient; but in relation to the particular articles of these two kinds of aliment, no specific direc- tions can be given which are applicable to all cases : for some dyspeptics are benefited by certain articles of food that are alto- gether intolerable to others. This is more especially apt to be 288 INDIGESTION. the case in those habitual dyspeptic cases, which depend on mere functional debility, with morbid sensibility of the stomach, uncon- nected with inflammation. In some cases the dyspeptic symp- toms are excited only by particular aliments; "and we must endeavour to ascertain whether a peculiar idiosyncrasy of the stomach prevails in such instances ; or whether there is a debili- tated condition of the organ that incapacitates it from digesting any food demanding considerable powers for its chymification." Every individual affected, and suffering under this grade of dys- pepsia, must in a great measure learn from his own experience, what articles of diet will or will not agree with him. In general, however, where the disease depends on mere debility of the diges- tive organs, without a fixed tenderness and fulness in the epigas- trium, the more digestible kinds of animal food, are decidedly the most proper. In such cases, a plain abstemious diet of this kind, together with the occasional use of gentle aperients, mild tonics, regular exercise, and a rigid avoidance of the usual excit- ing causes of the complaint, will rarely fail to establish a cure, or at least to procure an exemption from its more disturbing symptoms. Animal is undoubtedly much more digestible than vegetable food; and where the gastric irritation is not considera- ble, it will very generally be taken with the least inconvenience by dyspeptic persons. We may lay it down, therefore, as a ge- neral principle, that animal food is the most proper ; and of this the most tender muscular parts are to be selected. There is no- thing to be apprehended from the stimulant qualities of animal food, in cases depending on debility, without any particular mor- bid irritability or phlogosis of the digestive organs. Our object here is to obtain the most digestible food, and which is, at the same time, the least apt to enter into fermentative decomposition. By a food of this kind, the debilitated stomach is moderately ex- cited, and subjected to less labour; while the chyme is move speedily and perfectly formed, and the development of acid, flatus, &c. thus in a great degree prevented. It is very different, how- ever, with those cases of protracted and inveterate dyspepsia, that are attended with a red tongue, tender, and somewhat tumid epigastrium, and a firm pulse. Here the food, as I shall presently state more particularly, must be as bland and unirritating as pos- sible. Much attention has been directed to inquiries concerning the comparative digestibility of the various customary articles of food. All agree that the flesh of old animals, with the exception of beef and veal, is more digestible than that of young animals. The lat- ter contains much more mucilaginous matter than the former; and all mucilages are of difficult digestion. Animal jellies, and young meats, observes Dr. Philip, are what is commonly called light food, with a reference to their stimulating qualities, or tendency INDIGESTION. 289 to excite fever—and hence, in persons recovering from fever, or in extremely irritable habits, we prescribe the animal jellies, or young meats, which contain them in abundance, in preference to the meats of old animals. In dyspepsia, however, from mere gastric debility, animal jellies remain long in the stomach, from their indigestible nature, and cause therefore more disturbance and distress than beef or mutton. Tender beef, mutton, and all kinds of game—more especially venison, are usually of easy digestion, and generally agree much better with dyspeptics dur- ing the early stages of the disease, than any other articles of diet. Pork and veal are, with most persons affected with indigestion, altogether inadmissible; and fish, too, seldom agree well except when taken in very small portions, and in a boiled state. The most oppressive kinds of poultry are geese and ducks; and «tur- key is more oppressive than fowl, which, next to mutton, is, perhaps, upon the whole, the lightest animal food in common use, if the skin be avoided." Pheasant is the least easy of digestion of the different kinds of wild game: but partridge and hare are in general readily digested by weak stomachs. Soft-boiled eggs will sometimes agree very well with dyspeptics; but care must be taken not to eat the coagulated portions of the albumen. Sim- ple roasting or boiling is the best way of preparing meat for persons labouring under indigestion-;fried articles of food being in general very oppressive. There is no aliment more offensive to a weak stomach than new-made bread. By mastication it is converted into a tenacious paste, which "is not easily pervaded by the gastric juice," and is therefore always very slowly con- verted into chyme. The bread used by a dyspeptic person should always be several days old: and, for a change, crackers, or "pilot bread, may be used. Some individuals derive much advantage from the employment of bran-bread, but I have reason to think that where there exists a morbid sensibility of the stomach, it is generally decided y injurious. The only benefit that can be ob- tained from bran-bread, beyond what may be derived frem com- mon bread, arises from its gently stimulating the bowels, and keeping up regular alvine evacuations; but I have known it to produce disagreeable irritation both in the stomach and bowels by the small cuticular scales of the grain which it containl^d winch are almost insoluble in the gastric fluid. Cheese rnHk cream and butter, unless taken in°very moderate portionTare apt to become oppressive. I have known dyspepti/ind vuduals however who were much benefited by the habitual use of cream and crackers at their meals. Fresh vegetables are very genera lv injurious particularly cabbage, peas, beans, and abovf all cu cumbers, lettuce, celery, and other articles of this kind token in the form of a salad, or ,n an uncooked state. Of fruits, pears currants goose he™, whortleberries, and melons, are ^Z^ZZ^t 290 INDIGKSTION. to prove injurious. Mealy potatoes and turnips are among the best articles of this kind for dyspeptic subjects. All kinds of pastry- such as hot cakes, pies, puddings, &c. are entirely out of the ques- tion. The food of a person labouring under dyspepsia from gastric debility, should be chiefly taken in a solid state. Soups and broths very rarely do well in cases of this kind. I have already stated, that slow eating, and perfect mastication, are all-important observances in dyspepsia, and that but very little drink should be taken dur- ing, or soon after meals. Moderate portions of brandy and water usually answer well in slight cases of indigestion, but in the more aggravated forms of the disease, they are exceedingly im- proper. Simplicity in diet, too, is of great importance to the comfort of dyspeptics; and what is of equal, if not still greater importance, is, to take but moderate portions of food into the stomach at each meal. It must not be forgotten, that the foregoing dietetic observa- tions apply only to those cases of indigestion which are free from a morbidly sensitive and irritable, or an inflamed condition of the digestive organs. The signs by which these conditions may be detected have already been mentioned; and it is of the utmost importance to form a correct diagnosis on this subject. So far from solid animal food being the best aliment in cases of this kind, nothing but the lightest farinaceous articles of diet can be borne with any degree of comfort, or are compatible with the restoration of the healthy state of the stomach. These cases must indeed be treated in every respect as in- stances of chronic gastro-enteritis, and the observations that I have made with regard to the diet in these affections, are there- fore fully applicable to inveterate cases of dyspepsia. Medicinal treatment.—When the disease depends on func- tional derangement from mere debility or inactivity of the diges- tive organs, the bowels are generally torpid, and loaded with feculent mat ler; and hence an important indication in cases of this kind is to procure regular alvine evacuations by diet if possi- ble; if not, by the occasional use of gentle aperients. When first consulted in dyspepsia of this grade of gastric disorder, it will in general be necessary to prescribe a laxative sufficiently active to evacuate the bowels freely; but when the infarcted state of the alimentary canal has once been removed, the gentlest articles of this kind, and in doses barely sufficient to procure one or two consistent evacuations, should alone be employed. If, indeed, the action of the bowels can be regularly maintained by dietetic regulations, it ought always to be preferred to the exhibition of laxatives. This, however, can rarely be adequately done, and al- most all dyspeptics find it necessary to resort more or less fre- quently to remedial means for procuring regular alvine evacua- tions. Rhubarb in union with some aromatic or stimulating sub- INDIGESTION. 291 stance, will in general answer well as an aperient in such cases. The following pill* may be taken a short time before the princi- pal meal; and where there is much acidity in the stomach, the rhubarb may be advantageously given in combination with from ten to twenty grains of the carbonate of soda, or with thirty or forty grains of magnesia. No remedy, however, has appeared to me to act more favourably as an aperient in the milder grades of habitual dyspepsia, than small doses of ipecacuanha in union with aloes and the extract of hyoscyamus. From personal experience, I know that in some instances at least, the effects of this combi- nation are peculiarly soothing and sufficiently aperient! Emetics were formerly much employed in dyspepsia; but ex- cept in recent attacks from a surfeit or very irritating and indi- gestible ingesta, their use is now very properly almost universal- ly condemned. Where it may be deemed advisable to excite vomiting, we may generally effeet this purpose by copious draughts of lukewarm water, or what is still better, a strong infusion of chamomile flowers, or of the eupatorium perfoliatum. When these do not procure adequate emesis, an ordinary dose of ipeca- cuanha may be administered. Tartar emetic is decidedly ob- jectionable, even under the strongest indications for the employ- ment of an emetic in dyspepsia. Where the disease is connected with morbid sensibility of the stomach, or with ehronic inflam- mation, no circumstances, perhaps, can justify the exhibition of an emetic. In the grade of indigestion now particularly under consider- ation, besides the dietetic measures already indicated, and an at- tention to the regular maintenance of the alvine evacuations, mild tonics in combination with alkalies, gentle exercise, and the avoidance of the usual exciting causes of the disease, will ge- nerally restore the healthy functions of the digestive organs. A weak infusion of colomba, or of gentian, with a portion of the carbonate of soda, or of potash, may be employed for this purpose. The ferruginous preparations also are often peculiarly beneficial in cases of debilitated digestive powers, without any prominent hepatic derangement The tartrate of iron given in union with a small portion of ipecacuanha, has done much good in my hands in no inconsiderable number of eases. J The chalybeate mineral * R. Pulv. rhaei gr. ii. ----aloes gr. ss. . „ ----, ^P3'01 ff1"- >—M. To be made into a pill. j R. G. aloes soccot. Qi. P. ipecac, ^ss. Extract, hyoscyamus 9i.—M. Divide into 20 pills. Take one .r night on going to bed. H one at * R. Tart, ferri 31. Pulv. ipecac, gr. v.—M. Divide into 3 equal parts Take one ,vp„, morn.ng, noon, and evening. 4 P aKe one every 292 INDIGESTION. waters also, will occasionally procure more benefit in instances of this kind than any other tonic. The white mustard seed has of late years been a very fashionable remedy for dyspepsia, and in cases of simple languor and weakness of the stomach, very con- siderable advantage may in general be derived from them. Four or five tea-spoonfuls of the unbruised seed should be taken during the course of the day. I have known several individuals habitu- ally subject to slow and painful digestion with torpor oT the bowels, much benefited by this remedy. It need scarcely be observed, that where the stomach is morbidly irritable and ten- der to pressure, this article cannot be taken without injurious consequences. Tonics are frequently much abused in this affec- tion, and may readily do much mischief where there is great irritability of the stomach or a state of phlogosis, and especially where the hepatic functions are prominently deranged. They can be employed with a prospect of advantage only in cases of torpor or weakness of the digestive organs. Indigestion seldom continues long, even in its milder grades, without involving the liver in functional disorder; and hence, alterative doses of mer- cury have of late years been among the most common means in dyspeptic affections. Where from the icterode state of the eyes and skin, and the appearances of the stools and urine, there is reason to suspect the existence of functional disorder of the liver, the use of alterative portions of the blue mass is decidedly indi- cated, and will generally afford benefit. From four to six grains of the blue pill may be taken every second or third night, with an occasional dose of some gentle laxative—such as small por- tions of rhubarb, or one or two Seidlitz powders, or a few of the laxative pills already mentioned. I have been much in the habit of giving the blue mass in union with a laxative, according to the following formula; and generally, as it appeared to me, with more advantage than when they are given separately and at dis- tinct periods.* Care must be taken, however, in prescribing mer- cury in this affection, not to continue its use until the general system becomes affected ; for general mercurial excitement is always improper in dyspepsia. Some individuals are always very disagreeably affected by the blue pill. I have met with dyspeptic patients in whom this mercurial invariably excited the most unpleasant sensations in the stomach, as well as great gene- ral restlessness and nervous irritation. When this is the case, we may generally gain our object by the internal use of the ni- tric acid diluted in a large portion of water ; or what has appear- • R. Massx hydrar. gi. G. aloes soccot. ^iss. , Tart, antimonii gr. ii.—M. Divide into 20 pills. Take one every other night, on going to bed. INDIGESTION. 293 ed to me still more advantageous, the nitro-muriatic acid bath, in the way mentioned under the head of chronic hepatitis. As palliatives, alkalies and opium are the best remedies we possess__the former for removing the burning and aching sensa- tions which are caused by acidity in the stomach, and the latter for allaying the colic pains that result from the irritation of the food, flatus, and acid in the stomach and duodenum. It is to be observed, however, that opium cannot be frequently employed in this affection without still further impairing the digestive pow- ers of the stomach; but the pains are often so extremely violent, that we are obliged to resort to this narcotic for relief. In those cases of dyspepsia which are connected with a high degree of morbid sensibility of the mucous membrane of the stomach and duodenum,the occasional use of this anodyne is peculiarly valuable. Without it, indeed, patients labouring under this variety of dys- pepsia, would enjoy but few moments of exemption from suffer- ing. Dr. Philip recommends Dover's powder, and advises that from two to four grains of it should be given every six or eight hours. This will commonly be sufficient to allay the general nervous irritation which is apt to occur in cases of this kind ; but when those violent gastric and duodenal pains come on, which at times rack the unfortunate dyspeptic, nothing but the largest doses of laudanum will be sufficient to allay his extreme suffering. I have known persons in the utmost degree of agony for hours, from irritation in the stomach and duodenum, who were obliged to take several hundred drops of laudanum before relief was pro- cured; and in this respect, I may, indeed, truly say with the poet— Atque utinam numero ne nos essemus in isto. Weak and slow digestion is frequently connected with a morbid sensibility of the nerves of the stomach and duodenum, inde- pendent of chronic inflammation of these organs. When the patient is subject to severe pains an hour or two after taking a meal—and more especially when the gastric distress is particularly excited by certain articles of food, which usually agree with other dyspeptics; and when, moreover, the edges of the tongue remain of a pale red, with a thin white fur over the middle, and the pulse is free from tension, though quick and small, and the skin generally sdft, and below the natural temperature, and, finally, when with these symptoms there is a disagreeable or painful feeling of emptiness experienced in the region of the stomach four or five hours after taking food, without any particu- lar tenderness to pressure on the epigastrium—when these symp- toms exist, there is reason for believing that an exalted sensibility of the gastric nerves is present without phlogosis. The diagnosis in relation to these circumstances, is of much more importance in a practical point of view, than seems to be generally supposed. Or. Philip speaks particularly in favour of the employment of 294 INDIGESTION. ammonia, in what he calls the second stage of indigestion, and it is, indeed, in many cases, deserving of all the encomiums which he has bestowed upon it. The instances, however, in which, according to my own observations, it is most apt to prove beneficial, are those in which there is a constant tendency to the generation of acid in the primse viae, in connexion with morbid sensibility of the mucous membrane of the stomach and duodenum. In cases of this kind, eight or ten grains of the carbonate of am- monia with five or six grains of Dover's powder may be taken several times during the day with much temporary benefit. Dr. Philip observes, that in cases of dyspepsia, where the surface is cold, the pulse feeble, with a feeling of general depression, and chilliness, "the ammonia is invaluable ; being less apt, than any other stimulus of the same power, with respect to the nerves to excite the heart and blood vessels; which, from the tendency of the disease, (in this the second stage) are inclined to a degree of excitement beyond that undue proportion to the state of the other powers." Much relief may also be obtained, in cases where the disorder is attended with much irritation and sensibility of the gastric nerves, from the liq. acetat. ammonise, in union with small doses of laudanum, or of the tincture of hyoscyamus. A table-spoonful of the former, with ten drops of either of these narcotic tinctures, may be taken two or three times daily. When there is much gastric irritation, with slight febrile symptoms towards evening, such as dryness and heat of the skin, burning in the palms of the hands and soles of the feet, and ten- sion of the pulse, the nitrate of potash will generally afford con- siderable relief. It may be advantageously given with minute portions of the tincture of ipecacuanha, dissolved in some muci- laginous fluid. From five to ten grains of the nitre, dissolved in a few ounces of barley-water, or of a solution of gum arabic, with 50 drops of tinct. ipecac, may be given every four hours. When the gastric irritation has assumed the character of chronic inflammation—that is, when in addition to the general symptoms just mentioned, the epigastrium becomes tender to pressure; the pulse tense and firm, and the edges and tip of the tongue red; tonics, purgatives, animal food, and all stimulating remedies are no longer admissible. Leeching or blistering over the region of the pylorus and duodenum, are here among the most important remedial measures. The latter, indeed, will often be found par- ticularly beneficial in cases attended only with high irritation, with- out actual inflammation. For the removal of that morbidly sensitive condition of the gastric nerves noticed above, there is, perhaps, no remedy so effectual as the application of a blister over the epigastrium. I have known patients who could scarcely take even the blandest articles of food without suffering a great deal of pain, enabled to digest light aliment with tolerable comfort after having INDIGESTION. 295 the region of the stomach blistered. Pustulation with the tartar emetic ointment, may also be resorted to with a fair prospect of advantage in such cases. Leeching, however, is always an ex- cellent preliminary to vesicating or counter-irritating applica- tions. There is but little advantage to be obtained from internal remedies in cases of this kind ; yet the nitrate of potash, dissolved in a large portion of some mucilaginous fluid, will occasionally assist in removing the dry and constricted state of the skin, and the distressing sense of internal heat. Dr. Philip advises the exhibition of small doses of tartarized antimony. I have, occasionally, derived some benefit from its administration in cases attended only with gastric irritation; but I doubt much of the propriety of employing this remedy where unequivocal signs of mucous inflammation of the stomach are present. Some writers recommend laxatives in this as in the milder varieties of the disease; but their tendency to irritate the tender and phlogosed mucous membrane of the stomach and intestines, renders them, I think, decidedly objectionable. Slight relief will, it is true, usually follow the operation of a purgative, but this relief is always but temporary, and is very often succeeded by an aggravation of the gastric distress and tenderness. The same objections do not, however, exist against the use of laxative enemata, and I do not, indeed, know any measure which is better calculated to afford ease in cases of this kind, than the daily use of one or two mild laxative clysters. Functional disorder of the liver is a constant attendant in cases of this kind; and it becomes necessary to em- ploy mercurials, either internally, or by frictions on the right hypochondrium. The employment of mercurials, however, re- quires great caution in the severer cases of the disease; for it is not uncommon to find the blue pill, even in small doses, to excite considerable intestinal irritation and general uneasiness. To avoid this occurrence, we may give this mercurial in union with a small portion of opium, or of the extract of conium. In general, it will be sufficient to administer one grain of the blue mass, with half a grain of opium, every night on going to bed, and care must be taken not to carry it to the extent of causing even a soreness of the gums. The correction of the biliary secretion, by a gradual introduction of mercury into the system, is generally attended with the additional advantage of an abatement in the tension and contraction of the pulse, and a diminution of the temperature and dryness of the skin. After all, however, our principal reliance in cases attended with a high grade of irritation or chronic inflammation, consists in the use of a bland and unirritating liquid diet, local depletion, revulsive applications, and the occasional use of alterative doses of blue pill or calomel, with laxative enemata and gentle exercise by gestation, or where,the strengtii of the system will admit of 296 INDIGESTION. it, walking, regularly, every day, until a slight degree of fatigue is induced. Let it be constantly borne in mind, that functional derangement of the stomach may be the consequence of mere debility and relaxation—or of high irritation and morbid sensibility—or finally of a chronically inflamed condition of the mucous membrahe of the digestive organs; and that, therefore, the mode of treatment, both medicinal and dietetic, which is proper in the first, will not answer in the second, and will prove decidedly pernicious in the third of these varieties. In the first, our object is to increase the tone and activity of the stomach; in the second, to sooth the irritation and morbid activity of this organ ; and in the third, to subdue inflammation, and obviate its consequence,—structural disorder. Sect. II.—Diarrhoea. Diarrhoea is an affection of the bowels, the characteristic symp- toms of which are : frequent and usually copious liquid stools of a feculent character—attended with more or less griping without tenesmus, and generally without febrile irritation. The proximate cause of diarrhoea consists, according to the sentiments of Cullen and some other writers, in increased peri- staltic motion of the intestinal tube. Unquestionably, an inordi- nate peristaltic action does take place in this affection ; but this increased action does not constitute the essential pathological condition of the disease, and cannot therefore be properly regard- ed as its proximate cause. Increased action of the intestinal canal may arise in two ways, namely : 1. The irritability of the bow- els may be in a natural state, whilst the substances which are brought to act on them are of a peculiarly irritating or exciting character. In this case the alvine discharges will generally cease soon after the irritating substances which have excited them are expelled, or their activity is destroyed—as is the case with the purging produced by cathartics, or the action of other transient irritants. 2. The irritability of the bowels may be preternatu- rally increased ; in which case, the ordinary secretions and con- tents of the intestinal canal, and even the mildest substances, will produce excessive peristaltic action, and of course frequent alvine discharges. Irritation of the mucous membrane of the bowels, therefore, constitutes the primary morbid condition in diarrhoea, of which the increased peristaltic motion and the inordinate alvine evacu- ations are the consequences. When the diarrhoea continues long, or assumes a chronic form, the mucous irritation becomes fixed, and unless it be counteracted by an appropriate treatment, gradu- DIARRHCEA. 297 ally passes into a state of chronic inflammation—more especially of the mucous membrane of the colon, and finally terminates in ulceration, and other forms of disorganization of this membrane. Broussais observes, that when diarrhoea continues beyond the thirtieth day, it is almost invariably connected with organic derangement of the mucous membrane of the colon. When the disease continues until the irritation passes successively into chro- nic inflammation and disorganization of the mucous tissue of the bowels, slight febrile irritation occurs—particularly towards even- ing, and a few hours after eating ; the pulse becomes quick, small, and frequent; the skin dry and harsh ; the body emaciates more or less rapidly ; and at last oedema of the feet and legs, and occa- sionally dropsical effusions into the cavity of the abdomen ensue. In this aggravated form, the patient is apt to experience extreme- ly severe colic pains an hour or so after taking food, and in gene- ral even the m ildest ingesta are followed by tormina, flatulency, and diarrhoeal discharges, and articles of food are sometimes passed in the stools in an imperfectly digested state. The appetite is generally very variable and capricious ; being sometimes vora- cious, and at others entirely depressed. The stools too vary much both in relation to frequency and appearance. They are sometimes slimy, mixed with more or less fecal matter ; at others adundant and watery—occasionally dark, reddish, or whitish, and often contain small portions of undigested food. On post mortem examination of subjects who have died from chronic diarrhoea, or from some other disease accompanied with this bow- el affection, we sometimes discover irregular patches of a fungoid appearance, and of a livid or dark red colour, slightly elevated above the surrounding parts, on the mucous membrane of some portion of the intestinal canal. In other instances, small well- defined ulcers with elevated edges, or extensive irregular ulcera- tions with ragged edges, are met with. Not unfrequently the coats of the intestines are thickened at the parts where these ulcers are situated ; and in some instances this thickening is so great as to diminish the area of the intestinal tube very consider- ably. In cases of this kind, says Broussais, the usual diarrhoeal symptoms are apt to alternate with attacks of costiveness, and death occasionally occurs under symptoms resembling those of ileus. Sometimes, instead of ulcers, the mucous membrane is covered with numerous tuberculous elevations of different sizes ; and occasionally extensive portions of this membrane are found covered with smooth cicatrices of ulcerations which have healed. Broussais observes that these ulcerations are always found most numerous in the coeeum, and about the lower portion of the colon. He thinks, and with great probability indeed, that when the feculent matters become fetid and putrid, whether from long retention or imperfect digestion, they cause irritation, and ulti- Vol. II. 38 298 DIARRHOZA. mately inflammation in that part of the mucous membrane where they are most apt to become accumulated; When death occurs at an earlier period of diarrhoea, the mucous membrane of the colon, and of the ileum, is usually found in a more or less red- dened or injected state, with slight thickening of its structure. This is particularly observed in those chronic diseases which during the latter period of their course are accompanied with colliquative diarrhoea. In the chronic diarrhoea of children, at- tending what is usually called marasmus, I have found in several instances, on dissection, the mucous membrane of the lower por- tion of the small intestines and of the colon, exhibiting extensive tracks of a congeries of minutely injected vessels. Causes.—The remote or occasional causes of diarrhoea are exceedingly various. They may be divided into those which act directly on the mucous membrane of the intestinal canal; and those which act indirectly through the medium of the gene- ral system. Of the former kind are all irritating substances received into, or generated in the alimentary canal; and of these the most common are: irritating and indigestible articles of food and drink; acrid and vitiated secretions from the liver and intes- tinal exhalents; worms; acid generated in the bowels; fresh fruit, particularly such as are very sweet, or acid, &c. Limestone water is particularly apt to give rise to copious diarrhoea in those who have not been accustomed to its use; and new made cider, before it has undergone the fermentative process, is also extreme- ly apt to excite this affection. Much, however, depends on the previous or habitual state of the irritability of the intestinal canal, with regard to the power of different articles to excite this affec- tion. Some individuals, apparently in a state of good health, cannot take particular articles of diet or drink without suffering more or less from griping and diarrhoea; whilst in others no un- pleasant effect whatever will result from the same articles. Idio- syncrasy clso appears occasionally to be concerned in the produc- tion of this affection by causes of this kind. Thus in some persons, fresh milk almost invariably excites diarrhoeal discharges; and I know an individual who generally becomes affected with diar- rhoea when he eats fresh oysters. Diarrhoea produced by causes of this kind is, however, almost always of temporary duration, and depends on simple irritation, which generally readily subsides after the offending matter has been discharged, and other excit- ing causes do not supervene. Nevertheless, if the bowels have previously been in an irritable condition, or the patient be labour- ing under some organic visceral affection, instances which com- mence from such local irritating causes are apt to continue, and unless particular attention be paid to a careful avoidance of the further influence of the exciting causes of this affection, to give rise DIARRH03A. 299 to high irritation, inflammation, and finally ulceration in some portion of the intestinal canal. \mong the causes of diarrhoea that affect the alimentary canal through the medium of the general system, cold, particularly when applied in a humid way to the feet or abdomen, is one of the most common and powerful. When produced by this cause, it constitutes the diarrhoea rheumatica or catarrhahs of the Ger- man writers. Cases of this kind are most apt to occur during damp and variable weather, and the evacuations are generally very liquid or watery. Slight rheumatic or catarrhal symptoms are apt to accompany the disease—such as toothach, transient pains in the extremities, short cough and coryza, together with slight febrile irritation, towards evening, attended with a dry mouth and great thirst. The tormina are usually exceedingly severe. The occurrence of diarrhoea from cold, or the conjoined agency of humidity and cold, depends, no doubt, on the centri- petal direction given to the circulation; in consequence of which the liver and capillaries of the mucous membrane of the bowels become engorged with blood, giving riso to a vitiated, or perhaps a superabundant secretion of bile and intestinal mucus, at the same time that the irritability of the bowels is morbidly increased. Diarrhoea appears also sometimes to arise from an epidemic condition of the atmosphere, independent of its thermometrical or hygrometrical states. This variety of the disease usually oc- curs in the autumn, when the nights begin to be cool, after a very dry and hot summer, and generally during the prevalence of other forms of intestinal diseases—particularly dysentery and cholera. Cases that proceed from causes of this kind are com- monly preceded by the same train of premonitory symptoms that usher in miasmatic fevers—such as a feeling of weight and anxiety in the praecordia, loss of appetite, bitter taste, tension and fulness of the abdomen, disturbed sleep, headach, some lassi- tude and aching pain in the back, and slight sensations of creep- ing chilliness. (Richter.) Diarrhoea arising from this cause fre- quently passes into the dysenteric form of the disease. It is probable that these cases depend on the conjoined influence of koino-miasmata and atmospheric vicissitudes—giving rise to in- creased irritability, functional disorder, and sanguineous engorge- ment of the liver and intestinal canal, in a way which will be more particularly referred to under the head of cholera. Besides these, there are many other general causes capable of producing violent and protracted diarrhoea. The repercussion of acute and chronic cutaneous eruptions sometimes gives rise to obstinate attacks of this disease. It may also be produced by violent affec- tions of the mind, particularly sudden terror and grief. Diarrhoea occurs very frequently in visceral and other local affections attended with suppuration and ulcerative disorganization. Thus SOO DIARRn03A. in the latter period of pulmonary consumption, colliquative diar- rhoea almost invariably occurs; and the same may indeed be said of every variety of disease attended with hectic fever, or exten- sive suppurations. In febrile diseases, diarrhoea sometimes occurs as a critical evacuation.* It can never be regarded as salutary, however, where it depends on the supervention of phlogosis, or high vas- cular irritation of the mucous membrane of the bowels. When the discharge is watery, reddish, or muddy, mixed with flocculi of mucus, and the abdomen is tender and the tongue dry and red along the edges, it always indicates an aggravated condition of the disease, and the existence of mucous inflammation, and is of course a highly unfavourable occurrence. Critical diarrhoea appears generally to depend on a copious secretion of bile, or an increased discharge from the intestinal exhalents, co-operating, probably, with a morbid irritability of the bowels; and hence, salutary discharges of this kind are almost invariably bilious, mixed with more or less feculent matter and intestinal mucus. Watery discharges, free from bile, are rarely if ever indicative of a favourable tendency of the disease. During dentition, chil- dren are very liable to diarrhoea; but as this discharge, when moderate and unaccompanied with much gastro-enteric irritation, is calculated to lessen the tendency to preternatural determina- tions to the brain, it should not be checked in instances of thia kind, unless it becomes excessive and very exhausting. Prognosis.—When the diarrhoeal discharge has been brought on by indigestible or irritating articles of food or drink, and con- sists principally of feculent matter and vitiated secretions, it may in general be readily checked, and unless greatly mismanaged, will rarely assume a dangerous character. In general, diarrhoea is most apt to assume a chronic and dangerous character when it arises from the influence of cold and damp air, Qr from the habi- tual use of unwholesome and indigestible diet, in individuals labouring under some chronic visceral affection, or whose general health has been much impaired by previous diseases, hardships, or a course of intemperate living. When we find the disease to continue long, with frequent, watery, and acrid discharges at- tended with tenderness in the abdomen to firm pressure, and extremely severe tormina, we may presume that there exists chronic inflammation, or at least high irritation in the mucous membrane of some portion of the bowels—and consequently that there is much danger of the occurrence of structural disorder in this tissue, if the disease be not soon removed by appropriate measures. Those cases of diarrhoea that assume a strictly chronic • Fr. Hoffman. Dissert de Diarrhoea in Febribus Malignis Morbis Acutus Salutari. Buchner, Dissert, de Diarrlioea in Febribus Exanthematicis Salute et Noxa. DIARRHQ3A. 301 character, and in which scanty and painful diarrhoeal evacuations of an unnatural appearance occasionally alternate with short pe- riods of constipation, and severe pains are experienced in the track of the colon an hour or two after eating, may be regarded as certainly dependent on mucous inflammation, and most proba- bly attended with more or less ulceration, and consequently with great danger and difficulty in effecting a cure. Diarrhoea from the irritation of dentition, as has just been re- marked, is rather a salutary than a dangerous affection; but when this symptom of enteric disease is accompanied with a pale and fretful expression of the countenance, a hard and tumid abdomen, frequent picking at the nose, voracious appetite, and the dis- charge of undigested portions of food in the stools, it must be considered as an affection of very serious import Treatment.—In the treatment of diarrhoea it should always be recollected that the characteristic alvine discharges, by which this affection is recognised, and from which its name has been derived, is a mere symptom of a primary intestinal disorder, and that our remedies must be especially directed against this, the essential malady. If, then, we reflect that the local intesti- nal disease consists either in simple irritation—or in irritation with chronic inflammation—or finally, in irritation with chronic inflammation and disorganization of the mucous membrane of a greater or less proportion of the bowels, according to the grade of violence and duration,of the malady, we shall have no difficulty in instituting a rational plan of treatment. In this, as in other affections, our remedial measures must be modified according to the nature of the exciting cause; Thus, where the disease is pro- duced by suppressed perspiration from cold, the restoration and maintenance of the cutaneous exhalation, along with the reme- dies to be presently mentioned, will be peculiarly proper; where the irritation is produced by vitiated or redundant bile, mercu- rial remedies are especially applicable; and where a surfeit, or acrid and offensive ingesta have given rise to the disease, laxa- tives are indispensable in recent cases. The principal indications in this form of intestinal disease therefore, are, 1. To remove as much as possible every source of intestinal irritation; 2. To allay the morbid irritability of the mucous membrane of the bowels; and 3. To diminish the determination of the blood to the vessels of the intestinal canal In recent cases, where there is reason to presume that the in testmal irritation is kept up by vitiated secretions, or other irri tating matters lodged in the bowels, recourse must be had to mild purgatives. This is especially necessary where diarrhoea is the consequence of indigestion, or of the reception into the sto- mach of indigestible and irritating articles of food; or where the bowels are mfarcted, or loaded with fecal matter, as occurs in 302 DIARRH02A. the marasmus of children. It must be observed, however, that it is only in the earlier periods of diarrhoea, or where the mucous irritation has not passed into the state of inflammation, that any material advantage may in general be obtained from purga- tives; and even in cases depending on simple irritation, the gentlest laxatives alone ought to be employed. Purgatives arc indeed, very often greatly abused in affections of this kind! Nothing is more common than the repeated use of active purga- tives in diarrhoea. An individual becomes affected with loose- ness of the bowels. If it does not soon cease spontaneously, he takes a purge. The bowel complaint, however, continues, 'and convinces him that there is still something left which must be removed. To make himself sure of his objects, he takes a more active dose; but the tormina and discharges, instead of being mitigated, acquire greater violence. Astonished at the obstinacy with which the offending matter sticks to the bowels, he deter- mines, once and for all, to get rid of the cause of his complaint, and swallows a double dose of the most active cathartic. He now begins to experience tenderness in the abdomen; the tormina and diarrhoeal discharges continue; in short, he has developed inflam- mation, which the most judicious management may not be capable of removing. We cannot, however, always abstain from laxatives in instances manifestly connected with inflammation of the internal membrane of the bowels. Thus, where phlogosis, or a state of irritation closely approaching inflammation exists, in connexion with an accumulation of feces and vitiated secretions, with a hard and tumid state of the abdomen—a combination of circumstances fre- quently met with in children, no hopes of procuring relief can be reasonably entertained, until these irritating matters are re- moved out of the bowels by a course of gentle aperient remedies. Fortunately, in cases of this kind, we may, in general, gain our object in this respect much more readily by mild, than the more active articles of this kind, when assisted by an appropriate diet. A grain of calomel at night, and a moderate dose of castor oil on the following morning, assisted with three or four laxative enemata during the day, will in general answer well in such cases, (marasmus) without doing any injury to the inflamed bowels. Castor oil is decidedly the best purgative in cases of diarrhoea, attended with a high degree of irritation or phlogosis. One or two grains of calomel, or three or four grains of blue pill, with from one to two grains of ipecacuanha, may be occasionally given to an adult, both with a view to its aperient effects, and its in- fluence upon the biliary organs, which always become more or less'deranged in diarrhoea of protracted continuance. Many writers recommend rhubarb as a suitable purge in this disease; and in recent cases, from irritating matters lodged in the bowels, DIARRH03A. 303 it will, no doubt, answer all the purposes that may be obtained from a remedy of this kind. In protracted instances, however, where there is high intestinal irritation, or chronic inflammation, it is much inferior to the cold pressed castor oil. From its tonic, along with its aperient powers, rhubarb was formerly thought to be peculiarly suited to the treatment of this affection, under the erroneous notion, that diarrhoea is generally the consequence of a relaxation or loss of tone in the intestinal tube. Where it may « be deemed necessary to administer an aperient in cases mani- festly connected with chronic inflammation, or a highly irritated condition of the bowels, the castor oil may be very advantageously given in union with from fifteen to twenty drops of laudanum. In all bowel affections attended with inordinate discharges, a preternatural determination of blood takes place to the vessels of the intestines, with more or less torpor'of the cutaneous exhalents. This is more especially the case in instances of long standing, and contributes very materially to the support of the intestinal irrita- tion. Remedies which are calculated to counteract this centripetal direction of the humours, are therefore especially proper in affec- tions of this kind. For this purpose, opium, in combination with small doses of calomel and ipecacuanha, constitutes an excellent remedy, after the irritating contents of the bowels have been evacuated by suitable laxatives. Opium and calomel have a direct tendency to allay the morbid irritability of the mucous membrane of the alimentary canal, and when given in conjunction with small portions of ipecacuanha, seldom fail to excite the activity of the cutaneous exhalents. In recent cases of diarrhoea, where the discharge depends on simple irritation of the bowels, the. exhibi- tion of one of the following pills every four hours, after the ope- ration of a dose of castor oil, will seldom fail to check the com- plaint* Minute portions of calomel, too, will frequently arrest the progress of the disease. (Dr. Ayre.) From a sixth to a fourth of a grain of calomel may be given every hour or two. In the diarrhoea of infants, arising from acidity of the prima vise, and deficient biliary secretion, this article, given in union with two „ or three grains of prepared chalk, is often peculiarly beneficial but as the irritation is apt to be transferred from the bowels to • the brain in young children, opium may do mischief, by promot- ing the determination to the head. Very frequently diarrhoea is induced and sustained by impaired digestion in consequence of a weakened state of the stomach Here alterative doses of calomel and the use of mild tonics., to- * &. G. opii gr. iii. Pulv. ipecac, gr. xii. Calomel gr. ii. Conserv. rosar. q. s. M. Divide into 12 pills, • 304 DIARRH02A. gether with simple, unirritating, and digestible diet, will com- monly prove beneficial. Astringent remedies have been much employed in diarrhoea; but where the mucous membrane of the bowels is in a state of high irritation or inflammation, articles of this kind are almost always decidedly pernicious. In instances where the discharge is kept up by a slight degree of irritation and relaxation of the in- testinal exhalents, benefit may occasionally be obtained from remedies of this kind; but even in such cases, they may in ge- neral be very properly dispensed with. The astringents most commonly employed in diarrhoeal affections, are kino, alum, acetate of lead, sulphate of zinc, and the infusions of logwood, blackberry-root, the root of geranium maculatum, &c. Astring- ents should never be resorted to where the tormina are very severe, and there is a tenderness or soreness to the touch in the abdomen. I have repeatedly known great injury done by the use of such articles in the ordinary bowel complaints of children; and there can be no doubt, that as a general rule, astringents deserve to be reprobated in affections of this kind. Judging from my own experience, opium and ipecacuanha are much more efficacious than astringents, even in instances which may be deemed favourable to the beneficial operation of the latter class of remedies. What I have hitherto said, refers more particularly to recent cases of diarrhoea, before the intestinal irritation has become fixed or converted into inflammation and its consequences. When the disease assumes a chronic character, it generally becomes exceed- ingly obstinate, and often resists every mode of remediate treat- ment. One of the most important measures in such cases, is the avoidance of every kind of stimulating aliment. The food should consist wholly of farinaceous fluids, light broths, animal jellies, rice, barley, oat-meal gruel, milk, &c. In all cases, indeed, whether recent or chronic, such a diet is decidedly the most proper; but in the latter form of the disease, it is absolutely essential to success in its treatment In some instances of chronic diarrhoea, we may succeed in removing the disease by a rigid adherence to this simple and unirritating diet in conjunction with the employment of small doses of calomel and opium, the occasional use of the warm-bath, leeching, and counter-irritating applications to the abdomen. I have in several instances derived great advantage from the em- ployment of small doses of Dover's powder, in union with the acetate of lead, according to the following formula." Not unfre- quently, all the means just mentioned, however judiciously em- • ]J. Pulv. ipecac, compos.^i. Pulv. acetat. plumb, gr. vi. M. Divide into 6 equal parts. S. Take one every 4 hours. DIARRHQ5A. 305 ployed, will entirely disappoint us in our attempts to remove the disease. I have known instances of this affection to continue for nine or ten months, although all the foregoing remedies, together with an appropriate diet, had been diligently used. In cases of this obstinate character, the internal use of balsam copaiva will sometimes do much good. What I have already said under the head of chronic enteritis, in relation to this remedy, applies fully to the chronic form of the present affection. It is not probable, however, that it can procure any permanent relief in cases at- tended with ulceration of the intestinal mucous tissue; yet, even in cases of this kind, I have known considerable temporary benefit derived from this article. In a case of pulmonary hepatization, with purulent expectoration, attended for nine months with con- tinued and extremely painful diarrhoea, the balsam copaiva emul- sion generally gave very considerable relief for four or five days, after which the symptoms recurred with their usual degree of violence, notwithstanding the use of this medicine. On dissection, a number of irregular ulcerations were detected in the mucous membrane of the colon and the lower portion of the small intes- tines. In a case of chronic diarrhoea of upwards of six months continuance, I succeeded in effecting a perfect cure by means of this remedy, given to the extent of from thirty to forty drops three times daily, and fifteen drops of laudanum with each dose. In this case, the diarrhoeal discharge depended, no doubt, on simple chronic inflammation, without ulceration of the mucous tissue. Dr. Elliotson has lately introduced a new remedy to the notice of the profession, for the cure of chronic diarrhoea, depend- ent on ulceration, which has been employed with much success at St. Thomas's Hospital in London—namely, the sulphate of copper in union with opium. Cases that had resisted almost all the remedies usually accounted the most efficacious in this affec- tion, yielded readily to this remedy. The dose is half a grain twice a day, with a grain of opium, increasing the quantity of the former article gradually to two and even three grains in a day. From the known good effects of weak solutions of this preparation when applied to chronic ulcerations, it is not impro- bable that its operation in this way may occasionally prove very serviceable in diarrhoea depending on ulcers of the mucous mem- brane of the bowels; and although the vegetable astringents are always unequivocally injurious in such cases, some benefit may also arise from its peculiar astringent influence on the engorged and dilated capillaries of the mucous membrane. Whatever in- ternal remedies may be resorted to in cases of this kind, it will always be proper to keep up the regular action of the cutaneous exhalents—and it is especially useful to excite the extreme ves- sels of the external surface of the abdomen. For this purpose, a broad flannel roller should be constantly worn round the body; Vol. II. 39 306 DIARR1I03A. and the patient must be particularly careful not to expose himself to the influence of damp and cold weather, and above all to avoid getting wet and cold feet. All kinds of alcoholic liquors also must be avoided. Mucilaginous fluids, such as infusion of mallows, or flaxseed, or barley water, slightly acidulated with sulphuric acid, form the best drink. Sect. III.—Cholera. Cholera is an affection of the alimentary canal, characterized by very frequent and violent vomiting and purging, with severe tormina, and cramps in the muscles of the abdominal parietes and extremities. The disease almost always comes on suddenly. Pain, and a sense of tension in the epigastrium, are generally the first symptoms by which it makes its attack. This is soon fol- lowed by violent colic pains about the umbilical region, accom- panied with exceedingly distressing nausea. In a few moments after the occurrence of these symptoms, vomiting and purging commence with extreme violence, and continue, with but very short intervals, until the system is exhausted, if speedy relief be not obtained. During the intervals between the attacks of vo- miting, the patient is usually harassed with continual nausea, and an indescribable feeling of distress in the epigastrium. The alvine discharges are at first thin and watery, and generally, with little or no admixture of bile; nor is the fluid ejected from the stomach, usually, of a bilious character, during the early period of the disease. After the disease has continued for an hour or two, however, the bile begins to make its appearance pretty copiously in the evacuations, and towards the conclusion, the fluid discharged consists, in many instances, almost entirely of bilious matter. As the disease advances, the tormina become more and more severe and continual, and.the purging and retch- ing are almost incessant. One of the most distressing affections belonging to this disease, are the extremely painful cramps which, in severe cases, occur in the abdominal muscles, and in those of the inferior extremities. In cases of no great violence, the cramps occur principally, and sometimes exclusively, in the muscles of the legs; but in rapid and very severe attacks, the muscles of the trunk, as well as of the upper and lower extremities, are alike affected in this way. The thirst is always exceedingly urgent; but every thing received into the stomach is almost immediately thrown up again. As soon as the disease is completely developed, the pulse is small, feeble, irregular, or intermitting; the hands and feet become cold ; the countenance pale, shrunk, and expres- sive of great distress; a cold sweat breaks out on the extremities and face; and extreme prostration speedily ensues. CHOLERA. 307 Cholera is one of the most rapid and fatal forms of disease. It seldom continues beyond twenty-four hours, without terminating favourably or fatally; and in many instances it ends in death, in the course of three or four hours, and sometimes in a much shorter period. In the cholera of India, death generally takes place within two or three hours after its commencement. In this extremely fatal variety of cholera, the patient is generally suddenly seized with great prostration, unquenchable thirst, a scarcely perceptible pulse, cold and clammy sweats, cramps in every part of the body, inexpressible anxiety of feeling, extreme restlessness, syncope, excruciating tormina, constant retching, and very frequent stools of a thin, whitish, or starchy fluid. If the patient survive this, the first stage of the disease, which is by no means common, some degree of reaction usually ensues in the course of from twenty to forty hours; and the liver begins to pour out an abundance of dark, thick, vitiated bile, which is discharged in the stools, and which may be regarded as an indi- cation of a favourable crisis in the disease. Etiology and Pathology.—A superabundance of vitiated bile in the stomach and bowels, was formerly, and, by some, is still regarded as the immediate cause of this very dangerous malady. The term cholera* is, indeed, sufficiently expressive of the no- tions once universally entertained, concerning the nature of this affection. Dr. Cullen says, " the matter ejected, both upwards and downwards, appears manifestly to consist chiefly of bile ;" and Dr. Gregory, though he rejects the idea of its dependance on a redundant and vitiated secretion of bile, says that the disease " commences with nausea and unremitted bilious vomiting, &c." In truth, almost all writers, up to the time of Dr. Bateman and Dr. James Johnson, mention a copious and vitiated bile as the exciting cause of this affection; but the erroneousness of this sentiment is now well known by all who have kept pace with the progress of pathological science. So far, indeed, from there being a redundant secretion of bile in cholera, there is actually a deficient formation of this fluid, from functional torpor of the liver; and it would appear that the hepatic torpor is in direct proportion to the violence of the disease. No one, indeed, who has attentively observed the early symptoms of cholera, can for a moment doubt of the correctness of this statement; for, how- ever abundant the discharge of bile may be after the disease has continued for some hours, this fluid never appears in the evacua- tions during the early period, or what may be termed the first stage of the disease. The observations and researches that have been published of late years—and they have not been limited— m relation to the pathology of cholera, render it evident, that the • From zotoi, bile, and ' a circU- dfsLT ThVVSCarCeIyeVer n0t!C6d in the °ther varieties of the ~ lhe hvrer appears to be as inactive in this, as in the precedng form of cholera; for when once fully developed he evacuations, dunng the early period of the disease, ar^whoW devoid of any appearances of bilious matter, consisting either of a wh, ish, frothy, or of a watery, and almos colourleJ fluid If the d sease does not rapidly exhaust the vital powers, and termi nate falally during the first few days, the patient begin""to eZ'- c ate; the extremities become cold; the head, and surface ofX abdomen extremely warm; the skin dry and harsh thecounte 310 CHOLERA. by proper remedial measures, the little patient, by degrees, be- comes somnolent; he sleeps with the eyes half open, rolls about his head when awake, and at last sinks into a" state of insensibi- lity and coma, and dies, under symptoms resembling those of the last stage of hydrocephalus. When the disease is very protracted in its course, aphthae usually appear on the tongue and inside of the cheeks ; the face acquires an ©edematous appearance ; the alvine discharges become so acrid as to excoriate the parts about the anus; and towards the fatal conclusion, spots of effused blood under the cuticle, sometimes appear on various parts of the sur- face. The duration of this variety of cholera is exceedingly various. It may prove fatal in five or six hours; or continue for several weeks, and even months, until the body is reduced to a state of extreme emaciation, and yet terminate favourably. The majority of deaths takes place before the termination of the ninth day. When death takes place early in violent and rapid cases, the liver, and vessels of the mucous membrane of the alimentary canal are found, on dissection, strongly engorged with blood; "and where the disease had continued for some length of time before death, ulceration and even abrasion of the lining membrane of the stomach and bowels," are usually discovered.* The etiology of the cholera of infants differs in some import- ant circumstances from that of the ordinary form of the disease in adults. Both these varieties of cholera are almost exclusively confined to the hot months of the year; but cholera infantum is vastly more prevalent in large and crowded cities than in the country—a circumstance which does not obtain in relation to the cholera of adults. During a practice of twelve years in the coun- try, I met with but two or three cases of this disease in infants. Again, cholera infantum occurs almost exclusively during the third and twenty-fourth months of age; in other words, during the period when the process of primary dentition is going on. There are, therefore, three causes whose concomitant influence is extensively concerned in the production of this variety of cholera, namely, high atmospheric heat; the contaminated air of crowded cities; and the irritation produced by dentition. From the great prevalence of this disease during the hot months of summer in the more filthy parts of crowded cities, it has been supposed that it is of malarious origin, and "a mere variety of the bilious fever of our climate, the force of which is turned in- wards upon the intestines." (Condie.) In support of this senti- ment, it has been alleged by the respectable physician just quoted, that though seldom met with in salubrious districts of the coun- • Dr Condie. Observations on the Pathology and Treatment of Cholera In- fantum, &c. in the Philadelphia Journal of Med. and Phys. Sciences, May, !&»• CHOLERA. 311 try, "a majority of the children fall victims to cholera infantum in the neighbourhood of marshes, or in low, wet, and otherwise unhealthy situations." This, I apprehend, will not be confirmed by the observations of those who practise in the neighbourhood of paludal districts. Unquestionably, cholera is much more com- mon, both in infants and adults, in such localities, than in high. and salubrious parts of the country, and there can be no doubt, that miasmata have a cpnsiderable tendency to favour the occur- rence of cholera, whether in adults or in infancy. If, however, koino-miasmata be the principal agent concerned in the produc- tion of this malady, why is the disease so exclusively confined to a particular period of infancy in our cities ? And why, we may further ask, does it commence so early as in the latter part of June, and usually acquire its most extensive sway in July, before the ordinary paludal diseases a're wont to make their ap- pearance, except here or there perhaps a few instances? Let it be observed too, that we frequently find this fatal disease of in- fants extremely rife in this city, when scarcely any of the other diseases justly ascribed to the miasmata in question occur among our inhabitants. High atmospheric temperature and the irrita- tion of dentition, appear to be the principal remote causes of this affection. But as these causes very seldom produce cholera in infants enjoying the pure air of the country, there must be some other circumstance peculiar to populous cities, which especially favours their tendency to develop this disease. This accessory or predisposing cause consists probably in the impure air of ci- ties, by which the infantile system is rendered irritable, and pe- culiarly predisposed to suffer disturbance from the irritation of dentition. II seems to me highly probable that erethism of the brain, caused by the irritation of difficult dentition in the peculiarly irritable habit of body just mentioned, is frequently deeply con- cerned in the production of this malady. Throughout the whole course of the disease, the head is always preternaturally warm__ and in most instances the child is peculiarly restless and fretful for several days previous to the accession of the disease. The tendency of cerebral irritation to cause inordinate irritability of the stomach and bowels is well known. Diarrhoea is a very com- mon, and m general a salutary occurrence during the process of painful dentition. In the commencement of hydrocephalus, ^reat gastric irritability and frequent vomiting is very rarely absent In concussion of the brain, vomiting is often a very troublesome symptom: and sea-sickness, which is often so violent as to re- semble cholera, appears to depend entirely on the peculiar cere- bral excitement occasioned by the swinging or rocking motion of a vessel at sea he great tendency of cholera infantum, in ita chronic form, to terminate in a state of cerebral oppression and 312 CHOLERA. coma, seems also to show that the brain is especially predisposed to inflammation, or to that peculiar morbid condition which con- stitutes what is usually called acute hydrocephalus. We may, therefore, presume, that in the irritable condition of the system, produced by the influence of a very warm and con- taminated atmosphere, dentition causes more or less cerebral irri- tation, which being reflected on the stomach and bowels, renders them preternaturally irritable. If in this state of the alimentary canal, the cutaneous exhalents are over-excited and debilitated by high atmospheric temperature, the slightest reduction of tem- perature, a current of fresh air, or damp night air, will readily cause ja sudden torpor of these emunctories. The blood will re- treat from the surface to the internal organs, and give rise to en- gorgement of the vessels of the liver and mucous membrane of the bowels, by which the gastro-intestinal irritability will be still further increased, and the characteristic symptoms of the disease excited. Treatment of Cholera. The principal indications in the treatment of the cholera of adults, are to allay as speedily as possible the irritability of the stomach and bowels; to restore the action of the skin and liver; and to determine the circulation from the internal to the external parts. As the progress of this disease is always extremely rapid, the most prompt and energetic means should be at once resorted to, with the view of moderating its violence ; and for this pur- 'pose we possess no remedies so powerful and certain in their effects as opium, and the application of a large and active sinapism to the region of the stomach and liver. When the disease super- venes soon after having taken a full meal, or some indigestible and irritating articles of food or drink, the patient should be di- rected to take copious draughts of chamomile or balm tea, or warm water, in order to procure the speedy evacuation of the irritating substances lodged in the alimentary canal. In all cases, indeed, it will be proper, in the commencement of the disease, to allow the patient the free use of bland drinks, both with the view of washing out the contents of the intestinal canal, and of moderat- ing the painful and exhausting effects of frequent ineffectual efforts of vomiting and purging when the stomach and bowels are empty. As soon, however, as the irritating contents of the stomach and bowels are evacuated, a large dose of opium should be adminis- tered, and the patient kept from taking any drinks for at least thirty minutes after the medicine is taken. From 80 to 100 drops of laudanum should be given at once; and the same quantity, mixed with a small portion of warm water, thrown into the rec- tum. If vomiting occurs soon after the first dose is taken, the CHOLERA. 313 laudanum should be repeated in doses of from 80 to 40 drops every fifteen minutes, until its influence on the system is fully obtained. At the same time a large sinapism must be laid over the right hypochondrium and epigastrium. Instead of sinapisms, we may resort with nearly equal advantage to active rubefacient embrocations. I have in several instances derived very prompt benefit from the application of the oil of monarda punctata to the abdomen, in conjunction with the internal use of large doses of laudanum. This oil is one of the most active local irritants we possess. When applied in an undiluted state, it inflames the skin in a few minutes, and causes exceedingly severe burning pain in the part. The spirit of turpentine may also be used for this purpose, but its effects are less prompt and powerful than those of the ol. monarda. Upon the prompt and free use of opium and external revulsive applications, our chief reliance must be placed. The practice of giving warm spiced brandyv and other powerfully exciting articles of this kind, is highly improper. Brandy may be allowed in the latter stage of the disease, when the prostration is extreme, and it is absolutely necessary to sup- port the sinking powers of the system by potent diffusible sti- mulants ; but if it be given during the early period of the disease, with the view of moderating the excessive vomiting and purg- ing, it will not only generally disappoint our expectations, but of ten manifestly aggravate the symptoms of the complaint. The sedative powers of opium, however, are eminently calculated to allay the extreme irritability of the alimentary canal, and when promptly and efficiently given, will seldom fail to procure com- plete relief in the course of sixty or eighty minutes. In not a single instance in which I have resorted to this valuable remedy, did it fai to arrest the vomiting and purging within the period SSL?ent!°ned' and the onI7 fatal case I ever saw, was treated chiefly with warm spiced brandy. If from six to eight grains fifteT^r > mtr.oduced int0 the ^madi, and retaintd for taintv r 7 T^V™ ma^ calculate> aImo*t with cer- tainty, on the speedy subsidence of the disease. When the lauda- num is immediately thrown up again, it should £ repeated again and again, until its effects are obtained. I have k£e* course of an hour given nearly an ounce of laudanum in this the epigastrium, which may be speedily donP L «? IT 314 CHOLERA. applied by means of a sponge upon the whole region of the stomach; and as soon as the patient feels considerable pain from its impressions, the part is to be washed with a solution of the carbonate of potash. The cuticle may now be easily detached, so as to leave the cutis exposed and raw. Upon this surface, from ten to twelve grains of morphia may be applied, either in the form of a plaster, or by sprinkling the powder over it, and covering it with a piece of linen thinly spread with simple cerate. By this procedure we at once obtain the advantage of a powerful counter-irritating application, and of the full influence of the opium. When the irritability of the stomach and bowels is in some degree allayed, it will be proper to employ calomel in small but frequent doses, with the view of stimulating the action of the liver. Half a grain of this article may be administered every half hour, and continued until the alvine discharges become bilious, or #the disease is subdued. Dr. Ayre speaks highly in favour of minute and frequent doses of this remedy in cholera, and there can be no question as to its entire adaptation to the treatment of this affection. Where the disease is very violent and rapid, however, we cannot depend on its operation without the conjoined influence of efficient doses of opium. It may be very advantageously given in union with powdered opium, in the proportion of two grains of each, every half hour, until the narcotic effects of the former are manifested, when the calomel should be continued alone in half grain doses. The warm bath may be used with occasional advantage in the commencement of the disease; and where the exhaustion is great, and the muscles of the extremities affected with severe cramps, much benefit will generally result from rubefacient frictions—particularly from frictions with a strong tincture of capsicum. When the pulse sinks and the extremities become cold, the patient should be wrapped in flannels soaked with hot brandy, and recourse had to the internal administration of diffusible stimuli. One of the best articles of this kmd, according to my own experience, is a solu- tion of camphor in vitriolic ether. Of a solution of a drachm of camphor in an ounce of ether, a tea-spoonful may be given every half hour until the re-action is considerably increased. In one instance, where the pulse was scarcely perceptible, and the ex- tremities cold and clammy, this solution, given in the way just mentioned, produced the happiest effects. I have stated above, that drinks should be withheld for some time after administering the first dose of laudanum, in order, if possible, to prevent it from being thrown off before it can produce its impressions on the stomach; with this exception, it will always be proper to allow mild mucilaginous fluids in a warm state—such as barley-water— as long as the vomiting and purging'continue; for, as has already been stated, the exhaustion produced by the excessive vomiting CHOLERA. 315 and purring, is much less rapid when the stomach and bowels are freely supplied with fluids, than when they are nearly empty, and the evacuant efforts are ineffectual or attended with but small dischcirffcs. After the disease is subdued, the patient should take light and nourishing diet, such as animal broths. It will also be proper, during the period of convalescence, to wear a flannel roller round the abdomen; and to take a few grains of blue pill, with a grain of ipecacuanha, every evening, on going to bed; and when the digestive powers remain weak, a table-spoonful of the infusion of colomba, or gentian, or a wine-glassful of chamomile tea, with a few grains of the carbonate of ammonia, may be taken three or four times daily. Treatment of Cholera Infantum. Although the morbid condition of the liver and alimentary canal, in cholera infantum, does not appear to differ from that of the cholera of adults, yet the treatment proper in the former, differs in several very essential points from that which is best calculated for the removal of the latter variety of the disease. Besides the indications already mentioned for the treatment of ordinary cholera, we have, in the present variety, the important one of obviating irritation and sanguineous congestion of the brain; and hence opium, which is decidedly the most valuable remedy in the cholera of adults, cannot be employed without great hazard of doing mischief in the cholera of infants. Some practitioners, under an idea that the stomach contains offending matter, which spontaneous vomiting is incapable of throwing off, commence the treatment with the exhibition of a gentle emetic; but this practice is not only founded on an erroneous view of the pathological condition of the alimentary canal, but what is still more to the purpose, is generally decidedly injurious. From what was said above, in relation to the pathology of this affection, it would appear that torpor of the liver and skin, in connexion with cerebral irritation, constitute the immediate cause of the excessive irritability of the stomach and bowels. Our principal object, therefore, must be, to restore these two func- tions; to obviate irritation and sanguineous congestion in the brain; and to determine the blood from the engorged vessels of the liver and mucous membrane of the alimentary canal To answer these purposes, I generally commence the treatment with the application of from ten to twelve leeches to the temples, the exhibition of minute portions of calomel and ipecacuanha, and a arge stimulating poultice over the abdomen. I am persuaded, by what I have repeatedly observed in my practice, that great 316 CHOLERA. benefit will in general result from local depletion from the head, as well as from the application of blisters behind the ears, or on the back of the neck, in this affection. Within the last four years, I have not treated an instance of this complaint, in which I did not at once apply blisters behind the ears, and in most instances, with unequivocal advantage. This at least I may confidently affirm, that since I have adopted this practice, I have been much more successful in the management of this disease than previous- ly. Where the pulse is irritated and the head very warm, leech- ing at the temples or behind the ears is particularly indicated, and will seldom fail to procure very manifest relief. In an ex- tremely severe case which I lately attended in a child about eighteen months old, twelve leeches applied to the back of the ears, was almost immediately succeeded with great abatement of the violence of the symptoms. With the view of moderating the gastro-intestinal irritation, and of stimulating the action of the liver, minute portions of calomel and ipecacuanha constitute, I think, the most valuable internal remedy we possess for combat- ing this disease. From one-sixth to a quarter of a grain of calo- mel in union with half a grain of ipecacuanha, should be given every hour or two, and continued until the evacuations become mixed with bilious matter. Let it be borne in mind, that so long as the liver remains torpid, and the alvine discharges free from bilious matter, the disease may be regarded as still possess- ing all its violence and dangerous tendency, whatever temporary abatement may occur in the severity of the vomiting and purging. The appearance of bile in the stools, whether green or dark, is always to be hailed as a very favourable sign, and the sooner the liver can be brought to resume its secretory action, the greater in general will be the probability of ultimate success in our attempts to subdue the disease. Ipecacuanha in small doses is a most ex- cellent auxiliary to the calomel, in affections attended with mor- bid irritability and excessive peristaltic action of the alimentary canal. Its tendency to counteract inordinate action of the bowels, when given in small doses, is well known; and its tendency also to excite diaphoresis, still further enhances its applicability in this and other similar intestinal affections. Where, from a tumid and tense state of the abdomen, there is reason to presume that the bowels are loaded with fecal matter, the quantity of calomel a! each dose should be larger, so as to procure its purgative opera- tion. I have occasionally given a grain every two hours until its evacuant effects were procured, and afterwards continued it in doses of about one-sixth of a grain every hour. Dr. Edward Miller appears to have been the first physician who particularly recommended minute doses of calomel in cholera infantum; and jnder judicious management it is unquestionably a very valuable emedy in this affection. Except under the circumstances just CHOLERA. 317 mentioned—namely, a loaded state of the bowels, purgatives are not, in general, advisable in the commencement of the disease. Where the disease continues, however, until the liver, under the exciting influence of the calomel, pours out a large quantity of bile, mild laxatives are highly useful. In a case which I attended during the present season, the vomiting and purging were in a great measure arrested on the third day of the disease. The in- fant, however, sunk into a state of stupor, from which it was very difficult to rouse it As the evacuations from the bowels were very dark and small, and the vomiting had ceased, I prescribed a full dose of castor oil. In about two hours after the oil was taken, copious evacuations of a pitch-like matter took place from the bowels; and the little patient was almost immediately freed from the alarming symptoms of cerebral opression under which it laboured. Where the disease comes on gradually, and proceeds slowly, it may perhaps be better to commence at once with pur- gative doses.of calomel, than with the minute alterative portions mentioned above. In cases of this kind, the bowels are, frequent- ly, much loaded with fecal matter, which it is of much importance to evacuate, as speedily and completely as can be done without resorting to very active or irritating purgatives. At the same time that the means already indicated are em- ployed, external revulsive applications to the abdomen, more especially to the epigastrium and right hypochondriac region, should be used. So far as my own experience enables me to judge, blistering the region of the stomach is decidedly the most efficient application of this kind in the present affection. Before the blister is applied, the part should be slightly bathed with spirits of turpentine, in order to procure vesication as speed Iv as possible. I have seldom, however, suffered the vesicatory to remain on the skin longer than four hours. As bLT^^ •s uniformly inflamed, which in children occurs generally n about four hours, and sometimes much sooner, thegcantharides should be removed, and an emollient poultice applied over th' whole abdomen, ncluding of course the inflamedsurfaceTltil will, in a short time, excite the inflamed vessels to pour out a nianifestly ^&gfi£ft£ gjffi^f< *> ^ ■fuS. ^ehf:A:z^Te^7*the tr<~ the skin is yer; dry and hTs7*6 thT^7 ind,icated' when While the patiL I iJ^i^&^^£% 318 CHOLERA. will be proper to apply a napkin wet with cold water to the head. Various other external applications to the abdomen have been recommended, for the purpose of moderating the gastro-intestinal irritability in this affection. Rubefacient embrocations and cata- plasms, made of stimulating herbs and spices, may be beneficially applied to the abdomen ; and where the disease is violent and rapid in its progress, recourse should be had to the most active articles of this kind—such as sinapisms, ol. monarda,* spirits of turpentine, and even diluted nitric acid, in the way mentioned for the treatment of the cholera of adults. I have already stated, as a general rule, that the use of opium is highly improper in this affection. The great tendency to con- gestion and irritation of the brain, in this species of cholera, ren- ders all medicines of this kind decidedly prejudicial, when given in the early period of the disease, or where, in its advanced stage, symptoms of cerebral oppression are manifestly present. Never- theless, where the disease assumes a chronic form, and the patient is very restle'ss and wakeful, with a dry, harsh, and withered state of the skin, and there are no particular marks of cerebral con- gestion, small doses of Dover's powders, in union with minute Portions of calomel, will sometimes produce very excellent effects. n a few instances of this kind, I have given half a grain of Do- ver's powder, with the sixth of a grain of calomel, and two grains of magnesia, every two hours, to a child under two years old, with unequivocal advantage. I must confess, however, that I have witnessed some instances of this kind, in which the employment of this narcotic was speedily followed by more or less stupor and cerebral oppression, without any beneficial effect on the intestinal disorder. With regard to the astringent and absorbent remedies, formerly so much employed in this affection, we can scarcely pronounce too strong a sentence of condemnation against their use in the acute form or stage of this malady. I am entirely persuaded, that "much of the mortality of the disease has been produced" by the injudicious employment of cretaceous juleps, astringent mixtures, aromatic draughts, and opiates. Where the disease be- comes chronic, or continues rather in the form of chronic diar- rhoea than of cholera, the milder astringents may occasionally do some good. Thus, I have, in a few cases, known a decoction of the root of the geranium maculatum in milk, procure considera- ble advantage; but I have much more frequently found it, either to produce no manifest impression on the disease at all, or to do injury. The employment of unirritating tonics, in the chronic • R. Ol. monarda %\. Spin-it camphorse gai. M. CH0LEHA. 319 form of the disease, attended with great debility and relaxation, is much more apt to afford relief, than the use of astringents and absorbents. I have frequently procured considerable benefit, in the advanced periods of the disease, from the employment of a solution of the tartrate of iron. Forty grains of this preparation may be dissolved in two ounces of water, to which half an ounce of the lemon syrup is to be added. Of this, from thirty to forty drops may be given to an infant, four or five times daily. Dr. Robert Jackson speaks very highly of finely powdered charcoal in diseases of the intestinal canal attended with diseased secre- tions ; and Dr. Condie states, that he has used this article with very decided advantage, "in the latter stage of the disease, when it had become, in some degree, chronic, and the discharges from the bowels were acrid, dark-coloured, and offensive." From my own experience, I can say nothing of this remedy, but I do not doubt its occasional usefulness under the circumstances just men- tioned. From five to ten grains of the powdered charcoal, with four or five grains of rhubarb and a grain of ipecacuanha, may be given every three hours. (Condie.) When, from the violence and rapidity of the disease, or its long continuance, the exhaustion becomes very great, the extre- mities cold, and the pulse very small and feeble, internal, as well as external stimulants, become necessary. Under such circum- stances, stimulating frictions, together with the internal use of wine-whey, milk-punch, or a weak solution of the carbonate of ammonia, are indispensable to support the sinking energies of the To relieve the colic pains which are apt to occur from flatulent distention of the bowels in the advanced periods of chronic cho- era infantum Dr. Condie strongly recommends a few drops of «£5fi!v Srpe?tl^i and my °Wn exPerie^e enables me to Ktoffif n°f 'thlS rTduy- 1 have' SeneraI1^ howe™V preferred the oil of jumper to the terpentine, and I am inclined atter'Norererr^""^6^^111 ^ -pect?than the latter. JNo remedy has appeared to me so promptly to allav colir weak si?™T thG GXPulsi0n 0f flatus £™ tie ££•£ as a the diet, throughouUh^holtru£ tf he Ee Tthe'chH LeX:Drt^iZ itsliquid -^ W mult tapioca, sago, ItLTL ^^Z^^ST^ fn^^eTcSra "?* ^^^WfiS racter, jThave know! beef t« T^"^' °f a chronic <*a. 320 CHOLERA. chronic cholera infantum, the appetite sometimes suddenly begins to crave urgently for certain strong and stimulating articles of food, such as salted herring or shad ; old bacon ; salted and smok- ed beef, &c., whilst the stomach loathes all the lighter and unir- ritating articles of nourishment enumerated above. When this occurs, it will be proper cautiously to gratify the newly awaken- ed appetite, however opposed to the ordinary dietetic rules the indulgence may appear to be. "I have seen many children re- cover," says Dr. Rush, "from being gratified in an inclination to eat salted fish, and the different kinds of salted meat. In some instances they evince an appetite for butter, and the richest gra- vies of roasted meat, and eat them with obvious relief to all their symptoms." Without these strong instinctive calls of nature, however, it would be highly improper to allow such coarse arti- cles of food ; yet where the inclination for them is strongly ex- pressed, it may, and ought to be gratified. Nothing contributes more to the removal of this disease, than the enjoyment of the pure air of the country. Whenever it is practicable, the little patient ought to be removed into the country; for this change is often sufficient to remove the disease, in a short time, without any other remedial applications. If the circumstances do not admit of a removal from home to a suitable situation in the country, some advantage may be gained, by carrying the patient about in the open air ; and still more, by frequent rides into the country in an open carriage. As preventive measures, gestation, or residence in the pure air of the country; the avoidance of cool night air after a very warm day; nourishment at the breast during the process of dentition, or where circumstances render this impracticable, a very light liquid diet—particularly milk, and a thin preparation of arrow- root, with beef-tea, or weak chicken-broth, tepid bathing, and lancing the gums as soon as they become swollen by the protrud- ing tooth, are the most important. Sect. IV.—Colic. Writers have divided colic into a great many varieties ; but as most of these distinctions are mere nosological refinements, I shall notice those only which have a practical bearing. The most common variety of colic is that which is occasioned by irritating and indigestible articles of food, and which Dr. Gregory, from this circumstance, calls accidental colic; but which is more commonly designated by the term flatulent, from the prominent symptoms of indigestion and flatulency which always attend this painful affection. COLIC 391 1. Flatulent Colic. A weak and irritable state of the digestive organs, predisposes, in an especial manner, to this variety of colic. In persons so pre- disposed, even the ordinary articles of food will sometimes give rise to the disease; and when food of an indigestible character is taken, more or less suffering from colic is almost inevitable. Salted meats—all kinds of pastry—crude vegetables, such as cu- cumbers, celery, and unripe fruit—sour fruit—fresh and warm bread, &c. are especially apt to excite the disease in persons labouring under weak digestive powers. When articles of this kind are received into the stomach, no inconvenience is usu- ally felt until an hour or two after they are swallowed. In some instances, where the stomach is weak and irritable, the food passes into the bowels in an imperfectly digested state; in which case, the colic pains may not come on for several hours after eating, and usually occur mdst severely about the umbilical re- gion. More commonly, however, the pain commences in the stomach or duodenum, before the offending substances have had time to pass lower down in the alimentary canal. At first, the patient.experiences a sense of distention and uneasiness in the pit of the stomach, or occasionally in the left iliac region. This is soon followed by a dull, peculiarly distressing, and sickening pain in these parts, accompanied with a feeling of strong distention of the stomach and bowels. The pain now rapidly increases in vio- lence, until it becomes extremely severe. In some cases, the pains continue, with but short remissions, for several hours. More commonly, however, they occur in severe paroxysms, with com- plete, though transient intervals of ease. During the exacerba- tions, the patient is apt to move to and fro, with the body bent forwards, and the hands firmly pressed against the abdomen When the stomach is the principal suffering organ, large quanti- ties of air, are, from time to time, forced up, and this is generally immediately followed by some mitigation of the pain When the colon is the part chiefly affected, the flatus sometimes passes off downwards ; but this seldom takes place to any considerable extent, until he disease is about terminating. The bowels are always torpid in this affection, and the tongue soon becomes covered with white fur. & 1BB Diagnosis.-The diagnosis of this variety of colic is not at- tended with any difficulty. The relief obtained from firm ab- dominal pressure-the agitation and writhing motions of {he patient, as well as the absence of fever, and the Zoxvsmal titu^f 1^1 "? ^"^ --tationsof'flatusr^ From LLf,TT 7 [T\ S^o-intestinal inflammation. Vol II ™y d,StinSuished by the absence of 322 COLIC bilious vomiting, as well as of the icterode appearance of the eyes, of the extreme obstinacy of the constipation, and of the headach and bitter taste in the mouth, which characterize the bilious variety of colic. From colica pictonum it is readily distinguished by the hardness and retraction of the abdominal muscles, and the gradual accession of the colic produced by lead. Prognosis. —Flatulent colic is not attended with much dan- ger, unless it terminates in inflammation of the gastro-intestinal mucous membrane—a termination which sometimes, though rarely, occurs. In some instances, where the flatulent distention is very great, it produces paralysis of a portion of the bowels, or destroys, to a degree, the power of contraction, giving rise to habitual costiveness, and an especial tendency to a recurrence of the complaint. It is not improbable, that paralysis of a portion of the intestinal canal, induced in this manner, may be the prin- cipal occasion, in some cases of introsusception, or invagination of the bowels. Where flatulent colic is produced by very indi- gestible and irritating ingesta, it may give rise to rapid inflamma- tion and gangrene. Treatment. —The treatment of this variety of colic is seldom attended with much difficulty. In slight cases, where the fla- tulent pains are seated in the stomach, and there is no reason to presume the existence of chronic irritation in the mucous mem- brane of this organ, we may, in general, soon procure relief by administering some of the carminative and antispasmodic stimu- lants. Dry frictions with flannels or a flesh-brush, is an excel- lent means for removing flatulent pains of the stomach. By rapid frictions on the epigastrium, the flatus is generally discharg- ed in copious torrents, and where there is no fixed irritating cause in the stomach that requires removal, we may often, in this way, put a termination to the gastric pains. From five to ten grains of camphor, with about thirty drops of vitriolic ether, and the same quantity of laudanum, has frequently afforded prompt relief in my hands. The oil of juniper or the spirits of turpen- tine will also generally allay the pain in slight cases. Articles of this kind will, in general, give relief where there is no parti- cular irritating cause lodged within the alimentary canal; but where the disease is the consequence of crude, indigestible, and irritating ingesta—or where it comes on within an hour or two after taking a full meal of stimulating, mixed, and indigestible food, carminatives and antispasmodics will not only be insuffi- cient, but generally decidedly injurious, unless they are used in conjunction with proper evacuants. Where there is reason to be- lieve that the offending matter is still in the stomach—which may be presumed to be the case when the disease comes on with- in an hour or two after taking a full meal, recourse should at once be had to an emetic dose of ipecacuanha. To moderate the COLIC. 323 excessive suffering of the patient as speedily as possible, we may administer some carminative along with the emetic. From twen- ty to twenty-five drops of the essence of peppermint, may be advantageously given in such cases, with about thirty grains of ipecacuanha. When the pain is confined to the bowels, occupy- ing the colon, an active purgative, in union with aromatics, or with some of the more volatile antispasmodics, ought to be given, and purgative enemata administered at short intervals until the bowels are freely moved. Castor oil with spirits of turpentine is an excellent purgative in colic from the irritation of acrid sub- stances or imperfectly digested articles of food lodged in the bow- els. I have often employed this mixture with prompt and com- plete success. In some instances, however, the sufferings of the patient are so extremely great, that we cannot wait for the opera- tion of a cathartic to procure relief. In such cases, almost the only remedy upon which any reliance can be placed is opium, given in large doses. From two to three grains should be given at once, or what is better, an equivalent dose of laudanum. This will always procure relief in the course of forty or fifty minutes; and in many instances of this severe character, nothing but this remedy, in enormous doses, will allay the extreme agony of the patient. The opium, when given in large doses in this affection, does not materially impede the subsequent operation of cathartics —and the administration of a purgative should never be neglect- ed as soon as the violence of the disease is moderated.* When the disease occurs in robust and plethoric habits, venesection should be practised, in order to obviate the occurrence of inflam- mation, and to promote the operation of the necessary purgatives. Little or no advantage usually results from the employment of external revulsive applications ; yet when after the subsidence of the colic pains, the epigastrium remains tender to pressure, and the tongue becomes furred in the middle, with a florid appearance of the edges, leeching and blistering cannot be safely dispensed with. After the disease has been subdued, the patient should confine himself to the lightest and most digestible articles of food for several days. . * F°r tl,is PurP«>se we may use either castor oil and turpentine, in the propor- tion of six drachms of the former to two drachms of the latter—or the following R. Extract, colocynth. compos. Jss. Calomel Qi. Tart, antimonii gr. i. M. Divide into 10 pills. Take 2 every hour until the bowels are freelv moved. —Or, ' % Pulv. jalapa gr. xvi. Calomel gr. viii. M. To be taken all at once. 324 COLIC 2. Bilious Colic. There is another variety of colic, which, from the manifest derangement of the biliary organs, and symptoms indicative of a superabundant or vitiated secretion of bile, has with propriety been denominated bilious colic. This variety of the disease appears to depend on the same remote cause which gives rise to intermitting, remitting, and other forms of miasmatic fevers; and it accordingly most com- monly occurs during the autumnal months—particularly after a long continuance of a very warm and humid state of the atmo- sphere. Before the more urgent and characteristic symptoms of the dis- ease come on, the patient generally experiences headach, loss of appetite, a bitter taste in the mouth, thirst, nausea, and occasion- ally bilious vomiting. After these symptoms have continued for an indefinite period of time, acute pain in the stomach and bow- els supervenes, moving at first from one part of the abdomen to another, though generally most severely felt about the umbilicus. This pain is often intensely severe during the exacerbations. In the early stages of the complaint, pressure on the bowels affords some degree of relief; but as the disease advances, the abdomen becomes tender to the touch. Nausea and bilious vomiting occur more or less frequently from the commencement of the malady; and the patient always experiences a temporary abatement of his sufferings immediately after a spell of vomiting. Although the stomach is morbidly irritable, and extremely apt to be excited to vomiting, yet the bowels are almost invariably extremely torpid, being generally in a state of obstinate constipation from the be- ginning of the disease. The pulse seldom deviates materially from its natural condition during the early period of the com- plaint; but in the advanced stage it becomes increased in fulness, force, and frequency. In violent cases, the hands and feet are sometimes quite cold during the exacerbations of the pains. About the second or third day of the disease, the eyes and skin become more or less suffused with a yellow tinge; and in some cases, indeed, these manifestations of biliary disorder occur seve- ral days before the pain in the abdomen commences. In cases of great severity, the nervous system usually suffers considerable disturbance—the patient becoming despondent, and affected with slight spasmodic twitches in the muscles of the ex- tremities.* Dr. Staley, in the interesting paper on this disease just referred to, observes, that he has sometimes met with cases • An Inquiry relative to the Causes, Nature, and Treatment of Bihoi By Dr. Henry Staley, of Maryland.—See Medical Recorder, rol. vi. p. COLIC 325 in which much numbness and tremor of the superior extremities occurred; and he saw one case in which the "arms were so completely paralyzed that all power of voluntary motion was destroyed." Paralysis of.the wrists has indeed been frequently noticed as an occurrence in this affection, and this circumstance has been adduced as an argument in favour of the identity of this affection with the variety of colic produced by lead. Eructations of flatus are very common in bilious colic; and as in the former variety of the disease, they are always followed by a temporary mitigation of the abdominal pain. Causes.—I have already said that bilious colic appears to de- pend on the same remote cause which gives rise to autumnal bili- ous fever. Dr. Rush includes this variety of colic among the usual forms of miasmatic fevers; and Dr. Staley observes, that he has uniformly found "the cases of bilious colic most numerous after a summer remarkable for the prevalence of bilious remit- ting and intermitting fever." My own observations correspond fully with these statements. In the autumns of 1821-2 and 3, when bilious remittents prevailed very extensively, I met with a greater number of cases of bilious colic than had previously come under my notice during a period of fifteen years. Although' there can scarcely exist a reasonable doubt, that koino-miasmata is inti- mately concerned in the production of this malady—more espe- cially when it prevails, in a degree, epidemically ; it must never- theless be admitted, that other causes, of a sporadic character, occasionally give rise to this affection. I have met with cases of strongly marked bilious colic under circumstances that precluded all ideas of the agency of miasmata. It is generally believed that the liver is morbidly active in this disease—and that a redundant secretion of bile is one of its most essential conditions. This idea is favoured by the circumstance, that from the very commencement the fluid thrown from the stomach is always mixed with a considerable portion of bilious matter. There is much reason, however, to doubt the correct- ness of this opinion. Dr. Staley observes, with much plausibili- ty, that if we reflect on the quantity of bile which is secreted in a healthy individual, and the obstruction which exists to its passage downwards, from the constipated state of the bowels in tins disease, we can have no difficulty in accounting for the quan- tity of bile discharged by the mouth, although there be a paucity in the secretion. It is not improbable, indeed, that so far from there being too copious a secretion of bile in this disease, there .s, m tact, generally, a deficiency of this fluid. The functions of the liver are unquestionably deranged, and the bile secreted is without doubt, vitiated That thisls the case, may be nferred « wrVT T Wh,ch|bi,r, C0HC bearS t0 ^lera^n analo- gy which has been particularly noticed by many writers. Dr. 3.26 COLIC. Gregory observes, "that bilious colic is closely allied to bilious diarrhoea and cholera, occurring along with them, and apparent- ly differing from them only in some unessential features." The opinion that the liver is in a state of torpor, rather than of in- creased activity, is moreover strengthened by the fact, that so soon as the alvine discharges become bilious, an amendment of the disease usually takes place; and that however frequent the discharges may be, they seldom procure any particular relief when they are devoid of bilious matter. " When bilious stools are not brought away," says Dr. Gregory, " it is common to find chocolate coloured motions passed, frequently in vast quantity, reducing the patient to a state of great weakness." Dr. Musgrave, in a valuable paper on this disease, states that he invariably found the liver in a highly congested state, and in the majority of in- stances there were strong marks of intestinal inflammation and its consequences.* The etiology of bilious colic does not appear to differ mate- rially from that which is common to cholera, dysentery, &c. The atmospheric heat and miasmata act probably as predisposing causes; and sudden changes of atmospheric temperature, by which the cutaneous exhalents and secretory vessels of the liver are struck torpid, and the blood determined to the internal organs, constitute perhaps the principal exciting cause of the disease. Treatment.—The principal indications in the treatment of bilious colic are: to free the bowels of their irritating contents; to allay the morbid irritability of the stomach and intestinal tube, and to restore the healthy actions of the liver. Some writers speak very favourably of the employment of emetics in the begin- ning of the disease, and there can be no doubt of their usefulness where there is much nausea, without full vomiting in the com- mencement of the attack. Under such circumstances, the exhi- bition of an emetic, should be among the first measures resorted to for the removal of the disease. Much bilious matter, of a viti- ated appearance, is usually thrown off, and considerable tempora- ry relief, almost invariably, ensues. In cases attended with much spontaneous vomiting, it will not be necessary to resort to the use of emetics. In such instances, it will be sufficient to request the patient to take copious draughts of eupatorium or chamomile tea, or some other diluent, in order to facilitate the complete evacuation of the vitiated bile and other irritating matters lodged in the stomach. Where an emetic is indicated, the tartanzed antimony will in general answer better than any other article of this kind, on account of its greater tendency to excite the action of the liver and of the alimentary canal. Many writers advise the exhibition of purgatives, as soon as the stomach has been well * Med. Repository, Nov. 1825. COLIC 327 freed of its irritating contents. But in the majority of cases, the stomach is so extremely irritable, that medicines of this kind can- not be retained a sufficient length of time to enable them to act on the bowels. As the early evacuation of the intestinal canal, however, is all-important, measures should be immediately taken to allay the gastric irritability, so as to enable us to administer a cathartic with a prospect of advantage as early as possible. So far as my own experience enables me to decide, calomel is de- cidedly the best internal remedy we possess, for preparing the stomach for the reception and retention of purgatives. Given in small and frequent doses, in conjunction with the application of sinapisms or epispastics to the epigastrium, this mercurial will seldom disappoint us in allaying the irritability of the stomach, sufficiently to enable us to administer with effect the necessary cathartics. What renders this remedy still more useful as an an- tecedent measure to the use of purgatives, is its well known powers to correct functional disorder of the liver, as well as its tendency to co-operate as an aperient with the purgatives which are to follow. After the stomach has been freed of its contents, either by spontaneous vomiting, or the operation of an emetic, half a grain of calomel may be given every half hour, at the same time that a large epispastic is applied to the region of the stomach and liver, and continued until the gastric irritability is moderated. When this is accomplished, a full dose of some active purgative should be administered; and for this purpose We may give from fifteen to twenty grains of calomel, followed in about three hours with an ounce and a half of castor oil, or a draught of strong in- fusion of senna and manna. In some instances, however, none of the usual purgatives will be retained, notwithstanding the pre- vious employment of small doses of calomel and counter-irritatinc- applications to the epigastrium. Where this is the case, it is best to depend on calomel alone, with the view of procuring the eva- cuation of the bowels. "When the gastric irritability is very great,calomel," says Dr. Staley, "combined with gum-arabic, will be retained, when every other cathartic will be rejected " 1 his corresponds entirely with my own experience. I have in several instances, ultimately procured free alvine evacuations by administering from five to six grains of this mercurial every three or four hours, until from twenty to thirty grains are taken and then assisted by repeated purgative enemata. The employ- ment of enemata should, indeed, always accompany the use of purgatives in this affection. An excellent injection for this purpose, is the following mixture of castor oil LIi turpentine^* * R. 01. ricini giss. Spir. terebinth. |ss. Infus. sem. lini. Oj. Sapo venet. ji. M. 328 colic. or we may use a strong infusion of senna and Glauber salts. As soon as the bowels are freely evacuated, a full dose of opium ought to be administered. This valuable narcotic allays the irri- tation and spasmodic contraction of the intestines; and when given in combination with calomel, it does not impede the sub- sequent operation of cathartics, and tends, in no small degree, to equalize the circulation, and to excite the cutaneous and he- patic functions. When the obstinacy of the disease is very great, and the bowels resist the effects of purgatives, the calomel, with an occasional dose of opium, should be given with a view to its constitutional influence. In general, cathartics will operate freely as soon as the mercurial influence is manifested by the soreness of the gums. A general mercurial action has, in fact, a most bene- ficial influence upon the disease, whatever may be its grade of violence; and in prescribing calomel in the commencement of the disease, with a view to its purgative effects, we must not lose sight of the more permanent and equally important influence, procured by its specific effects upon the system, and particularly upon the liver. Deranged hepatic function constitutes, probably, the foundation of the malady ; and the removal of this morbid condition should be held a primary object in the treatment After the bowels have once been freely evacuated, we must by all means endeavour to keep up regular alvine evacuations through- out the subsequent course of the disease. For this purpose, cas- tor oil, or infusion of senna and manna, with an occasional dose of calomel, and the daily use of one or two purgative enemata, will in general answer very well. In robust and plethoric subjects, or where the pulse is vigor- ous and tense, and the tenderness to abdominal pressure consider- able, blood-letting is a very important auxiliary remedy in this affection. It not only tends to moderate the irritability of the stomach, and to favour the regular operation of the necessary purgatives, but what is still more important, it lessens the liability to inflammation, which, in plethoric and robust habits, is always very considerable in this affection. When the pulse is vigorous, it will be best, at once, in the commencement of the disease, to draw blood to the extent of making a decisive impression on the system; and the operation may be advantageously repeated when- ever the state of the pulse, and other symptoms, indicate its pro- priety, at every stage of the disease. Epispastics, sinapisms, and warm fomentations, also, are valua- ble auxiliaries to the remedies already mentioned. When the irritability of the stomach is very great, or when the epigastrium and abdomen are very tender to the touch, a large epispastic should be applied over the region of the stomach—having pre- viously practised an efficient blood-letting—and an emollient ca- taplasm laid over the lower part of the abdomen. These applica- COLIC. 329 tions assist, in no inconsiderable degree, to allay the irritability of the stomach ; and they are especially useful, also, to obviate intestinal inflammation—an occurrence which it must always be our principal aim to prevent When in the beginning, the fluid thrown from the stomach is of an acrid quality, alkaline remedies should be administered. Calcined magnesia maybe given either in union or in alternation with other purgative medicines; or from twenty to thirty grains of the bi-carbonate of potash, dissolved in a draught of senna and manna. The warm bath occasionally affords considerable relief in vio- lent cases of this affection ; and warm fomentations to the abdo- men may be very beneficially used. After the disease has been subdued, much care is necessary on the part of the patient, in relation both to diet and exposure. There are few diseases which are so apt to be re-excited by even slight errors in either of these respects, as the present one. For eight or ten days after an attack of this disease, the diet should be of the lightest and most digestible kind. Rice, sago, dry toast, beef tea, &c. should be used for three or four days, after which, small quantities of the njost digestible meats may be allowed. It is particularly important to avoid getting cold and damp feet. To lessen the liability of a relapse, it will be proper to wear a flannel roller round the abdomen for some time after the subsid- ence of the disease; and the patient must be particularly caution- ed against drinking very cold water, during the first three or four days of convalescence. 3. Colica Pictonum. This variety of colic has been described under a diversity of names—as dry gripes ; Devonshire colic ; colica pictavensis ; c, satununa ; c. damnoniensis; rachialgia metallica; painter's colic, &c. It generally makes its approaches in a very gradual manner —commencing with symptoms of gastric derangement, such as irregular trnd weak appetite, foul eructations, languor, slight nau- sea, constipation, with transient pains, and a feeling of weight and tightness in the abdomen, more or less drowsiness, and disincli- nation to mental and corporeal exertion. By degrees, the pain in the epigastrium and umbilical region becomes more and more severe and constant. The abdomen is hard, retracted, and some- what tender to pressure, the bowels immoveably torpid, and the stomach, in most instances, very irritable. The pain in the abdo- men suffers occasional remissions, but, except for a moment after vomiting, and in mild cases, no perfect intermissions take place, as in the other varieties of colic. The exacerbations of the colic pains are protracted in duration, and exceedingly agonizing; and, 330 COLIC during the first two or three days, the retching and vomiting is generally very distressing, although a momentary mitigation is usually experienced, immediately after the contents of the stomach are ejected. In violent and rapid cases, or what may be called the acute form of the disease, the pains extend from the umbilical region upwards to the chest and arms, and downwards to the pelvic viscera, giving rise to paroxysms of violent pain in the region of the bladder and rectum, with much difficulty of voiding urine, and a distressing sense of weight, constriction, and bearing down in the lower part of the abdomen. During the exacerba- tions, the anxiety and agitation are extreme—cold sweats break out on the extremities and face; the countenance is pale, contract- ed, and expressive of great suffering ; and in some cases of very great violence, partial syncope, delirium, convulsions, paralysis of the wrists, and severe pains in the extremities occur. "When remedial measures fail to make a favourable impression on the dis- ease, the vital energies at last begin to sink; the abdominal pains abate; the stomach becomes extremely tender and puffy; the thirst unquenchable ; vision imperfect; and finally, oedema of the feet, drowsiness, a pale, livid hue of the face, and occasionally, sup- pression of urine, and more or less tenesmus, with great dyspnoea, ensue ; and the patient dies under symptoms pf apoplexy, or in a state of syncoptic insensibility. Colica pictonum, if not subdued by an appropriate treatment, or if the remote cause continues to act on the system, or the pa- tient has already suffered one or two attacks of the disease, is particularly apt to assume a chronic character, and to become associated with a variety of fixed and peculiarly distressing affec- tions. The excretory and nutritive functions become impaired ; the mental and physical energies torpid; the capillary circulation extremely inactive, giving rise to a pale, sallow, and leaden hue, and a shrivelled, dry, and harsh state of the surface of the body; the temper becomes irritable, desponding, taciturn, and gloomy; the countenance lurid, and expressive of deep suffering; the body emaciates ; the fore-arms become wasted and palsied; the abdo- men exceedingly hard, painful to pressure, and tumid^; the legs oedematous, with pains in the joints, particularly in the ankles and toes, and great tenderness of the soles of the feet The patient is extremely restless at night, his vision becomes weaker and weaker, the oedema extends up the legs, and the abdomen en- larges with dropsical accumulations. In some cases, paraplegia, epilepsy, mania, or total imbecility of mind ensue; and the patient is at last reduced to a state of complete exhaustion and emacia- tion, and dies under symptoms of apoplexy, or of dropsical effu- sion into the cavity of the thorax, pericardium, »1 •. On post mortem examination, traces of inflammation, with patches of disorganization, almost always occur in the mucous- colic. 331 membrane of the stomach and intestinal canal. Frequently, por- tions of the intestines are so contracted as scarcely to admit the passage of an ordinary sized quill; and occasionally the stomach, and whole track of the bowels, are in a state of preternatural con- traction. The vessels of the abdominal and thoracic viscera are generally very turgid with blood ; but the muscular structure, every where, exhibits a pale and exsanguious appearance. The omentum is often marked with livid spots. M. Thomas, a late French writer, states, that in the dissection of eleven persons who had died of this disease, he found the meninges of the brain strongly injected, together with softening, and other morbid ap- pearances of the cerebral structure, with serous or sanguineous extravasations between the membranes. Causes and nature.—Lead, in whatever way and form it may be brought to act on the system, is almost the only well ascer- tained cause of this variety of colic. It would seem that the fumes of melted lead, and the white oxyde of this metal, are most apt to act injuriously on the animal system, and to give rise to this extremely distressing affection. It has been said, that the acetate of lead is incapable of producing this disease, and that no apprehensions need be entertained on this account, in prescribing the internal use of this article. It must be admitted, indeed, that the acetate manifests a much less deleterious tendency in this way, than any of the other forms under which this metal may exert its poisonous influence on the system. It would appear that the tendency of lead to produce colic is not confined to the human species. It has been distinctly noticed, that in the neigh- bourhood of smelting furnaces and white lead manufactories, pigs, poultry, and other animals, occasionally become affected with a similar disease. Plumbers, painters, glaziers, gilders, the workers in lead mines, and in white lead manufactories, are most exposed to the influence of this poison, and of course almost pecu- liarly liable to this disease. Formerly, it was the practice, in some parts of Europe, to put litharge into new made wine, for the purpose of rendering it palatable, or to convert acid into sweet wine. This gave rise to the extensive prevalence of this form of colic in some districts ; and it is from its endemic pre- valence at Poitou in France, from this cause, that the disease obtained the name of colicapictonum. It has been contended, nevertheless, that other causes are ca- pable of producing this variety of colic. Crude wine, fresh cider, and other drinks, acidulated with fresh vegetable juices, are men- tioned as possessing a tendency, under otherwise favourable cir- cumstances, to produce this disease ; but the correctness of this opinion has, I think, with great propriety been doubted ; for, if the circumstances attending the occurrence of instances of this kind are accurately investigated, it will, perhaps generally, be 332 COLIC found, that in such cases these drinks had been tainted with lead employed in some part of the machinery or vessels made use of. Without doubt, such beverages may give rise to severe colic ; but we have no satisfactory evidence that they are capable of pro- ducing the protracted train of distressing symptoms which are known to arise from the poisonous influence of lead. Larrey, and some other late writers assert, that atmospheric vicissitudes, in conjunction with malaria, are a frequent source of this form of colic ; but it is probable, that when produced by these causes, the disease does not differ from the preceding variety—namely bili- ous colic. It has indeed been maintained, that the affections called bilious and lead colic, are essentially the same; but, although the former often bears a very close resemblance in its course and phenomena to the latter, the more decided manifestations of bili- ary derangement in the former, and the great aptitude of the lat- ter to pass into a chronic state and to become complicated with various affections of a most distressing character, among other distinctive circumstances, seem to indicate a radical distinction between them. Of the nature or proximate cause of colica picto- num, there is but little known of a satisfactory character. That the nervous system is prominently affected, is very evident; but whether the ganglionic, or the cerebral nerves, are the seat of the primary irritation, is by no means evident. M. Thomas, to whose dissections I have already referred, conceives that the primary location of this affection is in the brain ; but the facts upon which he grounds this opinion—namely, the very obvious traces of high vascular congestion, and other organic affections of the brain which are frequently detected on post mortem examination, arc by no means satisfactory ; since they may, and I presume arc, rather the ultimate effects, than the causes of the malady. The disease may be compared to a tetanic spasm of the intestinal canal, the result probably of a primary morbid condition of the ganglionic nerves, gradually extending to the nerves of relation. Treatment.—The indications for prescribing in this affection are : 1, to allay the pain and spasm of the bowels; 2, to evacu- ate the intestinal canal; 3, to correct and excite the hepatic and intestinal secretions ; and 4, to obviate the occurrence of inflani- jnation in the stomach and bowels. As the tendency to intestinal inflammation in this affection is always very considerable, it will be proper, in the first place, to reduce the momentum of the circulation, more especially in ro- bust and plethoric subjects. If the pulse is hard and full, a vein should be immediately opened, and the blood suffered to flow until a manifest impression is made on the action of the heart and arteries. Blood-letting does not appear to exert any direct influ- ence over the violence of the symptoms, but it is obviously pro- per as a means to lessen the chances of (he supervention of jnflam- COLIC. 333 mation, and it tends in no inconsiderable degree, to render the operation of the other remedies more certain and beneficial. As soon as the action of the pulse has been moderated, we must prescribe with the view of allaying the pain and spasm of the intestinal canal; for unless this be effected, little or no advantage can be gained from the use of purgatives, on the free operation of which much of our ultimate success depends. For this pur- pose opium is decidedly the most valuable remedy we possess. When given in large doses, it not only allays the spasm and excruciating pain in the bowels, but by these effects it contributes also very greatly to the free operation of cathartics. In order to excite the action of the liver, and to obtain the general mercurial influence on the system as speedily as possible, as well as to pre- dispose the bowels to be properly affected by the subsequent purgatives, the opium should be administered in union with ca- lomel. Two grains of opium, with five or six grains of calomel, should be given every two hours until the abdominal pains are removed. After the pain has been thus allayed, the calomel should be continued, at the same intervals of time, in two or three grain doses, with half a grain of opium, until the gums begin to manifest the mercurial influence. As soon as this is perceived, recourse must be had to active purgatives ; and it will scarcely be advisable to resort to them before the general mercurial action has been obtained : for previous to this, the most active cathar- tics will almost universally fail; and what is still more unfavour- able, they frequently give rise to severe vomiting and gastric distress, with but very small or no alvine evacuations, however vigorously urged. When, however, the mercury has affected the system, the skin generally becomes moist and of a natural temperature, and a full dose of an active purgative will rarely fail to procure free evacuations. I have repeatedly given opium and calomel for three or even four days before an attempt was made to evacuate the bowels ;'and I have had much reason to be ..satisfied with the result. Castor oil in union with the spirits of turpentine constitutes a very excellent purgative in cases of this kind. An ounce of the former with three/drachms of the latter may be taken at once, and half this quantity repeated afterwards every hour until the bowels are freely moved. I have not in a single instance, failed to procure free evacuations from'the a< ministration of this mixture, after the gums had become affect- ed with the.calomel. A strong infusion of senna and manna, with a portion of Epsom salts dissolved in it, will also, in gene- ral answer well as a purgative in this affection; but it is less eertain I think, than the oil and turpentine, and much more apt to produce very severe tormina during its operation. If the pain ".^"h 1 !Cr °,,erat,1°!1 °f the PurSati^s, recourse should be • has also bee" icsorted to with excellent effect. Dr. Ayre, who considers this 390 DIABETES MELLITUS. disease as depending on chronic inflammation of the kidneys, considers the application of leeches over the region of the kid- neys as the most effectual means we possess, for subduing this malady. It appears, however, that he has founded both his theory of the pathology of the disease, and his high opinion of the efficacy of local depletion, on the fortunate result of but a single case; a foundation, which it must be confessed is much too infirm to justify us in placing any great reliance on his experience in this respect. I should be inclined to prefer cupping to leech- es, as the former, besides its evacuant effect, is decidedly the most powerful derivative measure. Opium.—There is no article which possesses so much repu- tation as a remedy in diabetes as opium. Since the time of Fer- riar, there have, perhaps, been few cases of diabetes treated in England and in this country, in which this powerful narcotic has not been tried in some form or other. Without speaking in very extravagant terms of its efficacy in this disease, general experience justifies the declaration that it is one of our most useful remedies in this malady. Besides its tendency to diminish the inordinate secretion of urine, it is particularly useful in subduing that ner- vous irritability, which, in most cases, becomes so distressing in this disease. Dr. Warren was one of the first who employed this narcotic extensively in this affection, (Lond. Med. Trans. College of Phys. vol. iv.) Dr. Ferriar also used it in nearly all the cases he relates ; he gave it in combination with bark and uva ursi, in the proportions of a scruple of each of the latter to half a grain of the opium, three or four times daily. In conjunction with this combination, be directed the use of lime water and an animal diet. Prout regards opium as decidedly the best remedy we possess for the cure of this affection ; and of all its prepara- tions, he thinks Dover's powder is the best. It must not be for- gotten, however, that where the pulse is strong and firm, blood- letting is an important, if not an essential, preliminary, to the employment of this narcotic. "The first immediate effect of opium upon the urine, says Prout, is to increase its specific gra- vity. This depends on the diminished secretion of water, while the sugar remains unaltered, in consequence of which the urine is rendered more concentrated, and consequently heavier. As the remedy is persevered in, the urine acquires its original specific gravity, and becomes even lighter. The quantity of sugar is diminished, and that of urea much increased, sometimes so much so as to become greater than natural. Lithic acid soon after makes its appearance in abundance, and the urine acquires altogether a more natural colour and appearance, &c." Latham states that he has obtained much advantage from a combination of the car- bonate of iron and opium, in cases of a chronic character, and attended with much debility and nervous irritation. Much of DIABETES MELLITUS. 391 the benefit which results from the use of opium, depends, proba- bly, on its tendency to excite the exhalents of the surface. A diaphoresis, in whatever way it may be produced, rarely fails to check the excessive flow of urine, and this effect is always a con- siderable advantage, although the urine may remain saccharine. From five to eight grains of Dover's powder may be taken every four hours ; or we may give a grain of opium, either by itself or in combination with uva ursi and lime water, two, three, or four times daily. It is of importance, when the patient is put on the use of this narcotic, to keep his system constantly and pretty equally under its influence. Opium may also be advantageously given with lime water. From thirty to forty drops of laudanum, in a gill of lime water, may be given three or four times daily. The Germans have been much in the habit of giving large doses of alum in this affection. Cases are related, in which scruple doses of this article were given several times daily with very de- cided benefit. Dr. Venables speaks very favourably of the effects of the phosphate of iron in this affection. «I have been really struck," he says, "with the efficacy of the phosphate of iron in excessive discharges of urine. The quantity of this secretion, is rapidly reduced under the use of this salt, and indeed its qualities sensi- bly altered. The bulimia also, which attends diabetes, is reduced, and the powers of digestion invigorated and increased. The dose may be gradually increased from a few grains to half a drachm three or four times daily." T?.nn',t?Kter' w^ interestinS and valuable series of Hospital virion 'mnd ^ " CaS6 °f diabetCS' Where the disease resisted various modes of treatment, until "hard work, aided by warm clothing and a scruple of Dover's powder at night, entirely ™ movedthe disease." Dr. Johnson, in remarking on tins case observes, « it is evident that the skin, as an extensfve outlet syS pathizing powerfully with almost all the glandular viscera isTn work, warm clothing, and large doses o' W 2'r » T the case which terminated favo.imM,, i„ , Powder- In the Dover's powder T^Z^lolZZ? ^^ """l* three times daily. This willI »V.™it ■. een Srains each, two or three da^s; and\b?gS^™£eT*1&r the firef to me to be considerably enhanced hi L *<>. remedy appeared —■ There can „& ^&™%?£%Z 392 DIABETES MELLITUS. labour, by favouring free exhalation from the surface, will often assist very materially in subduing this disease. Some have re- commended the warm bath with the same view, but this remedy has too strong a tendency to relax and debilitate the system, to admit of very frequent application in this affection. Frictions with dry flannel, however, are not subject to the same objection, and they have been resorted to with manifest benefit. Magnesia has of late years been recommended in England, as a remedy of considerable powers in diabetes. Dr. Trotter has published an account of five cases which were effectually treated with this article. He directed his patients to take from one drachm and a half to two drachms of the pure magnesia, in twenty- four hours. The relief obtained, he says, was generally prompt, and attended with no unpleasant consequences. In one instance out of three in which I have prescribed the magnesia, a manifest impression was made on the disease, but the relief obtained was only temporary. I have met with several accounts in the Journals since the publication of Dr. Trotter's cases, in which the benefi- cial effects of this article are set forth in diabetes. I suspect, how- ever, that its usefulness is chiefly confined to that form of urinary disease, in which the urine, though morbidly increased in quan- tity, is wholly free from any saccharine matter. Emetics are recommended by Richter, in the treatment of this disease. He has given an account of several cases which were cured by the use of ipecacuanha in doses sufficient to produce active emesis. In one case, he asserts that the disease was re- v moved completely in the course of twenty-four hours. It would seem, however, that these cases were characterized only by an increased discharge of urine, for he no where mentions a saccha- rine urine. Indeed, the custom which prevailed formerly, of in- cluding all the urinary affections which are attended with a pre- ternaturally copious discharge of urine, under the head of diabetes, throws no small degree of ambiguity and uncertainty over the recorded experience of the practitioners of the preceding ages. Among the remedies which have been employed with success in this malady, the carbonate of ammonia deserves respectful mention. Dr. Neumen, of Berlin, has given an account of a case which yielded to the use of this remedy, continued for about four months. The dose was gradually increased from five grains thrice daily, to fifty grains in the day. I have heard of two other instances, in which benefit was obtained from this article, though both cases finally terminated fatally. Alkaline remedies have indeed been very frequently employed in the treatment of dia- betes. Lime water especially, was at one time much resorted to in this disease. Ferriar seems to have placed considerable re- liance on it, since we find it mentioned in every case which he has reported. I have myself used it in three or four cases, in DIABETES MELLITUS. 393 conjunction with uva ursi, but I did not perceive that any advan- tage arose from its exhibition. Rollo thought very favourably of the powers of the ammonium sulfuratum, or hepatized ammonia, which he rarely failed giv- ing in conjunction with the more important measure of an ex- clusive animal diet. In some instances, he administered the kali sulfuratum to the extent of from one to two drachms daily, for several weeks. The application of an epispastic over the sacrum, or the region of the kidneys, has been thought a very useful auxiliary in the cure of this disease. Rollo, Frank, and Marryat, speak favour- ably of this practice; and I am inclined to think that it deserves attention. In the case which terminated favourably under my care, two large epispastics were applied on the inside of the thighs; as, however, several other active means were used at the same time, it is impossible to say what share this, or indeed any of the other remediate measures, had in the production of the favourable result. Tonics were formerly much resorted to in the treatment of diabetes—a practice which was founded on the supposed flaccid and debilitated condition of the kidneys and digestive organs. Ferriar gave the cinchona with opium and uva ursi; but the earlier phy- sicians more commonly employed the metallic tonics—more es- pecially iron. Where the system is much relaxed and exhausted, I doubt not at all, that the sulphate of quinine may be often very usefully given. If I am not mistaken, Prout advises the employ- ment of this preparation in union with opium. I have heard of an instance in which the administration of three grains of quinine with a grain of alum and the same quantity of ipecacuanha, ad- ministered three times daily, produced very excellent effects. The mineral acids also are said to have been given with com- plete success in this affection. Gilby affirms, that out of four cases, he cured three with the internal use of the nitric acid; and Scott succeeded in one case with the same remedy. Brea, more- over, cured a case of this disease with the nitric acid given inter- nally, together with mercurial frictions over the lumbar region. Besides the remedies already mentioned, a vast variety of other means are noticed by authors; all of which have been used with more or less advantage, if we are to place any credit in the state- ments that have been given. Among these may be mentioned the following, as perhaps most entitled to attention: viz alum •* spir. turpentine; tinctura ferri muriatis; flor. zinci; cuprum am- momacum;t mercury;* digitalis; the internal use of cantharides;§ • Selle. Beitr. zur Natur. und Arzneiwiss. Bd. i. tP- Frank. De Curand. Homin. Morb. p. 65. \ J. Frank. Ratio Instit. Clinic. Ticinem. p. 208. § Brisbane. Select Cases, &c. Steelier, Hufeland's Journal. Bd 6 Vol. II. 50 394 DIABETES MELLITUS. valerian; assafoetida; catechu; kino; camphor; myrrh; phospho- ric acid ; phosphate of soda; phosphate ofSiron. I have hitherto said nothing concerning the dietetic means for treating this disease, which, after all, are perhaps the most im- portant and indispensable to success. Rollo was the first who adopted fully the plan of restricting diabetic patients to an ex- clusive animal diet, with the view of keeping out of the circula- tion, as much as possible, the saccharine principles which vege- table substances alone afford. When we recur to what has been stated above concerning the close chemical analogy between urea and sugar; the former being little else than a duplication of the constituent parts of the latter, with the addition of a large pro- portion of azote; it would seem that in diabetes there is a great deficiency of azote in the blood, in consequence of which the kidneys cannot form urea; but instead of it, secrete the saccha- rine matter which characterizes the disease. Now, as animal sub- stances—especially the muscular parts, contain a large proportion of azote, whilst vegetables contain little or none of it, it appears probable, that the benefits which result from the former kind of food, arise from the abundant azote which it furnishes to the system, by which the kidneys are enabled to secrete urea instead of saccharine matter. This accords with the gradual changes which occur in the urine in the progress of amendment—for in proportion as the quantity of sugar decreases, that of the urea increases. Whatever may be thought of these speculative views, it is very generally admitted, that an exclusive animal diet constitutes de- cidedly one of our most efficient means for curing this disease. It is true, that within a few years, Dr. Starky, physician of the Cork general dispensatory, has adduced some facts which would seem to show, that, contrary to the common opinion, vegetable substances, or such as contain sugar, will sometimes prove more beneficial than animal food. He states that he has cured several cases of this disease with a vegetable diet, and a drachm of phos- phate of soda three times daily. Dr. Johnson also seems inclined to place some reliance on the occasional usefulness of a vegetable diet in this affection. Were these cases attended with a saccha- rine urine? I am much inclined to believe that this fact is not always inquired into; physicians being satisfied that they have a case of diabetes before them, when they find the patient suffering great thirst, ravenous appetite, and an enormous discharge of urine. All these symptoms may, however, exist, without the disease being diabetes—at least diabetes of the kind we are now considering. I shall presently have to describe a variety of this disease, in which there is an excess of urea, and in cases of this kind, a vegetable diet is decidedly indicated, and useful. It is this latter disease, perhaps, which Dr. Starky treated; and if so, DIABETES MELLITUS. 395 we need not wonder that a vegetable diet was found so useful. The observances to be attended to, in the regulation of the diet for a patient affected with this disease, may be summed up as fol- lows: Fresh bread and potatoes should be avoided; but the patient may use moderate portions of pilot bread, and biscuit. It is of great importance that the quantity of food taken at each meal, should not be more than the stomach can readily digest. Roasted or boiled beef, beef-steak, mutton, lamb, and game, should form the principal part of the food; and it is said that fat meats are, in general, more beneficial than the lean parts. For drink, the pa- tient may use water, alum whey, weak brandy and water, milk and water, and beef or chicken tea. Sect. II.—Diabetes Insipidus. I proceed now to the consideration of those urinary diseases in which the inordinate secretion by the kidneys is attended with an excess of one or more of the regular ingredients of healthy urine. These affections bear so close a resemblance to diabetes mellitus, that up to the time of Willis they were comprehended, indiscriminately, under the single term diabetes. Collectively, trfey constitute the disease which has since the time of this wri- ter been denominated diabetes insipidus; but as they are cha- racterized by very different conditions of the urine, it is more consistent with scientific accuracy, to treat of them, as Prout has done, under their several appropriate heads. In one variety of these urinary affections, the characteristic state of the urine consists in an excess of urea, with an augment- ation of its quantity, often not inferior to that which occurs in diabetes mellitus. Bostock has given a particular account of a case of this kind, in the third volume of the Medico-Chirurgical Transactions, with an analysis of the urine, from which it appears that the patient discharged on an average twenty pints daily, containing seven and a half ounces of urea, without a particle of sugar. But no writer has investigated this disease so minutely, and described its course and phenomena so accurately, as Dr Prout, in his highly valuable work on the diseases of the urinary organs. In this affection, there is almost invariably a very fre- quent and distressing desire to pass urine, both by day and nio-ht In some instances, though exceedingly seldom, the quantity of urine is not much increased. In a great majority of cases con tous diuresis is a prominent symptom. b«The ^dty T^n.TZ weatoiT/h t°,,be Particula^ Iiab^ * be increased by( old Z ance; ft l£ ^ ^^^ mentaI agitation' ^some -nstances the patient experiences a considerable sense of uneasi- 396 DIABETES INSIPIDUS. ness or aching pain in the loins, and along the course of the ureters, and there is occasionally a good deal of irritation at the neck of the bladder, extending along the urethra." The skin generally retains its regular functions, being often moist, with general diaphoresis, even when the urinary affection is exceed- ingly aggravated. The desire for food and drink also, is not morbidly urgent, except in very violent cases; nor are the sto- mach and bowels often particularly deranged—the tongue being generally clean, and the alvine discharges regular, both in time and appearance. It would appear from the observations of Prout and others, that persons of a thin and spare habit of body, " with a sort of hollow-eyed anxiety of expression in their countenance," are the most liable to this complaint. With respect to the causes of this form of urinary disease, little is known of a definite character. Prout observes, that whatever debilitates the system, and particularly the urinary organs, may give rise to the complaint. There is another variety of urinary disease, in which the pre- sence of a large portion of albuminous matter in the urine is the characteristic symptom. This is the variety which has probably been most commonly described under the name of diabetes insipi- dus; for along with its albuminous principle, the urine is always greatly increased in quantity. There are two varieties of albu- minous matter occurring in the urine—namely, the chylous and the serous. The first, according to the observations of Prout, occurs most frequently; " it may, however, be remarked, (says this writer,) that strongly defined instances of either variety are not very common, and that by far the most frequent form which the disease assumes, seems to be of an intermediate character; that is to say, the albuminous matters partake in some degree of the properties of both those of chyle and serum; though gene- rally more those of the chyle." A morbidly copious discharge of chylous urine was known and described by the ancients as a variety of diabetes. Celsus divides too great a profusion of urine into thin and thick; the former kind, he says, though most frequent, is less dangerous than the latter variety, in which a great quantity of urine is discharged, together with chyle or milk, and the body consequently rapidly deprived of its nutrient principles. Some writers deny that the chyle ever passes off with the urine, as has been stated. They assert, that where the urine has exhibited a milky colour, it must have arisen from pus formed in the kidneys, and intimately min- gled with the urine in its passage down the ureters to the bladder. That this is a mistaken opinion, is satisfactorily attested by some of the most observant physicians, of both ancient and modern times. The appearance of chyle in the urine has been noticed even in apparently healthy subjects. Van Swieten, in his Com- DIABETES INSIPIDUS. 397 mentaries, says, "that he has seen in himself some hours after a meal, and especially after hard walking, his urine turbid and milky at the moment that it was evacuated ;" and, he adds, that he had afterwards observed the same kind of urine in others. Galen also seems to have noticed this chylous state of the urine. (De Aliment. Facult. Lib. i. c. 2.) But the authority of Prout is alone sufficient to establish the opinion that the milky appear- ance of the urine in cases of this kind, depends solely upon the presence of unchanged chyle. When, along with the chyle, there is a large portion of albuminous matter in the urine, this fluid undergoes a spontaneous coagulation, assuming the appearance nearly of blanc-mangi. Mr. Elliotson, in his edition of Blumen- bach's Physiology, relates a remarkable instance of chylous urine. This case occurred in a young married woman. In the morning, the coagulum of chyle in the urine was pale, with pink streaks; in the evening it was whife. After fasting for twenty-four hours, the coagulum " was extremely pale, with pink streaks." This kind of urine is extremely prone to decomposition, becoming speedily very offensive to the smell. • In some instances, says Prout, the urine, on standing awhile, "throws up a sort of creamy matter upon its surface." The general symptoms which accompany this affection, after it has continued long, and is violent, do not differ materially from those that attend diabetes mellitus. In violent cases, the thirst becomes very tormenting, the appetite craving, and the skin dry and harsh, with progressive emaciation. In less aggravated cases, the constitutional symptoms are generally mild, and in some in- stances scarcely perceptible. The patient, however, generally complains of some degree of uneasy feeling in the pracordium, and a sensation of languor and feebleness in the muscles of the loins. I have seen two cases, in relaxed, debilitated, and emaci- ated females, in which the urine seemed to consist almost wholly of albuminous matter, mixed with a small portion of chyle In both these cases, the urine changed to a jelly-like mass after standing an hour or two. Prout has given an account of a similar case. « 1 he first specimen of urine, voided in the morning;," he says, "consisted of a solid jelly-like mass or coagulum, oflpale- ^™H°T.r « The SeC°nd Specimen' voided5after breakfast, resembled the first in its general character, but exhibited a whey or slightly milky colour. The third specimen, voided in the evening, after an early dinner, was the most remarkable, and so closely resembled chyle in all respects, that it could scarcely be distinguished from this fluid. Buuwsiy ue Causes.— No age, it seems, is wholly exempt from the forma- lonof chylous urine although it occurs mort commonly after odrS^Chod HllfG't"" " PerS°nS °f an ™ble habftof »»«), and impaired digestive powers from a previous course of 398 DIABETES INSIPIDUS. free indulgence in the pleasures of the table, and in spirituous drinks. The exciting causes appear to be such chiefly as have a tendency to weaken and irritate the kidneys. Violent passions of the mind, and protracted courses of mercurial remedies, are also accounted among the ordinary exciting causes of this disease. Prognosis.—This complaint is not attended with much danger, and in its milder form may continue for many years without producing any very serious consequences. In the more aggravat- ed cases of chylous urine, however, a great degree of languor and emaciation sooner or later ensues; and life is ultimately de- stroyed, either by the supervention of hectic, or a gradual and total exhaustion of the vital powers. One of the above named cases, that came under my notice, terminated in phthisis pulmo- nalis. The last variety of urinary disease I have to mention, is that in which there occurs an excess of the earthy phosphates in the urine. This affection is by far more common and distressing in its consequences, than either of the two preceding urinary com- plaints. Prout is, I believe, the first writer who has given a de- finite and circumstantial account of the phenomena and character of the urinary affections, characterized by a deposition of earthy phosphates. A preternatural copiousness of urine forms, in ge- neral, a conspicuous circumstance in this variety of the disease. In some instances, indeed, the quantity discharged is not inferior to that which occurs in the most perfect cases of diabetes. The urine is invariably pale-coloured; and, in many instances, it is perfectly colourless and pellucid. When this is the case, the quantity discharged is always very profuse, and it deposites no sediment on being left to cool. Occasionally it happens that the quantity of urine is not much greater than natural; and, in this case, it is usually somewhat opaque, and deposites a very copious pale-coloured sediment after standing awhile. In none of the kindred affections, already considered, does the urine manifest so great a tendency to decomposition as in the present complaint. In a very few hours after being voided, it becomes alkaline, and emits an extremely pungent and disagreeable smell. Connected with these morbid conditions of the urine, there always exists very great irritability of the general system, and an obvious de- rangement of the digestive functions. The patient is tormented with flatulency, nausea, costiveness, or diarrhoea; attended with a sense of weight and oppression after taking food; and variable and capricious appetite. "The stools are extremely unnatural, being either nearly black or clay-coloured, or sometimes like yest These are always accompanied by more or less of a sen- sation of pain, uneasiness, or weakness in the back and loins. There is a sallow, haggard expression of the countenance; and as the disease proceeds, symptoms somewhat analogous to those DIABETES INSIPIDUS. 399 of diabetes begin to appear—such as great languor, depression of spirits, coldness of the legs, complete anaphrodisia, and other symptoms capable of extreme debility." (Prout.) Prout, to whom I am indebted for the foregoing description of this affection, asserts, that "a large proportion of the cases which have come under his own observation, were distinctly traced to some local injury of the back—such as a fall from a horse, &c." Among the general causes, he enumerates protracted depressing passions ; excessive fatigue. The most common local causes, besides the one already mentioned, are, some irritation about the bladder, or urethra, especially when of a chronic cha- racter—" such as a foreign substance introduced into the bladder, including all sorts of calculi; the retaining of a bougie or catheter in the urethra; strictures of the urethra in particular constitu- tions ;" and disease of the prostate gland. When injury of the spine is the exciting cause of the disease, the prognosis may, in general, be regarded as unfavourable. Prout observes, that this affection "very rarely gives origin to calculus in the kidneys." Treatment for diuresis with excess of urea.—Experience has shown that tonics, in union with opium and alkalies, constitute the most useful remedies in this variety of the disease. From one to two grains of quinine, with from twenty to thirty grains of the bicarbonate of soda, may be given three times daily, and an opiate administered in the evening. Much advantage may also be obtained from alterative doses of mercury. Three or four grains of blue pill, with one or two grains of ipecacuanha, should be given every other evening, or smaller doses may be given every evening. Gentle purgatives, too, are useful in this variety of the complaint. A mixture of magnesia and rhubarb will, in general, answer better than any other aperient in cases of this kind. The diet should be simple, unirritating, and di- gestible ; and all kinds of stimulating drinks must be avoided Some benefit will occasionally result from the use of lime-water and milk, in conjunction with the remedies just mentioned • but the principal object should be to establish the healthy action of the liver and digestive organs. In diuresis attended with an excess ofphosphatic salts in the urine, opium, according to the experience of Dr. Prout is de- cidedly the best remedy we possess. The great object n this variety of the disease, is to allay the general irritability which s so Prominent a symptom in this affection. Where opium is ob- jected to by the patient, we may resort to the use of hyoscyamus in union with uva ursi, with considerable advantage. Two or hree grains of the extract of hyoscyamus, with from twenty to hirty grains of pulverized uva ursi, should be given tvvke or three times daily, according to the urgency of ^^J 400 DIABETES INSIPIDUS. I have, in several instances of this disease, employed the follow- ing pills with a most excellent eftec}.* Mr. Prout mentions a strong infusion of the alchimilla arvensis as a very useful reme- dy for the purpose of allaying the irritability of the bladder. When the irritability of the system is in some degree moderated by the narcotics just mentioned, tonics are more particularly pro- per—and of this class of remedies, the mineral acids, in conjunc- tion with cinchona or quinine, are decidedly, the most valuable in this affection. The nitric, or nitro-muriatic acid, diluted in water, should be freely administered, and continued until the character of the urinary deposite is changed. When the mine- ral acids are disagreeable to the stomach, the citric acid may be employed ; but this latter is not, in general, equal to the nitric, or nitro-muriatic acids. From one to two drachms of these acids, diluted in a sufficient quantity of water, may be taken daily. The diluted acid should be sucked through a glass tube or quill, to prevent the teeth from being injured. Ten grains of the ex- tract of hyoscyamus may be dissolved in a pint of water, to which a drachm of the nitric acid is to be added, and which may be used in divided doses during the day. At the same time that acids are employed, it will be proper to keep down the general and local irritability, by the use of opium or hyoscyamus ; and after the phosphatic condition of the urine has been, in a great measure, removed, by the use of the acids, quinine and iron, in full doses, constitute the principal remedies. Dr. Venables strong- ly recommends the use of the phosphate of iron in this affection. He asserts, that it seldom fails to lessen the quantity of urine dis- charged. Some benefit may also be obtained from local applications of a stimulating character to the loins—such as plasters of Burgundy pitch, galbanum, turpentine, or stimulating embrocations. Active purgatives are injurious. Prout states, that he has known the most serious consequences brought on by a small dose of calomel, which, by inducing diarrhoea, and consequent debili- ty, aggravated all the symptoms. Nevertheless, costiveness is almost equally injurious, and particular care should be taken to keep up a regular action of the bowels. This may, in general, be accomplished by the use of two or three Seidlitz powders, or small doses of castor oil, without the risk of inducing frequent and debilitating stools. Prout says, that mercury, in all its forms, is calculated to do much harm ; and all alkaline remedies must be rigidly avoided. . The diet should be mild and nutritious. In general, the lean • $. Extract, hyoscyam.---- Pulv. camph. aa ^ss. Mucilag. g. arab. q. s. . M. Divide into thirty pills. S. Take one four times daily. DIABETES INSIPIDUS. 401 parts of tender meats afford the best food for patients affected with this variety of urinary disease. In some instances, however, a diet of this kind, from the very irritable state of the general system, renders the patient very uncomfortable during the period of digestion. In such cases, farinaceous, and particularly aces- cent vegetable articles of food, will usually answer very well. Sect. III.—Lithiasis. There Is no subject in pathology which has of late years been more patiently and minutely investigated, than the secretion of sabulous matter with the urine, and its formation into calculous concretions. The latest and best works on this subject, are those of Dr. Marcet, Mr. Brande, and Dr. Prout; and it is to the ex- cellent treatise of the latter that I am chiefly indebted for the following facts and observations. Urinary deposites.—There are three forms of urinary depo- sitions, namely: 1. Pulverulent sediments—appearing on the sides and bottom of the vessels in which the urine is left to cool, in the form of a very fine sedimentous powder. These pulverulent depositions are usually of a red colour, inclining sometimes to a brown, and at others, to a yellow hue. In a general way, they may be stated to consist of two classes of calculous matter—namely, the lithates of soda, ammonia, and lime, constituting what are usually called, lateritious or pink sediments; and the phosphates of lime, mag- nesia, and ammonia, constituting the white sediments. These sediments exist in a state of solution in the urine, and are depo- sited only when it cools, or an acid is added. 2. Crystallized sediments, called gravel or sand, consisting of minute, irregular grains, suspended, not dissolved, in the urine; and of course sink to the bottom of the vessel almost as soon as the urine is voided. They consist of lithic acid nearly in a pure state; or of a triple combination of phosphoric acid, magnesia, and ammonia; or finally, of oxalate of lime. The first are red, the second white, and the third of a dark blackish green colour.' These different varieties of gravel are never voided together in the same urine, though in the pulverulent state the two former often occur in union with each other. 3. Solid concretions.—These result from the gradual agglo- meration of the two former varieties—forming what are termed urinary calculi. Of these concrete masses, Prout mentions thir- teen varieties; but a description of these does not properly come within the scope of the present work, the general pathology and remedial management of the different lithic diatheses, being the Vol. II. 51 ° 102 LITHIASIS. objects to which the attention of the physician is more particu- larly called. In relation to the comparative frequency of the different varie- ties of urinary deposites, it appears from the data collected by Dr. Prout, that the lithic acid predominates in more than one-third of the whole number of urinary calculi; and it has moreover been ascertained, that lithic acid very generally constitutes the central nucleus, even in the other varieties of calculi. It would seem, therefore, that the deposition of lithic acid must be considered as the primary process in the formation of urinary calculi; and that the phosphate and oxalate formations are the result of a gradual transition from the lithic acid, to the phosphatic or oxalic diathesis. In the progress of this transition, the lithic acid depo- sition is in the first place changed into the lithate of ammonia, with a loss of the tinge derived from the colouring principle of the urine. After some time, this latter gives place to the deposi- tion of sediment, composed chiefly of carbonate and phosphate of lime, and this is finally succeeded by the phosphates of lime and magnesia, in combination with ammonia. It is a curious cir- cumstance in the pathology of lithiasis, that although the deposi- tion of lithic acid or its compounds is very frequently followed by the phosphatic and earthy deposites, yet " it may be laid down as a general law, that in urinary calculi, a decided deposi- tion of the mixed phosphates is never followed by other deposi- tions." Notwithstanding the various forms and appearances which uri- nary calculi present, they may be classed under four heads, accord- ing as one or the other of the following elementary substances predominate ; namely, 1. the lithic acid and its compounds ; 2. the oxalate of lime ; 3. the cystic oxide ; and 4. the earthy phos- phates. The abnormal conditions of the system which give rise to the secretion of these lithic substances, are with propriety dis- tinguished as peculiar diatheses; and we accordingly have the lithic acid diathesis—the phosphatic diathesis—the cystic oxide diathesis—and the oxalate of lime diathesis, as the four cardinal points of attention in the pathology of lithiasis. 1. Lithic Acid Diathesis. The urinary -sediments which belong to this diathesis, are cither pulverulent or crystallized. When the former is the case, they consist of some combination of this acid with an alkaline basis, generally ammonia ; but when the depositc is crystalline, it consists nearly of pure lithic acid. These amorphous sediments may be classed under three heads, LITHIASIS. 403 corresponding to the colour which they possess, namely: the yellow, the red or lateritious, and the pink sediments. The yellow depositions, varying from almost a white to a brown colour, consist of the lithate of ammonia tinged by the colouring matter of the urine. These are the sediments which occur in the urine of healthy, or slightly dyspeptic individuals, but when they occur in abundance, they indicate a tendency to an excess of lithic acid audits consequences. Children are most subject to the yellow lithates in the urine. The red or lateritious, varying from nearly a white to a deep brick-red colour, consists, like the former variety, of the lithate of ammonia, and sometimes of lithate of soda ; deriving their red colour partly from the purpurates of soda and ammonia, and the colouring matter of the urine. The presence of the red colour of these depositions, or rather of the purpurates upon which this colour depends, may be regarded as a certain indication of a febrile or inflammatory condition of the system. To this, says Dr. Prout, " I have never seen a decided exception." In gene- ral, the deeper the colour or redness of the sediment, the more decidedly phlogistic is the condition of the system. The pink sediments are much less common than the other two amorphous sediments belonging to this diathesis. "Like the other two varieties, they consist essentially of the lithate of am- monia, but they derive their colour exclusively from the pur- purate of ammonia. The pink sediments are most apt to occur in chronic visceral inflammation, particularly hepatitis ; and we frequently meet with it in dropsy, hectic fever, and in the more aggravated forms of dyspepsia. The sediments which occur in he sweating stage of remitting and intermitting fever, and during he favourable crisis of gout, rheumatism, and other febrileaffec? tions, are of the lithic acid kind. iW says, that in three fn. theTrine? "" * ^^ WhUe Ufhatoot S°da ^posited to Of the causes which favour the excessive secretion of lithin acid or its compounds.-The circumstances which te^nd to nro duce a redundancy of lithic acid sediment in the urine mcteo™" «^r^r1 {t\~?and feb/iie ^tiontc; u. j.rrors maiet.—lhe mere excess of wholesome fn„j heavy md.gesuble, irritating, or unwholesome artices of 21 '' lakmg full mca s at unusual hours • ;„ d™( ,"' let; deranges the digestive power, will 2, ' "hateVer resists °r .ition'of the litlfate rf EST'WtZT'Z"" 'V1*0- tte^^^^ Rented bread, --^ZJSjSa^^ b. Excessive „„,/ ^usnal corpm„, m,l mtntal a.„liun^ 404 LITHIASIS. or want of exercise, are accounted among the exciting causes of the lithic depositions in the urine. c. Debilitating circumstances.—Whatever is capable of di- minishing the vital energies, has a particular tendency to give rise to urinary depositions of this kind. The depressing pas- sions, want of nourishment, great fatigue of body or mind, &c. seldom fail to induce these sediments in the urine. d. I have already referred to the frequency of the lithic acid sediments, in the urine of persons labouring under fevers of an inflammatory character ; and particularly during the critical per- spirations which occur in gout, rheumatism, intermitting and hec- tic fever, and in acute and chronic inflammation of the liver, as well as in various other affections attended with a phlogistic dia- thesis. In aggravated cases of dyspepsia, these urinary'deposi- tions are rarely wholly absent. With regard to the exciting causes of the crystallized depo- sitions, or the excess of uncombined lithic acid in the urine, dif- ferent opinions have been expressed by the late writers on this subject. According to Majendie, the excessive secretion of this acid in the urine is very particularly favoured by articles of food that contain an abundance of azote, and, therefore, especially by animal food. This opinion is predicated on the facts, that azote enters into the composition of lithic acid, and that animals con- fined to food destitute of azote, produce no lithic acid, whilst those which live almost exclusively on animal food (which contains an abundance of azote) secrete large quantities of pure lithic acid. Notwithstanding these plausible facts, later experiments and ob- servations have afforded abundant evidence, that the formation of this urinary acid is independent of the quantity of azote intro- duced with the aliment, and that there are numerous other circum- stances which favour or oppose its secretion by the kidneys. From a series of experiments performed by Dr. Philip, with the view of elucidating this subject, he draws the following conclu- sions : " 1. That acid and acescent ingesta tend to increase the de- position of lithic acid from the urine, and to prevent that of the phosphates. " 2. That a diet composed of a large proportion of animal food, tends to lessen the deposition of lithic acid, and to increase that of the phosphates. " 3. That every thing which promotes the action of the skin, tends to prevent the deposition of lithic acid, and to occasion that of the phosphates. " 4. That dyspepsia tends to increase the deposition of lithic acid, and to lessen that of the phosphates, both by producing aci- dity of the primae viae, and by rendering the skin inactive. ft 5. That indolence has the same tendency, both by inducing LITHIASIS. 405 dyspepsia, and by lessening the activity of the skin in proportion tZy,TZLonderMe degree, the influence of thei ordinary causes of an excess of lithic acid in the urine, as well as the con- ttofonal symptoms which attend the active state of this diathe- sis TL,chilPdrenbornof gouty and dyspeptic parens, "are exceedingly liable to lithic acid deposites in the urine. Such children Ire very apt to manifest a frequent desire to pass urine, with very small discharges, and evident pain or uneasiness during and immediately after micturition. If on examination the urine is found to be charged with this sediment, immediate means should be used to counteract the diathesis, " as there is much greater risk at this period of life than at any other, of the forma- tion of stone in the bladder." There seems to be less disposition to form lithic acid deposites between the ages of puberty and forty, than at any other period of life. There is less risk too, says Prout, of the formation of urinary calculi between the ages just mentioned, than at other periods; for except in cases attended with an extremely copious secretion of this acid, it generally passes off entirely with the urine, in the state of gravel. Between forty and forty-five years of age, the constitutional habit of body, in most individuals, undergoes a considerable change; and concomitantly with this change, the lithic acid dia- thesis is frequently very strongly developed. Not only do we, in general, find persons who have passed this stage of life secrete much larger quantities of lithic acid, or its compounds, than pre- viously, but there appears to be a manifest disposition in the con- stitution at this period, " to separate the acid in a concrete state, —thus giving origin to the formation of renal calculus," and the consequent train of various distressing secondary symptoms. The general symptoms which usually accompany an excessive secretion of lithic acid, are—pain and uneasiness in the region of the kidneys; a sensation of irritation and heat at the neck of the bladder, and in the urethra; a frequent desire to void urine, " which is passed in small quantities at a time, and without afford- ing the usual relief, the sensation still continuing as if some urine were left behind in the bladder." Dyspeptic symptoms—par- ticularly acidity and flatulency in the primae viae, are among the most common symptoms of the lithic acid diathesis. * Medicul Transact, of the College of Physicians of London, vol. vi. ait. 9. 40G LITHIASIS. 2. Phosphatic Diathesis. The phosphatic deposites from the urine arc generally amor- phous, though occasionally they appear also in a crystallized form. The deposition of the phosphates rarely occurs as an ori- ginal affection, being almost universally consequent " to the other forms of urinary deposition, and more especially the lithic acid and oxalate of lime." The crystallized phosphatic sediments consist, almost univer- sally, of the triple phosphate of magnesia and ammonia. In con- nexion with the appearance of this sediment in the urine, which is of a yellowish white colour, the patient generally complains of dyspeptic symptoms, general nervous irritability, some pain and uneasiness in the loins, lassitude, and want of mental energy. The urine is generally copious and pale, and when suffered to stand awhile, becomes covered with an iridescent pellicle, con- sisting of minute' crystals of the ammoniated phosphate of mag- nesia. The urine is very apt to enter into the process of decom- position, and to become alkaline and putrescent. Sometimes this crystallized deposite is formed immediately after the urine is void- ed ; but more commonly the crystals do not appear until the urine has become cool, or begins to putrefy. The amorphous phosphatic sediments are always composed of a mixture of phosphate of lime, and the triple phosphate of magnesia and ammonia—the former constituting by far the great- er proportion. Some writers of eminence maintain that these sedimentous matters are not separated from the blood by the kid- neys, but wholly and exclusively by the inner coat of the blad- der, from a peculiar morbid condition of this structure. Prout admits that the phosphate of lime is sometimes derived, in part, from the mucous membrane of the bladder—but he doubts, "if any portion of the triple phosphate is ever derived from this source," the kidneys being, according to his observation, the only source from which it proceeds. The general symptoms which accompany an habitual and copi- ous deposition of the amorphous phosphates from the urine, are often peculiarly distressing. The general system, both physical and mental, is almost always extremely irritable ; and great de- rangement of the digestive organs, manifested by flatulency, nau- sea, constipation, or exhausting diarrhoea ; extremely variable and unnatural stools—being black, or whitish, and sometimes resem- bling yest—accompanied with a dull aching pain, and a peculiar feeling of weakness in the loins. The countenance, in aggravat- ed cases, becomes sallow and haggard, "and as the disease pro- ceeds, symptoms somewhat analogous to those of diabetes ensue, such as great languor and depression of spirits, coldness of the LITHJA6IS. 407 legs, complete anaphrodisia, and other symptoms of extreme de- bility." The urine is pale and often very copious. With regard to the causes of the urinary sediments, composed of phosphates, writers have expressed some difference of opinion. Dr. Marcet, and M. Brande, maintain that the use of alkaline remedies, when continued for some time, has an especial tendency to give rise to the phosphatic depositions, and this opinion has been particularly acted on in the remedial treatment of urinary disorders of this kind. Dr. Prout, on the contrary, considers this tendency of alkaline remedies as very trifling, and scarcely worth attention, either in an etiological or therapeutic point of view. The occasional causes of the present variety of urinary deposites, are either of a local or general character. Injury of the back, as a blow or fall, says Dr. Prout, is a very common source of this affection ; and its occurrence is also particularly promoted by excessive fatigue, and the protracted influence of debilitating mental emotions. Irritations about the neck of the bladder or urethra, from whatever source they may proceed, particularly when operating for a considerable length of time, have an especial tendency to give rise to the secretion of phos- phatic sediments, and hence the presence of a small uric calculus in the bladder very frequently becomes surrounded by a mass of urinary phosphates—so as to present the character of a phospha- tic calculus externally, whilst its central portion, or nucleus, con- sists of lithic acid, or of the lithate of ammonia. Treatment. Treatment for the lithic acid diathesis.—-To counteract the excessive secretion or formation of lithic acid depositions from the urine, our principal aim must be to establish the healthy action of the digestive organs. For this purpose, we must in the first pace adopt proper dietetic regulations; for without an especial attention to this point, little or no benefit will be deriveTfrom any remedial measures. The patient must be put on a nlai™ digestible and nourishing diet, and be particularly cautioned against taking very full meals. "An error in quaLTvisuf SfTi-iW SayS Dr- Prout> "ttoWinf hty of the diet" Indigestible, mixed, and irritating articles of food, particularly fresh and unfermented bread solid f^Vn ssn sa;Ued and dried meats' ^Sr^Ss and acescent aliment must be carefully avoided -e,in^-r:rsr&^^s 408 LITHIASIS. vegetable tonics, are particularly beneficial. One of the follow- ing pills may be taken every second or third evening, until the hepatic and intestinal functions are restored to a healthy condi- tion. * If they do not procure one or two full evacuations on the following morning, a small dose of magnesia, or one or two Seidlitz powders, may be taken, to promote their operation. The regular use of alkaline remedies is an important measure in the remedial management of this diathesis. From fifteen to twenty grains of magnesia, taken in a glass of soda water, will often an- swer this purpose very well. The sal aeratus (potassae aerata,) too, is an excellent alkaline in such cases.t From one to two drachms, dissolved in a few ounces of a very weak infusion of colomba or gentian root, may be taken once or twice daily. Twenty or thirty drops of the liquor potassae may also be em- ployed. It appears from the experiments and observations of Dr. Philip, that the regular action of the cutaneous exhalents tends very con- siderably to lessen the deposition of lithic acid from the urine; and he observes, that the lithic acid is much more effectually thrown off by the cutaneous exhalents, when merely the insen- sible exhalation is augmented, than when the sensible perspira- tion is increased. The action of the skin should therefore be duly supported by regular exercise, the occasional use of the warm bath, small doses of the pulvis antimonialis or tartar emetic, and the wearing of flannel next the skin.J Prout says, that warm sea-bathing is sometimes "particularly beneficial, though occa- sionally the gravelly deposite seems to be increased under its use;" which latter circumstance he ascribes "to the use of the hard waters that generally prevail along the coast;" for the use of such water is especially injurious in the lithic acid diathesis. * R. Mass. pil. hydrarg. gi- G. aloet. sacc. gr. xvi. Tart, antimon. gr. iss.—M. Divide into 16 pills.—Or, R. Calomel gr. iv. Pulv. antimonialis gr. vi. Extract, colocynth. compos, gr. vi. Extract, hyoscyam. gr. iii.—Divide into 4 pills. Take one at bed-time, twice or thrice a week; and followed the next morning by an active dose of the sulphate of magnesia. - j- This preparation is made by dissolving half a pound of the sub-carbonate of potass in ten ounces of water, adding two ounces of sub-carbonate of ammo- nia; after it has effervesced, it is crystallized. $ Dr. Philip observes, that "the effects of Dover's powder on the urine are transitory, apparently ceasing as soon as the sweat ceases to flow. But those of the tartrate of antimony may generally be perceived for several days after it is taken, during which it still seems to lessen the tendency of the urine to deposite lithic acid. I have also repeatedly observed, that the deposition of lithic acid was not so effectually prevented by tartrate of antimony when it produced nau- sea, as when no sensible effect was experienced from it."—Loc cit. p. 202. LITHIASIS. 409 In cases accompanied with a general irritable state of the sys tem, or with much irritation in the urinary organs, narcotics should be used—particularly opium and hyoscyamus. Although a regular action, and even a moderate degree of looseness of the bowels is very desirable in the management of this affection, yet care should be taken, not to employ very active purgatives. About the age of forty, a particular tendency is apt to occur to rid the system of the cause of constitutional irritation in this dia- thesis, in consequence of which, the kidneys secrete an unusual quantity of lithic acid, "and by this process give great relief to the system at large." It is thus that diuretics are often highly serviceable at this period of life; which, favouring the secretion of large quantities of lithic acid, and thus causing a kind of artifi- cial crisis—frequently give great relief to the constitution. Prout says, that muriatic acid, in union with opium, will often answer very well for this purpose; and Dr. Henry has known a combi- nation of turpentine and laudanum to " bring away several ounces of* lithic acid in the course of a day or two." For this purpose we may also have recourse to various vegetable diuretics with occasional benefit—particularly the infusion of monarda punc- tata, of erigeron heterophyllum; alchemilla arvensis: sem. daucus carota, and of galium aparine. When the kidneys are in a state of high irritation or inflammatory excitement, these diuretics must be employed with great caution; and it would seem, also, that they are "not adapted to any other species of deposite than crystallized lithic—nor even to this form of the disease, when it occurs in very young or very old subjects." In what is usually called a fit of the gravel—an affection which "consists in the secretion of a large portion of lithic acid by the kidneys," preceded, as well as accompanied, usually, by general constitutional irritation and febrile movements, the treat- ment does not differ materially from that which has already been described, "except that it must be more active." Thus vene- sect.on, cupping, or leeching from the region of the kidneys, and active mercurial purges with antimonial powder, ought to be efficiently employed before diuretic remedies are prescribed The warm bath, or warm fomentations applied to the loins, in con junction with the less stimulating diuretics just mentioned, with the addition of colchicum, will seldom fail to procure considera- Jft ".h * V^ antiPhl°Sistic «*i»»en is indispensable, and after the attack is over, the patient should adhere strictly to the dietetic rules mentioned for counteracting the lithic diathesis Treatment proper in the phosphatic diathesis.-lt wa^be- fore^ stated, that a peculiarly irritable state of the system fs one o the most constant, and in general the most distressfng cirCum T^tZfXU{ ^^ completely developed form of Z^pZ^a- ticdiathesis. An important indication, therefore, is to diminish 410 LITHIASIS. this unnatural irritability, and to restore the general health of the system, at the same time that measures are adopted to correct the morbid condition of the urinary organs. Opium, according to the experience of Dr. Prout, is the only beneficial remedy for allaying the morbid irritability of the constitution; and it should be given in large and repeated doses—from one to five grains three times daily, according to the urgency of the symptoms. After the irritable state of the system has been, in some degree, reduced by the use of this narcotic, recourse should be had to tonics—particularly to the mineral acids, cinchona, the ferrugi- nous preparations, uva ursi, &c. The acids are not only benefi- cial by their general tonic influence, but they tend also, in a di- rect manner, to lessen the alkaline character of the urine. Where the mineral acids disagree with the stomach, the citric acid should be used. Local applications to the region of the kidneys—such as a large pitch, soap, or galbanum plaster; and in very severe cases, setons or issues in the back, will often assist considerably in mitigating the violence of the symptoms. Active purgatives are apt to prove injurious: and those saline purgatives that contain a vegetable acid, are said to be particularly improper in this affection. " Mer- cury in all its forms, especially when pushed so far as to produce its specific effects on the constitution, seems capable of doing a great deal of mischief." If small alterative doses of this medicine are indicated, they should be given in union with opium. All alkaline remedies must be strictly avoided, and diuretics of every kind are almost equally improper in the phosphatic diathesis. Hard waters, used as drink, "are literally poison in this form of the disease." The drink should be distilled, or the softest water that can be procured. In moderate cases, where the irritation is chiefly confined to the urinary organs, hyoscyamus in union with uva ursi, with an occasional small dose of opium, should be administered. In cases of this kind, I have known much benefit derived from taking from half a pint to a pint of a weak infusion of the monarda punctata during the day. Prout speaks very favourably, in the slighter cases of this affection, of the employment of the infusion of alchcmilla arvensis. The diet should be digestible, mild, and nourishing—such as the lean parts of the most tender kinds of meat. Some writers direct the use of an acescent vegetable food, but Dr. Prout is in- clined to prefer an animal diet. Much, of course, will depend on the state of the stomach, in relation to the propriety or im- propriety of these different kinds of food. When the irritation of the mucous membrane is great, animal food will be found too stimulating ; and, on the other hand, the greater digestibility ol this kind of diet renders it decidedly proper where the digestive LITHIASIS. 411 powers are weak, with an absence of mucous irritation of the sto- mach. A tranquil state of the mind has a most important curative influence. "The influence of mental anxiety," says Dr. Prout, " is really astonishing in this disease; and absence from care, the exhilarating air of the country, and such exercises as are consist- ent with the patient's condition, will, perhaps, more than any thing else, contribute to the cure, particularly in the slighter cases, and when the cause is not local injury." Sect. IV.—Ischuria Renalis. Suppression of urine is always a very formidable affection, whether it occurs as an idiopathic malady, or secondarily, in the course of other diseases. This affection must not be confounded with mere retention of the urine. In ischuria the functions of the kidneys are more or less suspended or destroyed, the secre- tion of urine being either morbidly diminished, or entirely sup- pressed In retention of the urine, on the other hand, the urine is regularly secreted by the kidneys, and conveyed into the bladder; but from some cause or other, an inability to evacuate it occurs, and being thus retained, it gradually accumulates, un- til, in some instances, the most distressing, and even fatal conse- quences occur. Ischuria renalis may be partial or complete. In the former case, very small portions of urine are, from time to time, dis- SEin^Th? !adfe\und- Wtom. often extremely distressing The patient is harassed with a very frequent desire to pass off the urine, accompanied with more or less uneasiness in soT' "^ 3 ^"t °f dul1' h™y wei§ht in th* iHac regbna^ oweTpToTthTat^10 ^ tTderneSS thr°USh0Ut the whSe n,nl,P •*• abdomen, together with great anxiety of feeling nausea, vomiting, and occasionally hiccough. In almo tallb? p"^ "leM -here the suppression pression of urine is nnt h„..,J , tbe kldn«ys- Sup. Painful SymptoS^-i,tmen«onTe7 MyS attended «* the periences neither £Zr weil 1"*°™ '^' ',he Patient «- 412 ISCHURIA RENALIS. related five instances of this kind.* Cases of this kind, would seem to depend on total paralysis of the kidneys. Whatever may be the immediate cause of the suppression, or with whatever phenomena it may be accompanied in its early stage, symptoms of cerebral oppression never fail to ensue, if the disease continues for two or three days, and often in the course of thirty hours, if the urinary secretion is not in some degree restored. Indeed, one of the most singular circumstances attending this disease, is the inevitable tendency to coma and effusion in the brain. In complete suppression, depending on paralysis of the kidneys, where little or no uneasiness is experienced in the abdomen or urinary organ, the patient, in the course of the second or begin- ning of the third day, begins gradually to sink into coma, and finally dies in a state of complete stupefaction. Mr. Abercrombie, in an interesting paper on this affection, has related five cases, all of which terminated in this way. t Where inflammatory action of the kidneys is the proximate cause of the suppression, the co- ma is frequently preceded by delirium, and convulsions some- times finally ensue. I have already adverted to the strong urinous smell of the per- spiration which occurs in the latter periods of this complaint;}: and it appears from various cases that have been published, that a vicarious secretion of urine sometimes, though indeed very rarely, takes place from particular organs or parts—more especi- ally from the umbilicus. Dr. Hastings has related a most inter- esting case of ischuria renalis, in which, many days after the commencement of the disease, considerable quantities of urine were discharged from the umbilicus, for three days in succession* Dr. Hasting! refers to some of the older liters for accounts of similar cases Schenk relates two instances of this kind; and a caTe is recorded by Sennertus, as having occurred under the observation of the celebrated Platerus, in which, in consequence of a otal inactivity of the kidneys a urinous fluid^ was coP-u y discharged from the right ear.H Instances of his complaint are 2E3d£ in whict a fluid resembling urine was copiously • OntheNecessityofCautioninthe Estimation of Symptoms in the last SUje of some Diseases. .. 1ft91 s Midland Medical Reporter, No. 4. .„„msa per multa) die' !"]T' | One of these cases « u> 'f^t^^lSb-vi. de UrinfcP- ™. urina tandem per nmbilicum urmam proflmt. una. a. TCI** SSS- nat. tredecin, g^ZgZgZS.t Jito —. -2££."S£ EST*- *■ >^- ISCHURIA RENALIS. 413 discharged by vomiting, and by stool. Vallsneri has given an account of a case of ischuria, in which copious discharges of a urinous fluid occurred from the stomach. Water is always found more or less abundantly effused into the cavities of the brain, and has, in general, a very perceptible urinous smell. Causes.—The immediate cause of suppression of urine may be either inflammation, or paralysis of the kidneys, or mechanical obstruction. Nephritis is always attended with a greater or less suppression of the urinary secretion; but as both kidneys are very rarely inflamed at the same time, there is, in general, a sufficient quantity of this excrementitious fluid separated from the blood, by the sound kidney, to obviate any particular danger from this source. Of course, whatever is capable of causing much irritation, or inflammation of the renal organs, may become the remote cause of this affection. Schenk relates a fatal case, which was caused by a blow on the loins; and on post mortem examination, a con- siderable abscess was discovered between the muscles contiguous to the kidneys. Laelius a Fonte has recorded a case, in which the left kidney was gangrenous; and in several cases related by Hildanus and Bonetus, the kidneys and neighbouring parts were extensively inflamed.* The suppression of haemorrhoids and of the menses has been known to give rise to this affection; and its occurrence from gouty irritation has been frequently noticed. Dr. Prout observes, that when there are no signs of renal inflamma- tion present, "and the patient has been subject to gout, or if a female, to hysteria, the ischuria may be supposed to depend, in part at least, on spasm." The healing up of old ulcers, has also given rise to total suppression of the urine. A very remarkable case of this kind is related by M. Dupont, physician to the Hos- pice de Gournay, in which a lady had an ulcer on one of her legs of twenty-five years continuance, which was rapidly heal- ed by an ointment. Soon after the ulcer was cicatrized, she was seized with pains in the abdomen, attended with nausea, some ever, red and dry tongue, and abdominal distention. Almost total suppression of urine speedily ensued. After a few days con- tinuance and ineffectual treatment, a blister was applied over the cicatrix of the ulcer, which had the effect of speedily freeing he patient of her disease. The sudden application of cold to the body, particu arly during the flow of the menses, has occasionally given rise to fatal ischuria. The case related by Hasting men- tioned above was produced in this way; and one of he cases of suppression from renaj paralysis, mentioned by Sir H Sr was excited by the influence of cold, while the patienf was under the operation of mercury. It would seem tW «„»,• ? ■• Abercrombie's Memoir, already referred to. 414 ISCHURIA RENALIS. of the brain or of the nerves, without any immediate connexion or dependence on inflammation. " The presence of a mechanical cause may be suspected," says Dr. Prout, "when the person has been previously subject to calculous affections. Generally, how- ever, in this latter case, the effects cannot be ascribed altogether to the simple operation of the mechanical cause, but in part also to the inflammation or spasm, or both, which it is liable to pro- duce, and the affection thus assumes a mixed character." A fatal case of this disease is related by Dr. Teeling, which occurred in a very gouty individual. On post mortem examination, the right kidney wras found diminished in size, and the cavity of its pelvis filled with gray-coloured, rough calculi, about the size of small peas, and the whole internal surface of the kidney was "firmly coated over with a fine gravel, resembling pulverized free-stone." In the upper part of the ureter, belonging to this kidney, a cal- culus was found as large as a small almond, " which blocked up its cavity." Some calculi were also found in the pelvis of the left kidney. Prognosis.—The prognosis in ischuria, is always extremely unfavourable. So long as the suppression is not complete, a reasonable hope may be entertained of an eventual recovery ; for even a small secretion of urine by the kidneys, will in gene- ral keep off the more alarming symptoms of cerebral oppression for a considerable time, and give greater opportunities for subdu- ing the renal affection. When the suppression is complete, the disease almost always terminates fatally in the course of four or five days, and often as early as the third day. Sir Henry Hal- ford, in the paper already quoted, states, as the result of his observations, that a complete suppression of the secretion of urine cannot continue beyond three days without terminating fatally. This, however, is incorrect. Dr. Laing has related an instance where the secretion of urine was suspended for nine days, and nevertheless terminated favourably ;* and Dr. Brown mentions one case in which the secretion was suspended for six days and six hours, and in another, the suppression continued eleven days, yet both patients recovered.t A very extraordinary instance of this complaint is described in Hufeland's Journal for August, 1827, in which the action of the kidneys was wholly suspended for seven weeks, without any particular inconvenience, although no urinous fluid was secreted vicariously. Treatment.—The treatment in this affection must be modifi- ed, according to the particular morbid condition of the kidneys, as well as according to the nature of the remote cause. When symptoms of renal inflammation exist, the treatment already point- * Edinb. Med. and Surg. Jour. vol. x. f Essays, &c. on Medical Subjects. See Med. Chir. Rev. Dec. 1828. ISCHURIA RENALIS. 415 ed out for the cure of nephritis should be energetically pursued. Venesection, cupping, leeching, the warm bath, purgatives, emol- lient enemata, sinapisms, and even blistering over the region of the kidneys, constitute the principal remediate measures. In cases attended with no decided manifestations of inflammatory action in the kidneys, diuretics are the means upon which our chief reliance must be placed. In general, stimulating articles of this kind have been found most beneficial—more especially where the disease appears to depend wholly on a torpor or paralysis of the kidneys. Spirits of turpentine, both in the form of injections, and internally in doses of from twenty to thirty drops every two hours, have been employed with a very good effect. When the bowels are constipated or inactive, the turpentine should be giv- en in union with castor oil, in doses sufficient to procure pretty free purging. The remarkable case mentioned above from Hufe- land's Journal, was cured by a mixture of oil of amber, Venice turpentine, and balsam copaiva?, after a great variety of other medicines had been ineffectually used. 1 have seen two cases of incomplete suppression, attended with a somnolent condition, in nervous females, which were removed by a mixture of juniper oil} sweet spirits of nitre, and laudanum.* Mercury has been recommended for the use of this affection, and some interesting cases have been reported, illustrative of its beneficial influence. In the case already referred to, related by Dr. Brown, mercury was freely given, and he states, that very soon after the mercu- rial fetor of the breath was noticed, a pretty copious discharge of urine ensued, and the patient recovered. Valisneri also gives an account of a case which was cured by mercury. In Dr. Laing's case, which, however, was manifestly attended with both local and general inflammatory action, the remedies employed were blood-letting, repeated three times daily, saline diuretics, and the warm bath. Mr. Raymond strongly recommends the application of a large blister across the region of the kidneys. He has related several cases in which the flow of urine soon followed vesication over the loins, after a variety of remedies had been ineffectually employed.t Lieutaud recommends emetics for the cure of ischuria renalis. % * R. Ol. juniper Sss. Spir. nit. dulc. gi. Tinct. opii !ji.—M. Take a tea-spoonful every two hours. \ Med. Obs. and Inquir. vol. v. Appendix. i Nonnullos enim decumbentes et cum morte colluctantes hocce praesidiis tem- pestive adhibito ex orci faucibusereptos vidi.—Synop. Prox. Med. torn. i. p. 269. 416 RETENTION OF URINE. Sect. V.—Retention of Urine. Retention of urine is by no means an uncommon affection ; and though not, in general, so dangerous and difficult of being cured as ischuria, it is often met with under circumstances which ren- der it a most alarming malady. The immediate cause of retention of urine consists, either, 1, in a loss of the expulsive power of the bladder and of its detru- sor muscles; or 2, in mechanical obstruction of the urethra, or neck of the bladder. 1. Paralysis or loss of the expulsive power of the bladder, generally arises from over-distention of this viscus. After the middle period of life, the sensibility of the bladder, in some in- dividuals, gradually diminishes as age advances; and this insen- sibility occasionally becomes so considerable, that the urine fails more and more to impart the due degree of stimulus to the blad- der; in consequence of which it is often suffered to accumulate inordinately, before the desire to evacuate it is experienced. The bladder then, from its torpid and relaxed condition, is incapable of completely expelling its contents, and the action of the abdo- minal muscles is called into aid to effect this purpose. From this deficiency of the expulsive powers, the bladder is not entirely emptied; and more urine is daily left in the bladder, until at last, only a small portion of its contents is evacuated, at each attempt to urinate. Finally, from the occurrence of slight general indis- position from cold, or from some adventitious local affection, as diarrhoea, suppressed haemorrhoids, riding on horseback, fatigue from exercise, &c. a total inability in the bladder, even with the aid of the abdominal muscles, to overcome the ordinary power of the sphincter, ensues, and complete retention of the urine is the consequence. Retention from paralysis is not, however, entirely confined to old people, and may arise from difficult parturition ; blows or falls on the back; injury of the spine ; excessive onanism ; and from paraplegia; and it sometimes occurs in the latter stage of typhus, and other forms of low fever. This variety of the disease is readily distinguished by the fa- cility with which the catheter may be introduced, and by the general course and progress of the complaint. No symptoms indicative of mechanical obstruction of the urethra, or of inflam- mation, precede or accompany the disease. The approach or tendency to the complaint, is indicated by the stream of urine, though sufficiently large, becoming weaker and weaker. The patient is obliged to stand a long time, and to make considerable effort with the abdominal muscles, before the urine begins to flow; and the quantity discharged gradually becomes smaller and RETENTION OF URINE. 417 smaller, whilst the desire to urinate becomes more frequent and urgent. Retention from paralysis of the bladder, is much less alarming and dangerous in its consequences, than when the retention oc- curs from inflammation or obstruction; but it often continues for many months. I have known several instances, apparently of spontaneous occurrence, in which the daily use of the catheter was necessary for three months before the bladder regained suffi- cient expulsive power to discharge its contents. This form of the disease is not in general attended with much distress, unless the urine be suffered to accumulate until the bladder becomes very greatly distended. Indeed, cases sometimes occur, in which the patient is not even aware that a retention of the urine exists; for the bladder may gradually become enormously distended, and give rise to uneasiness, although more or less urine is regularly discharged at each attempt to urinate. Instances of this kind, have even been mistaken for abdominal dropsy; for when the dis- charge of urine, though in diminished quantities, continues, the abdominal distention and uneasiness may, on a superficial ex- amination, be readily ascribed to dropsical effusion. A case is mentioned as having occurred in St. George's Hos- pital, where the patient was thought to be labouring under ascites. Paracentesis abdominis was in contemplation, " when the house- surgeon happened to introduce a catheter, and drew off many quarts of water, with immediate reduction of the abdominal swell- ing."* Similar instances are mentioned in the article on this affection in the Diet, des Sciences Medicates. A woman was supposed to be affected with aseites, and tapping was determined on, at the same time that diuretics were diligently employed: finally, in consequence of the sudden occurrence of complete retention of the urine, the catheter was introduced, and a large quantity of water was unexpectedly drawn off. The abdominal swelling soon disappeared. Another case is related, in which re- tention of the urine was mistaken for dropsy, which, after va- rious measures had been employed ineffectually, was speedily cured by the use of the catheter; and an instance is mentioned in the same work, where the patient died from rupture of the blad- der—the patient having been treated for ascites. Dr. Felici of Milan, has related the case of a woman who considered herself pregnant. She laboured under oedema of the feet; enormous swelling of the abdomen; violent and painful efforts to void urine, which passed off in small quantities; pains in the thighs; dysp- noea ; palpitations ; a sense of suffocation from the slightest mo- tion ; pufliness of the face; frequent pulse; and a dry cough. Under these symptoms she had laboured a considerable time be- Mcd. Chir. Rev. April, 1825.—p. 523. Vol. II. 53 418 RETENTION OF URINE. fore Dr. F. saw her. He suspected retention of urine. The catheter was introduced, and nearly fourteen pints of water drawn off. 2. Retention of the urine from inflammation.—Inflamma- tion of the urethra and bladder is one of the most common causes of retention of the urine, and may be produced by a great variety of causes—such as irritation from calculus ; irritating diuretics, particularly terebinthinate remedies and cantharides ; gonorrhoea ; stimulating injections into the urethra ; the incautious introduc- tion of the catheter or bougie ; the spread of inflammation from neighbouring parts ; an acrid or irritating state of the urine ; the sudden suppression of perspiration by cold ; cold and damp feet; the suppression of hemorrhoids and the catamenial discharge; excessive venery and onanism ; mechanical injuries received on the pubic region or upon the perinaeuni ; general fever and con- stitutional irritation ; metastasis of gout and rheumatism, &c. When the neck of the bladder or urethra is inflamed, the penis is usually somewhat enlarged and tender to the touch, and when the exciting cause consists of calculous irritation, considerable pain is generally experienced in the glans penis. Cases depending on inflammation are attended with severe burning pain in the neck of the bladder, with tenderness to pressure of the perinseum and the parts immediately above the pubis. The desire to void urine is very frequent, and extremely urgent and painful. Fever is an early attendant; and the patient is apt to experience nausea and occasional vomiting. All attempts to introduce a catheter or bougie give excruciating pain. It must, nevertheless, be observed, that the inflammation upon which the suppression depends, is not always seated in the bladder or ure- thra, but sometimes in the parts contiguous to this viscus. Thus, retention of urine may arise from inflammation of the rectum, by causing high irritation,, and vascular engorgement of the mu- cous membrane of the bladder and urethra, or spasmodic con- striction of the urinary passage ; or finally, the inflammation may spread to the detrusor muscles, and destroy their powers of regu- lar action. Chronic inflammation of the mucous membrane of the bladder is very frequently attended with dysury, strangury, and sometimes with retention of urine. Retention from this cause is most commonly met with in old people ; and in such as have laboured under protracted and badly managed gonorrhoea; or in individuals affected with vesical calculi. It may also arise from metastasis of gout and rheumatism; from haemorrhoidal irri- tation, and repelled chronic diseases of the skin. The diagnosis of retention from chronic inflammation and vas- cular engorgement or tumefaction of the mucous membrane of the bladder, is often attended with considerable difficulty. In gene- ral, a sense of tickling and uneasiness is at first experienced in RETENTION OF URINE. 419 the bladder, extending some distance into the urethra. After some time an almost constant gnawing pain is felt in these parts, with more or less difficulty of voiding the urine ; and in some instances temporary incontinence of urine alternates with dysury. The urine discharged contains a large quantity of very viscid mucus, mixed sometimes with considerable portions of purulent matter. In this state, the disease may continue for a long time, with occasional attacks of more or less obstinate and painful re- tention of the urine. In such instances, the whole bladder is usually found, on dissection, contracted, so as not to contain more than half a pint of water, with its coats thickened and indurated, and the internal surface varicose, or covered in parts with con- cretions of the urinary phosphates. Sometimes ulcers of various sizes, warty excrescences, or a pustular eruption, occurs on the mucous membrane. Retention of urine, from causes of this kind, may be distinguished from enlargement or disease of the prostate or stricture near this gland, by the very gradual progress and increase of the difficulty of passing the urine ; and particularly by the slight difficulty which is in general encountered in intro- ducing the catheter ; and, finally, the occasional temporary incon- tinence of urine, which in many instances occurs. Soemmering states, that chronic inflammation, and the consequences just men- tioned, are almost invariably attended with a very peculiar unea- siness and numbness of the thighs, amounting, in some instances, to a state of incomplete paralysis. The prognosis in such cases is always very unfavourable, more especially when there is reason to suspect structural lesion of the bladder. 3. Spasmodic retention of urine. —In cases of this kind, the retention occurs suddenly. The patient is seized with extremely painful and urgent efforts to void urine ; but only a few drops pass off under great suffering. The pain in the' bladder is cutting, and attended with a sense of constriction and pressing down, which by females is often compared to labour pains. The ure- thra is sensible, sometimes painful throughout, and the patient is often harassed with very distressing erections. The pain is not increased during the flow of the small quantity of water that occasionally passes off; but immediately after the last drops are expelled, it becomes very severe, attended with a sensible spas- modic contraction in the perinaeum. In this way it may continue for a longer or shorter time, until at last the pain and urgency to urinate, pass off by a considerable flow of urine. The pain in this variety is not constant, nor is it increased by pressure on the perinseum or pubic region. There is no fever, but the pulse is small and contracted. The catheter is usually passed with great difficulty, and often cannot be introduced into the bladder at all. Spasmodic retention does not, however, often occur as a purely 420 RETENTION OF URINE, spasmodic affection. In many instances, slight inflammation of the bladder, or of some neighbouring part, renders the neck and upper portion of the urethra so extremely irritable, that the stimulus of the urine causes the sphincter to contract spasmodi- cally. The spasm may also be excited by mechanical irritants. This variety of the disease is most apt to occur in irritable and nervous individuals, and in such as are predisposed to colicky affections. It is sometimes suddenly excited by mental emotions, particularly terror and grief. Gouty and rheumatic irritation ; irritation of the rectum from ascarides, and other causes ; cold and humidity, particularly when applied to the feet; irritating diuretics ; haemorrhoidal irritation; gonorrhoea ; stimulating injec- tions, by heightening the irritability of the bladder and sphincter muscles; may give rise to spasmodic retention of the urine. This variety of the disease is not in general attended with any particular danger or obstinacy. By frequent recurrence, it is, however, liable to terminate in inflammation, and thus ultimately to give rise to very serious consequences.* 4. Retention from mechanical obstruction of the urethra or neck of the bladder.—Obstruction to the discharge of the urine may depend on a calculus lodged in the bladder, or impacted in the urethra ; stricture, more or less permanent, of the urethra; enlargement and induration of the prostate gland ; thickening and induration of the mucous membrane of the urethra ; pressure from tumours in the neighbouring parts, or from the gravid ute- rus, retroverted, or prolapsed uterus; foreign bodies accidentally introduced into the bladder; polypi and fungoid tumours in the bladder; very viscid mucus and coagula of blood clogging up the urethra; hernia ; and a varicose state of the vessels of the neck of the bladder. Of all these causes, however, stricture, and cal- culi lodged in the urethra, are incomparably the most common causes, of obstruction. Retention of the urine, whatever may be its cause, becomes highly alarming, if it continues beyond twenty-four hours, with- out being in some degree relieved. In general, complete reten- tion of urine proves fatal in four or five days ; and I have known an instance which terminated in gangrene and effusion of the urine as early as the end of the third day. It is generally sup- posed, that when the bladder at last gives way, and pours out its contents into the cavity of the abdomen, it is ruptured or lace- rated by the violent distention. This, however, is rarely the case ; for in nearly all instances that prove fatal, the urine finally gains exit through an opening formed by ulceration of some portion of the vesical parietes, or by the occurrence of gangrene and softening, through which the water bursts from the distended • Richter, Spec. Therap. B. iv. p. 392. RETENTION OF URINE. 421 bladder. In some instances, the lower portion of the bladder forms adhesions with the surrounding parts, and then ulcerates— the urine being infiltrated into the cellular structure about the rectum, scrotum, and perinseum. In such cases, extensive mor- tification and sloughing usually take place in these parts, before the disease terminates in death. Instances have occurred, in which adhesion took place between the bladder and. rectum, and the urine was discharged by the anus, with an eventual recovery of the patient. (Richter.) Ulceration and effusion of the urine into the vagina sometimes occur in females. The anterior and superior part of the bladder has been known to ulcerate, so as to give exit to the urine into the cellular tissue of the abdominal muscles, giving rise to extensive oedema of the anterior part of the body and thighs, with gangrene and fistulous ulcerations. Instances have occurred, in which the urine was evacuated by the umbilicus. (Richter.) Most commonly, however,- the bladder ulcerates directly into the cavity of the abdomen, and occasions fatal peritonitis. When the bladder gives way, the tumefaction and tension of the abdomen suddenly subside, and the abdomi- nal parietes become soft and relaxed, until peritonitis ensues, when the usual tenderness and tension of this affection occur. Retention of urine does not, however, always terminate fatally by ulceration or rupture of the bladder, and consequent extravasa- tion. Occasionally, death ensues before the bladder gives way, under symptoms resembling those which have been mentioned as occurring in the last stage of fatal ischuria renalis. In such cases, the distention is not confined to the bladder, but occupies the whole course of the ureters, which have been found enor- mously enlarged ; and the pelves of the kidneys even, are some- times considerably dilated by the accumulated urine. When these conditions occur, the secretion of urine is ultimately arrest- ed ; the patient becomes comatose, or is seized with convulsions or spasmodic respiration, his perspiration acquires a urinous smell, and he finally dies in a state of apoplectic stupor. On dissection, water of a distinctly urinous smell is generally found effused between the meninges, and into the cavity of the brain. There is another variety of retention of urine—renal retention —which arises from an obstruction of the ureters, either by inflam- mation and obliteration of their cavity, or by being plugo-ed up with calculi, coagula of blood, or compressed by a tumour in some contiguous part. In such cases, the ureter, above the obstruction, becomes more and more dilated, until it acquires, in some instan- ces, a very great size, and the kidney itself ultimately becomes greatly distended. Callisen has seen the pelvis of the kidney so dilated as to contain nearly a quart of u,rine ; and the ureters have been found dilated to the size of the colon. (Desgranges.) Walter states, that he saw the kidneys so enlarged as to resemble the 422 RETEXTION OF URINE. bladder, with its parietes attenuated almost into a membrane." Such cases usually terminate fatally under symptoms of cerebral oppression. The diagnosis of renal retention is, however, so extremely difficult and uncertain, that its presence can never be inferred with sufficient probability of correctness, to found on it any prac- tical indications; and it is here mentioned, rather as a pathologi- cal phenomenon, than as a subject for therapeutic observations. Treatment.—From the foregoing observations, it is obviously of the utmost importance, in the treatment of this affection, to be particularly acquainted with the various immediate causes of uri- nary retention ; and never to proceed to the employment of re- medial measures, until strict inquiry has been made into the nature of the existing obstacle to the urinary evacuation. From ignorance or inattention to this important rule, diuretics are often given, where the cause consists in permanent stricture; or perse- vering, rude, and ruinous attempts made to introduce the catheter, in the same condition of the urethra. There is another point which should be strongly impressed on the attention of the prac- titioner—namely, never to tamper too long with warm baths, tobacco injections, and various similar remedies, where the ob- structing cause resists proper measures for perhaps forty-eight hours—more especially if it consists of stricture or impacted cal- culus. I have seen two instances which were thus tampered with for five days, and sacrificed to the timidity or want of decision of the practitioner; although the lives of both could, in all proba- bility, have been saved, if tapping had been seasonably performed. In one case, where the obstruction was manifestly of a character which precluded all reasonable hopes of being removed sufficiently early to save the life of the patient, tapping was proposed and urged by a surgeon, but postponed by the other two medical attendants until next morning. On the following morning, the operation was again put off until the afternoon, to try the effects of a tobacco enema. In the afternoon the bladder gave way, and the patient died. In retention of urine from paralysis, the catheter is the only proper means for evacuating the contents of the bladder; and where the disease is unattended with enlargement of the prostate, its introduction may in general be effected with the greatest ease. The object here, both in a palliative and cu- rative point of view, is to obviate undue distention of the bladder; and as the loss of its expulsive power is very rarely transient, and the urine re-accumulates with more or less rapidity, it becomes necessary, in such cases, to draw off the urine every six or eight hours. I have known cases in which this operation was required • Einige Krankh. der Nieren und Ilarnblase, &c. Berlin, 1802. S. 5—16, tabi ii. iii. and iv. RETENTION OF URINE. 123 four times daily for several months, before the bladder recovered its powers. When the distention of the bladder is very great, the urine generally flows off very slowly through the catheter, and unless pretty firm pressure is made with the hands on the external vesical region, the greater portion of the urine will re- main in the bladder. Some surgeons recommend the introduction of a flexible catheter, and leaving'it in the bladder. When this is done, the external orifice of the catheter must be closed with a small plug, which the patient may from time to time remove, and give exit to the accumulated water. In some cases, attended with an inirritable state of the urethra and neck of the bladder, this practice may answer very well—more especially when the pati- ent is remote from his surgeon, and cannot be conveniently visit- ed at regular hours. With many patients, however, it causes much irritation, and cannot be borne without great inconvenience. Whilst proper attention is paid to the regular discharge of the urine, by means of the catheter, remedies should be employed with the view of restoring the lost tone of the bladder. For this purpose, cantharides, used both internally and externally, have been generally esteemed a very useful remedy. From twenty to thirty drops of the tincture may be taken two or three times daily, and continued until slight symptoms of strangury ensue. Richter speaks very favourably of a union of cantharides and camphor, in the proportion of a fourth of a grain of the former to one grain of the latter, given four times daily. Frictions with the tinctura lyttae, and terebinthinate embrocations over the hypogastric region, will assist in restoring the contractile power of the bladder. I have known unequivocal benefit obtained from a blister applied over the pubic region; and Richter recommends the application of a fresh onion, beat up into a pulp, to the peri- naeum. The internal use of the spirits of turpentine, of juniper oil, of the animal oil of Dippel, Peruvian balsam, and according to Jahn, the infusion of solidago virga aurea, may all be used with more or less advantage in cases of this kind. Cold water dashed upon the lower part of the abdomen and perinaeum, or in- jected into the rectum, has been found very beneficial in this affection.* Richter states, that in some cases of retention from vesical paralysis, almost immediate and very considerable relief was obtained by pouring water from the spout of a pitcher, in a stream descending several yards, upon the hypogastrium. Old people-often find a great deal of difficulty in voiding the urine—they are obliged to stand a long time before the urine be- gins to flow, and at last it passes off in a very weak stream, though with little or no uneasiness in the bladder. Persons who are thus affected, may sometimes derive considerable benefit from the use * Richter, Spec. Therapie, Bd. iv. p. 377. 424 RETENTION OF URINE. of the phosphoric acid, as recommended by Dr. Valentin.* One drachm of this acid is to be dissolved in two drachms of distilled water, of which ten drops should be taken every two or three hours in a little water. Retention of urine from inflammation, requires of course the usual efficient local and general antiphlogistic measures. Un- less the symptoms of vesical distention be very urgent, it will be most prudent to endeavour to reduce the inflammatory con- dition of the parts, before an attempt is made to draw off the water with the catheter. A very efficient blood-letting—ad syn- copen, in robust and full habits, together with the free application of leeches to the perinaeum, cupping on the iliac and pubic re- gions, emollient clysters, fomentations, mild purgatives, and the internal use of antimony, constitute the means upon which our main reliance must be placed for removing the malady. Having used local and general depletion, and emptied the rectum by enemata, an anodyne clyster should be given an hour previous to the introduction of the catheter. The catheter will be much more easily introduced into the bladder, and with much less suffering to the patient, after these measures have been efficiently employed. The warm bath—especially the hip-bath, is a valua- ble auxiliary in such cases. It should be repeated every two or three hours, where conveniences are at hand for its proper em- ployment. The patient should drink moderately of the blandest diluents, and emollient enemata ought to be frequently adminis- tered during the day. After efficient general depletion, calomel and opium usually procure more advantage than any other inter- nal remedy. Where the disease is the consequence of an ineffec- tual hemorrhoidal effort, or of suppressed haemorrhoids, leeching around the anus is especially proper. Whatever other measures be employed, local depletion in this way, is one of the most im- portant of our curative means in every variety of inflammatory retention of the urine. For the treatment of spasmodic retention of urine, a great variety of remedies have been recommended. The warm bath often causes the urine to flow almost as soon as the patient is im- mersed ; but in some instances it fails entirely in procuring relief. Various local applications by frictions have been advised, and may be employed with occasional benefit. A, liniment composed of two drachms of spirits of turpentine, the yolk of an egg, with six ounces of peppermint water, is particularly recbmmended by Kieser.t Richter applied bruised onions to the perinaeum and pubis, with evident good effects. The application of decoctions of stramonium, conium, and of poppy heads, may also be tried * Archiv. fur Pharmacic. Bd. i. st. iii. 332. | Hufeland's Journal. An. 1820, st. iii. p- 92. RETENTION OF URINE. 425 with some prospect of benefit in cases of this kind. Anodyne ene- mata are particularly indicated, and occasionally afford very prompt relief. I have known an instance which had resisted the warm bath, and various other remedies, for five or six hours, speedily relieved by an injection of two drachms of laudanum in about a gill of warm milk, into the rectum. Bingham and others, strongly recommend tobacco injections; and they sometimes procure very speedy relief; although, occasionally, they cause great and even dangerous prostration and distress, without any advantage. Internally, opium, in purely spasmodic cases of the disease, sometimes does much good ; but in order to obtain any decided advantage from this narcotic, it should be given in large doses, so as to bring the system fully under its influence. Rich- ter states, that he has known the following pills to relax the ure- thral spasm, in a very short time.* Of late years, the muriated tincture of iron has been a good deal employed in spasmodic re- tention of the urine. From twenty to thirty drops should be given every ten minutes, until nausea is produced. The late Mr. Cline, of London, speaks in the highest terms of this article, as a remedy in this variety of the disease. I have known it to be successfully employed in several instances of this kind. It should be particularly observed, however, that it is only where the re- tention depends on spasm of the urethra or sphincter of the blad- der, that any benefit can be obtained from this medicine. There is much reason for believing that it is often given in retention from stricture, and even from inflammation ; and that it has thus unjustly lost credit as a remedy in the spasmodic form of the disease. From the decided and speedy relief it procured in the few cases to which I have just alluded, I am well satisfied that it deserves particular attention as a means for removing spasmo- dic retention. Most writers, in referring to Mr. Cline's expe- rience with this remedy, state that he gave but six or seven drops at a dose; but Dr. Johnson asserts, ai#no doubt correctly, that this is a mistake, and that Mr. Cline gave it in doses of from twenty to thirty drops every ten minutes, until nausea was pro- duced. The attempt to introduce the catheter, so long as the spasm of the urethra continues, is almost invariably abortive; and it is, indeed, highly improper to persist in the efforts to pass it into the bladder, where the spasmodic contractions are powerful, and resist the first few moderate attempts. It is surprising with what force the urethra sometimes contracts on the catheter, after it has • R. G. assafcetid. ^ss. P. rad. ipecac. — opii aa gr. iv. Ol. mentb. pip. gtt. iv. M. ft.—Divide into two grain pills. Take ten pills, three or four times daily. Vol. II. 54 426 RETENTION OF URINE. been introduced to a considerable distance during a temporary relaxation of the spasm. So firmly is the instrument grasped, at times, that it is with difficulty drawn out again. Even where the urethral spasm is so far allayed, by the means just mentioned, as to enable the patient to force out small and interrupted jets of urine, the catheter can seldom be introduced into the bladder without a great deal of difficulty; for the urethra, in such cases, is so extremely irritable, that the irritation produced by the ca- theter generally excites immediate and insurmountable spasmodic contractions. If we succeed in introducing the instrument to near the bladder, its progress is almost invariably arrested by the contraction of the sphincter and upper portion of the urethra. By holding it awhile in one hand, and gently rubbing the peri- naeum with the fingers of the other, we may sometimes succeed in slipping it in, with little or no difficulty. Retention from stricture, and other mechanicalobstructions, is by far the most alarming form of the disease. The means to be employed when the retention depends on stricture in the ure- thra, are, local and general bleeding—particularly by leeches ap- plied to the anus and perinaeum, and cupping on the lumbar re- gions. After the action of the pulse has been reduced by these depletory measures, the patient should be put into a warm bath, more especially the hip-bath, and large injections of warm water and oil thrown into the rectum. When the bowels have been thus evacuated, great relief will in general result from an opiate enema, composed of barley decoction and from fifty to eighty drops of laudanum; and internally five or six grains of Dover's powder every two or three hours, together with a repetition of the warm bath, and tepid diluent drinks, should be used until the skin becomes uniformly moist. Should all these means fail in procuring adequate relief, it will be proper to introduce with due caution a small bougie, "not to draw off the urine, but with the view of restoring fkL natural action of the muscles of the parts." Mr. Bell, from whose excellent work the foregoing mode of management is chiefly drawn, gives the following direc- tions for introducing the bougie in such cases. "The patient should be standing, or resting on his knees if he is in bed. Take a wax bougie, oil it, soften it, give it the proper curve to pass the turn of the urethra, introduce it into the bladder; now make gentle pressure above the pubes; make the patient exert himself to discharge the urine; sprinkle cold water on his thighs; with- draw the bougie while he continues the effort; and when he has the sensation as if he could pass the urine, withdraw the bougie altogether, and the urine will probably flow." Even where we fail to reach the bladder with the bougie, the patient may often be relieved by pressing a small bougie gently forward, till the point of it has wedged itself into the stricture, when the hypo- RETENTION OF URINE. 427 gastrium is to be gently pressed, and the patient directed to exert himself to pass the urine; and at the same time his hands should be put in cold water, or some of it sprinkled on his thighs, (Bell). If these efforts fail, an attempt may be made with a very small catheter; and where, after all, the stricture is insurmount- able, recourse to the operation of puncturing the bladder is the only means left us for preserving the life of the patient. As to the employment of caustic, or of metallic bougies for breaking through the stricture, nothing useful can be expected from them, unless the stricture be very narrow, and not situated too high up; which, however, is but very rarely the case. W'hen the symptoms become urgent, and the general and local means already indicated have been ineffectually employed, it would be unne- cessarily placing the patient's life in great jeopardy, by relying on the slow, and, after all, uncertain process, of working through the stricture with caustic. With regard'to the mode of operating either for puncturing the bladder or laying open the urethra in perinaeo, above the stricture, and introducing a flexible tube through the artificial opening into the bladder, the reader must consult the writings of surgeons—particularly the valuable trea- tise on the urethra, &c. by Charles Bell, edited by Mr. Shaw. It may be observed, however, that in retention from urethral stric- ture, it is not often necessary to puncture the bladder; since an incision into the membranous portion of the urethra above the obstruction, will in general answer every purpose that can be obtained from an operation of this kind. It would seem, that, at present, the majority of surgeons prefer the suprapubian opera- tion, where puncture of the bladder is determined on. When re- tention from pregnancy cannot be relieved by pushing up the bladder, or by change of position during the efforts to pass water —such as lying down on the back with the hips raised, the ca- theter is the only proper means for relief. If the pressure of the uterus against the urethra, opposes the introduction of the cathe- ter, the patient must be placed on her back, with the hips ele- vated, and the womb pushed up with the finger of one hand, whilst with the other the catheter is introduced. When the sup- pression is connected with retroverted uterus, the bladder is usual- ly raised so high above its proper location, that it becomes ne- cessary in general to use the male catheter, in order to reach the cavity of the bladder. Sect. VI.—Dysury. Difficulty and Pain in voiding Urine.—Strangury. Difficulty and pain in making water, without any particular tendency to retention of the urine, is a very common complaint. 428 DYSURT. In general, whatever is capable of increasing the irritability of the bladder, or of giving rise to the secretion of an acrid urine, will cause more or less pain and difficulty in voiding the urine. It is particularly apt to occur where there is an excess of uric acid secreted with the urine; and where the urine is charged with the earthy phosphates, it is seldom absent,—although in this latter case the urine is generally more copious than natural, and does not properly come under the designation of dysury, which implies difficulty/in passing the urine, is well as pain. The usual sensations of dysury are—uneasiness in the neck of the bladder; frequent, painful, and slow micturition, with a sense of tenesmus or straining in perinaeo,—particularly at the moment the last drops are voided ; and a cutting or burning sensation in the posterior part of the urethra. It may be produced by a great variety of causes, such as excess in eating, and in drinking spi- rituous liquors; the free use of condiments; irritating diuretics; onanism; excessive venery; acid ingesta; inflamed haemorrhoids; ascarides; suppressed catamenia; the irritation of vesical calculi; astringent injections; redundancy of lithic acid, or of the phos- phatic sediments in the urine; leucorrhoea; repelled cutaneous affections; rheumatism and gout. It occurs in inflammatory fevers, particularly in hepatitis, jaundice, scurvy, and from ver- minous irritation and dentition in children. Strangury is an extremely distressing affection. There is a continued urgency to void urine, which passes off in small quan- tities, or drop by drop, with the most severe burning and cutting pains in the neck of" the bladder. Cantharides are peculiarly apt to give rise to this affection; and some individuals are so very susceptible in this respect, that they cannot have a blister applied to any part of the body, without suffering more or less from stran- gury. The spirits of turpentine, also, is very apt to occasion this painful irritation of the neck of the bladder. Treatment.—Where there is reason to suppose that the dis- ease depends on simple irritation of the neck of the bladder from some accidental cause—as injections, gonorrhoea, &c.—it will, in general, suffice, to empty the bowels by mild laxatives, and to order copious draughts of bland diluent drinks, such as barley water, flaxseed tea, or a solution of gum arabic, and perhaps an anodyne enema, and rest. When the disease is dependent on an excess of the lithic or phosphatic sediments, the measures already mentioned under the head of lithiasis, for counteracting these secretions, must be re- sorted to. "When the urine is perfectly natural both in quan- tity and quality, and contains no mucous, purulent, or bloody deposite, there is reason to infer that the cause of the irritation is not connected with the urinary system, and must be sought for elsewhere, as in the rectum, or uterine system in females." DYSURT. 429 (Prout.) Should it depend on an haemorrhoidal effort, recourse , must be had to the means mentioned in the chapter on haemor- rhoids, for counteracting it*. Nervous and hysterical females are liable to extremely violent pains in the neck of the bladder and urethra, and which are generally most intensely felt immediately after discharging urine. Opium and camphor is the only remedy that I have found decidedly useful in cases of this kind. Four or five grains of Dover's powder, with three grains of camphor, taken three times daily, will seldom fail to remove the com- plaint. Infants, as has already been said, are subject to violent pains of this kind, in passing urine during the process of dentition. The existence of the complaint is recognised by the violent shrieks which they utter on voiding the urine. The proper treat- ment in such cases is to open the bowels freely with castor oil, or rhubarb, and to exhibit twice daily one-sixth of a grain of ca- lomel, with a fourth of a grain of ipecacuanha. In the evening, a drop or two of laudanum should be administered. I have ne- ver failed of speedily removing the affection by these remedies. When these cases are attended with a copious secretion of the phosphate of ammonia, (an occurrence by no means uncommon,) magnesia, which is so frequently administered to infants, is de- cidedly prejudicial. In old people, this affection is generally attended with a dis- eased condition of the internal coat of the bladder, or calculous irritation, or disease of the prostate. The careful physician will, of course, endeavour to ascertain the cause; and for this purpose it is particularly important to examine the urine, and the state of the prostate, by examining through the rectum. Females subject to leucorrhoea, are apt to suffer the most ex- cruciating pains on voiding urine, from an extremely irritable and tender state of the orifice of the urethra. So sensible is this part, in some cases of this kind, that the slightest touch with the finger gives rise to extreme pain. I have found no remedy so ef- fectual, in cases of this kind, as a weak solution of lunar caustic. Two grains to an ounce of water, to which a watery solution of opium is to be added, should be used two or three times daily as a lotion to the part; and a little lard applied with the finger, after each application of the wash. A strong solution of borax will also sometimes give relief; and I have used the citrin ointment, mixed with an equal quantity of oil of almonds, with much bene- fit. At the same time, however, that these applications are used, , it will be necessary to use frequent injections of a weak tepid so- lution of sulphate of zinc, or of alum, into the vagina, and to em- ploy other means for counteracting the leucorrhoeal affection. For the relief of strangury", caused by cantharides, &c. and which consists of a slight degree of inflammation of the neck of 430 DYSURY. the bladder, copious draughts of mucilaginous diluents, opiates, fomentations, and where it is extremely severe, leeching at the perinaeum, should be used. An anodyne enema will, in general, procure very considerable relief. The Germans are in the habit of administering camphor for the removal of strangury, but al- though I have used it repeatedly, I have never known it to afford any unequivocal advantage. The free use of flaxseed tea, or of barley water in conjunction with the spirit, aether, nitrici, and an opiate enema, will rarely fail to allay the suffering very materi- ally. Dr. John Davy asserts, that the introduction of a catheter almost invariably procures immediate relief in strangury from cantharides. " It should be introduced with delicacy and caution, just slipped into the neck of the bladder, and kept in only a few seconds. The process is seldom very painful, and the relief is al- most immediate."* Seot. VII.—Enuresis.—Incontinence of Urine. This, though not in general a painful affection, is always a very troublesome and distressing complaint. The urine passes off in- voluntarily ; sometimes constantly, in drops, as it is secreted and conveyed into the bladder; at others, only after a considerable portion has been accumulated in the bladder, the impulse coming on so suddenly and irresistibly, that the utmost efforts of volition are not able to restrain its immediate flow. In some instances the involuntary discharge occurs by day and night, whether the patient be awake or sleeping—in other cases, by far the most common, it takes place only at night during sleep. This affection may, therefore, be divided into three varieties. 1. Enuresis paralytica.—In incontinence of urine, from pa- ralysis of the sphincter of the bladder, the urine passes off con- tinually, as it is secreted by the kidneys, without pain, and even without the least sensation of its occurrence. In such cases the diagnosis is not, in general, attended with difficulty. In very old people it is, nevertheless, not uncommon to find the urine to dripple off involuntarily, without any particular paralytic affection of the sphincter. These cases occur in the slighter instances of partial retention of the urine, from-a weakened state of the expul- sive powers of the bladder; for, when the urine accumulates in the bladder to a certain degree of distention, the resistance to a further dilatation of the bladder, in conjunction with the pressure of the abdominal muscles, slowly forces the urine into the ure- thra, and causes it to pass off guttatim. This variety of incontinence often occurs as a symptom of • Edinb. Med. and Surg. Journ. 1828. ENURESIS. 431 some general disease. Thus, it is frequently met with in the lat- ter stages of low fevers—in paraplegia and hemiplegia ; and it is occasionally the consequence of concussion of the brain, and spinal injuries. Richter observes, that an inability to retain the urine has arisen from plunging into very cold water. Among the local causes of this affection, the most common are—difficult parturi- tion ; injuries done to the neck of the bladder hy the unskilful employment of obstetrical instruments; a large calculus located in-the neck of the bladder; lythotomic operations; great dilata- tion of the neck of the bladder in the extraction of a calculus. The prognosis in this variety of the disease is generally unfa- vourable, and when it occurs as a symptom in febrile affections, it is always one of the most dangerous indications. Mere local paralysis of the sphincter of the bladder is indeed not dangerous, so far as the life of the patient is concerned, but it is an exceed- ingly annoying complaint, and by the urine constantly drippling off, very painful and distressing excoriations on the inner part of the thighs, scrotum, and perinaeum, almost always occur. 2. Enuresis from mechanical causes, independent of paraly- sis of the sphincter of the bladder, is not unfrequently met with. Most of the mechanical or organic causes mentioned under the head of ischuria, may, under certain circumstances, give rise to incontinence of urine. Tumours pressing on the bladder—as the gravid uterus; dropsical or scirrhous enlargement of the ovaria; tumours of the mesenteric glands; of the rectum, and of the neck of the uterus, have been known to give rise to this affection. It may also be produced by prolapsus uteri; hernia, or prolapsus of the bladder; by the irritation of vesical calculus; tumours and excrescences from the internal surface of the bladder, &c. These causes seem to operate in the production of incontinence of urine, by the pressure which many of them make on the bladder, and by the almost constant nisus to evacuate the urine, by which the sphincter may at last become so debilitated and relaxed, as to suf- fer the urine to pass off slowly and involuntarily; and cases have occurred, which arose from ulcerative destruction of a part of the sphincter. 3. There is a variety of incontinence of urine, described by Richter under the name of enuresis spastica, which sometimes occurs in very nervous or hysterical individuals, and which may therefore with more propriety be called nervous enuresis. The inability to retain the urine occurs in sudden and irregular attacks. The patient suddenly feels a most urgent desire to void the urine, and the impulse is so irresistible, that, in spite of the utmost ef- forts of volition, the urine immediately passes off without allow- ing time to withdraw, or even to reach for a vessel. This variety of the affection occurs also occasionally in very young children. Its most common exciting causes appear to be—ascarides; hae- 432 ENURESIS. morrhoidal affections; suppressed catamenia; gouty irritation; and leucorrhoea. Frequently, however, no obvious causes of this kind are present, and the disease apparently arises from a morbid irritability of the urinary passages, in connexion usually with a very excitable or nervous state of the general system. 4. Enuresis nocturna—This is a very common complaint among children, and occurs also occasionally in adults. When awake, the individual subject to this affection experiences no in- convenience whatever in this respect; but at night, while sleep- ing, and lying on the back, the urine is apt to pass off, either involuntarily, and without the least consciousness of its occur- rence, or voluntarily, under the influence of a dream. In chil- dren, this variety of incontinence of urine is often "associated with some tendency to urinary disease, and very frequently a disposition to gravel; or sometimes, as in young females, with constitutional irritability and weakness; and in advanced life this affection is almost always associated with some organic or other affection of the neck of the bladder or prostate gland." In those cases where the discharge occurs in consequence of a voluntary effort during a lively dream, the urine, on examination, will al- most invariably exhibit "some unnatural property, and most generally a strong disposition to, or actual deposite of gravel. " Hence," says Dr. Prout, " I have been led to infer that in this species of urinary incontinence, the acrid properties of the urine ;are chiefly in fault, and that these, favoured, perhaps, by the position of the body, and probably, also, by the morbid sensibi- lity of the bladder, excite so vivid an impression on the imagina- tion, as actually to lead to a voluntary discharge of the urine." That urinary incontinence may occasionally occur in this way, cannot be doubted; but it may justly be questioned whether the causes here assigned are so commonly concerned in the produc- tion of this affection as is supposed by the author just quoted. It is certain that we may sometimes prevent the recurrence of the evacuation by exhibiting remedies calculated and intended to produce an irritation or tenderness in the neck of the bladder; as, for instance, cantharides—a circumstance which does not seem to favour the idea that the affection depends on the irritation of acrid urine. Habit, no doubt, often has a principal agency in keeping up this affection. When children neglect to pass off the urine on going to bed, the bladder is apt to become distended in the course of the night. This stimulus excites the brain, and awa- kens a lively dream, occupied with a desire to urinate, and the sphincter yields to the instinctive effort to void the urine. In cases where the urine passes off involuntarily, and without the person being conscious of it during sleep, Dr. Prout thinks that there probably always exists " some morbid condition of the ENURESIS. 433 urinary organs," which it is in general extremely difficult to overcome, and continues, often, long after the age of puberty. Treatment.—From the foregoing remarks on the various and very distinct character of the causes and pathological conditions of urinary incontinence, it is obvious, that the modes of treat- ment proper for its removal must be equally various and diverse in different cases. When the incontinence depends on general palsy, recourse must be had to the treatment mentioned under the heads of paralysis. In instances of urinary incontinence from mere local paralysis of the sphincter vesicae, without any manifest spinal affection, or organic cause, we must endeavour by tonics and local stimulants to re-excite the activity of the sphincter. Among the means that have been proposed for this purpose, the following are the most important. Alum, in doses of twenty grains every four hours, with mucilage of gum arabic. This, ac- cording to Selle, has occasionally removed cases of long continu- ance. The tincture of cantharides will sometimes produce a very good effect. It should be given in gradually increased doses three or four times daily, until a feeling of ardor urinae or stran- gury ensues. Dr. Otto, of this city, has recently published an account of three cases of incontinence of urine, which yielded un- der the employment of uva ursi and the muriated tincture of iron. One of the cases was congenital, and the remaining instances were inveterate. During the present summer, I prescribed these remedies in a long standing case, and the result was entirely satisfactory.* Externally, cold bathing or cold water poured from a height on the pubis, and dashed upon the perinaeum, will some- times do good. Richter recommends cold injections into the bladder; and in females, cold water may be beneficially injected into the vagina. Electricity and galvanism have also been em- ployed with success in cases of this kind.t Stimulating fric- tions, of various kinds, will occasionally assist in restoring acti- vity to the sphincter. M. Lair, in a memoir on this affection, refers most cases of incontinence of urine to a want of equilibrium in power between the body of the bladder and its neck, the lat- ter being in an atonic or relaxed condition. This view of the subject, led him to seek for a mode of stimulating the neck of the bladder, without affecting its body* With this intention, he introduced, by means of a catheter, the tincture of cantharides, so as to touch the urethra in its prostatic part, as well as the neck of the bladder; and he affirms, that by this mode of management he cured three cases of this malady.J Dry-cupping the perinaeum, and blisters applied to the sacrum, are also very useful measures » North American Med. Jour.—Oct'r. 1830. ■j* Loder's Journ. der Chirurgie. B. iv. lift. i. * Med. Chir. Rev. January, 182r. p. 244. Vol. II. 55 434 ENURESIS. in cases of this kind. M. Canin has lately related two cases, be- fore the French Academy of Medicine, which were cured by these applications. In one of them, in a lad about fourteen years of age, the disease had already continued two years. It required eighteen applications of the cups, in the course of a month, be- fore the cure was effected. In the other case, also in a young person, the cups were applied twenty times, and a blister laid over the sacrum, before the cure was completed. In both in- stances, various means had been tried without any apparent ad- vantage. In urinal incontinence from mechanical causes, we can seldom do more than palliate the disorder, or procure temporary relief. When it occurs from the pressure of the gravid uterus, nothing but the delivery of the child will in general remove the com- plaint; yet in some instances, incontinence of the urine occurs about the third and fourth month of pregnancy, and after having continued for a time, goes off spontaneously, before the termina- tion of the regular period of gestation. In nervous or spastic urinary incontinence, anodyne enemata, together with uva ursi in union with Dover's powder, or with the extract of stramonium, and the employment of tonics—particularly, iron, quinine, and the oxyde of zinc, with a nourishing and digestible diet, regular exercise in the open air, early rising, and, in general, whatever is calculated to invigorate and to allay the morbid irritability of the system, constitute the appropriate means in cases of this kind. Wendt speaks very favourably of the expressed juice of the me- sembryanthemum crystallinum, in the incontinence of urine which occurs in very nervous individuals. When the patient is affected with leucorrhoea, or ascarides, or with an irritated state of the rectum from haemorrhoids, particular attention should, of course, be directed to the removal or mitigation of these affections. For the removal of enuresis nocturna, a great variety of means have been proposed, but they have not been very often applied with much success. The disease generally disappears, as children approach the age of puberty, and often at a much earlier period; and this occurs apparently from the powerful influence of a sense of shame, and a determination, during the waking state, to resist the desire to micturate, which occurs in dreams during sleep. Mr. Prout observes, "that when the incontinence in children is associated with gravel, it is of the utmost consequence that this circumstance be attended to; and that the remedies appropriate for counteracting the formation of these urinary deposites, should be employed before any other means are used to restrain the urinary incontinence,"—for without this, almost all other remedies will be in vain. The urine should therefore be carefully inspected, both in its recent state and after it has stood awhile; and if a se- diment either of the lithic acid or phosphatic variety be deposited, ENURESIS. 435 recourse should be Immediately had to the remedial measures mentioned under the head of lithiasis, in a preceding section of this work. After this object has been accomplished, we may proceed to the employment of tonics, and some one of the vari- ous remedies or modes of management which experience has shown to be capable of doing good. Among these, there is no article which has been more generally prescribed than the tinc- ture of cantharides, with the view of producing a slight degree of strangury, or considerable ardor urinae; so that the pain ex- cited by the first efforts to micturate, may excite and awaken the patient, and thus interrupt the habit which always ultimately contributes chiefly to the recurrence of the discharge. This ar- ticle may be beneficial also, by increasing the sensibility and ac- tivity of the sphincter, and thereby enabling this muscle to make greater resistance to the expulsive efforts of the bladder. The same effect may sometimes be derived from the application of a blister to the sacrum. I have known an instance of long standing, removed by the use of the spirits of turpentine, in doses of from fifteen to twenty drops three times daily, until a considerable degree of ardor urinae was produced. Where these remedies do not afford relief, and there is reason to believe that the inconti- nence depends on a morbid irritability of the neck of the bladder —which is often the case in adults, an opiate administered on going to bed, will sometimes have the effect of preventing the evacuation during the night. Children should always be required to empty the bladder just before going to bed, and when they awaken at night, they ought to be taught to rise and pass off the urine. By this, we may often prevent the occurrence of the dis- order, and even occasionally obviate it after it has occurred. Mr. Charles Bell makes the following observations in relation to this subject, and which are worthy of particular attention in the management of this complaint. " Incontinence of urine," he says, " never takes place but when the boy is asleep upon his back; and the cure is a simple one. He is to accustom him- self to sleep upon his face or side: the urine is not passed, nor is he excited to dream of making urine, while he keeps this posi- tion. The circumstance is unaccountable, until we reflect on the position of this master-spring of the muscles of the bladder—the sensible spot, a little behind ana below the orifice of the blad- der. When a person lies upon his belly, the urine gravitates towards the fundus; but when he lies on the back, it presses upon this sensible spot, and distends that part of the bladder which is towards the rectum." 436 HYDROPS. CHAPTER VIII. CHRONIC DISEASES OF THE SEROUS EXHALENT VESSELS. Hydrops.—Dropsy. Dropsy, or rather the effused and accumulated fluid which constitutes the most conspicuous external character of this disease, must be regarded only as an effect of a primary morbid condition of the solids. This morbid condition of the solids constitutes the essential malady, to which the physician's attention must be di- rected in order to obtain rational views concerning its nature and remediate management. The cure of this disease does not de- pend merely on the removal or evacuation of the aqueous accu- mulation, but principally, if indeed not entirely, on the removal of that disordered state of the vascular system, upon which the dropsical collection depends. Here, then, the fundamental ques- tion meets us: In what does this morbid condition of the solids consist, and in what particular structures is it chiefly located ? According to the late Dr. Rush, the morbid action which gives rise to dropsieal accumulations, is seated in the arterial system, and is, in its nature, closely allied to inflammation. Dropsical accumulations, agreeably to his views, are the result of an in- creased action of the exhalent vessels, attended with a general pyrexial condition of the system. The correctness of this doc- trine is now very generally, we might, perhaps, say, universally, admitted. Indeed, the removal of dropsy from the cachexia to the pyrexia, is justly regarded as one of the most important of modern improvements in pathology. That the increased secre- tion or effusion of serum, which occurs in dropsy, depends on a condition, which, if not identical, is at least closely allied to in- flammation, receives the greatest degree of probability from the following circumstances: Every one who has observed the progress of inflammation, knows, that at the period when the inflammation is passing off, or changing to the subacute or chronic state, an effusion of serum is apt to occur into the surrounding cellular tissue or contiguous cavities. Thus, rheumatic inflammation, gout, and sprains, fre- quently pass off by an effusion of serum into the circumjacent cellular structure. It is well known, too, that hydrothorax is by no means an uncommon sequel of pleuritis ; and hydrocephalus pf arachnitis. Indeed, the pathological fact, that all inflammations of the serous membranes, if not very violent, or speedily termi- nated in resolution, end in effusion, is directly corroborative of HYDROPS. 437 the correctness of this view of the pathology of dropsy. It is therefore highly probable, that the morbid action which exists in the tissues from which the dropsical effusions occur, partakes more or less of the nature of inflammatory excitement; but it seems likely, that it is always of the lowest grade of phlogosis, amount- ing, in some instances, probably, only to an irritation bordering on actual inflammation. It would appear, indeed, that a consider- able degree of inflammation is incompatible with serous exha- lation—and that this effect can occur to any material extent, only where the vascular irritation is somewhat below the grade of actual inflammation. To this doctrine of the nature of dropsy, objections of much plausibility have been urged. When duly estimated, however, they do not appear to possess any solid value. It has been stat- ed, for instance, that dropsy is not unfrequently the consequence of profuse haemorrhage and of other exhausting causes, and that in such cases, at least, neither the general symptoms, nor the nature of the causes, justify us in considering the disease as one of an inflammatory character. Against this, however, it may be observed, that local irritative or inflammatory action, and great debility and exhaustion, are by no means incompatible. Sub- inflammation may exist in one structure or organ, whilst the general system exhibits all the characteristic traits of debility and cachexy. The post mortem phenomena which occur in the hu- man subject, and in animals who have died from haemorrhage, would seem to show, indeed, that even in dropsies from haemor- rhage, there exists a morbid state, allied to inflammation in the membranous structures from which the effusion occurs. The experiments of Mr. Seeds and of Kellie, show that in animals bled to death, the meninges of the brain, and other membranous tissues, almost invariably exhibit a highly injected and congested 6tate, similar, in all respects, to what occurs in actual inflamma- tion. In many instances of this kind, a considerable quantity of watery effusion was found within the head ; and in some instan- ces, high and tumultuous action of the heart and arteries occurred shortly before the animals expired. I have met with several cases, in which internal inflammation occurred, apparently in con- sequence of excessive losses of blood. I attended a gentleman, a few years ago, who was reduced to the utmost degree of exhaus- tion compatible with life, in consequence of a long-continued and almost uninterrupted loss of blood from the rectum, and who, finally, became anasarcous over the whole body, while at the same time, his eyes were very considerably and obstinately inflamed. The phlogistic character of dropsy is sometimes strik- ingly illustrated by the conversion of inflammatory diseases into dropsy, and vice versa. In a late number of the Medico-Chirur- gical Journal, there is a case related, in which rheumatism was 438 HYDROPS. Syfdrlf 5°Trted int° dysentery, erysipelas, peritonitis, and Although it must be admitted, that an increased exhalation of senim constitutes the chief immediate cause of dropsical accu- mulations, yet it is'probable, that there always exists a simulta- neous diminution of absorption in the surface from which the effusion takes place. In the first place, it may be observed, that vascular irritative excitement or inflammation in a part, is neces- sarily attended with a preternatural afflux, and consequently, sanguineous congestion in such part. This being the case, it fol- lows, that the capillaries of the structures from which dropsical effusion occurs, must be in a state of repletion or sanguineous congestion. Now, it is a truth, I believe well established, that the function of absorption from the cavities and cellular tissue, is chiefly, if not entirely, performed by the veinous extremities. The experiments of Majendie, of Meckel, of Tiedemann, and Gmelin, have placed this physiological fact beyond all reasonable doubt. It appears, moreover, to be equally well established, that the process of absorption is accelerated or diminished, according as the capillaries contain a lesser or greater quantity of blood. When they are full and congested, and the current of blood moves along sluggishly, absorption is comparatively slow; and vice versa. This fact was long ago noticed by Home in his Essay on Croup. "The less blood," he says, "there is in the veins, the more rapidly will absorption be effected." When it is considered, therefore, that the tissues from which the dropsical effusions occur, are, as is believed, in a state of subinflammatory action, or at least of vascular irritation, and that the capillaries of these tis- sues must consequently be in a state of fulness or congestion, it would seem to follow, that the process of absorption must be correspondingly diminished. Hence, in every case of dropsy, there are, probably, two simultaneous morbid conditions present, namely, increased exhalation, and decreased absorption. Etiology.—The principal general causes of dropsy are me- chanical obstructions to the free return of blood to the heart; the influence of cold; excessive haemorrhages; disease and inactivity of the kidneys; repelled cutaneous eruptions ; suppressed habitual discharges; chronic diseases which tend to exhaust the system; arsenic ; and some of the acute exanthematous affections, particu- larly scarlatina and measles. Dr. Ayre, in his treatise on this dis- ease, denies that mechanical obstruction ever has any direct agency in the production of hydropic effusions. When dropsy supervenes on scirrhus of the liver, he considers it the conse- quence of the slow inflammation of the indurated viscus, extend- ing to its peritoneal covering, and thence along the abdominal • Med. Ciiir. Kcv. vol. vi. p. 197. HYDROPS. 439 peritoneum. It is not improbable that the disease may, in some instances, be developed in this way; but it seems much more likely, that the congestion which necessarily occurs in the portal system in such cases, produces, by degrees, that irritated condi- tion of the peritoneal capillaries which gives rise to the effusion. It is a well established fact, that habitual sanguineous congestion in a part, tends ultimately to excite a low degree of inflammation. We may reasonably presume, also, from the above observations on the influence of vascular turgescence in diminishing absorp- tion, that this process is in such cases morbidly diminished, even before capillary irritation and consequent preternatural exhalation have commenced. The influence of obstructions to the return of blood to the heart, in producing serous extravasations, is suffi- ciently illustrated by the oedema which occurs when ligatures are passed round an extremity. Cold rarely produces hydropic affections, unless there exists a predisposition to the disease. Of all the causes which predis- pose to the occurrence of dropsy from the influence of cold, the most powerful are scarlatina, measles, and the mercurial excite- ment. Neither these two exanthematous affections, nor mercury, are apt to give rise to dropsy, unless they co-operate with cold, or vicissitudes of atmospheric temperature. They leave the sur- face of the body in a highly sensible and irritable condition, and the cutaneous exhalation is usually carried on freely during the period of convalescence. When the body, in this condition, is exposed to the influence of cold, the cuticular exhalents are pe- culiarly liable to become torpid ; and congestion in the capillaries of the subjacent cellular tissue almost necessarily ensues. This tissue being already predisposed to morbid excitement from the previous exanthematous affection, passes readily, under the com- bined influence of these circumstances, into a state of irritation or subinflammatory action, whence dropsical effusions proceed. It is not improbable, however, that in some instances of dropsy from scarlatina or measles, the disease may be the immediate consequence of the extension of the inflammation or irritation from the skin to the subsequent cellular texture. The fact, how- ever, that dropsy from these affections occurs but very rarely when the patient is carefully protected from cold, would seem to show, that the disease is not apt to arise from an extension of the inflammation to the cellular tissue. Dropsies from cold are frequently attended with slight catar- rhal symptoms, and are always manifestly of a phlogistic charac- ter. When blood is drawn, it is almost always found sizy ; and the pulse is tense, quick, and frequent—more especially in those cases which occur as the sequela of scarlatina or measles. The effusion generally takes place very rapidly. The variety of 440 HYDROPS. dropsy which most commonly proceeds from cold, is anasarca^ although some degree of abdominal effusion is not uncommon. In relation to dropsies from excessive haemorrhages, or other profuse and long-continued discharges, we have two observations to make, in elucidation of their etiology. In the first place, it would seem to be well established, that excessive losses of blood are almost invariably attended or immediately followed by irre- gular determinations, or foci of congestion, in one or more of the serous membranes. It is thus that the red and injected appear- ance of the arachnoid and other membranous structures occur in animals, when killed by bleeding. The structures which may have thus become the foci of determination, gradually pass into a state of irritated action, which ultimately, in most instances, gives rise to dropsical effusions. There is, however, another cir- cumstance connected with the production of dropsy by excessive losses of blood, which, though little estimated by pathologists, has, I am convinced, an important concern in the causation of the disease. I have already observed above, that immediately after a profuse loss of blood, absorption goes on with unusual activity. The blood-vessels are rapidly replenished with crude fluids ; for the absorbents being extremely active, nearly all the aqueous fluids, received into the stomach, are speedily absorbed into the circulation ; and this is especially favoured by the very great thirst which almost always occurs after excessive sanguine- ous losses. The blood being thus inordinately supplied with a crude and watery fluid, becomes more irritating to the heart and capillaries, and diluted to such a degree as to pass off more readily by the exhalents. That this is not a hypothetical view of the subject, is shown by the experiments of Harles and Schulze, both of whom rendered animals hydropic by drenching them copiously with water, after they had abstracted from them large quantities of blood. Haller also bears testimony to the fact, that copious haemorrhages produce an increase of serous fluid in the blood. Dropsy from haemorrhage is generally of the anasarcous kind. The blood, in these cases, always contains a very great over-pro- portion of serum, the crassamentum being very small, usually cupped, and often covered with a buffy coat. The pulse is fre- quently full and active, though not hard or tense. Dropsical effusions from haemorrhage, rarely supervene immediately after the loss of the blood. Several weeks, usually, intervene between the haemorrhage and the occurrence of the dropsical swellings. Diseases or torpor of the kidneys, is another, though not a very common cause of dropsy. Dr. Bright* has recently pub- lished some interesting cases of this kind. In nearly all these * See hi» Reports of Medical Cases. London, 1827. HYDROPS. 441 instances, the kidneys were found in a state of disorganization. In dropsies depending on deficient urinary secretion from renal torpor or organic disease, the urine almost invariably contains a large portion of albuminous matter. Among the causes of dropsical effusions, we may also mention amenorrhea, diabetes, chronic gout, the intemperate and habitual use of spirituous liquors, and in short, almost every chronic affection or cause which is capable of exhausting the constitution, or causing important functional lesions. General symptoms.—A dry and harsh skin is almost univer- sally present. The appetite is usually impaired—but when the disease is the consequence of haemorrhage, the appetite for food is sometimes particularly strong. The thirst is generally consider- able, and sometimes very urgent. The bowels are commonly inactive, though readily moved by laxatives. The pulse is irri- tated, and usually indicative of a pyrexial state of the system; for however small and febrile, it is almost always quick and frequent. The urine is scanty, and generally of a deep red colour; some- times jumentose—and occasionally, though rarely, whey-like or chylous. In a diagnostic point of view, much attention has of late years been paid to the appearance and character of the urine. Dr. Blackall has investigated this subject with minute attention; and the observations of Ayre and Wells, have thrown further light on it. The circumstance which has particularly occupied the attention of these physicians, in relation to this subject, is the absence or presence of coagulable matter or serum in the urine of hydropic patients. In many instances of this disease, a greater or less proportion of coagulable serum exists in the urine, whilst in others this excretion is wholly devoid of coagulable matter. Observation would seem to show, that this occurrence is inti- mately connected with the general state of the system; for it would appear that in those cases of dropsy which are attended with an obvious phlogistic diathesis, and especially such as arise from the influence of general causes, the urine, with scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine, may therefore be regard- ed as a pretty correct index of the degree of general inflamma- tory excitement attending the disease. Serous urine may be considered as a kind ofpyrexometer in hydropic affections, which, though not universally to be relied on, is yet sufficiently constant to entitle it to the attention of the practitioner. I am satisfied, from considerable attention to this subject, that in almost every instance where thoie is coagulable serum in she urine of dropsical patients, the general condition of ihc system will be found mani- festly phlogistic. In the dropsies which occur -.Iter scarlatina, the urine generally ^om.un? a large portion of serum; whilst in Vol. 11. * 5G 142 HYDROPS. local dropsies, and in which the general vascular system does not participate, little or no serum is detected in the urine. (Ayre.) When the urine is high-coloured, scanty, and, on cooling, depo- sites a red sediment, or remains muddy, the liver, probably, is in a state of organic disease. (Cruikshank.) After all, it is highly probable, from what is said above, that every case of dropsy is essentially phlogistic, so far at least as relates to the immediate local excitement which gives rise to the effusion. The general system, however, does not always partici- pate in the local affection—the heart and arteries receiving no sympathetic impulse from the local, irritated, or sub-inflammatory action. In such cases, the general circulation is languid, and de- bility and relaxation characterize the disease. Wrhere the heart and arteries do sympathize with the local hydropic affection, and this is by far most commonly the case, the pulse will manifest more or less of a pyrexial state, being sometimes full, hard, and active, or small, tense, quick, and frequent. 1. Ascites.—Dropsy in the Cavity of the Abdomen. Ascites, or abdominal dropsy, is very generally dependent on visceral induration, more especially on scirrhus of the liver or spleen. Whatever, therefore, has a tendency to produce indu- ration of these viscera, may become the remote cause of this form of dropsy. Among the most common and powerful of these causes, may be ranked the habitual and intemperate use of alco- holic liquors; protracted agues; hepatitis; and inveterate dyspep- sia. Whatever may be the remote cause of ascites, however, chronic inflammation of the peritoneum constitutes, no doubt, the immediate and essential cause of the abdominal effusion. Sub- acute inflammation of this membrane, in whatever way it may be produced, terminates perhaps always in effusion; although in some instances, this may not be so copious as to constitute drop- sy. In the majority of fatal cases of ascites, the peritoneum ex- hibits a highly injected state ; and in many instances, the traces of previous inflammation are still more conspicuous and unequi- vocal, its structure being either thickened and otherwise altered, or covered with an infinitude of milliary tubercles. Occasionally, indeed, no marks of pre-existing inflammation whatever are to be seen; but the investigations of modern pathologists have ren- dered it abundantly manifest, that where no disorganization or structural change has been effected, the mere redness, or inject- ed state of inflamed parts, may and does often disappear in arti- culo mortis, or even post mortem. Besides the causes I have just mentioned, it will be sufficient to observe, that every thing which is capable of producing slow inflammation of the peritoneal lining of the abdominal cavity, ASCITES. 443 may give rise to this variety of dropsy—such as cold ; parturi- tion ; blows on the stomach; enteritis; metastasis of cutaneous eruptions, gout, or rheumatism; suppressed habitual discharges; and infarcted bowels. Diagnosis.—The only condition which is likely to be mis- taken for ascites, is pregnancy. From this state it may be dis- tinguished by the fluctuation; the uniformity of the tumour; the lateral pressure and distention of the abdomen on lying on the back ; the oppression of breathing on lying down, so as to raise the pelvis and abdomen higher than the chest; the thirst; the paucity of the urine; the dryness of the skin; which characterize effusion into the abdomen. And, on the other hand, the absence of the peculiar symptoms of pregnancy, assist us in forming a correct diagnosis. When the dropsical accumulation becomes very great, much uneasiness and general disturbance in the system arise from the mechanical irritation which it causes by its pressure on the organs and parietes of the abdomen. Respiration becomes short and anxious; the stomach will admit of but small quantities of drink or food ; the fibres of the abdominal m«scles yield, and the whole abdomen becomes sore and tender to the touch, and a dry and short cough generally comes on in the advanced stage of the dis- ease. Ascites is very rarely wholly unconnected with anasar- cous swellings. Ultimately, oedema of the feet and legs, if not more diffused cellular effusion, ensues. Tke urine is much more apt to be very high-coloured and sedimentous in ascites than in the other forms of dropsy. The bowels too are more torpid, es- pecially in aggravated cases. 2. Hydrothorax.—Dropsy of the Chest. Hydrothorax generally supervenes gradually, without causing, in its initial period, any particular inconveniences or disturbance calculated to excite much attention or suspicion of the true nature of the malady. At length, however, the patient begins to ex- perience a sense of oppression and tightness at the lower part of the sternum, with slight difficulty of breathing when at rest and in an erect posture. He now finds, that on lying down, or using active bodily exertion, especially on ascending an acclivity or stairs, the dyspnoea and sense of suffocation are greatly increased. When recumbent in bed, he raises his head and shoulders high by means of pillows, which, by diminishing the pressure of the effused fluid on the lungs, generally enables him to obtain some sleep. His sleep is, however, frequently interrupted by sudden and violent starts, and feelings of alarm and terror. The pulse is irregular, and commonly very hard; the thirst urgent; the urine seanty, high-coloured, and sedimentous. As the disease advances, 444 nVDROTHORAX. the feet become ocdcmatous; the counteaance is expressive of anxiety and alarm, and of a mixed pallid and livid aspect. There is generally a dry and short cough attending the disease, more especially when the patient lies down, or uses bodily exertion. All the foregoing symptoms increase, if the disease continues unchecked in its course, until the quantity of fluid in the chest is so great, as to prevent the patient from lying down even for a moment, and obliges him to take his short and disturbed pe- riods of sleep in a sitting or leaning posture. The extremities are generally cold, and more or less benumbed. Of all the foregoing symptoms, the sudden starting during sleep is, according to Baglivi, the most certain pathognomonic symptom of this disease. Laennec, however, asserts, that this symptom is sometimes absent; yet, when it does occur, it may be viewed as a very strong evidence of the existence of thoracic effusion. Hydrothorax may occur either as an idiopathic affection, or as one symptomatic of organic disease of some viscus of the chest or abdomen. The former variety of the disease is very rare. (Laennec.) By far the greater number of cases are of the latter kind. Organic cardiac disease is the most common source of symp- tomatic hydrothorax. Structural disorder of the liver and spleen may also give rise to the disease, and cases are recorded, which appeared to have arisen from organic disease of the stomach. Chronic inflammation of the pleura, occurring as the sequel of acute pleuritis, is always attended with hydropic or sero-puru- loid effusion into the chest. A tuberculous state of this membrane, and aneurismal dilatations and ossifications of the large vessels within the cavity of the chest, sometimes give rise to this malady. Besides these peculiar causes, hydrothorax may be produced by any of the general and particular causes mentioned above. Dr. Ayre observes, that a plethoric state of the system predisposes especially to serous effusion into the cavity of the chest—more particularly in persons who have passed the middle period of life, and who have indulged freely in the pleasures of the table. The correctness of this observation will be acknowledged by every one who has paid due attention to this subject. When this dis- ease arises from some general cause, the effusion almost invaria- ably occurs only in one side of the chest; but in those cases which come on in consequence of organic or structural disorder, the dropsical effusion, almost without exception, takes place at. once in both sides of the thorax. (Laennec.) Prognosis.—Idiopathic hydrothorax is not often a dangerous or unmanageable affection. Laennec says, that he considers the instances of death from the idiopathic variety of the disease, as rare as one in two thousand, when under the control of judicious remediate management. Indeed, even in the .symptomatic vai i- HYDROTHORAX. 445 ety of the disease, we may frequently succeed in removing the effused serum ; but this seldom affords permanent relief, since we can but very rarely thus remove the organic disorder upon which the effusion depends, and which consequently still conti- nues to take place, and gives rise to further accumulation. Dr. Ayre asserts, what indeed I am well inclined to admit, that " the means which are sometimes used for the removal of the water in symptomatic hydrothorax, have now and then the effect, at the same time, of removing the organic disorder which gives rise to the effusion." Sir Henry Halford affirms, that he has ascertained from much experience, that if "the swelling in the feet or legs disappears without an increased discharge of urine, the patient generally dies very soon, and most frequently sud- denly."* I have myself remarked this circumstance in several cases. Diagnosis.—Ability to lie down only on the side affected, if the effusion has taken place only in one side. Percussion pro- duces a very obscure and dull sound. The percussion should be made while the patient is in a sitting posture. General agita- tion, cough, and a sense of suffocation when firm pressure is made on the abdomen just below the ribs, so as to push up the viscera against the diaphragm. Inability to rest and sleep in a recumbent posture. If with these symptoms there is habitual cough ; starting during sleep ; tension and irregularity of the pulse; slight oedema of the feet, and of the integuments of the chest; great dyspnoea on ascending an acclivity or stairs, with a disposition to syncope, we may pronounce on the existence of an effused fluid in the cavity of the thorax with confidence. (Roux's edition of Desault's Surgery.) 3. Anasarca—Cellular Dropsy. This form of dropsy consists in a morbid collection of serous fluid in the subcutaneous cellular tissue ; and this accumulation may be either generally diffused throughout the whole body, or confined to a part of greater or less extent. The ordinary, and most unequivocal sign, by which effusion into the cellular tissue is detected, is the pitting from firm pressure with the fingers. Anasarcous effusion commonly commences in the feet and legs, and thence rises up over the body, with more or less rapidity. This, of all the forms of hydropic disease, is the most frequently connected with a sluggish and languid state of the system ; and it is this form of the disease especially, which is apt to supervene on excessive losses of blood, and other exhausting or debilitating causes. The skin is exsanguious, and of a peculiar sallow or • Transact. College of Phys. of London, 1820. 44G ANASARCA. pallid cast; and the patient frequently manifests a great disposi- tion to drowsiness, with a depressed or sluggish state of the intellect. Anasarca is often attended with some degree of abdo- minal effusion ; and the latter, when it forms the primary affec- tion, is rarely wholly free from anasarca. When anasarca arises from general causes, however, it is rarely connected with ascites. In nearly all instances in which these two forms of dropsy co- exist, the effusions into the internal cavities precede those into the cellular membrane, (Ayre.) Local anasarca may be produced by whatever impedes the free return of the blood by the veins. Hence, the gravid uterus, tight bandages, and the pressure of in- durated glands in the groins, often give rise to oedema of the feet and legs, by compressing in some degree the iliac veins. Merc debility too, especially when aided by a long-continued erect posture, will have the same effect; and hence the frequency of oedema during the debility of convalescence from fevers. In nearly all organic diseases of the heart, oedema ultimately occurs in the feet and legs—more particularly in cases attended with ossification of the valves. Anasarca, from suppressed perspira- tion in consequence of the influence of cold, generally comes on and proceeds to its acme rapidly. Prognosis.—This form of dropsy is not often attended with much danger when it occurs as an idiopathic affection—that is, without organic disease, and in consequence of some general re- mote cause, such as cold, arsenic, scarlatina, haemorrhage, &c. When unattended with abdominal or thoracic effusion, it is, upon the whole, much more frequently removed by remediate treat- ment than the other forms of dropsy. The more rapidly the dis- ease supervenes, the more easy in general is its removal. Causes.—Haemorrhages; suppressed perspiration from cold, particularly after scarlatina, or when the system is under the in- fluence of mercury; the long-continued internal use of arsenic ; intestinal irritation ; great debility and exhaustion; repelled cu- taneous eruptions; chronic gout; excessive and long-continued diarrhoea; indurations; organic disease of the kidneys, &c. are the most common causes of this variety of dropsy. Treatment of Dropsy. if the pathology which is laid down in the commencement of this chapter be correct, the principal indications to be pursued in the treatment of dropsy are, 1, to subdue the local subinflamma- tory or irritated action of the structures from which the dropsi- cal exhalation takes place; and, 2, to promote the absorption and remoyal of the effused fluid. The first of these general indica- tions is to be fulfilled; 1, by diminishing the general momentum of the circulation where it is preternaturally great; and, 2, to ANASARCA. 447 derive the blood, as much as possible, from tho capillaries imme- diately implicated in the morbid effusion, and to equalize the cir- culation. The second general indication is to be fulfilled; 1, by promoting the activity of the various serous emunctories; 2, by diminishing the quantity of blood circulating in the venous ex- tremities of the structure from which the dropsical fluid is poured; and, 3, by stimulating the activity of the absorbent system. One of the first and most important measures to be adopted in estab- lishing an adequate derivation of blood from a part, is to diminish the general impetus of the circulation. In vain will we endea- vour to diminish the preternatural afflux of blood to an irritated or inflamed part, if the vis-a-tergo of the circulation, or its gene- ral momentum, be suffered to remain undiminished. Whenever, therefore, the pulse is active, or tense and frequent, in dropsy, blood-letting is an all-important measure. By reducing the mass of the circulating fluid in such cases, we not only predispose the veins to absorb more rapidly, but we contribute, moreover, in a direct way, to the reduction of the process of effusion. I have known one or two efficient bleedings to cause an immediate and conspicuous amendment in the disease.* Muscular debility does not constitute any objection to blood-letting, provided the pulse be active, tense, or hard and frequent. The arterial system may be irritated to vigorous action, whilst the muscular system mani- fests a state of languor and debility. Of course, where the pulse is feeble and languid, venesection is uncalled for and improper. Having moderated the momentum of the general circulation, where it was too great, considerable advantage may, in general, be obtained from local bleeding, by cups, or leeches, applied to the chest or abdomen, according as the effusion may have taken place in one or the other of these cavities. Blisters, also, often assist materially to the successful treatment of ascites and hydrothorax. They tend in a direct way to de- rive the circulation from the irritated or congested serous mem- branes, from which the effusion occurs, and consequently to lessen the effusion, and promote the absorption of the dropsical fluid. In anasarca, or in any other forms of disease attended with ana- sarcous effusion, neither leeching, nor cupping, nor blisters, can be applied without some risk of gangrene, or mortification. Lit- tle or no peculiar advantage can, indeed, be expected from local abstractions of blood in anasarca; and the same observation ap- plies to blistering. Dr. Ayre speaks very favourably of the effects of a seton fixed in the integuments of the chest in hydro- thorax. In one instance of this form of dropsy, which came un- * Dr. Hohnbaum has recorded a case of ascites, which, after paracentesis had been repeatedly performed, was removed by a spontaneous epistaxis.—Analen der Medizin. vol. iv. p. 2G6 of the Sequel. 448 ANASARCA. der my observation, much benefit appeared to result from this measure. I should prefer, however, resorting to blistering and cupping, as being decidedly more derivative and prompt in their influence, than setons or issues. In ascites, leeching, followed by blistering, or cupping, ought never to be neglected, unless the anasarcous state of the surface be such as to render these mea- sures hazardous. Cathartics.—Drastic purgatives have, from the earliest pe- riods of medicine, held a high rank among the remediate means employed in dropsy. They constitute, in fact, a very important class of remedies in this affection. Very active purgation not only often carries off the effused fluid, but in some instances has the effect of removing that morbid state of the peritoneal capil- laries, upon which abdominal dropsy depends. The efficacy of hydragogues is generally more conspicuous in abdominal drop- sy, than in the other varieties of this disease. Their influence upon the morbid condition of the peritoneum, is much more di- rect and powerful, from its contiguity to the mucous membrane of the intestinal tube, than upon the more remote structures con- cerned in the other forms of dropsy. Though, in general, less beneficial in anasarca and in hydrothorax, cathartics are neverthe- less frequently of considerable service even in these forms of dropsy ; nay, in some instances, the effects of active purgation in removing dropsical fluids from the chest, are surprisingly prompt and complete.* Physicians have varied, and still differ in opinion, as to the particular articles of this class of remedies best calculated to procure the desired advantages. It is, indeed, agreed, that those purgatives which are most apt to cause copi- ous ivatery stools—or as they are called, hydragogues, are de- cidedly the most efficient in diminishing dropsical accumulations; but there exists some diversity of sentiment in relation to the rela- tive value of this variety of cathartics. Cremor tartar may be placed at the head of this class of arti- cles, in reference to hydropic affections. It is mild, cooling, and potent in its operation as a hydragogue, and possesses the addi- tional and peculiar advantage of exciting, at the same time, con- siderable diuresis. Dr. Ferriar's statements afford strong testi- mony of its usefulness in abdominal and anasarcous dropsy. Out of forty-three cases treated chiefly with this remedy, thirty-three were cured—a result, which, however, has been but rarely ob- tained by other practitioners. In my own practice I have had unequivocal examples of the efficacy of a course of purgation with this article. I have for ten years past been in the habit of prescribing it according to the following formula, and as it ap- peared to me, generally with peculiar efficacy.— * Print's Principles of Pathology, \>. 2&J ANASARCA. 449 R. P. crem. tart. ^is9. P. eulphat. potassx 33s. P. scillae maritim. Sfii. Tart, antimonii gr. ii.—M. S. A tea-spoonful of this mixture is to be taken four or five times daily. Given in this way, it has never failed, in my hands, to pro- duce copious watery stools, together with a considerable flow of urine, and frequently diaphoresis.* Elaterium is another valuable hydragogue in the treatment of dropsy. Dr. Ferriar asserts, that it surpasses all other articles of this kind, in the removal of dropsical accumulations; and it continues to be a favourite hydragogue with many of the most eminent practitioners of the present day. Dr. Clutterbuck, es- pecially, attaches great value to this article, as a remedy in drop- sy. I have employed it in a considerable number of cases of this disease, but it has not, in my hands, produced advantages equal to those I have derived from cremor tartar. Indeed, I have met with instances in which it did manifest harm, by the violent irri- tation it caused in the mucous membrane of the bowels. It must be constantly borne in mind, that although an excitation of the serous emunctories of the intestinal tube will in general afford advantage, yet when the effects of purgatives on the mucous membrane transcend this grade of excitement, and establish an irritation, bordering or actually passing into subacute inflamma- tion, mischief must inevitably be the consequence. In prescrib- ing such active purgatives, therefore, great care must be taken, lest in our anxiety to produce copious aqueous evacuations, we establish a morbid and permanent irritation in the mucous mem- brane of the bowels, and thus create a new and highly injurious focus of morbid sympathies in the system. Whenever such arti- cles cease to produce copious watery stools, when given in ordi- nary doses, and leave a general sensation of soreness or tender- ness in the abdomen, we are admonished to desist from their further employment. Active cathartics will generally bring off copious watery stools for the first two or three times that they are administered; but by being again and again repeated, they will at last cease to ex- cite the desired evacuations. A larger dose is then perhaps re- sorted to, but the stools will be still more incomplete and pain- ful. Determined to overcome the supposed torpor of the bowels, the physician now prescribes a still more powerful dose, but in- stead of procuring free and watery evacuations, the patient will probably be harassed by small mucous stools, attend with great • This formula wa9 first published by a German writer of the name of Lang- hans. 1 have known it to remove dropsical accumulations very speedily, after a great variety of diuretics and hydragogues had been used without much advan- tage. Vol. II. 57 450 ANASARCA. tormina or tenesmus. Thus, mucous inflammation will be estab- lished in the intestinal tube, and a disease, which under a more judicious treatment might perhaps have been removed, is ren- dered incurable. Gamboge is also a favourite hydragogue with some practition- ers ; and I have myself employed it with much advantage. I have, however, always given it in union with cremor tartar, in the proportion of from two to four grains to a drachm of the lat- ter article. It has appeared to me less apt to excite permanent irritation in the bowels than elaterium. Gamboge is the hydra- gogue which Dr. Ayre prefers. He gives it as Dr. Ferriar did, to the amount of four or five grains at a dose, triturated with a few crystals of super-tartrate of potash. The gamboge rarely fails to cause copious watery stools. With regard to the frequen- cy with which hydragogue remedies ought to be administered in the treatment of dropsy, we must be governed by the general strength of the system, and the particular effects resulting from their operation. When the strength of the patient will admit, the purgatives may be repeated every two or three days, provided they do not produce great tormina and soreness, and provided also that they cause free evacuations. I cannot but think, how- ever, that the use of these remedies is frequently carried to an injurious extent in the present disease. Employed occasionally, and interchangeably with diuretics, they generally contribute materially to the reduction of hydropic affections, more especially of ascites and anasarca. But to exhibit them daily for a week and longer, must put the system to a severe trial, and even if the water be removed, frequently lay the foundation of much future suffering and infirmity. Much praise has lately been given to the Caincae root, (chio- coca racemosa) as a remedy in dropsy. It is said to operate pow- erfully as a hydragogue and diuretic, and some remarkable instances of its efficacy in dropsy, have recently been published, in the medical journals of Europe. This root has lately been imported into this country, and may be had in this city. The mode of employing it is as follows: R. Rad. chiococce racemos. §ii. Aq. bullient. ifeiss.—M. To be boiled down to gviii. Of this a table spoonful 19 to be taken three or four times daily. Diuretics, of all our remediate means, are the most universal- ly employed, and relied on, in the treatment of dropsy. The kid- neys appear to be the most direct and manageable outlet for dropsical effusions, and an important part of the treatment of this disease consists in exciting these emunctories to increased action. Observation has shown, that a full and phlogistic habit of body is much opposed to the free operation of diuretic remedies; and ANASARCA. 451 hence bleeding and purging in such a state of the system, are in- dispensable preliminary measures to the employment of remedies intended to promote the renal secretions. Equally difficult is it in general to procure the operation of diuretics in cases where the dropsical effusion is very extensive, and where the blood-ves- sels are drained of the serous portion of their contents. To obvi- ate the difficulty which arises from this source, it will often be sufficient to allow the patient copious draughts of water, or of some other bland fluids. Dr. Cullen states, that dropsies have been cured by the free use of diluent drinks, without any other remedies. I have known an instance of extensive anasarca cured, after a course of ineffectual treatment, solely by the free indul- gence in eating water-melons. Much dispute has existed as to the propriety of allowing patients the free use of aqueous pota- tions. It has been strenuously asserted by some, especially the older writers, that the plentiful use of drinks in this disease, is decidedly prejudicial. Others, on the contrary, have maintained that this grateful indulgence is not only harmless, but often mani- festly beneficial. Upon this subject, however, no universal rule can be laid down; for the fact appears to be, that, in some instan- ces, a liberal indulgence in the use of drinks is followed by un- favourable consequences ; whilst, in other cases, manifest benefit results from it In all those instances of hydropic effusion which are the result of excessive haemorrhage, copious draughts of di- luent, drinks are, according to my own observations and views, decidedly detrimental. When the blood-vessels are suddenly deprived of a large portion of their contents by haemorrhage, their veinous extremities absorb with great rapidity whatever aqueous fluid may be taken into the system. The blood-vessels will therefore soon be replenished, if much fluid be taken into the stomach; and as this circumstance, from the large proportion of crude watery fluid in the blood-vessels, must favour the drop- sical effusion, as explained in the beginning of this chapter, injury can scarcely fail to result from the free use of diluents in such cases. The blood, in dropsies from haemorrhage, consists almost wholly of serum, the crassamentum being always exceedingly small; and the more drink there is taken in such cases, the long- er will the morbid disproportion between these two constituents of the blood continue. Upon this point, Dr. Parry makes the following observations, which go directly to strengthen the above sentiments. " When dropsy is associated with large haemorrhages, it does not usually accompany them, but comes on after they have ceased; and I have concluded, that it is the effect of the fluids taken into the stomach being absorbed too suddenly for the re- lative state of the vessels, which therefore strive, if I may be allowed the expression, to get rid of it by every outlet." It ap- pears to me manifest, therefore, that in such cases of dropsy, it 452 ANASARCA. will be advantageous to abstain as much from the use of drink as the urgent thirst will admit. In instances arising from other causes, however, and in which the general diathesis is manifestly phlogistic, a moderate indulgence in the use of mild beverages may be allowed with advantage. When, indeed, the thirst is great, and the blood sizy, diluent drinks may be regarded as de- cidedly remedial, and should be very freely taken. Among the diuretics recommended in the treatment of dropsy, the following are the most important, viz. squill, digitalis, acetate of potash, nitrate of potash, cantharides, juniper berries, colchi- cum, spirit of turpentine, erigeron heterophyllum, and parsley. Among these articles, the squill is the most frequently em- ployed, and is, upon the whole, the most useful diuretic in the treatment of hydropic affections. It does not, however, appear to be equally beneficial in all the varieties of this disease; for where there exists much febrile reaction, and the general diathe- sis is decidedly phlogistic, its effects are rarely conspicuously salutary. In instances of dropsy, on the contrary, where the urine is scanty, high-coloured, and sedimentous, with no very decided phlogistic habit of body, its powers are in general peculiarly be- neficial. Almost all writers agree that squills are, generally, the best diuretic we possess in hydrothorax. Blackall, M'Lean, Ayre, and many other respectable writers on this subject, re- commend this article as particularly calculated to do good in this variety of dropsy; and my own experience has furnished me with abundant evidence of the propriety of this recommendation. The squill is commonly prescribed in union with other articles, and it would appear that its diuretic powers are frequently con- siderably enhanced by such combinations. Home thought that its diuretic effects were often much increased, by uniting it with some article calculated to promote its emetic powers; but Cullen strenuously opposed this opinion, and pointed out its erroneous- ness. Perhaps the best adjunct to squills is calomel—especially in the treatment of hydrothorax. I have been most satisfied with the triple compound of squills, nitrate of potash, and calomel, according to this formula. R. Pulv. scillsc 7)i. P. nitrat. potassac sjii. Calomel gr. v. M. Divide into ten equal parts. S. give one every four hours. The only objection which exists against this combination, is its tendency, in some instances, to produce gastric disorder; such as pain in the stomach, nausea, or vomiting. When effects of this kind occur, and the arterial system is not too much excited, one-fourth of a grain of opium should be added to this mixture. The addition of calomel to the squill, it may be again observed, is peculiarly valuable in hydrothorax; for, although this mcrcu- ANASARCA. 453 rial will frequently do much good in the other forms of dropsy, its tendency to increase diuresis, when given in this combination, is generally much more conspicuously displayed in the former variety of the disease. Dr. Blackall asserts, that squills act much more powerfully on the kidneys when given in as large doses as the stomach will bear without nausea, than when given in small portions. Dr. Ayre, on the other hand, recommends the exhi- bition of this article in small but frequent doses; and Richter is in favour of this mode of administering it. I prefer giving the squill, in doses of from one to two grains, every three or four hours, whether singly or in combination. The squill is also fre- quently given in Combination with digitalis; and many add to this combination, small doses of calomel. In anasarca from scar- latina or cold, digitalis may in general be very advantageously given in this manner. The most serious objection to the employment of squill, is its aptitude to irritate and derange the digestive organs. Its tenden- cy, in this way, is so considerable in some individuals, that it cannot be used at all. Indeed, some persons appear to have an idiosyncrasy against the influence of this article—rendering even small doses injurious. Besides the formula given above, I will add another one, which, in some instances, has, in my hands, produced copious discharges of urine. R. Pulv. rad. scill. gr. viii. Pulv. pip. nigu. gr. x. P. nit. potass, gr. xviii. Submuriat. hydr. gr. iv. Pulv. opii gr. ii. This (altered from Fordyce,) is to be given once daily. I have found this combination particularly efficacious in cases attended with much languor and relaxation of the system. Richter men- tions it as peculiarly useful in cases of this kind. Digitalis is another valuable diuretic for the treatment of dropsy. The most opposite opinions, however, are expressed in relation to its powers in this disease. By many it is highly ex- tolled ; whilst some speak of it as of little or no essential value. The weight of good testimony is, nevertheless, decidedly in fa- vour of its usefulness ; although, generally, it is undoubtedly in- ferior to the squill, as a diuretic in hydropic affections. Accord- ing to the observations of Withering and others, digitalis seldom does much good in persons of a robust habit and tense fibre. Its beneficial powers are most apt to be manifested in subjects of a relaxed and irritable habit of body. Dr. M'Lean entirely confirms this observation of Withering. He asserts, that he has seldom derived any particular advantage from this article, in persons of a corpulent habit and an inirritable fibre; but in such as were of " a weak, delicate, irritable constitution, with a thin, smooth, 454 ANASARCA. and soft skin," he has generally succeeded well with this remedy. So far as my own experience enables me to judge, 1 am inclined to think, that there are good grounds for these observations. Dr. Blackall observes, that digitalis is our best remedy in those cases of dropsy which occur after scarlatina and measles; an observation which I believe to be well founded. I have known the diuretic effects of this article, in such/cases, promptly efficient in removing the dropsical accumulation. Digitalis would appear to be especially useful in those cases of dropsy that are attended with a very scanty secretion of urine, be- coming turbid when cold, and coagulating when exposed to the heat of a lamp, and depositing a red sediment after standing for some hours. (Blackall.) When the urine of hydropic patients, though loaded with serum, is pale and crude, and rather abundant, digitalis, according to this writer, very seldom does any good. In such cases, he says, the squill is the best diuretic we possess. These observations deserve particular attention, in the selection of an appropriate diuretic ; for, although they may not be univer- sally, or perhaps even very generally, applicable, there is suffi- cient correctness in them, as a general guide, to afford considera- ble assistance in the adoption of our remediate means. Digitalis is not often employed singly. The most common mode of prescribing it, is in combination with squills. In cases attended with considerable febrile excitement, it may be very advantageously given in union with nitre. In very feeble habits, where there is much restlessness, spasmodic dyspnoea, and fre- quent and distressing urgency to void urine, I have known a combination of opium with digitalis to afford much relief. The addition of opium to this, or to whatever other diuretic may be used, is especially called for in cases attended with frequent and ineffectual efforts to evacuate the bowels—a condition which is sometimes superinduced by the inordinate use of drastic purga- tives. Digitalis ought to be administered in substance; it has appeared to me to do most good, when given in small but fre- quent doses—that is, from one-sixth to one-fourth of a grain, every hour or two, until its peculiar influence on the system is perceptible. In general, this article is more effectual in remov- ing anasarca than ascites, and ascites than hydrothorax. Many physicians are in the habit of prescribing it, in union with calo- mel; and there can be no doubt, that under certain circumstances, this combination will act with peeuliar advantage. Drs. Blackall and Paris, however, decidedly condemn this practice. Conceiv- ing that the curative powers of digitalis, in dropsy, are dependent on its sedative effects, they maintain that calomel, being a stimu- lant of no inconsiderable powers, is incompatible, as a therapeu- tic agent, with the digitalis, and that it mu.>i. necessarily tend rather to counteract than to promote the salutary influence of the ANASARCA. 455 latter. This objection appears to me hypothetical; and it cer- tainly is frequently contradicted by experience. There is no good ground for believing that the diuretic effects of this article depend on its sedative powers ; for the former effect is generally most conspicuously evinced when the action of the heart and arteries is least reduced ; and, on the contrary, diuresis is some- times entirely wanting, when the sedative influence of the digi- talis is the most conspicuous. In general, the more phlogistic the diathesis, the more appro- priate will this article be. In such cases, we may employ it with the twofold intention of exciting an increased flow of urine, and of moderating the general vascular irritation. Cantharides have been employed, with no inconsiderable de- gree of success, in the treatment of dropsy. * Where the general habit is weak and sluggish, and, especially, where the disease is connected with an original torpor of the kidneys, this article sometimes excites copious diuresis. Hufeland recommends the following formula for administering the cantharides in this dropsy. R. Pulv. canthar. 9'u. Amyd. dulc. §i. Sacch. alb. §iss.—M. Rub them together in a mortar, and make an emulsion, by adding gradually ten ounces of warm water. Of this a table- spoonful is to be taken every two or three hours, until symptoms of strangury supervene. I have known this mixture to reduce anasarca from suppressed menses, very speedily. It appears to be particularly adapted to cases arising from suppressed cutaneous affections. (Richter.) Colchicum autumnale has not, hitherto, been much employed in the treatment of dropsy ; its powers, however, deserve more attention in this respect, than it appears, as yet, to have obtained. I have derived great benefit from this medicine in a case of ana- sarca, apparently the consequence of a gouty habit; and I am dis- posed to place considerable reliance on it in all cases attended with a rheumatic or gouty diathesis. I have found it most effica- cious as a diuretic, when given in union with the sulphate of pot- ash. In the case just alluded to, I gave forty drops of the vinous tincture, with a scruple of the powdered sulphate of potash, every six hours. The Nitrate of potash has been much employed, and occasion- ally with the happiest effects, in hydropic diseases. It is usually given in combination with other articles—particularly squills and digitalis. I have employed it by itself, with much benefit, • Prispane's Select Cases. Chalmers on the Diseases of South Carolina. Ro- bertson's Treatise on the Powers of Cantharides used internally. Kdinb. 1826. 456 ANASARCA. in a few cases of ascites. It will rarely do any good in hydro- thorax. From its known antiphlogistic powers, it is manifestly only in cases characterized by a phlogistic habit of body, that any particular advantages can be looked for. When the pulse is small, corded, and irritated, nitre and opium in combination, frequently do much good. From fifteen to twenty grains of the former, with from one-fourth to half a grain of the latter, may be given every three hours. I have known this combination to render the pulse soft and expanded, the skin moist, and the urine copious. There are a number of other diuretic remedies, all of which have been used with more or less of success in the treatment of dropsies. It is by no means uncommon to succeed in removing dropsical accumulations through the renal emunctories, by some simple diuretic article, after the more powerful and esteemed re- medies of this kind have been tried without success. I have known the infusion of the erigeron heterophyllum, to bring on copious diuresis, and to reduce dropsical swellings speedily, after the remedies already mentioned had been given unsuccessfully. This is, indeed, an article which merits no small degree of atten- tion, as a diuretic, in this disease. It may be conveniently em- ployed as a ptisan, along with the squill, digitalis, or some other more powerful article. The infusion of the seed of daucus caro- ta, too, is an excellent diuretic, and has been a good deal em- ployed by the practitioners of this country. Of a similar charac- ter are juniper berries,'lactuca virosa, gallium aperine, horse radish, and a number of other diuretic vegetables, employed as domestic remedies, and occasionally also in regular practice. Of the usefulness of the gallium, I can speak from experience. I knew an instance, where a strong infusion of this vegetable re- moved a long standing case of abdominal dropsy in a very short time. Whatever remedies may be prescribed, the concomitant use of some one of these ptisans will generally contribute, more or less, to the success of the treatment. When the stomach will bear it, the erigeron will, in general, answer better than any of the other articles just mentioned. This was a favourite medicine with the late Dr. Wistar. It is well to have a variety of diure- tics at hand, in the treatment of dropsy; for in some instances, a number of the most active medicines of this kind will be used without the least perceptible action on the kidneys, and yet, at last, there will be some one found, which will speedily produce copious diuresis. It is a good rule to vary the prescription, if after a reasonable time, and proper auxiliary measures, the desired effect does not ensue.* • Dropsy is a disease by no means so uniform In its character as is generally supposed. U arises from a great variety of reroute causes—in the most opposite ANASARCA. 457 Diaphoretics are mentioned by Celsus as among our best means for the cure of dropsy. We can very rarely procure the full operation of diuretics, so long as the skin remains uniformly dry and harsh. The union, therefore, of antimonials with diuretics, will, in instances of a decidedly phlogistic character, often assist materially in removing dropsical accumulations. Sydenham ap- pears to have placed very considerable reliance on the employ- ment of antimony in this affection, although his principal object in prescribing it was the production of active vomiting—an effect which sometimes procures the speedy absorption and removal of dropsical accumulations from the abdomen and cellular tissue. I have never myself employed antimony with this view; but as a diaphoretic, I have known it to produce very happy effects. In those cases of anasarca and ascites, which occur in consequence of suppressed perspiration from cold when the system is under the influence of mercury, or after an acute cutaneous disease, I know of no remedy which will more certainly procure relief than antimony, given in minute and frequently repeated doses. I have also known it speedily successful in a case of anasarca from a protracted intermittent. In general, wherever the excit- ing cause of the disease is cold, or connected immediately with torpor of the cutaneous exhalents, antimony ought not to be ne- glected as a means of relief. I have always given it dissolved in a large proportion of some diaphoretic beverage—such as infu- sions of juniper-berries, wild-carrot seed, parsley, or erigeron. One grain may be dissolved in a pint of any of these ptisans, and drank ad libitum during the day, so that at least one, and, if convenient, two pints, may be taken in this space of time. Mon- ro speaks favourably of a combination of antimony and opium: when the disease is attended with a rheumatic habit, this mixture is often especially beneficial. It must not be forgotten, however, that very profuse perspiration and diuresis are incompatible; all that is requisite, in relation to the action of the skin, when we continue to act on the kidneys, is to render it soft, relaxed, and moderately moist. states of the system, with regard to vascular action and repletion—it is dependent on various organic affections; appears as a consequence of different acute and chronic affections, and is attended with diverse and distinct characters of the urinary secretion. Thyse circumstances point out much diversity in the general character of the disease itself, and it is not reasonable to suppose that any one particular diuretic is equally applicable to the disease under all these diversities of general character. When, moreover, we take into view the diversities of con- stitutional habit—of idiosyncrasy—and the e\er-varying stale of th<- organic I'unc- tion.i—we can readily conceive, that out of a great number of diuretics, there might not be more than one which is calculated, in a particular instance, to ex- cite the action of the kulneys. it is, therefore, a good rule, to vary the prescrip- tion, if after a reasonable time, and proper adjuvant measures, the desired effect does not follow. Vol. 11. 58 \ \ 458 ANASARCA. In those cases of anasarca, in which the skin is cold and very dry, with a sluggish action of the pulse, the black sulphuret of iron is a medicine of excellent powers. Dr. Archer, of Norfolk, has reported an interesting case which was speedily cured by this remedy. It is also mentioned by Alibert,* as an excellent me- dicine in anasarca attended with great relaxation and weakness. I have had occasion to prescribe it in two instances of this kind —both the consequence of immoderate lochia, and great previous debility ; and the results were highly gratifying. This article generally excites a glow of warmth throughout the whole body, attended with a peculiar tingling sensation in the extremities ; and, in most instances, a profuse perspiration ensues a few hours after it is taken. Besides its diaphoretic effects, it is also pecu- liarly calculated to do good in such cases, by its tendency to invi- gorate the assimilating functions. I am not aware that any advan- tages are to be obtained from this article, in any other cases than such as proceed from excessive haemorrhages, or other exhausting and relaxing causes. Diaphoretics are in general decidedly use- ful only in anasarcous dropsy. Among the ancient Romans, it was customary to excite sweating in this disease, by burying the body up to the neck in warm sand ;t and I may here also men- tion the use of oiled silk, which, when closely applied over the surface of the body, generally excites a considerable perspiration. This application is particularly useful in local dropsical effusions into the cellular tissue. % Emetics have by some been highly extolled for their power of removing dropsical accumulations. I have already mentioned Sydenham as an advocate for their employment in this disease ; and I may add the authority of Richter, Lentin, Cruikshank, and Pinot, in their favour. I knew an instance of ascites which was removed by spontaneous and protracted vomiting ; but I have never yet prescribed remedies with a view to their emetic operation in this disease. Mercury is a favourite remedy, with many of the American physicians, in the treatment of dropsy ; and there can be no question as to its utility in certain modifications of the disease. In cases depending on hepatic and splenic disorder, it constitutes our main stay ; and in the treatment of hydrothorax, it is gene- rally highly beneficial. In instances which occur in consequence of excessive haemorrhage, or other exhausting.causes, and in sub- jects of a scorbutic or depraved habit of body, mercury cannot be employed with propriety. Some degree of firmness of the general habit may be regarded as the most favourable for the exhibition of mercury, with a view to its constitutional influence. * El£mens de Therapeutique, torn. i. p. 180. f Celsus. De Medicina, lib. iii. cap. xxx. $ Kichter. Specielle Therapie, vol. iii. p. 59. ANASARCA. 459 (Blackall, M'Lean.) A decidedly inflammatory condition of the system, however, is opposed to the beneficial influence of mercury in this disease ; and where such a diathesis is conspicu- ous, antiphlogistic measures must precede its employment Ca- lomel is the preparation usually prescribed m dropsy. As a gene- ral rule, mercurialization should not be carried beyond the extent of producing only a slight soreness of the gums;—profuse ptya- lism being not only unnecessary to procure the peculiar advan- tages of this remedy, but sometimes, perhaps generally, injurious in its consequences, more especially in anasarca. This article, as has already been stated, is almost always given in combination with some diuretic, particularly squills and digitalis. In ascites, much benefit may sometimes be derived from mercu- rial frictions on the abdomen. From some cases which have been recently published, it appears that subacute inflammation of the peritoneum often yields to mercurial frictions, without scarce- ly any aid from other means. Laennec has cured cases of effusion into the abdomen by this application, after a variety of other remedies, usually relied on, had been employed without benefit.* Tonics were, at one time, much employed in dropsy. The disease was supposed to depend chiefly on debility and relaxa- tion, and every effort was accordingly made to invigorate the system. In general, this class of remedies is not only useless, but injurious. Occasionally instances are met with, in which tonic remedies produce very good effects. Where the general debility and languor are very great, and the pulse feeble and sluggish, bark, iron, particularly the muriated tincture, and the vegetable bitters, may perhaps be used with advantage. Gum kino, in large doses, cured a case, after various other remedies had been used without benefit, t The sulphate of copper has been frequently given with complete success in cases of dropsy attended with great vascular debility. Gardane, Chalmers, and Wright, mention successful instances of this kind. This remedy has been generally given in combination with opium, in doses of a grain of each three times daily. It were, indeed, almost an endless task to give an account of all the remedies, which, under peculiar circumstances, have removed dropsical accumulations. The following are the prin- cipal articles of this kind. Ipecacuanha, Dover's powder, helle- borus niger, pillulae hydragogse janini, radix sambuci, the fixed alkalies, J millepedes, lactuca virosa, garlic, scandix cerefolium, * Revue M£dicale, Mai, 1824. f Medico-Chirurg. Review, July, 1827. t The alkalies are sometimes decidedly beneficial. Monro, Pringle, Mead, and Fallot, speak of them in terms of encomium, as remedies in dropsy. They are said to be particularly applicable in cases attended with great atony. They have been generally given in union with vegetable bitters. 1 attended an old 460 ANASARCA. apium graveolens, onions, iris palustris, sorbus aucuparia, balsam copaiva, turpentine, olive oil, opium,* apocynum cannabinum, pipsissiwa, trifolium fibrinum, camphor, and asparagus. Dr. Laurie has published cases which tend to show that the internal use of nitric acid is often very efficacious in those forms of drop- sy which succeed to acute febrile diseases, t The external application of diuretic agents, has of late years been employed with considerable success in this disease, by some of the French physicians. It would appear from the accounts which have been published, that the kidneys may often be as actively excited by diuretics applied in frictions to the surface of the body, as when taken internally. Where the stomach is weak and irritable, a condition so peculiarly opposed to the regular operation of diuretics, the external mode of using them, if, in truth, their remediate influence may be thus fully obtained, would be decidedly preferable. I have seen but one instance of this disease, in which the production of diuresis was attempted in this way, and this case afforded me sufficient evidence, that some ad- vantage, at least, may be obtained from frictions on the abdo- men, with diuretic remedies. In a recent number of the Revue Medicate, % there are four cases of thoracic and abdominal dropsy recorded, which were successfully treated upon the iatraleptic plan. The author, Dr. Guibert, directed frictions on the chest, or the abdomen, or the thighs, according to the form of dropsy present, with the following fluid. R. Tinctura scillae. ---------digitalis. • ---------sem. colchic. aa ^ss. 01. camphorat. t^iss. M. The frictions to be made with flannel three or four times daily, and continued from five to twenty minutes. Concomitantly with this external application, he ordered a diuretic mixture to be taken internally, composed of squills, digitalis, and nitrate of potash in equal quantities, and a somewhat larger portion of thri- dace, in doses of two grains and a half of the mixture twice daily. "The iatraleptic method of treating dropsy," says Dr. G., "has lady, during the present year, (1828) affected with ascites and anasarca of the inferior extremities, in whom I found no remedy so useful as the salt of tartar in union with the expressed juice of tansy. She took ten grains of the alkali with a table-spoonful of the juice, thrice daily. The celebrated Frank thought highly of the powers of the alkalies in dropsy. His formula is,— R. Kali, carbon, fbj. Herbae absinth. 3ji. lnfunde c. viii. rhen. Ibj. Digere per xxiv. horas cola. Dose, one ounce every four hours. * I have prescribed opium in a case attended with a rheumatic habit with une- quivocal benefit. f Analen der Medizin. vol. iv. p. 266. * Septembre, 1828, p. 349. ANASARCA. 401 appeared to me particularly efficacious in abdominal dropsy, and it is chiefly to the external employment of the above diuretic li- niment, that I think myself warranted to ascribe the success which attended my efforts in the above cases. The internal remedies which I employed at the same time, seemed to me very useful auxiliary measures, but they could not, I am persuaded, have by themselves produced the very copious urinary discharges, resem- bling almost complete diabetes, which occurred in these cases under this treatment. In all of these cases, and I might adduce others equally remarkable, the dropsical swellings were reduced with surprising rapidity. The iatraleptic mode of treating this disease is attended with little or no inconvenience to the patient. It should not, however, be adopted, until the phlogistic state of the system is reduced by appropriate antiphlogistic means. In idiopathic ascites and anasarca, this mode of treatment will suc- ceed almost without exception." Among the external means which may be resorted to with occasional advantage in ascites, a tight flannel bandage worn around the abdomen will frequently prove decidedly beneficial. This application was much extolled by the late Dr. Monro, in the treatment of abdominal dropsy. I have repeatedly found such a bandage of advantage, particularly after the dropsical swellings had been in part removed, but continued stationary for some period. The effects of the bandage will be increased, if previous- ly soaked in a strong solution of salt, and dried again before it is applied. Would not the powers of such a bandage be still more enhanced, by imbuing it with a strong infusion of squills, or of some other active diuretic ? After all, our efforts to prevent or remove dropsical effusions are but too frequently foiled; and it becomes necessary, in order to prolong the life of the patient, and to gain more time for re- mediate applications, to evacuate the collected fluid by means of a puncture into the cavity which confines it.* It is usual to de- lay this operation until every other measure for the removal of the fluid has been found unavailing, and the distention from the effused water has become so great as to threaten immediate dan- ger. This is one of those errors in medical practice, which, though readily and generally acknowledged by practitioners, it • It is truly surprising what large quantities of water are sometimes drawn in the aggregate, in cases of abdominal dropsy. M. Lecourt de Cantilly has re- lated an instance in which the operation of tapping was performed one hundred and thirty-five times in the course of six years, and by which the aggregate amount of two thousand seven hundred pounds of water was drawn off'. Mead mentions a case ,(?noniia) in which tapping was performed seventy times in live years and seven months, which yielded one thousand nine hundred pounds of water. M. Louyer Villermay relates an instance where tapping was undergone five hundred times, the patient having finally tapped himself.—Revue Medicate, Juillet, 1828. 462 ANASARCA. is extremely difficult to correct, on account of the great dread which all surgical operations, and especially such as penetrate into the large cavities, are so apt to excite in patients. Being, more- over, universally viewed as the last resource, and only for a temporary procrastination of the fatal conclusion, few are willing to submit to the operation, until all other means for removing the water have been tried. Without doubt, however, tapping is by far the most direct and certain means for removing dropsical accumulations, and it is as safe in its consequences as any of the other measures that may be adopted for this purpose. Were tap- ping more early resorted to in ascites than it always is, there can be but little doubt, that its permanent usefulness would-be greatly enhanced. The mere mechanical irritation of the effused fluid, when the distention is very great, must tend to keep up that morbid condition in the peritoneum which gives rise to the effu- sion. The earlier this over-distention is taken off, the greater, one may reasonably presume, must be the chance of effecting a radical cure, by some of the means already mentioned—more es- pecially by local bleeding, blistering, mercury, and frictions. Indeed, the operation is by no means simply palliative in its consequences. There are many cases on record which were per- fectly cured, solely by removing the water by an operation. Frank, Lentin, Richter, Desault, Fothergill, and qthers, relate cases of this kind ; and there is reason to presume, that if tapping were not so commonly delayed until the disease has assumed an inveterate character, such fortunate terminations would be much more frequent than they are under the present plan of procras- tinating it* * M. Lhomme, in January, 1827, communicated to the French Royal Academy of Medicine an inveterate case of ascites, which, after hydragogues, diuretics, and tapping, had been fully but unavailingly employed, was speedily cured by the injection of the vapour of wine into the cavity of the abdomen through an orifice made with a trochar. He was led to the employment of this anceps remedium, by having read in the Annates de la Medicine Physiotogique, an account of two cases of abdominal dropsy which were cured by the same means. The vapour of wine was injected sixteen times without causing any pain or particular uneasi- ness in the abdomen, with the exception of some slight colic pains which required no remediate attention. At the time of reporting the case, two years had already elapsed from the period at which the injection was made and the malady arrested. M. Lhomme tried the same means in another case, but without success. No un- pleasant consequences, however, resulted from the operation. It is not difficult to conceive how such a measure might put a stop to dropsical effusion, if a state of chronic inflammation of the peritoneum be its cause. It is well known that stimulating applications are generally the only means effectual in removing in- flammations of a low or languid grade of excitement. We thus remove gleet, chronic ophthalmia, and chronic bronchitis, by stimulating injections, collyna, and inhalations of the vapour of tar.—Revue Me'dicak, vol. i. p. 343. SCROFULA. 463 CHAPTER IX. CHRONIC AFFECTIONS OF THE LYMPHATIC SYSTEM. Sect. I.—Scrofula. Scrofula appears in a great variety of forms and grades of violence—varying from the slightest habitual deviations from health, to the most distressing, rapid, and fatal forms of local and general disease. In a general way, scrofula may be divided into two distinct forms; namely, its latent and its active states. The former constitutes what is usually called the scrofulous habit or diathesis; and the latter, the state of full development and acti- vity of the disease. The scrofulous habit, or predisposition to the active forms of the malady, is characterized by the following phenomena: a pe- culiar delicacy and languor of the countenance, wkh a soft, rosy tint of the prolabia and cheeks ;* or a pale, soft, flaccid, and ap- parently tumid aspect of the countenance, with a dull lead-colour- ed circle round the mouth, and a swollen appearance of the upper lip. The hair is generally fair, and the eyes blue or black. The head, particularly the posterior part, is usually large, and the temples flattened, or somewhat depressed. There is, in general, a great proneness to slight catarrhal affections, during which the wings of the nose and upper lip are apt to become swollen. The edges of the eyelids are much disposed to become inflamed, and where the scrofulous tendency is strongly developed, the tarsi are almost constantly red and tender. The digestive powers are usually weak and irregular, and the bowels are apt to be either constipated, or affected with painful mucous diarrhoea. The ap- petite, also, is very variable—being sometimes entirely depressed, and at others very urgent. The urine commonly deposites a whitish sediment, and becomes turbid some time after it is pass- ed. A disposition to transient swellings of particular parts, as of the face and scrotum, is mentioned by some writers as belong- ing to this habit. In female children, a leucorrhceal discharge is apt to occur, from'time to time; and in very young children, excoriations behind the ears, scabby eruptions about the head and * This appearance of the countenance is particularly met with in those instan- ces of a scrofulous habit, in which a particular tendency to phthisis pulmonalis exists. Mr. Lloyd, however, asserts, that there are no just grounds for regarding the white and rosy cheek, the flaxen hair, and azure eyes, as marks indicative of the scrofulous habit. 464 SCROFULA. lips, obstinate ophthalmia, together with a fretful and irritable temper, are among the most common phenomena attending the scrofulous diathesis. The growth of the body usually proceeds slowly; but the mental powers are generally precociously de- veloped, and often astonishingly active. This dormant or inac- tive state of the disease may continue for many years, and at last pass off without terminating in any particular local affections. More commonly, however, the scrofulous habit gradually ac- quires strength, and at last, under the influence of the usual ex- citing causes, shows itself in its more obvious and active form. The lymphatic glands along the neck and other parts, become enlarged and firm to the touch, in which condition they may re- main for years, without either receding or going on to a more ac- tive form of disease. In general, however, they pass by degrees into slow inflammation, which at last terminates in suppuration or scirrhus. When they suppurate, which is by far the most com- mon mode of termination, they form chronic indolent ulcers, from which a thin, milky, and somewhat viscid fluid is copiously discharged, and which are always extremely slow in cicatrizing. The cicatrices left by these ulcerations are, in general, easily dis- tinguished from those left by other ulcers. They arc peculiarly uneven, irregular, and conspicuous. In connexion with these tumours or ulcerations about the neck, the eyelids and conjuncti- va are very apt to become affected with obstinate inflammation ; and, in some instances, much irritation occurs in the mucous membrane of the nose and bronchia. In a more advanced stale of the disease, the salivary and thyroid glands, as well as the pancreas and other internal glandular parts, become enlarged and indurated. Scabby eruptions appear on different parts of the sur- face ; the extremities of the long bones enlarge; ulcerations occur in the cartilaginous structures; some of the bones become carious; the large joints inflame and suppurate; in some instances the ver- tebrae become diseased ; and occasionally the bones and soft parts of the nose, palate, and fauces, arc more or less rapidly destroyed by ulceration! There is, in short, scarcely any part of the body which is not sometimes the seat of the frightful ravages of this affection. The most common forms of scrofula, however, are, tubercular phthisis pulmonalis; white swelling, or disease of the hip and knee joints, and ophthalmia. The general progress and duration of scrofula are exceedingly various. In some cases it is developed in infancy, whilst in others the constitutional tendency to the disease remains dormant until the age of puberty, or to a period much later, before it manifests itself in an active state. Some individuals are more or less allected with scrofulous disease of the lymphatic glands during the great- er period of a long life, without experiencing any particular suffer- ings from this source. Much more commonly, however, some SCROFULA. 465 one or more of the distressing and fatal consequences already mentioned, ensue before the age of manhood. Although scrofula is vastly more common during childhood than at any other pe- riod of life, yet the occurrence of decided scrofulous affections in new-born infants is an exceedingly rare phenomenon. Mr. Lloyd, nevertheless, states, that he found the lungs of an eight months foetus tuberculous—the mother having died of phthisis pulmonalis; and a few similar instances may be collected from writers on this subject. The manifestations of the scrofulous habit seldom make their appearance before dentition commences. Causes.—Scrofula, or rather an especial predisposition to this disease, is one of those constitutional habits or tendencies which often occur in children as an hereditary diathesis. This, how- ever, is by no means the only source of the scrofulous habit; for that it may be generated in individuals originally of sound con- stitutions, and born of parents perfectly healthy in this respect, by various external influences, admits of no doubt. The causes which are acknowledged to be most frequently and actively con- cerned in the production of a predisposition to this disease, are— 1. Climatic and atmospheric influences. It would appear that the influence of hot climates, in infancy and early youth, has a considerable tendency to predispose the system to the oc- currence of the scrofulous diathesis, from the subsequent influence of a cold and variable, and damp atmosphere. Scrofula is a very uncommon disease in the East and West-Indies; but when the children of Europeans, born in these climates, or even the na- tives, are brought to reside in the variable climates of Europe and this country, they are in general particularly liable to suffer more or less from scrofulous affections. "We know at least," says Dr. Allison, "that a great majority of the inhabitants of the West and East Indies, both negroes and Hindoos, are unusually prone to scrofula when they come to temperate climates."* A cold, humid, and variable atmosphere, more especially when aid- ed by deficient and unwholesome nourishment, appears to have a strong tendency to favour the development of the scrofulous habit. It is from this cause, probably, that in the deep and nar- row valleys of Switzerland and Savoy, in which the atmosphere is very variable and humid, certain forms of scrofula are so very common. In Holland, and in some of the marshy districts of England, this disease is said to be peculiarly prevalent. 2. The impure and confined air of populous cities also seems particularly capable of promoting the occurrence of scrofulous diseases. It is certain, at least, that in the same amount of popu- lation, this malady is vastly more common in large and crowd- ed cities than in the salubrious districts of the country. " It is * Observations on the Pathology of Scrofulous Diseases, &c. p. 397. Vol. II. 59 466 SCROFULA. notorious," says Dr. Gregory, " that the population of our large manufacturing towns—Manchester, for instance—pent up during the day in cotton mills, are of all others most affected with it." 3. Deficient and unwholesome food, with the usual attend- ants, squalidness and mental depression, may contribute to the production of the scrofulous diathesis. Without doubt, however, coarse, indigestible, and irritating articles of diet, when habitually and freely used by young children, have a much more decided tendency to produce this affection, than mere deficient or innu- tritious aliment. An improper dietetic management of very young children, in relation both to quantity and quality, is pro- bably one of the most common sources of scrofulous affections. By over-distention of the stomach, or the use of heavy, irritating, or indigestible food, dyspepsia and high irritation of the gastro- intestinal mucous membrane will seldom fail to supervene; and as this condition of the stomach and bowels is usually attended with a morbid appetite, more food is habitually taken into the stomach than can be digested, and the gastro-intestinal irritation is thus kept up, until the chylopoietic and assimilating functions, and indeed the whole system, become intimately deranged. No- thing is more common than to meet in children, who have been mismanaged in this way, and who are almost constantly eating from morning to night, glandular swellings along the neck, and scabby eruptions on the head and face, with tense and tumid ab- domens, and other symptoms of gastro-intestinal disorder, where, from the health of the parents, no hereditary taint can be pre- sumed to exist. Chronic inflammation, or habitual irritation of the mucous membrane of the stomach and bowels, is pro- bably much more frequently concerned in the formation of the scrofulous habit, than seems to be* generally supposed. There are few children long affected with what is usually called marasmus, who do not subsequently manifest a predisposition to scrofulous affections. 4. Various diseases possess a tendency to give rise to the scrofulous diathesis. This is especially the case with measles, scarlatina, and whooping-cough; but it would seem, that it is rather by the influence of cold, and errors of diet, during the stage of convalescence from these diseases, that the scrofulous habit is generated, than by any direct tendency in these affections to de- velop this diathesis. Without specifying any more causes of this kind, however, we may observe, in a general way, that whatever tends permanently to derange the digestive powers, and to debilitate the general system during infancy and childhood, is calculated to engender a predisposition to scrofula. My own observations, though limited in relation to this dis- ease, have led me to the conviction, that disorder of the digestive organs, from whatever cause it may arise, often constitutes the SCROFULA. 467 principal source of scrofulous symptoms. Upon this point, the observations of Dr. Carmichael appear to me to possess much interest and value. "I have adduced,'" he says, " incontrovert- ible facts, which demonstrate that disorder of the chylopoietic viscera precedes and accompanies the symptoms of scrofula, and that there are the strongest grounds for believing that such dis- order is, in a very great majority of cases, the immediate cause of the disease. A defective digestion continued for any length of time, must as certainly produce chyle or blood of a vitiated quality, and unfit to replenish the waste of the body, as the con- stant use of unwholesome food. A disordered state of the sys- tem first ensues, and is followed by various local complaints. It is highly probable, however, that the gastro-intestinal irritation, which always attends, in a greater or less degree, where the digestive functions continue long in a disordered condition, contributes as much, and perhaps much more, to the production of the scrofulous symptoms in such cases, than the vitiated chyle which is prepared by the stomach."* It need scarcely be observed, that where there exists an here- ditary or natural predisposition to scrofula, the foregoing causes have an especial tendency to excite it into a state of activity; for it is sufficiently obvious, that whatever is capable of originating the peculiar diathesis in question, will be still more apt to call it into action where it already exists. Scrofula cannot be communicated by inoculation, or in the manner of a contagion. Hufeland inoculated healthy children with matter taken from mild scrofulous ulcers, without the least perceptible consequences on the health of the inoculated indivi- duals.! Mere local ulcers or scabby affections have, indeed, been known to occur from the frequent application of the matter dis- charged by ulcerations of this kind. Thus, healthy children who sleep with persons affected with scrofulous scabby eruptions about the head, will sometimes become affected with similar disorders. But these do not possess the character of true scrofula. Pathologists have expressed a variety of opinions in relation to the essential nature of the scrofulous diathesis ; but the most plausible doctrine upon, this point is, that the scrofulous habit consists in constitutional or acquired excess of irritability in the lymphatic system, in connexion with a weak condition of the assimilative powers. Prognosis.—Where the predisposition is hereditary, the chance of subduing scrofula, after it has manifested itself in an active form, is always extremely small. Nevertheless, it is a fact well established, that even where the diathesis is manifestly * Carmichael on the Venereal Disease, p. 351. t Ueber die natur, kendniss, und heilart der scrophel krankhert, p. 105. 468 SCROFULA. congenital, moderate cases of the disease not unfrequently disap- pear entirely about the age of puberty, or after the corporeal development is completed, and the age of manhood has arrived. It must be observed, however, that these epochs in the physical development of the system, are much more frequently attended with results of a very contrary character ; for it is precisely at these stages of life, that the scrofulous habit is most apt to pass from a latent to an active state. Similar observations apply to the effects of acute general diseases. Severe febrile affections have been known to remove incipient scrofula, inhabits obviously predisposed to the disease ; but, as has been already stated, it is vastly more common to find the disease more or less rapidly developed by violent febrile affections—more especially measles, scarlatina, and small-pox. In some instances, the disease slowly continues to develop itself, until the stage of puberty or manhood has arrived, when it remains stationary during the subsequent period of life. In forming a prognosis, as to the probability of effecting a cure, or of a spontaneous subsidence of scrofula, parti- cular regard must be had to the following circumstances. 1. The nature of the predisposing and exciting causes. Where a number of causes of this kind co-operate in the pro- duction of the disease ; and especially where the situation and circumstances of the patient are such as to render an entire remo- val of them impracticable, the chances of advantage from reme- dial management must, of course, be exceedingly limited. Among the poor and squalid, who can neither procure proper nourish- ment, nor protect themselves against the injurious influences of cold, it is next to impossible to effect a cure, when the disease shows itself in an active form. I have already stated the greater difficulty of removing hereditary scrofula, than those cases which arise from external influences. 2. The age of the patient and the duration of the malady. The younger the patient is, the more easy, in general, will it be to remove, or effectually coun- teract, the progress of the disease. When the disease makes its first active appearance after the age of puberty or of manhood, the ehances of being able to suspend its progress are but small, and still less to remove the symptoms altogether. 3. The degree of violence of the disease. So long as the disease remains in a latent state, and is manifested only by the symptoms which characterize the scrofulous diathesis, a reasonable prospect of success may be entertained from proper remedial management Even so long as the disease shows itself only in the usual form of glandular swellings about the neck, without any indications of tubercular formations in the lungs, a judicious treatment will sometimes arrest the further progress of the disease, and occa- sionally gradually effect a removal of the scrofulous symptoms. When these tumours become irregular, uneven, immoveable, pain- SCROFULA. 469 ful, and inflamed, the difficulty of arresting their progress, and still more of effecting their entire reduction, may be regarded as nearly insuperable ; and the prognosis will be the more unfavour- able in proportion as these tumours are numerous. Suppurated scrofulous tumours, when they are situated externally, and not attended with a strong constitutional tendency to the disease— are not, in general, to be regarded either as more dangerous, or difficult of management, than mere inflamed tumours, although they are always extremely tedious in their progress, and cicatrize very slowly. Indeed, the suppuration of external glandular swellings is sometimes attended with a manifest melioration of the general scrofulous symptoms ;* and when suppurations of this kind occur in individuals labouring under slight incipient symp- toms of pulmonary tubercles, they should be encouraged, rather than suppressed or cicatrized, unless, indeed, they begin to assume very unfavourable or dangerous appearances. When febrile symptoms, cough, and emaciation, supervene, all hopes of suc- cessful treatment may be abandoned. 4. The seat of the local scrofulous affections forms, also, an important consideration in estimating the probable issue'of cases of this disease. So long as the disease appears to be concentrated upon the external glan- dular structures, some prospect of an eventual removal of the malady may, with reason, be entertained ; but when the ravages of the disease occur in deep-seated structures, or internal organs —particularly in the lungs, and mesenteric glands, all ideas of ultimate recovery may be abandoned as entirely hopeless. Treatment.—The first, and decidedly the most important part of the management of scrofulous affections, is a constant and careful avoidance of the various exciting causes enumerated above. Without an especial attention to proper observances in relation to this point, nothing, or at best but very little, can be effected by remedial treatment. The enjoyment of a pure, dry, and equable air ; an attention to proper clothing, so as to obviate, as much as possible, the injurious influence of atmospheric vicissi- tudes ; a wholesome, abstemious, but nourishing diet; regular exercise in the open air ; and cleanliness ; constitute the means upon which our hopes of successful opposition to the progress of the malady must chiefly be placed. So long as the disease shows itself only by a general scrofulous habit, without any important local affections, the diet should be simple, nourishing, and diges- tible ; and it is of great importance that the meals be taken at regular intervals, and no more food taken into the stomach at once, than can be easily and completely digested. All kinds of stimulating irritating articles of food must be carefully avoided ; * Bordeu, Recueil des pieces qui on tremporte le prix de l'Acad. Royal de Chirurg., vol. iii. p. 69, as quoted by Richter. 470 SCROFULA. and the same observation applies to every species of stimulating drink. The lean parts of tender and digestible meats may be moderately taken at noon ; and for children light animal broths ; liquid, mucilaginous, or farinaceous preparations ; barley, rice, boiled apples, turnips, and milk, constitute proper articles of nourishment. With regard to the clothing of individuals labour- ing under a strongly developed scrofulous habit, it should be so regulated as to preserve as equable a temperature of the body as possible. Flannel should be worn next the skin, except in very warm weather, when it may be substituted by cotton. The influence of a pure and dry air, and if possible of an equable cli- mate, is all-important to the successful management of this mala- dy. It would appear, from the observations of some writers, that the air along the sea-coast is often peculiarly beneficial in scrofulous affections ; but these are advantages which can seldom be enjoyed but by the wealthy, and the majority of scrofulous subjects in large towns cannot even obtain the benefits of a pure country air, so desirable in the treatment of this affection. In- activity and indolence are to be shunned as decidedly favourable to the progress of the malady. Walking, gestation in an open carriage, or, when the patient is old enough, riding on horseback, should be regularly practised when the weather is favourable. The patient should rise early from bed, and retire seasonably in the evening, and particularly avoid the damp and chilling night air. With regard to the medicinal treatment—whether for latent or active scrofula, the prominent indications are—to restore or maintain the integrity of" the digestive, perspiratory, hepatic, and intestinal functions, and to support the general energies of the sj'stem. Of these indications, the regular maintenance of the action of the bowels and of the liver may be regarded of primary importance. For this purpose recourse must be had to calomel, or blue mass, in conjunction or alternation with proper aperients. Some diversity of opinion is expressed by writers as to the best mode of administering mercurials in this affection ; ahd some even condemn them almost entirely as remedial means in scrofu- la, but most assuredly without just grounds. Undoubtedly, much caution is required in the employment of mercury in this disease, or where the scrofulous diathesis exists ; for it cannot be ques- tioned, that much mischief is apt to result from the constitutional or salivant influence of this article. Nevertheless, when it is given in small doses at proper intervals, followed by a mild laxa- tive, or even in occasional purgative doses, its effects are often unequivocally beneficial, in every variety of scrofulous disease. When the bowels are in a loaded condition, and torpid, the treat- ment should be commenced by pretty active doses of some pur- gative, and this should be repeated every third or fourth day, SCROFULA. 471 until there is reason to believe that the fecal accumulations have been removed. For this purpose, from two to six grains of ca- lomel, according to the age of the patient, should be given late in the evening, and followed, next morning, by a dose of rhubarb, castor oil, or Epsom salts. When the intestinal canal has been adequately evacuated in this way, it will, in general, be better to depend on the exhibition of from two to three grains of blue pill, every night, with a pretty smart purgative every fourth or fifth day. From such a course of management, in conjunction- with proper dietetic regulations, I have in several instances obtained the most decided benefit. Mr. Lloyd gives five grains of blue pill every night, with half a pint of the compound decoc- tion of sarsaparilla twice a day; and if the bowels are not moved during the forenoon, be administers some 1 axative, so as to pro- cure moderate evacuations. This plan he pursues until the ac- tion of the bowels becomes regular, and then goes on exhibiting the compound calomel pill, in five grain doses, every second night, for an indefinite time.* The pills I have already frequently mentioned in the course of this work, appear to me peculiarly well adapted as an alterative in scrofulous affections. I have repeatedly prescribed them -in cases of this kind with an excel- lent effect, t The employment of mercurial aperients should be persisted in, as long as the alvine evacuations continue to exhibit an unnatural appearance. Mr. Farr recommends mercurial fric- tions, as preferable, in his estimation, to the internal administra- tion of this medicine, more especially in children. He directs five grains of the unguentum hydrargyri fortius to be rubbed in upon the arm or leg of children from four to eight years old; eight grains in children from eight to twelve years of age, and twelve grains for subjects of from twelve to fifteen years old. "The frictions are to be continued until no portion of the oint- ment can be observed to stain a clean finger when applied to the part. "\ Mr. Lloyd makes the following judicious observations in relation to the remedial treatment of scrofula in children. " Every one must have observed that the same medicine may act very differently on children even of the same age ; and that what purges one violently, will have no effect on another. We should, too, be very careful not to exhibit violent purges ; and we should particularly avoid large purgative doses of calomel, as, I am convinced, they often produce more general irritation than • A Treatise on the Nature and Treatment of Scrofula, &c j R. Massac pil. hydrarg. gss. G. aloes soccot. gr. x. Tart, antimon. gr. i. M. Divide into twelve pills. S. Take one every night, or second night, according to the state of the bowels. t A Treatise on the Nature of Scrofula, &c. pp. 47, 48. 472 SCROFULA. the evacuation they occasion from the bowels Is able to relieve; and that they often so much weaken the stomach, that it is a very long time before it is able to recover its natural powers." To keep up a regular action of the bowels "any of the mild purgatives may be employed ; and if one does not appear to have the pro- per effect, we should desist from its use and substitute another." Although purgative doses of calomel are apt to prove injurious, " we may derive the greatest assistance from exhibiting alterative doses of this article." The dose should be varied from a half to one grain, according to the age of the child, and repeated twice or thrice a week. After the action of the liver and bowels has been in some de- gree brought to a regular state, benefit will in general result from the employment of the tonic vegetable bitters ; and where the digestive functions are much impaired, it will be proper to re- sort to the moderate use of tonics, in conjunction with the alter- ative and aperient treatment, as soon as the fecal accumulations have been evacuated by a few brisk purges, in the beginning of the treatment. Tonics are, indeed, generally recommended as peculiarly advantageous in counteracting the scrofulous diathesis; but I am inclined to think, that, except where the digestive powers are very feeble, and the mucous membrane of the sto- mach free from irritation, the active employment of remedies of this kind, is seldom attended with advantage. Most assuredly, they are decidedly indicated where the general system is languid and debilitated; but in children, high mucous irritation of the alimentary canal is so frequently present in scrofulous affections, and the general habit is often so irritable and prone to inflamma- tory excitement, that the indiscriminate use of tonics must be frequently productive of mischief. When the alvine and hepatic functions are restored by alteratives, aperients, and proper die- tetic regulations, " the symptoms of debility and relaxation al- most always soon disappear, under the use of a nourishing and digestible diet, regular exercise, warm clothing, and the enjoy- ment of pure air." Most writers speak favourably of sea-bath- ing as a means of invigorating the system and counteracting the scrofulous disposition. When the disease manifests itself in the form of a general scrofulous habit, without the presence of local affections, in a state of active progress, benefit may, no doubt, be obtained from this measure; but it does not appear to possess any peculiar powers, as many formerly supposed, in promoting either the discussion of scrofulous tumours, or the healing of the ulcers which proceed from them. (Lloyd.) It is also decidedly objec- tionable, where the scrofulous habit tends strongly to the forma- tion of tubercles in the lungs, or where tubercular matter has al- ready been deposited in the pulmonary tissue; and, the same ob- servation applies to the employment of the usual internal tonics. SCROFULA. 473 The tonics most generally prescribed are cinchona, gentian, steel, the mineral acids, and the quinine. Of these articles, the quinine appears to be particularly useful in certain states of scrofulous affections. Mr. Rennie, in a very excellent paper on the treat- ment of this disease, states, that he has found this preparation more effectual in allaying irritability, and that febrile diathesis which depends on atony of the stomach, than any other tonic he has ever used.* In the first volume of this work, (p. 414,) I have already referred to Dr. Mackenzie's observations on the valuable powers of the sulphate of quinine in scrofulous ophthalmia; and in one instance of well-marked scrofula in an infant, which lately came under my notice, one grain of quinine given three times daily, after proper evacuants, afforded unequivocal advantage. Where, along with the symptoms of gastric debility, much acidity prevails in the prima; viae, alkaline remedies should be given, either by themselves, or what is usually more advantage- ous, in union with weak infusions of the tonic vegetable bitters. The alkalies have indeed long been regarded as peculiarly bene- ficial in the management of scrofulous affections. Mr. Farr strong- ly recommends Brandish's liquor potassae as a remedy for indu- rated, inflamed, and suppurated scrofulous tumours about the neck, as well as "in the thickening of the ligaments and periosteum, with caries of the bones." He asserts, that he has found this medicine "pre-eminently successful both in arresting the further progress, and effectually eradicating a disease so destructive to human life." He employs it in connexion with the mercurial frictions mentioned above. A drachm of this preparation is to be given twice a day to a child from four to six years old; to a patient of from six to eight years old, one drachm and a half; and to one over eight years old, two drachms are to be given in any agreeable drink. Its operation is slow, and must be long con- tinued.t What has been said, applies particularly to the constitutional treatment of scrofula. When the disease appears in an active form, the same general management may still be proper, to a greater or less extent, with additional remedies adapted to the local affections, and Varied according to circumstances. M. Dupuytren adopts a treatment in scrofula, differing mate- rially from the methods of treatment generally followed. During the early period of the disease, he endeavours to fortify the con- stitution by the usual means resorted to in affections of this kind. When the complaint has advanced, to what he calls its second stage—which is characterized by febrile irritation, local pains, * London Medical Repository, 1825. \ The formula for preparing Brandish's liquor potossx is given in the Edinburgh Dispensatory, edited by Dr. Dyckman. p. 459. Vol. II. 60 474 SCROFULA. swelling and inflammations, he rigidly avoids all remedies of an exciting character, and treats the disease as an inflammatory affec- tion, by bleeding, leeching, low diet, &c.; and he asserts that by this mode of management he has often arrested the progress of the disease, and prevented caries of the bones, gibbosities, spon- taneous luxations, suppurations, and destruction of the organs. The authority of M. Dupuytren is not to be lightly rejected; and yet, I apprehend, that although decidedly proper in certain phlo- gistic cases, the antiphlogistic method he recommends, cannot be so generally applied with benefit, as his observations would ap- pear to indicate.* Glandular swellings.—So long as the glandular tumours re- main in an indolent state, all active local applications should be avoided ; for as discussive means they are wholly useless, where these enlargements depend on a scrofulous diathesis; and by their tendency to irritate and inflame, may greatly hasten the progress of the disease. Nevertheless, with the view of preventing the surrounding parts becoming irritated by the pressure of the en- larged gland, it may be proper to bathe the tumours " with salt water, or some other cooling lotion." (Lloyd.) When the tumours become inflamed and painful, however, local antiphlogistic appli- cations are in general decidedly indicated. Leeching, saturnine lotions, and cold applications, should be resorted to where the skin over the painful tumour is as yet free from tension and in- flammation; but "where several glands have coalesced, forming a large tumour, and the superincumbent skin is tense and disco- loured, the best applications are warm emollient poultices." The leeches should not be applied to the inflamed or discoloured skin of the tumours, but to the sound skin immediately surrounding the swellings. " It often happens, that when the swellings have arrived at this height an abscess forms; but it also happens, that they become indolent, and the pain and tension both subside. The tumour, however, remaining undiminished, will, upon ex- amination, be found to contain in its upper surface a small quan- tity of fluid. In this case the application of a blister, to be kept open for a few days, and repeated according to circumstances, will often promote rapid dispersion of the fluid, and indeed some- times of the whole tumour." In general, however, the application of blisters and other stimuli to glandular swellings, in an indis- criminate way, is calculated to do much mischief. The foregoing observations on the local management of scrofulous tumours, are drawn from Mr. Lloyd's excellent treatise on this subject, a work to which the.reader is referred for much valuable informa- tion in relation to the management of this alarming malady. » Raticr. On the Practice, &c. of the Parisian Hospitals. SCROFULA. 475 Scrofulous ulcers*—The successful management of scrofulous ulcerations, is always attended with great difficulty. A great variety of local remedies have been recommended for the cure of ulcers of this kind ; but without a judicious constitutional treat- ment, they are rarely capable of procuring more than temporary benefit, and when applied without great discrimination, may readily do much mischief. Mr. Rennie, who has paid particular attention to the effects of topical applications in scrofulous ulcer- ations, states that he has found the following compositions highly beneficial in foul and indolent sores of this kind.t When the thickened purple edges of the ulcers overlap the surface, and prevent cicatrization, they should be destroyed with some escha- rotic, and for this purpose the kali purum, or the nitrate ol silver, should be employed. Mr. Lloyd recommends the former, in preference to any other applications of this kind. Slightly astringent ointments or lotions generally agree better with scro- fulous sores, than such as are more stimulating. A weak solution of the sulphate of copper, in the proportion of four grains to an ounce of water, or of lunar caustic, or the nitrate of mercury, will usually answer all the purposes that may be expected from such applications, Mr. Lloyd considers the diluted citron oint- ment as the best local remedy for promoting the healthy granu- lation and cicatrization of scrofulous sores. Whatever topical remedies may be employed, and whether the local affection consist merely in enlargement of the lympha- tic glands, or in ulcerations, it must not be forgotten that our main reliance should be placed on an appropriate constitutional treatment. Besides the general remedial measures already men- tioned, and which may be deemed indispensable in all instances of scrofula, there are a vast variety of remedies which have been strongly recommended for the cure of this affection : and there * The only signs by which a scrofulous ulcer may be distinguished from one of a different character, are: "its occurring after a suppurated scrofulous tu- mour—the peculiar dull red, or purple colour of its edges—its remaining indo- lent for a great length of time, neither increasing nor diminishing in size, and its being attended with that particular state of health which invariably prevails in the scrofulous constitution."—Lloyd. f R. Picis nigra: tbi. -----liquids lt>iss. ----resina: Ibii. M. ft. emplast.—Or, K. Picis liquid, fbss. ----niger. Ibi. ----resina: ibi. M. ft. emplast.—Or, I£. Picis liquid, ibiii. ----resina: fbiv. Al. ft. emplast. To be heated and spread at tho time of application, not, however, too thinly The i.est thickness seems to be from one to ♦wo liner 1.or. ritat. p, 194. 476 SCROFULA. can be no doubt, that some of them, at least, may, under certain circumstances or modifications of the malady, occasionally prove serviceable. The iodine has of late years been a good deal used in scrofu- lous affections ; and in certain forms of the disease, it is, without doubt, deserving of much attention. In mere local lymphatic tumours, its powers are unquestionable ; but it does not appear to possess any decided remedial powers over glandular enlargements and ulcerations, depending on a scrofulous habit of body. In scrofulous inflammation of the eyes, it Ys said, by some writers, to be very useful—a statement which I have not, however, found verified in my own practice, although I have used it a long time, and in efficient doses, in five cases of this kind. For the removal of insulated strumous tumours about the neck, it is de- cidedly the most effectual remedy we possess. The only three instances of this kind in which I have employed it, disappeared under the use of frictions with the ointment of the hydriodate of potash* It should be observed, however, that a preternatural sensibility or irritability of the system ; a tendency to irregular determinations, and the presence of internal local congestions ; prominent gastric and intestinal derangement; febrile symptoms, general plethora, diarrhfjea, a disposition to haemorrhages, and an inflamed or sensible state of the tumours, are decided contra-indi- cations to the employment of this article, whether used exter- nally or internally. Mercury.—This article, as has already been stated, is of unquestionable utility, under cautious management, in scrofulous affections, by its tendency to correct the hepatic and alvine func- tions, and thereby contributing essentially to the restoration of the general health and vigour of the constitution. It has been supposed, however, to possess direct and specific powers over the scrofulous action, by its constitutional influence ; but for this opinion there does not appear to exist any good foundation. It is, nevertheless, true, that in old and obstinate ulcerations of a scrofulous character, minute doses of corrosive sublimate, in union with some alterative ptisan, such as the compound decoc- tion of sarsaparilla, will sometimes prove surprisingly beneficial. I have succeeded in curing several remarkably severe and obsti- nate cases of this kind, unequivocally of a scrofulous nature, by the continued employment, of a tenth of a grain of this mercurial, thrjee daily, in conjunction with the free use of sarsaparilla de- coction ; and there are, perhaps, few practitioners, who have not * R. Hydriod. potassa: Qii. Axungiac ^iss. Liq. potassa: canst, gtt. v. M. ft. ungt. Of this ointment, a poilion about the size of a small nut- meg should be rublied in upon lite tumour twice daily. SCROFULA. 477 witnessed its occasional good effects in similar instances of the disease. Except so far as it tends to correct the actions of the liver and bowels, this article does not appear to possess any direct power of dispersing scrofulous tumours ; but, on the contrary, when its influence is carried to the extent of producing a manifest general mercurial action in the system, it not unfrequently accele- rates the progress of these enlargements, and deteriorates the general habit of the body. Narcotics.—Most of the official narcotic extracts were formerly much extolled as remedies in every variety of scrofulous affec- tions. The confidence of the profession in their powers, has, however, long since, in a great measure, passed away ; and al- though some relief may occasionally be obtained from the em- ployment of these articles, their effects on the disease rarely amount to more than a mere palliation of its symptoms, or a tem- porary suspension of its progress. The most celebrated of these articles, are—conium, belladonna, hyoscyamus, and solanum dulcamara ; but there are a great variety of other vegetable reme- dies of a similar character, that have been particularly praised for their occasional good effects in scrofula. Thus, tussilago farfara is much extolled by Hoffman ; and Meza strongly re- commends digitalis in small doses.* The expressed juice of fumaria; chaereofolium ; beccctbunga ; sonchus ; lactuca ; ma- rubrium album, and taraxacum, have all had their advocates as remedies in this disease. Of all these articles, however, conium is decidedly the best; and which, in combination with small doses of muriate of mercury, I have known to do much good in scrofulous ulcerations. The muriate of barytes was much in vogue as a remedy for scrofula some thirty years ago. It was introduced to the parti- cular notice of the profession by Dr. Crawfordt ; and Hufeland, soon afterwards, published a small treatise with cases illustrative of its remedial powers in this disease.:): Many other writers have published statements favourable to the employment of this article ; but general experience did not confirm these accounts ; and it has long since sunk almost into total, though, as I have some reason to think, not entirely merited neglect. I have employed it in several cases of scrofulous ophthalmia, with une- quivocal advantage ; and I am persuaded that in some instances, at least, its powers might be very beneficially called into aid in the management of this intractable malady. It is slow in its effects, and must be used for a considerable time, before any obvious amendment occurs in the disease. For the mode of • De digital, purpur ejusque usu in scrofulus medico. Jena:, 179. f Duncan's Medical Comment, vol. iv. Dec. ii. p. 433. t Volstund. Darstell. d. kriifte u. anwendung d. salzsaur. schwererde, &c. 478 SCROFULA. employing it, the reader is referred to page 413 of the first vo- lume of this work. Of a similar character is the muriate of lime,—an article which, at one time, had considerable reputation as a remedy in scrofulous complaints. Thirty drops of a solution of one drachm of this salt to two ounces of water, is to be taken every three hours, and the dose gradually increased until it begins to affect the stomach. Fourcroy, Beddoes, and Hufeland, speak very fa- vourably of its powers. Twenty years ago, I saw it employed in a case attended with several very large scrofulous tumours on the neck, and an ulcer in the left axilla, and although it did not accomplish a complete removal of the external affections, its bene- ficial influence was very manifest. In the early period of my practice, I employed this article in a considerable number of in- stances of scrofulous ophthalmia, and eruptions about the head in young children, and, as it appeared to me, with some advantage in several cases. General experience, however, has not establish- ed its usefulness, and it is now entirely neglected as a remedy in this affection. Antimony, by its tendency to counteract inflammatory action, and to keep up the regular cutaneous exhalation, is a highly use- ful medicine, under proper management, in certain varieties and stages of scrofulous affections. Under the head of phthisis pul- monalis, I have already spoken of its usefulness in counteracting the progress of tubercles in the lungs. This article is particular- ly useful when the glandular swellings manifest a tendency to pass into a state of inflammation; and in minute doses, it will co- operate very advantageously, with warm clothing, to prevent the general scrofulous diathesis from passing into the active forms of the disease. That it possesses any direct or specific influence over the scrofulous action, cannot indeed be admitted; but by its general operation in promoting the secretions, and opposing an inflammatory tendency in the system, it is calculated to do much good in affections of this kind. Weikard and Richter re- commend the following combination in scrofulous cutaneous erup- tions.* Some of the German writers speak very favourably of the effects of large and frequent doses of assafoetida in scrofulous caries of the bones. Schmucker, in particular, has published a very favourable account of its powers in affections of this kind. Where the general circulation and habit is languid, benefit may • R. Ant'.mon. crude alcoholis ?Jvi. G. guaiaci ^ss. Extract, aconit. Jji. Sacchar. albi. xx. . Mucilag. g. arab. q. s. M. To be made into boluses of \v grains each. One of these is to be taken four times daily by an adult SCROFULA. 479 be obtained from this remedy; but its beneficial influence in cases of this kind, appears to depend solely on the general excitement and invigoration it imparts to the system. Richter recommends the following formula.* Of the importance of tonics, in .conjunc- tion with aperients, and the cautious employment of mercurials, for counteracting the scrofulous diathesis, 1 have already spoken, and I need here only repeat, that although unquestionably of pri- mary consequence where the system is languid, and the digestive powers feeble, they are not only useless, but often prejudicial, where the general habit is phlogistic, and the alimentary canal in a state of high irritation. During the active progress of glan- dular swellings, that is, whilst they are in a state of inflammation and suppuration, tonics can rarely be given without mischief. After the active state of the inflammation has terminated in foul and languid ulcerations, they may, in general, be used with pro- priety and advantage. In old scrofulous ulcerations, attended with general debility and relaxation, the employment of large doses of cinchona, quinine, or steel, is sometimes an indispensa- ble auxiliary to the local applications and general alterative reme- dies that may be deemed proper. The following combination forms an excellent tonic in old scrofulous ulcerations, or in gene- ral where tonics are indicated in this affection, at any period of its course.t The aromatic tonics, says Richter, deserve much attention, in scrofulous affections attended with general relaxation and debility, and where the ulcers are foul and indolent. Of course, where there is a disposition to inflammation, they are decidedly objec- tionable. Weikard particularly recommends calamus; Richter speaks favourably of cloves; and Hufeland mentions a decoction of rad. helenii; cort. winteranus; cort. et lig. sassafras; and where the general habit is very torpid, Thilenius advises the use of the essential oil of sassafras, as, often, peculiarly beneficial. • R. Antimon. sulphuret. nigr. gii. G. assafoctid. giii. Extract, cicuta 5Jss. --------aconit. gr. xv. M. Divide into four grain pills. S. Take from four to five pills, twice or thrice daily. t R- Ferri limatur. vel pulver. ^iii. P. rhaei J)ii. G. ammonia: gii. Tart, antimon. gr. iii. M. Divide into three grain pills. S. Take four pills three times daily.—Or, R. Ferri limatur. Jjii. G. assafoetid. ^i. G. aloes socc. gr. x. M. Divide into sixty pills. S. Take two, four times daily. 480 BRONCHOCELE. Sect. II. —Bronchocele.—Goitre. I his very remarkable disease consists of a chronic enlargement of the thyroid gland. It commences with a small tumour on one or both sides of the larynx and trachea, which gradually in- creases in size, until, in the course of years, it acquires, in many instances, an enormous bulk, occupying the whole anterior part of the throat, from ear to ear, and projecting considerably beyond the chin, and occasionally even extending down to near the middle of the chest.* In the early period of the disease, the tumour is always soft, elastic, and spongy to the touch; the colour of the skin natural, and moveable over the enlarged gland. In the progress of its enlargement, however, the tumour becomes more and more firm, until at last, in severe cases, it acquires great density and firmness in certain parts, whilst small portions retain their original soft and spongy state. Although indolent or free from pain or ten- derness during the early period of its progress, and in many cases of moderate size always so, yet in the majority of instan- ces, where the tumour becomes large and indurated, transient pains are at times felt darting through the enlarged gland, at the same time that the skin assumes a slightly red or copper colour, and the veins of the neck become large and turgid. No incon- venience whatever is experienced from the disease while the tumour remains soft and of a moderate volume; but when it ac- quires a large size, it generally gives rise to more or less difficulty of respiration, and a slight change or loss of clearness of the voice. In some cases the enlargement extends inwardly, so as to cause considerable pressure on the oesophagus and large blood-vessels in the neck, occasioning difficulty of swallowing, and, at times, great anxiety and palpitations of the heart, throbbing of the caro- tids, and dangerous and even fatal congestions in the brain. The progress of the enlargement is sometimes very irregular. The tumour in some instances remains stationary for a consider- able time, then rapidly increases in size for a short period, and a in general "strik- ingly benefited by the mild employment of mercury." 532 SYPHILIS. Without, however, extending these observations as to the par- ticular circumstances under which the employment of mercury may be proper or improper, it will be sufficient to observe, in a general way, that in all instances where the cutaneous and other secondary symptoms do not yield in a reasonable course of time to the use of sarsaparilla, the compound decoctions of the woods, antimonials, rest, an equable temperature, and simple and unirri- tating diet, recourse should unquestionably be had to a more or less active course of mercury. Where the constitutional symp- toms are attended with much general irritation or febrile excite- ment, the use of mercury ought to be delayed until the general phlogistic and irritable habit of the body has been moderated by the use of the measures just indicated. It should also be particu- larly borne in mind, that where the ulcerations in the throat are attended with high inflammation and swelling, mercury cannot in general be safely administered until this local inflammatory condition has been moderated by general antiphlogistics, emol- lient gargles, the inhalation of aqueous vapour, perfect rest, low diet, and nauseating antimonials. In instances attended with an irritable habit of body, much advantage will usually result from the employment of opium or hyoscyamus in conjunction with mercurials. This combination is more especially necessary in cases attended with much pain in tjie extremities or bones, and where the mercury seems to augment the general irritation. So far as my own limited expe- rience has enabled me to judge, I am well satisfied that the regu- lar employment of full doses of Dover's powder will in general very materially enhance the good effects of mercury, under almost every variety and circumstance of the disease. One of the most important observances in the employment of this remedy, is the rigid avoidance of a cold, damp, and variable atmosphere. If the patient can be induced to remain in his room, which should, however, be kept perfectly clean and well ventilated, and at a uniform temperature, the beneficial influence of the mercury will be much more certainly obtained than when he walks about in the open air, unless the weather be warm and dry. The diet too should be of the lightest and least irritating kind, and every sort of stimulating drink must be especially interdicted. It has already been stated, that in the commencement of the constitutional symptoms, it often becomes necessary to employ measures for the reduction of the general phlogistic habit, be- fore mercurial remedies can be with propriety resorted to. It may also be observed, that even in inveterate cases, the use of aperients, the warm bath, and especially the compound decoc- tion of sarsaparilla, continued for three or four weeks, are SYPHILIS. 533 often decidedly useful preliminary measures to the employment of mercury. WTith regard to the extent to which the mercurial action is to be carried, no precise rules can be laid down for the manage- ment of secondary venereal affections. It is admitted, neverthe- less, that it seldom becomes necessary to induce full ptyalism__ a moderate and equable action, maintained for a considerable length of time, being commonly sufficient to procure all the advantages that can be derived from this remedy. To this, how- ever, exceptions will occur ; and where the disease does not yield under the combined influence of an alterative course of this me- dicine, and the usual diaphoretic or depurative ptisans, we ought certainly to push the mercury to the full extent of its influence, where no symptoms or circumstances exist which seem to con- tra-indicate its vigorous employment. Some difference of opinion prevails as to the preparation of mercury most eligible for the treatment of venereal affections. In recent cases, the blue pill, with or without ipecacuanha, is gene- rally preferred. In chronic syphilitic affections of every form, I have scarcely ever employed any other mercurial than the corro- sive sublimate, in doses of from one-eighth to one-sixth of a grain, with two grains of the extract of cicuta, three times daily. Professor Zondi has, within a few years, published a new mode of using mercury in chronic venereal complaints, which I have known employed in two instances with extraordinary success. He makes one hundred and twenty pills out of twelve grains of corrosive sublimate, and directs them to be taken in the following way; On the first day one is taken; on the second none; on the third two; on the fourth none; on the fifth three pills; and so on, increasing the dose by one pill every other day, and omitting them on the intervening days, until they are all taken, by which time the cure is completed. During the treatment, infusion of senna is to be taken, so as to keep up a regular action of the bowels, and the patient is restricted to half the ordinary quantity of his food, and is permitted to leave his house only during very fine weather. About two years ago I saw this plan of treatment put in practice with complete success. The patient was affected with venereal nodes and caries, with ulcers on different parts of his body, and had been long wholly unfit for any kind of employment. I had him under treatment for six months; in three of which he used the compound decoction of sarsaparilla, and the three last months he was under an alterative course of mercury, without deriving any particular benefit from all I prescribed. He was then admitted into the Pennsylvania Hospital, and underwent two full mercurial courses, but he came away without being in the least relieved. My friend, Dr. Mcering, had expressed to me a wish for a proper subject to put Zondi's mode of treatment to 534 SYPHILIS. a fair trial. I took him to this patient: he prescribed the corro- sive sublimate in the above way, and in five weeks the patient was relieved of all his symptoms; and he is now perfectly heal- thy, and has made several long voyages since he underwent the treatment. Sarsaparilla and guaiacum in the form of a ptisan, are, with- out doubt, highly valuable remedies in the treatment of venereal affections; and in conjunction with antimonials, a simple diet, warm bathing, and aperients, will often remove the milder forms of the disease without the aid of mercury. Although I should not be disposed to depend solely on these means, yet the sarsa- parilla infusions, in common use, can hardly be omitted with propriety, in conjunction with mercurials, in the cure of such af- fections. A great variety of formulae have been proposed for preparing these ptisans; but the following are acknowledged to be among the most effectual.* An excellent mode of administer- ing mercury, is to give it in solution in a ptisan of this kind. As a local application to the chronic and foul ulcers which oc- cur in some instances on different parts of the body, as well as to • R. Rad. sarsaparil. 3T1. Flor. borag. officin. Petal, ros. gall. Fol. sennse. Sem. anis. aaSjii. Sacch. communis, Mel. despumat. aa Ifeii. Boil in a sufficient quantity of water to extract the virtues of the sarsaparilla. Strain, and add the sugar and honey; then boil it down to the consistence of a syrup. To each pound of the syrup may be added one grain of corrosive subli- mate. The dose is from one to two ounces twice or thrice daily. This is the Strop de Cuissinier. R. Rad. sarsaparilla Lign. guaiac. offic. aa Ibi. Fol. senn. G. arab. aa 3M. Rad. zingiberis 3SS. Aq. fontanx Ifex. Boil the two first ingredients in water for one hour; strain, and add to the re- siduum the same quantity of water as before, then boil it for two hours, and to- wards the end of the boiling add the other ingredients: strain, and to both de- coctions add— Sacch. communis. Mel. opt. aa ibiii. . „.. . Boil the whole to the consistence of a syrup. The dose is 311. twice or thrice daily. Tills is the rob antisyphilitic of Laffecteur. I have used the following syrup with peculiar advantage : R. Rad. sarsaparilla: 3 iii. Fol. chimaphyllac umbel. 3T1. Sulphuret. antimonii, enclosed in a linen cloth, .V Aq. bullient. Ibiii- Boil it down to three half pints; then add— Mel. despumat. 3" viii. I)OSC__a wine-glassful four times daily SYPHILIS. 535 those which are seated in the fauces> the black or yellow mercu- rial washes, or a weak solution of blue vitriol, will in general answer a very good purpose. Although mercury is unquestionably the most important reme- dy we possess, for the cure of syphilis and certain syphiloid affections, there are several other articles highly worthy of atten- tion as means for removing diseases of this kind. Amon«- these, gold appears to be the most valuable. I have employed the ?nu- riate of gold in ten or twelve cases of constitutional syphilis, and in several instances, with complete success. One case of long standing, and extremely severe, which had resisted the re- peated employment of mercury, and sarsaparilla, was entirely cured by the use of this preparation in-union with the extract of cicuta. I have usually commenced with one-tenth of a grain three times daily, and gradually increased it to one-sixth of a grain. It should be given in the form of a pill, and the patient must be directed to avoid taking acids into his stomach. The best mode of using it is in union with the extract of conium or of hy- oscyamus. Without the addition of some article of this kind, it often gives rise to very unpleasant sensations in the stomach. For a more particular account of the remedial powers of this ar- ticle, the reader is referred to my work on the Materia Medica. The acetate of copper (verdigris) has been highly extolled by some German physicians, as a remedy in syphilitic affections. M. Schlegel has published a number of cases illustrative of its good effects in diseases of this kind. He asserts, that by the following combination, he has almost uniformly succeeded in removing even the most inveterate syphilitic affections.* This article was for- merly much employed in scrofulous and other varieties of ulcer- ative diseases, and I have myself given small doses of it in affec- tions of this kind with the happiest effect. It may be given in doses of from one-eighth to one-sixth of a grain three times daily ; and when united with full doses of the extract of cicuta, it is ca- pable of doing much good in obstinate scrofulous and venereal ul- cerations, t The carbonate of ammonia, too, has had zealous advocates as a remedy in syphilitic affections. In conjunction with full doses of opium, it is capable of procuring much benefit in cases attended with a debilitated and irritable state of the system. In a case I attended about a year ago, twenty grains of the carbonate of am- • R. JErugo sris gr. ii. Solve in aceti concent. 9'ii. Camphora: gr. iv. Opii gr. ii. Mica: panis q. s. ut fiant pilul. No. 40. Take from 5 to 10 three times daily. \ See Kbcrle's Mat. Med. vol. i. p. 304, 3d edition. 536 SYPHILIS. monia with a grain and a half of opium were given three times daily with the happiest effect. The patient was much debilitated, and in a peculiarly irritable condition, with a large, foul, and sa- nious ulcer on the sternum. Under the use of this combination the ulcer healed, and the general health of the patient was greatly improved. For the cure of venereal nodes, when not attended with much febrile irritation, we possess no remedy more frequently success- ful than arsenic. I have repeatedly prescribed from ten to twelve drops of Fowler's solution, twice or thrice in a day, with entire success. This potent article is also a valuable medicine in the arthritic or rheumatic pains which are apt to succeed syphilis and ill managed mercurial courses. From one-tenth to an eighth of a grain of arsenic, with two grains of the extract of aconitum, should be given three times daily. For the same purpose, I have also used the sulphate of zinc with excellent effect. Two grains of this article united with half a grain of opium, may be given three times daily. In several very severe and obstinate cases, this combination procured great and permanent relief. Buboes. Buboes are often extremely troublesome affections; and in irri- table and scorbutic habits, or from an abuse of mercury and im- proper exposure, often give rise to the most destructive and unmanageable ulcerations. Buboes may arise either from mere sympathetic irritation, or from absorption of the venereal virus. The former variety of buboes is not uncommon in virulent go- norrhoea; and they arise, often, from the superficial ulcerations and patchy excoriations which occur on the internal surface of the prepuce and glans penis. Sympathetic buboes often disappear as soon as the primary local irritation upon which they depend is removed. Sometimes, however, they become indolent, and remain stationary for a long time. In instances of this kind, mercurial frictions, blistering, or simple emollient poultices, will either dispose them to disperse or to proceed to suppuration, after which they readily heal. I have lately used frictions with the hydriodate ointment, in a case of indolent sympathetic bubo, with marked benefit. Swediaur divides buboes into the tonic and atonic; a dis- tinction which is frequently verified in practice. The former are attended with symptoms of active inflammation in the tumour, and with an evident phlogistic state of the general system. The pulse is full, hard, and quick, and the local pain violent and con- stant. The atonic bubo is accompanied with the reverse condi- tions—the symptoms indicating general debility. So long as the inflammation is not very high, or signs of com- BUBOES. 537 mendng suppuration have not yet made their appearance, efforts should be made to disperse the tumour as speedily -as possible. It is a common opinion, that the dispersion of a bubo without bringing it to suppuration, is apt to be followed by dangerous consequences, under the idea that the venereal poison may be retained in the system, and give rise to subsequent unpleasant affections. For this apprehension, however, there is not the least foundation. Many practitioners are in the habit of depending chiefly on mercurial frictions upon the tumour or on the inner surface of the thighs, for the purpose of discussing buboes ; but this prac- tice is very rarely followed with success, unless active antiphlo- gistic means, both local and general, be employed at the same time. The most efficient means for reducing inflamed buboes, where the general habit is phlogistic, are ; local and general bleeding, saline purgatives, nauseating doses of tart, antimony, a very simple and unirritating diet, perfect rest, together with cold astringent lotions—particularly lead-water to the tumour, and mercurial frictions on the inner surface of the thighs. When the general irritation or phlogistic excitement is not considerable, venesection may be dispensed with ; but in instances attended with a bright red erysipelatous appearance of the skin over the tumour, in robust and plethoric habits, scarcely any thing will avert suppuration, except very efficient general blood-letting. When these measures do not arrest the progress of the bubo, and its tendency to suppuration is uncontroulable, means should be used to promote the suppurative process ; and for this purpose, I know of nothing better than emollient poultices. In atonic buboes, advancing slowly, and remaining for weeks in nearly a stationary condition, without manifesting a tendency either to suppuration or to resolution, the application of blisters to the tumour will often succeed in dispersing it, or at all events expedite its termination in suppuration. Both Mr. Carmichael and Mr. Bacot recommend blisters, as, in general, decidedly the best applications to indolent buboes. The former observes, that, "in such cases, (hard and indolent buboes,) the greatest advan- tage may be derived from the repeated application of blisters to the indurated bubo, which soon either causes the dispersion or suppuration of the tumour;" and Mr. Bacot says it is a practice which he has pursued for nearly fifteen years, with the most sa- tisfactory results. (Loc. cit. p. 24.) When buboes of this kind occur in persons of a languid and feeble state of the body, much benefit will sometimes be derived from a generous diet, and the use of tonics and wine. When we fail to disperse the tumour, and it has been brought to suppurate, the matter should not be suffered to ulcerate an opening through the integuments. A free incision, with a common abscess lancet, Vol. II. 6S 538 BUBOES. should be made into the cavity and the matter evacuated. When the buboes advance to suppuration, while their integuments are firm, and but little discoloured, Mr. Bacot advises the passing a small seton through the base of the tumour. Mr. Swediaur and some other writers, however, think it much better to suffer sup- purated buboes to open spontaneously by ulceration ; for the arti- ficial opening, he says, " is often made too early, before the ab- scess is fully maturated." This, however, is an argument rather against the improper, than the judicious use of the lancet; for it is not improbable that an incision made before the tumour is fully suppurated, may give rise to unpleasant consequences. It is un- doubtedly proper to delay making an incision until the abscess appears to be matured, but after this has been brought about, it is difficult to conceive any advantage from suffering the matter to remain some days longer confined. When the abscess is laid open, it will generally heal under the use of gently stimulating ointments and emollient poultices ; but in some instances the ulcerative process continues; or the abscess acquires an indolent and unfavourable character, which prevents it from healing. In syphilitic bubo, mercury is indis- pensable ; but where there is a scrofulous or a scorbutic habit, and in instances where the general system is enfeebled and irri- table, the worst consequences will sometimes follow the active employment of mercurials. When a bubo assumes a more unfa- vourable aspect under the use of mercury, it should be immedi- ately discontinued, and opium with sarsaparilla decoction freely used ; and in feeble habits, recourse must be had to cinchona, the mineral acids—particularly the nitrous acid and opium, with a generous diet and pure air. When the opened abscess remains stationary, soft, and flabby, discharging a copious thin ichorous fluid, we may inject a weak solution of sulphate of copper, or of the yellow mercurial lotion (corrosive sublimate gr. x., lime- water gviii.) into the cavity, and apply stimulating cataplasms —such as a common poultice with a few drachms of cinchona mixed with it; or pieces of linen moistened with the tincture of galbanum over the sore. The internal use of opium or cicuta in full doses, will also be particularly serviceable in cases of this kind. The regular use of the latter narcotic is especially valuable in cases attended with symptoms of scrofula. When the bubo opens while a portion of it remains indurated, Mr. Swediaur recommends repeated cathartics, and the applica- tion of irritating remedies, such as the mercurial ointment, weak solutions of corrosive sublimate, &c. The solution of sulphate of copper, or the black mercurial wash, will often answer well in such cases. Sometimes the ulcers formed by suppurated buboes become surrounded with projecting, indolent, and unolermincd edges; BUBOES. 539 " and if these edges are not removed by art, the ulcer will re- main for months, and perhaps years, without healing." In such cases, says Carmichael, " caustic, however powerful, is so slow in its operation upon the extensive and undermined edges of the buboes, that 1 always make use of the scalpel for their removal; and this treatment has caused many of them to heal in five or six weeks, which would have resisted any other mode of practice as many months. Full courses of mercury always increase their tendency to burrow, and to extend their circumference." In foul and sanious ulcers of this kind, without the elevated and indurated edges just mentioned, much benefit will sometimes result from charcoal or carrot poultices; and where the surface is spongy and indolent, the application of nitric acid by strips of linen moistened with it, often produces a very excellent effect. Minute portions of the muriate of mercury, in conjunction with full oloses of the extract of cicuta, very generally contribute materially towards the successful management of ulcerated bu- boes. When the system is irritable, opium in large doses, or the extracts of cicuta, or hyoscyamus, should be regularly given with- out the mercurial. Sect. III.—Amenorrhoea. This is one of the most common forms of menstrual disease, which, though sometimes borne without any material inconve- nience, seldom fails ultimately to derange the general health, and unless remedied, often leads to the most distressing and danger- ous consequences. The exciting causes of amenorrhoea arc exceedingly various. Every thing which is capable of deranging the general health, has a tendency to excite irregularities or suppression of the ca- tamenial discharge. Organic and inflammatory visceral affections —more especially pulmonary consumption—chronic hepatitis, and gastro-intestinal phlogosis or irritation, are rarely unaccom- panied by menstrual irregularities, and often by a total and ob- stinate suppression of this evacuation. Mental emotions, parti- cularly protracted grief and despondency, and sudden terror or violent anger, have a powerful tendency to arrest the catamenial discharge. Metastasis of rheumatism—of erysipelas—and of chronic cutaneous affections; habitual haemorrhoidal discharges, as well as other varieties of haemorrhage, leucorrhoea, and defi- cient and unwholesome nourishment, may also give rise to this affection. But by far the most common cause of amenorrhoea is cold, operating on the system either during the interval of the menstrual periods, or immediately before the menses are about to appear, or finally during the actual flow of the evacuation. 540 AMENORRHOEA. When the exciting cause acts during the interval of the cata- menial periods, the menses will either not make their appearance at the next period, or they will, perhaps, begin to flow sparingly for a few hours, and then cease. In general, no material incon- venience is felt from the absence of the ev«acuation, and in some instances it returns spontaneously at the succeeding period. Oc- casionall}', however, considerable uneasiness in the pelvic region, pain in the loins, irregular determinations of blood to the head or chest, and in nervous subjects, various hysterical symptoms, are the immediate consequences of the suppression. But although the system frequently bears the suppression of this evacuation without any materially unfavourable consequences during the first six or eight weeks, more or less derangement of the general health invariably ensues, if the menses fail to make their appear- ance after the second or third period. The usual symptoms which ultimately arise from this affection are: languor and debility; a pale and sickly expression of the countenance; swellings of the ankles; various nervous affections, such as paroxysms of palpita- tion of the heart, and dyspnoea; flatulent and spasmodic pains in the bowels; loss of appetite; and in relaxed and leucophlegmatic habits, leucorrhoea. In subjects predisposed to phthisis pulmona- lis, or to some other local or general disease, protracted suppres- sion of the catamenial evacuation is always particularly danger- ous, from its strong tendency to develop such affections. When the menses are suddenly suppressed, whilst they are flowing; or when the remote cause of the obstruction is applied immediately before the impending appearance of the evacuation, the consequences are much more violent and sudden. In such cases, the most alarming symptoms sometimes almost immediate- ly follow the suppression of the discharge. In some cases, parox- ysms of violent spasmodic pains occur in the bowels and stomach, attended occasionally with severe retching. In other instances, strong determinations of blood take place to the brain, giving rise to raving delirium, hysteric mania, convulsions, or a temporary loss of sensation and voluntary motion. Sometimes extremely alarming palpitations of the heart, with great difficulty of breath- ing, occur; and in some cases the irritation passes at once upon the sanguineous system, occasioning high febrile reaction, and local inflammatory affections. Treatment.—When one or more of the violent affections just mentioned succeed the sudden suppression of the menses, the first object must be to allay the alarming and painful symptoms, with- out any immediate attention to the restoration of the evacuation. The attempt, indeed, to reinstate the catamenial secretion, at the period when it becomes arrested, is almost always abortive -, yet the remedies which may be proper to palliate or remove the pre- AMENORRHOEA. 541 sent symptoms, will occasionally have the effect of bringing back the suppressed evacuation. In young and plethoric subjects, or where strong determina- tions of blood take place to the head or lungs, efficient venesec- tion should be promptly resorted to. We can, indeed, seldom allay the violent spasmodic and painful symptoms very material- ly by this measure alone; but in the habits just mentioned, it constitutes an essential preliminary to the successful employment of other remedies—particularly opium and ether, which in most instances afford more speedy relief than any other remedies we possess. Active cathartics and purgative enemata, sinapisms to the inferior extremities, warm pediluvium, and antispasmodics, are the principal means to be relied on. In weak and nervous females, it will not be necessary, and often improper, to bleed. In cases of this kind, warm pediluvium, with a few full doses of laudanum and camphor, will in general speedily allay the alarm- ing and painful symptoms which often accompany this accident. Dr. Dewees states, that he has found nothing to answer so well where the pain in the stomach or lower part of the abdomen is severe, "as an injection composed of a gill of thin starch, a tea- spoonful of laudanum, and thirty grains of finely powdered cam- phor ; and if it be complicated with hysteria, the addition of three tea-spoonfuls of the tincture of assafoetida, instead of the camphor, may be useful." I have in several alarming instances known very complete relief obtained from the injection of laudanum in- to the bowels ; but where the stomach will retain the medicine, it will act more promptly when administered by the mouth. Little or no benefit, however, will result from an ordinary dose of this narcotic in cases of this kind. From two to three grains of opium, with ten or fifteen grains of camphor, should be given at once. It should be particularly recollected, that where the ten- dency to cephalic congestion is strong, or in full, young, and vigorous subjects, an efficient abstraction of blood must be pre- mised to the use of these remedies. In one case of suddenly suppressed menses, attended with wild raving and paroxysms of extreme pain in the stomach, half an ounce of the tincture of secale cornutum completely allayed all the symptoms in less than fifteen minutes. A vast variety of remedies have been recommended for the purpose of restoring the suppressed catamenial evacuation; but we may safely affirm, that the amount of injury which has been done by the indiscriminate and unseasonable exhibition of medi- cines of this kind, (emmenagogues) is incomparably greater than that of all the advantages which have as yet resulted from their employment. I do not wish to be understood as condemning, unqualifiedly, the use of such remedies; for under judicious ma- nagement, they are not only often decidedly useful, but in some 542 AMENORRHOEA. cases, indispensable to success. The practice, however, of resort- ing to active emmenagogues in the beginning of the treatment, without an especial regard to the general state of the system, and the peculiar circumstances of the case, under an idea that they possess a direct or specific power of restoring this secretion, has been, and no doubt will continue to be, the source of various and irremediable misehief. Amenorrhoea in young subjects is at first almost invariably ac- companied by a manifest phlogistic habit of body. In instances of this kind, moderate abstractions of blood, aided by a simple and unirritating diet, laxatives, and regular exercise in the open air, are all-important remediate measures. Where the disease has developed local inflammations, or sustains irregular determina- tions to internal organs, especial means should be used, in con- junction with the general remedies just mentioned, to counteract the local affection, before any direct attempt is made to excite the uterine vessels. Blisters, rubefacients, the warm bath, antimo- nials, &c. may all be beneficially employed under circumstances of this kind. In France, the application of leeches to the pudendum is a very common practice, and there can be no question as to the proprie- ty and favourable tendency of this practice. M. Chomel recom- mends the application of four or five leeches daily, for five or six days in succession, at the expected menstrual period. Some days previous to the employment of the leeches, he orders dry cupping on the upper and inner part of the thighs, and warm vapour baths to the lower part of the body.* When the suppression occurs in relaxed and debilitated females, with a small, feeble, and languid pulse, the first object should be to invigorate the general system, and to improve the digestive and alvine functions. Iron ;t mild tonic bitters; a simple, but nourishing diet, exercise by gestation, arid gentle aloetic aperi- ents;! are especially indicated in such cases. I have derived much advantage in amenorrhoea,* attended with languor and de* * Rev. Med. January, 1828. f R. Ferri. phosphat. 31. Pulv. zingiberis gii. ------aloes soccot. gr. v. M. Divide into ten equal parts. S. Take one twice or thrice daily.—Or, R. Extract, gentian, 3.. Sulphas, ferri. gr. iv. G. aloes, socc. gr. v. M. Divide into twenty pills. S. Take one every morning, noon, and evening. t R. Pulv. rhaei. giv. G. aloes Qi. Pulv. capsici. i. Muc. g. arab. q. s. M. Divide into twenty pills. Take two at night on going to bod. AMENORRHOEA. 543 bility, from the black sulphuret of iron, in union with small portions of ipecacuanha. Five grains of the former, with one of the latter, may be given three times daily. It is proper to ob- serve, however, that even in cases attended with much languor and weakness, mild aperients are sometimes important remedies, preliminary to the employment of tonics; for it is not uncommon to find the bowels exceedingly loaded in such cases, and there can be but little advantage derived from invigorating measures, so long as this condition of the intestinal canal continues. Sometimes cases that come on slowly, and apparently without any direct exciting cause, will be found, on close examination, to be connected with chronic irritation, or phlogosis of the mucous membrane of the bowels, from a remora of fecal matter in the bowels, or from the habitual use of a superabundance of coarse, irritating, or indigestible aliment. I have recently seen a remark- able instance of this kind. The patient, a labouring woman, about twenty-five years of age, had suffered a long time under amenorrhoea, and the usual attending nervous symptoms. When I first saw her, she was debilitated, and considerably emaciated, but stated that her appetite was very craving. As she ascribed all her complaints to the absence of the menstrual discharge, she had taken a great deal of medicine, obtained from one of our pub- lic charitable institutions, for the purpose of "bringing on her courses." On examination, I found her abdomen tumid and hard, the tongue like a piece of raw flesh along the edges and point, and the appetite voracious—in short, with all the symptoms of high irritation of the mucous membrane of the stomach and bow- els. I ordered her a few doses of castor oil, and put her on the exclusive use of rye-mush and milk for her diet, with which she faithfully complied. In four weeks the tension and fulness of the abdomen had subsided, and the tongue presented a much bet- ter appearance. The diet was continued, with the addition of a little weak animal broth at noon, and I prescribed an emulsion of balsam copaiva, in small doses, to be repeated thrice daily. This she continued for four weeks, at the end of which time she thought herself quite well, although the menses had not yet returned. She was now put on the use of the following pills,* which in two weeks restored the long suppressed catamenia. By thus pursuing a general treatment adapted to the particular circumstances of the case, we may often restore the menstrual evacuation; and should we even fail in effecting this purpose, we shall, nevertheless, gain some advantage, by placing the system * R. Sulphat. ferri. gr. v. G. myrrh. G. aloes aa gr. x. M. Divide into twenty pills. S. Take one every morning, noon, and evening. 544 AMENORRHOEA. in a condition favourable to the operation of the remedies more directly calculated to act upon the uterine system.* Dr. Dewees speaks in the highest terms of praise of the tinc- ture of guaiacum as an emmenagogue. " I have for more than eight and thirty years," he says, " almost daily used this medicine in suppressed catemenia; and more especially in those of long standing, without its having failed in any case proper for its use,—that is, where the suppression was not the consequence of disease of the uterus or of pregnancy." This is, indeed, great praise; for Dr. Dewees must have treated perhaps several thou- sand cases of this affection during the long period he mentions. That Dr. Dewees has been eminently successful with the employ- ment of this remedy is unquestionable; yet it may be mentioned as a singular circumstance, that although I have employed it in no small number of cases of this affection, and, as I thought, in a vigorous and persevering manner, I have never known it to pro- cure the least apparent benefit, except in one case only. It must be observed, too, that although the doctor's mode of employing this remedy has been for many years well known to the practi- tioners of this city, I have, as yet, met with none who has been even moderately successful with it. Dr. Dewees himself notices this fact. "I have learned," he observes, "that some of my brother practitioners have not been equally successful with it— but I think 1 can readily account for their failure; first, from their not placing the system in a proper situation for its use; and se- cond, by not properly persevering in the remedy." The medicine in which I have hitherto most confided as an emmenagogue, after the system was duly prepared by general treatment, is aloes, in small doses, in combination with the ex- tract of savin and ipecacuanha, according to the following for- mula, t I have, indeed, often failed with this medicine; but, upon the whole, I have more frequently succeeded with its employ- ment than with any other article or combination. The tincture of melampodium, too, has occasionally succeeded well in my hands; and within the last few years^ I have employed the spirits • These remedies appear to promote the menstrual evacuation, solely by their tendency to determine the blood to the pelvic viscera, or more particularly to the uterus ; and it is hence obvious, that where symptoms of high irritation or chronic inflammation of the uterine system are present, all medicines of this kind are highly improper. When, for instance, a puruloid leucorrhocal discharge attends, with other signs of vaginal irritation, purgatives, low diet, rest, emollient injections into the vagina, and, perhaps, local bleeding, are indispensable preli- minary measures. \ R. G. aloes socc. gr. xv. Extract, sabin. J}ii. Pulv. ipecac. T)i. Mucilag. g. arab. q. s. M. Divide into forty pills. Take two pills three times daily. AMENORRHOEA. 545 of turpentine with success in several cases. Where hysterical symptoms attend, peculiar advantage may sometimes be obtained from the following pills.* The tincture of cantharides, too, has been highly recommended as a remedy in this affection. Dr. Joseph Klapp, of this city, has published an account of his ex- perience with this article, from which it would appear, that under judicious management, it will often operate very beneficially.t It should be given in gradually increased doses, beginning with twenty or twenty-five drops three times daily, until a slight de- gree of strangury is produced, when it must be omitted, and re- sumed when the urinary affection has subsided. This article is certainly worthy of particular attention as an emmenagogue, after proper evacuations have been made. I have but seldom prescrib- ed it; but in one of the few instances in which I employed it, the menses were very speedily restored after it was carried to the extent of causing slight strangury. This remedy is especially adapted to cases that are attended with leucorrhoea—but in such instances, it is particularly important to reduce the local inflam- matory action of the vagina, by proper local and general reme- dies, previous to the employment of the cantharides. There is, indeed, scarcely an end to the number of articles and combina- tions that have been boasted as remedies for exciting the men- strual secretion; but so far as my experience enables me to judge, they are all much more apt to fail than to succeed in restoring the suppressed catamenial function. Dr. Lavagna, within the last five or six years, has published an interesting statement of the good effects of injections of the aqua ammonia, diluted with water, into the vagina, as a remedy for the suppression of the menses. Dr. Hosack also, has reported a case of ten years' dura- tion, which yielded to the employment of the ammonia in this way. Ten or twelve drops of the aqua ammonias purse, mixed with an ounce of milk or water, is to be thrown into the vagina by means of a syringe, four or five times daily. If this does not produce a very perceptible sensation in the part, a few drops more of the ammonia must be added to the subsequent injections; but if the irritation be excessive, the quantity must be diminished. Dr. Hosack diluted a drachm of the ammonia with a pint of rain- water, of which a syringe full was thrown into the vagina three times daily. The cure was accomplished in five weeks. J 1 have heard of but one instance of the employment of this remedy in • R. G. aloes Jjii. — assafoctid. 3I1. — myrrh. Jss. Sulph. ferri. Jss. M. Divide into three grain pills. Take two twice daily. . f Med. Recorder, vol. 1. $ New-York Med. and Phys. Jour. Vol. II. 69 546 DYSMENORRHEA. this city; and in this case it failed in doing good. The testimony, however, that has been published in its favour, is respectable, and well worthy of attention. Sect. IV.—Dysmenorrhcea.—Painful and Imperfect Men- struation. Dysmenorrhcea is a common, and generally an extremely ha- rassing affection. It may occur at every period during the men- struating stage of life; but it appears to be most common between the twentieth and thirtieth years of age, and in subjects of an irritable and sanguineous temperament. In many instances, se- vere pains are experienced in the back, loins, and lower part of the abdomen, for' five or six hours previous to the appearance of the menstruous evacuation. This, however, soon ceases, and an immediate aggravation of the torturing pain follows. Sometimes the catamenia begin to flow moderately, with little or no previous pains; but in an hour or two they become suddenly arrested, at the same time that violent pains come on in the hips, hypogastrium, loins, back, and thighs, with a distressing sensation of forcing or bearing down in the pelvis. Occasionally, a very slight men- strual discharge continues uninterruptedly for three or four days, accompanied throughout with extremely severe pains in the pel- vis and lower portion of the abdomen; and in some rare instances, the catamenial evacuation, although attended with great suffering, is sufficiently copious and prolonged in its course, and may even exceed the regular duration and quantity of an ordinary healthy menstruation. (Jahn, Burns.) In by far the greater number of cases, however, the evacuation, as has just been stated, begins to flow moderately, and after an hour or two ceases again, under great sufferings. Some patients are much harassed by severe head- ach or nausea, and paroxysms of violent retching and vomiting, during the first few hours of the complaint. These pains continue for a period, varying from two or three hours to several days, terminating commonly in the discharge of a pseudo-membraneous substance from the vagina, similar in ap- pearance to the decidua. Females labouring under painful men- struation generally experience two distinct kinds of pain ; name- ly : the intermitting expulsive pains resembling those of labour or abortion ; and the constant menstrual pains in the back, pelvis, loins, and thighs, which occur often in regular menstruation, shortly before the appearance of the evacuation. (Dewees.) Dr. Dewees observes, that there are two distinct states of this affection, which in a prognostic point of view are worthy of at- tention. Thus, in some cases the mammae sympathize strongly with the uterus—becoming tumid, and often very painful and DYSMENORRHCEA. 547 tender to the touch ; whilst in other cases the breasts remain wholly free from any affections of this kind. The former variety of cases, says Dr. Dewees, are much more manageable than the latter—an observation which I believe to be well founded, how- ever inexplicable it may be. Some writers seem to think that the formation of a pseudo- membraneous substance upon the internal surface of the uterus is always present in this affection, and constitutes, in all instances, the immediate cause of the difficult and painful menstruation. This, however, does not appear to be founded on correct obser- vation. I have known females to suffer very painful and incom- plete menstruation for two, three or four periods in succession, and afterwards menstruate regularly without any particular diffi- culty, where no membraneous matter whatever was at any time discharged. It must moreover be observed, that painful menstru- ation is not universally attended with a scanty flow of the catame- nial fluid. I have met with several instances, where, in point of quantity and duration, there was nothing irregular in the men- struation, but where, notwithstanding, extreme suffering attended each menstrual period. This, we may reasonably presume, could not take place, if the internal surface of the womb were coated with false membraneous matter. It may indeed be supposed, that the bloody secretion in such cases is furnished by the ves- sels of the mouth of the womb, or even by those of the vagina ; but this assumption is extremely improbable. It cannot be denied, that in very many cases, such membraneous concretions are present, and exercise a direct agency in the production of the difficulties which occur in this affection. It is nevertheless cer- tain, that these masses of concreted lymph are themselves the product of a morbid action of the secreting vessels of the uterus: and there can scarcely exist a doubt, that this diseased vascular action may of itself produce the difficulty and pain in question, independent of the formation of pseudo-membraneous matter. I cannot accord with Dr. Dewees, in his notions concerning the etiology of this affection, or rather "of the membraneous productions so often yielded in dysmenorrhcea." " Before I attempt an explanation of the formation of this membrane," he says, " I must direct the attention to a very remarkable circumstance in the character of the menstrual blood, namely, its not possessing the property of coagulation. From this it appears, that the blood, or a part of it, has suffered some change by, the action of the uterine vessels ; and that this change has been imposed upon the coagulating lymph by the process of secretion. Now, it is not difficult to suppose that the uterus, like every other organ, may have its functions impaired ; in conse- quence of which the texture of the coagulating lymph, instead of bein