V ■ *' .i-rctft.-:^ ;;:«?;;' ' v:-::^"'*■:. ., ,1 *. > ■ .•< . : . •»'.VA ■' >\ ,'" j^.^'V ; ' % V -l ■'' *J* ■"* ^'^X'v."//*"'/ u^pr- PP% 1 v v.-v YipPrJl-if. ■ Y/ .** cr<\ i.r ppP'- , t iMt&^-p- Ft* .7.4 P A .'' >.:p/>F./-J-'F: ppp^vpsc-p P4PffPF.\:.. fpwP ?s:t.>j%>Z,t*F ■■ "'Pfif FlPl/PPr UPSPFP-,:- A TREATISE ON THE PRACTICE OF MEDICINE. BY JOHN EBERLE, M.D., PROFF>M>R OF THE THEORY AND PRACTICE OF MEDICINE IN JEFFERSON MEDICAL COLLEGE; OF MATERIA MEDICA AND BOTANY IN THE OHIO MEDICAL COLLEGE; AND OF THE THEORY AND PRACTICE OF MEDICINE IN THE TRANSYLVANIA UNIVERSITY; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA; AND CORRESPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BERLIN, IN PRUSSIA ; ETC., ETC., ETC. WITH NOTES AND ADDITIONS BY GEORGE M'CLELLAN, M.D. IN TWO VOLUMES, VOL. II. SIXTH EDITION. PHILADELPHIA: GRIGG AND ELLIOT, 9 NORTH FOURTH STREET 1845. <►' .r\ v. a. c i Entered according to the Act of Congress, in the year 1846. 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. rKiiii-tirKU: T.. K. & P. 6. COLLINS, FKINTF.T.R 24921 CONTENTS OF VOLUME II. CHRONIC DISEASES. CHAPTER I. Of Chronic Nervous Diseases. Page General Observations, --...... 9 Sect. I. Apoplexy, ......... 12 Sect. II. Paralysis,..........31 1. Hemiplegia,........34 2. Paraplegia,........36 3. Paralysis Partialis, ------- 37 Sect. III. Epilepsy, .........49 Sect IV. Catalepsy, .........72 Sect. V. Chorea,..........79 Sect. VI. Conyulsive Affections of Infants, .....91 Sect. VII. Hysteria,........* - 102 Sect. VIII. Puerperal Convulsions, - - - - * - - 115 Sect. IX. Tetanus,.......» 120 Sect. X. Hydrophobia,.........135 CHAPTER II. Chronic Nervous Affections, in which Intellectual and Moral Faculties are Disordered. Sect. I. Mental Derangement,........149 1. Mania,.........159 2. Monomania,........161 3. Dementia,........163 4. Idiotism,.........164 Sect. II. Delirium Tremens,.....►.- 171 CHAPTER III. Local, Chronic Nervous Affections. Sect. I. Neuralgia,..........179 Sect. II. Amaurosis,........» - 197 VI CONTENTS. Page CHAPTER IV. % Chronic Affections of the Respiratory Organs. Sect. I. Asthma,.......- 206 Sect. II. Whooping-Cough,......." 218 Sect. III. Asphyxia,..........231 Sect. IV. Pneumothorax, - .......242 CHAPTER V. Chronic Diseases of the Heart. Sect. I. Of the Diseases of the Heart,.......247 1. Hypertrophy of the Heart,......254 2. Dilatation of the Ventricles, ------ 255 3. Aneurism of the Aorta, ------- 257 Sympathetic Affections of the Heart, - - - - - 263 Sect. II. Angina Pectoris,.......- - 266 CHAPTER VI. Chronic Diseases of the Alimentary Canal. Sect. I. Indigestion,..........272 Sect. II. Diarrhoea,..........288 Sect. III. Cholera,......... . . 297 Cholera Infantum,........ - 300 Sect. IV. Colic,.......... 310 1. Flatulent Colic, - - -.....311 2. Bilious Colic,.....- - . 313 3. Colica Pictonum,........318 Sect. V. Ileus,...........325 Sect. VI. Constipation,.........330 Sect. VII. Intestinal Worms, ■.......332 Sect. VIII. Haemorrhoids,.........343 Sect. IX. Jaundice,.......... 354 CHAPTER VII. Chronic Diseases of the Urinary Organs. Sect. I. Diabetes Mellitus, .-..___ Sect II. Diabetes Insipidus, ----... o8n Sect. III. Lithiasis,.......__ 1. Lithic Acid Diathesis,...... _S7 2. Phosphatic Diathesis, - -'. Sect. IV. Ischuria Renalis,...... Sect. V. Retention of Urine,...... Sect. VI. Dysury,......... Sect. VII. Enuresis,........ CONTENTS. VI1 Page CHAPTER VIII. Chronic Diseases of the Serous Exhalant Vessels. Hydrops,.........417 1. Ascites,.........423 2. Hydrothorax,........424 3. Anasarca,........425 CHAPTER IX. Chronic Affections of the Lymphatic System. Sect I. Scrofula,..........442 Sect II. Bronchocele,.........457 CHAPTER X. Chronic Disorders of the Assimilative Functions. Sect. I. Scorbutus, -.........468 Sect. II. Chlorosis,..........473 CHAPTER XL Chronic Diseases of the Sexual Organs. Sect. I. Gonorrhoea,..........479 Sect. II. Syphilis,..........490 Buboes,.......- - - 510 Sect. III. Amenorrhea, - - - -.....513 Sect. IV. Dysmenorrhea,.........519 Sect. V. Leucorrhoea, --.......525 APPENDIX. Cholera Asphyxia—Spasmodic Cholera,......533 A TREATISE ON TEE PRACTICE OF MEDICINE. CHRONIC DISEASES. CHAPTER I. OF 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, ren- ders it a fit recipient for the powers of reason and moral feeling. 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 human organization. The chronic diseases of the nervous system may be divided into two classes—viz: 1. Those in which the sensorial or muscular func- tions are morbidly affected, either separately or conjointly; 2. Those in which the intellectual and moral powers are disordered. The first of these classes comprehends a great variety of affections —characterized either by & perversion, or a morbid activity or abo- lition 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 functions are nu- merous. Reil mentions a case in which the whole surface of the body VOL. II.—2 10 GENERAL OBSERVATIONS. was insensible to heat or cold, and incapable by the touch of distin- guishing hardness from softness in bodies. Dufour gives an account of a similar case.* Sauvages.relates the case of an individual wlio always heard two voices, one an octave higher than the other, when any one spoke to him. Individuals have lost the power of distin- guishing 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 exceed- ingly 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 manifests itself by excru- ciating pain in some part of the body, as in the various forms of neuralgia. The sensorial functions may also be weakened or entirely destroyed, 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 will be suspended. This general 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 accompanied by any perceptible respiratory and arterial actions, and although, like coma, the immediate conse- quence of impeded cerebral function, yet they are manifestly depend- ent on different conditions of the encephalic circulation. The patho- logy in relation 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 in several, or in the majority of the muscles of the body. These convulsive or spasmodic muscular contractions are divided by au- thors into tonic and clonic. In the former, the contractions are per- manent, as in tetanus ; in the latter they occur in quick alternation, with relaxation, as in hysteria and epilepsy. There exists, however, no essential difference between these varieties of convulsive muscular action. They indeed often occur at the same time in the same indi- vidual, some muscles remaining 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 fre- quently the result of a mere temporary sympathetic irritation of the brain, from causes of a transitory character, or susceptible of being removed; whilst the latter usually depend on a more intimate affec- tion of the nervous system, from catfses over which we have little or no control. Convulsions, or general spasmodic affections of the vol- untary muscles, must, therefore, be regarded as the external manifesta- tions of certain morbid actions or conditions of the brain and nerves The brain, or spinal marrow, is the immediate source of the muscular * Reil, Fieberlehre, bd. iv, p. 64. GENERAL OBSERVATIONS. 11 irritation; and the violence, duration, character, and extent of the convulsive affection, depend 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 temporary suspension of consciousness, and of the sensorial functions. In others, as in tetanus and chorea, the mind and sensorial powers remain unaffected until the disease be- comes 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, (sardrosis,risus sardonicus,) giving an expression of malignant laughter to the countenance ; tonic con- traction of the muscles of the jaws (trismus); spasmodic affection of the oesophagus; convulsive 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 spasmodic 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 affections ; but these appear to depend more frequently on some local irritation than upon a reflected cerebral impression. The whole arterial sys- tem is sometimes affected with clonic convulsive action. This is particularly apt to occur from sudden and violent mental agitation ; from gastric irritation ; and from organic affections of the heart (angina pectoris, 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 cerebral irritation produces mental derangement, presents a variety of modi- fications, both in relation to the degree and the particular character of the hallucination. In some instances, there is a general derange- ment 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 understanding 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 con- vulsive affections, as epilepsy, chorea, or apoplexy. In some in- stances, 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 * 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. 12 APOPLEXY. disorder sometimes pass into each other, and present an almost infi- nite diversity in their particular phenomena. They may arise from causes acting directly on the brain, and from impressions conveyed sympathetically to this organ from remote visceral affections. What- ever 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 sensorium commune. Under the particular head of these affections, I shall enter more fully into the etiological consideration of this subject. Sect. I.—Apoplexy. 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 functions continue with little or no perceptible disturbance. In some instances, the apoplectic attack comes on suddenly with- out 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 individuals 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 tur- gid 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, mani- fested by incoherent talking; disturbed and heavy sleep; loss or unusual weakness 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 nau- sea. In some instances, a numbness is felt in the fingers or in one side of the body shortly before the attack supervenes. In general, the symptoms which announce the approach of an apoplectic 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 attack ensues; in others, they occur with occasional remissions or intermis- sions, for several weeks or months, and even years. Occasionally the most alarming of the foregoing symptoms occur and continue for a longer or shorter time, without terminating in an attack of this dis- ease. The premonitory symptoms often become considerably aSha. h, eTrtiih touco to £wov juo'voy araga t* etsj* IXa£OT£jov \yiK i\n (is) §ata,T0( avrZ, tin t*atla iri^ittTM, a.ttl toJ a-wXnvof yivtrai.—Origines Contagii, Auctore Dr. C. F. H. Marx. Homer, also, in several places, refers to this disease. Thus Tencer calls Hector a mad dog :— Tourw >'ou Kva.fx.at BaWlny xvva, \vipa.—Fciad, lib. viii, V. 299. At Argos there was anciently an annual festival, called Cyrocephantes, during which, all the dogs that were running at large were killed.—Gorrey, Sur la Rage. Journ. de Medecine, t. xiii, p. 93. t De Morb. Acut., p. 206, edit. 1722, as quoted by Van Swieten. X Callisen in Collect. Societ. Med. Havn., vol. i, ob. 32. Gruner's Almanachfuir Aerzte, 1786, p. 184. Salzb. Med. Chir. Zeitung, 1795, b. iii. p. 80. 136 HYDROPHOBIA. of the year; yet in some extremely warm and cold countries, this disease is said to be entirely unknown, or, at most, exceedingly un- common. In South America, Egypt,* Syria, the West Indies, Sweden, and Kamschatka,t hydrophobia, we are told, has been rarely if ever known to occur. Its spontaneous occurrence has also been thought to be particularly favoured by certain occult atmospheric constitu- tions ; and this opinion is countenanced .by the fact that the disease has been known to occur at certain times and places in an epidemic manner.J Besides these presumed occasional or predisposing causes of hydrophobia, it has been alleged that putrid food, the protracted want of food and drink, unsatisfied venereal passion,§ and violent rage, are capable of originating this affection. Dr. Mease states that a number of dogs fed upon the carcases of horses that were left unburied near this city, and that many of them soon afterwards be- came affected with rabies. Rougemont relates similar examples of the apparent generation of this affection by putrid animal food. On the other hand, however, it has been observed that the dogs that crowd the streets of Constantinople feed almost exclusively on putrid animal substances, and yet hydrophobia is said to be almost wholly unknown at that place. "Putridity," says Dr. Good, "is perhaps the ordinary state in which dogs and cats obtain the offal, on which for the most part they feed: they show no disgust to it, and it offers a cause far too general for the purpose." With regard to the want of food and drink, as a cause of hydrophobia, Richter states, that in hot climates dogs have been known to perish for want of water, without having been seized with rabies. Direct experiments, too, have been made by confining dogs, both during very warm and cold seasons, and allowing them nothing but water without food, or salted and putrid meats, but no drink, without any of them becoming affected with this disease.|| It is nevertheless probable that these causes, though not of them- selves capable of producing this disease, co-operate often with other influences in exciting its development. With regard to the tendency of violent rage to impart properties to the saliva of certain animals, capable of producing affections very similar, or as some assert, iden- tical with hydrophobia, many confirmatory observations are extant. Lister mentions an instance of fatal hydrophobia produced by the bite of an enraged dog,T and similar cases are related by Dr. Park- inson and Linguet.** The bite of an enraged cat, also, has been known to give rise to fatal rabies in the human species. Rossi gives * Le Cointre, Journ. de Med., torn, vi, p. 265, as quoted by Richter. t Langsdorf s Reisen., b. ii, p. 443. X Fehr. Etwas Ueber d. Hundswuth. Mease on Hydrophobia. $ Hildenbrand, Eein Wink zur Naehern Kenntniss u. Heilung d. Hundswuth, p. 4. II Ribbe. Natur. u. Medic. Geschicte der Hundswuth Krankheit. If Tract, de Quibusd. Morb. Chronic, p. 43. ** Journ. Politique, No. 1775, quoted by Richter. HYDROPHOBIA. 137 an account of three cases of this kind.* Weikard states that a wo- man, n separating two fighting fowls, was bit by one of them, from which she became affected with fatal hydrophobia ;t and Le Cat mentions a similar event from the bite of an enraged duck.J The instances in which affections simulating hydrophobia have arisen from the bite of infuriated men, are by no means very rare. Van Swieten mentions a case of this kind,§ and other examples are re- lated by Weikard, Meekreen, Wolff, and Zacutus Lusitanus, as cases of genuine rabies. It is not improbable, however, that many of the reputed cases of hydrophobia, said to have arisen from injuries of this kind, were in reality peculiar forms of tetanic affections ; for the dread of water, which has been generally regarded as pathognomonic of rabies, has been frequently known to occur in cases unequivocally tetanic. The contagion of rabies belongs to the palpable or fixed morbid animal passions; and does not admit of being diffused in the atmo- sphere—at least not in such a state as to retain its power of affecting. It would seem, however, to retain the power of affecting the system a very long time after it is generated. Cases are related in which the saliva of hydrophobic patients adhering to clothes, has given rise to the disease in persons who afterwards were employed to clean or mend them. Richter mentions the case of a woman who became affected with rabies in consequence of having mended a garment that was torn by the bite of a rabid dog.|| The period which intervenes between the insertion of the conta- gion of rabies and the commencement of the disease, is exceedingly various. It very rarely appears before the end of the third week, and in some instances the contagion remains dormant for six, nine, or even twelve months before its effects are manifested. From forty to sixty days may be regarded as by far the most common latent period of this contagion. Dr. Dickson states, that of seventeen per- sons who were bitten by the same dog, ten became affected with the disease at different periods from the fifteenth to the sixty-eighth day after the infliction of the bites.1T Instances, indeed, have been noticed, in which the disease came on as early as twenty-four hours after the bite of a rabid dog; and Boudot mentions a case which supervened during the first night.** It is exceeding doubtful, how- ever, whether these cases were truly hydrophobic. The alarm occasioned by the bite of a rabid dog, may of itself be sufficient to cause spasmodic and nervous symptoms, simulating this disease, in persons of nervous temperaments. Authors, moreover, mention cases which did not supervene until several years after receiving the * Turiner Med. Abhand., 1802. t Philosoph. Arzt. s. iv, p. 186, quoted by Richter, X Recueil Periodique, ii, p. 90. $ Commentaries, § 1130. * || Specielle Therapie, bd. viii, p. 378. 1J Med. Observ, and Inquiries, vol. iii, art. 34. ** Essais Antihydrophobique, 1771, p. 121—Richter. 138 HYDROPHOBIA. hydrophobic contagion ; but the instances which are related as having occurred eighteen, twenty, and even forty* years after the insertion of the virus, require an effort of faith which few, I presume, are willing to exercise. There is, however, a very remarkable and well authenticated case related, of a woman who had been bitten by a mad dog, and in whom the wounded part inflamed and broke open every spring for eighteen years in succession. In the spring of the nineteenth year, the part became red and painful, without opening, and the immediate consequence was furious mania, with an insur- mountable horror of water. By the application of blisters to the affected part, blood-letting, and mercurial purgatives, she was cured.t Without doubt, however, the occurrence of this affection after the infliction of a bite from a rabid animal, may be promoted by the alarm and mental anxiety which an accident of this kind always excites to a greater or less degree. It would appear also that violent anger or vehement mental emotions, of every kind, and from what- ever cause they may arise, have no inconsiderable tendency to hasten the occurrence of this affection after its contagion has been intro- duced into the system. Observation would seem to show, too, that high atmospheric temperature has a similar tendency of promoting the activity of this contagion. It is said that the disease almost inva- riably comes on much earlier in hot climates than in the temperate latitudes. Richter mentions the free use of spirituous drinks and inordinate venereal indulgences, as causes capable of hastening the supervention of the disease.^ Several very striking examples, illus- trative of the influence of the latter cause in this way, are mentioned by Rougemont. It is a fortunate circumstance, that the bite of a rabid animal is by no means generally followed by hydrophobia. The predisposition to the morbific influence of this contagion does not appear to be very strong in the human species; and in many instances an entire insusceptibility seems to exist to its operation. It is from this cause, in part, at least, that we sometimes find only one or two out of a number of individuals bitten by the same dog, become rabid. Without doubt, too, the circumstances attending the infliction of the bite, often have a particular agency in hastening, retarding, or preventing the occurrence of the disease. When the animal bites through clothes, more especially woolens, the virus is probably often so completely wiped from the teeth before they pene- trate the skin, as to prevent infection. It has already been observed, that in the human subject hydro- phobia, or genuine rabies, appears to have but one origin ; namely, the application of the hydrophobic contagion to a raw or excoriated surface. It has, nevertheless, been asserted, that unequivocal rabies has occurred in the human species without the agency of a specific virus; and Richter, as well as many other respectable authorities, are inclined to admit the possibility of such an occurrence. Mangor * Rougemont, loc. cit., p. 123. t Richter's Chirurg. Biblioth., b. v, p. 686. X Act. Reg. Soc. Med. Hav., vol. ii, p. 408—Richter. HYDROPHOBIA. 139 gives an account of an instance, where a melancholic man became affected with hydrophobia wholly unconnected with contagion, of which he died on the sixth day. His wife, who, during the course of the disease, frequently kissed him, also became affected with the dis- ease and died of it on the fifth day. Dr. Barth has related a very remarkable case of hydrophobia which was excited by cold. The patient, a man about forty years old, was subject to hemorrhoids, hypochondriasis and profuse sweat- ing of the feet. He bathed his feet in cold water, and in a few hours afterwards was seized with violent general spasms of the clonic character. The skin of the body was icy cold to the touch. The spasm occurred every eight or ten minutes, and continued about a minute. Among other things, the patient was ordered to drink warm elder tea; " but the moment the patient attempted to drink, he was suddenly seized with a most violent spasm of the throat, and pharynx, and the fluid was immediately thrown out of the mouth; the eyes were convulsively distorted; the neck became fright- fully distended, and the head thrown backward ; the chest and the abdomen were raised from the bed while the hands and feet moved convulsively, and a hoarse sound, like that made by persons suffo- cating, was uttered by the patient." The disease yielded to sina- pisms, antispasmodic injections, warm pediluvia, and stimulating frictions. (Rut's Magaz., vol. 21, No. 1, 1S28.) Symptomatic affections closely simulating hydrophobia are not very uncommon. A dread of water—exciting spasms and feelings of indescribable horror when attempts are made to drink—has been frequently noticed as an accidental occurrence in various diseases. Inflammation of the brain, uterus, and particularly of the heart, and of the cardiac extremity of the stomach, are most apt to become com- plicated with hydrophobic symptoms. Nervous affections, more especially hysteria and hypochondriasis, may also assume the pheno- mena of rabies; and instances are mentioned, in which mania and epileptic paroxysms have terminated in symptoms of hydrophobia.* The narcotic poisons—particularly stramonium, belladonna, and aco- nitum—have been known to produce spurious hydrophobia ;t and it has been the consequence of suppressed menstruation by violent mental emotions. (Richter.) Malignant and other violent forms of fever are sometimes attended, in the advanced period of their course, with many of the characteristic symptoms of rabies. Schmucker relates a case of dropsy, in which the " water-dread" was for atime as strongly manifested as it usually is in genuine hydrophobia; and Frank saw an instance of its occurrence in diabetes.! In the last stage of pulmonary consumption, in hepatic obstructions, in jaundice, and in other chronic visceral affections, hydrophobic symptoms have been known to occur; and the occurrence of phenomena of this kind in tetanus is far from being uncommon. * Richter, Specielle Therapie, b. viii, p. 197. t Harles, Ueb. d. Behandl. d. Hundswuth, p. 72. X Epitom., &c, lib. v, p. i, p. 54. 140 HYDROPHOBIA Symptoms.—In nearly all instances of this affection, certain local and general premonitory symptoms occur for a longer or shorter period previous to the appearance of the characteristic phenomena of the disease. If the wound by which the contagion was communi- cated be not yet fully closed, it assumes a more or less livid appear- ance, with raised and inflamed edges, and begins to discharge a thin ichorous matter a few days before the accession of the proper hydro- phobic symptoms. Where cicatrization has been fully completed before the disease begins to develop itself, the cicatrix generally becomes slightly elevated, painful, inflamed, and finally often opens, forming an ill-looking ulcer with elevated borders, from which a thin, acrid and offensive matter is discharged. The pain in the affected part is often very severe; and sometimes gradually extends itself throughout the whole limb. It is said, that the pain in passing inwards from the part that was bitten, always proceeds along the course of the nerves towards their origin. Sometimes, however, little or no inflammation and pain in the injured part are noticed before the accession of the disease, with the exception usually of an occasional transient stinging sensation in the cicatrix. In some instances the patient experiences a peculiar torpor and numbness of the injured extremity. The general premonitory symptoms consist usually in lassitude, muscular prostration, indisposition to corporeal and mental exertion, flushes of heat alternating with transient sensations of chilliness, nausea, sometimes bilious vomiting, thirst, constipation, want of ap- petite, anxious respiration, and, in general, all the symptoms which usually precede the development of febrile diseases.* In some cases a constrictive sense of pain is felt in the extremities, passing gene- rally from the wounded part, and finally fixing itself in the head. (Richter.) The sleep is commonly disturbed by alarming dreams, and attended with slight spasms of particular muscles, and twitching of the tendons. The temper is almost invariably prominently affected shortly before the invasion of the disease. The patient is unusually reserved, suspicious, taciturn, and tormented with gloomy forebod- ings; sometimes, though indeed seldom, he is animated and talk- ative. There is commonly an extreme degree of sensibility and repugnance to the impressions of cool air. In men, the desire for venery is often almost irresistible a short time before the disease comes on, and Hamilton states that the scrotum is usually very strongly, and, as it were, spasmodically contracted. These precursory symptoms sometimes continue for seven or eight days before the actual occurrence of the disease; but their ordinary duration varies from two to four or five days. Occasionally, indeed, no premonitory symptoms whatever are noticed before the accession of the disease. The only symptom which is never wholly absent in this disease, as it affects the human species, is the extraordinary dread or horror of liquids — more especially of water. Patients labouring under * Richter, loc. cit., p. 129. HYDROPHOBIA. 141 rabies may, indeed, sometimes experience a temporary abatement or even absence of this torturing symptom, but in all instances it occurs in a greater or less degree, and generally remains throughout the whole course of the malady. In general, the mere sight of liquids, or the sound of pouring water from one vessel into another, brings on violent suffocative spasms; and the attempt to swallow water or to bring it to the lips, commonly excites a degree of horror and agitation truly frightful. Even the sight of polished surfaces, as of a mirror, or the rustling sound of bed curtains, of currents of air, or of running water, will, in the more violent grades of the dis- ease, immediately renew the spasms and feeling of horror. Occa- sionally, however, this extraordinary horror is manifested only against water; for patients have been known to take small portions of other fluids, as of soups, milk, and wine, in a lukewarm state. The thirst is always extremely urgent, and though the suffering from this source is generally very great, the patient dares not attempt to swallow any liquids. The secretion of saliva is profuse, and from an inability to swallow it, the patient continually spits it out in every direction, "often desiring those around him to stand aside, as conscious that he might thereby injure them." During the whole course of the disease occasional remissions occur. Whilst these continue, the patient often appears calm, talks deliberately about his feelings or his affairs, and cautions those who are about him not to approach him too closely when under the paroxysm of madness, lest he should injure them. Notwithstanding this partial calm, there are always a peculiar wild- ness and appearance of alarm in the expression of the countenance: the motions are quick and hurried; the eyes cast about with an air of suspicion ; and if the patient attempts to lie down and obtain some rest, he usually soon starts up again with great agitation and anguish of feeling. During the exacerbations, the expression of the counte- nance is wild, furious, agitated, and agonized; the eyes are blood- shot, sparkling, projecting, and expressive of rage and terror; the muscles of the face, throat, chest, and sometimes the extremities, are thrown into spasms; respiration is interrupted or convulsive; the arms are thrown about; the fists clenched; the teeth violently gnashed; the mouth foaming; with an unconquerable disposition to bite every thing that comes within the patient's reach. In violent paroxysms, furious and maniacal raving occurs, attended often with an entire absence of consciousness. These paroxysms usually last from about fifteen to thirty minutes. Many patients, however, do not become furious or maniacal during the spasmodic exacerbations, and retain almost the full command of their mental powers, from the commencement to the fatal close of the malady. In some in- stances a tormenting degree of salacity is experienced during the intermissions, attended with continued painful erections, and occa- sional involuntary discharges of semen. Patients affected with rabies generally walk about through the room, or remain sitting up as long as their strength admits of this effort, for the horizontal posture is almost always borne with much difficulty. Hydrophobia is very rarely attended by distinct febrile symptoms, 142 HYDROPHOBIA. except sometimes towards the conclusion of the disease. At first the pulse generally does not materially differ from its natural condition; but in the latter periods of the complaint it always becomes small, irregular, weak, and very frequent. The eyes are in general very sensible to light; and the countenance is pale during the remissions, but turgid and flushed during the paroxysms. Some patients are from time to time affected with vomiting, attended with a burning heat in the pit of the stomach. The morbid sensibility to the impres- sions of low temperature, which occurs generally among the premo- nitory symptoms, often rises to an extreme degree during the course of the disease. Towards the termination of the malady, the tongue becomes rough, harsh, chapped, and often aphthous. The surface of the body is usually constricted and dry, the bowels constipated, and the blood drawn from a vein often dissolved and very fluid. (Richter.) The duration of hydrophobia is fortunately not long. Most patients die as early as the second or third day of the disease. It is rarely protracted beyond the fifth or sixth day; although instances have occurred which did not terminate under fourteen or fifteen days. Post-mortem appearances.—The morbid phenomena, detected by dissection, in those who die of hydrophobia, are extremely various in different cases, and throw but very little or no light on the true nature of this affection. It is said that the process of decomposition often commences very early after death, and proceeds with great rapidity.* The surface of the body is usually of livid redness, and the muscles, and particularly the tendons, are unusually rigid. Strong vascular congestion of the meninges and brain, with serous, or sero- sanguineous effusion between the membranes and into the ventricles, are among the most common phenomena. In some instances, the brain has been found unusually firm and dry, (Morgagni;) in others extremely soft. The mucous membrane of the mouth and fauces, and particularly about the glottis, is usually inflamed, and sometimes con- siderably tumefied or cedematous. In some instances, however, these parts did not exhibit any material deviation from their natural con- dition, (Morgagni, Vaughan;) in others, instead of inflammation, the mucous membrane of the mouth and fauces was of a rose-red colour, with a varicose dilatation of some of its blood-vessels.t The cervical ganglia have been found inflamed. The lungs are often greatly en- gorged with blood, and their mucous membrane irritated or inflamed. In some cases the mucous tissue of the stomach and bowels exhibits evident marks of previous inflammation ; and the same phenomena are occasionally met with in one or more of the abdominal viscera. Metzler, Benedict, Gherardini, and Autenreith have found the nerves leading from the wounded part manifestly inflamed to a considerable extent of their course. It must be observed, however, that many in- stances have been reported, in which scarcely any morbid appearances whatever were detected on post-mortem examination. * Sauvages—De la Rage. Morgagni; De Sedeb. et Caus. Morbor., lib. ii, art. xix. t Krukenberg, as quoted by Richter. HYDROPHOBIA. 143 With regard to the proximate cause or pathology of hydrophobia, there is but very little, or nothing, known of a satisfactory character. The very numerous opinions that have been expressed upon this sub- ject, resolve themselves into : 1,those which regard the sanguiferous system as the primary location of the disease, viewing it as essen- tially an inflammatory affection: and 2, those which place the essential irritation exclusively in the nervous system. The general sentiment, at present, is in favour of the latter doctrine; but there exists nothing beyond plausible conjecture and hypothesis, with regard to the parti- cular character of the nervous affection, or the portion of the nervous system chiefly implicated. Without entering into any discussion on this obscure subject, it may be observed, that although the essential phenomena of the disease point unequivocally to a morbid condition of the brain and nerves, we have equally conclusive evidence that the arterial system is in a state of morbid excitement; for without diseased vascular action there could be no hydrophobic virus secreted. The opinion, however, that it is an inflammatory affection, is certainly not sustained by the symptoms of the disease. That local inflam- mation should sometimes occur during the progress of the malady, is indeed to be expected; but even this occurrence does not appear to be so common as has been asserted; for many of the repeated examples of local inflammation, were probably merely instances of strong vascular injection or engorgement, with its occasional consequent serous effu- sion, produced either during the course of the disease, or in articulo mortis. Rabies is, I presume, essentially a cerebral affection. The peculiar dread of liquids, the paroxysms of fury, or mental agitation, spasms, and general feelings of anguish and alarm, without any manifest febrile symptoms, all indicate that the disease is essentially connected with, or dependent on, a morbid excitement or condition of the brain, independently, it would seem, of diseased vascular action or phlogosis. Treatment.—After all that has been said and done in relation to the nature and remedial treatment of rabies, there is, perhaps, no other affection which is so decidedly beyond the control of all the resources of our art as this appalling malady. That it is essentially an incurable disease cannot indeed be affirmed; for however unsuc- cessful the efforts of physicians may hitherto have been, there is certainly nothing in its characteristic phenomena, which should lead us to assert that it is necessarily fatal, or to abandon the hope that some mode of management or remedy may yet be discovered, capa- ble of arresting its progress. Indeed, unless we discredit the autho- rity or judgment of several physicians of good repute, we must admit that instances of genuine hydrophobia have been successfully sub- dued by remedial treatment. Unfortunately, however, such favour- able results have been so exceedingly rare, that they can scarcely sanction any expectations of advantage from remedial applications, after the disease has made its appearance. Our reliance must, therefore, be entirely placed in the prompt and energetic employment of prophylactic measures; and for this purpose, local applications to the wound, with the view of prevent- 144 HYDROPHOBIA. ing the absorption of the hydrophobic virus, are decidedly the most efficient remedies. As soon as possible after the infliction of the bite, the wound and surrounding surface should be carefully washed with warm, or, as Hunter recommends, cold water; and immediate efforts made to pre- vent the further passage of the virus into the system. If the bite be of a character, and in a part which admits of its entire excision, this, if speedily done, affords undoubtedly the most certain protection against the occurrence of the disease.* If the bite be on the hand, particularly when the teeth of the animal have penetrated deeply between the bones, it will be best to ampu- tate : and this is especially proper if only the fingers are wounded. Some have preferred destroying the wounded part with the actual cautery, and there can be no doubt of the efficiency of this measure, if employed soon after the bite has been received. The free appli- cation of caustic potash may also be resorted to with success where the wound is superficial; but where it has penetrated deeply, it can- not supply the place of excision, or the actual cautery. In slight wounds, the application of cupping glasses, as is recommended by Dr. Barry, for the purpose of arresting the effects of poisoned wounds, would, perhaps in most cases, be sufficient to prevent the occurrence of rabies. Dr. Good "strenuously recommends the immediate appli- cation of a tight ligature to the affected part, a short distance above the wound, if its situation will admit of it." Besides these local measures, ivhich alone deserve our confidence, a vast variety of internal remedies have been recommended, with the view of counteracting the hydrophobic virus. Of all other diseases, indeed, rabies has afforded the widest scope for empiricism and char- latanry. Innumerable remedies have, at different times, been lauded as infallible preventives of this affection; but sad experience has hitherto nullified all these pretended specifics. The most celebrated of these remedies is belladonna. This arti- cle was first used by Mayerne. Munch asserts, that in 176 instances the occurrence of the disease was prevented by this medicine ;t and * [By a free excision of the wound after the bite of a rabid dog, I have pre- vented hydrophobia in every case to which I have been called before the access of a paroxysm. I pinch up the integuments as deeply as possible between the left thumb and fingers, and shave out all the parts around and below the wound, if it be a superficial one, and then dissect out the bottom, if it be a deep-seated one. A cupping glass over the wound and a ligature above it will then promote a sufficient hemorrhage to discharge all the virus. Under this treatment, Mr. Robeno, a tailor, in Southwark, escaped after two severe bites on the outside of the calf of one of his legs—when a woman, who had been bitten just before by the same dog in the same street on one of her hands, was seized a week after- wards with a fatal hydrophobia. My friends, the two Dr. Klapps, treated her by the ligature and caustic, and also by the plentiful use of the decoction of Scutel- laria.—Ma] + Dissert, de Belladonna Efficaci in Rabie Canina Remedio. HYDROPHOBIA. 145 we have the authority of Stark, Jahn, Bucholz,* Sauter,t and Hufe- land,:!: in favour of its prophylactic powers against this affection. Anagalis arvensis.—This is one of the oldest remedies for the pre- vention of rabies. Both Galen and Aetius recommend it for this purpose. It formed the basis of several celebrated nostrums, for- merly vended in this country; and its powers have been particularly extolled by Ravenstein, Cartheuser,§ Chabert, Ribbe, Stoeller, and other writers on this disease. IJchen cenereus constituted the prin- cipal ingredient in the pulvis antilyssus of Dambiere.|| The cele- brated Mead asserts, that in more than one hundred instances, he prevented the disease by this remedy. The water plantain (alisma plantago) has, of late years, attracted much attention as a prophylactic remedy in this affection. It was first employed in Russia ; and many respectable names might be cited in favour of its powers in this respect. The powdered root or bulb is given in doses of from a scruple to a drachm once daily. The root, it is said, should be collected about, the latter end of August. The Scutellaria lateriflora is fresh in the recollection of every one, as a highly boasted preventive of this malady. Lik§ other articles of this kind it has had its day ; and there are probably now very few, if any, physicians, who would place the least reliance on its powers —as it certainly does not appear to deserve any confidence what- everA Boerhaave, Erpenbeck, Moneta, and others, speak highly in favour of the internal and external use of vinegar as a preventive in this affection. A tablespoonful of strong vinegar is to be given three or four times daily for several weeks. Much has also been said in praise of the internal use of cantharides as a protection against rabies. This remedy is mentioned by Rhazes: and among the moderns, Werlhof,** Bucholz, and particularly Rust,tf have * Hufeland's Journal, bd. v, p. 378. t Ibid., bd. vi, p. 679. X Ibid., bd. xvi, p. 113. $ Fundamenta Materia Medica. II Two drachms of this substance, with half an ounce of black pepper, was given every morning for four days.in succession, in a cup of warm milk; and the patient directed to use the warm bath daily for a month afterwards. 1[ Besides the vegetable substances mentioned in the text, the following have been employed, and especially recommended, for the prevention of rabies. Rad. Cynosbati, (Van Swieten;) Celtis australis; phytolacca decandra, (Harles:) celtis ambralis, (Hufeland's Journal, bd. xxxii;) valerian, (Bouteille;) nux vomica, (The- besius, Leidenfrost;) faba St. Ignatii; datura stramonium, (Mease, Cooper, Harles, Brera, Hannemann;) tobacco, (Barton's Med. and Phys. Journ., vol. ii, p. 122;) lycopodium clavatum, (Hildebrand:) camphor, (Sehmueker:) gentiana pneumo- nanthe; hypericum dubium; thaiictrum flavum ; paris quadrifolia; cichorium intybus; genista tinctoria; ranunculus sceleratus; campanula patula, and glome- rata; polypodium bistorta; mercurialis perennis, &c. ** Opera Omnia, part iii, p. 699. ft Ueber d. durch den biss ein. hundes veranlaste Wasserscheu—in dessen Magazin. f. d. gesammte heilkunde, 1816, b. i, p. 97. VOL. II.--H 146 HYDROPHOBIA. spoken decidedly in its favour. Axter,a German surgeon of deserved celebrity, states, that he never knew the internal administration of cantharides to fail in preventing rabies. As principal surgeon of the general hospital at Vienna, he had frequent opportunities of treating cases of this kind, and his opinion, as Richter observes, is entitled to great weight, as it is founded on a long course of very exten- sive experience. He gives one grain of the powdered cantharides daily in union with tartar emetic, for five or six days in succession, and keeps the wound open for six weeks, by vesicatories and pow- dered cantharides.* No remedy has had more repute as a preventive of hydrophobia, than mercury. Astruc, Sauvages, Van Swieten, De Haen, Tissot, Portal, and Werlhof, regard this article as the most certain prophy- lactic we possess against rabies. Many examples, illustrative of its good effects, have been reported ; but the instances in which saliva- tion has failed to prevent the occurrence of the disease, are, perhaps, no less numerous, and it is now generally regarded as entitled to but very little confidence in this respect.t Within the last few years, M. Coster, a French surgeon, has published some statements which would seem to show that chlorine has the power of decomposing and destroying the hydrophobic virus. Two tablespoonfuls of chloruret of lime are to be dissolved in half a pint of water, with which the bitten part must be frequently bathed. It is said to have proved successful when applied six hours after the bite was received. Cold bathing or affusion is recommended by Celsus and Coelius Arelianus, as a powerful prophylactic means in this affection. Cases of its successful application are mentioned by Van Swieten, Saba- tier, Andry, and others ; and it can scarcely be doubted, that by its invigorating and alterative effects, it is, at least, a very proper auxi- liary to whatever other measures may be employed to obviate th« disease. % Besides the remedies already mentioned, a vast number of nos- trums and mixtures have had a temporary reputation as prophylac- tics against rabies. These, however, have all passed into merited neglect; and at present, there is perhaps no article of this kind that is countenanced by any respectable member of the profession. Most of the foregoing remedies have also been employed for the purpose of curing the disease after it has actually made its appear- ance. Stark asserts, that he cured two cases of hydrophobia by the exhibition of belladonna in large doses; and Sauter relates several remarkable instances which yielded to the powers of this remedy.J He gave it in doses of from eight to twelve grains of the powdered * Richter's Specielle Therapie, b. viii, p. 278. f The carbonate of ammonia (Martinet, Darluc;) musk, (Dalby, Nugent, Tissot, Gmelin;) acetate of copper, (Leib.;) copper filings, (Cothenius -,) phosphorus, (Zinke;) arsenic, (Lond. Med. and Phys. Joura, 1789,) have all been recommended fw their prophylactic powers in this affection. X Hufeland's Journal, bd. xi, p. 3. HYDROPHOBIA. 147 root every forty-eight hours. Shallern also cured a case of com- pletely developed rabies by the use of this narcotic* A case is re- lated in Hufeland's Journal, (b. 44,) which was successfully treated by a combination of anagalis, marum verum, and basilicum; and the celebrated Vogel asserts, that he cured several well-marked cases with a decoction of the anagalis.t According to Martinet, the liquid caustic ammonia has arrested the disease in four instances. He gave sixty drops at first, and afterwards fifteen drops every two hours, with a few ounces of a strong decoction of cinchona every four hours. J Rust states, that he succeeded in subduing the disease, in one instance, with large and repeated doses of cantharides;^ and Axter prevented the full development of the disease, after unequi- vocal symptoms of its attack had already made their appearance. The meloe majalis was used successfully by Kortum; and Selle em- ployed them with decided benefit. The very free use of mercurial remedies—particularly in the form of frictions, in conjunction with baths and musk—is said to have been employed with success in some instances of rabies, (Callisen, Rougemont.) Dr. Munckly has related a case which yielded under the influence of a free mercurial salivation.|| Olive oil, both externally and internally employed, is said to have removed this affection. Both Celsus and Ccelius Arelianus recommended frictions with warm oil as an efficient remedy in rabies. Vater has adduced facts illustrative of its curative powers in this affection,! and Shad well, an English physician, has given an account of a case, which would ap- pear to have yielded to the internal and external use of sweet oil.** The cold plunging-bath, or copious affusions, is mentioned by Van Swieten, as having succeeded in arresting the progress of rabies ;tt and Morgagni refers to similar instances of success; although he himself saw an instance in which the patient died almost instanta- neously on being plunged into cold water. Dr. Amell has related a case in which pumping for two hours and a half on the patient, was decidedly beneficial.$:): Copious blood-letting also has been much insisted on as a remedy in hydrophobia, and there was not wanting well-authenticated in- stances of its beneficial effects. Pourpart asserts that prompt and very copious abstractions of blood, so as to induce complete syncope, * Bernstein'sNeu. Beitraeg.,b. ii. See also Hecker's Annal d. gesammt. Med., bd. ii, p. 90—quoted by Richter. t Praslectiones. X Richter's Specielle Therapie, bd. viii, p. 320. $ Salzb. Med. Zeit., 1811, No. 76. || Med. Transact., vol. xi, art. xii. If Programma de 01. Olivar. efficacia contra morsum cams rabida—as quoted by Richter. ** Mem. of the Med. Society of London, vol. iii. ft Commentaries, vol. iii, p. 576. XX Med. Recorder, 1824. 148 HYDROPHOBIA. has effectually arrested the disease;* and Dr. Hartley cured a case by taking away 120 ounces of blood in the course of a few days.t In one case, blood was drawn to the extent of producing syncope during each paroxysm of the rabies, with the happiest effect;J and Dr. Russell states that a vein was opened in a young women affected with rabies, and suffered to bleed until she fell down m a state of syncope, with the effect of arresting the disease.§ Dr. Rush was a strenuous advocate for copious venesection in hydrophobia. We may also cite the cases reported by Burton, Grisley, Willoughby,and par- ticularly the interesting instances related by Tymon,|| Schoolbreedj Wynne,** Goeden,tt as striking examples of the occasional good effects of decisive bleeding in this affection. In Dr. Tymon's case, blood was at once drawn until the pulse could be scarcely felt, and 100 drops of laudanum administered, with injections of 300 drops of laudanum every two hours. On the following day two grains of opium with four grains of calomel were administered every two hours, and continued to the sixth day, when ptyalism, with gradual subsi- dence of the disease, occurred. In the case reported by Dr. School- breed, about fifty ounces of blood were drawn from a large orifice at once. Syncope ensued, and the disease was for a time manifestly moderated. As the symptoms appeared to increase again, he was once more bled to fainting, which had the effect of completely sub- duing the water dread, and paroxysms of fury. Calomel and opium were given for some time, under the use of which the patient's health was re-established. Parry, nevertheless, considers these two cases as very equivocal instances of rabies; but the histories given of them leave us little or no room to doubt that they were genuine instances of hydrophobia. A number of cases have indeed been reported, in which the most energetic depletion did not produce the slightest im- pression on the disease. Dupuytren, Magendie, Breschet4J Bellingen, Horn, Marshal, Olbers, Hufeland, Rust, and others, state that they have not derived the least advantage from this measure. In conclusion, it is proper to state that, among the prophylactic measures, a regulated regimen, gentle exercise, an attention to the regular action of the bowels, and particularly avoiding violent mental emotions, overheating, violent exercise, as well as the influence of sudden atmospheric vicissitudes, and all kinds of stimulating drinks, are all important observances. * Histoire de l'Academie des Sciences, Paris, 1699. t Philosophical Transactions, 1738, X Gentleman's Magazine, Sept., 1752. § Historical Magazine for 1792. II Edin. Med. and Surg. Journ., 1813, p. 22. H Tbid., Jan., 1813, p. 30. ** Med. and Phys. Journ., Nov., 1814. ft Hufeland's Journal, bd. xlii, p. 64. XX Orfila, Toxicology, &c. MENTAL DERANGEMENT 149 CHAPTER II. CHRONIC NERVOUS AFFECTIONS, IN WHICH INTELLECTUAL AND MORAL FACULTIES ARE DISORDERED. Sect. I.—Mental Derangement. Without stopping to inquire into the nature and laws of the hu- man understanding, or into its mysterious connection with the animal body, it will be enough for our purpose to observe, that all the per- ceptions of the mind, and consequently all the materials upon which alone it can exert and manifest its powers, are derived from impres- sions communicated to it through the medium of the body. It is here assumed, therefore, that without a morbid condition of those parts of the organization which receive and convey to the mind the elements of thought, and which thus constitute, as it were, the connecting link between intellect and the external world, insanity can have no ex- istence. Pathologists have endeavoured to ascertain the seat of the primary irritation of insanity; but the observations we have upon this point are as yet vague and unsatisfactory. Pinel maintains that the pri- mary seat of mental derangement is located in the epigastric region, whence the morbid irritation is propagated to the common sensorium. This is an old doctrine. Areteeus* observes, " verum prascipuae furo- ris et melancholias sedes viscera sunt;" and it is indeed extremely probable, that in some instances, at least, the primary source of insanity consists in an irritation seated within the abdomen. The intimate sympathetic relation that subsists between the brain and the chylo- poietic viscera, is well known. A derangement in the functions of the one seldom fails to induce a corresponding disorder in the func- tions of the other. Sudden fear, or disappointment, or violent anger dissipates in a moment the keenest appetite; and a disordered state of the digestive organs is no less apt to give rise to torpor of intellect, irresolution, despondency, and waywardness of temper. In whatever part of the body the primary irritation may be located, it must, how- ever, always be communicated to the brain, the mental organ, before the intellectual faculties can be deranged; and the proximate cause of insanity may therefore be regarded, as consisting in morbid cere- bral excitement, existing either as a sympathetic or primary affection. As the musician cannot draw melodious tones from an instrument that is defective, so the mind cannot produce harmonious and correct thought, when its organ, the brain, is in a state of morbid excite- ment; and it matters not whether this morbid condition be the result * De Caus. et Sign. Morb. Diut., lib. i, a 37. 150 MENTAL DERANGEMENT. of causes acting immediately on the brain, or of such as primarily affect other organs, whose sympathetic relations are such as to throw the irritation upon the common sensorium. What is the nature of the cerebral affection upon which the derange- ment of the intellectual faculties immediately depends ? According to Dr. Rush, it consists in a morbid action on the blood-vessels of the brain; whilst others view it as simply a state of nervous or cerebral irritation, without any necessary connection with disordered vascular excitement. That the capillary blood-vessels of the brain are in a state of morbid excitement in perhaps all instances of mental derange- ment, is, I think, extremely probable. Whether, however, this irre- gular vascular action in the Drain constitutes an essential condition of insanity, or whether it be only one of the consequences of the pri- mary cerebral irritation, may admit of some doubt. No nervous irritation can be long maintained without inducing diseased action in the blood-vessels. However this may be, insanity, doubtless, always depends on disordered function of the brain; and the deranged cerebral function is probably invariably the result of morbid action of both the medullary structure and the blood-vessels of this organ. Causes.—The predisposition to insanity is,in many instances, very evidently dependent on an hereditary peculiarity of organization, Dr. Rush mentions several very striking examples of this kind.* Esquirol asserts, that, according to his own observations, one-half of the cases of insanity which occur among the wealthy, and at least one-sixth of those among the poor, depend on hereditary predisposi- tion ;t and according to a tabular statement given by Dr. Casper,! it appears that in the different hospitals in Paris, the proportion of cases depending on hereditary predisposition, is to the whole number as about 1 to 4§. Esquirol states that he has met with an instance of seven sisters and brothers out of one family having been affected with insanity ;§ and Haslam mentions ten families, in every one of which, several cases of mental derangement occurred. || Dr. Rush ob- serves, that the following, among other peculiarities, attendthis disease, where the predisposition to it is hereditary : "1, weaker exciting causes develop the disease than where the predisposition to it has been acquired; 2, it is apt to come on about the same period of life at which it appeared in the patient's ancestors; 3, children horn previous, are less apt to become insane, than such as are born after the occur- rence of mania in their parents ; 4, in some instances of families in which madness has existed, the disease passes by the understanding in their posterity, and appears in great strength, and eccentricity of memory and of the passions, or in great perversion of their moral faculties." The liability to mental derangement is greatest between the twen- * On the Diseases of the Mind, second edition, p. 48. t Diet, des Sciences Medic, Art. Folie. X Characteristic der Franzosischen Medicine, von J. L. Casper, p. 380. $ Loc. citat. II Observations on Madness and Melancholy, p. 231. MENTAL DERANGEMENT. 151 tieth and fortieth years of age; and according to the observations of Esquirol, more particularly between the ages of twenty-five and thirty. The following tabular summary in relation to this point, drawn up by Dr. Casper from the observations of Pinel, Esquirol, Haslam, and others,* shows that from the thirtieth to the fortieth years of age, the occurrence of insanity is decidedly more common than during any other equal period of life. During childhood, or before the age of puberty, mania occurs very rarely. Instances are nevertheless mentioned, in which insanity appeared at a very early period of life. Dr. Rush saw two cases in children only two years old; in one instance it appeared during the seventh, and in another during the eleventh year of age. Haslam also relates an instance which occurred in a girl only four years old ; in another instance the disease came on in the seventh, and in a third one about the tenth year of age. Old age is almost equally unfavourable to the occurrence of mania. Dr. Rush states that he has met with but four instances in which the disease came on after the sixtieth year of age. It has moreover been observed, that maniacs rarely live to a very protracted age. Dr. Casper, however, mentions a very remarkable exception to this general fact. A coloured woman, he says, who had laboured under mental derangement for upwards of eighty years, was brought into the Hospital Salpetriere in a state of raving insanity, at the very advanced age of one hundred and seventeen yearsA In relation to the relative frequency of insanity in the two sexes, it is pretty generally admitted that it is more common in females than in males. Haslam gives a statement, from which it appears, that during a period of forty-six years, there were 4832 female, and only 4042 male lunatics admitted into the Bethlehem Hospital in London. It appears, however, from the inquiries of Dr. Casper, that the proportion of female over male lunatics is much greater in France than in England. It is worthy of notice that the predisposition to mental derange- ment is very generally connected with black, or dark brown hair, Age. 30 40 50 60 70 to to to to to 40 50 60 70 80 380 236 130 51 0 403 205 115 66 23 527 362 143 131 0 78 30 46 15 8 28 28 27 9 4 Pinel, in the Bicetre, from 1784—94 (males) admitted. Esquirol, in Salpetriere, from 1811—14 (females) admitted, Haslam, Bethlehem hospital, from 1784 —94 admitted, Esquirol's private institution, 1811—14 (wealthy patients,) Hospital of Retreat at York, 1796—1811 (Quakers,) 15 20 to to 20 30 65 339 171 135 113 488 0 150 8 44 t Med. Chir. Rev., Sept., 1820, p. 25. 357 1156|1416 861 461 272 35 152 MENTAL DERANGEMENT. and a dark complexion. Esquirol states that out of two hundred and twenty-seven females affected with mania, one hundred and fifty-two had dark, thirty-nine fair, and thirty-six gray hair. Dr. Rush informs us, that of nearly seventy patients in the Pennsylvania Hospital, who were examined with a reference to this fact, in the year 1810, "all except one had dark-coloured hair." In some re- gions, mental diseases are manifestly endemic. This is the case with the Cretins in many of the gorges of the mountainous districts of Europe : and it would appear that this disease is found only where the soil is calcareous* The exciting causes of mental derangement are usually divided into the moral and physical—or into those which affect the animal organization through the medium of the mind, and those which act directly upon the body.t Of the former kind are—intense mental * Med. Chir. Rev., Sept., 1820, p. 25. PHYSICAL CAUSES. Hereditary, - Pregnancy, - Epilepsy,..... Suppressed Menstruation, Puerperal State. - Old Age, Coup de soleil, - Injuries of the Head, Congenital, - Fever, ...... Apoplexy, - Malformation of the Skull, Fire and other injurious Substances, Syphilis, ------ Imprudent use of Mercury, Onanism, - Intoxication, - Worms, ------ Suppressed Cutaneous Diseases, Suppressed Haemorrhoids, MORAL CAUSES. Grief,...... Unfortunate Love, - Fanaticism, - - - - - Fright,...... Jealousy, ..... Anger, ------ Distress and Want, - - - . Mortified Pride, - Disappointed Ambition, - - - Intense and Protracted Study, Misanthropy,..... Vives Revolutions d'esprit, Political Causes, (a) - ~ (C r3 — j—I 105 11 11 55 52 60 12 14 13 60 14 24 105 31 46 25 8 1 38 8 18 14 16 77 14 1 16 12 13 2 o^2 §•! = en **. rr 150 4 2 19 21 4 4 4 12 10 1 18 14 31 (a) Casper, loc. cit., p. 380. MENTAL DERANGEMENT. 153 application to one subject; violent rage ; jealousy; excessive joy; sorrow; hatred; terror; surprise; fanaticism; unrestrained imagina- tion; disappointed love, ambition, or vanity ; mortified pride; cha- grin; protracted mental depression ; and religious enthusiasm. From the preceding table it would appear that grief, distress, want, and disappointed love, are decidedly the most common exciting causes of insanity. Mr. Pinel observes, that a frequent and powerful source of insanity is the struggle between the principles of religion, morality, and education, on the one hand, and the urgent influence of the natural propensities and the passions on the other. Among the causes that act directly on the body, the following are the principal; inanition from excessive hemorrhage or defect of food; intoxication; suppressed habitual discharges, particularly the cata- menial; onanism; inordinate venereal indulgence ; restrained or un- satisfied venereal passion; worms in the alimentary canal; blows or falls on the head; apoplexy ; epilepsy; repercussion of chronic cutaneous eruptions ; pregnancy ; parturition ; the puerperal state ; syphilis; intense pain ; very low and high atmospheric temperature ; an inordinate or improper use of mercury; various narcotic poisons; atmospheric influences; gastro-intestinal irritation ; the healing up of old ulcers ; and the various forms of acute diseases. From the table given above, it appears that verminous irritation is no uncommon cause of insanity. Dr. Casper informs us that Esquirol stated in his lectures, that he had known eleven persons cured of mania after the expulsion of a large number of lumbrici by the use of anthelmintics. Mania appears indeed often unequivocally connected with intestinal irritation. The observations of Dr. E. Percival and Dr. Prichard on what the latter terms enteric mania, may be con- sulted with much advantage. In these cases the morbid condition of the alimentary canal is generally decidedly marked. The gastric, biliary, and intestinal secretions are depraved ; the bowels are loaded, tumid, flatulent, and much constipated ; sharp and transient pains are felt in the abdomen ; the tongue, fauces, and velum pendulum, be- come red, injected, and tender; the appetite is irregular, or there is much aversion to all kinds of food. The puerperal state too is a fre- quent exciting cause of mental derangement. According to Haslam, eighty-four out of sixteen hundred and sixty-four maniacal patients admitted into Bethlehem hospital, came on soon after parturition. The proportion of cases from this cause, in relation to the whole number of admissions into the hospitals in Paris, has been estimated at about one to thirteen. Esquirol observes, that moral influences are generally more concerned in the production of puerperal mania, than the physiological changes that are effected in the system by child-bearing. * The despair and heart-rending grief which seduction, loss of reputation, and abandonment, inflict upon some; the blighted hopes of success in life, and the consequent anticipations of poverty and want; the faithless and unkind conduct of the cherished father ; these, and a number of other similar moral influences, frequently act, * Journal de Medecine, par Sedillot, torn. 61. 154 MENTAL DERANGEMENT. in co-operation with the debility, exhaustion, and general physiological condition present in the puerperal state, in the development of mental derangement. Out of ninety-two cases of puerperal mania admitted into the Hospital Salpetriere during a period of four years, thirty-seven became affected with the disease between the first and fourteenth days after parturition ; seventeen, between the fifteenth and sixteenth days; nineteen, between the sixty-first day and the eleventh month after confinement, and during lactation, and nineteen immediately after ceasing to suckle. (Casper.) Atmospheric influences also have a manifest agency in the causa- tion of insanity. It appears that summer and spring are decidedly most favourable to the occurrence of mental diseases. Casper asserts, that the admissions into Esquirol's private institution, during the six months from March to September, amounted to double the number that were admitted during the remainder of the year; and by the fol lowing statement of the admissions into the Hospital Salpetriere, for each month, during eight years, we perceive this fact sufficiently illustrated.* It appears, therefore, that high atmospheric heat is more favourable to the occurrence of mania thau cold weather. Prostitution, and i,ts train of evils, syphilis, intoxication, and mer- cury, appear to be very common sources of. insanity in populous cities—and according to Esquirol, particularly so in Paris. It is asserted, that a twentieth part of the insane females admitted into the Salpetriere were previously prostitutes. It is stated by Casper, that mental derangement from intoxication is found by the records of the Parisian hospitals to bear a proportion to the whole number of admis- sions, as 1 to 23 with females; and 1 to 10 with males. In England, the proportion of lunatics from this cause appears to be greater. It has been estimated to amount to about one-fifth of all the cases that occur. Dr. Rush states, that at one time the number of maniacs in the Pennsylvania Hospital, in which the disease was excited by the excessive use of ardent spirits, amounted to one-third of the whole number! Onanism, says Dr. Rush, is much more frequently the cause of in- sanity in young persons than is generally suspected.t According to the foregoing etiological table, it would appear that in Paris, insanity from this cause occurs in the proportion of one out of fifty-eight in women of the lower order of society; and one out of fifty-one in males of the same class. In the higher classes it occurs in both sexes in the ratio of about one to twenty-three. Sudden suppression of the cutaneous transpiration often gives rise to mental derangement. Esquirol mentions the case of a man who * Admissions of lunatics in the Hospital Salpetriere from 1806 to 1814. Janu- ary, 162; February, 173; March, 187; April, 196; May, 243; June, 251; July, 265; August, 239; September, 206; October, 197 ; November, 198; and December, 191. t " La masturbation, ce fleau de l'espece humaine, est plus souvent, qu'on pense, cause de folie, surtout chez le riches." Esquirol, Diet, des Scien. Med., Art. Folie. MENTAL DERANGEMENT. 155 was subject to copious sweating about the head. He became insane in consequence of having washed himself with cold water, with the view of restraining the profuse perspiration. "A young man waded across a rivulet while freely perspiring. He had a rigor on going to bed, and immediately afterwards became maniacal." Mental derangement, from repelled cutaneous affections, is by no means uncommon. Some very striking instances of this kind are related by Dr. Casper. He saw in one of the hospitals in Paris, a maniacal female of a plethoric habit, in whom the healing up of an old fistulous ulcer, on the left arm, excited the disease. A blister was laid upon the arm, which caused violent phlegmonous erysipelas over the whole extremity, and the re-opening of the ulcer. The patient was almost immediately relieved of her mental disease. In a short time, however, the ulcer cicatrized again, and the mania returned. He mentions another instance of mania, which came on immediately after healing an old ulcer on the leg. The ulcer was re-opened by local applications, and the mental affection disappeared. A young physi- cian became affected with erysipelas : the inflammation subsided, and was substituted by mania. After a long time he suffered a second attack of erysipelas, and the mania disappeared. Mania sometimes occurs in connection with consumption. There is, at this time, a young lady under my care, who has, for the last nine months, been in a state of complete insanity from this cause. About a year ago, phthisis pulmonalis developed itself in her system. Three months after unequivocal symptoms of the pulmonary affec- tion had come on, she became taciturn, morose, and finally maniacal. The consumptive symptoms continue, but she does not appear to be conscious of any disease of this kind. She coughs much, expecto- rates but little, has irregular hectic exacerbations, and night sweats. Haslam, indeed, denies that such a complication has ever occurred ; and maintains, that cases of this kind are to be regarded as co-exist- ing or concomitant diseases, without any mutual dependence between them.* The occurrence of insanity, as a consequence of pulmonary phthisis, is, however, well established. Dr. Casper saw an instance of this kind in the Hospital Salpetriere. When the cough and hectic symptoms were present, the patient was entirely free from derange- ment of mind; but in the absence of the phthisical symptoms, the patient was furiously insane. Sudden reverse of fortune is one of the most frequent causes of melancholy. Out of four hundred and eighty-two melancholic patients admitted into the Hospital Salpetriere in the course of four years, forty-eight cases arose from this cause. It is generally believed that the moon has a decided influence upon maniacal subjects—an opinion which, I am inclined to believe, is founded on correct observation. Esquirol, however, entertains a different opinion. He observes, in- deed, that the insane are generally much more agitated and boister- ous about the full moon; but the same thing, he says, occurs about the break of day every morning. He thinks that light is the cause * Loc. cit., second edition, p. 591. 156 MENTAL DERANGEMENT. of this increased excitement of the maniacal symptoms at both periods. Light, he says, agitates all lunatics. Prognosis.—The degree of sanability of maniacal cases has of late years been an object of very particular inquiry ; and the various reports that have been published on this head, show that the number of instances in which a cure is effected is by no means inconsidera- ble. From the following tabular statement,* drawn up by Dr. Cas- per, from official reports, it appears as a general result, that in France * FRANCE. Period. 11 S d z; ~ "6 P o t5 CD s a '3 B CD Discha'd partially relieved. TJ 1 o m ft Decimal propor-tion of cured. Hosp. Salpetriere, Pinel, Esquirol, the same, Pinel, Hospital Bicetre— Chamseru, Hospital Charenton, Pinel, Fodere, Royer—Collard, Chamseru, Esquirol's priv. Ins., Dubuisson's, 1801—1805 1806 1807 1812—1814 1807 1789—1800 1803 1806 i of 1807 1801—1813 1002 333 289 891 102 97 499 355 214 335 300 473 160 136 413 33 33 161 134 91 173 177 250 33 70 36 370 140 83 142 5 0.47 1-5 .48 .47 1-18 .46 1-5 .32 1-3 .34 .32 1-4 .36 .2-3 .42 1-2 .51 7-11 .59 Sum for France, 4417 1984 I 0.44 9-11 ENGLAND. . Bethlehem, according to Haslam, 1748—1794 8874 2557 .28 7-9 Haslam, (dif. acc't,) 1784—1794 1664 574 .34 1-2 St. Luke's, Tuke, 1751—1819 12173 5091 1013 166 5903 .41 5-6 Hospital at York, Fodere, 1777—1807 1739 746 192 141 410 250 .42 7-8 Retreat at York, Tuke, 1796—1811 149 49 26 47 18 9 .32 4-5 Hosp. at Manchester, Fodere, 1766—1805 1686 667 190 85 220 324 .39 1-2 Hospital at Montrose, Act of Pari., 1805—1815 154 34 36 54 25 5 .22 1-13 Hosp. at Nottingham, Burrows, 1812—1819 336 179 39 48 70 .53 1-4 Hospital at Exeter, Burrows, 1801—1819 626 355 53 45 173 .56 5-7 Hospital at Glasgow, Burrows, 1819 183 39 10 106 28 .21 1-3 Hosp. at Manchester, Burrows, 1820 350 74 31 190 2 71 .21 1-7 Bethlehem, Act of Par- liament, 1800—1815 4810 1839 .39 1-4 Sum for England, 32744 12204 10.37 2-5 MENTAL DERANGEMENT. 157 0.44-a. of maniacal patients are cured; whilst in England the propor- tion is not so great, being only 0.37^ of the whole number. In looking over the foregoing table we observe that the annual 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 proportion 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 decreased 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 1813 Total number. 209 212 206 204 188 209 190 163 208 216 total. Of which were cured 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 1 129 137 143 129 129 129 110 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 eigh- teen, but of one hundred and twenty-five inveterate cases, he suc- ceeded only in five instances. In the Retreat at York, England, out of sixty-six patients cured of insanity, twenty-seven were affected 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 ineffectual treatment, the chance of cure in in- sanity will be about as one to thirty. Unfortunately, relapses are very common in mental diseases. In the Hospital Saltpetriere, relapses, according to the observations 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 * Casper, loc. cit., p. 405. 158 MENTAL DERANGEMENT. months, and particularly at those seasons in which the disease had made its attack in the first instance. (Esquirol.) Dr. Hallaran ob- serves, that when a violent fit of mania subsides rapidly, it is par- ticularly 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.* According to the observations of Esquirol and Georget, the mor- tality 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 seventy-five died in the months of March, April and May; one hundred 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 contagions and epidemic diseases than individuals who are of a sound mind. This fact has been particularly noticed by Rush, Dubuisson, Mead, Willis, Reil, and Cox. Mania sometimes terminates spontaneously, in consequence, ap- parently, 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 pro- fuse discharges of urine or tears, and, according to Bufl'on, of the semen. In general, the difficulty of curing monomania and melancholy, is greater than of the other forms of mental derangement. Haslam observes, that when melancholy alternates with raving madness, the chance of a cure is extremely small; and when monomania or melan- choly 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 able to remember what has recently transpired about them. Mania, con- nected with paralysis or epilepsy, may be regarded as absolutely hopeless. In general, acute and furious mania is much more under the control of remedial management than low, torpid 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 correspond- ing 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. * Haslam, loc. ck., p. 79. MENTAL DERANGEMENT. 159 Post-mortem phenomena.—Notwithstanding the zeal and industry ith which post-mortem examinations have been pursued in relation mental diseases, we have as yet derived but very little information Din such researches concerning the nature and seat of insanity. squirol assured Dr. Casper that he had dissected the brains of more an twelve hundred subjects who had died of mania, and that he d not in a single instance discover any morbid appearances which e not found also in subjects who had never suffered any mental seases whatever. In almost every instance, however, he found the vo hemispheres of the cranium of unequal size—and this, he says, is ie most constant phenomenon, and perhaps the most worthy of tention.* Haslam, Reil, Esquirol, and others, state that in the majority of ises the brain is found preternaturally soft. Esquirol found the rain very soft in twenty-nine instances out of forty-four subjects; i fifteen it was of a firm consistence. According to Georget, how- irer, softening of the brain is much more frequent than would ap- ear from Esquirol's statement. Ossification of the dura mater is, ^cording to the observations of Esquirol, no uncommon occurrence i maniacal subjects. He observes, moreover, that he invariably mnd a very firm adhesion of the lining membrane of the lateral entricles to the adjoining substance of the brain. In several in- ances, Georget found the cerebellum totally disorganized. (Casper.) Among the abnormal circumstances discovered in the thorax and bdomen, Esquirol mentions one in relation to the position of the ransverse colon, which is of a very remarkable character. This ortion of the intestinal tube, he says, is sometimes found sunk down ) low as to pass into the pelvis, and often placed in a perpendicular istead of a transverse position. The phenomenon occurs most Dmmonly in persons who labour under melancholia. It must be bserved, however, that Mr. Lawrence asserts that instead of having mnd this position of the colon in those who had laboured under isanity, he has seen it only in such as had never been affected by ny mental diseases whatever. We perceive, from these contradictory bservations, how little reliance is, in general, to be placed on the weeping inferences which are so frequently drawn from post-mortem ppearances, in relation to the proximate cause and essential location f diseases. The diseases of the mind may be divided into four classes: viz., tania, monomania, dementia, and idiotism. I. Mania. General mental derangement is characterized by a rapid succes- on of incoherent ideas, and violent excitement of the passions, ex- ressed by great agitation, loud vociferation, singing, menaces and lry. Mania is generally preceded by a marked change in the habits. * Diet, des Sciences Med., Art Idiotism. 160 MENTAL DERANGEMENT. tastes, attachments, and passions of the patient. He is usually ani- mated, his sensibilities are keen, his ideas rapid, his temper irritable, jealous and wayward. He is eccentric in his conversation and con- duct; often betrays an unusually vicious disposition; he sleeps but little; is harassed by frightful dreams; forms various and extrava- gant 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 unneces- sary or useless articles of furniture, clothing, &c. Costiveness, a craving appetite, vertigo, cephalalgia, a sense of throbbing and ten- sion in the head; and a dull and wild expression of the eyes, are among the common premonitory symptoms of mania. When the disease is once completely developed, the expression of the counte- nance is wild, and often ferocious; the eyes are prominent, spark- ling, 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 sometimes craving, at others wholly absent; the bowels constipated, and the urine small in quantity and high-co- loured. 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 remark- able among the physical phenomena of mania, are continued watch- fulness, and a very peculiar disagreeable odour, which exhales from the patient's body and excretions, and impregnates his cloths and bedding. (Esquirol.)* Some patients are tortured 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 percep- tions 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 recognize the objects and persons around him; mistakes "friends for strangers, and common visitors 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 sometimes so powerfully excited, that its representations prevail over those of the senses. The patient hears voices, holds conversations with persons who he imacines 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 empire 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, * This peculiar smell issuing from the bodies of maniacal patients, is also par- ticularly noticed by Wagoner, Simes, and Reil.—Reil, Fieberlchre, b. iv, p. 348. MENTAL DERANGEMENT. 161 leap out of the windows, and to commit various other acts of fury. The sense of modesty and delicacy is generally wholly obliterated, and " people of the finest previous feelings will deliver themselves up to the most indecent or culpable actions, without the conscious- ness of impropriety." Mania may be continued, intermittent, or remittent. A single paroxysm may continue from a few days to several months, before 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 passed 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 " taci- turnity, downcast looks, a total neglect of dress and person, long nails and beard, disheveled 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 subjects." This class of mental diseases comprehends many varieties, 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 hallucina- tion relates to the patient's own body, or to the circumstances which he conceives have an especial sinister influence upon his own system, fortune, or happiness. The suggestions of his morbid imaginatioti are taken from realities. He believes himself afflicted with certain incurable and fatal diseases, "particularly with consumption, cancer, stone, and above all, with impotency and 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 stomach or bowels. Some patients believe themselves * 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 ex- citement, and to this three months of complete fatuity will succeed. t Some years ago there was a foreigner—a barber, in Lancaster—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 regularly every morning went about a mile to the river Conestoga to supply him- (self with water, which he asserted could contain no poison, since the fish continued to live in it. VOL. II.—12 162 MENTAL DERANGEMENT. tra nsformed into inferior animals, as dogs, cats, wolves,* oxen,t 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,.liko 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 himself 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. (Tulpius.) Zacutus Lusitanus mentions a person who believed that 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 dis- tressing 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, continued to perform his profes- sional duties for some time, although labouring under the fixed hallu- cination 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 Provi- * Qui lycanthropia detinentur, noctu, domo egressi, lupos in cunctis imitatur, et donee dies illucessat, circa defunctorum monumenta plerumque vagantur.—P Mgineta. De re Med., lib. iii, cap. 16. t This was the case with the daughter of the king of the Argives, whom Virgil mentions.—Protides implerunt falsis mugibus agros. Eclog. vi. The madness of Nebuchadnezzar appears also to have been of this kind. X Alter gallos cantare audiens, ut hi alarum ante cantum, sic ille brachiorura plausu latera quatiens, animantium sonum imitatus est.-~Galm.de locis qffectis, lib. iii, c. vi, as quoted in ReiFs Fieberlehre. I Reil, Fieberlehre, b. iv, p. 39. MENTAL DERANGEMENT. 163 dence, and necessary for the general welfare of the world.* 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.t 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 enthusiastic votaries of all pursuits and arts of men. The alchymists, the searchers after perpetual motion, the metaphysicians, the politicians, the knight-errants, and the travel- ers, have all in their turns furnished cases of this form of derange- ment.'^ III. Dementia. This variety of mental disorder "consists not in false perception, 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 ancf reason. The judgments are generally excited by sensible objects, but ideas, collected together without order, frequently constitute a paroxysm of the disease. It is always accom- panied with great volubility of speech, or with bodily gestures, per- formed 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 quarrel- some, malicious and kind, generous and miserly, all in the course of the same day."|| Dementia is, therefore, directly opposed, in its phenomena and cha- racter, to monomania; for in this latter variety of insanity, the mind is fixed upon some particular subject, and upon which alone it hal- lucinates ; 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." * Pinel mentions a case of a monk who imagined that the Holy Virgin had commanded him to murder a person whom he considered an unbeliever. t Poole's Life of Tasso, p. 48. X Of this kind of hallucination was that of the man mentioned by Horace:— ------Fuit haud ignobilis Agris Qui se credebat miros audire tragoedos, In vacuo, laetus sessor, plausorque theatro. Cetera qui vitse servaret munia recto More, &c. S Boileau says:— Tous les hommes sontfous; et malgre tous leur soins, Ne different entre eux, que du plus au du moins.—Sat. iv, p. 27. II Rush on the Diseases of the Mind, chap. ix. 164 MENTAL DERANGEMENT. IV. Idiotism. This varietv consists in a defective development, or impairment, of all the intellectual faculties, amounting sometimes to a total absence of mind; and in some instances, even to a destitution 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, kc. 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 irremediable. 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 Lu- natic 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 £33 for medicines and instruments during the year 1819; and in the institutional 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 consider- ably smaller than at present. Even at the present day, much more medicine is employed, according to Dr. Casper, for the cure of insa- nity, 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 seclusion. 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, soothe and admonish them in a tone of kindness and af- fection, and appear among them, not as a stern ruler, but as a sym- pathizing 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 be done in the management of patients labouring under mental diseases. 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. Humanity and reason combine against the employment of such remedial mea- * 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. Casper, loc! cit., p. 413. r MENTAL DERANGEMENT. 165 sures; and the triumph of reason and good feeling over cruelty and error, is nowhere more delightfully illustrated than in the improve- ment that has of late years been effected in this respect. Instead of subduing the miserable maniac with implements of terror and torture, or keeping him in trembling subjection 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 man- agement 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 insists upon the importance of separation and proper seclusion ; and the most eminent of the English, German, and French writers, advise the adoption of this measure. " Confined to a regular life and discipline," says Es- quirol, "the patient is naturally led to reflect on this change in his situation ; while the necessity of living among and submitting to the control of strangers is to him a powerful stimulus to regain his lost freedom and reason." When thus confined, the medical attendant must in the first place endeavour to obtain the confidence and good will of the patient. Kindness, consolation, affability, and in some cases a moderate yielding to the hallucination, will in general soon acquire the patient's confidence. Having gained this point, he must "soothe the irritable, repress the insolent,cheer the desponding,calm the excited, check the forward, encourage the timid, resist the impor- tunate 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. Whenever the wea- ther 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 particularly 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. Various amusing exercises—"as playing at quoits, the chase, shooting, and f-ven chess, checkers, cards, and push-pin, should be preferred to idle- ness." (Rush.)' Indeed, in cases of a moderate grade of maniacal excitement, traveling 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 attended with difficul- ties and privations, and performed through a strange country. It is on this account, perhaps, that foreigners are more apt to be cured in 166 MENTAL DERANGEMENT. England, than natives, (Wills;) and that strangers sent to Pans 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 particular error, or false ideas under which the patient labours, and this is more especially to be observed with monomaniac patients. On the other hand, however, peremptory and absolute contradiction, 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 current 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 im- proper 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 agree- able nature. When they are upon the recovery, we may oppose their opinions and incoherent tales, by reasoning, contradiction, and even ridicule." Where the insanity turns upon some prominent idea, or passion, much benefit may sometimes be obtained by dexterously exciting s.ome counteracting emotion, or sentiment. Esquirol states, that a melancholic man, who was in a state of great despondency, 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 rous- ing of inert faculties, form a third principle of moral treatment. For instance, endeavour to convince 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 some- times be effected. In some instances it will be proper to substitute a real for an imaginary grievance." If a melancholic is harassed by ennui, withdraw him from 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, imagines himself abandoned by his friends, we may sometimes promote his recovery by depriving him of every testimony of their affection, and thus awaken- ing 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. MENTAL DERANGEMENT. 167 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 humane observa- tions. " No one was ever laughed or scolded out of hypochondriasis. It is scarcely likely that we should elevate a person's spirit by insult- ing his understanding. The malady of 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 noxious 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 tran- quilizer. Haslam condemns the former mode of restraining patients, in strong terms. It is certainly an offensive and oppressive mode of coercion in a state of furious mania. Haslam employs 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 tranquilizer, 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 a mania, is the total exclusion of light from the patient. This is daily practised in the Salpetriere. When a maniac 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 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, soli- * Essays on Hypochondriacal and other Nervous Affections. By John Reid, M. D. 168 MENTAL DERANGEMENT. tude, low diet and cold affusions, 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 evacua- tion in general mental derangement; and the old established traile- ment de I'Hotel Dieu, says Pinel, consisted almost entirely of re- peated blood-lettings. In the Parisian and English institutions, we are told that venesection is now but rarely employed in mental dis- eases. There can be no doubt, however, that the abstraction of blood will often contribute considerably 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 connection with "great wakefulness, redness of the eyes, a ferocious countenance, and a noisy and refractory be- haviour." When the disease assumes the grade of phrenitis, with raving delirium, a hard and bounding pulse, throbbing of the caro- tids, 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 attended with sup- pression of an habitual sanguineous evacuation, cupping or leeching near the parts from which such discharges occurred, 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 are often very useful auxiliaries in the remedial management of lunatics. Where there is reason to believe that the bowels are in a loaded condition, or irritated by vitiated secretions, that is, where the tongue is furred, with pain on pressure in the re- gion ofthe 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 pre- fers mercurial purgatives, with the view of exciting the biliary secre- tion ; and in instances where tension and tenderness exist in the right hypochondrium, there can be little doubt of their superiority. "There are cases," says Dr. Rush, "in which purges should be given daily, so as to excite an artificial diarrhoea," and calomel and jalap should be preferred for this purpose. When there is reason to suspect the existence of verminous irritation, anthelmintics should be given, in conjunction or alternation with active purgatives. Infusion ofthe root of spigelia, followed by a full dose of turpentine and castor oil, gene- rally answers this purpose better than any other articles of this kind. * De la Folie, p. 293. t D. Ratier, Formulaire Pratique des Hopitaux Civiles de Paris, &c., &c. MENTAL DERANGEMENT. 169 Emetics may occasionally be employed with manifest advantage, in the milder forms of mental derangement—more especially in melan- cholia, and in recent cases of hypochondriasis. They are improper, however, where there is much cerebral irritation, or in cases attended with much febrile excitement. Esquirol 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, "cannot 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 prejudicial 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 advan- tage, 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 employed. 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 recommended ; but almost all recent writers agree, that it very rarely produces any good effects, but on the contrary often manifest injury. In puerperal mania, however, Dr. Grooch 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.i: 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 emmenagogues, in conjunction with efficient abstractions of blood, and warm semi- cupia. He considers the tincture of melampodium and the oil of turpentine, as decidedly the best emmenagogues in cases of this kind. * Observations on the Causes, Symptoms, and Treatment of Derangement of the Mind, &c. By Paul Knight, M. D. t Observations on Puerperal Insanity. Transact, of Lond. College of Phys., 1820, vol. vi. X Loc. cit. 170 MENTAL DERANGEMENT. Georget also recommends the use of emmenagogues, 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 insanity in the Parisian hospitals. In the Salpetriere, the women use the warm bath two or three times a week, unless an apoplectic 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, clothes 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 affec- tions. In young, robust, and sanguineous patients, particularly when the skin is dry and preternaturally warm, considerable benefit will occasionally accrue from cold affusions. More advantage, however, may, in general, be obtained from the application 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 headache, 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 weeping 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 employed 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 erethism, torment the patient, increase his irritability, and convince the insane that he is a victim to our cruelty.J 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 exhibition of vomits, rouse the energies of the nervous system, in the most desperate cases of alUnees 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 * Esquirol, loc. cit. t Des Vesanies on Maladies Mentales, p. 225. x Loc. citat. DELIRIUM TREMENS. 171 is entrenched, as it were, in the brain. It must be loosened, or weak- ened, by depleting remedies, before it can be dislodged, or translated 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 " immense power" in subduing general and cerebral excitement. "A patient subjected to its action, is speedily affected with giddiness and sick- ness, 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 ofthe circular swing should induce apoplexy ; having attentively examined the sources of these fears, I conclude them to be ground- less ; 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 re- laxation of the skin, very generally predispose to sound and refresh- ing sleep.* Music sometimes has a most soothing influence over the distracted and raving minds of maniacal patienis. Dr. Rush observes, that "lively tunes are as offensive as comic representations in this dis- ease." Tissot relates an instance of insanity which was permanently removed by music ;t and we read that Saul's melancholy was dis- sipated by the harp of David.— Tange lyram digitis, animi dolor omnis abibit, dulcisonum reficit tristia corda melos. Sect. II.—Delirium Tremens.—Mania ct, Polu. This very remarkable variety 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 addicted to the inordinate use of opium, and, perhaps, other narcotic stimu- lants. So long as the customary quantity of the stimulus is taken, the disease seldom, if ever, supervenes ; but if from necessity, sick- ness, or a temporary disgust, the ordinary stimulating 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 ofthe use of these articles."^: * Loc. cit., p. 63. t Reil's Fieberlehre. X See an able and highly interesting memoir on this disease, by Dr. Coates, of this city, published in the North American Med. and Surg. Journ., vol. vii, p. 34. 172 DELIRIUM TREMENS. The disease usually commences with lassitude, general indisposi- tion, 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 patient 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 disorder, becomes loquacious, says he feels well, and is tormented with a more or less continued succession of various alarming, disgusting, and ludicrous apparitions. He fancies that he sees dogs, snakes, cats, mice, and other animals in his room, and dis- gusting vermin crawling over the bed, and on his clothes, or that various persons have entered his room, for the purpose of robbing, killing, or annoying him. To avoid these and other horrid illu- sions, 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, vociferates, threatens, and sometimes raves violently. Sometimes he fancies that he hears loud and strange noises around him, over head, in an adjoining apartment, or loud and frequent knocking at the door. His mind and body are in a continued state of 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 contra- dicted, he usually becomes much exasperated, and insists with vehe- mence 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 dis- ease rises to a high grade, the patient becomes violently and often furiously delirious, talks incessantly, is restrained with difficulty, and is unable to recognize his friends and acquaintances. Patients affected with this disease do not appear to be susceptible of much bodily pain. " They never seem to experience any suffer- ings 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 inflammatory affection, accom- panied with pain, the principal disease seems to disappear, even to the eye of the experienced practitioner, 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 com- monly soft, full and quick, without strength or tension. The skin DELIRIUM TREMENS. 173 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, sensorial 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 the day but little mental halluci- nation is noticed. In some cases, the symptoms described above, continue, with but slight remissions, 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.1 Dr. Arm- strong observes that when convalescence is not restored within the first mouth, 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 supervention "of diarrhoea or vomiting. The occurrence of profuse discharges 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 dis- ease is accompanied by some local inflammatory affection or general fever. In full and robust habits, the disease not unfrequently termi- nates in fatal convulsions or apoplexy. Pathology.—It appears to be generally admitted that this disease has its primary and essential location in the sensorium commune, and that it is wholly independent of inflammation or vascular 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 excitability 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.t Dr. Joseph Klapp, of this city, has published a series of cases, with obser- vations, 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 consider- able plausibility.:{: It is asserted, in support of this opinion, that dis- section almost uniformly discloses traces of previous inflammation in the stomach ; that, in nearly all instances, nausea, vomiting and a * Loc. cit., p. 225. t Med. Chir. Rev., Feb., 1828, p. 484. X Eclectic Repertory, vol. vii, p. 259. 174 DELIRIUM TREMENS. 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 remedial management that has hitherto been recommended. In reply to these arguments it may be observed, that post-mortem 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 in- flammation ofthe alimentary canal very often supervenes 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 sto- mach as a state of inflammation; although Dr. Stoughton, who advocates the gastric pathology of this affection, lays particular stress on the post-mortem signs of phlogosis in the stomach, as em evidence of the correctness of this pathology. Dr. Klapp seems to consider the gastric affection as rather the reverse of inflammation—as a state of torpor, 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 fallacious mode of reasoning. We may admit, to the full extent, the beneficial influence of emesis, and yet consistently deny our assent to the doc- trine which alleges that the stomach is the primary seat of the dis- ease. With regard to the foul tongue, vomiting, &c, mentioned 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 inspection." Dr. Sutton mentions them only as symptoms accompanying the dis- ease, where it occurred in connection 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 al- though 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 dangerous 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 DELIRIUM TREMENS. 175 of violent forms of fever, and more especially during the existence of acute visceral inflammation, it almost invariably 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 organic affection. Subjects of this kind, generally, rapidly sink under the disease. (Armstrong.) When the delirium becomes constant, the pulse rapid and very small, the ex- tremities 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 particularly unfavourable sign, when coma, with sonorous respira- tion or convulsions, ensues. 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 lam well persuaded it does—on a morbid activity of the sensorium, independent of in- flammation 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 ofthe brain is almost invariably the consequence, not of the application, 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 exhaust- ing 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—thai 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 maybe 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 nar- cotic. When the bowels are constipated, and there is reason to presume that they are in a loaded state, a purgative should be admi- nistered before recourse is had to the opium. This, like all other affections, may come on while the intestinal canal is charged with vitiated secretions 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 preparatory and auxiliary to the employment of opium in this disease would appear to be very obvious. It has appeared to me, indeed, that without this precaution, the free use of opium has a 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 176 DELIRIUM TREMENS. 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. I at once directed two&rains 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, uninterruptedly muttering indistinct 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 pre- ceding day. With much difficulty I got him to swallow about an ounce of castor oil, with three drachms of oil of 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 recognized 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 tranquil sleep, which lasted several hours. He recovered under the use of this narcotic, without any other remedy. I cannot, indeed, assert with certainly that the comatose state mentioned above was the result ofthe influ- ence of the opium; but I am led to 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, indeed, 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. 1 mention these facts, not to deter from the use of this valuable, and, 1 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 arith- metical or a geometrical increase—whether five grains, or thirty grains in addition, are sufficient to endanger the patient's life."* The quantity of opium which it is usually necessary to administer, before the desired soporific effect is produced, is often truly enormous. In some instances, from twenty to thirty grains, in divided but fre- quent doses, are required, before the full advantage 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. * Coates, loc. cit., p. 214. DELIRIUM TREMENS. 177 With regard to the employment of blood-letting in this affection, the opinion of the profession seems to be pretty well settled as to its general impropriety and inefficiency. 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."* Dr. Arm- strong, 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 constitutions that have not been shaken by reiterated drunkenness, he has known early and moderate vene^ section of much use." The experience of Dr. Brown, of New-York, coincides with the observations 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 "t The experience 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 treatment, in uncomplicated cases of the disease.! My own experience is en- tirely 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 sanguineous 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 ofthe head, and a state of delirium approaching the raving of phrenitis, immediate and very decided benefit was derived from cupping. Blisters 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 Pennsyl- vania Hospital, observes, that blisters appear of more service than cupping, "as they did not equally weaken the patient." Emetics, as has already been intimated, deserve more attention as curative means in delirium tremens, than any other remedies that have been employed, with the exception of opium. In my own practice, I have had unequivocal testimony of the occasional use- fulness of emetics in this malady. In several instances, however, * Tracts on Delirium Tremens, &a, p. 66. t Med. Chir. Rev., February, 1828, p. 484. X Ibid., p. 485. VOL. II.—13 178 DELIRIUM TREMENS. they failed, in my hands, of doing any good; and in two cases, within the last six years, they were unequivocally injurious. To one patient, who had been long a confirmed drunkard, 1 administered, in divided doses, fifteen grains of tartar 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 extremely feeble—the extremities ice-cold, and a profuse, cold, clammy sweat broke out over the whole body. The patient sunk rapidly, and expired about four hours after the anti- mony 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 employment of opium, I am satisfied that the exhibition of an emetic is often peculiarly bene- ficial. I have known a few cases cured by emetics, with little or no other remedial applications ; but experience 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 testimony to the utility, in some cases, of premising an emetic to the use of opium. And, no doubt, this is often an im- portant 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 excited; and Dr. Brown mentions an instance in which thirty grains of this article were given before the desired effect was produced. 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 dash- ing two or three gallons of tepid water, strongly impregnated with salt, over the whole body, and then immediately drying 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 resorted 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 em- * Observations on Delirium Tremens, &c, by Dr. Stephen Brown, in the Med. Recorder, vol. v, p. 207. NEURALGIA. 179 ployed in delirium tremens. Dr. Coates considers camphor and assafetida " as powerful agents in restoring the mind to its equili- brium." 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, dur- ing the declension of the disease, with the happiest effect. Two drachms of it may be given every three or four hours during conva- lescence. The carbonate of ammonia, also, may be given with more or less benefit in slight cases, or during the subsidence 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 profession appears now very generally and strongly opposed to the employment of spirituous liquors in the treatment of this affec- tion. There is, indeed, something very revolting in the idea of exhibiting copious draughts of the very agent whose destructive influence has caused the wreck 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, assafetida, and Hoffman's anodyne, may be resorted to with propriety. During the course of the disease and particularly during conva- lescence, the diet should be light, unirritating, and fluid. Animal broths will, in general, answer better than any thing else.* 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 * [I caught an excellent idea some years ago from the inaugural thesis of a candidate for the degree of M. D. He was a pupil of Dr. Hunt, a distinguished practitioner of Northampton, Mass. He gave his preceptor the credit of having cured several cases of mania-a-potu by a novel plan of treatment, which consisted chiefly in removing all appearances of restraint or confinement, and allowing the patient to wander about the house and out of doors until he wore down the mor- bid excitability of his brain and nervous system. I have often since acted upon that idea, and tranquilized patients into a sound sleep after all other plans of treatment have failed.—Ma] 180 NEURALGIA. after this short and rather indistinct description was given, Dr. Fo- thergill published a paper, in which this painful affection is clearly and very circumstantially described, under the nameof/tf«« mor- bus nervorum excrucians, and since that period, various interesting and elaborate essays, and a multitude of cases, illustrating the cha- racter 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 Strasburgh, 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 pneumogastric and phrenic nerves, and even in the gang- lionic nerves arising from the solar plexus, renders the propriety of such divisions as specific distinctions very doubtful; and the more so, as they do not appear to involve any essential peculiarities, either in a pathological or therapeutic point of view. Unquestionably, however, certain nerves are much more liable to become the seat of this affec- tion than others ; and this is especially the case with the three grand divisions of the fifth, and the facial portion of the seventh pair of cere- bral 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 complete freedom from suffering. In general, much pain is experienced 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 succes- sion 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 remarkable circumstance, that the slightest touch, in many instances, causes much more suffering than firm pres- sure ; the former, generally, instantaneously bringing on a shock of the piercing nervous pain. In general, the pain is attended with consi- derable turgescence of the blood-vessels in the immediate neighbour- hood of the affected part; and this vascular engorgement, says Dr. Macculloch, sometimes "amounts to a species of inflammation, re- sembling that of rheumatism." Much general soreness in the part is usually left after the subsidence ofthe 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 NEURALGIA. 181 individuals of a nervous temperament, it is not uncommon to observe sympathetic affections of other and distant nerves, with which those affected have no other connection than that which exists through the medium of the sensorium commune. In some cases, the paroxysms are strictly periodical in their recur- rence, 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 ofthe disease ; and is particularly pointed out by Dr. Macculloch as an evidence of the affinity or rather identity of this affection with intermittent fever. Sometimes the disease assumes a chronic character, continu- ing in irregularly recurring paroxysms 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 consequence 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 ofthe nose, the angle ofthe 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 can- thus ofthe eye, forehead, eyelids, and in the ball of the eye, we may presume that the first branch ofthe fifth pair is affected ; and in cases where the tongue and lower jaw are the seat of much pain, the neu- ralgic irritation extends to the third branch ofthe trigeminus. Some- times 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 ofthe 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 de- scribed 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 t Neuralgia in the nerves of the extremities is by no means uncom- mon. Dr. Macculloch mentions a severe case that occurred 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 neuralgia, which affected the superficial * An Essay on the Remittent and Intermittent Diseases, including, generically, Marsh Fever and Neuralgia, &c. By John Macculloch, M. D. t [This pain must have been felt by a filament of the 1st branch of the 5th pair. According to sound physiology, the other is a nerve of special sense, and can never experience common sensation.—Ma] 182 NEURALGIA. nerves under and adjoining the inner edge of the nail of the ring-finger of the hand ;* and Dr. Pearson has given an account of a remarkable case affecting the extremity of the left thumb.t 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 has already lasted upwards of six months. Dr. Good, who makes a distinct species of such cases, under the term neural- gia pedis, describes an instance of this kind, which continued for several years. The paroxysms were transient, of uncertain recur- rence, and so severe as nearly to cause fainting, 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 immediately 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 alter- nating day a pain in one arm;" and in this way the disease con- tinued 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 affection is what Mr. Brodie has described under the name of hyste- rical white swelling; and he appears to think, " that nine out of ten of those unfortunate young women who have been doctored 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 neu- ralgia ; and it has also occurred in the thigh, particularly in the ante- rior 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, (neuralgias mammae,) is founded upon this location of the disease. He describes an interesting 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 mammas, or under the margin ofthe 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 * Surgical Works, vol. ii, p. 18. t Med. Chir. Transact., vol. viii, part i. X Med. Chir. Rev., Nov., 1828, p. 58. NEURALGIA. 183 is often associated with palpitation of the heart, or what is much more unusual, with unnatural pulsation of the organ,/, 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 sensation."* The internal organs, as was observed above, are no less liable to neuralgic affections than the external parts. Of the neuralgia ofthe 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 neuralgic 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 laudanum is adequate to allay. Dr. Dewees, in his Midwifery, mentions a remarkable instance of this kind, and I have not long 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 shoul- ders. The tongue is white, the saliva abundant, without thirst, and epigastric tenderness on pressure. Immediately after eating, the pain generally abates for sometime, 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 quan- tity. In violent and protracted cases, difficulty of breathing, palpi- tation 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, t 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 inter- mission, and the patient appeared to be entirely cured. On the twenty-second day afterwards, however, intense pain occurred in the * Observations on the Disorders of Females; connected with Uterine Irritation. By Thomas Addison, M. D., &c, Lond., 1830. t For a detailed account of the diagnosis between gastralgia, and chronic gas- tritis, see the section on gastritis in the first volume of this work. 1S4 NEURALGIA. 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 applied be- neath 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.* The kidneys, also, may become the seat of this affection. Dr. Maccul- loch states that he has met with an unequivocal instance of this kind. There is an exceedingly 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 irrita- tion in the ureters, but which appears, very manifestly, I think, to be purely 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 painful affections of this kind, in females of a nervous or hysterical tempera- ment. Dr. Jolly, in the second part of his Memoir on Visceral Neu- ralgia, has reported some severe and well-marked cases of neuralgia of the uterus. In one instance, the affection assumed a strictly quoti- dian intermittent type. After some manifestations of catamenial irregularity, the patient became affected with violent pains in the right iliac region, shooting into the pelvis, and extending to the left iliac region. These pains were acute, lancinating, recurring every three or four minutes, and soon acquired 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 appeared in good health, and without any pain, but about mid-day the paroxysms 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 interesting case of neuralgic affection of the trisplanch- nic 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, without any permanent favourable impression being made on the disease. At last, recourse was had to quinine and opium, during the intermis- sions, and under the use of these remedies the disease yielded speedi- ly.! Mr. Shaw has related a case, where the neuralgic affection was seated in the ulnar nerve, from the elbow to the little finger. * Med. Chir. Rev., March, 1829, p. 553. t Bib. Med., Juin, 1828. See, also, Med. Chir. Rev., Sept., 1828. NEURALGIA. 1S5 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 attacked. with severe pains in the uterus. It wrould 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,* 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 region of the loins—in a few days afterwards pains radiating along the temples, forehead, and upper eyelid of the right side came on—then distortion of the mouth to the left side, embarrassment 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 mentions another instance still more closely simulating 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 vetebra, 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 extremities, and passed along the course of the nerves to the extremities of the fingers. On closing the hand, the hiccup and pain would cease, but "on extending a single finger it would appear, and quick as lightning traverse the parts just men- tioned."! 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 mias- matic districts, the occurrence of affections of this kind is far from being uncommon; and their close affinity to intermittent fever seems to be sufficiently demonstrated by the strict periodicity of their cha- racter; and the remedies most successful in removing them, being the same that are most effectual also for the cure of fully developed inter- mittents. The symptoms, 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 * Rev. Medicale, Janvier, 1824. t Med. Chir. Rev., Oct., 1826. Journal Generate deMed., April, 1826. 186 NEURALGIA. and intermittents. «Immediately before the attack," says Dr. M., «if the pulse be examined, it will be found to put on that character which it possesses in the cold stage of intermittents, while through the pro- gress of the paroxysm it passes through the other analogous changes." There are also, most commonly, "some indications of a cold stage, generally obscure, it is true, as is the case in most of the anomalous and chronic intermittents, but still discernible." There is much rea- son to believe that individuals who have laboured under intermittents, may afierwards, even at remote periods, have relapses of the dis- ease 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 ofthe nature of intermitting fever, it is never- theless 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 probably most commonly the case when the affection occurs in the nerves of the mammas, on the side of the head, and in the heart, producing angina pectoris. I have seen an instance of excruciating 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 removed by a course of simple diet, mild tonics, blue pill, aperients, and laxa- tive enemata. The occurrence of neuralgia from mechanical injury of the nerves is by no means uncommon. In many instances of this kind, the neu- ralgic pains are seated at a distance from the part where the primary irritation or injury exists; but in others, the affection is located im- mediately in the injured nervous ramifications. 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 ofthe antrum high-morianum; 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, pre- viously to the development of the neuralgia of which he died, was twice affected with abscess in the frontal sinuses."* In a case of neuralgia ofthe face, Dessault found the foramen through which the nerve passed in a diseased state. Many cases are on record where neuralgia was produced by acci- dental injuries, such as wounds, bruises, &c. M. Feron has related an interesting instance of this affection, which was produced by a bite from a little girl in a state of delirium, inflicted on the back of * Med. Chir. Rev., April, 1828. NEURALGIA. 187 the second phalanx ofthe little finger of the left hand in an old lady. In a few days, excruciating pain was experienced in the little finger, spreading successively to the hand, forearm, and elbow, along the track of the cubital nerve. After cauterizing the wound, the pain extended to the axilla, and increased in severity; at last a sense of stricture and fullness or stuffing in the chest ensued, which was soon succeeded by violent cardialgia and vomiting. These symptoms, recurring in paroxysms, lasted six months.* A most distressing case is related, which was caused by a wound of the hand from the explo- sion of gunpowder. Amputation of the arm was twice performed, but the disease always returned in the stump as soon as it was cica- trized. The patient visited Paris, London and Edinburgh, where he consulted the most eminent of the faculty, but he derived no perma- nent advantage from the measures that were recommended. I once saw a case of great violence, which was produced by a fracture of the forearm. 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 imbedded in the wound. It may also arise from the irritation of a carious 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, patho- logists have expressed a diversity of opinions. Dr. Parry attributed the pain to "increased vascularity or determination of blood—per- haps amounting to inflammation—of the neurileme or vascular membranous envelop of the affected nerves." M. Vaidy, who has published a valuable memoir on this disease, entertains a similar view of its pathology. He considers all neuralgic affections as con- sisting in inflammation of the nervous tissues.! 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 irritation. The nerves, says Mr. Swan, are liable " to become enlarged and inflamed from irritation, just as muscles are from continued action ; but dissection, he says, has not shown those depositions 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 por- tions along the seat of inflammatory action.":); The general opinion at present is, that this painful affection is frequently the result of mere nervous irritation, without any necessary connection with vascular congestion or inflammation. Without doubt, however, inflammation or increased vascularity of the neurileme may give rise to the dis- ease ; and it may, I think, be assumed as a fact, that neuralgia may depend on different causes—on local inflammation or congestion of * Med. Chir. Rev., Sept.. 1821, from the Journal Complement., Mai, 1820. t Journ. Complement., Dec, 1820. X Dissertation on the Treatment of Morbid Local Affections of the Nerves. By Joseph Swan, &c. 188 NEURALGIA. the affected nerve—on organic disease of the brain—and most com- monly 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, paroxysmal, and usually transient, coming on with the suddenness of an electric shock, and ceasing as instantaneously. These circumstances, together with the exceeding aptitude ofthe slightest touch or motion of the affected part to renew the paroxysm of pain, and the entire absence of swell- ing 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 diversified, 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 treatment 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 re- medies that would fail in one which originates from gastric irritation, and a general morbid irritability ofthe system. Formerly, consider- able 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 rami- fications ; 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 scalpel, there would appear to be but very little or no chance of advantage from this measure. Mr. Swan, in speaking of this operation when the portio dura* is affected, says, that the attempt to divide the trunk of this nerve is not only attended with much diffi- culty, 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 principal branches will be divided." When the disease is located in the third branch of the * [The portio dura can never be the seat of neuralgic pams. I have had many opportunities of proving the truth of Sir Charles Bell's doctrine upon this subject in my observations upon the living body. It is totally insensible to the irritation of instruments of every kind, and is purely a nerve of motion, imparting both volun- tary and involuntary powers to the muscles of the countenance. When we have excited pains in our operations near the trunk of this nerve, they have arisen from a disturbance of the superficial temporal, the only sensitive nerve in that vicinity. Irritation of the portio dura produces a muscular rigidity or contraction of the vessels which it supplies, and division or compression, or simple impairment of its energy, produces an atonic muscular paralysis of the same parts.__Ma] NEURALGIA. 189 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 interesting example of the performance of tin's 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 dis- section was made between the back part of the parotid gland, and the mastoid process," the nerve exposed and a portion removed. 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.t This completed the cure. In cases of neuralgia in the nerves of the extremities, the removal of a portion of the affected nerve has been practised with success in no inconsiderable number of instances. Mr. Earle has reported a case,J 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 transmit- ting the nervous influence in a few days. M. Lisfranc cured a case of neuralgia ofthe 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."§ The practice of dividing the neuralgic nerve has, however, so frequently, we may say, so generally failed, that 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 remedial measures are ineffectual. In recent cases, depending on a constitutional cause, where the paroxysms recur periodically, tonics, particularly quinine and arse- * Loc. cit., p. 56. t [This last operation divided the inferior sensitive branch of the trigeminus— the real seat of the disorder. The first operation on the portio dura, which doe3 not enter the lower jaw, was necessarily unsuccessful in the way of relieving pain, and could only have produced an incurable paralysis of the muscles.—Ma] X Med. Chir. Transact., vol. vii. $ Med. Chir. Rev., July, 1826. l&O NEURALGIA. nic, 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 intermit- tents are known to do, without any medicine. About two years ago, I attended a lady labouring under quotidian paroxysms 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 bdrk and arsenic are decidedly the most efficacious remedies in intermittent neural- gia ; and this observation is confirmed by the experience of others. Mr. Shaw has used bark with marked success in neuralgic com- plaints ; and Dr. Kerrison asserts, that, according to his experience, cinchona is the most useful medicine we possess 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 cinchona.* 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 remedy, 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;t and M. Piedagnel succeeded, in a very short time, in curing this affection with this tonic.J Dr. Lalautie, physician to the Central House of Correction at Eysson, has related an instance of neuralgia which originated from a puncture of a ramification of the frontal nerve, and which had continued for ten years. The attacks came on periodically. 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 repeated every other day, and in two weeks the disease was entirely removed. From the observations that have been published, it appears, there- fore, that in intermittent, quotidian, or tertian neuralgia, and in these only, do the tonics just mentioned manifest any particular curative powers; and in all such cases, whether originating from * Journal Complement., December, 1820. t Magendie's Journal de Physiologie, 1822. X Lond. Med. Repository, 1821. NEURALGIA. 191 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 remedy 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,! Dr. Crawford,:}: Dr. Evans,§ Dr. Brothwick,|| Dr. Davis, Dr. Yates, Dr. Ayre, Dr. Marsden, Dr. Payne, Dr. Mar- shall 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 adapted 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 medi- cine in these and other painful affections unattended with an inflam- matory diathesis, and it is unquestionably entitled to much attention as a remedy in cases of this kind. Dr. BigbeelF has published 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 neuralgic com- plaints.** 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 subsides. It has appeared to me most effectual in cases attended with, and probably mainly dependent on, a general irritable condition 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 tremens. In two instances, in which I prescribed it for chronic rheumatism, it had this effect. The bella- donna, too, has had its advocates as a remedy in neuralgic com- * Cases of Tic Douloureux successfully treated. By B. Hutchinson. London, 1820. ! Lond. Med. and Phys. Journ., No. cclxxi, p. 271. X Ibid., 1823. k Edin. Med. and Surg. Journ., Jan., 1824. II Ibid. If Edin. Med. Chir. Trans., vol. i, p. 285. ** Med. Chir. Rev., June, 1828. 192 NEURALGIA. plaints; but its powers as an internal remedy are certainly much inferior to those of stramonium in this respect. Mr. Bailey, how- ever, speaks very favourably of its remedial effects in affections of this kind. He has related thirty cases in which the internal employ- ment of this narcotic proved more or less beneficial. He began with three grains of the extract, and repeated it in small doses, at short intervals, until relief was procured. Mr. Todd states that he has cured several cases of painful affections of the nerves, by the exter- nal application of a strong- aqueous solution of the extract of bella- donna 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.* Dr. Henry, an English surgeon, also has reported a case of this affection, treated successfully in this way, and in the Revue Medicate, for January, 1830, Dr. Claret has given the details of six cases of neuralgia, which yielded entirely to this treatment. He employed the extract by frictions. "Five or six frictions, with the extract of belladonna, were sufficient to cure a severe case of neuralgia in the supra-orbital nerve." In another case the cure was effected by two frictions; and in a third case, one friction, with ten grains of the extract, was suffi- cient to remove the complaint.! I have lately resorted to this prac- tice in a case of neuralgia in the sciatic nerve, with unequivocal advantage.^ The oil of turpentine, likewise, has been used with success in certain neuralgic affections. M. Sedillot§ 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 combination 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 ofthe 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 article has been found particularly efficacious; although it has also been used with success in other varieties of the disease. M. Martinet has published a paper on the use of this re- * 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 North Amer. Med. and Surg. Journ., vol.x, p. 194. X [The extract of aconitum has of late been much used for the same purposes. From its power of benumbing the sensations, it would appear to be especially calculated to afford relief in neuralgic pains.—Ma] $ Medico-Chir. Review. NEURALGIA. 193 medy 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 subjected to various other modes of treatment, without advan- tage.* M. Recamier, of the 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 affections ; and from some accounts that have been published, it would appear that benefit may be derived from this measure in certain cases ofthe disease. Without doubt, where the malady depends on an inflamma- tory 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 constitutional causes, and there are in- stances on record where it did much harm, as in the remarkable case related by Dr. Yeates.f 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 affection, 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 immedi- ately 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 mitigation of the patient's sufferings. Larrey advises that the moxa be applied repeatedly, if the first applications afford only partial relief. He has repeated the burning ten or twelve times, and followed the pain with the moxa wherever it fixed itself, before the disease was completely subdued.J 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 tight bandage applied over the whole extremity. Acupunctu- ration 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 operations 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 ofthe chest were affected.§ A case of facial neuralgia is related by Mr. Beddingheld,|| in which * Revue Medicale, Nov. 1828, p. 222. ! A History of a severe case of Neuralgia, occupying the nerves of the right thigh, leg, and foot. X [Blackening the cuticle over the origin and course of the pain with the re- peated application of a strong solution of lunar caustic often affords relief.—Ma] $ Revue Medicale, Janvier, 1825; and Archives Generates, Fevrier, 1825. II Compendium of Medical Practice. VOL. II. —14 194 NEURALGIA. the application of cerussa, with the view of paralyzing the 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 pa- roxysm 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. He 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, how- ever, the pain ceased entirely, and I found him calm and cheerful in the evening. On the following 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 removed, Was this a mere coincidence; or did the mag- net 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. Professor Von Hildenbrand,of Pavia, employs a bundle of metallic wires (facis et filis metallicis confectum), not thicker than common knitting-needles, firmly tied together, by wires of the same material, so as to form a cylinder about four or five inches long, and one inch or three-fourths of an inch in diameter. This is applied to the pained parts, previously moistened with a solution of sea-salt, when, as he asserts, it produces almost instantaneous relief. Occasionally, says Dr. Hildenbrand, the neuralgic pain is immediately entirely extin- guished, with the accompanying effect of a peculiar sense of emana- tion from the spot to which the metallic bundle or brush is applied. On withdrawing the brush the pain occasionally returns, but in a much less violent degree.! * [This pain could not have been seated in the portio dura. I repeat, it must have been in the trunk of the superficial temporal nerve which supplies sensibility to the parotidial and middle temporal region.—Ma] t To illustrate the extraordinary remedial effects of this agent, Dr. Hildenbrand relates the following case : " A man aged 30, affected with violent tic douloureux of the face, was admitted into the clinical wards of Pavia. On applying the metallic brush over the left frontal nerve, the pain immediately disappeared from that one, but fixed in the corresponding nerve of the right side, which had been previously free from pain. The very moment at which the brush was removed NEURALGIA. 195 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,! 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 vertebras. 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 ofthe spine, will very generally speedily remove the painful affection. They report some striking cases of the value of this practice; and the recent periodical medical publications furnish interesting testi- mony from other sources, in confirmation of their experience. An attention to proper dietetic regulations, and to the restoration or maintenance of the regular action of the liver and bowels, is of much importance in affections of this kind—more especially where the disease is attended with manifest symptoms of gastric derange- ment.:!: Gastralgia.^—For mitigating or removing this painful and dis- from the left frontal nerve, the pain returned to its original seat, and there remained, though already greatly abated in intensity. By applying a metallic brush to each supra-orbital nerve simultaneously, the original neuralgia of the left side was removed, without again appearing in the opposite side." If, in cases of this kind, the pain is purely nervous, without inflammatory irri- tation or change of structure—in which case its attacks are always periodical with perfect intermissions of freedom from pain—(- then the efficacy of the metallic brush may be pronounced infallible. But if the pain be continuous, or at least void of perfect intermissions, or if it is aggravated by pressure, or attended with redne?s, heat and swelling, in short, if there is reason to believe that the neuralgia is attended with active congestion or sub-inflammatory irritation, then the metal- lic brash will afford no benefit, nay, it may augment the severity of the pain." Edin. Med. and Surg. Journ., vol. xxxix, p. 492. * Teale on Neuralgic Diseases. ! Tate on Hysteria, &c. • X [Dr. Eberle has undervalued the operation of dividing the sensitive nerves, which are the actual seat of neuralgia. Before the distinction between the two classes of sensitive and motor nerves was understood, surgery often failed in consequence of dividing the wrong nerve, as the portio dura instead of one of the branches of the trigeminus or the ninth pair instead of the gustatory. When they cut on the distal side of the affected part, they also must invariably have failed. We now understand this thing better, and are guided in our operations by the brightest lights of science. On a proper occasion, I shall take the oppor- tunity of publishing the results which have followed my operations in extreme cases of neuralgia.—Ma] $ 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 196 NEURALGIA. tressing affection, which appears to be purely neuralgic, various remedies have been recommended; but they have seldom afforded 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, who do not find it necessary to resort to this narcotic. The misfortune, however, is, that those who have once experienced the delightful effects of this medicine, when suffer- ing under an attack of gastrodynia, will repeat 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. Daw- son* 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 renders talents useless, or take opium; for where is the man, who, racked with pain in the stomach night and day, can perform his duties in society, and enjoy life as it ought to be en- joyed ?" Unquestionably 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. This remedy is the saturated tincture of lobelia inflata, a few tablespoon- fuls of which have never failed to give me speedy relief, and to pro- cure me long intervals of exemption from the disease. 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 tincture of henbane, and the sul- phate of quinine, with a diet consisting chiefly of animal food, have been recommended in this affection, and in some instances considera; ble benefit may no doubt be derived from them. I have prescribed the oxyde of zinc in a number of cases, and occasionally with advan- and applying pressure by the hand. In some cases the pain is always in the sto- mach 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 ofthe spine, orthe 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. I have known a gentleman lie 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. Yet the patient, even on the rack of pain, is not ill: and the instant the pain ceases he is as well as he could wish." * Nosological Practice of Physic, p. 300. AMAUROSIS. 197 tage. Would not the use of the magnet, in the manner recommended by Laennec for the cure of angina pectoris, be beneficial in this com- plaint? 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 con- sisting chiefly of animal substances. It has appeared to me that this affection is often connected or dependent on an ineffectual hemor- rhoidal 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 frequent 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 hemorrhage 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 impressions 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, 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 ofthe 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 disorganizing 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 thick- ening, atrophy, absorption, or ossification of its sheath.* The causes which are capable of suspending or destroying the functional power of the retina and optic nerve, independent of per- ceptible organic change, are extremely various. Functional torpor of the optic apparatus may depend either on vascular turgescence of * Travers. Synopsis ofthe Diseases ofthe Eye, p. 141. 198 AMAUROSIS. the retina of the sheath of the nerve, or of its thalamus, or on defi- cient arterial circulation in these parts; or, finally, it may be the result of an idiopathic paralysis, or loss of sensorial power ofthe retina and its nerve. When the organic disorder that produces the amaurosis is seated in the eyeball itself, several, or all of the following phenomena ac- company the disease:—namely, dilated pupil, its contracting power being feeble or null; congestion of the veins ofthe conjunctiva; a bluish gray tint of the sclerotica; loss of regular 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." In many instances of organic amaurosis, a small circular spot of a pearly or greenish-yellow colour may be seen at the fundus of the eye, a small distance from the visual axis.* When the disease is the consequence of inflammation of the retina or choroid coat, and the inflammatory action has entirely sub- sided, we usually find the conjunctival veins varicose, the iris dis- coloured, thick, very vascular, and inelastic; the bulk ofthe 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 uneasiness, but rarely any distinct acute pains in the globe of the eye, and the sclerotica be- comes thinner and semi-transparent, admitting the reflection of the vascular texture of the choroid coat which occasions the above-men- tioned bluish-gray tint ofthe sclerotica. (Stevenson.) In some cases of organic amaurosis, an opaque w hite 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 fungus ofthe retina, which, in the progress of the dis- ease, involves the eye in one undistinguishable 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 immovable ; more or less stra- bismus, ptosis, or double vision of the affected eye, often exists; the carotids beat strongly; the face is apt to be flushed; a sense of fullness and tension in the globe ofthe eye is felt, with pain, and a feeling of pressure of the scalp; occasionally ringing in the ears ; disorder and irritability of the stomach; and somnolency. Luminous sparks or flashes appear before the eyes, particularly 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 apparently well, and awoke with more or less complete loss of sight in one or both eyes. * •'•' This appearance has been attributed to a circumscribed opacity of the retina, answering to the poros opticus. Others have supposed it to be the maculae lutea of Soemmering. It is, however, with more propriety, ascribable to a diminished secretion ofthe black pigment."—Stevenson on the Nature, Symptoms and Treatment of Amaurosis. AMAUROSIS. 199 Functional amaurosis from depletion occurs sometimes immediately after excessive hemorrhages, particularly uterine floodings. In this variety, as in that which arises from vascular congestion, the pupil is dilated and immovable, 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 vas- cular congestion in the head ; for there is no pathological fact better established than that strong determinations to the head often supervene as the immediate consequence of excessive sanguineous discharges.* It is of much importance to distinguish this from the former variety in a therapeutic point of view—for amaurosis from excesssive san- guineous 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 sight of which he alternately loses or regains by shutting or rubbing his eyes, or by moving his head in different directions." Sometimes the approach of the disease is announced by a peculiar 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 ad- vanced stage of the disease, coloured spectra, or luminous impres- sions of objects remaining 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 com- plete. When the pain continues severely, with but slight remissions, 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 torpor of 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 are " accompanied with convulsive quivering of the muscles of the eye and eyelids, and profuse lachry- •mation." Some patients affected with incomplete functional amaurosis, see * See the observations of Marshall Hall on this subject, in his '•' Medical Essays." The experiments of Dr. Seeds on the effects of excessive abstractions of blood in animals.—Med. Chirurg. Journ., No. vi, p. 107. 200 AMAUROSIS. more distinctly on first awaking 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 accord- ance with that of the sound organ, "provided both be allowed to remain open at the same time; but if the latter be 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 immovable; and frequently mis- shapen or irregular. It is sometimes smoky or clouded, or dark gray, or greenish gray, and occasionally of a reddish or yellowish- white appearance. Diagnosis.—Immobility and dilatation of the pupil furnish no certain evidence of amaurosis. In some cases of complete amau- rosis, 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.^ Moreover, the ciliary nerves may be para- lyzed, occasioning enlargement and immobility of the pupil, without amaurosis.§ Among the symptoms which may aid us in distinguish- ing amaurosis from cataract, writers particularly mention the dif- ferent appearances which the flame of a candle presents to persons labouring under one or the other of these diseases. 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 semitransparent 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 dimi- nished, "under different 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 afford- ing temporary benefit, or in causing diminution of vision, which does not occur in cases of incipient cataract." Prognosis.—Those cases which depend on organic lesion, may be regarded as incurable ; where, with total loss of sight, the iris is * Loc cit., p. 68. f M. Travers is of opinion, that, in cases of complete amaurosis, where the pupil is ofthe natural shape, but motionless, the retina has, most probably, under- gone some structural change. X When this is the case, says Mr. Stephenson, the disease is generally the result 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." § [I have seen a case in which the solar rays, especially when concentrated by* a lens, would dilate an amaurotic pupil to excess. The motions of the iris are some- times wave-like or vibrating in cases where amaurosis is supervening. It is an excellent rule, which the author has quoted from Travers, to cover the eyes alter- nately while the condition of the pupil under the vicissitudes of li^ht is examined. —Ma] AMAUROSIS. 201 immovably dilated, or preternaturally contracted, accompanied with violent pain in the head, or eye, or cranium, when the disease occurs as a consequence of apoplexy, blows on the head or eye, syphilis, or protracted internal ophthalmia ; and in cases where the above-men- tioned 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 constric- tion in the eyeball, accompanies the development ofthe disease ; 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 ex- pect relief from remedial management. Periodical amaurosis, also, unless of very long standing, is of a favourable character; and, in general, all those instances ofthe disease which are purely functional, or symptomatic of visceral irritation, or metastasis of gout, rheuma- tism, &c, may be regarded as susceptible of being cured. Causes.—When amaurosis is not the result of organic or structural 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 excessive losses of blood, vascular turgescence, and pressure of the retina, optic nerve, or its thalamus, is, perhaps, the immediate cause of the disease. I have already adverted to the great tendency to cephalic congestion in that exhausted state of the system which results from profuse hemorrhage, and in this state, vascular 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 general, much more liable to amaurotic affections than such as have light-coloured, or gray eyes. It has been stated, that the proportion of instances of this disease in dark-eyed persons, is to that of the cases which occur in individuals with light, or gray eyes, as twenty-five to one.! 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 eva- cuations ; as of the catamenial or hemorrhoidal discharges; the heal- ing up of old ulcers ; and the sudden retrocession of cutaneous erup- tions ; and of habitual perspiration of the feet. It is sometimes symptomatic of hysterical, epileptic, hypochon- driacal, 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 ofthe bowels;% * Weller. Manual ofthe Diseases of the Human Eye. f Jahn's Klinik der Chronischen Krankh., bd. v, p. 295. X Dr. Wishart has related an interesting case of amaurosis in the Edinburgh 202 AMAUROSIS. 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. Among the most common external causes of amaurosis, is intense application of the eye to the inspection of minute and bright objects,*—which, Mr. Stephenson thinks, tends to produce preternatural vascular turgescence in the retina and choroid coat. It may also be occasioned by falls or blows on the head; insolation; straining in parturition; evacuating the feces; or lifting—in short, by whatever is capable of causing preternatural sanguineous determination 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 diseases 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 remedial treatment. The functional or symp- tomatic 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 ethereal embrocations, &c, although setons, leeching and blistering are important auxiliaries. Under this point, however, Mr. Stevenson, as well as many others, differs widely from Mr. Travers. The for- mer agrees with Mr. Ware in regarding errhines as often particu- larly 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. Medical Journal for July, 1825, which was manifestly the consequence of intes- tinal irritation from indurated fecal matter. * u Hence the frequency of weakness of sight among the silk-stocking weav- ers, milliners, embroiderers, and other mechanics and artists whose occupations oblige them to exercise their visual organs with too little intermission and variety, in looking intently at their delicate, light-coloured, and highly illumined manipu- lations. Persons addicted to read, write, or perform much fine needlework, by the aid of candles, and what is much worse, by the brilliant and artificial light of lamps, rarely fail, if their organ of vision be constitutionally feeble, to discover, sooner or later, the greater or less decay of sight."—Stephenson, loc. cit., p. 121. t Researches, principally relative to the Morbid and Curative Effects of Loss of Blood, p. 71. AMAUROSIS. 203 When the momentum ofthe circulation is preternaturally increased, and the eye is somewhat tender and irritable, and particularly 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 violence of the symptoms shall have been mode- rated." Immediate attention must also be paid to the bowels. So long as the general habit is \>h\o%\sl\c, 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 nauseating doses, adminis- tered during the intermediate time. In relation to the employment of sanguineous evacuations in this affection, Mr. Travers observes, that although obviously proper in cases attended with general ple- thora and cerebral compression, yet where the undue determination of blood to the eye is attended with diminished tone ofthe vessels of this organ—a circumstance very common, he says, after deep-seated inflammation, or irritation 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 disposi- tion to contract, or has actually formed adhesions with the capsule of the lens, the application of belladonna, or stramonium in solution, to the eyes, says Mr. Stevenson, " must on no account be omitted," in order to prevent permanent contraction and obliteration of the pupil. The light should be excluded from the eyes where there are tender- ness and irritability of the organ; and all kinds of compressing 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 general vascular irritation, revulsive applications, particularly blistering, or a seton on the nape of the neck, and leeching at the temples and around the eyes 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 re- stored. 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.* * Schmucker's visceral pills were formerly much employed in Germany for the cure of this disease. They are made according to the following formula: 204 AMAUROSIS. I 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 the root of burdock (arclium 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 absence 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 of local irritated action, general depletion is not only useless, b*ut 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 conges- tion 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 immediate vicinity of the affected organ, as well as the consequent increased discharge from the mucous mem- brane 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 infusion of capsicum; vinous tincture of opium, &c. Electricity does not appear to possess any particular remedial powers injthis affec- tion ; and it is said to be even frequently injurious. Mr. Travers has not seen a single instance 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 unquestionable; and, under peculiar circumstances, may no doubt be again used with advantage; although they are certainly not so efficacious as they were formerly represented to be by physicians of high authority. In complete amaurosis, of a chronic or asthenic character, the R.—G. Sagapen.—Galban.—Sapo. venet. aa gi; Pulv. rhaei ^iss; Tart, emetic gr. xvi; Succ. glycyrrh. 3L Fiant. pill, singul. gr. v. Of these pills three are to be taken every morning and evening for a month. Richter recommends the follow- ing pills: R.—G. ammon.—Assafcetid.—Sapo. venet.—Rad. valerian.—Sumita arnicas—aa gii; 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 excel- lent purgative for this purpose: &.—Masses hydr. gi; G. aloes -ss; Tart, antim. gr. ii. Fiant. pill. No. xx. Take one every night on going to bed. AMAUROSIS. 205 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 in- stance of the success of this practice; although his own experience does not furnish him with-an example of its usefulness. Mr. Steven- son 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 exerting a more or less powerful influence upon the organ of vision, in proportion to the extent to which the atmospheric air contained in the cupping-glass is exhausted. The effect of this application is to occasion a great redness and tumefaction of the eyelids; an immediate distension of the conjunctiva; and a bulging forward, or protrusion ofthe whole globe ofthe eye, the ob- vious 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 strychnine 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 vesi- cated, and the cuticle removed, one-fourth of a grain of strychnia, finely levigated, was dusted over the excoriated 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, terminated successfully under this mode of management. In no instance did this remedy cause any injurious effects; although slight headache, 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 ofthe strychnia, and the use of opium, which is its pro- per antidote." One patient, after about seven grains of the strychnia had been applied, was seized with numbness and immobility of the lower extremities; 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 Westminster 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 hemorrhoidal discharge, aloetic purgatives, stimulating enemata, and leeching round 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 col- chicum, and sinapisms or blisters to the ankles. In instances that * Med. Chir. Rev., July, 1830, p. 442. 206 ASTHMA. arise from syphilitic irritation, a slow mercurial course, with infusion of sarsaparilla, &c, will be particularly indicated, and the same reme- dies are to be relied on where manifest hepatic disorder is present. If suppressed perspiration lie at the bottom of the disease, the warm bath, diaphoretics, particularly antimonials, both in nauseating and emetic doses, will be appropriate means. In short, the practitioner should always endeavour to ascertain the cause of the disease, and to counteract or remove this cause, if possible, by an appropriate course of remedial management.* CHAPTER IV. CHRONIC AFFECTIONS OF THE RESPIRATORY ORGANS. Sect. I.—Asthma. Asthma is a paroxysmal affection of the respiratory organs, cha- racterized by great difficulty of breathing, tightness across the breast, and a sense of impending suffocation, without fever or local inflam- mation. 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 fullness * [This last sentence in the chapter on amaurosis imparts a valuable hint to some practitioners. There is no disease in which the treatment is conducted more empirically, or what is called systematically, than amaurosis. Accordingly there is not much greater success than in tetanus or even hydrophobia. The plan which I have always formed is founded on a careful study of the pathology of each particular case. When vascular engorgement attends an amaurotic condition, a long continuance in the use of local depletion and derivation will sometimes succeed. An over-distended cornea, in addition to diuretics and hydragogues, will often require punctures of the cornea to evacuate the humours. I succeeded in one case of total amaurosis attended by hydrophthalmia of the aqueous humour in the left, and of the vitreous in the right eye, by giving an active course of Clutter- buck's elaterium combined with calomel, and occasionally tapping the two over- distended humours in each eye. I cured an English gentleman of complete amau- rosis in one eye, attended with syphilitic hemicrania and periosteal swellings of the scalp, by exciting a smart salivation, aided by the long-continued use of a vapour bath and diaphoretic decoctions. Dr. Beesley, of Texas, was restored to tolerable vision by the use of lunar caustic to blacken the integuments over the forehead and lid, and by the daily use of purgative doses of croton oil. In the case of a young lady, after removing a severe form of attendant spinal irritation, and reduc- ing the size of her over-distended eyeballs by the use of elaterium, and restored perfect vision by the use of electro-magnetic apparatus.__Ma] asthma. 207 in the epigastrium, acid eructations, inappetency or voraciousness, heartburn, flatulency, weight over the eyes, anxiety in the praec'or- dia, 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 stric- ture 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 coun- tenance 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 bein°- thrown open; or he starts from his bed and rushes to the win- dow°for fresh air, and is wholly unable to remain in the recumbent posture. The extremities 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, intermitting, accelerated, moderately full, and compressible; some- times 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 pro- ceeds, with remissions by day, and violent exacerbations at night, for three or four days in succession, 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. Breer states that the tem- perature 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 are 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 com- mencement of the paroxysm, as if an evacuation from the bowels would certainly greatly relieve them; but this feeling is almost inva- riably deceptive. No distinct 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 gene- rally admitted, that a predisposition to this affection is sometimes 20S ASTHMA. hereditary. This predisposition would seem to consist in a peculiarly irritable state of the pulmonary system, or more correctly, perhaps, of the pneumogastric nerve. That this nerve is the seat of that peculiar condition 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 derangement. 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 functions of the stomach and lungs, is in a state peculiarly susceptible of being thrown into morbid excitement in asthmatic individuals, and that this condition has pro- bably an important share in the predisposition in question. Authors have divided asthma into various species, founded prin- cipally on the different characters of the exciting or proximate 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 resulting from gastric or abdominal irrita- tion ; and 4, those depending on habit. This division is, however, altogether arbitrary, as it is manifestly founded on gratuitous prin- ciples ; for its dependence on an aerial acrimony in the lungs is a mere hypothesis; 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 con- tinues 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; A. plethoricum; A. urinosum; A. aereum; A. abdominale; A. nocturnum incu- bus; A. metallicwm; A. It causa specifica; A. ex debilitate; d. spasmodicum; and A. acutumperiodicum millari. 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 usefulness; 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 ofthe 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 maybe 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. ASTHMA. 209 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 unconfined air ; but there are many who breathe better in the impure atmosphere of populous cities or crowded rooms than in the fresh and uncontami- nated air of the country. Most persons 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 individu- als 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 capa- ble 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 irritating articles of food, vitiated secretions, or a loaded state of the bowels, is one of the most common exciting causes of the asthmatic parox- ysm. 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 gives 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 symp- toms alternated with the hemorrhoidal discharge. The suppression of the menses sometimes gives rise to nervous or hysterical asthma. 5. Metastasis of rheumatism and gout, and of various cutaneous affeclions, sometimes gives rise to more or less violent asthmatic symptoms. One of my patients, a rheumatic subject, has had seve- ral violent fits of asthma during the remissions of his arthritic affec- tion. M. 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 mo- mentum of the circulation, is particularly favourable to the occur- rence 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 par- * Med. Chir. Rev., vol. vi, p. 447. VOL. II.--15 210 ASTHMA. ticularly suppressed perspiration of the feet, may excite the 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 excited 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 sealing-wax. (Parry.) 10. But by far the most common exciting cause of asthmatic symp- toms is organic affection of the heart and aorta. Ossification 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 symptoms 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 ofthe cardiac affection. 11. Finally, asthma, like all other paroxysmal, nervous, and spas- modic 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, with- out the renewed application of the original exciting cause. Pathology.—Various and very discrepant opinions have been ex- pressed 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 especially from organic cardiac diseases, aneurism of the large arterial trunks, and pulmonary hepatization. The occurrence of purely spasmodic asthma, wholly independent of obvious structural 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 senti- ments 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 believe that the oppressed respiration depends on vascular engorgement of the mucous mem- brane of the bronchia, giving rise, by the tumefaction of this mem- brane, 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 opin- ion, and has endeavoured to prove that the bronchial ramifications * Rostan. ASTHMA. 211 are furnished with a coat of circular fibres, beginning where the car- tilaginous 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. I am convinced," he says, " that the asthmatic paroxysm may be induced 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 sometimes by both causes at once. With the exception of the different kinds of catarrh, the occasional causes of asthma and dyspnoea are almost always of a kind to give occasion to an immediate and evident dis- turbance 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, heliotrope, stored apples, &c; changes of atmospheric air, electricity, and other less appreciable conditions ofthe atmosphere."* Mr. Abernethy appears to entertain a similar view ofthe nature of asthma. He contends, that one ofthe principal causes of this disease is a morbid irritability ofthe mucous membrane ofthe air-cells. "A man," he observes,"having irritable lungs, may be sitting comforta- bly 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 difficulty 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 eminence have declared it as their opinion, that pure spasmodic asthma depends immediately on a constriction of the air- cells and smaller bronchial ramifications, by which the ingress of atmospheric air is impeded or prevented, and suffocative respiration produced. It has been objected to this doctrine, that we have no evi- dence of the existence of muscular fibres in the smaller branches of bronchia and air-cells; but M. Laennec observes that as such fibres do undoubtedly exist in the larger bronchial tubes, analogy must lead us to admit their existence in the ultimate ramifications. "Besides, it is by no means demonstrated," he says, " that muscular fibre is the only contractible tissue; indeed, 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 pul- * On the Diseases of the Chest, last edition, p. 414. t Lectures, p. 375. X Loc. cit., p. 408. 212 ASTHMA. monary contraction.* 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.t into the smallest bronchial ramifications; and by means of the galva- nic influence, he demonstrated the contraction of these fibres in the most unequivocal manner: Morgagni has very particularly noticed the fibres of the bronchia;t. and although their apparent tendinous character would seem to oppose the idea of their possessing contrac- tility, 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 in- fluence through the pneumogastric nerves, these fibres, and conse- quently the whole lungs, are thrown into a state of contraction; and finally, that by dividing the par vaga, the power of pulmonary, or bronchial contraction is destroyed, and dyspnoea produced. It is highly probable, therefore, that asthma consists essentially in a peculiar irritation of the pneumogastric nerves, in consequence of which the smaller bronchial tubes and air-cells are thrown into a state of spasmodic constriction, by which the regular ingress of air to the lungs is prevented. When we advert to the almost invariable ante- cedent and concomitant manifestations of functional disorder of the stomach in this affection, we have good reason 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 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 derangement or irritation of the pneumogastric nerves, appears, moreover, 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 ofthe nature of asthma as being without the least foundation, and ascribes the dyspncea to great vascular turgescence of the bronchial mucous membrane, by which the smaller respiratory passages are mechanically diminished * Undersuchungen uber die naechste ursache des hustens. Leipzig, 1829, p. 9. f Ueber den Bau der Lungen. X Extant in tunica intima ceu lacerti quidam insignes ex albicantibus fibrillia compacti. Hi digitos aliquot supra asperae arteriae divisionem initium capiunt, et secundum ejus longitudinem dispositi, interstitium illud,quodmemorabam,tenen- tes, ubi ad secundum bronchiorum divisionem pervenerunt; ibi primum solent per omnem undique bronchiorum superficiem ad istorem extrema versus decurrere. Quorum lacertorum usus nunc non existimo.—Adversaria Anatom. Adver., i, $ 25, § Journal de Progress. Vide Med. Chir. Rev., Jan., 1828. ASTHMA. 213 or closed, until the vessels relieve themselves 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 ofthe disease; and yet, in a considerable number of instances, I have known violent paroxysms of asthma greatly, and in one case com- pletely 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 effu- sions of blood would occasionally show themselves in the expectora- tion? The mere circumstance ofthe frequent inordinate secretion of mucus into the bronchia is no satisfactory evidence that great san- guineous congestion pre-existed in the mucous membrane of the lungs. It is well known that the process of secretion is wholly under the in- fluence of the nerves, and we do no violence to correct physiological data, in presuming that the redundant secretion of mucus is deter- mined by the irritation of the pneumogastric 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 symptomatic of, organic pulmonary or cardiac disorder, the prognosis is of course always peculiarly unfavourable; for in such cases, fatal dropsical effusion into the cavity of the pleura or the pericardium is almost a never-failing consequence of the disease. Spasmodic asthma result- ing 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 palliative, or radical, according as we prescribe for the mitigation and removal ofthe 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 ex- tremely 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 individual. 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 indica- tions of cure during the paroxysm are to diminish the pulmonary con- gestion, 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 214 ASTHMA. although venesection will rarely by itself make any decisive or per- manent impression on the paroxysm, its employment is always proper in robust and sanguineous 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 warranted by general experience. He considers bleeding " not only the most effectual remedy" in strong subjects, but in many instances 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 over-action of the heart, indicates pulmonary congestion; but ive must be careful not to abuse this practice, which, in general, only produces a temporary advan- tage." 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 employment. 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 stramonium, also, may be used with occasional advantage. The latter article, in particular, has done much good in several instances 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 up- wards of nine months. The leaves and roots 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.t In cases attended with catarrhal irritation, and a very copious secre- tion of viscid mucus into the bronchia, emetics sometimes procure considerable relief. The production of emesis is particularly 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 affection, as from full emesis. It is gene- * Gregory's practice, vol. i, p. 187, second edition. t [In France much use is made of the different preparations of belladonna. Both the extract and the tincture, especially of the root of the plant, are combined with antispasmodics and tonics in the treatment of asthma.—Ma] ASTHMA. 215 rally admitted that ipecacuanha is decidedly the best article for this purpose. It is said that the union of distilled vinegar and ipecacuanha forms a particular 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 asthmatic 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 palliative in the paroxysm 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 tablespoonfuls of strong vinegar taken at intervals of half an hour, and from inhaling its fumes. In the last two attacks, however, he derived no benefit from its employment. Bree speaks very favourably, also, of the union of acids and nar- cotics as palliatives in the asthmatic paroxysm. He recommends the following formula as an excellent combination of this kind.* In the asthma of old people, attended with deficient urinary secre- tion, 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 urine 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 individuals who derived advantage from its use during the paroxysm. In an- other 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 may occasionally be employed with some benefit in this disease; and for this purpose, the different preparations of the squill appear to be the best remedy. I have known the following * R.—Tinct. scill. gtt. x. Acid, nitric, gr. vi. Extract, hyoscyam. gr. iii. Aquae fontanee §iss.—M. This draught is to be repeated thrice daily. 216 ASTHMA. mixture to give much relief towards the termination of an asthmatic paroxysm.* 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 assa- fetida 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. (Symplocarpus fostida.) 1 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 two or three hours during the paroxysms, according to the urgency and obstinacy ofthe symptoms. Of all the remedies we possess, however, the lobelia inflata is, I think, decidedly the most valuable in this affection. Within 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 paroxysms of spasmodic asthma completely subdued in less than thirty minutes by this medi- cine. It appears to me that ergot does not more certainly act upon the gravid uterus during parturition, than the lobelia upon the pul- monary organs in asthma. I have even found it to mitigate the dyspnoea which occurs in consequence of organic affections of the heart. Since the publication 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 1 had previously witnessed. In one hour after the exhibition of the remedy, the patient's respiration was en- tirely free from difficulty or oppression. The good effects of a full dose of this medicine are often expe- rienced 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 tablespoonfui of the saturated tincture. " In three or four minutes," he says, " my breathing was free as it ever was. In ten minutes I took another spoonful, which occasioned sickness. 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 enjoyed as good health as perhaps before the first attack."t 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 * R.—G. Ammoniac. £i. solve in Acid, scillae §iss. Tinct. opii camp, ^ss.—M. Take a teaspoonful every hour, in a little clear and strong coffee. t Thacher's Dispensatory. ASTHMA. 217 tablespoonful of the saturated tincture may be given every ten or fifteen minutes. Within the last two years I have relieved two cases of long-standing asthma by ordering a large teaspoonful of the tinc- ture of lobelia to be taken upon the first approach of the paroxysm, and continued every ten minutes until nausea was occasioned. With the nausea the paroxysm immediately subsided. A great variety of other remedies have been employed with more or less advantage in asthma. The prussic acid was successfully 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 combination in cases of this kind—more espe- cially after the operation of a gentle emetic. The use of laxatives, with some absorbent, will, in general, afford some advantage in habitual cases, attended with dyspeptic symptoms, and torpor of the 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 ex- hibition of this remedy during the paroxysm, except under circum- stances especially indicating 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 galvanic 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 parox- ysms, recourse must be had to tonics, a regulated diet, a change of air or climate, and regular exercise ; and the usual exciting causes of the disease 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 func- tions. An occasional blue pill at night, followed by a gentle aperient * Med. Chir. Rev., January, 1828, p. 221. 218 WHOOPING-COUGH. 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 occupation of the mind, a light and simple diet, and the careful avoidance 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 disease is attended with a rheumatic or gouty diathesis, colchicum, diuretics and opium are especially indicated. When it succeeds the healing up of an old discharging ulcer, blisters and sinapisms to the part are proper. An- dral succeeded in curing a violent case by means of this kind. Here diuretics, also, are generally peculiarly beneficial. Where catarrhal irritation has excited the disease, 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, and regular exercise, are particularly proper. "Among the remedies best deserving notice in asthma," says Laennec, " I 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 ex- ternal applications."t Sect. II.— Whooping-Cough. This is unquestionably one of the most remarkable diseases with which we are acquainted. A cough, which is highly contagious in its nature—which has its regular rise, progress and declension—and which completely destroys the susceptibility ofthe system to a subse- quent or second invasion of the disease, is a phenomenon truly mys- terious and striking. It is maintained by some writers, that whooping-cough is compa- ratively 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 * [It is astonishing to witness the effects of a change of air in many cases. One of my patients could never sleep out of town without being seized with a paroxysm of asthma; while in the city, he was always in a great measure free from the dis- ease. One of my relatives could never visit Philadelphia without an attack. Some patients are always worse in the upper stories of a house; and one old gen- tleman was sure to be attacked if he got up as high as the third story chamber in either of our cities. Such facts should always be looked after in the selection of a suitable residence for every individual afflicted with this distressing com- plaint.—Ma] t Loc. cit., p. 419. WHOOPING-COUGH. 219 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 Apho- risms, speaks of a cough, which, from a 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 recorded; 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, headache and sneezing, with a slight hoarseness, and occasional op- pression of breathing. The sleep is generally disturbed 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 con- vulsive or spasmodic character, so far, at least, as the mere cough is concerned. The paroxysms of coughing nowcome 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 prsecordia. 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 ofthe disease, is always terminated by the discharge of a large quantity of viscid mucus; and the patient frequently experiences some pain in the chest immediately after the cough has subsided. In many cases, the cough continues until vo- miting 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 distressing sense of impending suffocation. Occasionally, the determination 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 com- pression 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, continuing commonly from two to four weeks. Fever is not essentially connected with the disease, 220 WHOOPING-COUGH. although in many instances there is a manifest febrile irritation pre- sent during some period of the complaint. Whooping-cough occurs almost exclusively during childhood. I have nevertheless met with two instances of the disease in subjects beyond the fiftieth year of age, and several in persons beyond the thirtieth and fortieth year. It is highly contagious, and occurs almost universally in an epidemic form. I have never yet met with a spo- radic case of this affection, although it cannot be doubted that such instances do occasionally occur. It would seem as if there existed some latent connection between the contagions of whooping-cough and measles; for the former frequently prevails most extensively, either immediately previous, or in alternation, or directly after the occurrence of epidemic measles.* Spring and autumn appear lo 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 atmospheric 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 sus- ceptible of it. At other times the disease manifests a violent and dangerous 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 super- added 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 patients, the more apt is the disease 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 born with a scrofulous diathesis, whooping-cough is exceedingly apt to call the strumous affection into action. Scrofu- lous ophthalmia, and glandular tumours in the neck, frequently suc- ceed whooping-cough. I know of no disease which is more to be dreaded than whooping-cough in subjects of an hereditary consump- tive habit. Where there is a predisposition to the formation of * Richter, Specielle Therapie. WHOOPING-COUGH. 221 tubercles, or where these exist in an incipient and dormant state, an attack of whooping-cough will rarely fail to develop phthisis pul- monalis. 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 atmosphere—a circumstance which always greatly aggravates the violence and danger of the disease. I have seen but few deaths from whooping- cough which were not attended with bronchitis, purulent expecto- ration, and hectic symptoms, from having taken cold. The matter expectorated in these cases has generally a very peculiar appear- ance, resembling more a mixture of cream and mucus, than any thing else I 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 are often thus protracted for five or six months. When the disease assumes a chronic character, from cold or some other casual circumstance, it sometimes ultimately ter- minates 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 occur- rence 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. CEdematous swell- ing of the feet and face is not an uncommon occurrence in this affection, and when it takes place towards the conclusion of the com- plaint, it is rarely followed by unfavourable consequences. When such swellings supervene in the commencement of the disease, how- ever, they portend much danger—more especially if they are accom- panied 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 symptoms of the disease. A sudden cessation of the cough, it has been remarked, is an unfavourable occurrence, and is frequent- ly followed by pulmonary inflammation. In general, the more fever there exists in this affection, the more violent and dangerous it may be considered. It is asserted by some writers, (Hufeland, loc. cit., p. 420; Lentin, Memorabilia, p. 36 ; Jahn, Kinderkankn., p. 399,) that children af- fected with some chronic cutaneous affection, as tinea, itch, &c, very rarely take this disease; and if they do become aflected with it, they 222 WHOOPING-COUGH. almost invariably pass through it in the lightest manner. This, how- ever, 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, epilepsy, 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 pulmonalis, and ophthalmia, appear to be the most common. When these and other consequences are taken in view—and they are by no means uncommon — we cannot but regard this disease as always one of very serious import. Whoop- ing-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 disappearance, 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. Causes.—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 suffi- cient grounds; and it seems to me just as improbable, as that small- pox or measles should arise from accidental causes. It may be said that all these diseases must have primitively originated from acci- dental causes—for the first case could not have arisen from a conta- gion generated by the disease itself. Nothing, in truth, is more mysterious and incomprehensible 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 in- stances a specific contagion. Riverius, Linnaeus, Dessault, Rosenstein, and more recently Clesius, maintain that whooping-cough is produced by the inhalation of mi- croscopic animalcula. Whooping-cough does not appear to possess a contagious character 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 af- fected person. It is accordingly almost always prevented by separat- ing the healthy from the affected portion of families. WHOOPING-COUGH. 223 Autopsic phenomena. The appearances discovered on post-mor- tem 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 complaint, 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 consequence 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 phe- nomena, where the immediate cause of death is so various, or de- pendent on such a diversity of accidental affections. As the respi- ratory 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 inflammation in the mucous membrane ofthe bronchia and larynx. Strong, Cullen, Astruc, Lettson, and Danz, mention these appear- ances 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 congest- ed, and the air-cells choked up with an extremely viscid mucus with- out any traces of bronchitis whatever. Lobenstein-Doebel relates an instance in which a considerable portion ofthe diaphragm was covered with a number of small pustules containing a purulent fluid.* After all, it is incontestable, that in many cases of death from this disease, no morbid appearances whatever were discovered on dissec- tion, and there are good grounds for believing, that the inflammation and other phenomena which have been detected on post-mortem examination, have no essential connection with the disease, but are altogether adventitious or secondary. Proximate cause.—The opinions that have been advanced con- cerning 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 ascribes it to the effects of irritating effluvia, cast off from the blood into the lungs, in conse- quence 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 mat- ters in the stomach. The opinion which appears to be most pre- * Richter's Specielle Therapie. 224 WHOOPING-COUGH. valent, at the present day is, that the disease depends on a peculiar bronchial inflammation; 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-mor- tem 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 charac- terize this disease, the advocates of this doctrine are forced to assume the position, that the inflammation in question is of a specific kind, capable of exciting the peculiar convulsive cough which distinguishes the disease. Whatever plausibility this doctrine may seem to pos- sess 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 cases 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 autopsical examination. That inflammation must frequently supervene in the trachea and bronchia in a disease in which the lungs are so violently and frequently agitated as they are in the present one, is indeed to be expected. Besides this accidiental source of pulmonary inflammation in whoop- ing-cough, there can be no doubt that the lungs are especially pre- disposed, by the same circumstance, to the injurious influence of atmospheric vicissitudes, and consequently to the supervention of pulmonary catarrh, or bronchial inflammation. From these circumstances, we have the strongest ground for be- lieving that the inflammation which is frequently detected on dissec- tion 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 inflam- mation 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 unequivocal symptoms of inflammation, and we may, therefore, reasonably 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 circumstance which is decidedly contradicted by almost universal observation. 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. The patient died suddenly of convulsions during a violent paroxysm of coughing. That in- flammation 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, WHOOPING-COUGH. 225 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 symp- toms of hectic fever. When cough depends on acute inflammation of the respiratory 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. Dur- ing 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 deve- lopment 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 cha- racter ; 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. It appears to me that whooping-cough is essentially a spasmodic or nervous affection, the proximate cause of which consists probably in a peculiar irritation of the eighth pair, or pneumogastric nerves. If we attend closely to the phenomena which immediately pre- cede and accompany a paroxysm of whooping-cough, we cannot but perceive unequivocal manifestations of a purely spasmodic condition of the respiratory apparatus. The sense of stricture in the breast and ofthe glottis, which is felt immediately before the fit of coughing —the sudden and convulsive character of the cough—the peculiar constrictive feeling in the prsecordia—the stridulous respiration, all point to a spasmodic state of the pulmonary system. That the irri- tation which calls forth the convulsive 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 interest- ing experiments 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 invariably excited. By injuring in the same manner the diaphragmatic nerve, no such effect ensued. According to these experiments, the act of coughing is per- formed almost wholly by the sudden spasmodic contraction of the diaphragm. By opening the abdomens of various animals, and ex- posing the lower surface of this muscle, he saw distinctly its violent vol. n.—16 226 WHOOPING-COUGH. convulsive contractions during the cough, which was excited by bruising, with a pair of forceps, the pneumogastric 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 recur- rent 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 uncontrollable in its progress, and that no treatment is capable of materially short- ening its course. This, I am persuaded, is an unfounded opinion. Sydenham, Werlholf, Hufeland, and several later German, Italian, and French writers, admit that it may be arrested 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 expe- rience does not permit me to doubt of its susceptibility of being cur- tailed in its progress; and many well-authenticated observations in confirmation of this fact, might be collected from recent publications. Although inflammation and fever do not constitute essential con- ditions of this disease, yet blood-letting may often be employed 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 disease, 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 con- gestions during the paroxysms of coughing, as well as to diminish the liability to the accidental supervention of inflammation. In cases attended with bronchial or pneumonic inflammation, bleeding is obviously indispensable; 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 espe- cially 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 par- ticipate, 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 princi- pally located, the alimentary canal, sooner or later, suffers functional disturbance, giving rise either to a remora of its recrementitious con- tents, or to a vitiated secretion of the fluids which are poured into WHOOPING-COUGH. 227 it. These latter consequences become in their turn sources of intes- tinal irritation, and I need not say how great a tendency such irrita- tion has to aggravate and sustain diseases, whatever may be their original source or character. The bowels are almost always in an unnatural condition in whoop- ing-cough. The evacuations are sometimes bilious, or almost wholly mucous; and, in many instances, dark and exceedingly 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 purging, however, is improper, as it tends to increase, rather than to moderate the intestinal irritation when frequently repeated. A grain or two of calomel in the evening, with a small dose of rhubarb on the following morning, will in gene- ral answer very well for this purpose. When there is considerable febrile irritation present, small doses ofthe sulphates of soda or mag- nesia may be preferable. Emetics constitute an important class of remedies in the majority of pulmonary diseases. They are especially indicated in those affec- tions of the respiratory organs in which there is an abundant secre- tion 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 bron- chia ; 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 pneumogastric nerves in the stomach. They are particularly useful in the whooping-coughs of infants; these are unable to throw off the viscid mucus that clogs the respiratory passages; and instances of death by suffocation 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 observed, that the very frequent repetition of emetics, more especially anti- mony, is apt to bring on much weakness and irritation of the sto- mach, 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. Fothergill speaks very highly ofthe following combination as an emetic in this affection: R.—Pulv. chel. cancror. jjss. Tart, antimon. gr. ii. Misce. Of this 1, H, 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. 228 WHOOPING-COUGH. The syrup of squills also forms an excellent emetic in very young patients. I have frequently prescribed this preparation, in union with a small portion of antimonial wine, with a very good effect. We may also prescribe the antimonal wine in union with an emulsion of * assafetida, with much advantage as a palliative. 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 disease 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 appeared to be beyond the hope of recovery, restored by this remedy. The observations of Hufeland and Alibert, not to add the testimony of many other writers, speak in terms nearly equally favourable, of the virtues of this narcotic in the present disease. A large mass of evidence might be adduced from the current medical publications, illustrative of the valuable powers of the belladonna 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 instances 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, is the means upon which our reliance must be almost entirely placed. In the purely spasmodic form ofthe disease, however, and where all symp- toms of inflammation are absent, it is often singularly eflicacious.t The extract of conium, lactuca viroso, hyoscyamus and opium, have also been favourably mentioned as palliatives in this disease. Dr. Butler states that he has frequently used the following mixture with marked benefit.! Opium is objectionable, both on account of its constipating effect, and its tendency to determine the blood to the * The dose should be one drop of the tincture for every year of the child's age, three times daily. When the narcotic effect is obtained, cease the remedy, and resume when it subsides. t [Dr. Jackson, formerly of Northumberland, once published some excellent observations upon the influence of belladonna in curing whooping-cough. He found the remedy very efficacious hi this disease.—Ma] X R.—Extract, conii gr. iii. Magnes. sulphat. J)i. Aq. carui JJv. Syrup, rhaed. 31.—M. Take thirty drops three times daily. WHOOPING-COUGH. 229 bTain. Some writers recommend the tincture of cantharides* Dr. Sutcliff asserts, that when given to the extent of producing strangury, it will sometimes, in a great measure, remove the disease in four or five days. This practice has also been pursued with success by Hufe- land ; and Lettson speaks very favourably of it. Sutcliff used it accord- tin 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 assa- fetida will occasionally palliate the symptoms in cases unattended with fever or strong pulmonary irritation. This article answers the double purpose of an expectorant and an antispasmodic. I have, in a few instances, known material relief obtained from a mixture ofthe vinegar of squills, and an emulsion of assafetida. Expectorants also will occasionally mitigate the violence of the symptoms. Dr. Pearson strongly recommends the following mix- ture, and I have myself known it to give considerable temporary relief. $ 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—continuing long after the usual period of its termination; and these cases are frequently con- nected 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 pulmonalis. In such cases strong doses of cin- chona, or quinine, are often peculiarly serviceable. This tonic may also be very beneficially used in cases of a purely spasmodic charac- ter, 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 inadmissible in cases attended with febrile irritation or bronchial inflammation. Dr. Ferriar placed much reliance on this remedy in cases free from fever. He asserts that, according to his own experience," arsenic is the only * Armstrong, Chambers, Millar, Buchholtz, Loder and others, speak much in favour of this remedy in whooping-cough. t R.—Tinct. Peruv. spirit, 31. Tinct. opii camphor, ^ii. Tinct. cantharid. B ii. Two drachms of this mixture are lobe taken thrice daily. X R-—Aq. fontanse ^i. Syrup. 3iii. Subcarbonat. sodae gr. xxv. Vin. ipecac, gi. Tinct. opii gr. vi.—M. The sixth part, every four or five hours, is the proper dose for a child between one and two years old. 230 WHOOPING-COUGH. remedy which promises to shorten the disorder 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 advantage, that I think it deserving of further trials." I formerly employed 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 solu- tion, 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 gene- rally 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 valu- able 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 precordial region, will, in many cases, make a powerful impression on the disease. This practice originated with Autenreith, and has been much employed by the German physicians. Dr. Meyer has removed all the symptoms of whooping-cough, in a few days, by the application of morphium to the external surface. He applies a small epispastic to the epigastric region, and after removing the epi- dermis, he applies to the denuded surface half a grain of morphium, triturated with a small portion of starch. The application is to be renewed every evening. An occasional emetic should also be admi- nistered, particularly in infants, in order to free the bronchise from the viscid mucus, t When the disease is complicated with pneumonic affections, blisters and rubefacients, in conjunction with venesection, 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 valu- able remedy. I have, in a few cases of this kind, prescribed this article with the most decided benefit; and I know, indeed, no other * R.—Antimon. tart. 9ii. Tinct. cantharid. %i. Aq. rosar. gii.—M. The tartar emetic is to be dissolved in the rose water, and then the tincture of cantharides added to it. t Archives Generaies, Oct., 1829. ASPHYXIA. 231 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 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 scam- mony in the latter stages of whooping-cough, attended with symp- toms of marasmus. Change of air, and exercise by gestation, generally have an excel- lent 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 remov- ing the patient into the country, and the free use of a milk diet. In cases attended with bronchial inflammation, this measure is inadmis- sible, as it rarely fails to aggravate the symptoms immediately. The diet should be light and digestible, and it is particularly im- portant to guard the patient against the influence of a cold, variable, and damp atmosphere. Sect. III.—Asphyxia.—Suspended Animation. The term asphyxia is here used to designate two varieties of sus- pended 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 incapable of con- verting 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.* Asphyxia from drowning.—When a person who has been sub- mersed 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, the epigastrium is tense and tumid. Considerable controversy has existed concerning the mode in which drowning causes death. Many have contended that suffocation is produced by the water rushing into, and filling up the cavity of the lungs. Haller, P. Frank,t Louis and Portal J mention cases in which * Good's Study of Medicine, vol iii, p. 367. t System ein. Vollstandiger Med. Polizei, vol. i, p. 186. X Instruction sur le Traitement des Asphyxies, 232 ASPHYXIA. 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 admission into the lungs. Tissot,* Goodwin,t Kite,:): Roesler§, and many other later writers, have published nu- merous observations in illustration of this fact; and it is now, I believe, universally admitted, that so long as the larynx retains any degree of irritability, 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 sen- sibility of the respiratory passages, that the moment water or any other substance not in harmonious relation with them conies in con- tact with the mucous membrane ofthe lamyx,the glottis is instantly thrown into a state of spasmodic constriction, which wholly prevents the ingress ofthe irritating fluid into the trachea. When the sensibility and contractibility of these parts are extinguished, however, the water may gain admission 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 drowning destroys life by apoplexy— that the functions of the brain are at once destroyed by strong vas- cular congestion and extravasation. Portal,|| who entertained this opinion, states that he found the vessels of the brain, as well as the right auricle and ventricle ofthe heart, jugulars, and descending cava, exceedingly turgid with blood in subjects that had died by drowning. This opinion is also advocated by Littre, Kite, Walter,1f and Boer- haave. 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. Champreax and Faissole assert, that they found no marks whatever of unusual sanguineous congestion in the brains of persons who had died by submersion.** Schragett and KuehnJJ state that they even found the vessels of the brain atmost entirely empty. Fothergill, in a number of experiments made on animals with a view of illustrating this subject, fully confirms these observations ;§§ and * Avis au Peuple, p. 426. t On the Connection of Life with Respiration, &c, p. 14. X An Essay on the Recovery from apparent Death. $ Diss. Inaug., &c. See Ed. Med. and Surg. Journ., No. lxxxii. 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 Effets des Vapeurs Mephitiques. Tf De Morbis Peritonei et Apoplexia. ** Erfahr u. Warneh iiber d. Ursach d. Todes bei Ertruuk. Dantzig, 1772—as quoted by Richter. ft Diss, de Submersis, 179.—Richter, Sp. Therap. XX Diss, de Causa Mortis Submersorum.—Richter, Sp. Ther. H A New Inquiry into the Suspension of Vital Actions, &c. ASPHYXIA. 233 Dr. Currie states that in every instance he examined, he found the vessels of the brain entirely free from distension. In nearly all in- stances, 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 ofthe mode in which death is brought on by submersion, and other analogous causes of asphyxia. When respiration is interrupted, the blood ceases to undergo the necessary chemical changes in the lungs; and black or venous, instead of florid and arterial blood, is imme- diately 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, therefore, one of the first effects of interrupted respiration towards the destruction of vitality, is a cessation of cere- bral action for want of red or arterial blood to excite the brain. The direct and instantaneous consequence of this cessation of cerebral action, is cessation ofthe 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, strangula- tion, or the inhalation of mephitic gases, commences therefore in the brain, and those vital actions that are immediately dependent on the exercise of its functions—namely, sensation, voluntary motion, thought, and the mechanical effort of respiration, 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 suffi- cient vitality remaining to afford a chance of being resuscitated by proper restorative measures. Mr. Brodie thinks it extremely im- probable that resuscitation can be effected after the heart has ceased to act; and this, he supposes, always occurs within a few minutes after the cessation of the respiratory function. Dr. Paris, and other late writers, have expressed the same sentiments on this point. Un- less, 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 are 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 submersion."t Dr. Roesler asserts, that he succeeded in resuscitating two rabbits, one after b\, and the other after 9\ minutes submersion; and a cat after having been submersed \\\ minutes. He observes, * Bichat on Life and Death, p. 136. t Gregory's Practice, second American edition, p. 247. 234 ASPHYXIA. however, that he "several times failed when the animals were taken out of the water instantly after they seemed to have expired," Ex- periments on inferior animals cannot, however, furnish us with any certain data with regard to the human subject. We learn, neverthe- less, from these experiments, that very considerable diversity occurs as to the time that animals may remain under water and still retain sufficient vitality to render resuscitation possible. We see it vary in the same species of animals, and in experiments conducted under pre- cisely 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 scep- ticism on this point to carry us so far as to reject, positively, the testi- mony upon which they are made. That such instances of recovery are, however, extremely rare, is sufficiently evident from the fact that the possibility of resuscitation after such protracted periods of submer- sion, is now very generally doubted. Various circumstances may contribute to hasten or retard the com- plete 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, that some diversity may exist in different indi- viduals 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, venae cavse, right auricle and ventricle of the heart, pulmo- nary 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 of 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 drown- ing, or whether they have been thrown into the water after they had been deprived of life. M. Orfila has paid particular 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 observations, more or less water always enters into the stomach when death occurs by drowning, but never when the ASPHYXIA. 235 dead body is thrown into water. The result, therefore, of his inqui- ries 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 ; provided that it has not been injected into the stomach after death, and that the water in the lungs is found in the ultimate ramifications ofthe brochia; and provided, also, that the body was not found in the vertical position. The pressure of a frothy fluid in the air-passages, he says, is only to be regarded as a presumptive evidence of submersion during life, and this is strengthened 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 still be deemed proper to make attempts to effect resuscitation, he should be immediately well dried, wrapped in blankets, and conveyed to a place convenient for the necessary applications. The principal object to be aimed at, is a restoration ofthe action ofthe lungs, at the same time that warmth is gradually communicated to the body. 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'Eti- olles 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 struc- ture of the air-cells and cellular texture ofthe lungs, and thus destroy all possibility of restoring the pulmonary functions; for it appears from experiments performed by the same gentleman on dead human subjects, that the pulmonary tissue may be readily ruptured by forcible inflation.t In endeavouring to restore the action of the lungs, the air should therefore be but moderately forced into the trachea—alternat- ing 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 practised on inferior animals in a state of * Revue Medicale, torn, xiii, p. 347. t Rapport sur un Memoire de M. Leroy d'Etio'.les, relatif a l'lnsufHation du Poumon, &c.—Revua Medicale, vol. xiii, p. 328. 236 ASPHYXIA. asphyxia, with complete success, after more than five minutes of sub- mersion. The galvanic 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 dia- phragm resumes its former position, and expiration takes place. The practice of compressing the chest and abdominal parietes in alterna- tion 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 contracti- bility of the diaphragm is excited. At the same time that the efforts to carry on artificial respiration 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 be taken, however, that the warmth be communicated in a gradual manner, for the sud- den application of a'high degree of heat could not fail to do irrepara- ble injury, by destroying the small degree of remaining excitability of the organization. Frictions with dry flannel or stimulating sub- stances, 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 infu- sion 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 generation. He asserts that he has known the most excellent effects produced 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 ether modes of exciting the vital powers have been recom- mended; such as exposing the eyes to the direct rays of the sun; applying volatile and stimulating fluids to the Schneiderian 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 sub- mersion ; 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 procured, by its tendency to relieve the oppressive venous congestions of the lungs. In general, however, no blood can be obtained by opening a vein, ASPHYXIA. 237 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 that 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 about the lips; succeeded by feeble, irregular and convulsive efforts to breathe; spasmodic tremor and agitation of the extremities; a small and weak pulse, beating at very long intervals; and a dis- charge of frothy fluid from the mouth. By degrees, 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 con- sciousness 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 neglected, and in four or five hours he sunk and expired. Warm wine, or weak brandy toddy with warm aromatic ptisans, as infusions 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 preclude all reasonable hopes of ultimate success, should not be too readily aban- doned. 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 com- mencement 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 elapsed 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, 238 ASPHYXIA. which, though less remarkable, perhaps, 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 abo- lishing, at once, all the sensibility and irritability of the nervous sys- tem. When mixed with a portion of atmospheric air, its sedative effects on the brain are less vehement and sudden; 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 inhal- ing 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 destruction of the vital powers, from the gas being more or less mixed with atmospheric air, the face exhibits a tumid and livid appearance, 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 cavae, 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 vein are commonly charged with a considerable portion of bloody serum, and the cellular struc- ture 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 epiglottis is generally erect, and the glottis pa- tulous.* Carbonic acid gas produces its fatal effects on the animal economy both by excluding the requisite portion of oxygen or respirable 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.| These facts show conclusively that in addition to the mere exclusion of respirable air, there is also * 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. t Carminati. De Animalium ex mephitibus, et noxiis halitibus interitu ejue- que Causae, p. 89. ASPHYXIA. 239 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 powerful sedative poison. There are several other gaseous substances, which, when inhaled in a concentrated form, produce immediate asphyxia or death. The fumes of sulphur, sulphuretted hydrogenous gas, nitrous gas, azote, hydrogene, and certain gaseous poisons, generated by putrefying animal and vegetable substances, destroy life with more or less ra- pidity. Of these gases, azote, and pure hydrogen, appear to destroy life simply by their not being respirable, or by preventing the che- mical 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 remaining, the patient may be generally soon recovered by conveying him imme- diately into the open air, supporting him in a sitting posture, dash- ing a little cold water upon his face and breast, applying dry fric- tions 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 manage- ment. 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 dipped in cold water ap- plied 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 respiratory effort is excited. In an instance to which I was called about a year ago, I found the patient without the slightest indications 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 continuing 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 return- ing life. Frictions with the flesh-brush, or with stimulating embrocations, are important auxiliaries in re-exciting animation in cases of this kind. We may also derive advantage from volatile stimulating 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, parti- cularly a solution of the carbonate of ammonia in a mucilaginous fluid. Richter speaks favourably of the injection of cold water and vinegar for this purpose. If the act of respiration be not soon ex- cited by the cold affusions, artificial inflation of the lungs must be * Bichat on Life and Death, p. 242. 240 ASPHYXIA. resorted to, in the way mentioned above. Upon these two means we must chiefly rely in our efforts to effect resuscitation. When the respiration is partially established, but continues very laborious, and with a rattling noise in the bronchia, considerable benefit will some- times result from the abstraction of from eight to ten ounces of blood fronrthe 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 stimu- lating beverage allowed. Galvanism has been employed, and, in some instances, with mani- fest advantage, in asphyxia from mephitic gases. The galvanic 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 im- mediately over the par vagum in the neck, just below the sterno- mastoid muscle. After the vital actions have been re-established, the arterial ex- citement, 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 indispensable, 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 excite the vital powers too much—which may readily be done—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 sud- denly 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 breasts 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. Sometimes blood is discharged from the ears, and suggilations of large extent are fre- quently found on the trunk and extremities. Internally, 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 vascular 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 powers, 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 ofthe muscles ofthe eye- ASPHYXIA. 241 lids, mouth, and throat, sometimes occur. Persons who are recov- ered from a state of asphyxia caused by lightning, generally suffer for a long time afterwards with tremors, painful sensation, swellings, and some degree of numbness in the extremities, 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 ener- gies in cases of this kind. Cold water should be copiously 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 animals in a state of as- phyxia 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 second shock affected a resus- citation.! M. Abilgaard also has related some instances of asphyxia from this cause, in inferior animals, in which resuscitation was effect- ed by a second shock of electricity4 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 44, ofthe first volume of this work. Instances of resuscitation from asphyxia, caused by intense cold, are by no means uncommon; and cases are related in which reani- mation was effected many hours, or even several days, after 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 communicated, it will inevi- tably 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 * Rettungsmittel in plotz. unfallen., p. 63. t Vorlesungen iiber. d. Rettungsmittel beim Scheintode, p. 121; as quoted by Richter, Spec. Therap., vol. viii, p. 647. X Loc. Med. Havnien. Collectan., &c, t. ii.—Good. $ Kruinilz. Oekonom. Encyclopa-dia, Th. xv, p. 261. Richter, Sp. Ther. VOL. II.—17 242 PNEUMOTHORAX. 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 care- fully dried with soft pieces of flannel, wrapped in blankets, and con- veyed 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 succeed in restoring symptoms of life, the temperature of the room should be very gradually increased, and bottles filled with lukewarm 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.—Pneumothorax. The collection of aeriform fluids in the cavity of the pleura, is termed pneumothorax. This is no very uncommon occurrence, and is always attended with the most distressing effects on the actiqn of the lungs and heart. In most cases the confined air is fetid, re- sembling 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 matter is effused into the cavity of the chest. When such a communication 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 always be very slow, and often wholly impossible from the valvular form of the opening, it accumulates with more or less rapidity, until the lungs are so greatly compressed as to render respiration 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 com- pletely 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, usually 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 pneumothorax experience great pectoral 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 a 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 pneumothorax occurs in the left side of the chest, the palpitation of the heart is usually felt in the right PNEUMOTHORAX. 243 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 respira- tory murmur distinctly in the least sonorous side, and not at all in the other, we may be assured that there exists pneumothorax 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 accu- mulate, the resonance of the chest returns in some degree, in the situ- ation occupied by the air, without, however, being as distinct as in the sound side. Day after day, the extent and intensity of this reson- ance increase ivithout any return of the sound of respiration: 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 auscultation and percus- sion, 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 peculiar 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 indi- cates the existence both of air and a puriform matter in the cavity of the pleura, with a fistulous opening between the cavity of the chest and the bronchia. This metallic sound, says Laennec, "exists only in that variety of pneumothorax which is complicated with empyema; and may be considered as a pathognomonic sign of this combination in conjunction with a fistulous opening into the bronchia." The metallic tinkling of pneumothorax 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 pneumothorax in examining by percussion and auscultation; particularly by those who are not accustomed to this mode of exploration. M. Laennec points out the following difference in the results obtained by the employ- ment of these diagnostic means in these two affections. " In pneumo- thorax, the respiratory murmur is wholly absent, except at the point between the scapula and spine, corresponding to the roots of the lungs. In emphysema, the respiratory sound is never completely 244 PNEUMOTHORAX. inaudible, and there is a slight rattle which never occurs in the former complaint. Pneumothorax 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 occupation." 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-mem- branous 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, irregular, 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 ofthe pleura and the bronchia. Causes.—Pneumothorax frequently occurs in consequence of tuber- culous excavation near the surface of the lungs, and the formation of a fistulous opening into the bronchia. Chronic 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 character of complete pneumothorax. 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. Pneumothorax 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 ofthe 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 pro- longation of life. It would seem, nevertheless, that spontaneous cures of this affection have taken place. Such a favourable termina- tion is, however, an extremely rare occurrence, and is supposed to take place in the following manner. The lung being strongly com- pressed by the air that rushes into the cavity of the pleura, through the aperture made into the bronchia, gradually collapses, if no adhe- sions exist, until it remains quiescent. In this state of collapse and PNEUMOTHORAX. 245 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 ofthe lesion or primary affection, upon which the pneumothorax 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 blistering, 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 softening, 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 punc- turing the thorax for the purpose of giving exit to the confined 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 in which he performed this operation, terminated fatally in a few hours after the puncture was made. The opening was made between the fifth and sixth ribs, and very little air, and no purulent matter escaped from the incision. This appears to have been a case of empyema conjoined with pneu- mothorax, for when after the death of the patient, an incision was made about the middle ofthe 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 pneumothorax. Riolan states that he has seen several instances of the successful operation of para- centesis on patients who were supposed to labour under dropsy, with- out anything having been evacuated from the chest but air. (Laennec.) These, doubtless, were cases of simple pneumothorax, and may be regarded as encouraging examples of the usefulness of this operation in the present affection, when uncombined with empyema. "Pneumothorax," says Laennec, "complicated with liquid effu- sion, and still more, with pulmonary fistula, is a case of a most serious nature, and leaves little hopes of a cure being effected. This, how- ever, must not be regarded as quite impossible even in the severest cases. I formerly proved the possibility of the cicatrization of tuber- culous excavations; and the observations of Bacqua, Jaymes, and Robin, (Journ. Ghi. de M'ed., 1S13,) 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 suc- cess." That the operation in question is a proper one, in perhaps every variety of pneumothorax, 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 246 PNEUMOTHORAX. 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 recorded of its having been performed in pneumothorax. There is a highly interesting case reported in the Medico-ChirugicalReview, (January, 1829,) in which the chest was punctured; but although great relief was the immediate consequence of the evacuation of the air, the patient in a few days sunk under the disease.* A case of pneumothorax is related by Dr. Davy, in which this operation was performed with entire success. The patient was af- fected 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 Chat- ham, he was one morning seized with a violent fit of coughing, and symptoms of pneumothorax immediately succeeded. 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 prevented by adhesions of the pleura at the point were 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 pre- ceding case, says Dr. Johnson, are the only instances in which this operation was performed for pneumothorax in England. * 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 instantaneous. The patient turned on his back, and breathed with comparative freedom." On the fourth day after the operation, the patient was found to be sink- ing, and. after a strong paroxysm of convulsions, expired on the afternoon of this 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 excavation. The right lung was much more tuberculous than the left; but the tubercles were in a quiescent state. Med. Chir. Rev., Jan., 1S29, p. 482. DISEASES OF THE HEART. 247 CHAPTER V. CHRONIC DISEASES OF 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 heart. The researches of Corvisart,* Kreysig,t Testa,J Laennec,§ Burns,|| and Abercrombie,! have thrown great light on this important class of dis- eases, and it is from these sources chiefly that the following observa- tions 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 ofthe lungs. Mental agitation, or corpo- real exertions, 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 breath- ing, attended with great weight and constriction in the breast, inex- pressible anxiety, a turgid and usually livid hue of the face, particu- larly of the lips, which are swollen and purple; distension of the veins in the neck and head, and an expression of extreme distress and suffering in the countenance. These paroxysms of dyspnoea often * Essai sur les Maladies et les Lesions Organiques du Cceur. t Die Krankheiten des Herzens. Berlin, 1814-17. X Delle Malattie del Cuore. § Treatise on the Diseases of the Chest; translated by J. Forbes, M. D.: 3d edition. II Observations on some of the most frequent Diseases of the Heart. By Allan Burns, 1809. IT Contributions to the pathology of the heart. Transact. Med. Chirurg. Society ofEdinb., vol. i, 1824. ** [The late Dr. Hope, of London, published at a later date an excellent work on this subject.—Ma] 248 DISEASES OF THE HEART. last but a few minutes, and rarely continue 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, (though rarely with any degree of ease on the right side,) but the sleep is much disturbed by alarming dreams, fre- quent startings, and spells of palpitation—obliging the patient sud- denly 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 symptoms of cardiac diseases is irregular action of the heart. Sometimes the heart beats tumultuously and indistinctly, which has been compared to the bubbling of boiling water; and at others it seems to be in a state of tremulous agitation. More commonly, however, it beats vehemently against the side of the thorax, so as to enable a person distinctly to hear its throbs, and to communicate a motion to the whole superior part of the body. Syncope, too, is no uncommon occurrence in diseases of this kind. The patient is liable to occasional attacks of partial fainting, often of long continuance, during which he experiences a feeling of great oppression and constriction in the region ofthe heart, a partial loss of consciousness and sensorial power, inexpressible anxiety in the prsecordia, with an extremely feeble and fluttering or intermitting pulse, and scarcely any perceptible respira- tion. From this state of adynamia, he sometimes passes suddenly into deep syncope, approaching the character of asphyxia, and after a short period, again suddenly recovers his entire consciousness.* In some cases, paroxysms of angina pectoris occasionally super- vene; and instances occur in which the cardiac disease gives rise to convulsions and apoplexy.t The habitual aspect of the countenance, during the intervals of the exacerbations of the dyspnoea, is usually pale and cachectic, with a leaden lividity of the prolabia, and puffy swelling under the eye. QSdema of the feet and legs is usually one of the earliest symptoms of organic affections of the heart. In the progress of the disease, oedema gradually extends higher, and often invades the scrotum, labia, and even the trunk. In some instances, the pulse differs but very little from its natural state, except during the occasional paroxysms of the dyspnoea and palpitation; but more frequently it is irregular, intermitting, and often has a peculiar jarring beat, or is sharp, exceedingly firm, and incompressible. Organic diseases of the heart are very generally attended with a peculiarly irritable temper, and a disposition to melancholy and hypochondria- sis.:!: Symptoms of indigestion, too, are very apt to occur in diseases of this kind; and in many instances there exists a strong tendency to hemorrhage, particularly from the lungs and the nose. Patients * Kreysig, loc. cit., b. i, p. 332. f Dr. Forbes. Edition of Laennec on the Diseases of the Chest X Testa, loc. cit. DISEASES OF THE HEART. 249 labouring under cardiac affections are liable to sudden and severe pains in different parts of the body. Dr. Adams has given the history of a very remarkable case, in which no pulse was to be felt in any artery of the body for six weeks ; neither were the movements of the heart perceptible by the hand applied to the chest; but an obscure, undulating motion could be heard by applying the ear to the region of the heart. On dis- section, the heart was found large and flabby ; the semilunar valves of the aorta were completely ossified; and the coronary arteries " were so completely converted into bone as to be quite solid, hav- ing no perceptible cavity except at the distance of an inch from their origin."* Dissection shows that cardiac diseases have a particular tendency to produce great engorgement of the capillary vessels, and it is to this circumstance, no doubt, that we have to ascribe the dropsical effusions into the cellular structure of the cavity of the chest, so common in these affections. In almost all those who die of organic disease ofthe heart, the mucous membrane of the alimentary canal exhibits a deep red, or violet colour, and, in most instances, " the liver and capillaries situated beneath the serous, mucous, and cuta- neous tissues, are strongly gorged with blood.t A very vivid red- ness of the internal surface of the heart and large vessels is also a very common phenomenon in subjects who have died of such affections, and this is particularly noticed where the affection con- sists in a morbid dilatation of the ventricles of the heart. Causes.—The etiology of the diseases of the heart is enveloped in much obscurity. There exists, no doubt, a natural predisposition in some individuals to affections of this kind; but our notions con- cerning the nature of this predisposition amount only to some plausible conjectures. An inordinate irritability of the heart and arteries has been mentioned as a circumstance predisposing to car- diac affections; and an original defect in the muscular energies of the heart, as well as a disproportion between the activity of this organ and the blood-vessels, may also, occasionally, be the foundation of such diseases. It is said, that the predisposition to organic affec- tions of the heart is in some instances manifestly hereditary, and its occasional prevalence in certain families renders this opinion very probable. Dr. Forbes refers to Lancisi, Albertini, Morgagni, Portal, Corvisart, and Testa, for striking examples of this kind; and a re- markable instance is related in the eleventh volume of the Medical Commentaries. A strumous habit is considered by Testa as a strong predisposing cause of organic affections of the heart; and Dr. Forbes says, that his own experience has led him to the same conclusion. " In this case," he observes, " I have thought that the disease is developed at a more early period than under other cir- cumstances. Perhaps in this case an original disproportion of the * Cases of Diseases of the Heart, &c. By Robert Adams, M. B., &c. &c. Dublin Hospital Reports. t Laennec, loc. cit., p. 592. 250 DISEASES OF THE HEART. parts usually exists." The remote causes of the diseases of the heart appear to be numerous, and very diverse in their characters. The following have been mentioned as the most common and powerful. 1. Moral Causes.—Corvisart, Kreysig, and others, assert that mental emotions are among the most frequent and powerful causes of structural diseases of the heart; and from the well-known influ- ence of violent affections of the mind on this organ, there can be no doubt, indeed, of their tendency, when frequently repeated, or of protracted duration, to give rise to such diseases. Dr. Forbes states, that he attended a poor woman " affected with organic disease of the heart, of many months' standing, which was suddenly produced by horror at seeing her infant scalded to death."* Instances have occurred, in which sudden terror, anger, or excessive joy, has deter- mined the blood so vehemently to the heart as to cause immediate rupture of its ventricles.t 2. Gout and rheumatism.—Organic diseases of the heart are probably more frequently occasioned by metastasis of gout or rheu- matism, than by any other cause. Sauvages mentions instances of cardiac affections, alternating with paroxysms of gout;| and Dr. Scudamore has related a remarkable case of palpitation of the heart of three years standing, which suddenly disappeared on the super- vention of an attack of articular gout.§ Rheumatism, however, appears to be still more frequently concerned in the production of cardiac affections. Dr. Cox has adduced some interesting examples of the dependence of the diseases of the heart on metastasis of rheu- matism. Numerous cases of organic diseases of the heart and peri- cardium, which he met with during his connection with Guy's Hos- pital, were referable to, or connected with rheumatism.|| Dr. Cox states, moreover, that his observations have led him to believe, that "the majority of cases of organic diseases of the heart in young people," are connected with rheumatism. Dr. James Johnson also observes, that " long and attentive observation" has convinced him, " that a very considerable proportion of those active enlargements or hypertrophiae of the heart which are now so frequently met with in practice, are dependent on rheumatism." Dr. David Dundas,1T and Dr. Hawkins** also, have published observations illustrative of the rheumatic origin of organic cardiac diseases; and Dr. Forbes has related several interesting instances of this kind.tt * Laennec on the Diseases ofthe Chest, third edition. t Richter, Specielle Therapie, b. v, p. 129. X Nosologia Method., torn, i, p. 518. $ A Treatise on Gout and Rheumatism, fourth edition, p. 44. II Observations on Acute Rheumatism and its Metastasis to the Heart, by Thos. Cox, M. D., Lond., 1824. H Med. Chir. Transact., vol. i. ** Rheumatism and some Diseases ofthe Heart. Lond., 1826. tt Original Cases, &c, p. 112, and p. 165. See also a note at p. 597 of his Trans- lation of Laennec on the Chest, fourth edition. DISEASES OF THE HEART. 251 3. Cutaneous diseases.—The repulsion of chronic cutaneous erup- tions may give rise to organic diseases of the heart. Kreysig says, that when cardiac affections arise from causes of this kind, the disease is apt to occur in the external or internal -membranes of the heart; and according to the observations of Testa, the most common struc- tural lesions resulting from repelled cutaneous affections, are thicken- ing and induration of the pericardium. Osiander mentions ulcerations of the external surface of the heart and of the pericardium ;* and Mekel has related a similar instance of disorganization of these parts, apparently the consequence of repelled cutaneous eruptions. Cardiac affections have also been known to result from the suppression of habitual perspiration ofthe feet, and from the healing up of old ulcers and issues. (Richter.) 4. Syphilis is also mentioned as no uncommon cause of diseases of the heart. Corvisart was of opinion that the excrescences which are sometimes found on the valves, usually depend on a syphilitic taint, and Lieutaud particularly refers to this disease as a cause of various structural disorders ofthe heart, t Mr. Bertin, however, thinks, that the influence of this cause, in relation to cardiac diseases, has been much overrated; an opinion which he was led to adopt after an experience of twenty years in the venereal hospital. Laennec also rejects the opinion of Corvisart with regard to the syphilitic origin of the excrescences on the valves. 5. Diseases of other organs, particularly such as are attended with long-continued and severe dyspnoea, are especially apt to give rise to hypertrophy or dilatation of the heart, through the constant efforts this organ is called on to perform, in order to propel the blood into the lungs, against the resistance opposed to it by the cause of the dyspnoea." Chronic pulmonary catarrh, phthisis pulmonalis, chronic peripneumony, empyema, and emphysema of the lungs, frequently give rise to these cardiac affections, and almost necessarily, where there exists a congenital disproportion between the size of the heart and the diameter of the aorta. (Laennec.) Chronic diseases seated in the abdomen, are also mentioned among the occasional causes of organic affections of the heart. Testa thinks, that induration and enlargement of the liver may give rise to diseases of this kind, but Corvisart, more correctly I think, regards the hepatic affection as the consequence, rather than the cause, of disease of the heart. " More probably," says Forbes, " it may be merely a concomitant, and the consequence of those chronic disorders of the stomach and upper bowels which are too frequent in all classes of people to be safely admitted as either a common cause or effect of affections of the heart." It is supposed that visceral enlargements within the abdomen tend to produce cardiac diseases by compressing the large vessels, and by impeding the circulation through the affected viscus, in consequence of which greater efforts of the heart are made to oppose these causes of obstruction. * Denkwiirtigkeiten, &c, Th. i, p. 146, as quoted by Richter. t Hist. Anatom. Med., torn, ii, ob. 510-516.—Sprengle. 252 DISEASES OF THE HEART. 6. Scurvy has also been supposed to be capable of giving rise to structural disease of the heart, more especially to a morbid softness and flabby state of its structure. 7. Congenital, disproportion of the different parts of the heart, and particularly between the left ventricle and the aorta, is no doubt at the bottom of the majority of the instances of hypertrophy and morbid dilatation. Where such a condition of the central organs of the cir- culation exists, everything which is capable of causing a long-con- tinued preternatural momentum of the circulation, or an impediment to the free passage of the blood through the lungs, or sudden and forcible determinations to, and congestions of the heart and large vessels may readily give rise to aneurismal dilatation of this organ. Playing wind instruments, carrying heavy burdens, or straining in lifting heavy weights, running, the inhalation of suffocating vapours, protracted rigors of intermitting and other febrile diseases, intoxica- tion, mental emotions, lymphatic and other tumours pressing on the carotids or some other arterial trunk, and a great variety of other causes of a like tendency, will be apt to produce structural disease of the heart in individuals thus predisposed by a congenital conforma- tion of this organ. Blows, falls, and external injuries of the chest, may likewise give rise to organic cardiac diseases. Inflammation of the heart, too, is frequently concerned in the development of affections of this organ. Indurations, morbid softening, excrescences, pseudo-membranous for- mations, adhesions, effusions into the pericardium, ulcerations, &c, may be regarded as the immediate consequences of cardiac inflam- mation, in whatever way this latter condition may be produced. Diagnosis.—The diagnosis of the diseases of the heart is attended with much difficulty. The symptoms of organic affections of this organ are particularly liable to be confounded with simple hydrotho- rax, hydro-pericardium, neuralgic angina pectoris, and even with asthma. Laennec asserts that none of the symptoms mentioned above can at all be regarded as pathognomonic, or sufficient to indicate dis- ease of the heart, " since they are common to many other affections, and particularly to almost every chronic disease of the lungs." There is much truth in this observation; but I apprehend, nevertheless, that the uncertainty of the diagnosis, founded merely on the symp- toms, is not in general so great as might appear from the sentiments expressed by Laennec. When we find a patient complain of more or less habitual dyspnoea, greatly aggravated on corporeal exertion; slight oedema of the feet; a puffy and anxious appearance of the countenance, with a livid hue of the prolabia; frequent palpitations or tumultuous action of the heart; an inexpressible feeling of anxiety in the region of the heart during the paroxysms of dyspnoea; the occasional sudden occurrence of elastic puffy swelling of the lower eyelids and the upper lip ; an irascible and gloomy temper; quick and short inspirations; a deep purple and bloated aspect of the face during the paroxysms of dyspnoea; with an absence of the peculiar wheezing and rattling noise in the lungs; and a free secretion of urine; when these symptoms are noticed, we have strong reasons for pre- DISEASES OF THE HEART. 253 suming that there exists some disease of the heart. The sudden and exceedingly distressing effects that arise from bodily exertions in dis- eases of the heart, are often sufficiently characteristic to distinguish them from simple hydrothorax. Every muscular effort, or unusual exercise, aggravates to an extreme degree the dyspncea and dis- tressing anxiety and agitation in organic cardiac diseases. Going up stairs or walking up a rising ground almost immediately excites the most alarming and suffocative paroxysms of dyspncea. Although these causes also aggravate, in some degree, the difficulty of breath- ing in simple hydrothorax, yet these consequences are by no means so violent and agitating in this disease as in the affections of the heart. Without doubt, however, mediate auscultation affords the most cer- tain means for recognizing the presence of organic cardiac diseases ; but the tact for profiting by this diagnostic test can only be acquired after a long course of careful experience, and it must, moreover, be observed, that even in the most experienced hands, the stethoscope more frequently gives fallacious indications with regard to the affec- tions of the heart, " than in any of the other diseases which it is cal- culated to discover." (Laennec.) Prognosis.—In general, the prognosis in diseases of the heart is particularly unfavourable. Nevertheless, much relief may sometimes be procured even in cases of great severity. We " sometimes," says Laennec, " see the judicious combination of blood-letting, diuretics, and tonics, remove the impending suffocation, the palpitation, and the dropsy, and restore the patient frequently for a long period to a tole- rable degree of health: and it is commonly only after a great many attacks recurring after considerable intervals, that the disease at length proves fatal." Death almost always occurs very suddenly, and not unfrequently when the patient seems to be free from any unusual disturbance from the disease. Indeed the mere degree of severity of the symptoms is often very fallacious inja prognostic point of view. In some instances, much continued uneasiness, with frequent exacerbations of distressing violence, will continue for many years before the disease terminates in death. In other cases, with less structural disorder of the heart, and no very severe symptoms, the disease will unexpectedly terminate fatally in a short period after the first manifestations of its presence. Dilatation and attenuation of the parietes of the ventricles; hypertrophy with softness ofthe muscular structure; and contraction or diminution ofthe openings ofthe heart, appear to be most apt to prove suddenly and unexpectedly fatal. The occurrence of other diseases in persons labouring under organic affections of the heart, always enhances the liability to a speedy unfortunate termination very considerably. Pregnancy, parturition, intermitting fever, &c, are especially calculated to increase the sufferings and dangers of structural cardiac affections. In some instances, diseases of this kind give rise to a protracted state of asphyxia, and cases of spontaneous resuscitation have occurred after the patient had been supposed to be dead. Forms of structural cardiac disease.—A great variety of organic affections of the heart, and its immediate appendages, are mentioned 254 DISEASES OF THE HEART. in the works on this subject. The following are the principal forms of these diseases: 1. Thickening and enlargement of the heart, or hypertrophy; 2. Attenuation of the parietes of the ventricles; 3. A morbid softness and flabby state of the structure of the heart; 4. Dilatation of its cavities; 5. Aneurismal pouches of its ventricles; 6. Ossifications of the valves, and other parts; 7. Excrescences of a warty character on the valves, and from the internal surface of the ventricles; 8. Contraction of the openings of the heart; 9. Absence of laceration, or ulcerative destruction of the valves; 10. Adhesions between the pericardium and the heart; 11. Tumours on the heart, pericardium, or aorta; and 12. Polypous excrescences. Of these affections, the severest and most common are : dilatation of the ventricles; hyper- trophy, or enlargement and thickening of the parietes, or the connec- tion of both these conditions. The following observations on these affections are drawn from M. Laennec's work on the diseases of the chest. 1. Hypertrophy of the Heart. The term hypertrophy is employed to designate an unnatural thickening or increase of the muscular structure of the heart, with- out a proportionate dilatation, though frequently with considerable diminution of its cavities. (Laennec.) In general this thickening is at the same time attended with an increased firmness of the structure of the heart; but it is also sometimes found connected with a mor- bid softening of its substance, though the latter condition appears to be the consequence of a distinct disease, as it frequently exists inde- pendently of hypertrophy. In some cases, the hypertrophy is con- fined to a single ventricle ; sometimes both ventricles are affected, with or without a similar condition ofthe auricles ; and occasionally, though very rarely, the auricles alone are found in a state of hyper- trophy.* M. Laennec states that he has seen the walls of the left ventricle more than an inch thick, and even as much as eighteen lines at the base. The thickening generally "diminishes gradually from the base to the apex. The columnar carnae of the ventricles, and the pillars of the valves, acquire a proportionate enlargement, and the septum between the two ventricles becomes also considera- bly thickened in the disease of the left ventricle." In many instances the cavity of the ventricles is diminished in size. Laennec has found the left ventricle so small in hypertrophy as " scarcely to be capable of containing an almond with its shell." The symptoms of hypertrophy of the left ventricle are: A strong and full pulse ; violent beating of the heart against the chest: and a violet or red tint of the face. The patient almost constantly feels the action of the heart; though very violent and tumultuous palpitations are less apt to occur in this than in some other affections of the heart. These symptoms, though frequently present, are not invariably so ; for in some very severe cases, the pulse is small and * Laennec. DISEASES OF THE HEART. 255 weak. The signs furnished by immediate auscultation, however in connection with the state of the pulse, and the appearance of 'the countenance, will in general enable us to recognize the presence of this affection. Between the fifth and sixth cartilages of the ribs the heart "gives a very strong impulse, and is accompanied by a duller sound than natural, and prolonged in proportion as the thickening is more considerable. The contraction of the auricle is very short productive of little sound, and consequently scarcely perceptible in extreme cases. The sound of the pulsation of the heart is confined to a small extent, being in general scarcely perceptible under the left clavicle, or at the top of the sternum ; sometimes it is confined to the point between the cartilages of the fifth and seventh ribs; and the impulse of the heart is rarely perceived beyond the same limits except during palpitation." Laennec, Berlin, Richerand, and others, consider simple hyper- trophy o( the left ventricle as peculiarly apt to produce apoplexy: but Dr. Kelly has very ingeniously, though certainly not satisfac- torily, controverted this opinion. When the right ventricle is in a state of hypertrophy, there is more dyspncea and the countenance is of a deeper hue, and in nearly all instances the external jugular veins are turgid, and have a mani- fest pulsating action communicated to them by the regurgitation of the blood. Laennec states that he has never found this symptom absent in hypertrophy of the right ventricle. The stethoscope gives the same results as when the left side is affected, with the exception that the heart is felt beating with most force at the bottom of the sternum, instead of the space between the cartilages of the fifth and sixth ribs. Laennec asserts, that the place where the action of the heart is most distinctly felt, may be regarded as a certain diagnostic in relation to this subject. When the hypertrophy exists in both ventricles," the signs consist in a reunion of those that belong to hypertrophy of each side; but those of the right side are almost always more marked." 2. Dilatation of the Ventricles. This constitutes the passive aneurism of the heart of Corvisart__ the ventricles being preternaturally dilated, their parietes attenuated and the muscular structure, in many instances, so soft that it may be' readily broken down by mere pressure between the fingers. The walls of the left ventricle have been found so thin as to measure scarcely two lines at the thickest part, and not more than half a line at the apex ; " while the right ventricle is sometimes so completely extenuated as to appear merely composed of a little fat and its in- vesting membrane." Though sometimes confined to one ventricle dilatation usually affects both at the same time. This condition of the heart is very commonly accompanied by other organic affections of this organ—particularly ossification of the valves, and congenital narrowness of the openings into the aorta or pulmonary artery; and Benin thinks that the morbid dilatation is always caused by 'these 256 DISEASES OF THE HEART. and other circumstances capable of impeding the free course of the blood as it is thrown out by the ventricles. This appears to be the most common of all the organic cardiac diseases, and seems gene- rally to be produced in a very gradual manner. In dilatation of the ventricles, the pulse is usually soft and weak, and the palpitations of the heart feeble and indistinct. Mr. Forbes thinks that pain, or a peculiar feeling of distress in the region of the heart, extending sometimes to the top of the sternum, between the shoulders and the left arm, as in angina pectoris, deserve notice as signs of dilatation of the heart. He refers also to headache, an affec- tion which he thinks " he can trace in a great number of cases to this condition of the heart as its exciting cause." When the left ventricle alone is thus affected, the contractions of the heart will be heard very distinctly with a clear and sonorous sound between the cartilages of the fifth and seventh ribs, through the medium of the stethoscope; and " the degree of distinctness of the sound, and its extent over the chest, are the measure of the dilatation. Thus when the sound of the contraction of the ventricles is as clear as that of the contraction of the auricle, and if it is, at the same time, percepti- ble on the right side of the back, the dilatation is extreme." (Laen- nec.) When the right ventricle is in a state of morbid dilatation, the pulse and action of the heart " are nearly the same as in dilata- tion of the left ventricle." In general the jugulars are distended; the oppression in the chest is apt to be great; anasarcous effusions occur; the countenance is usually livid, and bloody expectoration is very common. Laennec states that an habitually turgid state of the jugulars, unattended with a pulsatory motion, is the most con- stant and characteristic " of the equivocal signs of this affection." The only constant and truly pathognomonic sign is the loud sound of the heart, perceived under the lower part of the sternum, and between the cartilages of the fifth and seventh ribs of the right side. The palpitations which accompany this affection consist principally in an increase of the frequency and sound of the contractions, while at the same time, the impulse of the heart's action is frequently feebler than in the ordinary state of the patient. Laennec places but little reliance on percussion, as a means of forming a diagnosis in cases of this kind. In general, percussion at the bottom of the sternum elicits a dull sound. Dilatation with hypertrophy of the ventricles, is much more common than either of these affections separately, and may exist in one or both ventricles. The contractions of the ventricles in this affection may be very distinctly felt by the hand; "and if we atten- tively observe the patient, we frequently perceive the head, limbs, and even the bed-clothes, strongly shaken at each systole of the heart. If we press on the region of the heart, this organ seems to be irri- tated by the pressure, and beats more forcibly still." The pulse is full, hard, strong, frequent and vibrating; the pulsations ofthe super- ficial arteries are often visible. Percussion on the region of the heart almost always elicits a dull and obscure sound. With the stetho- scope, the pulsations of the heart are heard distinctly over a great DISEASES OF THE HEART. 257 extent—they may be perceived below the clavicles, on the sides, and a little to the left side ofthe spine. In some instances, when the heart palpitates strongly, besides the impulse of the heart, which seems communicated by a large surface, we can distinguish another shock which is sharper, clearer, and shorter, although occurring at the same time, and which seems to strike the walls of the chest with much smaller surface. This blow seems evidently occasioned by the apex of the heart. 3. Aneurism of the Aorta. Aneurismal dilatations of the aorta are very common. In some instances the dilatation exists without rupture of any of the arterial coats, constituting what authors call true aneurism; in others, the internal coat is ruptured, forming the kind of arterial dilatation de- nominated false aneurism. Sometimes a large extent of the aorta is in a state of morbid dilatation; but much more commonly the dilatation is confined to the ascending portion and arch. These aneurismal tumours often acquire a very large size. Laennec has seen them " as large as the head of a full grown fcetus." By com- pressing the heart and lungs, these tumours are apt to give rise to very alarming and distressing affections. When the coats of the artery are much diseased, or the dilatation becomes very great, the tumour sometimes bursts and causes immediate death. In some cases the "aneurism compresses the trachea, or one of the two bron- chial tubes; flattens and eventually destroys a part of them, and death ensues from the rupture of the tumour." The oesophagus may also be thus compressed, but this occurs but seldom. The heart is usually pushed to one side or downwards. Sometimes the aneu- rism bursts into the air-cells of the lungs; but rupture into the left cavity of the pleura is by far the most common. Aneurismal tumours of the aorta often destroy the vertebral column to a great depth, by causing gradual absorption, without leaving any other marks of dis- ease, such as caries, &c. When this takes place, the tumour becomes entirely destroyed on the side next the vertebrae—the naked bone forming the posterior wall of the sac. The sternum is also in some cases destroyed, when the aneurism is in the ascending aorta. When the arch of the aorta or the arteria innominata is the seat of the aneurism, the tumour often projects at the top of the sternum, or under the cartilages of the first false ribs of the right side. It is not always the largest aneurisms that most readily make their way ex- ternally. Sometimes those of the size of an egg produce this effect, whilst occasionally, those of the size of the head of a full grown fcetus remain quite covered, and even compressed by the sternum. (Laennec.) Diagnosis.—The signs of aneurism ofthe aorta, according to Cor- visart, are: inequality of the pulse in both arms; obscure sound on percussion; a rattling noise in the throat, "and dragging downwards of the larynx when the tumour presses upon the trachea; and a vol. n.—18 258 DISEASES OF THE HEART. whizzing or rushing at the top of the sternum perceptible by the hand." Laennec, however, places no reliance on these signs, and observes that aneurism of the aorta has no symptoms peculiar to it —the symptoms just noticed " being indicative merely of the change or compression of the adjoining organs." If, however we find under the sternum or below the right clavicle, the impulse of the circulatory organ isochronous with the pulse, and perceptibly greater than that of the veutricles examined in the region of the heart, we have reason to suspect dilatation of the ascending aorta or arch—the more so as it is extremely rare to feel the impulse ofthe organ ofthe circulation beyond the region of the heart, even in cases of the most marked hypertrophy. If this phenomenon is found constant after repeated examinations, we may consider the diagnosis as certain. Examined with the stethoscope, the aneurismal tumour usually elicits a peculiar purring thrill, and bellows-like sound. In general, however, aneu- rism of the aorta can only be recognized with certainty when it shows itself externally; but even when it passes through the walls of the chest, " it is not always distiuguishable from other tumours. The origin and progress of this affection are indeed sometimes so obscure as scarcely to give any reason for suspecting its existence;" and the first indication of its presence is often the death of the individual as instantaneously as if by a pistol-bullet. Treatment of the Organic Diseases of the Heart. The greater number of organic diseases of the heart must be re- garded as absolutely incurable. This, however, does not apply to hypertrophy and dilatation, whether existing singly or concomitantly with each other; for by a judicious and energetic course of treatment, both these cardiac affections may occasionally be entirely removed, and almost invariably greatly mitigated. M. Laennec observes, that " the greater number of practitioners are too much in the habit of de- spairing of success in cases of this kind, and therefore content them- selves with attacking such urgent symptoms as may arise in its progress; and yet I believe, there is no one who has not succeeded every now and then even by this symptomatizing treatment, in pro- longing for fifteen or twenty years the lives of individuals affected with organic diseases of the heart." Organic affections of the heart are indeed much more generally regarded as mere subjects of patholo- gical speculation than as diseases, in some instances at least suscep- tible of cure or melioration by proper remedial management. "We think such an estimate," says Dr. Johnson, "not only a false one,but pernicious in its consequences both to the patient and practitioner." The general and paramount indication in the treatment of organic cardiac affections—more especially of hypertrophy and morbid dila- tation, is to reduce and keep down uninterruptedly the momentum of the circulation; and this is to be fulfilled by lessening the mass of the blood by venesection, and a reduction in the quantity and nutri- tient qualities of the food, and by carefully avoiding every thing which has a tendency to increase the action of the heart and arteries. DISEASES OF THE HEART. 259 When there is reason to believe that there exists hypertrophy, the volume of the circulating fluid should be at once decisively dimi- nished by as large a blood-letting " as the patient can bear without fainting;" and this is to be repeated at intervals of three or four days, until the "palpitations have ceased, and the heart yields up a moderate impulse under the stethoscope." In cases where there is simple dilatation, without an increased thickness of the muscular structures of the ventricles, the abstractions of blood can scarcely be carried to a very great extent, or at least be very frequently repeated, without the risk of great prostration, or fatal syncope. In cases of this kind, it will nevertheless be highly proper to keep down the mass of the blood; but after one or two effectual bleedings this may be most prudently done by an extremely abstemious mode of living. A reduction of the ordinary quantity of food is indispensable to full success in cases of this kind. The good effects of blood-letting will be but temporary, and in general wholly inadequate, unless the rapid generation of new blood be at the same time obviated, by put- ting the patient on a very spare and diminished allowance of* diet. Laennec advises that the food should be diminished to one half at least of the ordinary quantity taken by the patient; and it should consist of mild and unirritating articles of diet, at the same time that the mass ofthe blood is kept down by repeated bleedings. All kinds of stimu- lating liquids must be rigidly forbidden. This course of depletion and low diet must be steadfastly pursued, the patient at the same time avoiding, as much as possible, every thing which may cause inordinate excitement of the circulatory system, particularly exercise, strong mental emotions, and stimulating ingestion. " When the patient has been two months without experiencing palpitations, and without increased impulse of the heart, we may lessen the frequency of the bleedings, and diminish in some degree the severity of the regimen, if the patient is not at all habituated to, or satisfied with his allow- ance. But we must return to the same means, and with the same rigour, if the augmented impulse ofthe heart should return." (Laen- nec.) This method of treating organic affections of the heart was first practised by Valsalva and Albertine.* In addition, however, to the foregoing measures, they kept their patients in bed during a period of forty days, and directed the frequent use of laxative enemata. Dr. Forbes states that he has resorted to this method of treatment with much temporary advantage, and he cites the names of Lancici, Guattini, Sabatier, Pelletan, Corvisart, Hodgson, Bertin, and others, in favour of its usefulness in organic cardiac affections. Morgagni also speaks of this reducing plan of treatment in affections of this kind with decided approbation ;t and there can be no doubt, indeed, of its direct tendency to lessen the violence of the symptoms, or to effect a cure in hypertrophy of the heart. Laennec observes, that even where the disease has advanced so far as to have induced great * Morgagni. De Sedibus et Causis Morbor., &c. Epistol. xvii, art. 3. t Loc. citat. Epistol. xviii, art. 30. 260 DISEASES OF THE HEART. dyspnoea, anasarca, and a general cachectic state of the system, "we must nevertheless fearlessly prosecute the plan of starvation and bleeding." When the symptoms just mentioned, namely, habitual dyspncea and dropsical effusions occur, diuretics will generally assist materi- ally in alleviating the sufferings of the patient. Dropsical effusions into the cavity of the pleura or pericardium almost invariably occur in the progress of organic affections of the heart, and it would appear that the immediate cause of death in many instances are effusions of this kind, impeding the actions of the lungs and heart. Diuretics can therefore rarely be dispensed with in affections of this kind, and they are in fact often decidedly palliative. We may frequently suc- ceed in removing the dropsical effusions from the chest, by the judi- cious employment of this class of remedies, so as to procure much temporary relief. The effusion, it is true, will generally soon return again, but I have known the life of an individual protracted for four or five years, by occasionally effecting a removal of the dropsical ac- cumulation. I attended an old lady some years ago who laboured under symptoms of hydrothorax; by low diet and the use of the squill and nitre, in doses of about two grains of the former to fifteen of the latter, I succeeded in removing the water from her chest, three times in the course of about fifteen months. She finally died sud- denly, and on dissection, the heart was not only in a state of remark- able hypertrophy, but the mitral valves were completely ossified. Some writers have strongly recommended digitalis as a diuretic in organic cardiac affections, attended with dropsical effusions; and from the known powers of this article to curb the action ofthe heart, it would seem to be peculiarly applicable in cases of this kind. Laen- nec, nevertheless, does not speak very favourably of its powers in the class of diseases now under consideration. He observes, that he has never found it to control the action of the heart, " even when the dose was carried to the extent of producing vomiting and vertigo." Its diuretic powers are equally uncertain, but of its occasional sedative, as well as diuretic influence, no doubt can be entertained, and as both these effects are peculiarly desirable in cases of this kind, it un- questionably deserves a fair trial, where we find other articles ineffi- cient. I have known the infusion of the erigeron heterophyllum to produce very active diuresis, and of course advantage, in one instance of cardiac disease accompanied by hydrothorax. Purgatives may also be resorted to with advantage, where the dropsical accumulations become considerable in cardiac affections; and they are more especially necessary where diuretics fail to pro- cure relief. One ofthe best medicines for this purpose is the follow- ing combination, which rarely fails to procure copious watery dis- charges from the bowels, and at the same time free diuresis.* # R.—Tart, potass, ^iss. Sulph. potass, ^ss. Pulv. scillae 3U. Tart, antimonii gr. ii.—M. S. Take a teaspoonful four or five times daily. DISEASES OF THE HEART. 261 When the cardiac affection consists in simple dilatation, the pulse, as has already been stated, is generally feeble and compressible, and the depletory measures must therefore be employed with caution. But even in cases of this kind we must endeavour to obviate a ple- thoric state of the vessels, by an occasional small blood-letting and an abstemious diet. The principal remedies here are the ferru- ginous preparations and the vegetable bitters. These may be bene- ficially given in union with some of the milder aromatic substances, particularly the infusions of valerian, cat-mint, and of orange flowers. (Laennec) To curb the action of the heart, digitalis is particularly useful in instances of this kind. From one-fourth to half a grain of the powder of this vegetable may be given every two hours until the frequency of the pulse is moderated, and it should be repeated afterwards in such a way as to keep up a slight sedative impression on the circulatory system. Cases of mere dilatation, however, are seldom permanently benefited by remedial treatment; and the pros- pect of effecting an entire cure is always exceedingly small. By the employment of chalybeate waters, or some of the officinal prepara- tions of iron, and weak infusions of the tonic vegetable bitters, and a simple and abstemious course of living, with a careful avoidance of all unusual corporeal exertions and spirituous potations, a considera- ble degree of comfort may be obtained by patients affected in this manner.* Baron Larrey, in his recent work,t has related some cases, from which it would appear that counter-irritation by means of moxa is capable of doing much good in dilatation and enlargement of the heart. He insists upon it, in opposition to Corvisart and others, that hypertrophy cannot be removed by the most rigorous system of depletion. He assures us, however, that during a period of more than thirty years, he has had frequent opportunities of witnessing the beneficial effects of counter-irritation. Adopting the opinion that in organic affections of the heart, the remote cause almost always consists in "some morbific principle, whether syphilitic, scrofulous, herpetic, or otherwise," he lays down two indications to be pursued in the treatment of these cardiac affections, namely, to counteract or destroy the primary specific cause, by specific remedies; and draw off the irritation from the heart, by establishing an external counter- * [By a long perseverance in the general course of treatment described by our author, I have witnessed apparent cures of several cases of hypertrophia ofthe heart; Certainly I have succeeded in the cure of three cases of aneurism of the ascending aorta even after the tumours had begun to protrude externally through the carti- lages of the ribs, on the right side, in two cases, and at the top of the chest, through the sternum and right clavicle, in the other. The blood gradually became co- agulated within the sacs in all these cases and finally confined the current of circu- lation within its natural channel. The solid tumour which resulted was by degrees reabsorbed in each of these cases, and the patients lived for years afterwards en- gaged in active employments.—Ma] t Clinique Chirurgicale. 262 DISEASES OF THE HEART. irritation bv 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 for- wards to the anterior cardiac region. His favourite formula for administering the mercurial remedies is the following: R.—Muriat. hydrarg. corros. Muriat. ammon. G. opii, aa gr. v. Aq. distil] at. fti. Misce ft. solutio. Of this, a dessertspoonful 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 chronic affections of the heart, that previously to having recourse to any remedies intended to act di- rectly on it, we ought to be assured that the digestive organs are in a healthy state —that their mucous surfaces are free from irritation— their vascular system not morbidly distended, and that the liver is performing the secretory functions freely and regularly. When de- rangements of this kind are present—a few leeches to the prsecordia or anus, some small doses of oxyde of mercury and castor oil, a mild and spare diet, and bodily and mental repose, will often do more to tranquilize the circulation than more active and rougher means. And, indeed, in many cases, more especially in the earlier stages, when the stethoscope gives but little information, it is not until we. have restored the organs to a comparatively healthy condition, that we can know hoiv far the disordered action of the heart de- pends on sympathy with these, or is the consequence of incipient organic lesion of the heart."* Concomitantly with the employ- ment 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. DISEASES OF THE HEART. 263 Sympathetic Affections ofthe Heart. Symptoms differing in no material circumstance from those which have already been mentioned as belonging to organic affections 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 disorder of its structure ; and the most alarming instances of this kind often result from ail 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 prescribing for cardiac affections. I have, in several instances, been consulted by persons subject to extremely violent paroxysms of palpitation, who were supposed to be labour- ing under chronic 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 paroxysms 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 eructations of flatus, there can be but little doubt that the cardiac affection is symp- tomat'ic of gastric irritation. Habitual debility and irritation in the digestive organs are particularly apt to give rise to such affeotions in persons of a plethoric and nervous habit of body. I was consulted, about eighteen months ago, by a gentleman of a very nervous tem- perament 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, immediately excite vehement palpi- tations ; 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 with flatulency, acidity, and other unpleasant sensations in the stomach. He was directed to take four grains of blue pill every other evening, an oc- casional dose of rhubarb in the morning, and put on a light and digestible diet, with exercise on horseback. In four weeks Ins com- plaint 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 eruption of the menses Nervous females, more especially those who labour under chronic hysteric affections, are also especially subject to palpitations of the heart. These cases are in general easily distinguished from organic affections of the heart, but as structural disease of this organ mav be associated with mere sympathetic irritation, it may be well to state more explicitly the signs by which nervous palpitation may be distinguished from'hypertrophy or dilatation of the heart. 264 DISEASES 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 deplora- ble instance of this kind, in a young man, which was finally re- moved by discontinuing this degrading habit, in conjunction with mild tonics, active exercise, and a regular, digestible, and nourish- ing 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, dysp- noea, and praecordial anxiety.* As the subject is one of great importance, I subjoin the following observations from Dr. Krimer's paper, as diagnostic of cardiac affec- tions 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 margin 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 headache, 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 breath- ing is usually short. Pain in the stomach is almost continually pre- sent, and the epigastrium is extremely tender to pressure " toithout 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 drowsiness, and always a remarkable disinclination to mental and corporeal action.t " In nervous palpitation, the first impression conveyed by the ste- thoscope is, that the heart is not enlarged. The sound, though clear, is not heard loudly over a great extent ofthe chest; and the impulse, though 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 * The reviewer of Dr. Krimer's paper observes: " The disgusting nature ofthe 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. t Hufeland's Journal der Heilkunde, Jan., 1827. DISEASES OF THE HEART. 265 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 agitation, 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 accord- ing to the particular condition of the general system, and the local organic irritations that may exist. The digestive functions must be particularly attended to, and the sources of intestinal irritation obvi- ated 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 portions 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 deplorable condition ; and which were afterwards cured by tonics, gentle exercise by ges- tation, the tepid shower-bath, and a digestible and nourishing diet. One young man, of a dyspeptic habit, was affected at times with alarming palpitation, and dyspncea. His physician, regarding it as active hypertrophy, bled him copiously. The disease, however, gra- dually 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 vio- lent paroxysm of palpitation and praecordial 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 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 charac- ter 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 ofthe mass of the circulating fluid. When sympathetic disease of the heart is inti- mately connected with general plethora, which is indeed frequently the case, it may be proper to practise one bleeding in the commence- ment 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 en- couragement ofthe ordinary secretions, particularly those ofthe skin and kidneys. 266 ANGINA PECTORIS. 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, extend- ing 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 ofthe 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 exertion gives rise to intense darting and constrictive pain in the cardiac region ; and the patient feels as if an attempt to move would inevitably cause imme- diate death. During the paroxysm, the countenance is pale and ex- pressive of great anguish, the extremities are cold, the heart palpitates violently, there is more or less dyspncea, 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 paroxysms 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 headache, hurried respiration, and anxiety of feeling in the praecordia. 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 I am now attending a girl under eleven years of age, who is * This disease has been described under a great variety of names, as asthma convidsium, by Eisner; arthritis diaphragmatica, by Butler: syncope anginosa, by Parry; asthma spastica arthriticum inconstans, by Stoeller; strenalgia, by Baume-; sthenocardia, by Brera; asthma dolirifkum, by Darwin ; sternodynia syncoptica etpal- pitante, by Sluis; pnigophobia, by Svvediaur; and cardodyne spasmodica, by Harles. ANGINA PECTORIS. 267 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 supervened ap- parently as sequelae of typhus fever.t In relation to the immediate or exciting causes of this affection, pathologists have expressed very different opinions. Heberden, KreysigJ and Parry§ attributed the disease to ossification of the coronary arteries, and this opinion is still entertained by many phy- sicians. Others have ascribed it to ossification of the semilunar valves ofthe 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 cartilagi- nous portion of the ribs; suppurative inflammation of the mediasti- num, 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 the bodies of those who have died of angina pectoris; and he wholly rejects the idea of its depending on organic cardiac disease.IT M. Laennec, also, denies the necessary connection 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 affection ofthe heart or large vessels."** It must, moreover,be observed,that ossification of the coronary arteries, and other structural diseases of the heart, are frequently met with in subjects who had never experi- enced 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 * [I once attended a young gentleman of this city, 21 years of age, who had been intemperate in his habits, and subject also to inflammatory rheumatism which had been translated to his heart, and produced the symptoms of pericarditis. The consequence was the development of a genuine angina pectoris, which came on in frequent and terrible paroxysms, and finally destroyed him on a voyage for the recovery of his health in the Gulf of Mexico.—Me.] t Klinik der Chronischen Krankheiten, bd. iv, p. 406. X Die Krankheiten des Herzens, 2 Th., 2 abhand., 5 Kap. $ Treatise on Syncope, Anginosa, &c. II [An eminent gentleman of the bar in Philadelphia, died some years ago of a paroxysm of this disease, and on a post-mortem inspection, I could discover no other signs of organic disease than a small patch of opacity in the serous mem- brane covering one of the ventricles. He had been subject in previous years to regular attacks of gout.—Ma] 1T Medico-Chir. Rev., March, 1829, p. 573. ** On the Diseases ofthe Chest, last edition; translated by Dr. Forbes. 268 ANGINA PECTORIS. of angina;"* 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 spontaneous removal of the disease, and its susceptibility, in some instances, of being cured, militate also directly against the doctrine of its necessary dependence on organic affections of the heart. Laennec avers that <• he has known many individuals who had suf- fered a few very severe but short attacks of angina pectoris, and had had no further return of it." Dr. Parry, who believed that the dis- ease was always caused by ossification of the coronary arteries, never- theless 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 arteries, and other organic cardiac affections, are very frequently connected with angina; " but nothing proves, even in such cases," says Laennec, " that the disease depends on affections of this kind, inasmuch as they are of various kinds, and as the angina 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 coronaries. 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."§ Dr. Johnson states, that in all the cases which occurred in his own practice, where post-mortem examination was made, there was a flabby and softened state of the muscular structure of the heart, connected in a few instances with ossification of the coronary arteries.|| Dr. Cook also mentions a peculiar flac- cidity and softness of the structure of the heart, " as a phenomenon usually found after this disease," sometimes with, and at others with- out the ossification of the coronaries or cardiac valves. IT Hypertrophy or dilatation of the heart, without any other organic disorder, is men- tioned by Laennec as no uncommon condition in this affection. About six years ago I attended a gentleman in consultation with Dr. M'Clel- lan, who was frequently affected with violent paroxysms of angina pectoris. In one ofthe 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 fingers. 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 * Treatise on the Digestive Organs, p. 274. t Manual of Anatomy. X Lectures and Observations on Medicine, p. 185. $ Med. Chir. Rev., April, 1826, p. 497. II Med. Chir. Rev., March, 1828, p. 430. H Loc. cit. ANGINA PECTORIS. 269 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 pneumogastric nerves; on the other hand, when there is simply a sense of stricture of the heart, without pulmonary pain or much difficulty of breathing, we may consider its seat to be in the nervous filaments which the heart receives from the grand sympa- thetic. Other nerves are also simultaneously affected, either by sym- pathy, 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 cervical 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 expressed by Dr. Johnson,* Jahn,t Jurin, De- sportes, and other writers. Mr. Teale refers the various symptoms of angina pectoris to a primary affection of some portion or portions of the spinal marrow, and the corresponding ganglia of the sympathetic. His reasons for adopting this opinion are : 1. The fact that most of the morbid phe nomena exhibited in the extreme branches or filaments of nerves, are seldom owing to disease in the nerves themselves, but to an affection of the nervous mass from which they are derived; 2. The tenderness or pain on pressing some portion of the spine, in most cases of angina pectoris; and the correspondence ofthe tender part of the spihe with the particular symptoms which are present—namely, tenderness in the lower dorsal portion of the spine, in conjunction with constriction and other affections ofthe stomach; and tenderness in the cervical part of the spinal column, with pains in the arms, breast, and shoulders, and palpitations; 3. The relief obtained, by counter-irritating and depletory measures applied to the spine—that is, to the lower dorsal portion, when the stomach is particularly affected, and to the cervical portion, when there are palpitations and affections of the arms, shoulders, &c.J Although this neuralgic affection of the heart may often depend on primary spinal irritation, as well as on organic cardiac disease, it may doubtless, also, be excited by other remote causes or irritations of the system. There are some well-authenticated facts on record, exemplifying the occasional dependence of this disease on dyspeptic irritation. I have already adverted to the two cases mentioned by Dr. Baillie, which ultimately recovered, and were evidently depend- ent " upon an imperfect digestion." Mr. Cook, also, to whose ex- cellent work on the diseases of the digestive organs I have referred * Med. Chir Rev., Nov., 1828, p. 197. t Loc. cit., bd. v, p. 407. X A Treatise on Neuralgic Diseases, &c. By Thomas P. Teale, Esq. 270 ANGINA PECTORIS. above, thinks that angina pectoris is occasionally excited « by de- rangement of the digestive organs, especially by dyspepsia." Several eminent writers have supposed that the disease depends on gouty irritation ;* and Lentint maintained that it is always of rheumatic origin. This, with some modification, appears, also, to be the opinion of Dr. Chapman; and there can be no doubt that a gouty or arthritic diathesis is often manifestly present, in those who are subject to this alarming cardiac affection. From all that has been ascertained, there- fore, in relation to this subject, it would seem that angina pectoris may be excited by various causes, both organic and dynamic, and that it consists essentially in a peculiar irritation 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 hope- less 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 ammoniae succinatae, have been most recommended for this purpose. I attended a patient some years ago, who was frequently seized with violent paroxysms of this affection, and who generally obtained considerable relief from a draught of very cold water. This patient died suddenly 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 tendency, in some instances, to mitigate the pain and constricted respiration.^ Dr. Good advises that the patient be immediately placed in an inclined position, with the head raised high; and an emetic instantly administered. If the pain and diffi- culty of respiration continue after the vomiting, " opium intermixed with camphor, ether, or other diffusible antispasmodics, should be freely employed." Emetics were, I believe, first recommended in 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 oppres- sion in the chest is great, and the habit robust and plethoric, blood- letting will occasionally afford some relief. According to Laennec, however, leeches applied to the epigastrium or region of the heart, sometimes prove more beneficial than venesection. Indeed, venesec- * Berger, Abhandl. f. Pract. Aerzte., b. x, p. 715. Hesse, Specimen Inaugurale Medicum de Angina Pectoris. t Beitrage sur Ausiibenden Arzneiwissenschaft, b. i. X Parry's Treatise on Angina Pectoris. § Medical and Philosoph. Comment., vol. iii, p. 180. ANGINA PECTORIS. 271 lion may very readily prove injurious in this complaint, and it ought not to be used, unless the indications for its employment are unequi- vocal. Dr. Parry, who particularly advocates the practice of venesec- tion in this complaint, advises that the blood " should be taken from a small orifice, the patient being placed in the horizontal position, while the physician 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 sinapisms 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 cardiac irrita- tion may be wholly symptomatic of gastric disorder, it will be pro- per, in all instances, to pay particular attention to the biliary and digestive functions. A mild diet, the occasional use of small por- tions 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 ;| 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 considerable prospect of benefit.§ Baumes speaks highly ofthe 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.1T 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 virosae. Sixteen grains of this extract are to be dissolved in two drachms of cinnamon water, of which fifteen drops must be taken every two hours.** Arsenic has been used with considerable benefit by Richter; and Smith em- ployed small doses of James's powder in union with castor and assafetida, with very good effects in some cases of this complaint.tt The celebrated Odier of Geneva restricted his patients to an extremely spare and simple diet, as the best means, in his opinion, for prevent- ing the return of the disease. Laennec asserts that the magnet is * [I have sometimes derived great advantage from cupping between the shoulders and over the epigastrium. In debilitated subjects, dry cupping by the use of common tumblers, exhausted of air by the aid of combustible matters in a state of flame, is the best application.—Ma] t Berger, loc. cit., bd. p. 708. X Annales de Literature Medicale Etrangere, vol. iv, as quoted by Richter. } New York Medical and Physical Journal, Dec, 1814. II Annales de la Societe Pratique de Montpellier, torn. xii. II Specielle Therapie, vol. v, p. 195. ** Journal, &c., 1809, st. i, p. 57. tt Medical Commentaries, Edin., vol. v, p. 78 272 INDIGESTION. one of the best means for palliating or preventing the paroxysms of angina pectoris that we possess. He uses it in the following manner: " I apply," he says, " two strongly magnetized steel plates, of a line in thickness and of an oval shape, and bent so as to fit the part, one to the left praecordial region, and the other exactly opposite on the back in such a manner that the magnetic current 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 com- monly produces au 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 attributed to the action of the oxydized 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 in- creased by previously blistering the part to a small extent, to which the anterior plate is applied. In the management of this affection, it is all important that the patient abstain from spirituous drinks, and avoid strong mental emo- tions of every kind. Inordinate venereal gratifications, too, are in general decidedly injurious; and strong corporeal exertions, particu- larly walking up hill, or rapidly ascending stairs, as well as sudden atmospheric vicissitudes, indigestible and irritating articles of food, must be carefully avoided. CHAPTER VI. CHRONIC DISEASES OF THE ALIMENTARY CANAL. Sect. I.—Indigestion. Indigestion occurs so frequently, and is attended with so discom- forting 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 sufferings, of which none but those who have experienced them can form an adequate idea. Com- mon, however, as indigestion is, and serious as are its consequences upon the health and happiness of man, there is perhaps hardly any indigestion. 273 other malady which is so commonly misunderstood, and consequently mismanaged. In order to obtain a correct view of the pathology of indigestion, and ofthe true indications for its remedial management, it is neces- sary to be acquainted with the physiology of the process of diges- tion. I can here, however, advert only to the prominent and essen- tial circumstances in relation to this subject. It appears, then, to be satisfactorily demonstrated, that the two following conditions are essential to the regular and healthy performance of the functions 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 chymification, where it is in contact with the stomach, be pushed forward towards the pylorus into the duodenum. 2. The regular secretion of a sufficient quantity of healthy gastric 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 concerned, is chiefly effected by the agency of this fluid, is, I think, established beyond all dispute. The experiments of Spallanzani, of Stevens, of Gosse, and those quite recently performed by Tiedemann 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. According to the experiments performed in relation to this point 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, chymification goes on regularly, but the chyle in the lacteals and thoracic duct is transparent and of a yellowish hue. Causes of indigestion.—It has just been said that the immediate cause of indigestion consists in a vitiated or deficient secretion of the gastric juice, and in deficient or irregular action ofthe 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 morbid excitement in the nervous structure of this organ, must necessarily tend to derange the healthy performance of these two functions. Accordingly, every thing which is capable of causing indigestion 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 producing both these effects simultaneously. Of these 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 temporary vol. n.—19 274 INDIGESTION. mental agitation depresses, nay, often wholly suspends for a time the keenest appetite and powers of digestion. These temporary depres- sions of appetite and powers of digestion from sudden emotions of the mind, are converted into protracted and exceedingly unmanage- able cases of dyspepsia, when the mental perturbations are of a chronic and depressing character. Protracted grief and despondency seldom fail to weaken the digestive powers and to bring on, ulti- mately, 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, indeed, are the sympathetic relations of the stomach with the whole and every part ofthe organization, that its functions become disturbed by whatever causes either general debility or organic disorder of any of the principal organs of the body. But by far the most common and powerful causes of indigestion are those that act directly upon the nervous extremities ofthe mucous membrane of the stomach. Whatever is calculated to cause perma- nent irritation in this membrane, has a direct tendency to produce this disease. I think it may be assumed as a pathological axiom, that the functions of secretion can never be deranged without the existence of irritation in the secreting organ. Irritation of the vas- cular extremities that secrete the gastric fluid, exists therefore in every case of indigestion. The causes which most frequently give rise to this irritation consist of over-distension ofthe 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 irritating impressions upon the stomach, it enters more or less into the fermentative process, and evoiVes new combinations, such as gas, acidity, &c, which enhance the irritating qualities of the contents of the stomach. Besides these consequences of too long a retention of imperfectly digested food in the stomach, the muscular powers of this organ will be diminished by the long and continued exercise to which it is subjected, as well as by the over-distension and irritation-caused by the gas. Portions, too, of the half-digested food will passu 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 «$' things is once produced by some error in diet, assisted, perhaps, by general causes, the slightest causes—even the ordinary digestible and plain diet taken in health—will not only sustain it, but often increase its violence, if favoured by other circumstances of a debilitating character. Dr. Philip thinks that over-disle/ision 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 pro- bable, however, I think, that it is not so much by an over-distension of the muscular coat of the stomach which a superabundance of in- gesta produces, that indigestion is caused, as by the mere excess of INDIGESTION. 273 food beyond what the stomach is capable of digesting. Suppose the utmost powers of the stomach to be capable 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. The portion will therefore irri- tate 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-distension, do not differ from those which are caused by indigestible articles of diet. A small portion 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 the process of 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 converting 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, neu- tralized 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 a%ates 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 neu- tralized by the food he has taken. It is for the same reason 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-seasoned food. These excite an artificial appetite, and keep up the desire fof 276 INDIGESTION. food longer than it would be sustained by the impressions 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. I have stated above, that a tardy peristaltic action of the muscular 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, however, that the reverse condition also very frequently obtains, in cases of painful and imper- fect 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 con- dition ofthe mucous membrane ofthe primse 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 fullness in the stomach after eating even a small portion of food. But notwithstanding this feeling of repletion, they soon complain again of the customary sense of emptiness in the region of the stomach, and crave 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 par- ticular uneasiness until an hour or two after eating, when they begin to experience pain and distension in the duodenum. In some cases the food is speedily hurried off by the bowels in an imperfectly di- gested condition, under very severe suffering from tormina and flatu- lent distension of the intestines. 4$ In some instances, severe and obstinate dyspeptic affections depend on a primary irritation of some portion ofthe spinal marrow, or ofthe roots of some of the spinal nerves. " Many cases of dyspepsia," says Mr. Teale, " which had resisted the usual mode of treatment, I have found to be connected with tenderness, on pressing some ofthe middle or lower dorsal vertebrae, and on removing the tenderness in the spine and neighbouring parts, by proper remedies, the stomach affection and attendant symptoms have been almost immediately removed." In addition to the ordinary symptoms of indigestion, patients affected in this way usually complain of a peculiar sense of faintness or sinking at the epigastrium, and a tightness or constriction along the inferior margin of the chest. In some instances, also, the patient is frequently much harassed with flatulency of the stomach. INDIGESTION. 277 This flatulency, says Mr. Teale, differs from that which arises from the decomposition of food so common in disorders ofthe stomach, by the rapid and copious formation of the air. The stomach is often, almost instantly, greatly distended with flatus, even when there is no obvious cause for its production. Sometimes the collection of air occurs more slowly, continuing for many hours or even days. Mr. Teale states that he has in some instances known firm pressure on the painful or tender part of the spine instantly to cause a sudden copious formation of flatus in the stomach. Symptoms and course.—The symptoms of indigestion differ con- siderably according to the stage of the complaint, or the degree and extent of the irritation. In the commencement the appetite is varia- ble, generally weak, and often entirely destroyed; the patient is troubled with flatulency, distension, acid eructations, and colic pains; the mind is, at times, depressed and languid; 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 feeling in the epigastrium. Sometimes the appetite is morbidly craving, but if the patient indulges freely in tak- ing 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 epigastrium tender to the touch; the mind irritable, discontented and gloomy. The colic pains, some time after taking food, are more fre- quent and severe; the bowels become irregular —being sometimes constipated ; at others affected with diarrhoea, during which, portions of food are occasionally passed off in an imperfectly digested state— the stools varying in colour, consistence, and character. The body now begins to waste, and the strength fails; the epigastric distress becomes severe and constant; the countenance assumes a haggard and sallow aspect, the patient complains of more or less difficulty of lying on the left side, the skin becomes dry and shriveled, and there is usually a morbid sensibility 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 affections in parts situated remotely from the stomach. Among these sympathetic affec- tions of indigestion, headache is the most common and annoying. Dr. Warner observes, that there are two sorts of dyspeptic headache, the one occurring while the process of chymification is going on slowly and imperfectly in the stomach, and the other after the chyme has left the stomach and passed into the duodenum. The former is dis- tinguished by a languid and feeble pulse, a slightly coated and whit- ish tongue, with very pale red edges, mistiness before the eyes, slight vertigo, and an apprehension of falling; slight nausea and uneasiness in the stomach; a sense of constriction about the fauces ; and some- times a coldness and numbness ofthe fingers ; and generally a feeling of weight in the brain. The second, or as Dr. Paris calls it, duodenal dyspeptic headache, is characterized by brilliant ocular spectra 278 INDIGESTION. 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 distension in the eyeballs. The tongue is commonly 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 a pathognomonic of this variety of the affection. These headaches 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 inflamma- tion. 2. On deficient or vitiated secretion of the gastric fluid, with vascular irritation or chronic inflammation of the mucous mem- brane of the stomach and duodenum, and a morbidly increased peri- staltic action of these organs. The characteristic symptoms of the former grade of indigestion are, weak appetite ; tongue covered with white fur; absence of epi- gastric tenderness, except after a paroxysm of colic from flatulent distension; costiveness; acid and fetid eructations; absence of habit- ual tension and febrile irritation of the pulse ; and the ability of bearing lean and tender animal food better than vegetable and fari- naceous 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, chapped, granulated or glossy appearance ofthe tongue ; a firm, tense, small, and somewhat accelerated pulse, with slight manifesta- tions of febrile exacerbations towards evening; emaciation ; 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 digestion ; fullness about the edge of the false ribs on the right side ; and 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 inflammation of such cases is seated in the mucous mem- brane of the pyloric 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 duode- num and pylorus is almost invariably somewhat distended, and very tender to pressure in such cases; and these circumstances, together with the tense and quick pulse, furnish the most certain diagnosis of the existence of high mucous irritation or chronic inflammation in dyspeptic complaints. INDIGESTION. 279 In some instances, the pain and tenderness extend across the epigastrium into the left side, and become fixed in the region of the 6pleen, or where the colon turns down to form the descending 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 existence in the region of the pylorus and duodenum."* It may depend on an inflamed and en- gorged condition of the spleen, in which case this viscus is generally found in an enlarged condition. It arises, also, sometimes, from en- largement of the left lobe of the liver, " which is always the part of this organ most affected in indigestion." According to the observa- tions of Dr. Philip, however, the most common cause of the pain and tenderness in the left side is the extension of the chronic in- flammation from the pylorus to the other parts ofthe stomach. There is generally much difficulty in distinguishing pain and ten- derness seated in that part of the colon which lies over the pylorus, from the same affections in this portion of the stomach and duode- num. " 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 re- gion of the stomach a short time before the bowels are moved, and more or less relief soon after their action." (Philip.) Pain and ten- derness on pressure cannot, however, be regarded as an unequivo- cal sign of inflammation in the pylorus and duodenum. This part sometimes becomes morbidly 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 h 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 exciiing 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 cisease. 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 * On the Treatment of the more Protracted Cases of Indigestion. London 1827, p. 19. 280 INDIGESTION. during the first stage of the process of digestion. The presence or absence of symptoms indicative of high irritation or sub-inflamma- tion in the mucous membrane of the stomach and duodenum will enable us to say, almost with certainty, whether an animal or vege- table 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 dys- peptics are benefited by certain articles of food that are altogether intolerable to others. This is more especially apt to be the case in those habitual dyspeptic cases which depend on mere functional debility, with morbid sensibility of the stomach, unconnected with inflammation. In some cases the dyspeptic symptoms are excited only by particular aliments ; " and we must endeavour to ascertain whether a peculiar idiosyncrasy of the stomach prevails in such in- stances, or whether there is a debilitated condition of the organ that incapacitates it from digesting any food demanding considerable powers for its chymification." Every individual affected, and suffer- ing under this grade of dyspepsia, 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 more on debility ofthe digestive organs, without a fixed tenderness and full- ness in the epigastrium, 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 exciting causes of the complaint, will rarely fail to establish a cure, or at least to procure an exemption from its more disturbing symptoms. Ani- mal is undoubtedly much more digestible than vegetable food ; and where the gastric irritation is not considerable, it will very generally be taken with the least inconvenience by dyspeptic persons. We may lay it down, therefore, as a general principle, that animal food is the most proper ; and of this the most tender muscular parts are to be selected. There is nothing to be apprehended from the stimulant qualities of animal food, in cases depending on debility, without any particular morbid 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 decompo- sition. By a food of this kind, the debilitated stomach is moderately excited, and subject to less labour ; while the chyme is more speedily and perfectly formed, and the development of acid flatus, &c, thus, in a great degree, prevented. It is very different, however, 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 as unirritating as possible. Much attention has been directed to inquiries concerning the com- parative 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 latter contains much more mucilaginous matter than the former; and all mucilages INDIGESTION. 281 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 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 dyspep- sia, 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 article of diet. Pork and veal are, with most persons affected with indigestion, altogether inadmissible; and fish, too, seldom agrees well except when taken in very small portions, and in a boiled state. The most oppressive kinds of poultry are geese and ducks; and "turkey 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." Pheas- ant is the least easy of digestion ofthe different kinds of wild game; but partridge and hare are in general readily digested by weak sto- machs. Soft-boiled eggs will sometimes agree very well with dys- peptics ; but care must be taken not to eat the coagulated portions of the albumen. Simple roasting or boiling is the best way of pre- paring 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 converted 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 1 have reason to think that where there exists a morbid sensibility of the stomach, it is generally decidedly injurious. The only benefit that can be obtained from bran-bread beyond what may be derived from common 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 contains, and which are almost insoluble in the gastric fluid. Cheese, milk, cream, and butter, unless taken in very mode- rate portions, are apt to become oppressive. I have known dyspeptic individuals, however, who were much benefited by the habitual use of cream and crackers at their meals. Fresh vegetables are very generally injurious, particularly cabbage, peas, beans; and above all, cucumbers, lettuce, celery, and other articles of this kind taken in the form of a salad, or in an uncooked state.* Of fruits, pears, currants, * [The capaciousness of some dyspeptic stomachs is remarkable enough. I have known several cases in which raw turnips and radishes, and even cucum- bers, could be eaten with impunity when the best selected articles of diet would 282 INDIGESTION. gooseberries, whortleberries, and melons, are generally most apt to prove injurious. Mealy potatoes and turnips are among the best arti- cles of this kind for dyspeptic subjects. All kinds of pastry—such as hot cakes, pies, puddings, &c—are entirely out of the question. 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 during, 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 improper. 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 observations apply only to those cases of indigestion which are free from a mor- bidly 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 instances of chronic gastro-enteritis, and the observations that I have made with regard to the diet in these affections, are therefore fully applicable to inveterate cases of dyspepsia. Medicinal treatment.—When the disease depends on functional derangement from mere debility or inactivity ofthe digestive organs, the bowels are generally torpid, and loaded with feculent matter, and hence an important indication in cases of this kind is to- procure regular alvine evacuations by diet if possible; if not, by the occa- sional use of gentle aperients. WThen 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 suffi- cient 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 ade- quately done, and almost all dyspeptics find it necessary to resort more or less frequently to remedial means for procuring regular alvine evacuations. Rhubarb, in union with some aromatic or stimulating always disagree. Dr. Chapman, in his excellent chapter on indigestion, relates a curious case of this kind, in which an exclusive diet of green corn effected a cure after every thing else had been rejected.—Ma] INDIGESTION. 283 substance, will in general answer well as an aperient in such cases. The following pill* may be taken a short time before the principal meal; and where there is much acidity in the stomach, the rhubarb may be advantageously given in combination with from ten to twenty grains ofthe carbonate of soda, or with thirty or forty grains of mag- nesia. No remedy, however, has appeared to me to act more favour- ably as an aperient in the milder grades of habitual dyspepsia than small doses of ipecacuanha in union with aloes and the extract of hyos- cyamus. From personal experience, I know that in some instances at least, the effects of this combination are peculiarly soothing and sufficiently aperient.! Emetics were formerly much employed in dyspepsia ; but except in recent attacks from a surfeit or very irritating and indigestible ingesta, their use is now very properly almost universally condemned. Where it may be deemed advisable to excite vomiting we may gene- rally effect this purpose by copious draughts of lukewarm water, or what is still better, strong infusions of chamomile flowers, or of the eupatorium perfoliatum. When these do not procure adequate eme- sis, an ordinary dose of ipecacuanha may be administered. Tartar emetic is decidedly objectionable, even under the strongest indications for the employment of an emetic in dyspepsia. Where the disease is connected with morbid sensibility of the stomach, or with chronic inflammation, no circumstance, perhaps, can justify the exhibition of an emetic. In the grade of indigestion now particularly under consideration, besides the dietetic measures already indicated, and an attention 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 generally restore the healthy functions of the digestive organs. A weak infusion of columba 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 cases.J The chalybeate mineral 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, * R.—Pulv. rhsei gr. ii. ----aloes gr. ss. ----capsici gr. i.—M. To be made into a pill. t R.—G. aloes soccot 9i. P. ipecac, gss. Extract, hyoscyamus 9 i.—M. Divide into twenty pills. Take one at night on going to bed. X R-—Tart, ferri ji. Pulv. ipecac, gr. v.—M. Divide into three equal parts. Take one every morning, noon and evening. 284 INDIGESTION. and in cases of simple languor and weakness of the stomach, very considerable advantage may in general be derived from them. Four or five teaspoonfuls ofthe unbruised seed should be taken during the course of the day. I have known several individuals habitually sub- ject to slow and painful digestion with torpor of the bowels, much benefited by this remedy. It need scarcely be observed that where the stomach is morbidly irritable and tender to pressure, this article cannot be taken without injurious consequences. Tonics are fre- quently much abused in this affection, 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. Indiges- tion seldom continues long, even in its milder grades, without involv- ing the liver in functional disorder; and hence, alterative doses of mercury 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 indicated, 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 portions of rhubarb, or one or two Seidlitz powders, or a few of the laxative pills already men- tioned. I have been much in the habit of giving the blue mass in union with a laxative, according to the following formula ; and gene- rally, as it appeared to me, with more advantage than when they are given separately and at distinct periods.* Care must be taken, however, in prescribing mercury 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 general rest- lessness and nervous irritation. When this is the case, we may generally gain our object by the internal use of the nitric acid diluted in a large portion of water; or what has appeared to me still more advantageous, the nitro-muriatic acid bath, in the way mentioned under the head of chronic hepatitis.t As palliatives, alkalies and opium are the best remedies we possess * R-.—Massa3 hydrar. aji. G. aloes soccot. J)iss. Tart, antimonii gr. ii.—M. Divide into twenty pills. Take one every other night on going to bed. t [The domestic remedy for dyspeptics which was so generally prescribed by the late Dr. Physick, has become quite popular in this country. It consists of a lixivium of one quart of hickory ashes and a teaspoonful of soot in a gallon of water. A wineglassful of this ley given three times a-day, is supposed to afford all the advantages derivable from a combination of potassa and creasote.—Mc] INDIGESTION. 285 __the former for removing the burning and aching sensations 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 powers of the stomach ; but the pains are so often 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 dyspepsia, would enjoy but few moments of exemption from suffering. 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 procured; 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, independent of chronic inflammation of these organs. When the patient is subject to severe pains an hour or two after taking a meal—and more espe- cially when the gastric distress is particularly excited by certain articles of food which usually agree with other dyspeptics, and when, more- over, 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 soft, and below the natural tempe- rature ; and, finally, when with these symptoms there is a disagreea- ble or painful feeling of emptiness experienced in the region of the stomach four or five hours after taking food, without any particular tenderness to pressure on the epigastrium—when these symptoms 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. Dr. Philip speaks particularly in favour of the employment of 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 primae viae, in connection with morbid sensibility ofthe mucous membrane ofthe stomach and duodenum. In cases of this kind, eight or ten grains of the carbonate 286 INDIGESTION. of ammonia 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 ofthe 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. acelat. ammoniae, in union with small doses of laudanum, or ofthe tincture of hyoscyamus. A tablespoonful 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 ofthe skin, burning in the palms of the hands and the soles of the feet, and tension of the pulse, the nitrate of potash will generally afford considerable relief. It may be advantageously given with minute portions of the tincture of ipe- cacuanha, dissolved in some mucilaginous fluid. From five to ten grains ofthe 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 is here one, of the most important remedial measures. The latter, indeed, will often be found particularly beneficial in cases attended only with high irritation, without actual inflammation. For the re- moval of that morbidly sensitive condition ofthe 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 com- fort after having 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 excellent 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 ofthe skin, and the distressing sense of internal heat. Dr. Philip advises the exhibition of small doses of tarfarized 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 INDIGESTION. 2S7 where unequivocal* signs of mucous inflammation ofthe 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 ofthe gastric distress and tenderness. The same objections do not, how- ever, 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 employ mercurials either internally or by frictions on the right hypochondrium. The employment of mercurials, however, requires great caution in the severer cases ofthe disease; for it is not uncommon to find the blue pill, even in small doses, to excite considerable intestinal irritation and general uneasi- ness. To avoid this occurrence, we may give this mercurial in ifnion 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 ofthe temperature and dryness ofthe 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 applica- tions, and the occasional use of alterative doses of blue pill or calomel, with laxative enemata and gentle exercise by gestation or where the, strength of the system will admit of it, walking regularly every day, until a slight degree of fatigue is induced. Let it be constantly borne in mind, that functional derangement ofthe stomach may be the consequence of mere debility and relaxa- tion—or of high irritation and morbid sensibility—or finally of a chronically inflamed condition of the mucous membrane of the di- gestive organs; and that, therefore, the mode of treatment, both me- dicinal 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 soothe the irritation and morbid activity of this organ; and in the third, to subdue inflammation, and obviate its consequence—structural disorder. * [No internal remedy can be brought into competition in this condition of things with small doses of the nitrate of silver, made into a pill with simple bread or gum Arabic. I have frequently given it in combination with extract of hyoscy&r mus, I to i gr. of the former to 1 gr. of the latter in each pill, repeated three timeg a day.—Mc] 2S8 DIARRHCEA. It should also be recollected that disorder of the stomach, attend- ed with harassing symptoms of indigestion, may be the direct con- sequence of spinal irritation. (Teale.) In all obstinate cases of indigestion, therefore, the spinal column ought to be carefully exa- mined, in order to ascertain whether any portion of it be tender or painful to pressure. It cannot be doubted that spinal irritation sometimes produces great disorder of the digestive organs; and in such cases, it would be in vain to expect any relief, so long as the spinal affection continues. In cases of this kind, the tenderness to pressure is generally confined to the lower dorsal vertebrae. Should such tenderness or soreness be found to exist, cupping over the affected part of the spine, repeated, at intervals of four or five days, according to the obstinacy of the spinal irritation, will seldom fail to remove all the dyspeptic symptoms. Blisters, or rubefacient frictions, also, over the affected portion of the spine, will sometimes afford complete relief in instances of this kind. 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 sen- timents of Cullen and some other writers, in increased peristaltic motion of the intestinal tube. Unquestionably, an inordinate peri- staltic action does take place in this affection; but this increased ac- tion does not constitute the essential pathological condition of the disease, and cannot therefore be properly regarded as its proximate cause. Increased action of the intestinal canal may arise in two ways, namely: 1. The irritability of the bowels may be in a natu- ral 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 sub- stances 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 preternaturally increased ; in which case, the ordi- nary secretions and contents 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 evacuations are the consequences. When the diarrhoea continues long, or as- sumes a chronic form, the mucous irritation becomes fixed, and unless it be counteracted by an appropriate treatment, gradually passes into a state of chronic inflammation—more especially of the mucous membrane of the colon, and finally terminates in ulceration, DIARRHOEA. 289 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 chronic inflammation and dis- organization of the mucous tissue of the bowels, slight febrile irri- tation occurs—particularly towards evening, 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 occasionally dropsical effusions into the cavity of the abdomen, ensue. In this aggravated form, the pa-* tient is apt to experience extremely severe colic pains an hour or so after taking food, and in general even the mildest ingesta are. fol- lowed 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 voracious, 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 abundant 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 bowel affec- tion, we sometimes discover irregular patches of a fungoid appear- ance, 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 ulcerations 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 considerably. In cases of this kind, says Broussais, the usual diarrhoeal symptoms are apt to alternate- with attacks of costiveness, and death occasionally occurs under symp- toms 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 mem- brane are found covered with smooth cicatrices of ulcerations which have healed. Broussais observes that these ulcerations are always found most numerous in the coecum, 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 ultimately 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 reddened 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 vol. n.—20 290 DIARRHffiA. diarrhoea of children, attending what is usually called marasmus, I have found in several instances on dissection the mucous membrane of the lower portion of the small intestines and of the colon, exhi- biting extensive tracks of a congeries of minutely injected vessels." Causes.—The remote or occasional causes of diarrhoea are exceed- ingly 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 general system. Of the former kind are all irritating substances received into, or generated in the alimentary canal; and of these the. most common are: irri- gating and indigestible articles of food and drink; acrid and vitiated secretions from the liver and intestinal exhalents; worms; acid gene- rated 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 pro- cess, is also extremely 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 affection. Some individuals apparently in a state of good health cannot take particular articles of diet or drink without suffer- ing more or less from griping and diarrhoea; whilst in others no un- pleasant effect whatever will result from the same articles. Idiosyn- crasy also appears occasionally to be concerned in the production 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 diarrhoea 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 exciting causes do not super- vene. Nevertheless if the bowels have previously been in an irri- table condition, or if the patient be labouring under some organic visceral affection, instances which commence 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 to high irritation, inflammation, and finally ulceration in some portion of the intestinal canal. Among 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 catarrhalis of the German 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 toothache, 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 DIARRH03A. 291 cold, or the conjoined agency of humidity and cold, depends, no doubt, on the centripetal 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 rise to a vitiated or per- haps 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 con- dition of the atmosphere, independent of its thermometrical or hy- drometrical states. This variety of the disease usually occurs in the autumn when the nights begin to be cool, and after a very dry and hot summer, and generally during the prevalence of other forms of in- testinal diseases—particularly dysentery and cholera. Cases that proceed from causes of this kind are commonly 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 fullness of the abdomen, disturbed sleep, headache, some lassitude and aching pain in the back, and slight sensations of creeping chilliness. (Richter.) Diarrhoea arising from this cause frequently passes into the dysenteric form of the disease. It is probable that these cases depend on the conjoined influence of kpino-miasmata and atmospheric vicissitudes—giving rise to increased irritability, functional disorder, and sanguineous engorgement 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 erup- tions sometimes gives rise to obstinate attacks of this disease. It may also be produced by violent affections of the mind, particularly sudden terror and grief. Diarrhoea occurs very frequently in visce- ral and other local affections attended with suppuration and ulcera- tive disorganization. Thus, in the latter period of pulmonary con- sumption, colliquative diarrhoea almost invariably occurs; and the same may indeed be said of every variety of disease attended with hectic fever, or extensive suppurations. In febrile diseases, diarrhoea sometimes occurs as a critical evacua- tion.* It can never be regarded as salutary, however, where it de- pends on the supervention of phlogosis, or high vascular irritation of the mucous membrane ofthe 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, * Fr. Hoffman. Dissert, de Diarrhoea in Febribus Malignis Morbis Acutus Salutari. Buchner, Dissert, de Diarrhoea in Febribus Exanthematicis Salute et Noxa. 292 DIARRHOEA. mixed with more or less feculent matter and intestinal mucus. Wa- tery discharges, free from bile, are rarely if ever indicative of a favour- able tendency of the disease. During dentition, children are very liable to diarrhoea; but as this discharge, when moderate and unac- companied with much gastro-enteric irritation, is calculated to lessen the tendency to preternatural determinations to the brain, it should not be checked in instances of this 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 consists principally of feculent matter and vitiated secretions, it may in gene- ral 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, or from the habitual use of unwhole- some and indigestible diet, in individuals labouring under some chro- nic 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, attended with tenderness in the abdomen on 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 ofthe bowels—and consequently that there is much danger of the occurrence of structural disorder in this tissue, it the disease be not soon removed by appropriate measures. Those cases of diarrhoea that assume a strictly chronic character, and in which scanty and painful diarrhoeal evacuations of an unnatural appearance occasionally alternate with short periods 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 probably attended with more or less ulcera- tion, and consequently with great danger and difficulty in effecting a cure. Diarrhoea from the irritation of dentition, as has just been remarked, is rather a salutary than a dangerous affection ; but when this symp- tom of enteric disease is accompanied with a pale and fretful expres- sion of the countenance, a hard and tumid abdomen, frequent picking at the nose, voracious appetite, and the discharge of undigested por- tions 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 recognized, and from which its name has been derived, are mere symptoms 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 intestinal 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 DIARRH03A. 293 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 dis- ease is produced 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, mercurial remedies are especially applicable; and where a surfeit, or acrid and offensive ingesta have given rise to the disease, laxatives 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 irri- tation ; 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 intestinal irritation is kept up by vitiated secretions, or other irritating matters lodged in the bowels, recourse must be had to mild purgatives. This is especially necessary where diarrhoea is the consequence of indi- gestion, or of the reception into the stomach of indigestible and irri- tating articles of food; or where the bowels are infarcted, or loaded with fecal matter, as occurs in 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 inflam- mation, that any material advantage may in general be obtained from purgatives; and even incases depending on simple irritation, the gentlest laxatives alone ought to be employed. Purgatives are, indeed, very often greatly abused in affections of this kind. Nothing is more common than the repeated use of active purgatives in diar- rhoea. An individual becomes affected with looseness 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 object he takes a more active dose; but the tormina and dis- charges, instead of being mitigated, acquire greater violence. Asto- nished at the obstinacy with which the offending matter sticks to the bowels, he determines, once and for all, to get rid ofthe 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 in- flammation, which the most judicious management may not be capa- ble 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 connection with an accumulation of feces and vitiated secretions, with a hard and tumid state of the abdomen—a combination of circumstances frequently met with in children—no hopes of procuring relief can be reasonably entertained, until these irritating matters are removed out ofthe bowels by a course 294 DIARRHCEA. 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 influence upon the biliary organs, which always become more or less deranged in diarrhoea of protracted continuance. Many writers recommend rhubarb as a suita- ble purge in this disease ; and in recent cases, from irritating matters lodged in the bowels, 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 inflam- mation, 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 re- laxation or loss of tone in the intestinal tube. Where it may be deemed necessary to administer an aperient in cases manifestly 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 pre- ternatural determination of blood takes place to the vessels of the in- testines, 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 irritation. Remedies which are calculated to counteract this centripetal direction of the humors, are therefore especially proper in affections of this kind. For this purpose, opium, in combination with small doses of calomel and ipecacuanha, constitutes an excellent remedy, after the irritating con- tents ofthe 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 exhibition 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 complaint.* Minute portions of calomel, too, will frequently arrest the progress * R.—G. opiigr. iii. Pulv. ipecac, gr. xii. Calomel gr. ii. Conserv. rosar. q. s.—M. Divide into 12 pills. DIARRHOEA. 295 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 ofthe primae viae, 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 trans- ferred from the bowels to the brain in young children, opium may do mischief, by promoting 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, together with simple, unirritating and digestible diet, will commonly prove bene- ficial. Astringent remedies have been much employed in diarrhoea; but where the mucous ^membrane iof 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 intestinal exhalents, benefit may occasionally be obtained from remedies of this kind; but even in such cases, they may in general be very properly dispensed with. The astringents most commonly employed in diarrhoeal af- fections are kino, alum, acetate of lead, sulphate of zinc, and the infusions of logwood, blackberry-root, the root of geranium macula- turn, &c. Astringents 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 ex- perience, opium and ipecacuanha are much more efficacious than astringents, even in instances .whicfr 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 con- verted into inflammation and its consequences. When the disease assumes a chronic character, it generally becomes exceedingly ob- stinate, and often resists every mode of remedial treatment. One of the most important measures in such cases is the avoidance of every kind of stimulating aliment. The food should consist wholly of fari- naceous fluids, light broths, animal jellies, rice, barley, oatmeal 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 remov- ing 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 coun- ter-irritating.applications to the abdomen. I have in several instances derived great advantage from the employment of small doses of Dover's powder, in union with the acetate of lead, according to the 296 DIARRH03A. following formula.* Not unfrequently, all the means just mentioned, however judiciously employed, 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 fore- going 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 attended 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 continued and extremely painful diarrhoea, the balsam copaiva emulsion 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 intestines. 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, dependent on ulceration, which has been employed with much success at St. Thomas's Hospital in London—namely, the sulphate of copper ih union with opium. Cases that had resisted almost all the remedies usually accounted the most efficacious in this affection, yielded rea- dily 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 ulcer- ations, it is not improbable that its operation in this way may occa- sionally prove very serviceable in diarrhoea depending on ulcers of the mucous membrane 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 ofthe mucous membrane. Mr. Kerr speaks very favourably of the effects of the persesquinitrate of iron in this affection. Several very long-standing cases yielded in a short time to the influence of this article. The dose, for an adult, is from twelve to twenty drops twice daily.t Whatever internal remedies * R.—Pulv. ipecac, compos. J)i. Pulv. acetat. plumb, gr. vi.—M. Divide into six equal parts. S. Take one every four hours. t The following is his method of preparing this nitrate : " Take of small chips CHOLERA. 297 mav be resorted to in cases of this kind, it will always be proper to keen up the regular action of the cutaneous exhalents-and it is esnecially useful to excite the extreme vessels of the externa surface of the abdomen. For this purpose, a broad flannel roller should be constantly worn round the body, and the patient must be particular y 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 must also 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 Morbus.) Cholera is an affection of the alimentary canal, characterized by very frequent and violent vomiting and purging, with severe tor- mina, and cramps in the muscles of the abdominal parietes and ex- tremities. 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 followed by violent colic pains about the umbilical region, accompanied with exceedingly distressing nausea. In a few moments after the occur- rence 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 vomiting, the patient is usually harassed with continual nausea, and an indescribable feeling of dis- tress 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 retching are almost inces- sant. One of the most distressing affections belonging to this dis- ease 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 or pieces of iron wire, an ounce and a half; nitric acid three ounces by measure; water, twenty-seven ounces; muriatic acid, one drachm. Put the iron into an earthenware vessel, and pour on the nitric acid, previously diluted with fifteen ounces of water. Set the vessel aside till the whole of the acid has united with the iron, so as to form a persesquinitrate; then decant the liquid from the portion of iron which remains undissolved, strain and filter. Add the muriatic acid with the remainder of the water, or with as much of that liquid as shall increase the whole solution to thirty ounces.—Edin. Med. § Surg. Journ., vol. xxxvii, p. 99. 298 CHOLERA. very severe attacks, the muscles of the trunk, as well as of the upper and lower extremities, are ahke 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 inter- mitting; the hands and feet become cold, the countenance pale, shrunk, and expressive of great distress; a cold sweat breaks out on the extremities and face ; and extreme prostration speedily ensues. 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 pe- riod. 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 tor- mina, 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 indication 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 notions once uni- versally entertained concerning the nature of these affections. 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 dependence 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, men- tion 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 ofthe 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 momentjloubt of the correctness of this statement; for, however abundant the discharge of bile may be after the disease has continued for some hours, this fluid never appears in the evacuations during the early period, or what may be termed the first stage of the disease. From jpXfl, bile, and {«*, to flow. CHOLERA. 299 The observations and researches that have been published of late years—and they have not been limited—in relation to the pathology of cholera, render it evident, that the liver, and indeed the whole system of the portal circulation, are extremely engorged with blood. In the cholera of India, the liver, in subjects who die during the first stage of the disease, is always found enlarged, and greatly engorged with blood, and the internal surface of the stomach and bowels marked with large patches of highly injected and distended vessels. In the cholera of infants, I have never seen an instance in which bile appeared in the evacuations, except after the disease had taken a favourable turn; and in the few dissections wiiich I have witnessed of subjects who had died of this disease, the sanguineous congestion of the liver, and mucous membrane of the alimentary canal, was very conspicuous. So far, therefore, our knowledge of the patho- logy of this affection appears to be sufficiently certain ; but how are we to account for the extreme irritability of the stomach and bowels, and the excessive vomiting and purging ? Can hepatic torpor and congestion in the portal system of vessels give rise to this morbid condition of the alimentary canal ? or are we to consider this state of the liver, and the general engorgement of the portal vessels, only as concomitant phenomena, and in no way causative of the cha- racteristic gastric and intestinal affections? From some of the cir- cumstances just mentioned, it would appear, indeed, that the hepatic torpor and congestion have no small share in the production of gastro- intestinal disorder. The fact, that the symptoms almost always begin to abate as soon as the liver resumes its functions, and pours out a' copious flood of bile^ strongly favours this opinion. Strong sanguineous congestion, and torpor of the liver, are almost always attended with great irritability of the stomach. In the malignant grades of bilious fever, the vomiting, during the first stage, is often incessant, and extremely distressing, whilst the fluid ejected is wholly free from bilious matter. If death takes place in this stage, the liver is always found exceedingly engorged with blood, and the vessels of the stomach are in a similar state of congestion; but when the disease continues until large evacuations of black and pitch-like bile take place from the bowels, an abatement of all the symptoms usually ensues. With regard to the remote causes of cholera, it is manifest that high atmospheric temperature constitutes the principal agents con- cerned in its production. In our own climate this affection appears almost exclusively during the warm months of summer; but it is nevertheless probable that elevated temperature acts rather as an essential predisposing, than as an exciting cause of the disease. Cool and damp night air, or exposure to a current of fresh air after the liver and skin have been over-excited by the previous influence of solar heat and exercise, is one of the most common exciting causes of this affection. When the cutaneous and hepatic functions, while in a state of inordinate activity, are suddenly arrested by the influ- ence of cold, the blood retreats from the surface to the internal ves- sels ; the portal circulation becomes engorged, and the capillaries of 300 CHOLERA. the mucous membrane of the bowels strongly congested. This in- jected or engorged state of the capillaries of the mucous membrane of the alimentary canal gives rise, we may presume, to morbid irri- tability of this structure, and, consequently, to the characteristic phe- nomena of the disease. Much may also depend on the influence of koino-miasmata in the production of this affection. The tendency of this agent to excite and derange the functions of the liver, is well known, and when operating in conjunction with high atmospheric heat, as it always does, its tendency to enhance the predisposition to this affection is, no doubt, very considerable. In some instances of intermitting fever, the paroxysms are ushered in by violent attacks of cholera, the-vomiting and purging usually coming on towards the termination of the cold stage, and continuing until the febrile reaction is fully developed. Sometimes cholera returns in quotidian paroxysms, commencing with a slight cold stage, and terminating in free perspiration, without any distinct hot stage. Cholera may also be excited by the direct irritation of indigestible and irritating articles of food and drink ; but causes of this kind rarely produce the disease unless the system is predisposed to it by a debili- tated state of the digestive organs, or by general relaxation and ex- haustion from the influence of high atmospheric temperature. Cholera Infantum. The cholera of infants differs in several essential points from the ordinary cholera of adults. It is almost always distinctly febrile, and very frequently commences in a gradual manner, with more or less diarrhoea, of several days' continuance, before the vomiting super- venes. It is also particularly liable to become protracted in its dura- tion, or to assume a chronic form, a circumstance which is scarcely ever noticed in the other varieties of the disease. The liver appears to be as inactive in this as in the preceding form of cholera; for when once fully developed, the evacuations, during the early period of the disease, are wholly devoid of any appearances of bilious matter, consisting either of a whitish, frothy, or of a watery, and almost colourless fluid. If the disease does not rapidly exhaust the vital powers, and terminate fatally during the first few days, the patient begins to emaciate; the extremities become cold; the head and sur- face of the abdomen extremely warm; the skin dry and harsh; the countenance pale and shrunk; the eyes dull and sunk; and the pulse small, irritated, and frequent. If the disease be not vanquished by proper remedial measures, the little patient, by degrees, becomes somnolent; he sleeps with the eyes half open, rolls about his head when awake, and at last sinks into a state of insensibility and coma, and dies, under symptoms resembling those ofthe last stage of hydro- cephalus. When the disease is very protracted in its course, aphthae usually appear on the tongue and inside of the cheeks; the face acquires an oedematous appearance; the alvine discharges become so acrid as to excoriate the parts about the anus; and towards the fatal CHOLERA. 301 conclusion, spots of effused blood under the cuticle, sometimes appear on various parts ofthe surface. The duration of this variety of cholera is exceedingly various. It mav 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 take 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, ulcera- tion 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 important 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 circum- stance which does not obtain in relation to the cholera of adults. During a practice of twelve years in the country, I met with but two or three cases of this disease in infants. Again, cholera infant- um occurs almost exclusively between 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 pro- duction 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 inwards upon the intestines." (Condie.) In support of this sentiment, it has been alleged by the respectable physician just quoted, that though seldom met with in salubrious districts of the country, " 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 practice in the neighbourhood of pa- ludal districts. Unquestionably, cholera is much more common, both in infants and adults, in such localities than in high and salu- brious parts of the country, and there can be no doubt that mias- mata have a considerable tendency to favour the occurrence of cho- lera, whether in adults or in infancy. If, however, koino-miasmata be the principal agent concerned in the production 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, dk)es it com- * Dr. Condie. Observations on the Pathology and Treatment of Cholera Infantum, &c, in the Philadelphia Journal of Med. and Phys. Sciences, Mav 1825. ' " 302 CHOLERA. mence so early as in the* latter part of June, and usually acquire its most extensive sway in July, before the ordinary paludal diseases are wont to make their appearance, except here or there perhaps a few instances? Let it be observed, too, that we frequently find this fatal disease of infants 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 irritation 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 cities, by which the infantile system is rendered irritable, and peculiarly pre- disposed to suffer disturbances from the irritation of dentition. It 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 concerned in the pro- duction of this malady. Throughout the whole course of the dis- ease, 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 very common, and in general a salutary occur- rence during the process of painful dentition. In the commencement of hydrocephalus, great gastric irritability and frequent vomiting are very rarely absent. In concussion of the brain, vomiting is often a very troublesome symptom : and sea-sickness, which is often so vio- lent as to resemble cholera, appears to depend entirely on the peculiar cerebral excitement occasioned by the swinging or rocking motion of a vessel at sea. The great tendency of cholera infantum, in its chronic form, to terminate in a state of cerebral oppression and coma, seems also to show that the brain is especially predisposed to inflammation, or to that peculiar morbid condition which constitutes 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 contaminated atmosphere, dentition causes more or less cerebral irritation, which being reflected on the stomach and bowels, renders them preterna- turally irritable. If in this state of the alimentary canal, the cuta- neous exhalents are over excited and debilitated by high atmo- spheric temperature, the slightest reduction of temperature, a current of fresh air, or damp night air, will readily cause a sudden torpor of these emunctories. The blood will retreat from the surface to the internal organs, and give rise to engorgement 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 character- istic symptoms of the disease excited. CHOLERA. 303 According to the pathological researches of Professor Horner,* cholera infantum consists in an inflammation ofthe mucous glands or follicles of the alimentary canal, and not in a common vascular or erythemoid inflammation of the intestinal mucous membrane. In most instances he found the mucous follicles very distinct to the naked eye,and their orifices enlarged and tumid. In the large intestines they were generally larger and more tumid, so as to present the ap- pearance of small grains of white sand sprinkled over the mucous membrane. Sometimes enlarged mieparous glands were, more or less, ulcerated; and in a few instances he found the follicles "converted into small cysts, of the transparency and size of the itch vesicle, which, on being punctured with a needle, and pressed, readily gave out their transparent fluid." The mucous membrane ofthe stomach and small intestines was, generally, of a more or less deep sienna colour—and, in some cases, portions of this membrane were so soft " that it could be very easily scraped off with the finger nail." 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 pro- gress of this disease is always extremely rapid, the most prompt and energetic means should be at once resorted to, with the view of mo- derating its violence ; and for this purpose 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 supervenes soon after having taken a full meal, or some indigestible and irritating articles of food or drink, the patient should be directed 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 a view of washing out the contents of the intestinal canal, and of moderating 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 administered, 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 rectum. If vomiting occurs soon after the first dose is taken, the laudanum should be repeated in doses of from 30 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 sina- * American Journal of Medical Sciences. February, 1829. 304 CHOLERA. pisms, we may resort with nearly equal advantage to active rube- facient embrocations. I have in several instances derived very prompt benefit from the application of the oil of manarda 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 appli- cations, our chief reliance must be placed. The practice of giving warm spiced brandy, and other powerfully exciting articles of this kind, is highly improper. Brandy maybe allowed in the latter stage of the disease, when the prostration is extreme, and it is absolutely necessary to support the sinking powers of the system by potent dif- fusible stimulants ; but if it be given during the early period of the disease, with the view of moderating the excessive vomiting and purging, it will not only generally disappoint our expectations but often 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 complete 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 fail to arrest the vomiting and purging within the period just mentioned; and the only fatal case I ever saw, was treated chiefly with warm spiced brandy. If from six to eight grains of opium can be introduced into the sto- mach, and retained for fifteen or twenty minutes, we may calculate almost with certainty on the speedy subsidence of the disease. When the laudanum is immediately thrown up again, it should be repeated, again and again, until its effects are obtained. I have in the course of an hour given nearly an ounce of laudanum in this way, before the gastric irritability was allayed, without any injurious consequences from its ultimate narcotic operation. Where this medicine is imme- diately rejected by the stomach, we may obtain its effects by external application, with almost the same promptitude and certainty as if it were retained in the stomach. For this purpose the cuticle should be removed from the epigastrium, which may be speedily done by means of the nitric acid, as practised by Mr. Powell in the cholera of India. Two parts of this acid diluted with one part of water are to be applied by means of a sponge upon the whole region ofthe stomach; and as soon as the patient feels considerable pain from its impressions, the part is to be washed with a solution ofthe 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 advan- tage of a powerful counter-irritating application, and of the full influ- ence of the opium. When the irritability of the stomach and bowels CHOLERA. 305 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. Haifa 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 pow- dered 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 ofthe disease; and where the exhaustion is great, and the muscles of the extremities affected with severe cramps, much benefit will gene- rally result from rubefacient frictions—particularly from frictions with a strong tincture of capsicum. When the pulse sinks and the extre- mities 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 kind, according to my own experience, is a solution of camphor in vitriolic ether. Of a solution of a drachm of camphor in an ounce of ether, a teaspoonful may be given every half hour until the reaction is considerably in- creased. In one instance, where the pulse was scarcely perceptible, and the extremities 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 and purging, 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 discharges. After the disease is subdued, the patient should take light and nou- rishing 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 re- main weak, a tablespoonful of the infusion of colomba, or gentian, or a'wineglassful 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 VOL. II.—21 306 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 sangui- neous 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 ofthe alimentary canal, but what is still more to the purpose, is gene- rally 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 con- nection with cerebral irritation, constitute the immediate cause ofthe excessive irritability of the stomach and bowels. Our principal object, therefore, must be, to restore these two functions; 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 ipeca- cuanha, and a large stimulating poultice over the abdomen. I am persuaded, by what I have repeatedly observed in my practice, that great 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 man- agement of this disease than previously. Where the pulse is irritated and the head very warm, leeching at the temples or behind the ears is particularly indicated, and will seldom fail to procure very manifest relief. In an extremely 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 ofthe 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 valu- able internal remedy we possess for combating this disease. From one-sixth to a quarter of a grain of calomel 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 possessing all its violence and dangerous tendency, whatever temporary abatement may occur in the severity of the vomiting and CHOLERA. 307 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 excellent auxiliary to the calomel, in affections attended with morbid 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 at each dose should be larger, so as to procure its purgative operation. I have occasionally given a grain every two hours until its evacuant effects were procured, and afterwards con- tinued it in doses of about one-sixth of a grain every hour. Dr. Ed- ward Miller appears to have been the first physician who particularly recommended minute doses of calomel in cholera infantum; and under judicious management it is unquestionably a very valuable remedy in this affection. Except under the circumstances just 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 ofthe 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 ofthe disease. The infant, 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 oppression under which it laboured. Where the disease comes on gradually, and proceeds slowly, it may perhaps be better to commence at once with purgative doses of calomel, than with the minute alterative portions mentioned above. In cases of this kind, the bowels are, frequently, 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 employed, 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 speedily as possible. I have seldom, however, suffered the vesicatory to remain on the skin longer than four hours. As soon as the skin is uniformly inflamed, which in children occurs 30S CHOLERA. generally in about four hours, and sometimes much sooner, the can- tharides should be removed, and an emollient poultice applied over the whole abdomen, including of course the inflamed surface. This will, in a short time, excite the inflamed vessels to pour out a copious quantity of serum under the cuticle, and form a large blister, which should then be opened and dressed with fresh mercurial ointment, prepared without turpentine or other-irritating substances. Where the general habit is phlogistic, and the pulse manifestly febrile, leech- ing both from the head and the region ofthe liver are important pre- liminaries to the employment of vesicatories. The warm bath, also, is an excellent auxiliary in the treatment of this disease; and this measure is especially indicated, when the skin is very dry and harsh, and the pulse quick and tense. While the patient is immersed in warm water up to the neck, it 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 cataplasms, made of stimu- lating 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 sina- pisms, ol. monardse,* spirits of turpentine, and even diluted nitric acid, in the way mentioned for the treatment ofthe 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 congestion and irritation of the brain, in this species of cholera, renders 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. Nevertheless, where the disease assumes a chronic form, and the patient is very restless and wakeful, with a dry, harsh, and withered state ofthe skin, and there are no particular marks of cerebral congestion, small doses of Dover's powder, in union with minute portions of calomel, will sometimes produce very excellent effects. In a few instances of this kind, I have given half a grain of Dover'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 injudi- cious employment of cretaceous juleps, astringent mixtures, aromatic * R.—01. monardae, gi. Spirit camphorae, gss. CHOLERA. 309 draughts, and opiates. Where the disease becomes chronic, or con- tinues rather in the form of chronic diarrhoea than of cholera, the milder astringents may occasionally do some good. Thus, I have, in a few cases, known a decoction ofthe root ofthe geranium macu- latum in milk, procure considerable advantage; but I have much more frequently found it either to produce no manifest impression on the disease a*t all, or to do injury. The employment of unirritating tonics, in the chronic form ofthe 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 ofthe 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 secretions; and Dr. Condie states, that he has used this article with very decided advan- tage, "in the latter stage ofthe 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 no- thing of this remedy, but I do not doubt its occasional usefulness under the circumstances just mentioned. 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 extremities cold, and the pulse very small and feeble, internal, as well as external stimulants, become necessary. Under such circumstances, 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 system. To relieve the colic pains which are apt to occur from flatulent distension of the bowels in the advanced periods of chronic cholera infantum, Dr. Condie strongly recommends a few drops ofthe spirits of turpentine; and my own experience enables me to speak favour- ably of this remedy. I have, generally, however, preferred the oil of juniper to the turpentine, and I am inclined to think it more cer- tain in its effects in this respect, than the latter. No remedy has appeared to me so promptly to allay colic pain, and promote the' expulsion of flatus from the bowels, as a weak solution of common soot sweetened with sugar. Particular attention must be paid to the proper regulation of the diet, throughout the whole course of the disease. If the child is weaned, nothing but the blandest liquid articles of food must be allowed. Boiled milk; liquid preparations of arrow-root, tapioca, sago, and rice; thin oatmeal gruel, barley decoction, or a solution of gum arabic, are the best articles for food and drink in every stage of cholera. In some instances, of a chronic character, I have known beef tea, or weak chicken broth, to produce a favourable change in 310 COLIC. the state of the stomach and bowels. In 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 smoked beef, &c, whilst the stomach loathes all the lighter and unirritating articles of nourishment enumerated above. When tnis occurs, it will be proper cautiously tp gratify the newly awakened appetite, however opposed to the ordinary dietetic rules the indulgence may appear to be. " I have seen many children recover," says Dr. Rush, "from being gratified in an inclination to eat salted fish, and the different kinds of salted meat. In some in- stances they evince an appetite for butter, and the richest gravies of roasted meat, and eat them with obvious relief to all their symp- toms." Without these strong instinctive calls of nature, however, it would be highly improper to allow such coarse articles of food; yet where the inclination for them is strongly expressed, 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 practica- ble, the little patient ought to be removed into the country; for this change is often sufficient to remove the disease, in a short time, with- out 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 protruding tooth, are the most im- portant.* 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. * [Daily scarifications ofthe gums in a still earlier stage of dentition after the manner prescribed by Dr. Marshall Hall, has become a popular method in this city.—Mc] COLIC. 311 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 predis- posed 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 cucumbers, celery, and unripe fruit—sour fruit—fresh and warm bread, &c, are espe- cially 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 usually 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 most severely about the umbilical region. 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 distension 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 distension of the stomach and bowels. The pain now rapidly increases in violence, 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 complete, though transient intervals of ease. During the exacerbations, 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 prin- cipal suffering organ, large quantities of air are, from time to time, forced up, and this is generally immediately followed by some miti- gation of the pain. When the colon is the part chiefly aflected, the flatus sometimes passes off downwards; but this seldom takes place to any considerable extent, until the disease is about terminating. The bowels are always torpid in this affection, and the tongue soon becomes covered with white fur. Diagnosis.—The diagnosis of this variety of colic is not attended with any difficulty. The relief obtained from firm abdominal pres- sure—the agitation and writhing motion of the patient; as well as the absence of fever, and the paroxysmal character of the pains, and frequent eructations of flatus, distinguish it prominently from gastro- intestinal inflammation. From bilious colic it may be distinguished by the absence of bilious Vomiting, as well as of the icterode appear- ance of the eyes, of the extreme obstinacy of the constipation, and of the headache and bitter taste in the mouth, which characterize the bilious variety of colic. From colica pictonum it is readily dis- tinguished 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 danger, 312 COLIC unless it terminates in inflammation of the gastro-intestinal mucous membrane —a termination which sometimes though rarely occurs. In some instances where the flatulent distension is very great, it produces paralysis of a portion of the bowels, or destroys to a de- gree, 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, in- duced in this manner, may be the principal occasion, in some cases of introsusception, or invagination of the bowels. Where flatulent colic is produced by very indigestible and irritating ingesta, it may give rise to rapid inflammation and gangrene. Treatment.—The treatment of this variety of colic is seldom at- tended with much difficulty. In slight cases, where the flatulent pains are seated in the stomach, and there is no reason to presume the existence of chronic irritation in the mucous membrane of this organ, we may, in general, soon procure relief by administering some of the carminative and antispasmodic stimulants. Dry frictions with flannels or a flesh-brush, is an excellent means for removing flatulent pains of the stomach. By rapid frictions on the epigas- trium, the flatus is generally discharged 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 turpentine will also generally allay the pain in slight cases. Ar- ticles of this kind will, in general, give relief where there is no par- ticular irritating cause lodged within the alimentary canal; but where the disease is the consequence of crude indigestible and irri- tating ingesta—or where it comes on within an hour or two after taking a full meal of stimulating mixed, and indigestible food, car- minatives and antispasmodics will not only be insufficient, but gene- rally decidedly injurious, unless they are used in conjunction with proper evacuants. Where there is reason to believe that the offend- ing matter is still in the stomach—which may be presumed to be the case when the disease comes on within an hour or two after taking a full meal, recourse should at once be had to an emetic dose of ipe- cacuanha. To moderate the excessive suffering of the patient as speedily as possible, we may administer some carminative along with the emetic. From twenty 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, occupying 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 turpen- tine is an excellent purgative in colic from the irritation of acrid sub- stances or imperfectly digested articles of food lodged in the bowels. I have often employed this mixture with prompt and complete success. In some instances, however, the sufferings of the patient COLIC. 313 are so extremely great, that we cannot wait for the operation 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 neglected as soon as the violence of the disease is moderated.* When the disease occurs in robust and ple- thoric habits, venesection should be practised, in order to obviate the occurrence of inflammation, 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. 2. Bilious Colic. There is another variety of colic, which, from the manifest de- rangement of the biliary organs, and symptoms indicative of a superabundant or vitiated secretion of bile, has with propriety been denominated bilious cholic. 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 commonly occurs during the autumnal months—particularly after a long continuance of a very warm and humid state ofthe atmosphere. Before the more urgent and characteristic symptoms of the disease come on, the patient generally experiences headache, loss of appetite, a bitter taste in the mouth, thirst, nausea, and occasionally bilious vomiting. After these symptoms have continued for an indefinite period of time, acute pain in the stomach and bowels supervenes, * For this purpose, we may use either castor oil and turpentine, in the pro- portion of six drachms of the former to two drachms of the latter—or the follow- ing pills: K.—Extract, colocynth. compos.. 3SS. Calomel 9i. Tart, antimonii gr. i.—M. Divide into ten pills. Take two every hour until the bowels are freely moved.—Or, ft.—Pulv. jalapa gr. xvi. Calomel gr. viii.—M. To be taken all at once. 314 COLIC 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 ex- periences 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 beginning of the disease. The pulse seldom deviates materially from its natural condition during the early period of the complaint; 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 several days before the pain in the abdomen commences. In cases of great severity, the nervous system usually suffers con- siderable disturbance—the patient becoming despondent and affect- ed with slight spasmodic twitches in the muscles of the extremities.* Dr. Staley, in the interesting paper on this disease just referred to, observes, that he has sometimes met with cases in which much numb- ness 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 tempo- rary mitigation of the abdominal pain. Causes.—I have already said that bilious colic appears to depend on the same remote cause which gives rise to autumnal bilious 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 re- markable for the prevalence of bilious remitting and intermitting fever." My own observations correspond fully with these state- ments. In the autumn 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 reason- able doubt that koino-miasmata is intimately concerned in the pro- duction of this malady—more especially when it prevails, in a degree * An Inquiry relative to the Causes, Nature, and Treatment of Bilious Colic By Dr. Henry Staley, of Maryland.—See Medical Recorder, vol. vi, p. 231. COLIC 315 epidemically; it must nevertheless 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 favourd 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 correctness of this opinion. Dr. Staley observes, with much plausibility, 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 constipa- ted state of the bowels in this disease, we can have no difficulty in ac- counting for the quantity 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 is, in fact, generally, a deficiency of this fluid. The functions of the liver are unquestionably deranged, and the bile se- creted is, without doubt, vitiated. That this is the case, may be inferred from the analogy which bilious colic bears to cholera—an analogy which has been particularly noticed by many writers. Dr; Gregory observes, "that bilious colic is closely allied to bilious diar- rhoea and cholera, occurring along with them,and apparently differing from them only in some unessential features." The opinion that the liver is in a state of torpor rather than of increased activity, is moreover strengthened by the fact, that so soon as the alvine dis- charges 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 inva- riably found the liver in a highly congested state, and in the majority of instances there were strong marks of intestinal inflammation and its consequences.* The etiology of bilious colic does not appear to differ materially from that which is common to cholera, dysentery, &c. The atmo- spheric heat and miasmata act probably as predisposing causes; and sudden changes of atmospheric temperature, by which the cutane- ous 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. 4 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 favour- * Med. Repository, Nov. 1825. 316 colic ably of the employment of emetics in the beginning of the disease, and there can be no doubt of their usefulness where there is much nausea, without full vomiting in the commencement of the attack. Under such circumstances, the exhibition of an emetic, should be among the first measures resorted to for the removal of the disease. Much bilious matter, of a vitiated appearance, is usually thrown off, and considerable temporary relief, almost invariably, ensues. In cases attended with much spontaneous vomiting, it will not be ne- cessary to resort to the use of emetics. In such instances, it will be sufficient to request the patient to take copious draughts of eupato- rium 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 tarfarized 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 ad- vise the exhibition of purgatives, as soon as the stomach has been well freed of its irritating contents. But in the majority of cases, the stomach is so extremely irritable, that medicines of this kind cannot be retained a sufficient lengfh 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 ex- perience enables me to decide, calomel is decidedly the best internal remedy we possess, for preparing the stomach for the reception and retention of purgatives. Given in small and frequent doses, in con- junction with the application of sinapisms or epispastics to the epi- gastrium, 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 antecedent 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. AfteWhe 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 infusion of senna and manna. In some instances, however, none of the usual purgatives will be retained, notwithstanding the previous employment of small doses of calomel and counter-irritating applications to the epigastrium. Where this is the case, it is best to depend on calomel alone, with the view of procuring the evacuation of the bowels. "When the gastric irritability is very great, calomel," says Dr. Staley, "com- bined with gum arabic, will be retained, when every other cathartic COLIC 317 will be rejected." This corresponds entirely with my own experi- ence. 1 have, in several instances, ultimately procured free alvine evacuations by administering from five to six grains of this mercu- rial every three or four hours, until from twenty to thirty grains are taken, and then assisted by repeated purgative enemata. The em- ployment 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 and turpentine;* 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 admin- istered. This valuable narcotic allays the irritation and spasmodic contraction of the intestines; and when given in combination with calomel, it does not impede the subsequent operation of cathartics, and tends, in no small degree, to equalize the circulation, and to ex- cite the cutaneous and hepatic functions. When the obstinacy of the disease is very great, and the bowels resist the effects of purga- tives, 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 beneficial influence upon the disease, whatever may be its grade of violence; and in prescribing calomel in the commencement of the disease, with a view of its purgative effects, we must not lose sight ofthe 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 regu- lar alvine evacuations throughout the subsequent course ofthe disease. For this purpose, castor oil, or infusion of senna and manna, with an occasional dose of calomel, and the daily use of one or two pur- gative enemata, will in general answer very well. In robust and plethoric subjects, or where the pulse is vigorous and tense, and the tenderness .to abdominal pressure considerable, 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 ple- thoric and robust habits,-is always very considerable in this affection. When the pulse is vigorous, it will be best, at once, in the commence- ment of the disease, to draw the blood to the extent of making a decisive impression on the system ; and the operation may be advan- tageously repeated whenever the state of the pulse, and other symp- toms, indicate its propriety, at every stage of the disease. * R.—01. ricini ^iss. Spir. terebinth. Jss. Infus. sem. lini. Oj. Sapo venet. 31.—M. 318 COLIC Epispastics, sinapisms, and warm fomentations, also, are valuable 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 previously practised an efficient blood-letting—and an emollient cataplasm laid over the lower part of the abdomen. These applications 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 may be given either in union or in alternation with other purgative medicines ; or from twenty to thirty grains of the bicarbo- nate of potash, dissolved in a draught of senna and manna. The warm bath occasionally affords considerable relief in violent cases of this affection : and warm fomentations to the abdomen 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 most digestible meats may be allowed. It is particularly important to avoid getting cold and damp feet. To lessen the liability to a relapse, it will be proper to wear a flannel roller round the abdomen for some time after the subsidence of the disease; and the patient must be par- ticularly cautioned 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. saturnina; c. damnoniensis ; rachialgia metallica; painter's colic, &c. It gene- rally makes its approaches in a very gradual manner—commencing with symptoms of gastric derangement, such as irregular and weak appetite, foul eructations, languor, slight nausea, constipation, with transient pains, and a feeling of weight and tightness in the abdomen, more or less drowsiness, and disinclination 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 somewhat tender to pressure, the bowels im- movably torpid, and the stomach, in most instances, very irritable. The pain in the abdomen suffers occasional remissions, but except for a moment after vomiting, and in mild cases, no perfect intermis- sions take place, as in the other varieties of colic. The exacerbations of the colic pains are protracted in duration, and exceedingly agoniz- COLIC 319 ing; and 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 exacerbations, the anxiety and agitation are extreme—cold sweats break out on the extremities and face; the countenance is pale, contracted, and expressive of great suffering; and in some cases of very great violence, partial syncope, delirium, con- vulsions, paralysis of the wrists, and severe pains in the extremities occur. When remedial measures fail to make a favourable impres- sion on the disease, the vital energies at last begin to sink ; the ab- dominal pains abate; the stomach becomes extremely tender and puffy; the thirst unquenchable ; vision imperfect; and finally, oedema ofthe feet, drowsiness, a pale, livid hue of the face, and occasionally suppression of urine, and more or less tenesmus, with great dyspncea ensue; and the patient dies under symptoms of apoplexy, or in a state of syncopic insensibility. . Colica pictonum, if not subdued by an appropriate treatment, or if the remote cause continues to act on the system, or the patient 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 affections. The excretory and nu- tritive 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 shriveled, 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 forearms become wasted and palsied; the abdomen 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 enlarges 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 emaciation, and dies under symptoms of apoplexy, or of dropsical effusion into the cavity of the thorax, pericardium, &c. On post-mortem examination, traces of inflammation, with patches of disorganization, almost always occur in the mucous mem- brane of the stomach and intestinal canal. Frequently, portions 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 contraction. The vessels of the abdominal and thoracic viscera are generally very turgid with 320 COLIC blood ; but the muscular structure, everywhere, exhibits a pale and exsanguinous appearance. The omentum is often marked with livid spots. M. Thomes, 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 mor- bid appearances 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-ascertained cause of this variety of colic. It would seem that the fumes of melted lead and the white oxide of this metal, are most apt to act injuriously on the animal system, and to give rise to this extremely distressing affec- tion. 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 acetates manifest 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 in- fluence of this poison, and of course almost peculiarly 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 prevalance at Poitou in France, from this cause, that the disease obtained the name of colica pictonum* It has been contended, nevertheless, that other causes are capable of producing this variety of colic. Crude wine, fresh cider, and other drinks, acidulated with fresh vegetable juices, are mentioned as possessing a tendency, under otherwise favourable circumstances, 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 in- vestigated, it will, perhaps, generally be 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 producing the protracted train of distressing symptoms which are known to arise from the poisonous influence of * [A new pathognomonic sign has of late been much insisted on by foreign physicians, i. e. a lividity or blueness of the gums, or rather of that portion of the gums which is immediately adjacent to the teeth. If lead has been in any way introduced into the system it is supposed that it must always discolour the gums in this way.—Mc] COLIC 321 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—name- ly, bilious 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 biliary derangement in the former, and the great aptitude of the latter to pass into a chronic state, and to become complicated with various affections of a most distressing character, among other distinctive cir- cumstances, seem to indicate a radical distinction between them. Of the nature or proximate cause of colica pictonum, there is but little known of a satisfactory character. That the nervous system is promi- nently 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 affec- tions of the brain which are frequently detected on post-mortem examination, are by no means satisfactory ; since they may be, and I presume are, 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 rela- tion. Mr. Teale thinks that colica pictonum always depends on a pri- mary irritation, or neuralgia of the spinal and sympathetic nerves. This corresponds nearly with the sentiments of Andral and Lob- stein on this subject. The former of these pathologists observes that lead colic is a nervous disease, in which the spinal marrow and plexus of the great sympathetic appear to be particularly implicated. Treatment.—The indications for prescribing in this affection are: 1, to allay the pain and spasm of the bowels; 2, to evacuate the intestinal canal; 3, to correct and excite the hepatic and intestinal secretions ; and 4, to obviate the occurrence of inflammation 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 re- duce the momentum of the circulation, more especially in robust 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 influence over the violence of the symptoms, but it is obviously proper as a means to lessen the chances of the supervention of inflammation, and it tends, in no incon- siderable 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 vol. ii.—22 322 COLIC spasm ofthe 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 purpose opium is decidedly the most valuable remedy we possess. When given in large doses, it not only allays the spasm and excruci- ating 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 predispose the bowels to be properly affected by the subsequent purgatives, the opium should be administered in union with calomel. 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 cathartics will almost universally fail; and what is still more '■unfavourable, they frequently give rise to severe vomiting and gastric distress, with but very small or no alvine evacuations, how- ever vigorously urged. When, however, the mercury has affected the system, the skin generally becomes moist and of a natural tem- perature, and a full dose of an active purgative will rarely fail to procure free evacuations. I have repeatedly given opium and calo- mel 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 administration of this mixture, after the gums had become affected with the calomel. A strong infusion of senna and manna, with a portion of Epsom salts dissolved in it, will also, in general, answer well as a purgative in this affec- tion ; but it is less certain, I think, than the oil and turpentine, and much more apt to produce very severe tormina during its operation. If the pain returns, after the operation of the purgatives, recourse should be again had to opium, and the mercurial impression must be maintained by the regular administration of a few grains of (calomel every three or four hours. Where the torpor and spasm of the intestinal canal offer a very strong resistance to the operation of cathartics, purgative enemata are very useful auxiliaries. A strong infusion of senna, with an ounce of Glauber salts dissolved in it; or an emulsion formed of two ounces of castor oil, with half an ounce of the spirits of turpentine, and a pint of warm flaxseed tea, should be repeatedly thrown into the rectum until the bowels begin to discharge themselves freely. After, the use of large doses COLIC. 323 of opium and calomel, however—more especially when a general mercurial excitement has been established—the difficulty of moving the bowels is seldom considerable. External counter-irritating applications rarely contribute materially either to mitigate the symptoms or to shorten the duration of their progress. Nevertheless, where from the violence and obstinacy of the disease there is reason to apprehend the supervention of gastro- intestinal inflammation, vesicatories, or pustulation with tartar emetic ointment, and leeching, ought by no means to be neglected. From some reports that have been published in the French journals, it would seem, indeed, that leeching is capable of doing much good in this affection. Recamier cured a case very promptly by the applica- tion of fifty leeches to the abdomen, after the routine treatment pur- sued in the Hospital La Charite had been ineffectually employed.* * This method of treating colica pictonum—which is denominated ■'■' Traitement des Peres de la Charite," consists in the following course of management:—On the first day, a purgative enema, made by boiling half an ounce of senna in a pint of water, and adding four ounces of the sulphate of soda, and four ounces of anti- monial wine, and during the day the patient takes occasional draughts of a drink made by dissolving an ounce of the sulphate of magnesia, and three grains of tartar emetic, in two pints of oinnamon water, with the addition of an ounce of the syrup of buck-thorn. At five o'clock in the evening an enema is administered, consisting of eight ounces of the oil of walnuts, suspended in twelve ounces of portwine. Three hours afterwards, a bolus, containing one grain of opium and a drachm of treacle, is given. On the second day, the " eau bewiie,11 an emetic potion, consisting of six grains of tartar emetic, dissolved in eight ounces of tepid water, is given; the half at first, and the remainder in half an hour. When the vomiting has subsided, draughts of a diaphoretic ptisan are given during the rest of the day, made by putting china root, lig. guaiac. and sarsaparilla, of each a drachm, into two pints of water, and boiling it down to one. An ounce of sassa- fras, and half an ounce of liquorice root are then added, and the mixture gently boiled and strained. At night, the above anodyne enema and bolus of opium are again administered. During the third day the patient drinks two pounds of the diaphoretic ptisan, to which, however, an ounce of senna is added—the whole being taken in four equal portions; and besides this, he continues the use of the ptisan without the senna. In the evening the above-mentioned purgative enema, composed of a decoction of senna, sulphate of soda, and antimonial wine; in two hours afterwards the anodyne enema, (walnut oil and portwine;) and in two hours more the anodyne bolus. The fourth day is commenced with a purgative potion, composed of two drachms of senna boiled from eight down to six ounces, to which are added half an ounce of the sulphate of soda, a drachm of powdered jalap, and an ounce of the syrup of buck-thorn; and the patient drinks the diaphoretic ptisan mentioned above, and in the evening, the oleaginous enema and the anodyne bolus are repeated. All the fifth day is occupied with the sodorific laxative ptisan used on the third day; with the purgative enema (used on the first day) at four in the afternoon; the anodyne (oil and portwine) enema, at six o'clock, and at eight the opium bolus. The treatment is adopted by Ratier. and it is said that it accom- 324 COLIC Wrarm fomentations and the warm bath may also be used with occa- sional advantage in this variety of colic. Alum is much praised by Richter and other German writers as a remedy in this affection ; and I have myself used it in some instances with remarkable success. Richter declares that it will sometimes procure relief where opium and all other remedies fail; and from a case which I treated lately, I am inclined to think that there is much foundation for this assertion. In this instance I employed venesec- tion, vesication to the epigastrium, and opium with calomel in very efficient doses. The pains and intestinal spasms were but moderate whilst the patient was under the influence of the opium, and on the evening of the third day very free evacuations were produced from the bowels by the castor oil and turpentine purge, assisted by ene- mata of senna infusion. On the following morning, however, the patient's sufferings were as great as at first; and although they were again allayed by opium, and the gums were manifestly affected by the calomel, it was evident from the general distress and firmness of the abdominal parietes, that the disease was not subdued. Another pretty free action of the bowels was obtained by the oil and turpen- tine, with the assistance of purgative enemata; but the patient's suf- ferings were still extremely severe on the following day. I now resorted to the alum, giving twenty grains of it with a grain of opium, every three hours. On visiting my patient next morning, I found him almost entirely free from pain, and was informed that he had five or six very copious evacuations during the night. He recovered rapidly under the use of purgative enemata, and an occasional dose of castor oil, with small doses of calomel and opium. M. Kapeler has for many years been in the habit of employing alum in this affec- tion, in the Hospital St. Antoine; and M. Montancaix has lately pub- lished nine cases, which furnish very striking evidence of the useful- ness of this practice.* This remedy was first employed by Grashuis,t and it is highly praised by Lentin.J Since the third edition of this work was published, I have wit- nessed the good effects of alum in two very severe cases of this spe- cies of colic. In one case, ten grains of alum with half a grain of opium, were given every two hours. In about twelve hours, the patient was almost entirely relieved, and under the further use of the alum, without the opium, his health was completely restored. In the other case I gave fifteen grains of alum, singly, every three hours, with the same favourable result. Alum is, without doubt, a remedy of great efficacy in this obstinate and painful affection, though, I be- plishes many cures. Dr. Lerminier also follows this practice rigidly, and with nb inconsiderable success. Pinel calls this method " empirisime consacre par une longue suite de saccesl7 * Arch. Medic, Novembre, 1828. t De colico pictonum tentamen. Amstel., 1752. Ejusd. Appendix decadem observationum sestens, 1755. X Memorab. circa arem, vitae genus, sanitat. etmorbos, Clausthaliens, p. 115. ILEUS. 325 lieve, but rarely employed for this purpose by the physicians of the United States. It is said that cold water dashed on the body and limbs of the patient has occasionally excited the action ofthe bowels after opium, calomel, the warm bath, and purgatives had been ineffectually used. For the removal of chronic colica pictonum, or the various distress- ing consequences of this affection, mercury is, without doubt, the best remedy we possess. It should be given to the extent of producing gentle ptyalism; and this should be regularly maintained for three or four weeks, during which the patient ought to go into the warm bath daily, and avoid with all possible care the influence of cold or atmo- spheric vicissitudes. Dr. Clutterbuck and other writers of eminence have found salivation to be the most effectual means we have for the cure of the paralysis of the wrists, produced by the poisonous influ- ence of lead. The nitrate of silver has also been used with success in paralysis from this cause. We may commence with half a grain three times daily, and gradually increase it to the extent of five or six grains in the twenty-four hours. When it causes purging, which it appears to be apt to do in this affection, it should be given in union with a small dose of opium.* During the treatment of this variety of colic the patient should take freely of fat animal broths, or chicken water ; and it is particularly important that he should avoid drinking cold water or stimulating fluids. To prevent the recurrence of the disease, it is of course abso- lutely necessary to avoid the influence of its remote cause; and there- fore to relinquish the employments which render the exposure to this cause unavoidable, such as painting, glazing, manufacturing white lead, &c. The utmost care is necessary not to take crude and acid articles of food and drink, and to avoid the influence of a humid and cold atmosphere for a considerable time after recovering from an attack of the disease. The free use of fat and oily articles of diet is said to counteract, to a very considerable extent, the poisonous influence of lead. Fat pork, and the daily use of two or three ounces of sweet oil in the morning on an empty stomach, will often protect the system a long time from the injurious effects of this poison; and those who are employed in lead mines, and in the manufacture of the preparations of this metal, are fully aware of the protecting influence of such articles of food, and generally use them very freely. Sect. V.—Ileus. Ileus very generally depends on the intussusception, invagination, or inversion of one portion of the intestinal tube into another. This unnatural position of parts induces irritation, which eventuates in spasmodic contraction ofthe muscular coat ofthe intestine, thus con- stricting the calibre of the enclosed gut, and preventing the regular passage of the feces. The invagination commonly occurs at the * Dr. Roberts. Med. Transactions, vol. v, art. 5. 326 ILEUS. termination ofthe small in the large intestines, the ileum and caecum being enveloped within the colon. It, however, frequently happens also in other parts of the intestinal tube, and it is by no means rare to see invaginations in several places in the same individual. Inva- ginations of the small intestines frequently take place in children, and occasion but. slight and temporary inconvenience. Ileus is not, however, invariably dependent on intussusception or mechanical obstruction of the intestinal tube. M. Corbin has related a case in which there was copious stercoraceous vomiting with colic pains and constipation, which was finally relieved by the purgative operation of a large dose of scammony. Cases, attended with painful stercora- ceous discharges from the stomach, have occurred, in which the fluids which were injected into the rectum were quickly vomited up, "show- ing that there was no permanent or organic obstruction in the bowels." An instance is mentioned in the Medico-Chir. Rev., (April, 1831,) in which " six or seven pints of warm water could be injected into the bowels, and soon afterwards it would be ejected by the mouth. No motion could be procured by the anus." Such cases may depend on an indomitable inversion ofthe peristaltic action ofthe bowels. Causes.—This disease may be produced by every thing which may tend to excite irritation or spasmodic action in the stomach and bowels. Among these may be enumerated irritating and drastic cathartics, emetics, or indigestible substances taken into the stomach—such as coins, glass, cherry or peach stones, and unripe fruit. Ileus is also occasionally produced by hernia, by wounds, or other injuries of the abdomen, by cold externally or internally applied, by intestinal calculi, by organic derangements of the alimentary canal, or by any thing which either directly or indirectly tends to contract or close the intes- tinal tube. Symptoms.—The indications of an attack of ileus are in some in- stances very insidious, and the organic cause or affection may have continued months or perhaps years unsuspected. It usually, however, comes on suddenly and without any premonition, by violent spas- modic and paroxysmal pains in the abdomen, eructations of wind, jactitation, frequent and ineffectual attempts at stool, distension of the abdomen, and all the symptoms of spasmodic colic. The bowels are constipated, although a discharge of the large intestines below the invaginated part may be accomplished by means of enemata or by nature. The stools are often mixed with, or consist entirely of coagu- lated blood. Upon examination of the abdomen, a hard, irregular, convoluted tumour may often be discovered, showing the situation, and perhaps the extent of the invagination. To the symptoms de- tailed, succeed obstinate constipation, hiccup, vomiting at first of the contents of the stomach, and ultimately of stercoraceous matter. The symptoms of inflammation may supervene -upon those of spasm, in which case the disease will become greatly aggravated, and the life of the patient put in imminent danger. Should the spasmodic con- striction and inflammation of the intestines be sufficiently severe, and continued for any great length of time, gangrene and mortification of the bowel will be the result, which will be indicated and accompanied ILEUS. 327 by cessation of pain, prostration of strength, and all the distinguishing and alarming symptoms of mortification. The invaginated portion, however, becoming gangrenous, sometimes sloughs off, and cases of recovery in this manner have been recorded. Twenty years ago I saw a case of this kind, in which, by the efforts of nature, adhesions formed, several inches of the bowel sloughed off and passed away by stool, producing immediate relief and a rapid recovery. Nature may also accomplish a favourable termination ofthe disease by over- coming the constriction, and procuring the disengagement of the en- closed intestine. Diagnosis.—The diagnosis of this disease is exceedingly difficult and uncertain. Attacking suddenly, with great violence, and with- out any premonitory symptoms, it is apt to be mistaken for spasmodic colic, colica pictonum, cholera morbus, or tympanitis. On the other hand, insidious as it frequently is, and accompanied with symptoms uncertain, and common to some other complaints, its very existence is often unsuspected, and it may easily be mistaken for other diseases. So uncertain are the diagnostic symptoms, that John Hunter, who paid particular attention to this subject, has declared that its existence could never be satisfactorily ascertained during life. Violent and spasmodic pains occurring in paroxysms, however, with long-continued and obstinate constipation ; fecal vomiting; distension of the abdomen; with a hard, convoluted tumour about the arch of the colon, will indicate its presence with a considerable degree of certainty. Prognosis.—Ileus is always dangerous. Occurring in robust and plethoric habitSjinflammation, folio wed by gangrene and mortification, is very apt to ensue. In delicate and irritable habits, the spasmodic constriction is carried to a great extent, and is productive of effects equally dangerous. The spasmodic or inflammatory action may, however, in some instances, be overcome, and the disease relieved. The skill ofthe physician, however ably and scientifically directed, will generally fail, in which case nature sometimes comes to our aid, and brings about results as unexpected as they are salutary. Pathology.—It has been said that ileus is a spasmodic disease, and that inflammation, gangrene and mortification are the consequences of the pre-existent spasm. In a late publication upon " the diseases ofthe stomach and bowels," Abercombie has advanced anew theory upon this subject. Having observed in a great number of post-mor- tem examinations, that distension of the bowel above the invagination was a uniform occurrence, he conceives the distension to be a paralytic affection of the intestine, in consequence of which the fecal matter cannot be propelled onward through the canal. The intussusception has, according to this theory, nothing to do with the disease. Ingeni- ous as this theory undoubtedly is, facts are wanting to support its claims to our notice. A careful review of the disease will convince us that it is entirely inadequate to account for the origin, symptoms, causes, effects and treatment of this disease. The spasmodic nature of ileus can admit of but little doubt. We have seen that ileus is produced by all the causes which give rise to spasmodic diseases generally—that it is indicated by symptoms peculiar to this class of affections; and we shall soon observe that every plan of treatment 323 ILEUS. which has been pursued with any prospect of success, has been based upon the position of the spasmodic nature of ileus. The remedies which Abercrombie himself proposes, are such as are eminently cal- culated to allay spasmodic action, without any view to the paralytic affection ofthe bowel. Dissections exhibit very clearly the pathology of ileus. The dis- ease appears to expend its whole force upon the intestines about the intussusception. This intussusception is very satisfactorily presented to our view* One portion of the bowel is drawn within another, and is there firmly constricted —so much so, that in some instances considerable difficulty is experienced in extricating it. Surrounding this invagination, the marks of inflammation are everywhere appa- rent. In some parts, and particularly at the constricted point, gangrene and mortification will generally be detected. Above the intussuscep- tion the intestine will be found distended by feces or flatus, which had been prevented from passing through the constricted portion of the tube. Below, the intestine is generally in a state of emptiness and contraction. In some* cases, several invaginations will be seen in different parts of the fecal tube—each one presenting to a greater or less degree the peculiarities just described. In the majority of cases, the invagination has been found at the arch of the colon, or at the termination ofthe small into the large intestines. The invagination, in the great majority of cases, will be observed to take place from below upwards, although the opposite occasionally obtains. Treatment.—The leading indication in the treatment of ileus is to alleviate, and if possible overcome the spasmodic action of the muscu- lar coat of the intestines, and thus prevent inflammation, relieve the intussusception, and open the bowels. At the very onset of the attack, we should endeavour, if possible, to ascertain the cause, and if hernia be detected, it should immediately be reduced. Cases of ileus have terminated fatally from a neglect of this precaution. Believing the disease to be spasmodic in its nature, and prone to become inflammatory in its progress, we should keep our attention steadily directed to the pulse, remembering that in this case, as well as in all other diseases of the intestines, it very frequently betrays us into error. The least tendency to inflammatory action should be combated by the free use of the lancet. Keeping in mind the rapidity of the progress, and the extreme danger of this disease, we should, without hesitation or delay, abstract blood largely. This alone will in many instances have a decided effect in subduing spasm and pre- venting the occurrence of inflammation. Great advantage may also be derived from topical bleeding by means of cups or leeches applied to the abdomen. Blood-letting having been premised, we may have recourse to antispasmodics with the happiest effects. Of these, opium is decidedly the best. To obtain its most beneficial effects, the sys- tem should be put completely under its impression, by the administra- tion of large and repeated doses. Under the influence of opium, spasm will be frequently allayed, the intussusception overcome, and the bowels evacuated. We may, at this period, with great prospects of success, interpose the use of purgatives. In the employment of these ileus. 329 remedies, we should select such as are mild in their operation and wentle in their effects. Calomel will be found to possess a superiority over every other cathartic. Given in doses of ten grains, alone or with one or two grains of opium, it will frequently be retained on the sto- mach when every thing else would be rejected. Castor oil in small and repeated doses, will frequently be retained, and may prove a useful adjunct. Much reliance is to be placed in enemata. Acting directly upon the diseased intestine, they will often display effects highly salutary. A great variety of enemata have been recommended, all of which may, in particular instances, have had a beneficial influence. Copious injections of warm water will sometimes prove an important auxiliary, by relaxing the spasm, distending the bowels, and perhaps overcom- ing the constriction. Dr. Wiltbank related to me a case of ileus, in which the only remedy that had any influence in overcoming the disease, was a large enema of warm water administered by means of a stomach-tube introduced its whole length per anum. This remedy is worthy of further trial. That the administration of ene- mata by means of the stomach-tube may exert a powerful action in overcoming an intussusception, appears very reasonable. Cold water administered in a similar manner may also have a salutary effect. Tobacco is a remedy of pervading influence upon the abdominal viscera, and evinces such decided relaxing properties upon the mus- cular system generally, that the most happy effects may be anticipated from its employment.* Great caution is requisite in its use: begin- ning with a weak infusion, the strength may be gradually increased, until the system is under its full impression. Of the terebinthinate enema, I know nothing from experience; but from the adaptation of turpentine to many of the diseases of the bowels, I am inclined to think favourably of its powers, more particularly in the sinking stages of the disease. These remedies failing, we should next have recourse to blisters. These are particularly efficacious in cases attended with inflamma- tory action. They should be sufficiently large to cover the whole abdomen. Cold affusions to the abdomen and legs have long been a favourite remedy, and we are led to believe may, in some instances, have proved serviceable. Crude mercury has been used in intussuscep- tions from time immemorial, and is still a favourite practice in Eng- land. Abercrombie recommends it in this disease, in doses of one or two pounds. Whether it has ever proved beneficial, is extremely doubtful. John Hunter's practice in ileus consisted in the adminis- tration of purgatives when the enveloped gut was drawn upwards, and of emetics when it was drawn downwards. But the difficulty of this plan of treatment lies in the impossibility of determining during the life of the patient, whether the constricted gut is drawn within the upper or lower portion of the intestine. * [I have relieved several desperate cases of ileus by the tobacco injection, after the previous use of blood-letting, and of calomel and opium.—Mc] 330 CONSTIPATION. All our remedies will however frequently fail, and the system will sink under the combined effects of spasmodic and inflammatory action. In this case stimulants are indispensable. In the administration of stimulants, it is desirable to select such as possess a purgative pro- perty. The tincture of rhubarb, and the wine or tincture of aloes, will be found to possess these qualities in an eminent degree. Taking into consideration the difficulty experienced in affording relief, and the imminent danger attending an attack of ileus, surgeons have within a few years advised the Caesarean operation. This operation, however, has been performed but in one instance. Dr. Fuschstius* relates a case, in which, after every remedy had proved unavailing, this operation was performed, the invaginated intestine drawn out, and a perfect cure obtained. Further trials of its efficacy in the relief of this disease, will be required, before we should be justified in recommending it as a general remedy. I have only to remark further, that we should resolutely persevere in the use of every remedy that our skill can devise, knowing that recovery is sometimes effected at a very late period, and when, to all appearance, no human effort could restore life. Sect. VI. — Constipation. Constipation is a term of relative import. For the due preserva- tion of health and comfort, it may be laid down as a general rule, that a daily evacuation of the bowels is indispensably necessary. There are, however, exceptions to this rule. It is by no means rare to see individuals who have a natural stool but once or twice in a week ; and cases have been reported, in which weeks, months, and, in one instance, seven years elapsed, without the appearance of a stool. These cases, however, are extraordinary, and should not affect the rule, that the bowels should be opened every day. Constipation of the bowels is generally referable to sluggishness of the peristaltic action of the intestines, or to torpor of the liver. Good ascribes it, in some instances, to excessive action of the intes- tinal absorbents, by which the fluid portion of the feces is too rapidly removed, and they are left dry, scybalous, and difficult to be evacuated. The symptoms attending constipation ofthe bowels are highly dis- agreeable. The breath is offensive; the mouth dry and out of taste; the tongue furred, more particularly in the morning, and at its root; there are ldss of appetite, nausea, headache, flatulence, and distension of the abdomen. The continuance of this affection is apt to induce indigestion, varices in the lower limbs, and piles. Causes. — Costiveness may be produced by an astringent diet, want of fresh air, and active exercise, confinement to any particular posture of the body, neglect of the calls of nature, stricture of the bowels, and other organic disorders of the intestines and liver, and pressure of the uterus during pregnancy. * Hufeland's Journal der Heilkunde. Feb.. 1826. CONSTIPATION. 331 Constipation is often a constitutional disease, or it may become habitual from the nature and continuance of the causes producing it. The studious, the sedentary, the indolent, and all whose occupation confines them within doors, and especially those who are under the necessity of remaining long in any particular posture of the body, are peculiarly obnoxious to this affection. Females, from their want of active exercise in the open air, and during the period of pregnancy, from the pressure of the impregnated uterus upon the bowels, are particularly subject to constipation. Treatment.—In attempting the relief of constipation of the bowels, it should be borne in mind, that simple and dietetic means will, in many instances, be sufficient to accomplish a complete cure. Ripe fruits, such as apples, peaches, pears, prunes, figs, gooseberries, straw- berries, possess aperient properties, sufficient, in many instances, to overcome the most obstinate habitual constipation. Boiled vege- tables are also proper articles of diet. The brown bread made of unbolted flour is a favourite remedy in this disease, and rarely fails in procuring regular and natural stools. All stimulating and astrin- gent articles, such as cinnamon, nutmegs, &c, are injurious, and should be sedulously avoided. Meat should be eaten sparingly and under-done; beef, mutton, fowls, and the various kinds of game, are the most proper animal food. , Exercise is also an important remedy in this affection. It should be regular, active, and in the open air: walking, or riding on horse- back will, in general, prove most salutary. Above alt, however, we should never lose sight of the necessity of a regular attempt at stool. This will frequently overcome attacks of this disease which have resisted every other means. An attempt at evacuations should be made daily at a certain hour, and although for a time we may be disappointed, yet perseverance will ultimately overcome the habit and relieve the disease. Should the treatment recommended fail, or the urgency of the case admit of no delay, we must, without loss of time, administer purgatives. In the selection of these remedies, such should be pre- ferred as operate mildly and effectually. The liver being usually implicated in this disease, the use of mercury in some form cannot be dispensed with. Commencing with calomel alone, or in combina- tion with rhubarb, aloes, jalap, or some other active cathartic, it should be continued until the bowels are freely evacuated. The operation of the cathartics may be greatly aided by the administra- tion of an enema. Injections are indeed an important remedy in this disease, and have, in this country and in England, been too much neglected. They should be simple, emollient, and frequentlyj^ repeated. f^ The bowels having been evacuated, should be kept in a soluble state by the use of laxatives. The remedy I have found most effec- tual for this purpose is a combination of the blue pill, aloes, and 332 INTESTINAL WORMS. tarfarized antimony,* which may be repeated as often as occasion requires. Inspissated ox bile, in pills of five grains each, has been highly extolled, and may, perhaps, in some instances, have proved serviceable. Powdered charcoal has of late years been much used in this disease; care should be taken in its administration, as it, like magnesia, may form concretions in the bowels, and thus increase the disease it was intended to relieve. When it is employed, it should be in combination with some more active cathartic. Castor oil with a few drops of the oil of turpentine, will often display very happy effects. Good quotes two very obstinate cases of constipation, in which affu- sions of cold water over the legs and pubes produced an almost immediate evacuation of the bowels. Should these remedies fail, and the habit become confirmed, the blue pill should be given every night for two or three weeks, and purged off on each succeeding morning by rhubarb. This will fre- quently succeed after every thing else has failed. If it, however, prove inadequate to the relief ofthe disease, the mercury may be pushed to moderate ptyalism. This being accomplished, the disease will, in general, immediately give way, and a rapid cure be effected. . When the constipation is so great, as to resist the operation of ca- thartics and purgative enemata, relief may, in general, be obtained by introducing a gum elastic tube (the stomach tube will answer) as high up the rectum as possible, without applying much force, and then throwing some purgative fluid, as infusion of senna, into the bowels. The quantity injected should be sufficiently large to cause considerable distension ofthe bowel.t Sect. VII.—Intestinal Worms. The origin of intestinal worms is enveloped in great obscurity. In whatever light this interesting subject is examined, insuperable diffi- culties present themselves to the mind. There are but two possible modes in which worms may be produced in the alimentary canal. They are either developed from ovula received into the stomach and bowels, from without, along with the food and drink—or they are formed in the intestines, independently of seminal matter, or ova ge- nerated by similar animals, by new chemical combinations, or what is technically called spontaneous generation. It does not comport with * R.—Massa ex. hydrarg. 9ij. Pulv. aloes grs. xij. Antim. tart. gr. i.—M. ft. Massa in pilul. No. xij. divid., one of which is the dose. t [The influence of galvanism has been relied upon in many cases by practi- ^-tioners in this city. One pole of a light battery is introduced into the mouth, and the opposite pole is attached to a metallic bougie in the rectum. Galvanic beads made of alternate balls of zinc and copper, strung on a piece of whalebone, have also been introduced up the rectum. I have never observed, however, that any permanent advantage has been derived from such measures.—Mc] INTESTINAL WORMS. 333 the design of this work to enter into a detail of the various arguments that have been advanced both for and against these views of the generation of intestinal worms; but it may be observed, that the supposition of their origin from ova received into the alimentary canal, necessarily presumes the existence of similar worms out of the body, by which these ova are generated. This, however, is not confirmed by accurate observation; for, although Linnaeus, Gmelin, and a few others, assert that both taeniae and ascarides have been found in stag- nant waters and in marshes, the ablest helminthologists of the present day, affirm that these worms differ very distinctly, both in structure and character, from those which are found in the intestines of animals. It must be observed, moreover, that earth worms of this kind are of exceedingly rare occurrence, and that they have been met with only in particular districts and localities—a circumstance which strongly discountenances the supposition, that they furnish the semina of intes- tinal worms, so common in man and in the inferior animals in every country and situation. The fact, too, that all intestinal worms almost immediately die when removed out of the body and exposed to the air, or placed in water, militates against the doctrine that they are the offspring of worms, whose natural habitation is out of the animal body; and finally, it has been satisfactorily ascertained, that earth worms and such as live in water, do not change their forms or character when accidentally received into the intestinal canal. Another circum- stance directly opposed to the opinion that the seminal rudiments of intestinal worms are generated by worms out of the body, and con- veyed, in some way or other, into the stomach and bowels of animals, is the fact that intestinal worms have been found in the bowels of new-born foetuses. Kerkringius asserts, that he discovered lumbrici in the stomach of a seventh-month foetus; and in another instance he found a great number of small worms in the bowels of an infant soon after birth. Pallas states, that Brendel found a tape-worm in the bowels of a new-born fcetus; and Heim, according to the testimony of Bloch, met with a similar instance. Rudolphi mentions a case which occurred to the celebrated Blumenbach, in which taeniae were found in the intestines of a recently born pup.* If this view of the generation of intestinal worms be rejected, and to me it appears to be altogether untenable, we are obliged either to confess our total ignorance concerning this mysterious process, which would perhaps be the most prudent, or to resort to the doctrine of spontaneous generation to account for the origin of these parasitic animals. I cannot here enter into the arguments which may be adduced in support of this doctrine; but it appears to me that an erro- neous sentiment of religion has here repressed the spirit of genuine philosophy—in other words, the prejudice, founded on a narrow view of the wise and mysterious scheme of Providence, has not permitted the majority of competent minds to view this interesting subject of research in its true light. The ancient dogma, omnia ex ova, may, I think, be rightfully questioned. When experience and sound * Dr. Bremser—iiber lebende Wiirmer in lebenden Menschen, p. 16. ,334 INTESTINAL WORMS. reason lead us to a conclusion in philosophy, we may safely abide by it, although it may at first sight appear to run counter to the cher- ished sentiments, drawn from the highest source of wisdom and good- ness. Of the causes that favour the production of intestinal worms. —However uncertain our notions may be, in relation to the origin of intestinal worms, observation has made us acquainted with the principal circumstances which favour their generation and increase. Among the remote causes that appear particularly to favour the pro- duction of intestinal worms, are,—a sedentary and inactive course of life; habitual exposure to a humid atmosphere ; the abundant use of fat, and farinaceous articles of diet, and of fresh milk; the use of more food than the stomach can readily digest, or than is necessary to maintain the health and vigour of the system. Dr. Bremser asserts, that in general all articles of food which furnish a very abundant supply of nutrient elements, when habitually taken in larger por- tions than the ordinary wants of the system require, are particularly calculated to favour the generation of worms in the alimentary canal. Some writers have mentioned the free use of sugar among the causes particularly favourable to the production of intestinal worms —but this has been denied by others, whose opportunities of forming a correct judgment on this point were considerable. From the occa- sional epidemic prevalence of verminous diseases, it wpuld seem that there are peculiar atmospheric constitutions, or aerial causes, which favour the generation of intestinal worms. The occurrence of epidemics of this kind has, indeed, been denied and even ridiculed by some ; but if we are to place any reliance on the concurrent testi- monies of some eminent writers, the fact of such epidemics having occurred must be admitted. Marie has given the history of a very remarkable instance of this kind, which occurred at Ravenna and the surrounding district. Bloch, too, has given an account of an epidemic worm-fever. That verminous affections are vastly more common in some countries or districts than in others, is unquestion- able. It is said that in Savoy and Chambray intestinal worms in every class of society are remarkably common, (Daquin, Bremser,) and the same observation has been repeatedly made of Holland and Switzerland. Bremser thinks that the abundant use of milk and cheese in the latter country is probably the principal cause of the great prevalence of worm affections among its inhabitants. The occurrence of the tape-worm is particularly common both in Swit- zerland and in Holland; and it is especially remarkable, that in the former country, the bothriocephalus latus (taenia lata), is by far the most common: whilst in Germany, the greater part of France, in Italy, and even in the Tyrol, the taenia solium (t. cucurbitina) is almost the only species of tape-worm met with. Rudolphi asserts, that in Sweden the bothriocephalus latus occurs very rarely, whilst the taenia solium is by no means uncommon. Species of intestinal worms.—There are five distinct species of intestinal worms, viz: 1. The tricocephalus dispar—(trichuris—tricocephalus homi- INTESTINAL WORMS. 335 nis—ascaris trichuria).—This worm, called by the English " the long thread-worm," is from an inch and a half to about two inches in length. About two-thirds of its length are almost as thin as a horse-hair, the remaining and posterior part being considerably thicker, terminating in a rounded or blunt extremity. The thin part is transversely striated; and the alimentary canal may be seen, by means of a lens, running from its thinner extremity in a direct line through the centre, into the thick posterior portion, where it assumes a fiat and spiral form. These worms are seldom numerous, and are principally found in the caecum. 2. Ascaris vermicularis.—(Oxyuris vermicularis—fusaria vermi- cularis—maw or thread-worm.) This is a very small white worm —the male being not above two liftes in length, with a rounded or blunt extremity anteriorly, tapering to a point posteriorly. The female is considerably larger, being from four to five lines in length, terminating in an extremely fine extremity posteriorly, resembling the point of the finest needle. These worms are found only in the large intestines, and principally in the lower part of the rectum, where they are often collected in almost countless numbers. 3. Ascaris lumbricoides. — (Furaria lumbricoides — lumbricus teres.)—These worms are from two or three to ten or twelve inches in length, round, of a yellowish-white or brownish-red colour, of nearly a ujiiform thickness, except at the extremities, which taper to a blunt point. They are from two to three lines in thickness. The head may be distinguished by a circular depression within a line of one of the extremities, terminating in three small tuberosities or valves, which the worm has the power of opening and closing. When they are opened, a very minute patulous projection may be seen, which constitutes the mouth of the worm. A very small groove passes longitudinally from one extremity to the other, on both sides. The alimentary canal terminates in a transverse depres- sion on the under surface near the posterior extremity. The male is smaller than the female, and may be distinguished by its shortly curved caudal extremity. In some instances the organs of genera- tion are conspicuous—consisting of two small cylindrical projections in the curved part of the tail. These worms inhabit the small intes- tines, and occasionally ascend into the stomach. 4. Taenia lata.—(Bothriocephalus latus—taenia membranacea—t. vulgaris.)—This worm often acquires a very great length—from thirty to forty feet and more. It is from four to ten lines in breadth, flat, white, and composed of a series of concatenated joints, resem- bling a piece of white tape. The head is armed with two processes, by which the worm attaches itself to the intestines. It inhabits the upper portion of the bowels and the stomach. 5. Taenia solium.—(Taenia cucurbitina.—t. osculis marginalibus.) —This worm is rarely if ever voided whole. It is passed off in pieces of a greater or less number of joints, or in single joints bearing a considerable resemblance to the seeds of gourd Pieces, however, upwards of twenty feet in length have been discharged, although generally not more than three or four joints pass off together. The 336 INTESTINAL WORMS. anterior part tapers off into a very fine thread-like extremity, the head being extremely small, and furnished at its sides with four small apertures (ascula). This is the most common species of tape- worm, and like the taenia lata, inhabits the stomach and small intes- tines. Symptoms.—The symptoms which usually arise from verminous irritation, and from the presence of which we may presume the ex- istence of worms in the alimentary canal, are—countenance pale, lead-coloured, with occasional transient flushes; eyes dull; pupils dilated, with a bluish semicircle around the lower eyelids; tickling in the nose ; tumid upper lip ; occasional headache, and humming in the ears; copious secretion of saliva; tongue slimy or furred; breath foul; variable appetite—being sometimes voracious,at others wholly gone; transient pains in the stomach ; occasional nausea and vomit- ing ; pains in the abdomen, particularly about the umbilical region; frequent slimy stools, or costiveness; urine turbid, yellowish, or milky; abdomen tumid and hard, with emaciation of the other parts of the body; lassitude; irritability of temper. None of these symp- toms, however, are certain indications of the existence of worms in the bowels—the only certain indication being the appearance of them in the evacuations from the bowels or stomach. The opinion which has been expressed by some writers, that worms are harmless inmates of the intestinal canal, is most assuredly not founded on correct observation. Without doubt, many of the affections usually ascribed to worms, arise from other causes; and it is quite probable that that peculiar condition of the alimentary canal which favours the production of worms, may be, frequently, mainly concerned in giving rise to the various general affections which attend the presence of worms in the stomach and bowels. That verminous irritation is, however, sometimes the direct and exclusive exciting cause of severe and dangerous affections, is unquestionable. Chorea, epilepsy, hydrocephalus, emaciation, convulsions, mania, paralysis, fevers, dropsy, and a vast variety of anomalous disorders, are some- times the immediate consequences of irritation from worms in the bowels, and occasionally speedily disappear after the expulsion of the worms. Esquirol states, that he has known eleven persons cured of mania, by the expulsion of a large number of lumbrici with anthel- mintic remedies. Treatment.—In prescribing for the removal or destruction of intestinal worms, it is of considerable consequence to confine the patient to a spare and liquid diet, and to exhibit, two or three mild purgatives a few days previous to the exhibition of the proper anthel- mintic remedies. With these preparatory measures, the ordinary vermifuge remedies will not disappoint us so often as without them. My own plan of management for the expulsion of the long round worm (lumbricoid,) is to put the patient on a liquid diet, and to order him a small dose of Epsom salts every morning for three or four days. On the fourth morning I direct a decoction of the root of spigelia, in the proportion of an ounce of the root to a pint of water boiled down to half a pint. This being sweetened, is to be INTESTINAL WORMS. 337 drunk in the course of three or four hours, by a child of from five to ten years old, commencing in the morning after having taken a little milk and water into the stomach. As soon as the whole of the decoction is taken, an active dose of calomel and jalap is to be ad- ministered, or a dose of castor oil and turpentine, in the proportion of half an ounce ofthe former to two drachms ofthe latter, given in doses corresponding to the age of the patient. I have rarely failed, by this plan, to procure the discharge of worms, where they existed in the bowels. A vast number of remedies and modes of treatment have been recommended for the expulsion of this species of intestinal worms. Bremser speaks very highly of the vermifuge powers of the following electuary.* A teaspoonful is to be given to a child every morning and evening for six or seven days. I have used this electuary in four or five cases with complete success. It should not be given to the extent of producing frequent and watery evacuations. I have found it to do most good when it procured three or four con- sistent stools daily. Rudolphi asserts, that the anthelmintic oil of Chabert (oleum empyreumalicum Chaberti) is decidedly the most efficacious vermifuge we possess; and both Bremser and Brera have added their testimony in favour of its usefulness in this respect.t Fifteen or twenty drops may be taken three or four times daily by children from two to seven years old. Small doses of calomel with the powdered roots of spigelia and valerian may also be resorted to with a prospect of advantage. There is danger, however, of pro- ducing ptyalism from giving calomel in this way—more especially as it is generally necessary to continue its use for several days before its anthelmintic powers can be properly obtained. The most effica- cious vermifuge remedies for the expulsion or destruction of the round worms, besides the articles already mentioned, are—chenapo- dium anthelminticum; sem. santonic; tin filings; garlic; conferva helminthocordon; spirits of turpentine; geoffrea surinamensis; the green rind of unripe walnuts ; and camphor. To prevent the rapid reproduction of worms, after they have been expelled or destroyed by anthelmintics, recourse must be had to tonics —particularly chalybeates, in conjunction with minute portions of aloes, and a plain and abstemious diet. A strong decoction of the helminthocordon has appeared to me not only very valuable as an anthelmintic, but particularly also to remove that debilitated and dis- ordered state of the alimentary canal, which favours the production * R.—Sem. santon. sive tanacet. rudet. contus. if ss. Pulv. rad. valerian, gii. ---------jalapae 33s—Qii. Sulphat. potassae giss—^ii. Oxymel. scillit q. s. ut fiat electuar.—M. t This oil is made by mixing one part ofthe fetid spirits of hartshorn with three parts of the spirits of turpentine, and suffering them to digest for four days. The mixture is then to be put into a glass retort, and distilled in a sand-bath until three- fourths of the whole have passed over into the receiver. This is to be kept for use in small and well-closed vials. vol. 11.—23 338 INTESTINAL WORMS. of worms. An ounce of this marine vegetable, with a drachm of valerian, should be boiled in a pint of water, down to one gill. Of this, a teaspoonful may be given every morning, noon and evening, with peculiar advantage, to children labouring under verminous affec- tions. I have, in several instances, known the use of this decoction to restore perfect health to children who were supposed to labour under verminous irritation, without any appearance of worms in the evacua- tions. It has appeared to me particularly beneficial in cases attended with the usual symptoms of worms, connected with want of appetite and mucous diarrhoea, arising from mere debility of the digestive organs, and vitiated secretions in the bowels. Ascarides.—These little worms are generally extremely annoying. During the day they seldom give rise to much inconvenience; but in the evening, and particularly soon after lying down, they usually occasion a very distressing, and, indeed, an almost insupportable itch- ing and titillation in the lower part of the rectum and the anus. So extremely distressing is the sensation which they cause in these parts, that nervous children are sometimes thrown into convulsions by it. In females, these worms sometimes pass into the vagina, and give rise to very great uneasiness. Dr. Bremser states, that he has known an instance in which symptoms of nymphomania were excited by the irritation of ascarides, which had made their way into the vagina. They are generally most troublesome during damp weather. The removal of ascarides is often attended with great difficulty, for although the inconveniences which they create may be removed for a time, they almost always recur again and again, in those who are once infested with these worms. From the location of these worms, in the lower part of the rectum, little or no advantage can be obtained from the use of anthelmintics administered by the mouth; and even active purgatives seldom evacuate them sufficiently. Aloes, however, from its decided tendency to act on the lower portion of the bowels, will occasionally expel them in great quantities, particularly when assisted with proper enemata. My usual mode of proceeding for the expulsion of these troublesome worms, is to prescribe three or four aloetic purgatives every second day, together with two or three ene- mata composed of a mixture of lime-water and milk, in equal pro- portions daily. Injections of a solution of aloes, or of infusions of any of the above-named vegetable anthelmintics, will generally bring off* an abundance of these annoying little worms. I have, in a few instances, brought them away in great quantities, by injections com- posed of spirits of turpentine mixed with milk, in the proportion of a teaspoonful of the former to a gill of the latter. The introduction into the rectum of a bougie smeared over with mercurial ointment, has been employed with success for the destruction of ascarides; and Nil Rosen speaks very favourably of injections composed of a drachm of refined sugar dissolved in warm milk. When ascarides have passed into the vagina, injections of cold water with a small portion of vine- gar, are, according to the experience of Dr. Bremser, the best remedy we possess. Dr. Van Vest asserts, that flowers of sulphur, taken in INTESTINAL WORMS. 339 the morning on an empty stomach, are one of the most efficacious remedies for the destruction and expulsion of these worms. Tape-worm.—For the expulsion of the tape-worm, a very great variety of remedies and modes of treatment have been recommended. The anthelmintics that have been found most effectual against this species of intestinal worms, are—polypodium felix; spirits of tur- pentine ; tin; valerian ; the bark of the pomegranate root; and the empyreumatic oil of Chabert. Whatever mode of treatment be adopted, it is always of much consequence to prepare the patient by proper diet and laxatives before the proper vermifuges are given. A spare and liquid diet, with the daily use of small doses of saline purgatives for four or five days, will greatly increase the chances of procuring the expulsion of the worm, by the use of anthelmintic or active cathartic remedies. The following is the substance of some of the most celebrated methods of treatment recommended for the removal or destruction of taenia. Alston's method.—On the first day the patient is actively purged with an infusion of senna and manna. On the following morning an ounce of pure tin filings, mixed with common syrup, is to be taken (by an adult): and on the second and third morning respectively half an ounce of tin filings is administered, which is followed on the fourth morning,by an active dose of senna and manna. Pallas speaks in very favourable terms of this mode of management, and assures us that he has several times succeeded completely in effecting the expul- sion of taenia with it. Bremser also has employed it with success in a few cases. Desault's met hod consists in the employment of mercurial frictions on the abdomen, followed by drastic mercurial purges. Herrenschwand's method.—A drachm ofthe powdered male fern root is to be taken morning and evening on an empty stomach, for two days in succession. On the morning of the third day the follow- ing purgative must be taken. * Three hours after this dose is swal- lowed, the patient must take an ounce of castor oil, and this dose must be repeated in an hour; if in three hours, after the second dose of oil, the worm has not been expelled, a third dose of it is to be taken; and should all these fail in procuring the expulsion of the worm, an injection of three ounces of castor oil in warm milk and water, should be administered in the evening. Hufeland's method.—A cup of a decoetion of garlic in milk is to be taken every morning on an empty stomach; and a tablespoon- ful of castor oil every morning, noon, and evening, with half an ounce of tin filings daily, and frictions on the abdomen, with petro- leum twice every day. The patient is to eat salted food. This method must be pursued for several weeks, or until the head of the worm is expelled. * R.—P. gambogiae gr. xii. Subcarbonat. potassa? gr. xxx. Sapo venet. gr. ii. Misce.—To be taken at one dose. 340 INTESTINAL WORMS. Nouffer's method.—This mode of treatment was at one time in high esteem ; and many very respectable names might be mentioned in testimony of its occasional efficacy for the expulsion of the tape- worm. In the evening the patient must take a bowl of panada for his supper ; fifteen minutes afterwards a glass of light wine with a biscuit; and if the bowels were not moved during the day, an enema composed of an infusion of mallows and a little common salt, with a few ounces of sweet oil, is to be administered. Early on the follow- ing morning, eight or nine hours after the panada was taken on the preceding evening, the following powder is to be administered, while the patient is yet in bed.* Should this be rejected by the sto- mach, a second dose must be taken. Two hours after this powder is swallowed, the following purgative bolus must be administered ;t after which the patient should drink a few cups of green tea, and walk about in his chamber. As soon as the purge begins to operate, a cup of weak tea must be drank at short intervals, until the worm passes off. When this occurs, and not sooner, he may take a mode- rate portion of animal broth. If this course of management do not succeed in bringing off the whole of the worm, it should be repeated in the same manner as has just been described. This method will frequently succeed in expelling the taenia bothriocephalus; but it does not appear that it is capable of effecting the expulsion of the t. solium. M. Odier recommends the use of three ounces of castor oil instead of the above purgative bolus ; and it would appear from the observations of other writers, that this modification of Madame Nouffer's plan is advantageous. M. Rathier speaks highly of the following composition as a reme- dy for the expulsion of tape-worm.$ Schmucker's method, which has been highly praised, consists in the employment of the seeds of sabadilla. The pods with the seeds are to be finely powdered; out of which boluses are to be made containing five grains of the powder. Having purged the patient well with rhubarb or Glauber salts, on the following morning, half a drachm of the sabadilla powder, rubbed up with an equal quantity of sugar, is to be takeri. This generally causes vomiting. In ah hour after this powder is taken, some barley-water or oat-meal gruel should be swallowed. On the next morning another dose of the * R.—P. rad filicis mar. ^ii—giii.—To be taken in six ounces of common water. t R-—Submuriat. hydrarg. P. scammon., aa gr. x. G. gambogiae gr. vi—vii.—M. ft. bolus. X R.—Pulv. herb, saben. gr. xx. Pulv. sem. ruth. gr. xv. v Submuriat. hydrarg. gr. x. 01. distil, tanacet. gr. xi. Syrup, folior. persicor. q. s. Ft. mass. ex. quo. form. bol. no. ii.—One of these boluses is to be taken in the morning and the other in the evening. INTESTINAL WORMS. 341 sabadilla powder must be administered, which will again excite vomiting. If no worms are discharged after this dose, the patient must take but fifteen grains of the powder on the following morning, but the same dose should be repeated in the evening ;"and the same doses are to be taken on the fourth day. On the fifth day, a purge, composed of thirty grains of powdered rhubarb with eight grains of rosin must be taken. On the morning of the sixth day, three of the above-named boluses must be swallowed, and the same number on going to bed. In this way the treatment must be continued for twelve, fifteen, or even twenty days; and Schmucker asserts, that when properly persevered in, it will seldom fail to effect the expul- sion of the worm. Bremser's method.—Mr. Bremser assures us, that, by the follow- ing method of treatment, he has succeeded in more than five hun- dred instances, in procuring the expulsion of the taenia solium. The cure is commenced by taking three times daily a teaspoonful of the electuary already mentioned for the expulsion of the round worm. (Sem. cinae; rad. valerian; p. jalap; and tart, vitriol.) When the whole of the portion ordered in the formula is thus used, two tea- spoonfuls of Chabert's anthelmintic oil must be taken every morning and evening in a little water. If it occasions vertigo, as is some- times the case, the dose should be diminished. After the patient has taken this oil about ten or twelve days, he must take a purgative ;* after which the use of the oil must be continued. In general it re- quires from four to five ounces of this oil before the cure is effected. The spirits of turpentine has of late years been highly recom- mended as a remedy for the expulsion of tape-worm. From two to three ounces of this article may be given at once, and followed in about two hours by a strong dose of castor oil. From the ac- counts which have been published, of the employment of this article as a vermifuge for taenia, there can be no doubt that it is well de- serving of attention as a remedy for this purpose. I have known it to be used with complete success in one instance. In a late num- ber of Hufeland's Journal, the following formula is highly recom- mended as a remedy against tape-worm:— R.—Tereb. venet. §i. Sapon. jalapin. ^ss. Extract, hyoscyam. gr. iv. Calomel gr. viii.—M. Divid. in pil. pond. gr. ii. Take four every three hours—the patient taking nothing but very thin broth for his food. If the worm is not expelled the first day, the use of the pills must be continued for three or four days. Dr. Wilde used this remedy with success in two cases; aud an instance was successfully treated with it in the Polyclinic Institute of Berlin.! * R.—Rad. jalap. 7)i. P. fob sennae ]§ss. P. sulph. potassae 3b—M. Divide into three equal parts. Take one every hour. t Hufeland's Journal. June, 1826. 342 INTESTINAL WORMS. The extract of the male fern has lately been employed for the cure of taenia with marked success. Dr. J. I. Ebers has given an ac- count of eight cases, in which this extract was used with the happiest effects. He gave from eighteen to twenty-four grains of the extract divided into two doses. In general this quantity has been sufficient to cure the patient. In some instances, however, it was necessary to repeat the dose three or four times. On the day after the extract was taken he administered an active cathartic, which generally brought away the worm. From his experience with this remedy, Dr. Ebers draws the following conclusions: 1. The extract of male fern root is one of the most certain means that can be employed against the tape-worm; 2. It generally kills the worm speedily; 3. It acts as a specific; 4. It does not expel the worm in a ball or mass as other anthelmintics usually do; 5. This medicine acts, usually, in a mild manner, and without producing any severe symptom: once only it produced some severe effects in a female, who had not the tape-worm; 6. It also expels ascarides, but does not kill them.* The root of the pomegranate also is a valuable remedy for the expulsion of the tape-worm. Dr. Ruggia, a physician of Naples, has employed it with great success; and Dr. Mile informs us that in his hands it has proved very effectual. I am informed by Dr. Mease, of this city, that he has used it in one instance with entire success; and he has heard of other instances in which it effected a cure, in this country. It is somewhat singular that this valuable remedy should so long have been neglected by the profession; for it is only within a few years past that we have heard any thing con- cerning its active anthelmintic powers, although, among the ancients, it appears to have been a favourite and common remedy for this purpose. Celsus prescribed it for the expulsion of taenia ;t and it is strongly recommended by JEtius, as a most efficacious remedy for this purpose.^ Two ounces of the fresh root are to be sliced finely, and slowly simmered in a pint of water down to half a pint. Of this decoction, one-third must be taken early in the morning on an empty stomach, and another third every two hours. If this does not expel the worm, the same is to be repeated next day, and so on. The diet should * Amer. Journ. Med. Sciences, vol. v, 214, quoted from the Journ. de Chimie Medicale. t Si lati sunt, aqua potui dari debet; in qua lupinum, aut cortex mori decoc- tus sit: aut cui adjectum sit contritum vel hyssopum vel piperis acetabulum, scammoniae paulum. Vel etiam pridie, cum multum alium ederit, vomat. Pos- teroque die malipunici tenues radiculas colligat, quantum manu comprehendet, casque con- tusas in aquas tribus sextariis de coquet, donee tertia pars superset; huic adjkiat nitri paulum et jejunus bibat. Interpositis deinde tribus horis duas potiones sumat talis aqua? vel muriae dura? huic adjectae; rum desideat, subjecta calida aqua in pelve.— Celsus, De re Med., lib. iv, cap. xvii.—I doubt whether any treatment proposed by modern physicians, is better calculated to effect the expulsion of taenia than the one here recommended by Celsus. X Tetral. iii, serm. i, c. 39, 40. HEMORRHOIDS. 343 be liquid, and an active purgative given after the third portion is taken.* Sect. VIII.—Hemorrhoids.—Piles. Hemorrhoids having of late years been considered as more espe- cially belonging to the province of the surgeon, we need not wonder that they are now much too exclusively regarded as mere painful tumours of a local character, the cure of which should never be delayed. Dr. Gregory observes, that the hemorrhoidal flux was for- merly " believed to be a salutary provision of nature for the advan- tage of the constitution. The sudden suppression of it, therefore, was highly dreaded. These notions have passed away; and piles are now regarded as a painful and disagreeable complaint, arising in most cases from local causes, the cure of which should never be de- layed." Upon this point, however, we may reasonably demur; for, without regarding this affection as "a special effort of the vis medi- catrix naturae," observation and experience have, I think, amply demonstrated the fact, that these tumours, and the consequent effu- sion of blood, are in many cases the consequence of plethora of the portal vessels generally, attended with a particular sanguineous de- termination to the vessels ofthe lower portion of the rectum, arising perhaps generally from constitutional causes, analogous to the san- guineous afflux to the uterus during the menstrual periods in females. The premonitory symptoms which usually precede the appearance of the hemorrhoidal flux—the molimina hemorrhoid alia—gene- rally indicate a preternatural afflux to, and congestion in the vessels of, the lower part ofthe abdomen; and I apprehend, the precept that the suppression of this hemorrhage should " never be delayed," would, if it were generally followed, afford no very gratifying illus- tration of the supposed advancement of our science in relation to this subject. Without doubt, hemorrhoidal tumours are sometimes the result also of mere local causes, and may be safely removed as soon as possible. But whether the original cause be local or general, we may well doubt the propriety of suppressing the discharge after it has become habitual. A deranged state of the circulation and plethora of the abdominal viscera, and especially of the lower portion of the intestinal canal, is * [I once caused the expulsion of an entire tape-worm from a young lady, by active purging with croton oil. During my attendance on the Philadelphia Alms House Hospital, I allowed a veteran sufferer fom the same evil to cure himself by permitting him to subsist for three days upon brandy and spirits of turpentine. His name was George Williams, and he had been afflicted with the disease in its worst form for several years. He swallowed the turpentine in half pint draughts at a time, and brandy in still larger quantities, both of which he repeated several times without exciting either strangury or intoxication. At the end of three days he expelled many yards of a large taenia, and was effectually cured. He remained well under my occasional observation for many years.—Mc] 344 HEMORRHOIDS. never absent in this affection, unless the piles arise wholly from local cause's, and consist rather of an indurated or thickened state of the mucous membrane than of vascular or varicose tumours. The Veins of the rectum, in consequence of this state of the portal circulation, become dilated or varicose, or the blood is effused into the cellular membrane beneath the mucous membrane of the rectum, forming sanguineous tumours. " In consequence," says Montegre, " of vari- ous causes which are sometimes beyond our cognizance, sanguineous determinations occur at certain periods, towards the lower part of the rectum. This, at first, gives rise only to a feeling of tension and weight in the pelvis and extremity of the rectum—which, as it is not attended with actual pain, is often scarcely noticed, and usually sub- sides in three or four days. After a longer or shorter lapse of time, these symptoms are renewed, which generally terminate in a dis- charge of florid blood, spread over but not mingled with the faeces. This blood issues by a kind of exhalation from the mucous membrane of the rectum, without any lesion or erosion of this tissue whatever. After these fluxionary movements have returned more or less fre- quently—sometimes after a few repetitions, tumours of a greater or less size, and more or less painful, begin to make their appearance."* As has already been intimated, there are two kinds of hemorrhoidal tumours, viz.: the vascular or varicose swellings just mentioned; and those firm, spongy tumours, more commonly called piles, which arise from a thickened and condensed state of submucous cellular tissue. These two forms of the disease may be readily distinguished from each other by the following characteristic circumstances. The former or varicose tumours are of a dark and bluish colour, soft and elastic to the touch, broader at the base than at the apex, rounded or some- what hemispherical, and considerably lessened by gradual pressure with the fingers, though quickly returning to their usual size when the pressure is removed. They generally occur in regular clusters, and often extend high up along the rectum. The other variety of hemorrhoidal tumours appears like small fleshy tubercles of a pale-red or brownish colour, situated a short distance above the margin of the anus, or descending like pendulous excre- scences from the rectum. They have a somewhat firm and spongy feel, "and when cut into, present a more or less compact surface, from which the blood oozes, leaving the texture pale and relaxed." When they are situated externally, they are paler and more elastic and transparent. These tumours frequently contain a small cavity in the centre, containing fluid or coagulated blood. More commonly, however, no such cavity exists, the whole substance of the tumour being infiltrated with blood, becoming at last coagulated and dark.t "The manner in which these hemorrhoidal excrescences are formed, is in general pretty uniform. The patient is at first made sensible of its development by a peculiar pricking, stinging sensation, generally within or around the margin of the anus, and on applying the finger * Dictionnaire des Sciences Medicares, art. Hemorrhois. t Practical Treatise on Hemorrhoids, &c.; by George Calvert, p. 35. HEMORRHOIDS. 345 to the part it is felt slightly elevated, as if some newly-formed sub- stance were forcing its way to the surface. The increase of these tumours, when once they become permanent, does not take place in every direction; they elongate rather than expand, the body being usually of a conical shape, and larger than the neck. Sometimes more or less blood is exhaled from their surface; on other occasions a serous fluid only is exhaled, or they remain nearly dry ; but in either case they generally disappear in a short time, and return again at an uncertain or irregular period, increasing in size, and becoming firmer in texture with each repetition." (Calvert.) General symptoms and consequences of hemorrhoids.—The ap- proach of an attack of hemorrhoids is frequently announced by various symptoms denoting a deranged state of the circulation. In most in- stances, the patient experiences, for several days, before any manifes- tations of the local hemorrhoidal affection occur, a sense of weight and pressure in the abdomen, with a peculiar feeling of uneasiness in the bowels, constipation, and a sensation of bearing down in the rectum or perineum, attended, frequently, with horripilation in the back and loins,* slight flatulent pains in the stomach and colon, scanty and high- coloured urine, pale countenance, an occasional confused sensation in the head, general lassitude and heaviness of the extremities, an irrita- ble and discontented state of the mind, a hard and contracted pulse, and a sense of anxiety and fullness in the epigastrium. In many cases an unusual desire for venereal enjoyment, with strong erections, and even nocturnal pollutions take place ;t and the patient often experi- ences a troublesome itching in the glans penis, and occasionally slight swellings and tenderness ofthe prepuce and testicles, attended some- times with a blennorrhceal discharge from the urethra.:): These symptoms are not, in general, continuous. They are apt to remit, or to disappear entirely for a short time, and then return again, especially on committing errors in diet, taking stimulating drinks, or making unusual corporeal or mental exertions. They generally con- tinue, in a greater or less degree, until the tumours either burst and relieve the engorged vessels, by a free discharge of blood, or until they begin to decline and disappear. In some cases, however, these mo- limina hemorrhoidalia, after having continued for some time, dis- appear again, without the occurrence of the local hemorrhoidal affection. The local affections which attend hemorrhoidal tumours, are some- times extremely severe and distressing. In some instances the elon- gated fleshy tumours, at last, become inflamed and give rise to severe pain—particularly during the expulsion of feces. When they are situated high up, they are often forced down past the sphincter, and from the irritable condition of the parts, and the enlarged and exquisitely tender state of the tumours, they cannot be again returned- In this situation they give rise to continued and extreme suffering, * Pinel, Nosograph. Philos., vol ii. f Lentin, Bertraeg. zur Ausuebent Arzneiwiss, vol. ii, p. 365. X Richter, Specielle Therapie, bd. iii, p. 350. 346 HEMORRHOIDS. and the inflammation occasionally runs so high as to cause suppura- tion and sloughing. When the inflammation extends to the surrounding mucous mem- brane, it gives rise to a blennorrhceal discharge from the tumours and lower portion of the rectum—consisting of a thin, acrid, and mucous secretion, which soils the patient's linen, and causes tenderness and excoriation about the anus. Sometimes the tumours break, leaving fissures, which, from the irritation caused by the motion of the parts, and the passage of indurated feces, as well as the acrid secretions, are converted into very painful irritable ulcers. Mont6gre has classed the pains which attend hemorrhoids under four heads. 1. Those which arise from active inflammation, characterized by heat, tension, and throbbing in the part, varying from a moderate degree of these sensations to the most excruciating sufferings. 2. Nervous pains, characterized by the intermissions and the very sudden increase and diminution to which they are subject, as well as the considerable relief which is generally obtained by pressure. These pains do not appear to depend either on fissure or strangulation^of the tumour, and often take place without any evident inflammation. They some- times supervene after the inflammation has v subsided, and may con- tinue, with variations of intensity, for several months, and occasionally much longer. (Montegre.) The pain which usually attends fissures, or rhagades of the tumours or edge ofthe anus, are distinguished by the following circumstances. On going to stool the patient experiences a slight stinging pain in a certain part of the rectum or anus. After the feces are expelled, the pain increases more or less rapidly until it becomes excruciatingly severe—in which state it usually continues until "exhausted, the patient falls into a sound sleep, from which he awakes free from suffering." No further pains are experienced until the patient again goes to stool, when they are renewed in the same way as before. Contraction of the anus is no uncommon consequence of habitual hemorrhoids, and may arise—1. From a number of tumours formed around the internal surface of the rectum, a short distance above the anus, which, when pressed down on going to stool, approximate each other, and diminish the passage so as to create more or less diffi- culty in voiding the feces—more especially when they are hard. 2. From induration of the cellular tissue near the extremity of the rectum, giving rise to a progressive decrease of the size of the passage, being in general unaccompanied with pain, except when the patient goes to stool, and the feces are hard. 3. From spasmodic constriction ofthe anus.—This appears to occur almost exclusively in persons of a nervous and irritable temperament. When the patient goes to stool, the sphincter of the anus being irritated by the feces, contracts spas- modically, and with such force, that extreme difficulty and pain occur in voiding the contents of the rectum, and any attempt to introduce the finger, with the view of examining into the state of the affected parts, is attended with the same difficulty and severity of pain. It is often wholly unconnected with inflammation or fissure. Sometimes HEMORRHOIDS. 347 ulcers, abscesses, and fistulae are formed near the extremity of the rectum, terminating occasionally in fistula ani. Among the most common consequences of this affection is a kind of tenesmus, with protrusion of the inner tunic of the rectum, so as to form a prominent and extremely sensitive ring around the anus— particularly after each attempt to expel the feces. The tenesmus seems, in part, to be caused by the afflux of blood to the affected parts, and also by the impressions of the feces upon the irritable mucous membrane of the lower part of the rectum, by which a fre- quent desire to stool is created, which being repeatedly assisted by ineffectual efforts to evacuate the feces, gives rise to permanent in- duration, scirrhus, and even cancer ofthe rectum. (Montegre.) Causes.—The causes of hemorrhoids may be classed- under two heads—namely, general and local. Among the general causes some are evidently simply predisposing; whilst others are more imme- diately concerned in exciting the hemorrhoidal affection. There appears to be a peculiar physical temperament or abnormal condition ofthe body, which predisposes in an especial manner to the occurrence of this affection; and it would seem that this hemorrhoidal constitution is often manifestly hereditary. Richter supposes that this predisposi- tion consists principally in an original inactivity of the circulation in the abdominal viscera, in consequence of which habitual congestion of the portal vessels is established. Be this as it may, it appears very evident that persons of a sanguino-bilious, or as it has also been termed, sanguino-melancholic habit of body, are most prone to hemor- rhoidal affections. Of the very" great influence of age in favouring the occurrence of this disease, there can be doubt. Hemorrhoids before the age of twenty-one years, is far from being common, and when the disease does occur at or before this period of life, it is almost always the consequence of local causes, or of other diseases giving rise to congestion in the portal vessels. f From thirty to fifty years of age is the period to which the appearance of these tumours is in a great measure confined. Those who remain free from the disease until they attain the age of fifty, seldom afterwards become more than very temporarily affected by it. Although pregnancy, and the final cessation of the menses, are well calculated to favour the occurrence of sanguineous congestion in the vessels ofthe abdominal viscera, and particularly of the rectum, yet, with the exception of the periods when these conditions are present, hemorrhoidal affections appear to be much more common in males than in females.* The influence of age in favouring the occurrence of this malady, may be accounted for from the natural tendency of the venous to pre- dominate over the arterial system, as individuals advance in age—and especially, from the equally manifest tendency in middle and advanced age to a sluggish state of the circulation in, or perhaps an increased sanguineous determination to the abdominal viscera, in consequence, probably, of a natural disposition, aided by the many causes which, as life advances, intervene, and tend to the same effect—such as * Jahn. Klinik. der Chron. Krank., bd. iii, 453, 348 HEMORRHOIDS. the depressing passions, a more inactive course of life, debility ofthe digestive organs, and consequent torpor of the liver and bowels. I have stated that the predisposition to hemorrhoids appears sometimes to be hereditary ; but it is probably, also, in many instances, acquired during infancy from improper dietetic management, and the habitual use of purgative medicines, so common, and in its ultimate tendency, so injurious a practice with nurses and mothers. Habits of life tending to determine the blood to the abdominal viscera, or to cause congestion in the portal vessels, are by far the most common source of hemorrhoidal affections. A studious and sedentary habit; a superabundance of high-seasoned and stimulating food; the depressing passions; the intemperate use of spirituous drinks; and the very free use of strong coffee,* are among the most active general causes of this affection. It is probable that these causes operate towards the production of hemorrhoids chiefly by producing weakness of the digestive organs, as well as torpor of the liver and intestinal canal—giving rise to habitual costiveness, and consequently to a sluggish and congested state of the portal circulation. When to these conditions is added the local irritation of the rectum and anus caused by the remora and passage of hardened feces, it is obvious that hemorrhoidal tumours must be especially apt to occur. Among the local causes of hemorrhoids, besides constipation, we may mention the abuse of active purgatives—particularly aloetic prepa- rations ; stimulating enemata; frequent excitation of the venereal organs; pregnancy; parturition; suppositories; clothes worn so tight as to compress the abdomen; ascarides ; irritating applications to the anus after going to stool; indurations of the liver or spleen ; riding on a hard trotting horse ; dysentery; the irritation of calculus in the bladder; enlargement ofthe prostate gland; lifting and carrying heavy burdens. Hemorrhoids have been divided into a great number of species; but although these classifications may be convenient for imparting a full view of the subject to learners, they do not appear to possess any particular practical value. It is sufficient to bear in mind, that there are two kinds of hemorrhoidal tumours—one consisting in a dilated or varicose state of the veins, which may inflame, burst, and give exit to copious discharges of blood ; and another kind, more common—consisting in firmer, fleshy, somewhat spongy elongated tumours or excrescences—which may inflame, open into fissures, ulcerate or remain entire, and give rise to the various painful and distressing affections already described. When the former tumours burst and bleed, they are called hemorrhoides fluentes, or bleeding piles : when the tumours do not bleed, they are termed h. coecae, or blind piles. Treatment.—May we, with safety, attempt to remove or suppress these tumours; and more especially, is it prudent speedily to sup- press the sanguineous discharges to which they give rise ? Upon this subject very discrepant opinions have been expressed. Cullen * Richter, Jahn, loc. cit. HEMORRHOIDS. 349 was of opinion that the disease is*but very rarely of a constitutional character; and, consequently, that it ought, in all cases, to be removed as speedily as possible ; as no danger, he presumed, need be appre- hended fromthe immediate suppression ofthe hemorrhoidal discharge. Dr. Gregory appears to be of the same opinion. This view of the sub- ject, however, would inevitably lead to very disastrous consequences, were it generally adopted in practice : for, although hemorrhoids are, in many cases, of a purely local character, and in such instances may be removed as soon as convenient, without any detriment to the system, yet both experience and analogy present us with abundant testimony of the dangerous consequences which are liable to result from a hasty interference with the hemorrhoidal discharge, where the disease is founded, as it very often is, on a constitutional predis- position.* In cases that depend on a constitutional hemorrhoidal tendency, and that have become habitual from long continuance or frequent recurrence ; or where the general health or some chronic affection has been improved by the supervention of hemorrhoidal dis- charge; and especially where the disease is preceded and accompanied in its progress by distinct manifestations of an hemorrhoidal effort in the system, very particular caution should be exercised in the appli- cation of remedies calculated to suppress the disease. Nevertheless, where the discharge is excessive, and endangers the life of the patient by the great depletion it causes, we need not hesi- tate to interfere with the progress of the disease, so far, at least, as to moderate the hemorrhage, and obviate the immediate and remote dangerous consequences from this source. The general indications to be kept in view in the remedial management of this affection are —to remove and counteract the tendency to plethora in the portal circulation; to obviate the predisposing and occasional causes; to moderate the hemorrhage where excessive; and to prevent and re- move local inflammation and its consequences. During what may be called the latent stage of the disease, when the various premonitory symptoms enumerated above, the molimina hemorrhoid alia, exist, a general treatment calculated to remove the plethora of the portal vessels, as well as all irritation and preternatural determination to the vessels of the rectum, should be pursued, with the view of obviating or moderating the approaching hemorrhoidal attack. For this purpose, the patient should be put on a light vege- table diet; and if the pulse be full and active, blood should be freely drawn. Particular attention too must be paid to the state of the bowels. If they cannot be kept in a soluble state by vegetable diet, some ofthe milder laxatives, particularly the flowers of sulphur and * [During the last 15 years, I have been in the habit of extirpating all trouble- some hemorrhoidal tumours, either by the knife or ligature, without any such troublesome consequences. Even after long-protracted hemorrhages which have resulted in complete anemias, I have succeeded in restoring excellent health by my operations. I may quote the high authority of Dr. Chapman upon this point, who invariably recommends extirpation of the tumours, in all vexatious cases.— Mc] 350 HEMORRHOIDS. cream of tartar,* with an occasional dose of blue mass in the evening, should be given once or twice every day, in doses sufficient to keep the bowels loose, without producing actual purging. The patient must lie on a matress, rise early, take gentle exercise by walking, avoid severe mental or very active corporeal exertions, abstain from stimulating drinks, as well as from condiments, and according to the observations of Jahn and Richter, from the use of strong coffee. Treatment of the hemorrhoidal discharge.—When the tumours burst and pour out blood, the patient almost always soon feels con- siderably relieved. The confusion and uneasiness in the head, the irritability and depression of the mind, as well as the general lassi- tude, tension, and aching in the loins, pressure and weight in the peri- neum, and in general all those symptoms which have been mentioned as indicative of the hemorrhoidal effort, abate very materially, and in many instances almost entirely disappear. So long as the hemorrhage remains moderate, it may with propriety be regarded as a salutary discharge, in reference to the radical affection, or state of the circula- tion in the portal vessels. It should always be recollected, that the discharge of blood is only one of the ultimate consequences of hemor- rhoids; and that as its direct tendency is to lessen the engorgement of the vessels of the rectum, and consequently to reduce the vascular hemorrhoidal tumours, it is obviously most proper to leave the hemor- rhage to itself, unless it becomes very profuse, or inordinately pro- tracted. We cannot, however, decide from the mere copiousness of the discharge, whether it should be regarded and treated as a morbid excess or otherwise ; for some individuals will bear very large evacu- ations in this way, whilst others will be much debilitated and ex- hausted by a smaller loss of blood. Whenever the pulse becomes weak, the countenance pale, and the prolabia exsanguious, with much debility, general relaxation, and spasmodic symptoms, means should be adopted to restrain or arrest the evacuation. Here it must be recollected, that this, as well as other varieties of hemorrhage, may be connected with a manifest phlogistic diathesis of the general sys- tem on the one hand, or a relaxed, prostrated, and sluggish state of the general and abdominal circulation; in other words, that there is * R.—Flor. sulph. crem. tart., aa ^§ss.—M. Take a teaspoonful twice or thrice daily. When the intestinal canal is in a debilitated and very torpid condition, Richter recommends the following composition: R.—Tartar depurat. Magnes. carbon. Flor. sulph., aa 3b. P. camphors gr. viii Pulv. sem. fcenicul.giii.—M. Divide into 14 equal parts. Take one every three hours. Hildebrandt speaks very highly of a mixture of sulph. sodae and tincture of rhubarb, as a laxative in such cases. Two drachms of the salt, dissolved in two drachms of water, to which the same quantity of the aqueous tincture of rhubarb is to be added. One half to be taken in the morning, and the other in the evening. HEMORRHOIDS. 351 an active and a passive state of the hemorrhoidal discharge. In the phlogistic or active form, the patient must be kept cool and quiet, in the horizontal position ; his drink must be bland, cool, and acidulated; and nitre dissolved in a mucilaginous fluid, should be exhibited inter- nally.* If these measures do not adequately moderate the discharge, recourse may be had to dry cupping over the loins or hypochondriac region ; or to sinapisms and blisters to the inner part of the thighs, or over the hypochondriac region ; and in very obstinate cases we must have recourse to injections of cold water or water in which a small portion of the acetate of lead or alum is dissolved; and occasionally it may become necessary to introduce a tampon into the rectum. Considerable benefit may sometimes be derived from the internal ad- ministration of one or two grains ofthe acetate of lead in such cases. It very rarely occurs, however, that any particular difficulty is expe- rienced in arresting the discharge where the general habit is not parti- cularly relaxed. The most obstinate and protracted cases of hemor- rhoidal discharge are those which are termed passive, in which the general system is sluggish, the countenance pale, and usually some- what bloated; the pulse small, feeble, and languid; and the muscular powers debilitated. In such cases, the hemorrhage will sometimes continue with but short intermission until the system becomes almost entirely exhausted, and anasarcous effusions take place in the extre- mities and face, with occasional paroxysms of violent palpitation of the heart, and a peculiarly pallid and bloodless appearance of the surface. In instances of this kind, the sulphuric acid with cinchona, tincture of cinnamon, chalybeate preparations, and particularly the acetate of lead with small portions of opium, will, in general, afford considerable relief. In such cases, the tincture of cinnamon, so generally recommended by the German writers in passive hemor- rhages, will often produce very excellent effects. From thirty to fifty drops of it may be given every three or four hours in conjunction with from eight to ten grains of the prussiate of iron. I have wit- nessed the good effects of these two articles in a case of remarkable obstinacy. There is no remedy, however, which, in general, produces such speedy salutary effects in chronic cases, connected with great languor and relaxation, as aloes, in small doses. This article is highly recommended by Jahn in cases of this kind,t for although one of the most improper medicines in the active or ordinary forms of the complaint, experience has shown that where the hemorrhage depends on debility or relaxation of the vessels, both in menorrhagia and in hemorrhoids, it is calculated to produce much good, by its tendency to excite the action of these vessels. Under the head of menorrhagia, I have already spoken of my experience with small doses of aloes in the passive form of the disease, and in relation to the present affection, * R.—Pulv. nitrat potassae giss. Aq. fontanae gvi. P. g. Arab. 3iii.—M. S. Take a tablespoonful every two hours. t Klinik. der Chron. Krankh., bd. iii, p. 557. 352 HEMORRHOIDS. I can affirm that its effects in two instances were very prompt and most beneficial. Jahn prefers the watery extract of this article, but I have given it as we find it in the shops, in conjunction with small doses of ipecacuanha.* The diet in such cases should be nourishing, but not stimulating, such as animal broths, jellies, soft-boiled eggs, &c. Benefit will also result from astringent injections, particularly solutions of alum, sage tea, infusions of the root of geranium macu- latum, of the blackberry root, &c. Treatment of hemorrhoidal tumours, or blind piles.—When these tumours are situated on the margin of the anus, they may, in general, be kept from causing any particular inconvenience, by always washing them with cold water after going to stool, and ap- plying moderate pressure, by means of a soft linen compress laid on them and secured by a T bandage. When they become irritated and painful, without much inflammation, washing them with cold water, and the use of mildly astringent and anodyne applications,! will usually afford considerable relief; but the ordinary astringent ointments, particularly those made of powdered nutgalls, are often decidedly injurious ; and where the inflammation is violent, they are almost always highly pernicious. The most soothing application I have ever used in cases of irritated and painful piles, is the following ointment.J To keep the bowels in a soluble state, where there is much irritation, the lenitive electuary, in union with powdered nitre, is an excellent medicine.§ It is necessary, however, to guard parti- cularly against purging; and where there is much inflammation present, this observance is especially important. The feces should be kept soft, but not liquid ; and one such evacuation daily will be sufficient. When the piles are inflamed, all astringent applications, with the exception of poultices'made with lead water, should be avoided. The patient must remain in a recumbent posture; and as the inflam- mation is almost always the consequence of some degree of strangu- lation of the tumour, by the contraction of the sphincter ani, an attempt should be made to press them within the sphincter. In many cases, however, the pain caused by even the slightest pressure is so intense, and the tumours are so much swollen, that all attempts to return them are abortive. In this case we must previously endea- vour to reduce the inflammation; and for this purpose, emollient * R.—G. aloes socc. gr. xx. Pulv. ipecac, gr. xxx.—M. Divide into forty pills. Take one every morning, noon and evening. t R.—Axungiae %i. Cerussae ,^i. Pulv. opii 9ii.—M. ft. ungt. X Take two ounces of lard and a drachm of flowers of sulphur; mix and rub them together between two plates of lead, until they acquire a black colour. $ R.—Elect, lenitivi §i. Pulv. nitrat. potass. 3b—Misce. Take a teaspoonful once or twice a day. HEMORRHOIDS. 353 fomentations and cataplasms—or cold lead water must be applied, and where the pulse is active, an efficient blood-letting from the arm should be practised. I have also known much good derived from the above-named mixture of nitre and lenitive electuary, given in small doses, so as not to procure an evacuation for the first twenty- four hours. The patient should take nothing but toast water, aud very thin farinaceous preparations for his food. Some writers have recommended the application of leeches to inflamed hemorrhoids, but the advantage to be derived from this practice is seldom con- siderable. Montegre is decidedly opposed to local depletion in this way, and thinks that leeches applied to the inflamed hemorrhoids tend often to aggravate the symptoms, by irritating and determining the blood to the parts. Scarifying the tumours, or making free inci- sions into them, will in general do more towards the reduction ofthe inflammation than any other applications. Dr. Hartshorne tells me, that he always pursues this practice in cases of inflamed piles ; and he has never known any dangerous consequences to follow the operation, but almost invariably unequivocal benefit. As soon as the inflammation is sufficiently reduced to enable us to press up the tumours within the sphincter, it should be done ; and cold water, with a small portion of the acetate of lead dissolved in it, cautiously injected into the rectum. Nothing produces a more soothing effect than cold injections in moderately inflamed piles; more especially when they are situated in the sphincter. Montegre places great reliance on the use of such injections, where the inflammation is not very intense, and where, moreover, the piles do not bleed. To relieve the pain and irritation which arise from fissures and ulcers of the lower part of the rectum, some surgeons recommend the removal of the tumours by which the pain is usually kept up; and there can be no doubt of the propriety of this practice, where other means fail to procure relief. The application of caustic, and gentle escharotic ointments or lotions, will in general be necessary, where the ulcers assume a chronic character, with elevated and in- durated edges; but undoubtedly the most effectual measure is excision of the tumours, or of the ulcerated part, when they are accessible to the knife. The excruciating intermitting pains which occur after each alvine evacuation, and in many cases without fissure or much inflamma- tion, apparently from an extreme sensitiveness of the nervous extre- mities of the affected parts; and which Montegre calls nervous hemorrhoidal pains, are more effectually relieved by cold ablutions and injections than by any other applications that have as yet been recommended. M. Montegre, who dwells particularly on this remedy, states, that he was led to resort to it from having observed, that "when patients affected with the complaint, happened to discharge their feces while bathing in a river or the sea, they sometimes escape the torment which ensued when they used a common commode." I have known much relief obtained from the application of the fol- lowing liniment to the protruded piles, after having washed them vol. n.—24 354 HEMORRHOIDS. with cold water.* Having applied the liniment, the tumours must be pushed up within the sphincter. . It is in cases of this kind, that Ward's paste will occasionally pro- cure very considerable relief, t I have used this electuary in a number of instances, and sometimes with great advantage. Dr. Gregory very justly observes, that although it maybe very difficult to explain on what principles this stimulating mixture proves useful, experience has fully demonstrated its powers. When, from a state of chronic irritation or inflammation of the mucous membrane of the rectum, there is a profuse or troublesome leucorrhoeal discharge from the anus, recourse may be had to the internal use of balsam copaiva, oil of turpentine, or the cubebs, and slightly astringent injections should be thrown into the rectum three or four times daily. For this purpose, a weak solution of sulphate of copper, (one grain to an ounce of water,) will in general answer very well. Where, however, the pain arises from hemorrhoidal tumours of a permanent character, located either on the margin of the anus, or high up, and brought to the view only by pressing down as in going to stool, the removal of them by ligature or the knife, may be con- sidered as the only means for effecting a radical or effectual cure; and this may always be safely done where the local inflammation and general irritability of the system are not very great, or when no habitual hemorrhagic discharge has been established. Where alarming consequences, or symptoms of general ill health, follow the suppression of hemorrhoids, we should endeavour to re-establish the complaint. This may usually be done without much difficulty by aloetic purgatives, small doses of the extract of savin, stimulating enemata, particularly terebinthinate or aloetic injections, leeching about the anus, semicupia, and cupping in the neighbour- hood. Richter strongly recommends the following combination for this purpose.^ * R.—01. amydalor. §i. Extract, stramonii 3b Sulph. morphise gr. vi.—M. ft. linimentum. f R.—Pulv. rad. enul. carnpan. Pulv. peper. nig., aa §viii. Pulv. sem. fcenicul. ^xii. • Mel. despumat. Sacch. albi, aa 3xvi.—The three first are to be intimately mixed; then melt the honey and sugar over a fire into a clear syrup; add the other ingredients and form an electuary. X R.—G. aloes. G. assafcetid. Extract, hellabor. neg. Ferri sulphur. Crocci orient, gi. Mucilage g. Arab. q. s.—Divide into grain pills. Take from five to eight every evening. JAUNDICE. 355 Sect. IX.—Jaundice.—Icterus, aurigo, morbus regius, morbus arcuatus. Jaundice consists in a disordered state ofthe liver or ofthe biliary passages, characterized by yellowness of the eyes and skin ; clay- coloured feces; a highly bilious urine ; and generally by a languid state ofthe circulation. In many instances the disease approaches very slowly and insidi- ously. It commences with a general feeling of languor, disinclina- tion to bodily and mental exertion, an irritable and dejected temper, weakness of appetite, constipation, acid eructations, slow and pain- ful digestion, slight flatulent pain in the bowels, a feeling of fullness and slight tension in the epigastrium ; anxiety in the praecordia, rest- lessness at night, a turbid urine usually depositing a copious pitchy sediment, slow and languid pulse, more or less nausea, and frequently transient creeping chills alternating with flushes of heat. After these symptoms have continued for a few days, a disagreeable itching over the whole body occurs ; the taste becomes bitter; the stools whitish or clay-coloured ; the urine of a deep saffron hue; and finally the white of the eyes, and the skin about the lips, neck and forehead assume a yellow colour, which speedily extends itself, until the whole surface acquires a uniform yellow hue. When the disease has arrived at this stage, the general debility and sluggishness, as well as the uneasiness and tension in the epigastrium, increase, and although the pulse is generally slow, full, and somewhat firm, slight febrile exacerbations almost always take place in the evening, with some augmentation of the temperature of the skin, and occasional transient sensations of chilliness, with much restlessness during the night. The skin is generally dry and husky. If the disease continues a long time, the body begins to emaciate; the evening febrile exacerbations become more conspicuous; night sweats ensue; and in many instances, drop- sical effusions at last take place into the cavity of the abdomen; re- spiration becomes anxious and oppressed, and where it verges to a fatal termination, a soporose and torpid condition comes on towards the conclusion. In some instances, however, the disease comes on so insensibly that no particular local or general manifestations of its approach are noticed until the eyes and skin begin to assume a yellow hue. When the disease makes its appearance in these two ways, it depends pro- bably on a morbid viscidity of the bile, in consequence of which, its passage from the liver into the intestines is impeded or entirely pre- vented. Sometimes, instead ofthe gradual manner just mentioned, the dis- ease commences at once with severe dull pain a little below and to the right of the pit of the stomach, increasing rapidly in violence, with excruciating exacerbations, spreading towards the left shoulder down to the loins, and throughout the whole epigastric region ; at the same time, the patient experiences almost incessant and extremely distress- ing nausea, attended with so great a degree of gastric irritability that 356 JAUNDICE. every thing swallowed is immediately thrown up again with the most violent and painful vomitive efforts. In such cases, the epigastrium is distended, and generally tender to the touch ; but the pulse usually differs but little from its natural condition. When the disease comes on in this manner, it commonly depends^on obstruction of the com- mon duct by a biliary concretion. The intensity and brightness of the icteric colour differ very consi- derably in different cases. In some instances, it is of a golden-yellow, in others of a greenish-yellow, and in others again it acquires a dark and almost black shade.* The latter two varieties are, generally, connected with organic diseases of the liver, such as enlargement, in- duration, and tubercles. In protracted cases of jaundice, the yellow colour is not confined to the skin, but pervades almost every part of the body. The adipose structure, particularly, acquires a bright saffron colour; and the internal membranous tissues are usually con- spicuously marked with the same tinge. It is, however, extremely uncommon to find the brain and nerves pervaded with its colour,and its appearance in the cartilages and bones is an almost equally rare occurrence. The fluids, too, become tinged with yellow. Mursinna gives an account of a fatal case of jaundice, in which he found the viscera of the breast and abdomen, as well as the meninges of the brain, of a deep yellow colour, and the serum which he found in the pericardium and ventricles of the brain was ofthe same colour and of a bitter taste.] It is from the tinge being communicated to the humours of the eyes, that to some jaundiced patients all objects appear of a yellow hue. Of the secretions, the urine is most conspicuously charged with the bilious colouring matter. It is so abundant in this fluid, that pieces of linen or paper dipped into it immediately acquire a yellow stain. In the milk of women affected with this disease, the colour and the taste of bile are hardly ever detected.- Heberden, indeed, as- serts that the presence of bile in this secretion has never been noticed; but in relation to the taste, I have myself observed an instance in which the milk was very perceptibly bitter. Dr. Good thinks that the cause of the very rare occurrence of yellowness in the milk of jaundiced females, arises "probably from its rapid passage and ela- boration from the fluids introduced into the stomach." I am inclined to think that this circumstance depends on the bile uniting with the oily portions of the lacteous secretion, and becoming thus suspended with it in the form of an emulsion. We know at least that in the duodenum, it is entirely owing to the union of the bile and the fatty portions of the chyme, that the chyle obtains its milky colour;\ and * Cases of this kind are usually called black jaundice, (melaskterus.) f Journal fur die Chirurgie, bd. ii, s. 222. X Mr. Brodie, from some experiments he performed, inferred that the principal purpose of the bile is to separate the chyle from the chyme; for he remarked, that, when the choledochus duct was secured by a ligature, and food then given, chymification went on in the stomach as usual, but no chyle could be found in the intestines or in the lacteals. The lacteals contained a transparent fluid, which he JAUNDICE. 357 it is not improbable that the union of oily and bilious matter may, in part, destroy or precipitate the bitter principle ofthe latter. This, at all events, must be the case in the duodenum ; for, notwithstanding the union of the chyme and bile, the fluid in the lacteals, resulting from the combination, and the thoracic duct, is wholly free from bit- terness. The duration of an attack of jaundice is extremely various, and depends, of course, almost entirely upon the greater or less degree of permanency of the occasional cause. In some cases the icteric symptoms come on rapidly under symptoms of great violence, and in a short time disappear again. This is most apt to be the case when the disease arises from the passage of a biliary concretion through the common duct, or from spasmodic constriction of this part. Some- times the disease is marked by manifest remissions, the yellowness of the skin and other symptoms increasing and abating at short but irregular intervals for a long time. Not unfrequently this malady assumes a strictly chronic character, without any particular feelings of ill health except slight dyspeptic symptoms, costiveness, and a disposition to indulge in sleep. More commonly, however, pro- tracted instances of the disease ultimately cause great emaciation supposed"to be lymph and the watery part of chyme. Herbert Mayo draws the same results from his experiments. These results are at variance, however, with the experiments of Leuret, Lassaigne, Tiedemann, and Gmelin. The former, after tying the duct and clearing out the bowels with castor oil, fed the animal^ twelve hours after the operation, with bread, milk, and sugar. Eight hours after this meal, the animal was killed. The food was found digested, and '-the tho- racic duct was distended with a yellowish-red transparent fluid, which coagulated on standing exposed to the air, and yielded the usual proportion of fibrin, albumen, and saline matters." Brodie, Mayo, Leuret, Lassaigne, Tiedemann, and Gmelin, ob- served that chymification went on as perfectly after the common bile duct was tied as in a sound animal. In the experiments of Tiedemann and Gmelin, the thoracic duct always contained an abundance of fluid, which was generally of a yellowish colour, (confirming in this respect the experiments of Leuret and Lassaigne, and partly also those of Brodie and Mayo.) This fluid coagulated like ordinary chyle ; the crassamentum acquired the usual red colour; in shorty the only difference between it and the chyle seen in a sound animal, was, that after tying the common duct it was never white or milky. The reason of this difference appears to be, that the white colour is owing to fatty matter taken up from the food by means ofthe bile, which possesses the power of dissolving fat, and probably, therefore, aids in effecting its solution in the chyle at the mouths of the lacteals. " Mr. Brodie appears to have been misled by the absence ofthe white colour which the chyle usually possesses; but which it is well known equally to want in ordinary digestion, if the foofl does not conta:n fatty matter.'* Tiedemann and Gmelin confine the agency ofthe bile in chylification, simply to the accomplishing the solution of the fatty matter. These experimentalists believe that the biliary secretion, besides its agency in chylification, is supplementary to the function ofthe lungs in freeing the blood of its carbonaceous and other-hetero- geneous principles. 358 JAUNDICE. and dropsical effusions, and often terminate in a state of apoplectic stupor. Causes.—The etiology of jaundice is, in many respects, still in- volved in much obscurity. In a general way, it may be said, that all the remote causes of this disease act either by obstructing or pre- venting the flow of bile from the liver into the intestines; or by im- peding, deteriorating, or suspending the secretory action of the liver. Of the former kind of causes are, 1. Biliary concretions plugging up the duct. 2. Spasm of the duct, which may be excited by acrid bile, duodenal irritation, and perhaps violent mental emotions. 3. Viscid mucus clogging up- the orifice of the common duct. 4. In- flammation and thickening of the coats of the duct. 5. Enlarge- ment and induration of a neighbouring part—particularly of the pan- creas, and perhaps of the mesenteric glands.* 6. Preternatural viscidity of the bile, by which its flow along the duct is greatly im- peded, or altogether prevented; pregnancy, and impacted feces in the colon. When by any of these causes the bile is prevented from flowing into the intestines, and thereby congested in the biliary pas- sages, it is generally believed to gain admission into the current of the circulation either by absorption or regurgitation, and to be after- wards secreted into the subcuticular tissues, giving rise to the yellow tinge of the surface. It is quite certain, indeed, that the jaundice will generally supervene speedily when an obstruction of this kind occurs in the common duct, and from the manifest presence of bilious matter in some of the secretions, we can scarcely doubt that in rela- tion to such cases this view of the etiology of the disease is in the main correct. MM. Tiedemann and Gmelin, in their interesting account of a series of experiments on digestion, state, that on passing a ligature round the common duct of animals, they found that about the third day the eyes became yellow, and the urine strongly imbued with a colouring matter, which, by chemical tests, they ascertained to be bile.t To this doctrine it has been objected, that no bile has ever been detected in the blood of patients affected with jaundice, a circumstance which certainly does not countenance the opinion that bile enters the circulation by regurgitation. Against the opinion that the biliary secretion is absorbed into the circulation, it is alleged * An interesting case of jaundice, which terminated fatally, is related in the Journal,de Progres, and in which the following phenomena wTere discovered on post-mortem examination. " Two or three inches from the origin of the duode- num there was a tumour with elevated edges, rather larger than a crown piece, the surface of which was uneven, very hard to the touch, of a whitish-yellow eolour, and very vascular. The different coats of the intestines were involved in the disease, which included, at one of its edges, the openings of the biliary and pancreatic ducts, which were extremely contracted and almost annihilated. The gall-bladder was extremely distended, and, when strongly pressed, a few drops of bile issued forth into the duodenum."—Med. Chir. Rev., July, 1828, p. 440. t Recherehes Experimentales Physiologiques et Chymiques sur la Digestion, second partie, p. 47. JAUNDICE. 359 that it is not at all probable that a fluid so irritating as the bile is, would be received by the extremities of the absorbent vessels, and there is much plausibility in this observation. Nevertheless, when we find the bile making its appearance in the urine, and often in the other secretions, together with a uniform yellow tinge, not only of the surface of the body, but also on the internal organs, at the same time that the white or clay-coloured feces show that there is no bilious matter poured into the intestines, and when, finally, dissection discovers to us a complete obliteration or obstruction of the common duct, we are forced to admit, that in consequence of the engorge- ment of the excretory ducts of the liver, from the exit of the bile through its natural passages being obstructed, it is in some way or other abundantly secreted by the kidneys, and its colouring matter at least copiously deposited in the subcuticular and various other tex- tures of the body. The admission of the bilious matter into the cir- culation is most likely by absorption; but it is not probable that the bile is thus introduced into the blood-vessels, in its state of complete combination. The serous and colouring matter alone may, perhaps, be taken up by the absorbents, while the most acrid and irritating portions are left in the liver. Both Deyeux* and Clariont found in the blood of patients labouring under jaundice a considerable portion of a yellow matter, which communicated a saffron stain to liver, just as the urine of such persons is known to do. Among the above-mentioned causes of obstructions to the flow of bile into the intestines, the most common undoubtedly are, biliary concretions, spasm of the duct, and preternatural viscidity of the bile. A very viscid state of the bile is probably much more frequently con- cerned in the production of this disease than seems to be generally supposed. Dr. Annesley, in his work on the diseases of India, states that he frequently found, upon post-mortem examination, " the gall- bladder loaded with a bile of a dark-green colour and so thick and viscid that it could scarcely be forced through the duets by squeezing the gall-bladder, although the blow-pipe or probe would pass readily along them, showing that the obstruction was then owing to the viscidity alone." When the disease is preceded and accompanied by a constant aching and soreness, with occasional extremely severe paroxysms of pain in the right epigastrium, together with great irri- tability of the stomach, we may infer that it arises from the passage of a gall-stone through the common duct. The suffering, in cases of this kind, after a longer or shorter period, suddenly ceases; and this occurrence may be considered as announcing the entrance of the cal- culus into the duodenum. From some late pathological researches by Andral, it appears that irritation and inflammation ofthe mucous membrane of the duodenum sometimes produce jaundice where no obstruction can be detected in the biliary ducts; and it is perhaps in * Considerations Chymiques sur le Sang des Icteriques.—Journal de Mede- cine, Messidor an. xii, p. 288. t Considerations Chymiques et MeJicinales sur le Sang des Icteriques, Pre- sentees et Soutennues a lecole de Med. 360 JAUNDICE. this way that the jaundiced hue of the skin is produced in yellow and other severe forms of bilious fever. Dr. Marsh has also related some cases which render it probable that inflammation of the mucous mem- brane of the duodenum is sometimes extended to the lining membrane of the ducts, whereby a contraction of these passages is produced, either by spasmodic constriction or by a thickening of their coats. Dr. Marsh observes, that hysterical women, of a relaxed and gross habit of body, are subject to a form of jaundice which, though strongly resembling those cases that arise from the impaction of a gall-stone in the common duct, appear, nevertheless, to owe their origin to a less permanent cause. Some mental commotion, and particularly an error in diet, seems, in most instances of this kind, to be the remote cause of the disease. These come on like a violent attack of bilious colic, or with symptoms resembling those which occur from the passage of a biliary concretion through the common duct. " A pain," says Sy- denham, " not less severe than that of the iliac passion, is felt at the region of the stomach, or somewhat lower, which is succeeded by copious vomitings of matter, sometimes green, sometimes yellow. To these symptoms are added, a depression of mind and despair exceeding that in any other disease. // is accompanied sometimes with a re- markable jaundice, which spontaneously subsides in a day or two. The Jeast commotion of mind, whether it be anger or fear, brings back the pain." When the pain subsides, large quantities of flatus pass off, either upward or downward; and the ejections from the stomach, during the continuance of the pain, are usually acid. I have attended an elderly lady in this city, who is precisely ofthe habit of body just mentioned, in five or six paroxysms of this kind. The disease always commences like a violent attack of bilious colic, attended with vomit- ing of a green and acrid bilious fluid. It seldom lasts longer than about forty-eight hours, by which time the surface ofthe body begins to become yellow, and soon acquires a deep jaundiced hue. In nearly all the attacks, I have been able to trace its origin to errors of diet or some mental commotion. Dr. Marsh says these cases may, in gene- ral, be readily recognized by the copious secretion of limpid urine which occurs in them. This, however, is only correct with regard to the appearance of this secretion in the very commencement, for com- monly in the course of thirty-six hours from the beginning, the urine becomes bilious, as in other instances of jaundice. The leading proxi- mate cause, in cases of this kind, is probably, spasmodic constriction of the gall-ducts, or preternatural viscidity of the bile. Duodenal irritation, from flatus or acrid bile, and imperfectly elaborated chyme appear to constitute the principal exciting causes of this variety of the disease. Leeches, fomentations, abstinence from food, purgatives, and full doses of opium, will always soon relieve the painful symp- toms of the complaint. Jaundice, as has been already intimated, may be produced also by causes that act upon the liver through the medium of the general system. Some of these causes appear to produce torpor of this organ, and consequent suspension of the biliary secretion; others, perhaps, give rise to the secretion of acrid bile ; which, stimulating JAUNDICE. 361 the ducts, may occasion spasm and retention of the biliary matter in the hepatic ducts ; and others, finally, gradually produce more or less disorganization of the liver. Of this variety of causes, are—intem- perance in the use of spirituous liquors ; irritating substances in the primae viae ; suppression of acute and chronic cutaneous eruptions; violent mental emotions, particularly grief;* constipation ; suppressed perspiration ; the slow influence of malaria; wounds of the scalp ; metastasis of gout; and perhaps mercury, t That the cessation or great diminution of the biliary secretion, whether from mere functional torpor or structural alteration of the liver, is capable of giving rise to jaundice, admits of no reasonable doubt. Cases of fatal jaundice have been reported, in which, upon post-mortem examination, the ducts were found entirely unob- structed, and the small portion of the bile found in the gall-bladder and liver, of a natural consistence.% When the elimination-of the recrementitious matter which enters into the composition of the bile is not duly effected by the organ destined for this office, the blood will necessarily become surcharged with this matter, and by a natural tendency of the animal economy to cast off what may be injurious to its welfare, the kidneys, as well as the general capillary system, will in a manner perform the office of the liver, and free the blood of a portion of its superabundant biliary elements, by depositing them into the subcuticular textures, as well as into other tissues, and particularly also in the urinary secretion. Prognosis.—The prognosis of jaundice varies of course according to the nature of the occasional cause, and the general vigour of the system. When the disease does not depend on organic affection, or obstruction of the common duct by large biliary concretions, it may, in general, be removed without much difficulty. Cases arising from violent anger, spasm of the duct, mucus clogging the orifice of the duct, and on preternatural viscidity of the bile, are often speedily removed by an appropriate treatment. In many instances arising from biliary concretions, the obstructing calculus is not so large as to cause it to be very long in passing through the duct into the duo- denum; and such cases, though often attended with extreme pain and gastric disturbance, usually disappear in the course of eight or ten days; but where the disposition to form biliary concretions is strong, which is not uncommonly the ease, the paroxysms of suffering * Dr. Marsh gives an account of a case, wmere a young girl, in the Lock Hos- pital, who had got cold while under the influence of mercury, was suddenly informed ofthe death of her uncle, the only one of her relations who had treated her with kindness; she immediately became universally jaundiced.—Dublin Hosp. Reports, vol. iii, art. 6. t Dr. Colles communicated an instance to Dr. Marsh, where a young gentle- man, after undergoing an alterative course of mercury, suddenly became deeply jaundiced. In a few days afterwards he died, in a state of delirium and convul- sions. On dissection, not the slightest change of structure Was discovered. The internal as well as external parts were strongly tinged with bile. X Stall, Ratio Medend., vol. iii, pp. 361—366. 362 JAUNDICE. and jaundice are apt to recur again and again, at longer or shorter intervals. It is said, that jaundice occurring in consequence of in- juries of the head, is, in general, particularly dangerous, and difficult to be removed.* The supervention of stupor, coma, or delirium, is always an extremely unfavourable sign. When the icteric tinge acquires a very dark appearance, approaching to a blackish hue, we may infer that the disease will be very obstinate, or probably altogether incurable ; for such cases are almost always dependent on incurable organic affection of the liver, or of the neighbouring organs. If, in cases of this kind, copious hemorrhages occur from the nose or lungs ; or if violent colic pains and profuse colliquative diarrhoea come on, the prognosis may be regarded as extremely unfavourable.! When the perspiration is so copiously charged with the colouring matter of bile as to communicate a yellow tinge to the patient's linen, there is reason to apprehend a total and obstinate obstruction to the passage of the bile into the intestinal canal. (Jahn.) The occurrence of tympanitis, dropsical effusions, slow febrile irritation, emaciation, and great muscular debility, leaves us but little hope of an eventual recovery.. Treatment.—From what has already been said concerning the etiology of jaundice, it is manifest that the treatment requires con- siderable modifications, according to the particular condition of the biliary organs, upon which the symptoms of the disease depend; for it should be recollected, that the phenomena which we denominate jaundice, are mere manifestations of some local or sympathetic dis- order of the biliary organs. When the disease commences with vio- lent pain in the epigastrium, with constant nausea and frequent vomit- ing, we may ascribe it either to a spasmodic affection of the bile ducts, and perhaps ofthe duodenum, from some local or sympathetic irritation ; or to the impaction of a biliary concretion in the common duct. In cases of this kind, our principal object, in the first place, must be, to relieve the extreme sufferings of the patient; and for this purpose, opium, the warm bath, leeching, frictions, and emollient applications to the epigastrium, are almost the only appropriate re- medies. If the patient be robust and very plethoric, blood should be at once drawn to an extent sufficient to make a decisive impres- sion on the system. I am inclined to think that blood-letting is too much neglected in cases of this character. I have, in several instances of jaundice, commencing in the way just mentioned, procured mani- fest advantage from an efficient abstraction of blood. Blood-letting may prove beneficial in various ways in this affection. By it we lessen the tendency to inflammation in the irritated parts; and it may favour the passage of biliary concretions through the duct, by its general relaxing powers. But it is also a very proper preliminary measure to the employment of opium, upon the liberal use of which, our principal reliance must be placed for palliating the painful symptoms. During the first stage of cases of this violent character, * Jahn. Klinik. d. Chronisch. Krankheiten, b. ii, p..395. t Richters Specielle Therapie, b. iv, p. 315. JAUNDICE. 363 emetics, and even purgatives, are out of the question—at least until the gastric irritability has been in a great measure allayed. After having drawn blood, where this evacuation is indicated by the pulse and general habit of the patient, a large dose of opium in union with calomel, should be immediately administered. Small doses of this narcotic will do no good—on the contrary, they often appear rather to add to the general distress of the patient. From four to five grains of opium, with ten or fifteen grains of calomel, should be given at once. When administered in such a dose, it rarely fails to allay the pain and gastric distress in a few hours. But in some instances, even this quantity is not adequate to remove the extreme sufferings ofthe patient, and it becomes necessary to repeat it in smaller doses, until the desired effect is produced. It is not, however, simply as an anodyne, that this narcotic may be beneficially employed in pain- ful cases of jaundice unconnected with febrile irritation. When the pain and obstruction to the flow of bile into the intestines are the result of spasm of the duct, we can resort to no remedy more directly cal- culated to remove this condition, than opium given in very efficient doses. At the same time that we have recourse to this powerful narcotic, the bowels should be emptied by purgative enemata, re- peated until a free evacuation is procured. Much benefit may sometimes be obtained from the warm bath, and where its employ- ment is practicable, it ought to be resorted to in conjunction with the measures just indicated. If by these means we succeed in allay- ing the violence of the symptoms, we may then have recourse to purgatives and emetics. The latter have been very generally recom- mended in cases where there is reason to apprehend the presence of a biliary concretion in the common duct. The relaxation and con- cussive agitation produced by the operation of an emetic, may con- tribute materially to expedite the passage of the concretion through the duct, an event which must be deemed essential to the removal of the disease. We are told by Dr. Darwin, that in two instances he saw upwards of thirty gall-stones voided by stools soon after the opera- tion of an emetic. We must not, however, forget, that great pain in the epigastrium, with irritability of the stomach, and a universal jaun- diced hue ofthe surface, may arise from high irritation, or inflamma- tion of the mucous membrane of the duodenum, without any ob- struction from biliary concretions ; and in such cases the exhibition of an emetic could not fail to prove injurious. These cases may be distinguished from calculous irritation ofthe ducts, by the very mani- fest presence of fever, or rather the small, quick, tense, and frequent pulse, and the warm and dry skin, which occur in duodenal inflam- mation; and the slow, full, and rather active state of the pulse, and entire absence of the usual symptoms of fever, in cases depending on obstruction to the course of the bile from biliary calculi. Where there is reason to suspect high duodenal irritation, or subacute inflam- mation, as lying at the foundation of the malady, recourse must be had to leeching, blistering, and fomenting cataplasms to the epigas- trium ; a bland and liquid diet; laxative enemata; cooling acidu- lated drinks ; small portions of opium and ipecacuanha in combina- 364 JAUNDICE. tion; and rest. The use of emetics and purgatives is out of the question. Various remedies were formerly recommended with the view of consuming or dissolving the biliary concretions lodged in the liver or its ducts; but the age of confidence in such remedies has passed by, and there is now but little attention paid to articles of this kind, with a view to their resolvent powers, although some of them may do good by their tendency to excite and alter the action of the liver. The alkalies, soap, a solution of the yolks of eggs in vitriolic ether, Durande's mixture, composed of two parts of vitriolic ether and one of spirits of turpentine, the natural mineral waters contain- ing carbonic acid gas in an uncombined state, and mercury, have been most generally employed for this purpose. With regard to the vitriolic ether and spirits of turpentine, Dr. Good very justly observes, that where there is a tendency to inflammation, they may do harm by their stimulant effects. In one case under my care, this mixture appeared to do much harm, for it manifestly increased the general irritation of the sanguiferous system, and gave rise to much epigastric tenderness. Where spasm of the duct may be presumed to be the primary affection, nauseating doses of antimony; hyoscyamus; assa- foetida; infusion of chamomile; active purgatives; emollient cata- plasms or fomentations; anodyne frictions, and enemata, are recom- mended by the older writers, but they are so greatly inferior to opium, the warm bath, and revulsive applications to the epigastrium, that they scarcely deserve any attention as remedies in this affection. In cases that come on gradually, with little or no pain in the region ofthe duodenum and duct, and where, of course, there is little or no probability ofthe existence of spasm or biliary concretions, the principal indication is to restore the regular functions of the liver, and alimentary canal. Unfortunately, we cannot determine, with any degree of certainty, whether such instances consist merely of functional torpor of this organ, or of a slow organic change of its structure, or of the gradual formation of an indurated enlargement ofthe pancreas, or of some other latent affection of the bile ducts, or duodenum near the opening of this duct, or finally of a loaded state of the colon j and our remedial measures must, therefore, often be applied under much uncertainty as to their fitness to the actual con- dition upon which the general icteric symptoms depend. The mere empirical prescription of remedies for the remote consequences, or symptoms of the primary hepatic disorder, or for jaundice, as is usually said, will not satisfy the scientific physician; and yet, in many cases, the minutest attention to the circumstances and phe- nomena of the disease, will enable us to form only plausible con- jectures as to its true nature. Where there is reason to presume that the primary morbid condition consists in functional inactivity of the liver, mercurials are the principal curative means. As this func- tional torpor is, however, itself, probably only a consequence of an irritation located elsewhere, particularly in the mucous membrane of the alimentary canal, it will always be especially proper to attend to the state ofthe bowels in all cases that come on slowly, and with- out any particular pains in the epigastrium. About two years ago, JAUNDICE. 365 I had a striking example, illustrative of the propriety of this latter observation. A young man, who had for several years laboured under weak digestive powers, became gradually deeply jaundiced, with clay-coloured feces and highly bilious urine. The liver was manifestly in a very inactive condition, and although no distinct pain was felt in the epigastrium, moderate pressure about the region of the umbilicus gave rise to great soreness and distress. He had already taken a great deal of medicine, under the direction of another physician, without the least perceptible advantage. I put him upon the lightest kinds of liquid farinaceous diet, and directed him to have fifty leeches applied to the epigastrium, and to use a laxative enema every morning soon after breakfast, and three grains of blue pill every night on going to bed. In less than a week after this treat- ment was commenced, he began to mend, and in the course of four weeks his health was entirely restored. Jaundice has been known to recur in a strictly periodical manner, and cases of this kind are, perhaps, always intimately connected with intestinal irritation. Bang mentions an instance of periodical jaundice, which, after many other remedies had been ineffectually used, was speedily cured by the application of a large blister over the right hypochondrium. In cases of this kind, unattended with high irritation of the mucous membrane ofthe intestinal canal, some advantage may also be derived from the extract or infusion of taraxacum; and some of the German phy- sicians strongly recommend the infusion of saponaria officinalis, a common plant in this country. The taraxacum is supposed to pos- sess considerable powers as a deobstruent; but its usefulness in affec- tions of this kind, if it really possesses any, arises probably from its mild aperient and diuretic operation. Mercurial frictions on the right hypochondrium are highly proper in such cases. A most excellent remedy for exciting the action of the liver, and promoting a healthy secretion of bile, is the nitro-muriatic acid bath, employed in the way mentioned under the head of chronic hepatitis, at page 273 of the first volume of this work. Many highly respectable testimonies might be cited in proof of the beneficial effects of this remedy in cases of chronic jaundice. 1 have myself used it with marked ad- vantage. Mercury, in alterative doses, and the nitro-muriatic acid bath, appear to be equally well adapted to the treatment of this affec- tion, whether it consists in mere functional torpor of the liver, or in vitiated biliary secretion; and in general, wherever the disease is gradual in its approach, and unaccompanied with.distant pain, these remedies deserve a full trial. When the disease continues a long time, and the icteric hue acquires a dark appearance, there will be much reason for suspecting the ex- istence of some organic affection of the liver. Cases of this kind are almost always entirely beyond the control of remedial measures; yet it will be proper, even under the most unfavourable circumstances, to make an effort to remove, or at least to arrest, the progress of the hepatic affection. External#revulsive applications, low diet, and the use of mercury or the acid bath, just mentioned, are the only means upon which the least reliance can be placed in cases of this character. 366 JAUNDICE. Where enlargement and induration of the spleen or pancreas exist, the tincture of iodine would, probably, be of service. Whatever be the precise nature of the hepatic derangement, a strict attention to proper dietetic regulations is of great consequence. The digestive powers are always weak in cases of jaundice, and an error in diet may not only cause great uneasiness and distress from the ordinary affections of dyspepsia, but what is more to be dreaded, may readily give rise to high irritation in the mucous membrane of the duodenum, as well as of the other portions of the alimentary canal, and thus tend, in no trifling degree, to increase the hepatic disease, or to develop inflammations. Where there is tenderness in the epigastrium, and, in general, in all recent cases commencing with violent symptoms, the diet should bet)f the lightest or least irritating kind. In instances that assume a chronic form, the food should be digestible and simple; and where there is reason to suspect the pre- sence of gastro-enteric irritation, it will not be prudent to allow solid food, even of the lightest and most digestible kind. There are few cases that have given so great a scope for empi- ricism as the one now under consideration. Articles of the most opposite, and in many instances of a decidedly pernicious character, have been extolled as specifics for the cure of this affection. The old and exceedingly absurd doctrine of " signatures," gave rise to the employment of the celandine,* and there are not wanting many highly respectable authorities in favour of its use in this malady. The agrimony, too, was formerly highly extolled for its efficacy in jaundice ;t and of late years the sanguinaria has. been brought for- ward as a valuable remedy in this affection. This remedy was much praised by the late Professor Smith, of New Haven. He gave the tincture in doses of from thirty to fifty drops three times daily. Hemp- seed boiled in milk, is another remedy which has been said to possess very useful powers for the cure of this affection. Sydenham strongly recommends rad. rub. tinctor.; and Baldinger relied much upon the use of small doses of ipecacuanha. It is not improbable that these, and many other remedies that have been mentioned, may, under peculiar circumstances, be occasionally serviceable; but as we are wholly without any rational indications for their use, their employ- ment is a kind of hap-hazard practice, which will be more likely to do mischief than good. * Jahn speaks very favourably of the following combination, where the disease depends on torpor of the liver, and a sluggish condition of the portal circulation. R.—Sulph. aurant. antimon. ^i. Gum. ammon. G. assafcetid. Feb tauri, aa -jii. Extract, chelidonii maj. q. s.—M. Divide the mass into two grain pills. Take from eight to twelve pills four times daily. t J. Hill. Method of Curing Jaundice and other Diseases of the Liver, by the Herb Agrimony. London, 1769. DIABETES MELLITUS. 367 CHAPTER VII. CHRONIC DISEASES OF THE URINARY ORGANS. Sect. I.—Diabetes Mellitus. Diabetes was known to the ancient Roman physicians, but it does not appear that they had any knowledge of the essential cha- racteristic of the disease—namely, the saccharine character of the urine. They seem to have considered the disease only as a rapid discharge, by the kidneys, of whatever drinks were taken into the stomach, without having undergone any changes by the digestive or assimilative functions. " Diabetes," says iEgineta, " est subitus potulentorum exitus, talibus per urinam redditis qualia pota fue- rant"—" a sudden discharge of liquids drank, which are voided by the urine, such as they were taken in by the mouth." Celsus, too, says diabetes consists in a greater discharge of urine than there are fluids taken in by the mouth; and Aretaeus, who has given an accu- rate description of the course and phenomena of this disease, defines it in the same way. The saccharine character of the urine in dia- betes, was not known or pointed out, until Willis directed the at- tention of the profession to it; and although this morbid condition of the urine is unquestionably the essential characteristic of diabetes, it has frequently been wholly left out of view in the definitions which have been given of this disease. Cullen himself has fallen into this error in his definition of this malady. "It consists," he says, "in the voiding of a preternatural quantity of urine;"—and in thus neglecting to notice the characteristic quality of the urine, he confounds it with diseases which are radically distinct from it, and which resemble it only in the circumstance of an unusually large flow of urine. There are at least three varieties of urinary disease, which are accompanied with a preternatural flow of urine, but which are nevertheless essentially distinct, as well from each other, as from the disease now under consideration. By diabetes then is meant that form of urinary disease, in which the urine is sensibly impregnated with saccharine matter, and voided in an unusually large quantity, being attended with great thirst, voracious appetite, and an obstinately dry and harsh skin. Diabetes usually makes its appearance in a very gradual manner, although in some instances it comes on suddenly, with slight chills and febrile commotions. When its invasion is gradual, it is generally attended from the first with various indications of a disordered state of the digestive organs—such as variable appetite, acid eructations, occasional nausea, and vomiting. 368 DIABETES MELLITUS. The quantity of urine discharged in this affection, is almost always extremely great; and in some instances truly enormous. I have seen two cases in which from twelve to fifteen pints of urine were discharged in the course of twenty-four hours, for several weeks. That such a drain from the system must cause great and rapid ex- haustion and wasting of the body may be readily conceived; and indeed, the utmost degree of prostration and emaciation never fails to ensue as the disease advances in its course. The urine in this disease is generally of a pale straw colour, ap- proaching sometimes to a shade of green.* Its smell is usually faint, resembling that of milk, or, according to some, that of fresh animal broths, and its taste is more or less sweet, from the sugar which it contains. Diabetic urine always contains very little or no urea, and in most instances it is entirely destitute of lithic acid. It enters very slowly into putrefactive decomposition, but passes readily into the acetous or vinous fermentation. In these circumstances it differs very essentially from the urine of other varieties of disease resembling diabetes—in which latter it always putrefies with great rapidity, and becomes exceedingly fetid. Symptoms.—The constitutional symptoms which attend this dis- ease, are—very urgent thirst; craving appetite; dry skin; a distress- ing sense of weight and uneasiness in the stomach after taking food; dry and parched mouth; white, foul, sometimes clean and red tongue; wasting of the flesh; a feeling of languor and aversion to exercise; debility; pain and weakness in the loins; irregular action of the bowels, being most commonly costive ; some degree of inflammation and pain about the prepuce and glans penis, and especially about the external orifice of the urethra; loss of virility; cold feet, with a tend- ency to oedema in the latter period of the disease; dull and aching eyes; indistinct vision, with vertigo; headache; and difficulty of breathing. As the disease gains violence, and draws towards the fatal termination, the gums become spongy and the breath fetid or disagreeable, and the voice rough, or extremely weak and whisper- ing. The emaciation and exhaustion proceed with great rapidity towards the conclusion, and the patient finally sinks into a state of somnolency or drowsiness, from which it is often extremely difficult to keep him roused even for a moment. In general, the pulse is but little or not at all accelerated in the early periods of the complaint; but in many instances it is even less frequent than in health. In the advanced stage of the disease, however, when the emaciation and exhaustion are very great, it is not uncommon to find the pulse very frequent and quick. In some instances the blood has been found sizy, or covered with a thick inflammatory crust. Home states, that the blood of one of his diabetic patients manifested a highly inflam- matory character, although the pulse was rather below the regular * Cases have been frequently observed, in which the inordinate secretion of urine has suddenly ceased, without any assignable cause. A distressing stran- gury has been known to supervene on the occurrence of such sudden cessations ofthe diabetic symptoms. (Dr. Carter, Med. Repos., 1823.) DIABETES MELLITUS. 369 standard in frequency and strengeth. It is by no means unusual for this disease to terminate in apoplexy—a circumstance somewhat remarkable, when we consider the exhausted and worn down con- dition of the system in the last period of the disease. In a case which I attended some years ago, the patient became completely lethargic for about eighteen hours previous to death, and during this period the urinary secretion was almost entirely suspended. I suspect, indeed, from this case, as well as from others which have come under my notice, that in all instances where the disease terminates in a state of stupor or lethargy, the secretion of urine is greatly, if not almost entirely suspended. The disease, in such instances, seems to pass from the kidneys to the brain—an occurrence which is not uncom- mon in ischuria renalis. The duration of diabetes is extremely various. In some instances, not more than four or five weeks intervene between the commence- ment and the fatal termination of the disease, whilst the majority of cases are protracted to several months, and occasionally to as many years. In some instances considerable remissions occur in the pro- gress ofthe malady ; and cases are mentioned, in which the diabetic symptoms recurred in a strictly periodical manner, with perfect inter- missions of longer or shorter duration. In some individuals there appears to exist a natural or constitu- tional predisposition to this disease; and there are many instances on record, which go to prove that this predisposition is sometimes here- ditary. I attended a young man labouring under this disease a few years ago, in consultation with Dr. Parrish, who had lost his mother and a sister by the same complaint. Dr. Prout mentions several in- stances of this kind; and similar cases are to be found in other works on this disease. Mr. Venables has recently directed the attention of the profession to the diabetic affections of children. He thinks that many of the cases that are considered as instances of marasmus, rickets, &c, are intimately connected with morbid and excessive urinary secretions. Several cases of gradual wasting, attended with great thirst and voracious appetite, came nnder his notice, which he ultimately ascer- tained to be wholly dependent on diabetic affections. Infantile dia- betes, says Mr. Venables, seldom appears till after the child has been weaned. The child, when the disease comes on, will lose its usual flow of spirits, and manifest an obvious state of general indisposition. After some time, it begins to waste in flesh—the skin becoming, by degrees, harsh, dry, and flabby, and very warm. "In the early state of the disease, the bowels are regular, and little or no deviation from the natural and healthy appearance of the alvine discharges is to be noticed. The tongue also, at the beginning, indicates no symptom of disease." After the disease has made some progress, the bowels become disordered, and the alvine evacuations are unnatural—being sometimes greenish, at others dark, and mixed with bile. At a still more advanced stage the abdomen becomes distended and tense, similar to what occurs in chronic enteritis or marasmus. The pulse is usually accelerated from the commencement, and soon becomes vol. n.—25 370 DIABETES MELLITUS. small, tense and wiry. "The most remarkable symptom, however, although it frequently escapes observation, is the inordinate discharge of urine. This discharge increases in quantity so gradually that it is not usually noticed. By the time it has become more remarkable, great thirst prevails." In the advanced stage of the complaint, the brain often becomes more or less affected. Headache, vertigo and temporary delirium occasionally occur, and when it proves fatal, the patient dies comatose, or apoplectic. The skin is always extremely dry and harsh to the touch ; and in general, considerable fever attends during the advanced periods; and this fever is almost invariably of a remitting form. In cases that continue, a long time, anasarca, and even general dropsy sometimes supervene. This is a condensed abstract of the phenomena of this affection, as given by Mr. Venables. That children may become affected with diabetes,cannot be doubted; but there is reason for suspecting, that in the disease just described, the diabetic symptoms are symptomaticoi gastro-intestinal irritation. In his post-mortem examinations, Mr. V. confines himself to the phenomena presented by the urinary organs, a restriction which is much to be regretted.* Of the exciting causes of diabetes onr knowledge is as yet but very limited and unsatisfactory. It would appear from the observa- tion of some writers, that males are more subject to the disease than females. According to Rollo, those whose digestive organs are un- usually active, and who indulge freely in the pleasures of the table, are most liable to this malady. The free and habitual use of condiments and of vegetable articles of diet, especially the farinaceous substances, is §aid to favour the occurrence of this disease in an especial manner. Protracted grief; despondency; deep sorrow; chagrin; and a sense of great affliction, when favoured by an exclusive vegetable, or by weak and innutritious diet, have been known to give rise to diabetes. Sudden atmospheric vicissitudes, more especially when attended with protracted humidity, are supposed also to be capable of giving rise to this disease.t That the habitual or frequent use of diuretic and spiritu- ous potations, should have a tendency to produce diabetes in persons who are naturally predisposed to it, can scarcely be doubted. It is probable, also, that renal calculi have sometimes produced this com- plaint. Upon this subject, however, all our sentiments are, as yet, in a great measure, conjectural; for the disease is frequently found to make its appearance without any assignable exciting cause whatever. J * A Practical Treatise on Diabetes; with Observations on the Tabes Diuretica, or Urinary Consumption, especially as it occurs in Children, &c. By R. Venables, M. B., &c. t iEtius asserts that diabetes has been known to occur in consequence of the bite of the colubar dipsas; and Frank mentions the same fact from his own obser- vations. Excessive indulgence in venery has also been known to give rise to thia disease. % Reil, Home, and others., assert that diabetes is sometimes infectious. This is exceedingly improbable. It is well ascertained, however, that in some dietrictd DIABETES MELLITUS. 371 Diabetes mellitus has been known to occur sympathetically from pregnancy. A very remarkable case of this kind is related in Dr. Osann's Clinical Reports. During five successive pregnancies, and throughout the whole of each period, the diabetic symptoms were very conspicuous. The quantity of urine discharged was exceedingly great, and on being analyzed, it was found to contain no inconsidera- ble portion of saccharine matter. The thirst was extremely urgent, but the appetite and digestive powers remained regular, and rather active."* Pathology.—The opinions which have been expressed concerning the pathological character of diabetes, are very various and contra- dictory. According to the celebrated Mead, its primary seat is in the liver, and not in the kidneys. Some pathologists have ascribed it to spasm in the secretory organs, and placed it among the spasmodic diseases. Others attribute this disease to suppressed perspiration, in consequence of cold, or some other adequate cause. The most pre- valent opinion on this subject, however, is that which ascribes the disease to a laxity of the kidneys, and to a debility of the urinary organs in general. Sydenham, Rollo, Cullen, and others, regarded this affection as depending primarily on a disordered state of the digestive organs, in conjunction with a defect in the assimilating functions. Home also entertained a similar idea concerning the pathology of this disease; he considered it as arising from a defect of the assimilative process. Quite recently, Dr. Ayre has published some observations on this disease, from which it appears that he considers it as depending wholly on chronic inflammation ofthe kidneys. Dr. Barry maintains, that the grand source of diabetes is to be looked for in the fluids; whilst Dr. Johnson is of opinion that it is a disease of the general system, or at least that its pathology cannot be fixed on any one particular organ; neither in the kidneys, the liver, the sto- mach, nor the lungs, exclusively. Whatever may be the essential nature of diabetes, or the primary seat of the disease, it appears quite certain, that the proper functions of the kidneys are greatly deranged or perverted in this disease. That this is the case can admit of no doubt, when we advert to the circumstance, that, according to the experiments of Nicholas, Gran- ville, and Wollaston, the serum of diabetic blood does not contain a particle of sugar. Its presence in the urine can, therefore, arise only from a perverted secretory action of the kidneys; and whatever may be the immediate causes of the functional derangement of these glands, its existence must be regarded as the proximate cause of all the characteristic phenomena of the disease. Another pathological condition, though less demonstrable than the former, is, as I conceive, a peculiar state of the blood, which may perhaps exist as the imme- diate cause of the perverted renal action. That the constituent ele- ments of the blood are not such as they are wont to be in health, is( it is vastly more common than in others. At Colombo, in India, it is so frequently met with, as almost to merit the title of endemic. * Jahresbericht des Poliklinischen Institutes zu Berlin 1823-4-5, p. 23. 372 DIABETES MELLITUS. rendered probable by the effects which different articles of aliment have, both on the saccharine quality, and on the quantity ofthe urine. If by an exclusive use of animal diet, the secretion of urine becomes less copious, and its saccharine character disappears, the inference naturally is, that by this kind of food the elements of sugar are reduced in the blood, and consequently less abundantly combined by the per- verted action ofthe kidneys. In health, there is always more or less urea secreted by the kidneys; but in diabetes, this peculiarly urinary compound is rarely formed in any appreciable quantity, and very often none at all. When we take into view the close chemical analogy which exists between this substance and sugar, it appears extremely probable that the urea, which is secreted in health, is, in diabetes, converted into sugar by the perverted action of the kidneys. According to the analysis of Prout, for instance, urea and sugar are composed of the following constituent elements— Urea. Sugar. 6.5 hydrogen. 6.5 hydrogen. 20.5 carbon. 40.0 carbon. 26.5 oxygen. 54.0 oxygen. 46.5 azote. — azote. Thus the absolute quantity of hydrogen in a given weight of sugar and of urea is precisely the same, while the quantities of carbon and oxygen of sugar are just double those of urea. From all this it would appear probable, that diabetic blood is deficient in azote, in conse- quence of which the kidneys are not furnished with a sufficient quan- tity of this element to form urea, of which it constitutes a large con- stituent part; and therefore sugar, which contains no azote, is the result of the renal action. This idea, first started, I believe, by Wol- laston, is rendered still more probable by the effects which an exclu- sive animal diet has in reducing the quantity of sugar in the urine, and increasing the formation of urea ; for the large proportion of azote which animal food furnishes to the blood, supplies this element in sufficient proportion for the formation of urea by the kidneys, in con- sequence of which the secretion of sugar is either much diminished or wholly arrested. From these observations it is probable, as I have already said, that the blood itself, in this disease, is defective in the regular proportions of its healthy constituent elements. But here we are necessarily led a step further in our inquiries into the pathology of this malady. What is it, namely, that causes this defective or abnor- mal condition in the composition of the blood ? We can think of but one cause, and that is, a defect of the digestive, but more especially of the assimilative functions of the system. Thus, then, it would appear that diabetes is a disease by no means local, or confined in its pathological state—but, on the contrary, one in which the digestive and assimilative functions, the state of the blood, and the particular functions of the kidneys, are all deeply and essentially implicated. After all, our views concerning the.pathology of this mysterious disease, are as yet, in a great measure, conjectural. In this uncertain state of our knowledge, therefore, I may be allowed to throw out a DIABETES MELLITUS. 373 conjecture on this subject, which must be left for future inquiries, either to refute or confirm. It is well ascertained that the bile con- tains a very considerable portion of a saccharine matter, called pircro- mel. May not a morbid condition of the liver, by which this consti- tuent of the bile is prevented from being formed, give rise to the vicarious secretion of a similar substance by the kidneys, and thus produce diabetes? An accurate analysis of the bile of a diabetic patient would throw much light on this point; and until this is done it must remain wholly hypothetical. Post-mortem appearances.—It is a singular circumstance, that the lungs are almost universally found in a diseased condition in those who die of diabetes. Dr. Johnson declares, that so far as his inquiries go, there is not a single instance on record, where, on dissection, pulmonic disease was not discovered in persons who had sunk under this disease.* The kidneys frequently exhibit an increased vascularity; and many writers state, that these organs are often enlarged, soft, flabby and otherwise diseased. Some traces of disease are also sometimes dis- covered in the mesenteric glands, in the lacteals, and in the mucous membrane of the alimentary canal. The bladder, also, sometimes exhibits a morbid condition, being considerably contracted, with its coats much thickened and indurated. The prognosis in this disease is always unfavourable ; few, com- paratively speaking, recover from its attack; and the cure, under the most favourable circumstances, is always tedious and difficult. I have seen but one case of recovery out of six that have come under my care. Cullen and Currie state that they never knew a single in- stance of this disease having yielded to remedial treatment; and the celebrated Frank succeeded only in two out of ten cases which he treated. Many other physicians have nevertheless been much more fortunate in their treatment of the disease ; and although it is certainly exceedingly difficult to cure this malady, it is not quite so intractable as Cullen was led to believe. Treatment.—The plans of treatment recommended in this disease by writers, are as various and discrepant as the notions which have been advanced concerning its pathology. A vast number of reme- dies have been mentioned as having been used with success in this intractable malady ; but as they have been generally introduced upon vague and hypothetical grounds, or adopted in a purely empirical * In a recent number of the Strasburg Hospital Reports, Mr. Surofh gives an account of a case of diabetes which proved fatal in a few months. On dissection, no apparent change was discovered in the kidneys, liver, spleen, or pancreas. But in the chest, the morbid phenomena far exceeded the symptoms during life. There were hydrothorax in the left side, hepatization of the left lung, and in its up- per portion a large cavernous excavation; universal adhesion of the right lung to the side, but its structure was sound; hydro-pericardium; aneurismal dilatation of the pulmonary artery, at least two inches in diameter. The blood was everywhere fluid in the vessels, and mixed with air. , 374 DIABETES MELLITUS. manner, there are but few of them which appear now to deserve any attention. I have already stated that the blood drawn from diabetic patients exhibits in many instances a decidedly inflammatory appearance. From this circumstance, and from the firmness of the pulse observed in some cases of the disease, a direct antiphlogistic treatment has been proposed and successfully practised by s-everal eminent physicians. Mr. Watt, of Glasgow, who, I believe, first resorted energetically to the depletory plan of treatment in this disease, has adduced several very interesting examples of its efficacy in this affection. Since the publication of his valuable work on this malady, venesection has been frequently resorted to, both in Europe and in this country ; and cases have been reported in which its usefulness appears to be well attested. It is indeed pretty generally admitted, that the abstraction of blood may, in some cases at least, be very advantageously practised, al- though there are very few, I think, who would be willing to accord to it as much importance as is done by Mr. Watt. Dr. Prout observes, that in recent cases of a manifestly phlogistic character, blood-letting is often a very valuable remedy. In very protracted instances, however, occurring in old and infirm subjects, and indeed in all cases attended with great debility, it is scarcely necessary to observe, that this remedy can very seldom be required. In one of the cases which I treated some years ago, the pulse was such as induced me to think advantage might be obtained from the abstraction of a portion of blood. The patient was accordingly bled to the extent of fourteen ounces, but instead of the benefit which I anticipated, an obvious aggravation of the affection was the consequence. It must be observed, however, that the only case which I have ever succeeded in curing was bled twice, and the pulse in this instance was by no means very active or hard, nor did the blood drawn exhibit the inflammatory crust. It appears, indeed, that blood-letting is, in general, better borne by dia- betic patients with a feeble state of the circulation, than in most other affections under the same state of arterial action. Mr. Watt relates a case of diabetes in which the pulse was slow, feeble, and irregular; there was also great prostration of strength, and the lower extremities were cold and oedematous. The blood was very dark, with a crassa- mentum as black as pitch, and wholly devoid of tenacity. Notwith- standing these appearances, the lancet was freely employed, and the result showed that it was proper and judicious. The bleeding was repeated six times, and it was not till the fourth repetition of it, that the appearance of the blood was changed, the crassamentum having now become dense and sizy on the top. On the fifth bleeding, the buffy coat was contracted to the size of a quarter of a dollar; after the sixth it was still firmer, and the serum exhibited a white milky appearance. The patient felt better after every bleeding, and he re- covered without much difficulty. In a late number of Majendie's Journal, (1828,) M. Lefevre has related a case of this disease which was successfully treated by blood-letting, in conjunction with an ex- clusive animal diet, the use of milk and lime water, and the hot bath every evening. Dr. Venables agrees with Dr. Watt, in regarding DIABETES MELLITUS. 375 blood-letting as a valuable curative means in this affection. " We should not be deterred," he says, "from repeating the bleedings merely because the blood does not exhibit the buffy coat. I have generally found that a dense milky appearance ofthe serum indicates inflammatory action, and this independently of the appearances pre- sented by the coagulable part. I have found the pulse rise under such circumstances, after venesection and a repetition of the operation required. He prefers repeated small bleedings to fewer larger ones. Upon the whole, I think it may be concluded that venesection is a remedy which deserves considerable attention in the treatment of this disease, although it is certainly by no means so generally salutary as was supposed not many years ago. Local bleeding by means of leeches and cups, has also been re- sorted to with excellent effect. Dr. Ayre, who considers this disease as depending on chronic inflammation, or inflammatory irritation of the kidneys, considers the application of leeches or cupping over the region of the kidneys 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 leeches, as the former, besides its evacuant effect, is decidedly the most power- ful derivative measure. Opium.—There is no article which possesses so much reputation as a remedy in diabetes as opium. Since the time of Ferriar, 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 declara- tion that it is one of our most useful remedies in this malady. Be- sides its tendency to diminish the inordinate secretion of urine, it is particularly useful in subduing that nervous 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 affec- tion, (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 proportion 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, he 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 pre- parations, he thinks Dover's powder is the best. It must not be forgotten, however, that where the pulse is strong and firm, blood- letting is an important, if not an essential, preliminary to the em- ployment of this narcotic. " The first immediate effect of opium upon the urine," says Prout," is to increase its specific gravity. This depends on the diminished secretion of water, while the sugar re- mains unaltered, in consequence of which the urine is rendered 376 DIABETES MELLITUS. 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 carbonate of iron and opium, in cases of a chronic character, and attended with much debility and nervous irritation. Much of the benefit which results from the use of opium, depends, probably, 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 considerable 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 decided benefit. Dr. Venables speaks very favourably of the effects of the phos- phate of iron in this affection. " I have been really struck," he. says, " with the efficacy of the phosphate of iron in excessive dis- charges of urine. The quantity of this secretion is rapidly reduced under the use of this salt, and indeed its qualities sensibly 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." Dr. Carter, in his interesting and valuable series of Hospital Re- ports, has related a case of diabetes, 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 removed the disease." Dr. Johnson, in remarking on this case, observes, "it is evident that the skin, as an extensive outlet, sympathizing power- fully with almost all the glandular viscera, is an important agent in the removal of this disease. Its agency, therefore, should never be neglected in the treatment of this disease." Dr. Marsh, in his valua- ble memoir on this disease in the Dublin Hospital Reports, speaks in high terms of the usefulness of exciting the action of the skin in diabetes. For this purpose he directed the same measures which I have just mentioned, as having been successfully employed by Dr. Carter—namely, hard work, warm clothing, and large doses of Dover's powder." In the case which terminated favourably in my DIABETES MELLITUS. 377 own hands, I united the Dover's powder to uva ursi in doses of fifteen grains each, three times daily. This will generally excite emesis for the first two or three days; and the good effects of the remedy appeared to me to be considerably enhanced by the vomiting which it produced. There can exist no doubt that very active exercise or labour, by favouring free exhalation from the surface, will often assist very materially in subduing this disease. Some have recommended 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 oojection, and they have been resorted to with manifest benefit. Magnesia has of late years been recommended m England as a remedy of considerable powers in diabetes. Dr. Trotter has pub- lished 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 beneficial effects of this article are set forth in diabetes. I suspect, however, that its usefulness is chiefly confined to that form of urinary disease, in which the urine, though morbidly increased in quantity, is wholly free from any sac- charine 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 removed 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 nowhere mentions a saccharine urine. Indeed, the custom which prevailed formerly, of including all the urinary affec- tions which are attended with a preternaturally copious discharge of urine, under the head of diabetes, throws no small degree of ambi- guity and uncertainty over the recorded experience of the practi- tioners 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 ter- minated fatally. Alkaline remedies have indeed been very fre- quently employed in the treatment of diabetes. Lime water, especially, was at one time much resorted to in this disease. Fer- riar seems to have placed considerable reliance on it, since we find it 378 DIABETES MELLITUS. mentioned in every case which he has reported. I have myself used it in three or four cases, in conjunction with uva ursi, but I did not perceive that any advantage arose from its exhibition. Rollo thought very favourably of the powers of the ammonium sulphuretum, or hepatized ammonia, which he rarely failed giving in conjunction with the more important measure of an exclusive ani- mal diet. In some instances, he administered the kali sulphuretum 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 Marry at, speak favourably of this practice; and I am inclined to think that it deserves attention. In the case which terminated favourably under my care, two large epis- pastics were applied on the inside ofthe 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 remedial measures, had in the production ofthe favourable result. Tonics were formerly much resorted to in the treatment of dia- betes—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 espe- cially iron. Where the system is much relaxed and exhausted, I doubt not at all that the sulphate of quinine may be often very use- fully given. If I am not mistaken, Prout advises the employment of this preparation in union with opium. I have heard of an in- stance in which the administration of three grains of quinine with a grain of alum and the same quantity of ipecacuanha, administered three times daily, produced very excellent effects. The mineral acids also are said to have been given with complete success in this affection. Gilby affirms, that out of four cases, he cured three with the internal use of the nitric acid; and Scott suc- ceeded in one case with the same remedy. Brea, moreover, cured a case of this disease with the nitric acid given internally, 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 ammonia- cum ;t mercury ;J digitalis ; the internal use of cantharides ;§ valerian; assafoetida; catechu; kino ; camphor; myrrh ; phosphoric acid; phos- phate of soda; phosphate of iron. I have hitherto said nothing concerning the dietetic means for * Selle, Beitr. zur Natur. und Arzneiwiss., bd. i. t P. Frank, De Curand. Homin. Morb., p. 65. X J. Frank, Ratio Instit. Clinic. Ticinem., p. 208. j Brisbane, Select Cases, &c, Stoeller, Hufeland's Journal, bd. vi. DIABETES MELLITUS. 379 treating this disease, which, after all, are perhaps the most important and indispensable to success. Rollo was the first who adopted fully the plan of restricting diabetic patients to an exclusive animal diet, with the view of keeping out ofthe circulation, as much as possible, the saccharine principles which vegetable 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 proportion of azote; it would seem that in dia- betes 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 saccharine matter which characterizes the diseases. Now, as animal substances, especially the muscular parts, contain a large proportion of azote, whilst vegetables contain little or none of it, it appears pro- bable, 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 decid- edly 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 Dispensary, 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 dis- ease with a vegetable diet, and a drachm of phosphate 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 saccharine urine ? I am much in- clined 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, 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 follows: 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, beefsteak, mutton, lamb, and game, should form the principal part of the food; and it is said that fat meats are, in general, more 380 DIABETES INSIPIDUS. beneficial than the lean parts. For drink, the patient may use water, alum whey, weak brandy and water, milk and water, and beef or chicken. 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, indiscrimi- nately, under the single term diabetes. Collectively, they constitute the disease which has since the time of this writer been denominated diabetes insipidus; but as they are characterized by a very different condition 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 augmentation of its quantity, often not inferior to that which occurs in saccharine mat- ter 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 disease of the urinary organs. In this affec- tion, there is almost invariably a very frequent and distressing desire to pass urine, both by day and night. In some instances, though ex- ceedingly seldom, the quantity of urine is not much increased. In a great majority of cases, copious diuresis is a prominent symptom. " The quantity of urine, (says Prout,) appears to be particularly liable to be increased by cold weather, and by all causes producing mental agitation. In some instances the patient experiences a considerable sense of uneasiness 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 gene- rally retains its regular functions, being often moist, with general dia- phoresis, even when the urinary affection is exceedingly aggravated. The desire for food and drink also, is not morbidly urgent, except in very violent cases; nor are the stomach and bowels often particularly deranged—the tongue being generally clean, and the alvine dis- charges 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 or 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 debili- DIABETES INSIPIDUS. 381 tates the system, and particularly the urinary organs, may give rise to the complaint. There is another variety of urinary disease, in which the presence of a large portion of albuminous matter in the urine is the charac- teristic symptom.* This is the variety which has probably been most commonly described under the name of diabetes insipidus ; for along with its albuminous principle, the urine is always greatly increased in quantity. There are two varieties of albuminous matter occur- ring 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 in- termediate character; that is to say, the albuminous matters partake in some degree of the properties of both those of chyle and serum ; though generally more of those ofthe 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 mingled with the urine in its passage down the ureters to the bladder. That this is a mistaken opinion, is satis- factorily 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 Commentaries, 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 Ali- ment. Facult., lib. i, c. 2.) But the authority of Prout is alone suffi- cient to establish the opinion that the milky appearance 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 * [This subject has been carefully investigated by Dr. Bright, of London, and bo much importance has been attached to it in consequence as to induce the fabrication of a new term in nosology, viz., "morbus Brightii."—Of late the same condition has been denominated by the European journalists, "albuminuria." The only practical result which has been derived from these inquiries, is that, when the urine exhibits coagulable matter under the influence of heat, just be- low the boiling point, an inflammatory condition of the kidneys may be suspected, which should be assailed by the appropriate antiphlogistic remedies. The gra- nulated appearance ofthe kidney described by Dr. Bright, is by no means essential to the pathology of this affection.—Mc] 382 DIABETES INSIPIDUS. albuminous matter in the urine, this fluid undergoes a spontaneous coagulation, assuming the appearance nearly of blanc-mange. Mr. Elliotson, in his edition of Blumenbach's Physiology, relates a re- markable 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 white. After fasting for twenty-four hours, the coagulum "was extremely pale, with pink streaks." This kind of urine is extremely prone to decom- position, becoming speedily very offensive to the smell. In some in- stances, 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 constitu- tional symptoms are generally mild, and in some instances scarcely perceptible. The patient, however, generally complains of some degree of uneasy feeling in the praecordium, and a sensation of lan- guor and feebleness in the muscles of the loins. I have seen two cases in relaxed, debilitated, and emaciated 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. " The first specimen of urine voided in the morning," he says, " consisted of a solid jelly-like mass or coagu- lum,of apale amber colour." The second specimen, voided after break- fast, 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 re- sembled chyle in all respects, that it could scarcely be distinguished from this fluid. Causes.—No age, it seems, is wholly exempt from the formation of chylous urine, although it occurs most commonly after the middle period of life ; and in persons of an irritable habit of body, and im- paired digestive powers from a previous course of 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 ordi- nary 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 pro- ducing any very serious consequences. In the more aggravated cases of chylous urine, however, a great degree of languor and emaciation sooner or later ensues; and life is ultimately destroyed, either by the supervention of hectic, or a gradual and total exhaus- tion of the vital powers. One of the above-named cases, that came under my notice, terminated in phthisis pulmonalis. The last variety of urinary disease I have to mention is that in DIABETES INSIPIDUS. 383 which there occurs an excess of the earthy phosphates in the urine. This affection is by far more common and distressing in itsu conse- quences than either of the two preceding urinary complaints. Prout is, I believe, the first writer who has given a definite and circum- stantial account of the phenomena and character of the urinary affections, characterized by a deposition of earthy phosphates. A preternatural copiousness of urine forms, in general, a conspicuous circumstance in this variety of the disease. In some instances, in- deed, 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 pel- lucid. When this is the case, the quantity discharged js always very profuse, and it deposits no sediment on being left to cool. Oc- casionally it happens that the quantity of urine is not much greater than natural: and in this case, it is usually somewhat opaque, and deposits 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 com- plaint. 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 exist very. great irritability of the general system, and an obvious derangement ofthe 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 appe- tite. " The stools are extremely unnatural, being either nearly black or clay-coloured, or sometimes like yeast. These are always accom- panied by more or less of a sensation of pain, uneasiness, or weak- ness in the back and loins. There is a sallow, haggard expression of the countenance ; and as the disease proceeds, symptoms somewhat analogous to those 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 portion 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; ex- cessive fatigue. The most common local causes, besides the one already mentioned, are some irritation about the bladder, or urethra, especially when of a chronic character—" such as a foreign substance introduced into the bladder, including all sorts of calculi; the retain- ing of a bougie or catheter in the urethra; strictures of the urethra in particular constitutions;" and disease ofthe 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 aflection " 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 384 DIABETES INSIPIDUS. most useful remedies in this variety of the disease. From one to two grains of quinine, with from twenty to thirty grains ofthe bicar- bonate of soda, may be given three times daily, and an opiate ad- ministered 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 pur- gatives, 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, unir- ritating, and digestible; 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 of phosphatic salts in the urine, opium, according to the experience of Dr. Prout, is decidedly the best remedy we possess. The great object, in this variety of the disease, is to allay the general irritability which is so prominent a symptom in this affection. Where opium is objected to by the pa- tient, we may resort to the use of hyoscyamus, in union with uva ursi, with considerable advantage. Two or three grains of the ex- tract of hyoscyamus, with from twenty to thirty grains of pulverized uva ursi, should be given twice or three times daily, according to the urgency of the symptoms. I have, in several instances of this disease, employed the following pills with a most excellent effect.* Mr. Prout mentions a strong infusion of the alchimilla arvensis as a very useful remedy for the purpose of allaying the irritability of the blad- der. When the irritability of the system is in some degree moderated by the narcotics just mentioned, tonics are more particularly proper— and of this class of remedies, the mineral acids, in conjunction 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 deposit is changed. When the mineral 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 ofthe 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 em- ployed, it will be proper to keep down the general and local irrita- bility by the use of opium or hyoscyamus; and after the phosphatic * R.—Extract, hyoscyam. Pulv. camph., aa gss. Mucilag. g. Arab. q. s.—M. Divide into thirty pills. S. Take one four times daily. LITHIASIS. 385 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 prin- cipal remedies. Dr. Venables strongly recommends the use of the phosphate of iron in this affection. He asserts, that it seldom fails to lessen the quantity of urine discharged. 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 debility, 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 mer- cury, 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 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 acescent 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 sabu- lous matter with the urine, and its formation into calculous concre- tions. The latest and best works on this subject, are those of Dr. Marcet, Mr. Brande, and Dr. Prout; and it is to the excellent treatise ofthe latter that I am chiefly indebted for the following facts and ob- servations. Urinary deposits.—There are three forms of urinary depositions, 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 yel- low 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, magnesia, and ammonia, con- stituting the white sediments. These sediments exist in a state of solution in the urine, and are deposited only when it cools, or an acid is added. 2. Crystallized sediments, called gravel or sand, consisting of vol. ii.—26 386 LITHIASIS. 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 varie- ties 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 agglomera- tion of the two former varieties—forming what are termed urinary calculi. Of these concrete masses, Prout mentions thirteen varieties; but a description of these does not properly come within the scope of the present work, the general pathology and remedial manage- ment of the different lithic diatheses being the objects to which the attention of the physician is more particularly called. In relation to the comparative frequency of the different varieties of urinary deposits, 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 ascer- tained^ 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 deposition 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 sonte time, this latter gives place to the deposition of sediment, composed chiefly of car- bonate and phosphate of lime, and this is finally succeeded by the phosphates of lime and magnesia, in combination with ammonia. It is a curious circumstance in the pathology of lithiasis, that although the deposition of lithic acids or its compounds is very frequently followed by the phosphatic and earthy deposits," yet it may be laid down as a general law, that in urinary calculi, a decided deposition of the mixed phosphates is never followed by other depositions." Notwithstanding the various forms and appearances which uri- nary calculi present, they may be classed under four heads, according as one or the other of the following elementary substances predo- minates ; namely, 1, the lithic acid and its compounds; 2, the oxalate of lime; 3, the cystic oxyde; and 4, the earthy phosphates. The abnormal conditions of the system which give rise to the secretion of these lithic substances, are with propriety distinguished as pe- culiar diatheses; and we accordingly have the lithic acid diathesis —the phosphatic diathesis—the cystic oxyde diathesis—and the oxalate of lime diathesis, as the four cardinal points of attention in the pathology of lithiasis. LITHIASIS. 387 1. Lithic Acid Diathesis. The urinary sediments which belong to this diathesis, are either pulverulent or crystallized. When the former is the case, they con- sist of some combination of this acid with an alkaline basis, gene- rally ammonia; but when the deposit is crystalline, it consists nearly of pure lithic acid. These amorphous sediments may be classed under three heads, 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 and its consequence. 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. in- flammatory condition of the system. To this, says Dr. Prout, " I have never seen a decided exception." In general, 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 ammonia," but they derive their colour exclusively from the purpurate of am- monia. 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 dys- pepsia. The sediments which occur in the sweating stage of remit- ting and intermitting fever, and during the favourable crisis of gout, rheumatism, and other febrile affections, are of the lithic acid kind. Prout says, that in three instances he has seen a perfectly white lithate of soda deposited in the urine. Of the causes which favour the excessive secretion of lithic acid, or its compounds.—The circumstances which tend to produce a redundancy of lithic acid sediment in the urine, independently of general local inflammatory and febrile affections, are: a. Errors in diet.—The mere excess of wholesome food; heavy, indigestible, irritating, or unwholesome articles of diet; taking full meals at unusual hours; in short, whatever resists or deranges the digestive powers, will produce or increase the deposition of the lith- ate of ammonia. Prout says, that, according to his observations, the articles most apt to give rise to this urinary deposit, «are animal 388 LITHIASIS. substances, and more especially heavy unfermented bread, or compact, hard-boiled fat dumplings or puddings." b. Excessive and unusual corporeal and mental exertions, or want of exercise, are accounted among the exciting causes of the lithic depositions in the urine. c. Debilitating circumstances.—Whatever is capable of diminish- ing the vital energies, has a peculiar tendency to give rise to urinary depositions of this kind. The depressing passions, want of nourish- ment, 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 sedi- ments, in the urine of persons labouring under fevers of an inflam- matory character ; and particularly during the critical perspirations which occur in gout, rheumatism, intermitting and hectic fever, and in acute and chronic inflammation of the liver, as well as in various other affections attended with a phlogistic diathesis. In aggravated cases of dyspepsia, these urinary depositions are rarely wholly absent. With regard to the exciting causes of the crystallized deposi- tions, or the excess of uncombined lithic acid in the urine, different opinions have been expressed by the late writers on this subject. According to Magendie, the excessive secretion of this acid in the urine is very particularly favoured oy 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 composi- tion of lithic acid, and that animals confined 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 observations have afforded abundant evidence, that the formation of this urinary acid is independent ofthe quantity of azote introduced with the aliment, and that there are numerous other circumstances which favour or oppose its secretion by the kid- neys. 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 deposition 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 ofthe 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 ofthe phosphates, both by producing acidity ofthe primae viae, and by rendering the skin inactive. " 5. That indolence has the same tendency, both by inducing dys- pepsia, and by lessening the activity of the skin in proportion as it impairs the vigour ofthe circulation. LITHIASIS. 389 " 6. That an acid passes off by insensible as well as sensible per- spiration."* It appears from the observations of Dr. Prout, that certain un- known circumstances, connected with the age of the patient, modify, in no inconsiderable degree, the influence of the ordinary causes of an excess of lithic acid in the urine, as well as the constitutional symp- toms which attend the active state of this diathesis. Thus, children born of gouty and dyspeptic parents, " are exceedingly liable to lithic acid deposits in the urine." Such children are very apt to manifest a frequent desire to pass urine, with very small discharges, and evi- dent 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 for- mation of stone in the bladder." There seems to be less disposition to form lithic acid deposits be- tween 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 diathesis 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 previously, but there appears to be a manifest disposition in the constitution 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 second- ary 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 affording the usual relief, the sensation still continuing as if some urine were left behind in the bladder." Dyspeptic symptoms—particularly acidity and flatulency in the primae viae, are among the most common symptoms of the lithic acid diathesis. 2. Phosphatic Diathesis. The phosphatic deposits from the urine are generally amorphous, though occasionally they appear also in a crystallized form. The de- position of the phosphates rarely occurs as an original affection, being almost universally consequent " to the other forms of urinary deposi- tion, and more especially the lithic acid and oxalate of lime." * Medical Transact, ofthe College of Physicians of London, vol. vi, art. 9. 390 LITHIASIS. The crystallized phosphatic sediments consist almost universally of the triple phosphate of magnesia and ammonia. In connection with the appearance of this sediment in the urine, which is of a yel- lowish-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 gene- rally copious and pale, and when suffered to stand awhile, becomes covered with an iridescent pellicle, consisting of minute crystals of the ammoniated phosphate of magnesia. The urine is very apt to enter into the process of decomposition, and to become alkaline and putrescent. Sometimes this crystallized deposit is formed immedi- ately after the urine is voided ; 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 greater proportion. Some writers of eminence maintain that these sedimentous matters are not separated from the blood by the kidneys, but wholly and ex- clusively by the inner coat of the bladder, from a peculiarly 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 observations, the only source from whieh it proceeds. The general symptoms which accompany an habitual and copious deposition of the amorphous phosphates from the urine, are often peculiarly distressing. The general system, both physical and mental, is almost extremely irritable; and great derangement of the digestive organs, manifested by flatulency, nausea, constipation, or exhausting diarrhoea; extremely variable and unnatural stools—being black, or whitish, and sometimes resembling yeast—accompanied with a dull aching pain, and a peculiar feeling of weakness in the loins. The countenance, in aggravated cases, becomes sallow and haggard, "and as the disease proceeds, symptoms somewhat analogous to those of diabetes ensue, such as great langour and depression of spirits, cold- ness of the legs, complete anaphrodisia, and other symptoms of ex- treme debility." The urine is pale and often very copious. WTith 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 reme- dies as very trifling, and scarcely worth attention, either in an etiolo- gical or therapeutic point of view. The occasional causes of the present variety of urinary deposits, 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 influ- LITHIASIS. 391 ence 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 phosphatic sedi- ments, 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 phosphatic calculus externally, whilst its central portion, or nucleus, consists of lithic acid, or of the lithate of ammonia. Treatment. Treatment for the lithic acid diathesis.—To counteract the ex- cessive secretion or formation of lithic acid depositions from the urine, our principal aim must be to establish the healthy action of the di- gestive organs. For this purpose, we must, in the first place, adopt proper dietetic regulations; for without an especial attention to this point, little or no benefit will be derived from any remedial measures. The patient must be put on a plain, digestible, and nourishing diet, and be particularly cautioned against taking very full meals. " An error in quantity is infinitely more important," says Dr. Prout, " than an error in quality of the diet." Indigestible, mixed, and irritating articles of food, particularly fresh and unfermented bread, solid fari- naceous preparations, salted and dried meats, and all kinds of acid drinks and acescent aliment must be carefully avoided. At the same time that attention is paid to the diet, it will be proper to use means for correcting the secretion of the liver and alimentary canal, and for keeping up a regular action of the bowels. With this view, mild aperients, followed by alkaline medicines, in union with weak infusions of some of the usual bitter vegetable tonics, are par- ticularly beneficial. One of the following pills may be taken every second or third evening, until the hepatic and intestinal functions are restored to a healthy condition.* 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 ope- ration. The regular use of alkaline remedies is an important mea- sure in the remedial management of this diathesis. From fifteen to twenty grains of magnesia, taken in a glass of soda water, will often answer this purpose very well. The sal asratus, (potassae aerata,) * R.—Mass. pil. hydrarg. gi. G. aloet. socc. 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. 392 LITHIASIS. too, is an excellent alkaline in such cases.* From one to two drachms, dissolved in a few ounces of a very weak infusion of Colombo or gen- tian root, may be taken once or twice daily. Twenty or thirty drops of the liquor potassae may also be employed. 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 insensible exhalation is augmented, than when the sensible perspiration 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.t Prout says, that warm sea-bathing is sometimes " par- ticularly beneficial, though occasionally the gravelly deposit 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. In cases accompanied with a general irritable state of the system, 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, are 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 diathesis, in consequence of which the kidneys secrete an unusual quantity of lithic acid, " and by this process gives 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 artificial 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 combination 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 mo- nardapunctata, of erigeron heterophyllum; alchemilla arvensis; * This preparation is made by dissolving half a pound of the subcarbonate of potass in ten ounces of water, adding two ounees of subcarbonate of ammonia: after it has effervesced, it is crystallized. t 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 deposit 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 nausea, as when no sensible effect was experienced from it."—Loc. cit., p. 202. LITHIASIS. 393 sem. daucus carol a, 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; it would seem, also, that they are "not adapted to any other species of deposit 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 treatment does not differ materially from that which has already been described, "except that it must be more active." Thus venesection, 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 conjunction with the less stimu- lating diuretics just mentioned, with the addition of colchicum, will seldom fail to procure considerable relief. A strict antiphlogistic regimen is indispensable, and after the attack is over, the patient should adhere strictly to the dietetic rules mentioned for counter- acting the lithic diathesis. Treatment proper in the phosphatic diathesis.—It was before stated, that a peculiarly irritable state of the system is one of the most constant, and in general the most distressing circumstance, at- tending the completely developed form of the phosphatic diathesis. An important indication, therefore, is to diminish this unnatural irri- tability, 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 irrita- bility of the constitution; and it should be given in large and repeat- ed 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 ferruginous preparations, uva ursi, &c. The acids are not only beneficial by their general tonic influence, but they tend, also, in a direct manner, to lessen the alkaline character ofthe 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 vio- lence 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. " Mercury in all its forms, * [Of these, the nitric acid, or the nitro-muriatic acid, is to be preferred in all respects. From 20 to 60 drops may be given three times a day largely diluted in gum water.—Mc] 394 ISCHURIA RENALIS. 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 occa- sional 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 mpnarda punctata during the day. Prout speaks very favourably, in the slighter cases of this affection, of the employment of the infusion of alcher&illa 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 inclined to prefer an animal diet. Much, of course, will depend on the state of the stomach in relation to the propriety or impropriety 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 of this kind of diet renders it decidedly proper where the digestive powers are weak, with an absence of mucous irritation of the stomach. A tranquil state of the mind has a most important curative in- fluence. " The influence of mental anxiety," says Dr. Prout, " is really astonishing in this disease; and absence from care, the exhi- larating air of the country, and such exercises as are consistent with the patient's condition, will, perhaps, more than any thing else, con- tribute 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 ofthe urine. In ischuria, the functions ofthe kidneys are more or less suspended or destroyed, the secretion of urine being either morbidly diminished, or entirely suppressed. 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 gradu- ally accumulates, until, in some instances, the most distressing, and even fatal consequences occur. Ischuria renalis may be partial or complete. In the former case, very small portions of urine are, from time to time, discharged from the bladder, under symptoms often extremely distressing. The pa- ISCHURIA RENALIS. 395 tient is harassed with a very frequent desire to pass off the urine, ac- companied with more or less uneasiness or pain, and a sense of dull, heavy weight in the iliac region, and in some cases much pain and tenderness throughout the whole lower part ofthe abdomen, together with great anxiety of feeling, nausea, or vomiting, and occasionally hiccup. In almost all instances of urinary suppression, febrile symp- toms are conspicuously present. The thirst is usually urgent, and where the suppression is complete, and continues for some time, pa- tients often experience a distinct urinous taste in the mouth; and the whole surface of the body, in instances of an obstinate character, ex- hales a very perceptible urinous smell. In cases attended with the foregoing symptoms, the suppression is, probably, always the conse- quence of high irritation or inflammatory action in the kidneys. Sup- pression of urine is not, however, always attended with the painful symptoms just mentioned. In some cases the patient experiences neither pain, nor weight, nor any particular uneasiness in the region of the kidneys and bladder. Sir Henry Halford has related five in- stances 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 ac- companied 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 at- tending 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 abdo- men or urinary organ, the patient, in the course of the second or be- ginning 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 coma is fre- quently preceded by delirium, and convulsions sometimes 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 vica- rious secretion of urine sometimes, though indeed very rarely, takes place from particular organs or parts—more especially from the umbilicus. Dr. Hastings has related a most interesting case of ischu- ria renalis, in which, many days after the commencement of the disease, considerable quantities of urine were discharged from the * On the Necessity of Caution in the Estimation of Symptoms in the last Stage of some Diseases. t Edinb. Med. and Surg. Journal, April, 1821. X Dr. Yeates (Med. and Phys. Journ., No. 29) relates instances of ischuria, in which the secretion of an urinous fluid by the skin was noticed; and Sauvage men- tions a case in which this phenomenon was distinctly observed. 396 ISCHURIA RENALIS. umbilicus, for three days in succession.* Dr. Hastings refers to some of the older writers for accounts of similar cases. Schenck relates two instances of this kind;t and a case is recorded by Sennertus, as having occurred under the observation of the celebrated Platerus, in which, in consequence of a total inactivity of the kidneys, an urinous fluid was copiously discharged from the right ear.f Instances of this complaint are on record, also, in which a fluid resembling urine was copiously discharged by vomiting, and by stool. Valisneri 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 inflam- mation of the renal organs, may become the remote cause of this affection. Schenck relates a fatal case, which was caused by a blow on the loins; and on post-mortem examination, a considerable ab- scess was discovered between the muscles contiguous to the kidneys. Lselius 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 hemorrhoids 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 * Midland Medical Reporter, No 4. t One of these cases was in a female. " Cum suppressa per multas dies fuisset urina tandem per umbilicum urinam profluit."—Obs., lib. iii, de Urina, p. 489, as quoted by Hastings. X Puella; cuidam annosnatae tredecim ciim aliquando copiose minxisset, urinam subito suppressam esse atque tunc aquam serosam ex aura dextra adeo affatim ccepisset effluere, ut una vice duae saepe emanarint idque dies aliquot.—Sennerti, Opera, lib. iii, p. viii, s. ii, cap. ix.—Hastings. § Several very extraordinary instances of long-continued suppression of urine have recently been reported. In Hufeland's Journal for August, 1827, there is a case related of a lady, who made no water for seven weeks. There was no vica- rious secretion of urine. "In another German Journal, there is a case reported, in which the secretion of urine by the kidneys was wholly, suspended for six months. The patient, a boy, became extremely emaciated and the bowels were obstinately constipated. He was also affected with occasional pains in the loins, vvhich were sometimes so severe as to throw him into convulsions. The abdo- men was greatly distended, but not apparently with fluid, as it emitted a hollow sound when struck."—Amer. Journ. Med. Sciences, vol. iii, p. 198. II See Dr. Abercrombie's Memoir, already referred to. ISCHURIA RENALIS. 397 are no signs of renal inflammation 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 Hospice de Gournay, in which a lady had an ulcer on one of her legs of twenty-five years continuance, which was rapidly healed by an ointment. Soon after the ulcer was cicatrized, she was seized with pains in the abdomen, attended with nausea, some fever, red and dry tongue, and abdominal distension. Almost total suppression of urine speedily ensued. After a few days' continuance and in- effectual treatment, a blister was applied over the cicatrix of the ulcer, which had the effect of speedily freeing the patient of her disease. The sudden application of cold to the body, particularly during the flow of the menses, has occasionally given rise to fatal ischuria. The case related by Hastings, mentioned above, was produced in this way; and one ofthe cases of suppression from renal paralysis, men- tioned by Sir H. Halford, was excited by the influence of cold, while the patient was under the operation of mercury. It would seem, that ischuria from paralysis of the kidneys, sometimes depends on a disordered state of the brain or of the nerves, without any immediate connection 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. Gene- rally, however, in this latter case, the effects cannot be ascribed alto- gether 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 was 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 calculus 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 extremeby un- favourable. 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 general keep off the more alarming symptoms of cerebral oppression for a considerable time, and give greater opportunities for subduing 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 * [Sympathetic irritation resulting from the influence of severe wounds and Burgical operations, occasionally produces a total suppression of urine. I have had this alarming condition continue for three days after an extirpation of a scirrhous parotid.—Mc] 398 ISCHURIA RENALIS. third day. Sir Henry Halford, 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 termi- nating 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, and yet both patients recovered.! 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 modified, 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 pointed out for the cure of nephritis should be energetically pursued. Venesection, cupping, leeching, the warm bath, purgatives, emollient enemata, sinapisms, and even blistering over the region of the kidneys, con- stitute the principal remedial measures. In cases attended with no decided manifestations of inflammatory action in the kidneys, diure- tics are the means upon which our chief reliance must be placed. In general, stimulating articles of this kind have been found most bene- ficial—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 given in union with castor oil, in doses sufficient to procure pretty free purging. The remarkable case mentioned above from Hufeland's Journal, was cured by a mixture of oil of amber, Venice turpentine, and balsam copaivse, after a great variety of other medi- cines had been ineffectuallyTisJed. I have seen two cases of incom- plete 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 mercurial 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 * Edinb. Med. and Surg. Journ., vol. x. t Essays, &c, on Medical Subjects. See Med. Chir. Rev., Dec, 1828. X R.—01. juniper ^ss. Spir. nit. dulc. 3b Tinct. opii 3b—M. Take a teaspoonful every two hours. RETENTION OF URINE. 399 attended with both local and general inflammatory action, the reme- dies 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 inef- fectually employed.* Lieutaud recommends emetics for the cure of ischuria rehalis.t 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 render 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 detrusor muscles; or 2, in mechanical obstruction ofthe urethra, or neck ofthe bladder. 1. Paralysis, or loss of the expulsive power ofthe bladder, gene- rally arises from over-distension of this viscus. After the middle period of life, the sensibility ofthe bladder, in some individuals, gradu- ally diminishes as age advances; and this insensibility occasionally becomes so considerable, that the urine fails more and more to impart the due degree of stimulus to the bladder; 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 abdominal 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 indisposition from cold, or from some adventitious local affec- tion, as diarrhoea, suppressed hemorrhoids, 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 con- sequence. 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 facility * Med. Obs. and Inquir., vol. vi. Appendix. t Nonnullos enim decumbentes et cum morte colluctantes hocce praesidiis tempestive adhibito ex orci faucibus ereptos vidi.—Synop. Prox. Med., torn, i, p. 269. 400 RETENTION OF URINE. with which the catheter may be introduced, and by the general course and progress of the complaint. No symptoms indicative of mechani- cal obstruction ofthe urethra, or of inflammation, precede or accom- pany 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 be- comes smaller and smaller, whilst the desire to urinate becomes more frequent and urgent. Retention from paralysis ofthe bladder, is much less alarming and dangerous in its consequences, than when the retention occurs from inflammation or obstruction ; but it often continues for many months. I have known several instances, apparently of spontaneous occur- rence, in which the daily use of the catheter was necessary for three months before the bladder regained sufficient 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 accumu- late until the bladder becomes very greatly distended. Indeed, cases sometimes occur, in which the patient is not even aware that a re- tention of the urine exists; for the bladder may gradually become enormously distended, and give rise to uneasiness, although more or less urine is gradually discharged at each attempt to urinate. In- stances of this kind have even been mistaken for abdominal dropsy; for when the. discharge of urine, though in diminished quantities, continues, the abdominal distension and uneasiness may, on a super- ficial examination, be readily ascribed to dropsical effusion. A case is mentioned as having occurred in St. George's Hospital, where the patient was thought to be labouring under ascites. Para- centesis 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 swelling."* Similar instances are mentioned in the article on this affection in the Diet, des Sciences Medicates. A woman was supposed to be affected with ascites, and tapping was determined on, at the same time that diure- tics were diligently employed : finally, in consequence of the sudden occurrence of complete retention of the urine, the catheter was intro- duced, and a large quantity of water was unexpectedly drawn off. The abdominal swelling soon disappeared. Another case is related, in which retention ofthe urine was mistaken for dropsy, which, after various 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 bladder—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 ab- domen ; violent and painful efforts to void urine, which passed off in small quantities; pains in the thigh ; dyspnoea ; palpitations; a sense * Med. Chir. Rev., April, 1825, p. 525. RETENTION OF URINE. 401 of suffocation from the slightest motion; puffiness of the face ; frequent pulse; and a dry cough. Under these symptoms she had laboured a considerable time before Dr. F. saw her. He suspected retention of urine. The catheter was introduced, and nearly fourteen pints of water drawn off. 2. Retention ofthe urine from inflammation.—Inflammation of the urethra and bladder is one of the most common causes of retention ofthe urine, and may be produced by a great variety of causes—such as irritation from calculus; irritating diuretics, particularly terebin- thinate remedies and cantharides; gonorrhoea; stimulating injections into the urethra; the incautious introduction of the catheter or bougie; the spread of inflammation from neighbouring parts; an acrid or irri- tating 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 perineum ; general fever and constitutional irritation ; metastasis of goutand 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 burn- ing pain in the neck of the bladder, with tenderness to pressure of the perineum and the parts immediately above the pubis. The de- sire to void urine is very frequent, and extremely urgent and painful. Fever is an early attendant and the patient is apt to experience nau- sea 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 urethra, but sometimes in the parts contiguous to the viscus. Thus, retention of urine may arise from inflammation of the rectum, by causing high irritation and vascular engorgement of the mucous membrane of the bladder and urethra, or spasmodic constriction of the urinary passage ; or finally, the inflammation may spread to the detrusor muscles, and destroy their powers of regular action. Chronic inflammation of the mucous membrane ofthe 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 hemorrhoidal irritation, and repelled chronic diseases of the skin. The diagnosis of retention from chronic inflammation and vascular engorgement or tumefaction of the mucous membrane of the bladder, is often attended with considerable difficulty. In general, a sense of tickling and uneasiness is at first experienced in the bladder, ex- tending some distance into the urethra. After some time an almost constant gnawing pain is felt in these parts, with more or less diffi- culty of voiding the urine; and in some instances temporary inconti- vol. n.—27 402 RETENTION OF URINE. nence of urine alternates with dysury. The urine discharged con- tains 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 retention ofthe 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 concretions of the urinary phosphates. Sometimes ulcers of various sizes, warty excrescences, or a pustular eruption, occurs on the mu- cous 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 introducing the catheter; and, finally, the occasionally temporary incontinence of urine, which, in many instances, occurs. Soemmering states that chronic inflamma- tion, and the consequences just mentioned, are almost invariably attended with a very peculiar uneasiness 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 urethra 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 spasmodic contraction in the perineum. 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 perineum 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, occur often as a purely 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 spasmodically. 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. KjiTjiXNnu« ur uRINE. 403 Gouty and rheumatic irritation ; irritation of the rectum from asca- rides and other causes; cold and humidity, particularly when applied to the feet; irritating diuretics ; hemorrhoidal irritation; gonorrhoea; Stimulating injections, 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, how- ever, 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 ofthe bladder.— Obstruction to the discharge of the urine may depend on calculus lodged in the bladder, or impacted in the ure- thra ; 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 uterus; retro verted, or pro- lapsed uterus; foreign bodies accidentally introduced into the blad- der; polypi and fungoid tumours in the bladder; very viscid mucus and coagula of blood clogging up the urethra; hernia; and a vari- cose state of the vessels of the neck of the bladder. Of all these causes, however, stricture, and calculi lodged in the urethra, are in- comparably the most common causes of obstruction. Retention ofthe urine, whatever may be its cause, becomes highly alarming, if it continues beyond twenty-four hours, without being in some degree relieved. In general, complete retention of urine proves fatal in four or five days; and I have known an instance which ter- minated in gangrene and effusion of the urine as early as the end of the third day. It is generally supposed, that when the bladder at last gives way, and pours out its contents into the cavity of the ab- domen, it is ruptured or lacerated by the violent distension. This, however, is rarely the case; for in nearly all instances that prove fatal, the urine finally gains exit through an opening, formed by ulcera- tion of some portion of the vesical parietes, or by the occurrence of gangrene and softening, through which the water bursts from the distended 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 perineum. In such cases, extensive mortification and sloughing usually take place in these parts, before the disease termi- nates 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 an- terior part of the body and thighs; with gangrene and fistulous ulcerations. Instances have occurred, in which the urine was evacu- * Richter, Spec. Therap., b. iv, p. 392. 404 RETENTION OF URINE. ated by the umbilicus. (Richter.) Most commonly, however, the bladder ulcerates directly into the cavity of the abdomen, and occa- sions fatal peritonitis. When the bladder gives way, the tumefaction and tension of the abdomen suddenly subside, and the abdominal 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 extravasation. Occasionally, death ensues before the bladder gives way, under symptoms re- sembling those which have been mentioned as occurring in the last stage of fatal ischuria renalis. In such cases, the distension is not confined to the bladder, but occupies the whole course ofthe ureters, which have been found enormously enlarged ; and the pelvis ofthe kidneys even, is sometimes considerably dilated by the accumulated urine. When these conditions occur, the secretion of urine is ulti- mately arrested, the patient becomes comatose, or is seized with con- vulsions or spasmodic respiration, his perspiration acquires a urinous smell, and he finally dies in a state of apoplectic stupor. On dissec- tion, 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 inflamma- tion and obliteration of their cavity, or by being plugged, up with calculi, coagula of blood, or compressed by a tumour in some con- tiguous part. In such cases, the ureter, above the obstruction, be- comes more and more dilated, until it acquires, in some instances, a very great size, and the kidney itself ultimately becomes greatly distended. Callisen has seen the pelvis of the kidneys so dilated as to contain nearly a quart of urine; 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 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 diffi- cult and uncertain, that its presence can never be inferred with suffi- cient probability of correctness, to found on it any practical indications; and it is here mentioned, rather as a pathological 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 par- ticularly acquainted with the various immediate causes of urinary retention; and never to proceed to the employment of remedial measures, until strict inquiry has been made into the nature of the existing obstacle to the urinary evacuation. From ignorance or in- attention to this important rule, diuretics are often given, where the cause consists in permanent stricture; or persevering, rude, and ruinous attempts made to introduce the catheter, in the same condi- * Emige Krankh. der Nieren und Harnblase, &c. Berlin, 1802. S. 5—16, tab. ii, iii, and iv. RETENTION OF URINE. 405 tion of the urethra. There is another point which should be strongly impressed on the attention of the practitioner—namely, never to tamper too long with warm baths, tobacco injections, and various similar remedies, where the obstructing cause resists proper mea- sures for perhaps forty-eight hours—more especially if it consists of stricture or impacted calculus. 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 probability, have been saved, if tapping had been season- ably 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 ofthe 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 opera- tion was again put off until the afternoon, to try the effects of a to- bacco 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 intro- duction may in general be effected with the greatest ease.* The object here, both in a palliative and curative point of view, is to obviate undue distension ofthe bladder; and as the loss of its expul- sive 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 four times daily for several months, before the bladder recovered its powers. When the distension ofthe 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 remain in the bladder. Some surgeons recommend the intro- duction 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 irritable state of the urethra and neck of the bladder, this practice may answer very well—more especially when the patient is remote from his surgeon, and cannot be conveniently visited 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 gene- * When the prostate is much enlarged, the difficulty of introducing the cathe- ter is sometimes very great. In such cases, this operation is, in general, much facilitated by the previous application of a poultice made of stramonium leaves, to the perineum.—See Dr. W. M. Fahnestocki s observations on this subject, in the Amcr- Journ. Med. Sciences, vol. v, p. 251. 406 RETENTION OF URINE. rally esteemed a very useful remedy. From twenty to thirty drops ofthe tincture may be taken two or three times daily, and continued until slight symptoms of strangury ensue. Richter speaks very fa- vourably of a union of cantharides and camphor, in the proportion of a fourth of a grain ofthe former to one grain ofthe latter, given four times daily. Frictions with the tinctura lyttae, and terebinthinate embrocations over the hypogastric region, will assist in restoring the contractile power ofthe bladder. I have known unequivocal benefit obtained from a blister appliedjOver the pubic region; and Richter recommends the application of a fresh onion, beat up into a pulp, to the perineum. The internal use ofthe spirits of turpentine, of juni- per oil, of the animal oil of Dipple, Peruvian balsam, and according to Jahn, the infusion of solidago virgu 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 perineum, or injected 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 begins 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 of the phosphoric acid, as recommended by Dr. Valentin.t 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. Unless the symptoms of vesical distension be very urgent, it will be most pru- dent to endeavour to reduce the inflammatory condition of the parts, before an attempt is made to draw off' the water with the catheter. A very efficient blood-letting—ad syncopen, in robust and full habits, together with the free application of leeches to the perineum, cup- ping on the iliac and pubic regions, 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 valuable auxiliary in such cases. It should be repeated every two or three hours, where conveniences are at hand for its proper employment. The patient may drink moderately of the blandest diluents, and * Richter, Spec. Therapie, bd. iv, p. 377. t Archiv. fur Pharmacie, bd. i, st. iii, 332. RETENTION OF URINE. 407 emollient enemata ought to be frequently administered during the day. After efficient general depletion, calomel and opium usually procure more advantage than any other internal remedy. Where the disease is the consequence of an ineffectual hemorrhoidal effort, or of suppressed hemorrhoids, leeching around the anus is especially proper. Whatever other measures be employed, local depletion in this way is one of the most important 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 immersed ; 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 pepper- mint water, is particularly recommended by Kieser.* Richter ap- plied bruised onions to the perineum and pubis, with evident good effects. The application of decoctions of stramonium, conium, and of poppy heads, may also be tried with some prospect of benefit in cases of this kind. Anodyne enemata are particularly indicated, and occa- sionally 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 lauda- num 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 sys- tem fully under its influence. Richter states, that he has known the following pills to relax the urethral spasm, in a very short time.t Of late years the murialed tincture of iron has been a good deal em- ployed in spasmodic retention 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 retention depends on spasm of the urethra or sphincter of the bladder 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 * Hufeland's Journal, an. 1820, st. iii, p. 92. t R-—G. assafetid. §ss. P. rad.ipecac. — opii, aa gr. iv. 01. menth. pip. gtt. iv.—M. ft.—Divide into two grain pills. Take ten frills, three or four times daily. 408 RETENTION OF URINE. 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 re- moving spasmodic retention. Most writers, in referring to Mr. Cline's experience with this remedy, state that he gave but six or seven drops at a dose ; but Dr. Johnson asserts, and 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 produced. 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 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 catheter generally excites immediate and insurmountable spasmodic contractions. If we succeed in introducing the instrument too 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 perineum with the fin- gers of the other, we may sometimes succeed in slipping it in with little or no difficulty. Retention from stricture, and other mechanical obstructions, is by far the most alarming form of the disease. The means to be em- ployed when the retention depends on stricture in the urethra, are local and general bleeding—particularly by leeches applied to the anus and perineum, and cupping on the lumbar regions. 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 gene- ral result from an opiate enema composed of barley decoction and fifty to eighty drops of laudanum; and internally five or six grains of Dover's powder every two'or three hours, together with a repeti- tion of the warm bath, and the 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 the 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 directions 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 RETENTION OF URINE. 409 bladder • now make gentle pressure above the tubes; make the pa- tient exert himself to discharge the urine; sprinkle cold water on his thighs- withdraw 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 hypogastrium 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 thigh. (Bell.) If these efforts fail, an attempt may be made with a very small catheter; and where, after all, the stricture is insurmountable, recourse to the operation of punc- turing 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. When the symptoms become urgent, and the general and local means already indicated have been ineffectually employed, it would be unnecessarily placing the patient's life in great jeopardy, by relying on the slow, and, after all, uncertain process, of working through the stricture with ca«tic. 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 treatise on the urethra, &c, by Charles Bell, edited by Mr. Shaw. It may be observed, however, that in retention from ure- thral stricture, 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 operation, where punc- ture of the bladder is determined on. When retention from pregnancy cannot be relieved by pushing up the bladder, or by change of posi- tion during the efforts to pass water, such as lying down on the back with the hips raised, the catheter is the only proper means for relief. If the pressure of the uterus against the urethra opposes the intro- duction of the catheter, the patient must be placed on her back, with the hips elevated, and the womb pushed up with the finger of one hand, whilst with the other the catheter is introduced. When the suppression is connected with retroverted uterus, the bladder is usu- ally raised so high above its proper location, that it becomes necessary in general to use the male catheter, in order to reach the cavity of the bladder. 410 DYSURY. Sect. VI.—Dysury. Difficulty and Pain in voiding Urine.—Strangury. Difficulty and pain in making water, without any particular tend- ency to retention of the urine, is a very common complaint. In general, whatever is capable of increasing the irritability ofthe blad- der, 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 particu- larly apt to occur where there is an excess of uric acid secreted with the urine-; and where the urine is charged with the earthy phos- phates, 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, as 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 spirituous liquors; the free use of condiments; irritating diuretics; onanism; excessive venery; acid ingesta; inflamed hentar- rhoids; ascarides; suppressed catamenia; the irritation of vesical calculi; astringent injections; redundancy of lithic acid, or of the phosphatic sediments in the urine; leucorrhoea; repelled cutaneous affections; rheumatism and gout. It occurs in inflammatory fevers, particularly in hepatitis, jaundice, scurvy, and from verminous irri- tation and dentition in children. Strangury is an extremely distressing affection. There is a con- tinued urgency to void urine, which passes off in small quantities, 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 strangury. 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 disease 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 phos- phatic sediments, the measures already mentioned under the head of lithiasis, for counteracting these secretions, must be resorted to. " When the urine is perfectly natural both in quantity and quality, and contains no^mucous, purulent, or bloody deposit, there is reason DYSURY. 411 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." (Prout.) Should it depend on a hemorrhoidal effort, recourse must be had to the means mentioned in the chapter on hemorrhoids, 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 been already said, are subject to violent pains of this kind, in passing urine during the process of dentition. The ex- istence of the complaint is recognized by the violent, shrieks which they utter on voiding the urine. The proper treatment 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 calomel, with a fourth of a grain of ipecacuanha. In the evening, a drop or two of laudanum should be administered. I have never failed of speedily removing the affection by these remedies. When the 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 decidedly prejudicial. In old people, this affection is generally attended with a diseased condition of the internal coat of the bladder, or calculous irritation, or disease of the prostate. The careful physician will, of course, en- deavour to ascertain the cause; and for this purpose it is particularly important to examine the urine, and the state of the prostate, by ex- amining through the rectum. Females subject to leucorrhoea, are apt to suffer the most excruci- ating 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 effectual, 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 citron ointment, mixed with an equal quantity of oil of almonds, with much benefit. At the same time, however, that these applications are used, it will be necessary to use frequent injections of a weak tepid solution of sulphate of zinc, or of alum, into the vagina, and to employ 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 ofthe neck of the bladder, copious draughts of mucilaginous diluents, opiates, fomentations, and where it is extremely severe, leeching at the perineum, should be 412 ENURESIS. 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 although 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. ether, nitrici, and an opiate enema, will rarely fail to allay the suf- fering very materially. 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 cau- tion, 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 almost immediate."* Sect. 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 invo- luntarily ; sometimes constantly, in drops, as it is secreted and con- veyed 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 re- strain 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 paralysis of the sphincter of the bladder, the urine passes off continually, 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 ge- neral, 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 weak- ened state of the expulsive powers of the bladder; for, when the urine accumulates in the bladder to a certain degree of distension, the resist- ance to a further dilatation of the bladder, in conjunction with the pressure of the abdominal muscles, slowly forces the urine into the urethra, and causes it to pass off guttatim. This variety of incontinence often occurs as a symptom of some general disease. Thus, it is frequently met with in the latter stages of low fever—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 parturition; injuries done to the neck of the bladder by the unskilful employment of obstetrical * Edinb. Med. and Surg. Journ., 1828. n.xvu njooio. 413 instruments; a large calculus located in the neck of the bladder ; lylhotomic operations ; great dilatation 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 para- lysis of the sphincter of the bladder is indeed not dangerous, so far as the life of the patient is concerned, but it is an exceedingly annoy- ing complaint, and by the urine constantly dripping off, very painful and distressing excoriations on the inner part of the thighs, scrotum, and perineum, almost always occur. 2. Enuresis from mechanical causes, independent of. paralysis of the sphincter of the bladder, is not unfrequently met with. Most of the mechanical or organic causes mentioned under the head of ischu- ria, 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 irri- tation of vesical calculus ; tumours and excrescences from the inter- nal 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 suffer the urine to pass off slowly and involuntarily ; and cases have occurred, which arose from ulcera- tive destruction of a part of the sphincter. 3. There is a variety of incontinence of urine, described by Rich- ter, 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 efforts of volition, the urine immediately passes off' without allowing 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; hemorrhoidal affections; suppressed catamenia; gouty irritation; and leucorrhoea. Frequently, how- ever, no obvious causes of this kind are present, and the disease apparently arises from a morbid irritability of the urinary passages, in connection 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 inconvenience whatever in this respect; but at night, while sleeping, and lying on the back, the urine is apt to pass off, either involuntarily, and with- out the least consciousness of its occurrence, or voluntarily, under 414 the influence of a dream. In children, 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 examina- tion, will almost invariably exhibit <• some unnatural property, and most generally a strong disposition to, or actual deposit 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 sensibility of the blad- der, excite so vivid an impression on the imagination, as actually to lead to a voluntary discharge of the urine." That urinary inconti- nence 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 production ofthe affection as is supposed by the author just quoted. It is certain that we may sometimes pre- vent the recurrence of the evacuation by exhibiting remedies calcu- lated and intended to produce an irritation or tenderness in the neck of the bladder; as, for instance, cantharides—a circumstance that 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 awakens 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 urinary or- gans," 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 treatment pro- per 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 paraly- sis. 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, according to Selle, has occasionally removed cases of long continuance. The tincture of cantharides will some- times produce a very good effect- It should be given in gradually ENURESIS. 415 increased doses three or four times daily, until a feeling of ardor urinae or strangury ensues. Dr. Otto, of this city, has recently pub- lished an account of three cases of incontinence of urine, which yielded under the employment of uva ursi and the muriated tincture of iron. One of the cases was congenital, and the remaining in- stances 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 perineum, will some- times do good. Richter recommends cold injections into the blad- der; and in females, cold water may be beneficially injected into the vagina. Electricity and galvanism have also been employed with success in cases of this kind.t Stimulating frictions, of various kinds, will occasionally assist in restoring activity to the sphincter. M. Lair, in a memoir on this affection, refers most cases of inconti- nence of urine to a want of equilibrium in power between the body of the bladder and its neck, the latter being in an atonic or relaxed condition. This view of the subject led him to seek for a mode of stimulating the ne'ck 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 a prostatic part, as well as the neck of the bladder; and he affirms that by this mode of ma- nagement he cured three cases-of this malady.J Dry cupping the perineum and blisters applied to the sacrum are also very useful measures in cases of this kind. M. Canin has lately related two cases before 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, before 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 instances, various means had been tried without any apparent advantage. 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 de- livery ofthe child will in general remove the complaint; 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 termination of the regular period of gesta- tion. In nervous or spastic urinary incontinence, anodyne enemata, together with urva 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 irrita-. * North American Med. Journ.—Oct., 1830. t Loder's Journ. der Chirurgie, b. iv, hft. i. X Med. Chir. Rev., January, 1827, p. 244. 41b „ x.i> u tu^aio. bility ofthe system, constitute the appropriate means in cases of this kind. Wendt speaks very favourably of the expressed juice of the mesembryanthemum crystallinum, in the incontinence of urine which occurs in very nervous individuals. When the patient is af- fected with leucorrhcea, or ascarides, or with an irritated state of the rectum from hemorrhoids, 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 ap- proach 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 at- tended to; and that the remedies appropriate for counteracting the formation of these urinary deposits, should be employed before any other means are used to restrain the urinary inconf inence," for with- out 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 sediment either ofthe lithic acid of phos- phatic variety be deposited, 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 accom- plished, we may proceed to the employment of tonics and some one of the various 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 tincture of cantharides, with the view of producing a slight degree of strangury, or considerable ardor urinae; so that the pain excited 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 article may be beneficial also, by increasing the sensibility and activity of the sphincter, and thereby enabling this muscle to make greater resistance to the expulsive ef- forts 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 turpen- tine, 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 incontinence depends on a morbid irritability of the neck of the blad- der, which is often the case in adults, an opiate administered on going to bed, will sometimes have the effect of preventing the eva- . cuation 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 disorder, and even occasionally obviate it after it has occurred. HYDROPS. 417 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 himself 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 position. The circumstance is unaccountable, until we reflect on the position of this master-spring ofthe muscles of the bladder—the sensible spot, a little behind and below the orifice of the bladder. 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." CHAPTER VIII. CHRONIC DISEASES OF THE SEROUS EXHALANT VESSELS. Hydrops.—Dropsy. Dropsy, or rather the effused and accumulated fluid which con- stitutes 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 directed in order to obtain rational views concerning its nature and remedial manage- ment." The cure of this disease does not depend merely on the re- moval or evacuation of the aqueous accumulation, 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 question meets us: In what does this morbid condition of the solids consist, and in what particular structure is it chiefly located? According to the late Dr. Rush, the morbid action which gives rise to dropsical 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 increased action of the exhalant vessels, attended with a general pyrexial con- dition of the system. The correctness of this doctrine 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 secretion or effusion of serum, which occurs in dropsy, depends on a condition which, if not identical, is at least closely allied to inflammation, receives the greatest degree of proba- bility from the following circumstances: Every one who has observed the progress of inflammation, knows vol. ii.—28 418 HYDROPS. 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, frequently 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 of arachnitis. Indeed, the pathologi- cal fact, that all inflammations of the serous membranes, if not very violent, or speedily terminated in resolution, end in effusion, is directly corroborative of 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, amounting, in some instances, probably, only to an irritation bordering on actual inflammation. It would appear, indeed, that a considerable degree of inflammation is incompatible with serous exhalation—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 plau- sibility have been urged. When duly estimated, however, they do not appear to possess any solid value. It. has been stated, for instance, that dropsy is not unfrequently the consequence of profuse hemor- rhage and of other exhausting causes, and that in such cases at least, neither the general symptoms, nor the nature of the causes, justifies 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 human subject, and in animals who have died from hemor- rhage, would seem to show, indeed, that even in dropsies from hemorrhage, 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, al- most invariably exhibit a highly injected and congested state, similar, in all respects, to what occurs in actual inflammation. In many in- stances of this kind, a considerable quantity of watery effusion was found within the head; and in some instances, high and tumultu- ous 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 consequence of excessive losses of blood. I attended a gentleman, a few years ago, who was re- duced to the utmost degree of exhaustion 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 HYDROPS. 419 sometimes strikingly illustrated by the conversion of inflammatory diseases into dropsy, and vice versa. In a late number of the Me- dico-Chirurgical Journal, there is a case related, in which rheumatism was successfully converted into dysentery, erysipelas, peritonitis, and finally, dropsy.* Although it must be admitted, that increased exhalation of serum constitutes the chief immediate cause of dropsical accumulations, yet it is probable that there always exists a simultaneous 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 necessarily attended with a preternatural afflux, and consequently, sanguineous congestion in such part. This being the case, it follows, that the capillaries of the structures from which dropsical effusion occurs, must be in a state of repletion or san- guineous 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 venous extremities. The experiments of Magendie, or 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 absorp- tion is accelerated or diminished, according as the capillaries contain a less or greater quantity of blood. When they are full and congested, and the current of blood moves along sluggishly, absorption is com- paratively 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 sub-inflammatory action, or at least of vascular irritation, and that the capillaries of these tissues must consequently be in a state of fullness or congestion, it would seem to follow, that the process of absorption must be cor- respondingly diminished. Hence, in every case of dropsy, there are, probably, two simultaneous mordid conditions present, namely in- creased exhalation, and decreased absorption. Etiology.—The principal occasional causes of dropsy are mechani- cal obstructions to the free return of blood to the heart; the influence of cold; excessive hemorrhages ; disease and inactivity of the kidneys; repelled cutaneous eruptions ; suppressed habitual discharges; chronic diseases which tend to exhaust the system; arsenic ; and some ofthe acute exanthematous affections, particularly scarlatina and measles. Dr. Ayre, in his treatise on this disease, denies that mechanical ob- struction ever has any direct agency in the production of hydropic effusions. When dropsy supervenes on scirrhus of the liver, he con- siders it the consequence of the slow inflammation of the indurated viscus, extending to its peritoneal covering, and thence along the abdominal 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 * Med. Chir. Rev., vol. vi, p. 197. 420 m utiura. system in such cases, produces, by degrees, that irritated condition 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 reasona- bly presume, also, from the above observations on the influence of vascular turgescence in diminishing absorptions, 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 pro- ducing serous extravasations, is sufficiently illustrated by the oedema which occurs when ligatures are passed round an extremity. Cold rarely produces hydropic affections, unless there exists a pre- disposition to the disease. Of all the causes which predispose to the occurrence of dropsy from the influence of cold, the most powerful are scarlatina, measles, and the mercurial excitement. Neither these two exanthematous affections, nor mercury, are apt to give rise to dropsy, unless they co-operate with cold, jor vicissitudes of atmo- spheric temperature. They leave the surface 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 exhalants are peculiarly 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 combined influence of these circumstances*- into a state of irritation or sub-inflam- matory action, whence dropsical effusions proceed. It is not impro- bable, however, that in some instances of dropsy from scarlatina or measles, the disease may be the immediate consequence of the exten- sion of the inflammation or irritation from the skin to the subsequent cellular texture. The fact, however, 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 catarrhal symptoms, and are always manifestly of a phlogistic character. When blood is drawn, it is generally 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 dropsy which most com- monly proceeds from cold, is anasarca, although some degree of abdominal effusion is not uncommon. In relation to dropsies from excessive hemorrhage or other pro- fuse 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 irregular determina- tions, or foci of congestion, in one or more of the serous' membranes. It is thus that the red and injected appearance of the arachnoid and other membranous structures occurs in animals, when killed by HYDROPS. [421 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, give rise to dropsical effusions. There is, however, another circumstance 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 imme- diately 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 cir- culation; and this is especially favoured by the very great thirst which almost always occurs after excessive sanguineous 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 exhalants. 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 hemorrhages produce an increase of serous fluid in the blood. Dropsy from hemorrhage is generally of the anasarcous kind. The blood, in these cases, always contains a very great over-proportion of serum, the crassamentum being very small, usually cupped, and often covered with a buffy coat. The pulse is frequently full and active, though not hard or tense. Dropsical effusions from hemor- rhage, rarely supervene immediately after the loss of the blood. Several weeks usually intervene between the hemorrhage 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 published some interesting cases of this kind. In nearly all these instances, the kid- neys were found in a state of disorganization. In dropsies depend- ing on deficient urinary secretion from renal torpor or organic dis- ease, the urine invariably contains a portion of albuminous matter. Among the causes of dropsical effusions, we may also mention amenorrhoea, 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 universally present. The appetite is usually impaired—but when the disease is the consequence of hemorrhage, the appetite for food is sometimes particularly strong. The thirst is generally considerable, and some- times very urgent. The bowels are commonly inactive, though readily moved by laxatives. The pulse is irritated, and usually indi- cative of a pyrexial state of the system; for however small and * See his Reports of Medical Cases. London, 1827. 422 HYDROPS. febrile, it is almost always quick and frequent. The urine is scanty and generally of a deep red colour; sometimes 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. Black- all has investigated this subject with minute attention; and the ob- servations of Ayre and WTells 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 coagu- lable 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 intimately 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 espe- cially 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 regarded as a pretty correct index of the degree of general inflam- matory excitement attending the disease. Serous urine may be Considered as a kind of pyrexometer 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 there is coagulable serum in the urine of dropsical patients, the general condition ofthe system will be found manifestly phlogistic. In the dropsies which occur after scarlatina, the urine generally con- tains a large portion of the serum; whilst in 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, deposits a red sediment, or remains muddy, the liver, probably, is in a state of organic disease. (Cruik- shank.) 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 participate 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 debility and relaxation cha- racterize the disease. Where 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. ASCITES. 423 1. Ascites.—Dropsy in the Cavity ofthe Abdomen. Ascites, or abdominal dropsy, is very generally dependent on vis- ceral induration, more especially on scirrhus of the liver or spleen. Whatever, therefore, has a tendency to produce induration 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 alcoholic liquors; protracted agues ; hepatitis ; and inveterate dyspepsia. Whatever may be the remote cause of ascites, however, chronic inflammation of the peritoneum constitutes, no doubt, the immediate and essential cause of the abdo- minal effusion. Subacute inflammation of this membrane, in what- ever way it may be produced, terminates perhaps always in effusion ; although in some instances, this may not be so copious as to consti- tute dropsy. In the majority of fatal cases of ascites, the peritoneum exhibits a highly injected state ; and in many instances, the traces of previous inflammation are -still more conspicuous and unequivocal, its structure being- either thickened and otherwise altered, or covered with an infinitude of miliary tubercles. Occasionally, indeed, no marks of pre-existing inflammation whatever are to be seen ; but the investigations of modern pathologists have rendered it abundantly manifest, that where no disorganization or structural change has been effected, the mere redness, or injected state of the inflamed parts, may and does often disappear in articulo mortis, or even post-mor- tem. Besides the causes I have just mentioned, it will be sufficient to observe, that every thing which is capable of producing slow inflam- mation of the peritoneal lining of the abdominal cavity, may give rise to this variety of dropsy—such as cold; parturition; 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 mistaken for ascites, is pregnancy. From this state it may be distinguished by the fluctuation ; the uniformity of the tumour; the lateral pressure and distension 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 un- easiness and general disturbance in the system arise from the me- chanical 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 muscles yield, and the whole abdomen be- comes sore and tender to the touch, and a dry and short cough gene- rally comes on in the advanced stage ofthe disease. Ascites is very rarely wholly unconnected with anasarcous swellings. Ultimately, oedema of the feet and legs, if not more diffused cellular effusion, 424 HYDROTHORAX. ensues. The urine is much more apt to be very high-coloured and sedimentous in ascites than in the other forms of dropsy. The bowels, tgo, are more torpid, especially in aggravated cases. 2. Hydrothorax.—Dropsy of the Chest. Hydrothorax generally supervenes gradually, without causing, in its initial period, any particular inconvenience or disturbance calcu- lated to excite much attention or suspicion of the true nature of the malady. At length, however, the patient begins to experience a sence of oppression and tightness at the lower part of the sternum, with slight difficulty of breathing when at rest and in an erect pos- ture. He now finds, that on lying down, or using active bodily ex- ertion, especially on ascending an acclivity or stairs, the dyspncea 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 scanty, high-coloured, and sedimentous. As the disease advances, the feet become oedematous ; the countenance is ex- pressive 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 periods 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. (Laen- nec.) By far the greater number of cases are of the latter kind. Organic cardiac disease is the most common source of symptomatic 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 inflam- mation of the pleura, occurring as the sequel of acute pleuritis, is always attended with hydropic or sero-puruloid effusion into the chest. A tuberculous state of this membrane, and aneurismal dila- tations 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 ANASARCA. 425 particular causes mentioned above. Dr. Ayre observes, that a ple- thoric 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 disease arises from some general cause, the effusion almost invariably occurs only in one side of the chest; but in those cases which come on in consequence of organic or struc- tural 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 in- stances of death from the idiopathic variety of the disease, as rare as one in two thousand, when under the control of judicious reme- dial management. Indeed, even in the symptomatic variety 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 continues to take place, and gives rise to further accumulation. Dr. Ayre asserts, what indeed 1 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 suddenly."* 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 produces a very obscure and dull sound. The percussion should be made while the patient is in a sitting posture. General agitation, 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 are 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 con- fidence. (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 * Transact. College of Phys. of London, 1820. 426 DROPSY. a part of greater or less extent. The ordinary and most unequivo- cal 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 hydro- pic disease is the most frequently connected with a sluggish and lan- guid 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 pallid cast; and the patient frequently manifests a great disposition to drowsiness, with a depressed or sluggish state of the intellect. Anasarca is often attended with some degree of abdominal 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 effu- sions into the internal cavities precede those into the cellular mem- brane. (Ayre.) Local anasarca may be produced by whatever im- pedes the free return of the blood by the veins. Hence, the gravid uterus, tight bandages, and the pressure of indurated glands in the groins, often give rise to oedema of the feet and legs by compressing in some degree the iliac veins. Mere 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 conva- lescence 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 sup- pressed perspiration in consequence of the influence of cold, gene- rally 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 remote cause, such as cold, arsenic, scarlatina, hemorrhage, &c When unattended with abdominal or thoracic effusion, it is, upon the whole, much more frequently removed by remedial treatment than the other forms of dropsy. The more rapidly the disease supervenes, the more easy in general is its removal. Causes.—Hemorrhages; suppressed perspiration from cold, par- ticularly after scarlatina, or when the system is under the influence of mercury; the long-continued internal use of arsenic; intestinal irritation; great debility and exhaustion; repelled cutaneous erup- tions ; chronic gout; excessive and long-continued diarrhoea; indura- tions ; 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 treat- ment of dropsy are, 1, to subdue the local sub-inflammatory or irri- DROPSY. 427 tated action of the structures from which the dropsical exhalation takes place; and, 2,4o promote the absorption and removal of he effused fluid. The first of these general indications is to be fulnllea 1 bv diminishing the general momentum of the circulation where it s preternaturally great; and, 2, to drive the blood, as much as pos- ble,from the capillaries immediately implicated in the morbid effu- sion and to equalize the circulation. The second general indication to be fulfilled; 1, by promoting the activity of the various serous Jm^tStW diminishing the quantity of blood circulating-in Tevenous extremities ofthe structure from which the dropsical fluid is poured • and, 3, by stimulating the activity of the absorbent sys- em One of the first and most important measures to be adopted in establish ng an adequate derivation of blood from a part, is to dimi- SS impetus of the circulation. In vain will we endeavour todSh the preternatural afflux of blood to an irritated or in- flamed part, if the vis-a-tergo of the circulation, or its general momen- S rapidly, nut we contribute, moreover, in a direct way, to the reduction of the prodss 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 arte- rial system may be irritated to vigorous action, whilst the muscular system manifests a state of langour and debility. Of course, where the pulse is feeble and languid, venesection is uncalled for and im- proper Having moderated the momentum ofthe 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. tmnnt nt Blisters, also, often assist materially to the successful treatment ot ascites and hydrothorax. They tend in a direct way to derive the circulation from the irritated or congested serous membranes, 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 anasarcous effusion, neither leeching nor cupping nor blisters, can be applied without some risk of gangrene, or mortification. Little or no V^!^™' tage can, indeed, be expected from local abstractions of blood in anasarca, and the same observation applies to blistering. Jr. Ayre speaks very favourably of the effects of a selon fixed^in the integu- ments of the chest in hydrothorax In one «rt^c» of th« form of dropsy, which came under my observation, much benefit appeared # Dr Hohnbaum has recorded a case of ascites, which, after paracentesis had been repeatedly performed, was removed by spontaneons e^t^s.-Analen der Medizin., vol. iv, p. 226 ofthe Sequel 428 DROPSY. 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 ana- sarcous state of the surface be such as to render these measures hazardous. Cathartics.—Drastic purgatives have, from the earliest periods of medicine, held a high rank among the remedial 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 capillaries upon which abdominal dropsy depends. The efficacy of hydragogues is generally more con- spicuous in abdominal dropsy than in the other varieties of this dis- ease. Their influence upon the morbid condition of the peritoneum is much more direct and powerful, from its contiguity to the mucous membrane of the intestinal tube, than upon the more remote struc- tures concerned in the other forms of dropsy. Though, in general, less beneficial in anasarca and in hydrothorax, cathartics are never- theless 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 copious watery stools, or, as they are called, hydra- gogues, are decidedly the most efficient in diminishing dropsical accu- mulations ; but there exists some diversity of sentiment in relation to the relative value of this variety of cathartics. Cremor tartar may be placed at the head of this class of articles, in reference to hydropic affections. It is mild, cooling, and potent in its operation as a hydragogue, and possesses the additional and pecu- liar advantage of exciting, at the same time, considerable diuresis. Dr. Ferriar's statements afford strong testimony 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 obtained 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 appeared to me, generally with peculiar efficacy : R.—P. crem. tart. ^iss. ' P. sulphat. potassae gss. J \ >., f/J ■■■>/• ii P. scillae maritim. -jii. &r" * ' ;" Tart, antimonii gr. ii.—M. S. A teaspoonful of this mixture is to be taken four or five times daily. Given in this way, it has never failed, in my hands, to produce * Pring's Principles of Pathology, p. 262. DROPSY. 429 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 practiti- oners of the present day. Dr. Clutterbuck, especially, attaches great value to this article, as a remedy in dropsy. 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 cre- mor tartar. Indeed, I have met with instances in which it did mani- fest harm, by the violent irritation 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 prescribing such active purgatives, therefore, great care must be taken, lest in our anxiety to produce copious aqueous evacuations, we establish a mor- bid and permanent irritation in the mucous membrane ofthe bowels, and thus create a new and highly injurious focus of morbid sympa- thies in the system. Whenever such articles cease to produce copious watery stools, when given in ordinary doses, and leave a general sensation of soreness or tenderness in the abdomen, we are admo- nished 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 excite the desired evacuations. A larger dose is then perhaps resorted to, but the stools will be still more incomplete and painful. Determined to overcome the supposed torpor of the bowels, the physician now pre- scribed a still more powerful dose, but instead of procuring free and watery evacuations, the patient will probably be harassed by small mucous stools, attended with great. tormina or tenesmus. Thus, mucous inflammation will be established in the intestinal tube, and a disease which, under a more judicious treatment, might perhaps have been removed, is rendered incurable. Gamboge is also a favourite hydragogue with some practitioners; and I have myself employed it with much advantage. I have, how- ever, always given it in union with cremor tartar, in the proportion of from two to four grains to a drachm of the latter article. It has * This formula was first published by a German writer of the name of Lang- hans. I have known it to remove dropsical accumulations very speedily, after a great variety of diuretics and hydragogues had been used without much advantage. Dr. Charles Hildreth, of Marietta, (Ohio,) recommends the following hydragogue mixture: R.—Crem. tart. 31J; Pulv. jalap 31; Nitrat. potassa? gi; P. gambogiae gr. vi.—M. Dose, one or two teaspoonfuls daily.—Amer. Journ. ofthe Med. Sciences. 4ao DROPSY. appeared to me less apt to excite permanent irritation in the bowels than elaterium. Gamboge is the hydragogue which Dr. Ayre pre- fers. 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 frequency 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 re- sulting from their operation. When the strength of the patient will admit, the purgatives may be repeated every two or three days, pro- vided they do not produce great tormina and soreness, and provided also that they cause free evacuations. I cannot but think, however, that the use of these remedies is frequently carried to an injurious extent in the present disease. Employed occasionally, and inter- changeably with diuretics, they generally contribute materially to the reduction of hydropic affections, more especially of ascites and ana- sarca. 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, fre- quently lay the foundation of much future suffering and infirmity. Much praise has lately been given to the Caincse root, (chiococa racemosa,) as a remedy in dropsy. It is said to operate powerfully as a hydragogue and diuretic, and some remarkable instances of its efficacy ill dropsy, have recently been published, in the medical jour- nals 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. chiococse racemos. 3H. Aq. bullient. Ifeiss.—M. To be boiled down to §viii. Of this a table. spoonful is to be taken three or four times daily. Diuretics, of all our remedial means, are the most universally employed and relied on, in the treatment of dropsy. The kidneys appear to be the most direct and manageable outlet for dropsical effusions, and an important part of the treatment of this disease con- sists 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 hence bleeding and purging in such a state of the system, are indispensable 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-vessels are drained of the serous .portion of their contents. To obviate 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, with- out any other remedies. I have known an instance of extensive ana- sarca cured, after a course of ineffectual treatment, solely by the free indulgence in eating water-melons. Much dispute has existed as to the propriety of allowing patients the free use of aqueous potations. DROPSY. 431 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 manifestly beneficial. Upon this sub- ject, however, no universal rule can be laid down; for the fact ap- pears to be, that in some instances, a liberal indulgence in the use of drinks is followed by unfavourable consequences; whilst in other cases, manifest benefit results from it. In all those instances of hy- dropic effusion which are the result of excessive hemorrhage, copious draughts of diluent 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 hemorrhage, their venous 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 dropsical 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 hemorrhage, consists almost wholly of serum, the crassamentum being always exceedingly small; and the more drink there is taken in such cases, the longer 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 hemorrhages, 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 relative state of the vessels, which therefore strive, if I may be allowed the expression, to get rid of it by every outlet." It appears to me manifest, there- fore, that in such cases of dropsy, it will be advantageous to abstain as much from the use of drinks as the urgent thirst will admit. In in- stances 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 decidedly 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 pot- ash, nitrate of potash, cantharides, juniper berries, colchicum, spirit of turpentine, erigeron heterophyllum, and parsley. Among these articles, the squill is the most frequently employed, 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 diathesis is decidedly phlo- gistic, 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 432 DROPSY. powers are in general peculiarly beneficial. 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, recommend 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 considerably enhanced by such combinations. Home thought that its diuretic effects were often much increased, by uniting with it some article cal- culated to promote its emetic powers; but Cullen strenuously opposed this opinion, and pointed out its erroneousness. Perhaps the best adjunct to squills is calomel—especially in the treatment of hydro- thorax. I have been most satisfied with the triple compound of squills, nitrate of potash, and calomel, according to this formula. R.—Pulv. scillae Qi. P. nitrat. potassse gii. 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 valua- ble in hydrothorax ; for, although this mercurial 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 kid- neys 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 exhibition 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 frequently 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 tendency 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 inju- rious. Besides the formula given above, I will add another one, which, in some instances, has, in my hands, produced copious dis- charges of urine. DROPSY. 433 R.—Pulv. rad. scill. gr. viii. Pulv. pip. nigr. 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 mentions it as pecu- liarly 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 extolled; whilst some speak of it as of little or no essential value. The weight of good tes- timony is, nevertheless, decided in favour of its usefulness ; although, generally, it is undoubtedly inferior to the squill, as a diuretic in hydropic affections. According 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, from persons of a corpulent habit and an irritable fibre; but in such as were of "a weak, delicate, irritable constitution, with a thin, smooth, and soft skin," he has generally succeeded well with this remedy. So far as my own experience enables me to judge, I am inclined to think, that there are good grounds for these observations.- Dr. Black- all ohserves, 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 observa- tions deserve particular attention, in the selection of an appropriate diuretic; for, although they may not be universally, or perhaps even very generally, applicable, there is sufficient correctness in them, as a general guide, to afford considerable assistance in the adoption of our remedial 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 febrile habits, where there are much restlessness, spasmodic dyspnoea, and frequent and distressing urgency to void urine, I have known a combination of opium with vol. n.—29 434 DROPSY. 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 purgatives. Digitalis ought to be administered in sub- stance ; it has appeared to me to do most good, when given in small but frequent doses—that is from oue-sixth to one-fourth of a grain, every hour or two, until its peculiar influence on the system is per- ceptible. In general this article is more effectual in removing ana- sarca than ascites, and ascites than hydrothorax. Many physicians are in the habit of prescribing it, in union with calomel; and there can be no doubt, that, under certain circumstances, this combination will act with peculiar advantage. Drs. Blackall and Paris, however, decidedly condemn this practice. Conceiving that the curative powers of digitalis, in dropsy, are dependent on its sedative effects, they maintain that calomel, being a stimulant of no inconsiderable powers, is incompatible, as a therapeutic agent, with the digitalis, and that it must necessarily tend rather to counteract than to pro- mote the salutary influence of the latter. This objection appears to me hypothetical; and it certainly is frequently contradicted by expe- rience. 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, diu- resis is sometimes entirely wanting, when the sedative influence of the digitalis is the most conspicuous. In general, the more phlogistic the diathesis, the more appropriate 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 degree 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 this formula for adminis- tering the cantharides in dropsy. R.—Pulv. canthar. Qii. Amyg. dulc. §i. Sacch. alb. §iss.—M. Rub them together in a mortar, and make an emulsion, by add- ing gradually ten ounces of warm water. Of this a tablespoonfiri 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.) * -Prispane's Select Cases. Chalmer^pn the Diseases of South Carolina. Ro- bertson's Treatise on the Power of Cantijarides used internally. Edinb., 1826. DROPSY. 435 Colchicum autumnale has not, hitherto, been much employed in the treatment of dropsy ; its powers, however, deserve more atten- tion in this respect than it appears as yet to have obtained. I have derived great benefit from this medicine in a case of anasarca, appa- rently the consequence of a gouty habit; and I am disposed to place considerable reliance on it in all cases attended with a rheumatic or gouty diathesis. I have found it most efficacious as a diuretic, when given in union with the sulphate of potash. 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 occasionally 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, in a few cases of ascites. It will rarely do any good in hydrothorax. 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 accu- mulations through the renal emunctories, by some simple diuretic article, after the more powerful and esteemed remedies 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 attention as a diuretic, in this disease. It may he conveniently employed as a ptisan, along with the squill, digitalis, or some other more powerful article. The infusion of the seed of daucus carota, too, is an excellent diuretic, and has been a good deal employed by the practitioners of this country. Of a similar character are juniper berries, lactuca virosa, galium apa- rine, horseradish, and a number of other diuretic vegetables em- ployed as domestic remedies, and occasionally also in regular practice. Of the usefulness of the galium, I can speak from experience. I knew an instance, where a strong infusion of this vegetable removed 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. W7hen the stomach will bear it, the erige- ron 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 diuretics at hand, in the treatment of dropsy; for, in some instances, a number of the most active medi- 436 DROPSY. cines 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 mea- sures, the desired effect does not ensue.* Diaphoretics are mentioned by Celsus as among our best means for the cure of dropsy. We can very rarely procure the full opera- tion 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 remov- ing dropsical accumulations. Sydenham appears to have placed very considerable reliance on the employment of antimony in this affec- tion, although his principal object in prescribing it was the produc- tion 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 anti- mony with this view : but as a diaphoretic, I have known it to pro- duce 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 ana- sarca from a protracted intermittent. In general, wherever the exciting cause of the disease is cold, or connected immediately with torpor of the cutaneous exhalents, antimony ought not to be neglected as a means of relief. I have always given it dissolved in a large proportion of some diaphoretic beverage—such as infusions 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. Munro 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 for- * Dropsy is a disease by no means so uniform in its character as is generally supposed. It arises from a great variety of remote causes—in the most opposite states of the system, with regard to vascular action and repletion—it is depend- ent on various organic affections; appears as a consequence of different acute and chronic affections, and is attended with divers and distinct characters of the urinary secretion. These 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 constitutional habit—of idiosyncrasy—and the ever-varying state of the organic (unctions—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 excite the action of the kidneys. It is, therefore, a good rule to vary the pre- scription, if, after a reasonable time, and proper adjuvant measures, the desired effect does not follow. DROPSY. 437 gotten, however, that very profuse perspiration and diuresis are in- compatible ; 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. 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 medicine 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 sensa- tion in the extremities; and, in most instances, a profuse perspira- tion ensues a few hours after it is taken. Besides its diaphoretic effects, it is also peculiarly calculated to do good in such cases, by its tendency to invigorate the assimilating functions. I am not aware that any advantages are to be obtained from this article, in any other cases than such as proceed from excessive hemorrhages, or other exhausting and relaxing causes. Diaphoretics are in general decided- ly useful 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 mention 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.J Emetics have by some been highly extolled for their power of removing dropsical accumulations. I have already mentioned Sy- denham 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 phy- sicians, in the treatment of dropsy; and there can be no question as to its utility in certain modifications ofthe disease. In cases depend- ing on hepatic and splenic disorder, it constitutes our main stay, and in the treatment of hydrothorax, it is generally highly beneficial. In instances which occur in consequence of excessive hemorrhage, or other exhausting causes, and in subjects 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 constitu- tional influence. (Blackall, M'Lean.) A decidedly inflammatory * Elemens de Therapeutique, torn, i, p. 180. t Celsus. De Medicina, lib. iii, cap. xxx. X Richter, Specielle Therapie, vol. iii, p. 59. 438 DROPSY. condition ofthe system, however, is opposed to the beneficial influence of mercury in this disease; and where such a diathesis is conspicuous, antiphlogistic measures must precede its employment. Calomel is the preparation usually prescribed in dropsy. As a general rule, mercuriahzation should not be carried beyond the extent of producing only a slight soreness of the gums;—profuse ptyalism being not only unnecessary to procure the peculiar advantages 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 mercurial frictions on the abdomen. From some cases which have been re- cently published, it appears that subacute inflammation of the peri- toneum often yields to mercurial frictions, without scarcely 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 relaxation, 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 advan- tage. 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. Several German physicians have recently employed the muriate of gold, in ascites and anasarca, with peculiar success. Dr. Wendt states, that he prescribed it in eight cases, in the hospital at Breslau, seven of which yielded entirely to its influence.!: This article often manifests decided diuretic powers, and as it is also an excellent alte- rative, resembling in this respect mercury, it may probably be par- ticularly suitable in cases connected with a depraved habit of body from the abuse of mercury, syphilitic taint, or an arthritic diathesis. , 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 principal articles of this kind. Ipecacuanha, Dover's powder, heleborus niger, pilulse * Revue Medicale, Mai, 1824. t Medico-Chirurg. Review, July. 1827. X Rust's Magazine, b. xxv. DROPSY. 439 hydragogae janini, radix sambuci, the fixed alkalies,* millepedes, lactuca virosa, garlic, scandix cerefolium, apium graveolens, onions, iris palustris, sorbus aucuparia, balsam copaiva, turpentine, olive oil opium,] apocynum cannabinum, pipsissiwa, trifohum 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 dropsy which succeed to acute febrile diseases.} The external application of diuretic agents has of late years been emoloved 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 internallv. 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 remedial 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 advantage, at least, may be obtained from frictions on the abdomen, with diuretic remedies. In a recent number of the Revue Medicale,^ there are four cases of thoracic and abdominal dropsy recorded, which were successfully treated upon the iatraleplic plan. The author, Dr. Guibert, directed frictions on the chest, or the abdo- men, or the thighs, according to the form of dropsy present, with the following fluid. R.—Tinctura scilla. -------digitalis. ------— sem. colchic, aa §ss. 01. camphorat. giss.—M. The frictions to be made with flannel three or four times daily, and * 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. I attended an old 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 atablespoonful 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- Herbe absinth, ^i. Infunde c. vin. rhen. Ibj. Digere per xxiv. horas cola. Dose, one ounce every four hours. . , . ., t I have prescribed opium in a case attended with a rheumatic habit with une- quivocal benefit. X Analen der Medizin, vol. iv, p. 266. $ Septembre, 1828, p. 349. 440 DROPSY. continued from five to twenty minutes. Concomitantly with this external application he ordered a diuretic mixture to.be taken inter- nally, composed of squills, digitalis, and nitrate of potash in equal quantities, and a somewhat larger portion of thridace, in doses of two grains and a half of the mixture twice daily. " The iatraleptic method of treating dropsy," says Dr. G., " has appeared to me particularly efficacious in abdominal dropsy; and it is chiefly to the external employment of the above diuretic liniment, that I think myself war- ranted 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, resembling almost complete diabetes, which occurred in these cases under this treatment. In all these cases, and I might adduce others equally remarkable, the dropsical swellings were re- duced 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 sys- tem is reduced by appropriate antiphlogistic means. In idiopathic ascites and anasarca, this mode of treatment will succeed almost with- out exception. Dr. Thomas Short,* of Edinburgh, has recently employed the marchantia hemispherica, as an external application in the form of cataplasm, with marked success in hydropic affections. Applied in this way, it often acts strongly as a diuretic. " In many cases," says Dr. Short, " it has been astonishingly successful, but it has, like other diuretics, failed. I cannot say, that I have ever known the slightest benefit derived from its internal use, although I have frequently administered it in the form of decoctions. Employed externally in the form of poultice, however, I consider it as a remedy of great value. The poultice is prepared by carefully picking and washing about two large handfuls of the leaves; these are thrown into a pot containing about a quart of boiling water, and simmered by the side of a fire for twelve hours, adding fresh water if required. It is then beat into a pulp, and as much linseed meal stirred in as to bring it to the consistence of a poultice, which is spread on flannel and applied to the abdomen (in ascites), and fastened with a pretty tight bandage —or it may be applied to the legs, if anasarca of the extremities alone exists. The poultice should be renewed every twelve hours. This poultice produces, in general, copious perspiration, and, at the same time, acts powerfully on the kidneys. In some constitutions it occa- sions feelings of great sinking and exhaustion, but I have never known it to do harm. A few small doses of the spirit, ether, nitros will, in general, soon remove this unpleasant sensation. The effects of this application are increased by the patient's drinking plentifully of warm fluids, and I have always preferred weak beef-tea or chicken-broth with the view of keeping up the strength. Opiates of all kinds I * Edinb. Med. and Surg. Journ., vol. xxxix, p. 129. DROPSY. 441 have found hurtful; but I employ warm clothing, and keep the patient in bed, during the whole period in which the poultice is applied."* Among the external means which may be resorted to with occa- sional advantage in ascites, a tight flannel bandage worn around the abdomen will frequently prove decidedly beneficial. This applica- tion was much extolled by the late Dr. Monro, in the treatment of abdominal dropsy. I have repeatedly found such a bandage of ad- vantage, 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 previously1 soaked in a strong solu- tion 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 pro- long the life of the patient, and to gain more time for remedial ap- plications, to evacuate the collected fluid by means of a puncture into the cavity which confines it.t It is usual to delay this operation until every other measure for the removal ofthe fluid has been found unavailing, and the distension from the effused water has become so great as to threaten immediate danger. This is one of those errors in medical practice, which, though readily and generally acknow- ledged by practitioners, it 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, moreover, 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 accumula- tions, and it is as safe in its consequences as any of the other measures that may be adopted for this purpose. Were tapping more early resorted to in ascites than it always is, there can be but little doubt, *■ The marchantia hemispherica, commonly called liverwort, grows abundantly in certain localities of the eastern and middle states of this country. It is a lichen, consisting Of membranous expansions, cut into rounded lobes, with entire edges, of a bright green colour on the upper surface, and a slightly purplish hue on the under side. It is usually found in moist and shady places, on the banks of rivers, and on rocks, and is to be met with at all seasons ofthe year, but is supposed to be in the greatest vigour about the end of August. t 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 related 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 (monita) in which tapping was performed seventy times in five 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 Medicale, Juilkt, 1828, 442 SCROFULA. that its permanent usefulness would be greatly enhanced. The mere mechanical irritation ofthe effused fluid, when the distension is very great, must tend to keep up that morbid condition in the peritoneum which gives rise to the effusion. The earlier this over-distension is taken off, the greater, one may reasonably presume, must be the chance of effecting a radical cure, by some of the means already men- tioned—more especially 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 others, 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 cha- racter, such fortunate terminations would be much more frequent than they are under the present plan of procrastinating it.* CHAPTER IX. CHRONIC AFFECTIONS OF THE LYMPHATIC SYSTEM. Sect. I.—Scrofula. Scrofula appears in a great variety of forms and grades of vio lence—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 dis- * M. Lhomme, in January, 1827, communicated to the French Royal Academy of Medicine an inveterate case of ascites, which, after hydragogues, diuretics, and tap- ping, had been fully but unavailingly employed, was speedily cured by the in- jection 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 Annales de laMedecine Physiologique, an account of two casesof abdominal dropsy which were cured by the same means. The vapour of wine was injected sixteen times without causing any pain or particular uneasiness in the abdomen, with the exception of some slight colic pains which required no re- medial 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 ar- rested.' M. Lhomme tried the same means in another case, but without success. No unpleasant consequences, however, resulted from the operation. It is not dif- ficult 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 inflammations of a low or languid grade of excitement. We thus remove gleet, chronic ophthalmia, and chronic bronchitis, by stimulating injections, collyria, and inhalations ofthe vapour of tar.—Revue Medicale, vol. i, p. 343. SCROFULA. 443 tinct forms; namely, its latent and its active states. The former constitutes what is usually called the scrofulous habits or diathesis; and the latter, the state of full development and activity of the disease. The scrofulous habit, or predisposition to the active forms of the malady, is characterized by the following phenomena: a peculiar delicacy and languor of the countenance, with a soft, rosy tint of the prolabia and cheeks;* or a pale, soft, flaccid, and apparently tumid aspect of the countenance, with a dull lead-coloured circle round the mouth, and a swollen appearance of the upper lip. The hair is gene- rally fair, and the eyes blue or black. The head, particularly the posterior part, is usually large, and the temples flattened, or some- what 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 dis- posed 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 appetite, also, is very variable—being sometimes entirely depressed, and at others very urgent. The urine commonly deposits a whitish sediment, and becomes turbid some time after it is passed. A disposition to transient swellings of particular parts, as of the face and scrotum, is mentioned by some writers as belonging to this habit. In female children, a leucorrhoeal discharge is apt to occur, from time to time; and "in very young children, excoriations behind the ears, scabby eruptions about the head and 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 developed, and often astonishingly active. This dormant or inactive state of the disease may continue for many years, and at last pass off without terminating in any par- ticular local affections. More commonly, however, the scrofulous habit gradually requires strength, and at last, under the influence of the usual exciting causes, shows itself in its more obvious and active form. The lymphatic glands along the neck and other parts become en- larged and firm to the touch, in which condition they may remain for years, without either receding or going on to a more active 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 common mode of termination, they form chronic indolent ulcers, from which a thin, milky, and somewhat viscid fluid is copiously discharged, and which * This appearance ofthe countenance is particularly met with in those instances 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 scro- fulous habit. 444 SCROFULA. are always extremely slow in cicatrizing. The cicatrices left by these ulcerations, are, in general, easily distinguished from those left by other ulcers. They are peculiarly uneven, irregular, and conspicu- ous. In connection with these tumours, or ulcerations about the neck, the eyelids and conjunctiva 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 state 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 surface ; 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 vertebrae become diseased; and occasionally the bones and soft parts ofthe nose, palate, and fauces, are more or less rapidly destroyed by ulceration. There is, in short, scarcely any part of the body which is not some- times the seat of the frightful ravages of this affection. The most common forms of scrofula, however, are tubercular phthisis pulmonalis; white swelling, or disease ofthe hip and knee joints, and ophthalmia. The general progress and duration of scrofula are exceedingly va- rious. 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 affected with scro- fulous disease ofthe lymphatic glands during the greater period of a long life, without experiencing any particular sufferings from this source. Much more commonly, however, some 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 period 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 fcetus 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 dis- ease, is one of those constitutional habits or tendencies, which often occur in children as an hereditary diathesis. This, however, is by no means the only source of the scrofulous habit; for that it may be generated in individuals originally of sound constitutions, 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 concerned in the production of a predisposi- tion to this disease are— 1. Climate and atmospheric influences. It would appear that the influence of hot climates, in infancy and early youth, has a con- siderable tendency to predispose the system to the occurrence of the scrofulous diathesis, from the subsequent influence of a cold and vari- SCROFULA. 445 able, 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 natives, 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. Alison, " that a great majority ofthe inhabitants ofthe West and East Indies, both negroes and Hindoos, are unusually prone to scrofula when they come to temperate cli- mates."* A cold, humid, and variable atmosphere, more especially when aided 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 narrow 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 ofthe marshy districts of England, this disease is said to be peculiarly prevalent. 2. The impure and confined air of populous cities also seems par- ticularly capable of promoting the occurrence of scrofulous diseases. It is certain, at least, that in the same amount of population, this malady is vastly more common in large and crowded cities than in the salubrious districts of the country. " It is 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 attendants, squalidness and mental depression, may contribute to the production of the scrofulous diathesis. Without doubt, however, coarse, indigest- ible, 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 innutritions aliment. An impro- per dietetic management of very young children, in relation both to quantity and quality, is probably one of the most common sources of scrofulous affections. By over-distension of the stomach, or the use of heavy, irritating or indigestible food, dyspepsia and high irritation of the gastro-intestinal mucous membrane will seldom fait to super- vene ; 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 chylopoieticand assimilating functions, and indeed the whole system, become intimately deranged. Nothing 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 abdomens, and other symp- toms of gastro-intestinal disorder, where,from the health ofthe parents, no hereditary taint can be presumed to exist. Chronic inflamma- tion or habitual irritation ofthe mucous membrane ofthe stomach and bowels, is probably much more frequently concerned in the for- * Observations on the Pathology of Scrofulous Diseases, &c, p. 397. 446 SCROFULA. mation 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 scrofu- lous diathesis. This is especially the case with measles, scarlatina, and whooping-cough; but it would seem, that it is rather by the in- fluence 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 develop 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 disease, have led me to the conviction, that disorder of the digestive organs, from whatever cause it may arise, often constitutes the 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, " incontrovertible facts, which demon- strate that disorder of the chylopoietic viscera precedes and accom- panies the symptoms of scrofula, and that there are the strongest grounds for believing that such disorder 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 constant use of unwholesome food. A disordered state of the system first ensues, and is followed by various local complaints. It is highly probable, however, the gastro-intestinal irritation, which always attends, in a greater or less degree, where the digest- ive 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 hereditary or natural predisposition to scrofula, the foregoing causes have an especial tendency to excite it into a state of activity ; for it is suffi- ciently 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 con- sequences on the health of the inoculated individuals.! Mere local ulcers or scabby affections have, indeed, been known to occur from the frequent application of the matter discharged by ulcerations of this kind. Thus, healthy children who sleep with persons affected with * Carmichael on the Venereal Disease, p. 351. t Ueber die natur, kendniss, und heilart der scrophel krankhert, p. 105. SCROFULA. 447 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 plau- sible doctrine upon this point is, that the scrofulous habit consists in constitutional or acquired excess of irritability in the lymphatic sys- tem, in connection with a weak condition ofthe assimilative powers. Prognosis.—Where the predispositionjs hereditary, the chance of subduing scrofula, after it has manifested itself in ah active form, is always extremely small. Nevertheless, it is a fact well established, that even where the diathesis is manifestly congenital, moderate cases of the disease not unfrequently disappear 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 Jhe ^physical developmeht of trie'''system, areT 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 affec- tions have been known to remove incipient scrofula, in habits ob- viously 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 con- tinues 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, particular 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 production of the disease; and especially where the situation and circumstances of the , patient are such as to render an entire removal of them impractica- ble, the chances of advantage from remedial management must, of *': course, be exceedingly limited. Among the poor and squalid, who can neither procure proper nourishment, 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._JJhave 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 iof the malady. The younger the ' patient is, the more easy, in general, will it be to remove, or effectu- ally counteract the progress ofthe disease. When the disease makes its first active appearance after the age of puberty or of manhood, the ■ chances of being able to suspend its progress are hut small, and still v 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 scrofu-, lous diathesis, a reasonable prospect of success may be entertained -^ 448 SCROFULA. 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 occasionally gradually effect a removal of the scrofulous symptoms. When these tumours become irregular, uneven, immova- ble, painful, 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 unfavourable in proportion as these tumours are numerous. Suppurated scrofu- lous tumours, when they are situated externally, and not attended with strong constitutional tendency to the disease, are not, in general, to be regarded either as more dangerous, or difficult of manage- ment, than mere inflamed tumours, although they are always ex- tremely 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 symptoms 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 successful treatment may be abandoned. 4. The seat of the local scrofulous affections forms, also, an important consideration in esti- mating the probable issue of cases of this disease. So long as the disease appears to be concentrated upon the external glandular struc- tures, 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. With- out 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 atten- tion to proper clothing, so as to obviate, as much as possible, the injurious influence of atmospheric vicissitudes; a wholesome, ab- stemious, 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 digestible; 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. Al * Bordeu, Recueil des pieces qui on tremporte le prix de l'Acad. Royale de Chirurg., vol. iii, p. 69, as quoted by Richter. SCROFULA. 449 kinds of stimulating irritating articles of food must be carefully avoided; and the same observation applies to every species of stimu- lating 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 labouring 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 climate, is all-important to the successful management of this malady. 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 scrofu- lous subjects in large towns cannot even obtain the benefits of a pure country air, so desirable in the treatment of this affection. Inactivity and indolence are to be shunned as decidedly favourable to the pro- gress of the malady. Walking, gestation in an open carriage, or, when the patient is old enough, riding on horseback, should be regu- larly practised when the weather is favourable. The patient should rise early from bed, and retire seasonably in the evening, and par- ticularly 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 system. Of these indications, the regular maintenance ofthe action ofthe bowels and of the liver may be regarded of primary importance. For this purpose recourse must be had to calomel or blue mass, in con- junction or alternation with proper aperients. Some diversity of opinion is expressed by writers as to the best mode of administering mercurials in this affection; and some even condemn them almost entirely as remedial means in scrofula, but most assuredly without just grounds. Undoubtedly, much caution is required in the em- ployment of mercury in this disease, or where the scrofulous diathesis exists; for it cannot be questioned, 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 laxative, 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 treatment should be commenced by pretty active doses of some purgative, and this should be repeated every third or fourth day, until there is reason to believe that the fecal accumula- tions have been removed. . For this purpose from two to six grains of calomel, 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 ade- VOL. n.—30 450 SCROFULA. quately 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 decoction of sarsaparilla twice a day; and if the bowels are not moved during the forenoon, he administers some laxative, so as to procure moderate evacuations. This plan he pursues until the action 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 pecu- liarly well adapted as an alterative in scrofulous affections. I have repeatedly prescribed them in cases of this kind with an excellent 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 frictions, as prefera- ble, in his estimation, to the internal administration of this medicine, more especially in children. He directs five grains of the unguen- tum 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 ointment can be observed to stain a clean finger when applied to the part."J Mr. Lloyd makes the following judi- cious observations in relation to the. remedial treatment of scrofula in children. " Every one must have observed that the same medi- cine 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 the evacu- ation 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 proper effect, we should de- sist 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 o\ 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. * A Treatise on the Nature and Treatment of Scrofula, &c. t H.—Massse pil. hydrarg. 3ss. 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. X A Treatise on the Nature of Scrofula, &c.; pp. 47, 48. SCROFULA. 451 After the action of the liver and bowels has been in some degree brought to a regular state, benefit will in general result from the em- ployment of the tonic vegetable bitters; and where the digestive functions are much impaired, it will be proper to resort to the mode- rate use of tonics, in conjunction with the alterative 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 stomach free from irritation, the active employment of remedies of this kind is seldom attended with ad- vantage. Most assuredly, they are decidedly indicated where the general system is languid and debilitated; but in children, high mu- cous irritation of the alimentary canal is so frequently present in scrofulous affections, and the general habit is often so irritable and prone to inflammatory excitement, that the indiscriminate use of to- nics must be frequently productive of mischief. When the alvine and hepatic functions are restored by alteratives, aperients, and proper dietetic regulations, « the symptoms of debility and relaxation almost always soon disappear, under the use of a nourishing and digestible diet, regular exercise, warm clothing, and the enjoyment of pure air." Most writers speak favourably of sea-bathing 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 pro- gress, 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 objectionable, where the scrofulous habit tends strongly to the formation of tubercles in the lungs, or where tuber- cular matter has already been deposited in the pulmonary tissue ; and the same observation applies to the employment of the usual internal tonics The tonics most generally prescribed are cinchona, gentian, steel, the mineral acids, and the quinine. Of these articles, the qui- nine appears to be particularly useful in certain states of scrofulous affections. Mr. Rennie, in a very excellent paper on the treatment of this disease, states, that he found this preparation more effectual in allaying irritability, and that febrile diathesis which depends on atony ofthe stomach, than any other tonic he has ever used.* In the first volume of this work? (p. 423,) I have already referred to Dr. Macken- zie's observations on the-valuable powers of the sulphate of quinine in scrofulous ophthalmia; and in one instance of well-marked scro- fula in an infant, which lately came under my notice, one grain of quinine given three times daily, after proper evacuants, afforded une- ^W^S^h the symptoms of gastric debility, much acidity * London Medical Repository, 1825. 452 SCROFULA. prevails in the primse viae, alkaline remedies should be given, either by themselves, or what is usually more advantageous, in union with weak infusions of the tonic vegetable bitters. The alkalies have in- deed long been regarded as peculiarly beneficial in the management of scrofulous affections. Mr. Farr strongly recommends Brandish's liquor potassae as a remedy for indurated, 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 connection 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 agree- able drink. Its operation is slow, and must be long-continued.* What has been said applies particularly to the constitutional treat- ment 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 materially from the methods of treatment generally followed. During the early period of the disease, he endeavours to fortify the constitution by the usual means resorted to in affections of this kind. When the com- plaint has advanced to what he calls its second stage—which is cha- racterized by febrile irritation, local pains, swelling and inflamma- tions, he rigidly avoids all remedies of an exciting character, and treats the disease as an inflammatory affection, 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, spontaneous luxations, suppurations, and destruc- tion of the organs. The authority of M. Dupuytren is not to be lightly rejected; and yet, I apprehend, that although decidedly pro- per in certain phlogistic cases, the antiphlogistic method he recom- mends cannot be so generally applied with benefit, as his observa- tions would appear to indicate.* Glandular swellings.—So long as the glandular tumours remain in an indolent state, all active local applications should be avoided; for as discussive means they are wholly useless, where these enlarge- ments depend on a scrofulous diathesis; and ljy their tendency to irritate and inflame, may greatly hasten the progress of the disease. Nevertheless, with the view of preventing the surrounding parts be- coming irritated by the pressure of the enlarged 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, * The formula for preparing Brandish's liquor potassa is given in the Edinburgh Dispensatory, edited by Dr. Dyckman, p. 459. t Ratier on the Practice, &c, of the Parisian Hospitals. SCROFULA. 453 however, loral antiphlogistic applications 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 inflammation; but " where several glands have coalesced, forming a large tumour, and the superincumbent skin is tense and discoloured, the best applications are warm emollient poul- tices." The leeches should not be applied to the inflamed or dis- coloured 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 examina- tion, be found to contain in its upper surface a small quantity 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 sometimes of the whole tumour." In general, however, the application of blisters and other stimuli to glandular swellings, in an indiscriminate way, is calculated to do much mischief. The foregoing observations on the local ma- nagement 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 information, in relation to the management of this alarming malady. 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 treatment, 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 ulcerations, states that he has found the fol- lowing 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 * The only signs by which a scrofulous ulcer may be distinguished from one of a different character, are: " its occurring after a suppurated scrofulous tumour—the peculiar dull red, or purple colour of its edges—its remaining indolent 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 con- stitution."—Lloyd. t R.-—Picis nigrse Ibi. ----liquidse ibiss. ----resinaj ffiii.—M. ft. emplast.—Or, R.—Picis liquid. Ibss. ----niger. Ibi. ----resinse Ibi.—M. ft. emplast.—Or, R.—Picis liquid. Ibiii. _____resinaj Jbiv.—M. ft. emplast. To be heated and spread at the time of application, not, however, too thinly. The best thickness seems to be from one to two lines.—Loc. citat., p. 194. 454 SCROFULA. some escharotic, and for this purpose the kali parum, or the nitrate of silver, should be employed. Mr. Lloyd recommends the former, in preference to any other applications of this kind. Slightly astring- ent ointments or lotions generally agree better with scrofulous 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 ointment as the best local remedy for pro- moting the healthy granulation and cicatrization of scrofulous sores. Whatever topical remedies may be employed, and whether the loeal affection consists merely in enlargement of the lymphatic 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 mentioned, 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 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 scrofulous 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 ja scrofulous habit of body. In scrofulous inflammation of the eyes, it is said by some writers to be very useful—a statement which I have not, however, found verified in my own practice, al- though 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 decidedly the most effectual remedy we possess. The only three instances of this kind in which I have employed it, disap- peared 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 deter- minations, and the presence of internal local congestions; prominent gastric and intestinal derangement; febrile symptoms, general plethora, diarrhoea, a disposition to hemorrhages, and an inflamed or sensible state ofthe tumours, are decided contra-indications to the employment of this article, whether used externally or internally. Mercury.—This article, as has already been stated, is of unques- tionable utility, under cautious management, in scrofulous affections, by its tendency to correct the hepatic and alvine functions, and thereby contributing essentially to the restoration of the general health and vigour of the constitution. It has been supposed, however, to possess * R.—Hydriod. potassae 9ii. Axungiae ^iss. Liq. potassse caust. gtt. v.—M. ft. ungt. Of this ointment, a portion about the size of a small nutmeg should be rubbed in upon the tumour twice daily. SCROFULA. 455 direct and specific powers over the scrofulous action, by its constitu- tional influence; but for this opinion there does not appear to exist any good foundation. It is, nevertheless, true, that in old and obsti- nate ulcerations of a scrofulous character, minute doses of corrosive sublimate, in union with some alterative ptisan, such as the compound decoction of sarsaparilla, will sometimes prove surprisingly beneficial. I have succeeded in curing several remarkably severe and obstinate cases of this kind, unequivocally of a scrofulous nature, by the con- tinued employment of a tenth of a grain of this mercurial, thrice daily, in conjunction with the free use of sarsaparilla decoction ; and there are, perhaps, few practitioners who have not 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 accelerates the progress of these enlargements, and de- teriorates the general habit of the body. Narcotics.—Most of the officinal narcotic extracts were formerly much extolled as remedies in every variety of scrofulous affections. The confidence of the profession in their powers, has, however, long since, in a great measure, passed away; and although some relief may occasionally be obtained from the employment of these articles, their effects on the disease rarely amount to more than a mere pallia- tion of its symptoms, or a temporary suspension of its progress. The most celebrated of these articles are—conium, belladonna, hyoscya- mus, and solanum dulcamara; but there are a great variety of other vegetable remedies 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 recom- mends digitalis in small doses.* The expressed juice of fumaria; chaereofolium ; beccabunga ; sonchus ; lactuca; marubrium 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 ofbarytes was much in vogue as a remedy for scro- fula some thirty years ago. It was introduced to the particular notice of the profession by Dr. Crawford ;t and Hufeland, soon afterwards, published a small treatise with cases illustrative of its remedial powers in this disease. J 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 ophthal- mia, with unequivocal advantage ; and I am persuaded that in some * De digital, purpur ejusque usu in scrofulus medico, Jenee, 179. t Duncan's Medical Comment., vol. iv, Dec. ii, p. 433. X Volstand. Darstell. d. krafte u. anwendung d. salzsaur. schwererde, &c. 456 SCROFULA. 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 employing it, the reader is referred to page 422 of the first volume 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 com- plaints. Thirty drops of a solution of one drachm of this salt to two ounces of water, are to be taken every three hours, and the dose gradu- ally increased until it begins to affect the stomach. Fourcroy, Bed- does and Hufeland speak very favourably 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 ex- ternal affections, its beneficial influence was very manifest. In the early period of my practice, 1 employed this article in a considerable number of instances 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 established 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 useful medicine under proper management, in certain varieties and stages of scrofulous affections. Under the head of phthisis pulmonalis, I have already spoken of its usefulness in counteracting the progress of tubercles in the lungs. This article is particularly useful when the glandular swellings manifest a tendency to pass into a state of inflammation; and in minute doses, it will co-operate very advan- tageously 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 promot- ing 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 recommend the following combination in scro- fulous cutaneous eruptions.* , Some of the German writers speak very favourably of the effects of large and frequent doses of assafetida, 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 are languid, benefit may be obtained from this remedy; but its beneficial influence, in cases of this kind, appears to * J&.—Antimon. crude, alcoholis gvi. • G. guaiaci ^ss. Extract, aconit. 3L Sacchar. albi %x. Mucilag. g. Arab. q. s.—M. To be made into boluses of xv grains each. One of these is to be taken four times daily by an adult. BRONCHOCELE. 457 depend solely on the general excitement and invigoration it imparts to the system. Richter recommends the following formula.* Ofthe importance of tonics, in conjunction with aperients, and the cautious employment of mercurials, for counteracting the scrofulous diathesis, I have already spoken, and I need here only repeat, that although unquestionably of primary 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 high state of 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 propriety and advan- tage. In old scrofulous ulcerations, attended with general debility and relaxation, the employment of large doses of cinchona, quinine, or steel, is sometimes an indispensable auxiliary to the local applica- tions and general alterative remedies that may be deemed proper. The following combination forms an excellent tonic in old scrofulous ulcerations, or in general where tonics are indicated- in this affection, at any period of its course.! 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 objectionable. Weikard particularly recommends calamus; Richter speaks favour- ably of cloves; and Hufeland mentions a decoction of rad. helenu; cort. winleranus; cort. et lig. sassafras; and where the general habit is very torpid, Tilenius advises the use of the essential oil ot sassafras, as being often peculiarly beneficial. Sect. II.—Bronchocele.—Goitre. This very remarkable disease consists of a chronic enlargement of the thyroid gland. It commences with a small tumour on one * R— Antimon. sulphuret. nigr. 311. G. assafcetid. 3iii. Extract, cicutae 3SS. ______ aconit. gr. xv.—M. Divide into four grain pills.—S. lake from four to five pills twice or thrice daily. | ft.—Ferri Hmatur. vel pulver. 3iii. P. rhcei 9ii. G. ammonias 3b. . Tart, antimon. gr. iii—M. Divide into three grain pills.-S. Take four pills three times daily.—Or, |£ _Ferri limatur. 3b. G. assafcetid. 31. G. aloessocc.gr. x.-M. Divide into sixty pills.-S. Take two four times daily. 458 BRONCHOCELE. or both sides of the larynx and trachea, which gradually increases 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 ofthe skin natural and movable over the enlarged gland. In the progress of its enlargement, how- ever, 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 tenderness during the early period of its progress, and in many cases of moderate size always so, yet in the majority of instances, where the tumour becomes large and indu- rated, 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 in- convenience whatever is experienced from the disease while the tumour remains soft and of a moderate volume; but when it acquires a large size, it generally gives rise to more or less difficulty of respira- tion, 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, occa- sioning difficulty of swallowing, and, at times, great anxiety and palpitations of the heart, throbbing of the carotids, and dangerous and even fatal congestions in the brain. The progress of the enlarge- ment is sometimes very irregular. The tumour in some instances remains stationary for a considerable time, then rapidly increases in size for a short period, and again continues nearly in the same state, or decreases until it again rapidly augments in volume. More gene- rally, however, the progress of the tumour is very gradual and regular. In many localities, where bronchocele prevails endemically, parti- cularly in the deep valleys of the Alps, the disease is very frequently attended with a stunted and deformed development of the body, and a corresponding deterioration ofthe intellectual faculties. It is thus, that amidst these magnificent and beautiful scences of nature, man alone is doomed to dwindle—to sink, under the inevitable influences that surround him, from his noblest prerogatives, to the lowest state of corporeal and intellectual deterioration. The unfortunate beings who are'affected in this manner—and in some situations, the majority of the native inhabitants are more or less affected—are stunted in growth, with enormous heads, tumid necks, and manifest a degree of mental hebetude which, in aggravated instances, amounts to absolute idiotism. This combination of affliction is called cretinism, and the unfortunates themselves, cretins. Bronchocele has, however, no necessary connection with the general debasement of the moral * Albert, Fodere, Larrey, Keate, and Sir Robert Wilson, have all related in- stances of this kind. BRONCHOCELE. 459 and physical constitution of man ; for, in many parts where the goitre is exceedingly prevalent, the development of mind and body is not impeded by the disease, or the endemic cause upon which it depends. Nevertheless, from the almost inseparable connection of these affec- tions, where cretinism prevails, we can scarcely doubt of their depend- ence on some peculiar modification of a common cause. The internal structure or substance of a goitrous tumour, varies ac- cording to its age, or stage of progress. Recent enlargements of this kind, consist generally of a gelatinous mass, or a cellular structure con- taining a glutinous fluid. Sometimes they exhibit a soft and spongy texture, with large cavities or cysts dispersed throughout their struc- ture, containing a serous fluid. Old tumours sometimes contain masses of ossified or cartilaginous substances, imbedded in a soft, friable, or adipose-like matter,* and in some cases the goitrous tumour is filled with dark blood. Morgagni found tumours of this kind composed almost entirely of a number of cysts filled with a viscid transparent fluid ; and occasionally the whole gland resembles a mellicerous or steatomatous tumour. Sometimes the goitrous enlargement consists almost wholly of a congeries of varicose veins.t Bronchocele very rarely enters into suppuration; and the occur- rence of active inflammati'on and ulceration is equally uncommon, and hardly ever takes place spontaneously, or without some exter- nal injury or irritating applications. Nevertheless, instances of spon- taneous suppuration have occurred; and this has, in some cases, eventuated in a complete cure of the affection. Petit has mentioned examples of this kind. Alibert has recorded a case, where an enor- mous strumous enlargement of the thyroid entered into suppuration, and disappeared after the discharge of above five pounds of purulent matter, (loc. cit., p. 467.) Suppuration does not, however, always, or even generally, terminate thus favourably. Sometimes the ab- scess ulcerates into the trachea, and causes suffocation. Instances of this kind are related by Morgagni, Valsalva, Lieutaud, Baillie, and Portal. ^ Diagnosis.— Although generally sufficiently distinctive in its ex- ternal "character, goitre, when not very large, and situated only in one of the lobes of the gland, may, on superficial examination, be mistaken for aneurism of the carotid artery, and still more readily for sarcoma of the trachea or neighbouring glands; and, perha'ps, for dilatation of the internal jugular vein. When the tumour accompanies the motions of the larynx and trachea in the act of swallowing, and is movable, wholly insensible, soft and spongy to the touch, and free from pulsa- tion, we may conclude that it is of a strumous or goitrous character. When, however, the tumour is situated on one side ofthe neck, directly over the carotid, a pulsatory motion will be communicated to it by this artery, and in this case, much difficulty may occur in the diagnosis. An instance is mentioned in the Diction, des Sciences M6d., where a tumour in the neck was pronounced to be aneurismal, by several * Morgagni, Benetis, Baillie, Richter. t Fodere, Essai sur le goitre et le cretinage. $ 8. 460 BRONCHOCELE. eminent surgeons, which was afterwards found by Boyer to consist entirely of an enlarged lymphatic gland in the neck. An interesting example of this kind occurred in this city. A tumour on the neck was regarded as aneurism of the carotid by Drs. Griffitts, Chapman, and Dorsey; which, upon dissection by Dr. Parrish, was subsequently ascertained to be composed wholly of an enlargement of a portion of the thyroid gland.* From scrofulous enlargements of the glands of the neck, goitre may, in general, be distinguished by the position of the tumour—and the firmness and greater proneness to inflammation and suppuration of the former, than the latter form of glandular disease. Mere dilatation ofthe internal jugular vein is also liable to be mistaken for broncho- cele; but the former may, in general, be distinguished from the latter, by its situation, which is usually just above the sternum; and by its softness and compressibility, its undulating or pulsatory motion, and the general turgescence of the vein, and the sudden return of the tumour when pressure is removed. Etiology.—One of the most singular circumstances in the history of this affection, is its permanent and extensive prevalence in certain localities, often of limited extent, whilst the inhabitants of the vici- nal districts are almost wholly exempt from the malady. In no part of the world is the disease so prevalent, and so distressing in its cha- racter, as in some of the valleys of the Alps and Appenines. In cer- tain districts of Switzerland and Savoy, almost the whole of the indigenous population are more or less affected with goitrous enlarge- ments. In the valley ofthe Rhone, at Martigny, St. Maurice, Aigle, Villeneuve, Bourg, Lucerne, and at Dresden, and in the valleys of Piedmont, this disease is extremly common. Goitre occurs also extensively in various parts of Asia—particularly in Chinese Tartary and in Hindostan; and in certain districts in Africa it is said to be very common. In England the disease occurs very frequently in certain mountainous districts of the counties of Derbyshire, Bucking- hamshire, Surrey, and Norfolk. In our own country, also, there are localities in which goitre is of frequent occurrence. At Ben- nington, Chittenden, Camden, Sandgate, Windsor, and Chester, in Vermont, bronchocele is very common. In the State of New York it is frequently met with at Oneida, the German Flats, in the Onan- daga valley, in the township of Manlius, at Brothertown, in the neighbourhood of Angelica in Alleghany county, and in various other localities in the north-western districts of the state. In Penn- sylvania it occurs not unfrequently at Pittsburgh, at Cannonsburgh, Brownsville, and along the Alleghany, Sandusky, and Monongahela rivers. It is met with in Virginia at Morgantown, and on the banks of the Cheat river. Where the disease prevails endemically, it occurs at all periods of life from infancy to old age. Saussure, indeed, asserts that those who remain wholly free from the disease until they have passed the * See an essay on Goitre, by Dr. W. Gibson, in the first number of the Phila- delphia Journal of Med. and Phys. Sciences. BRONCHOCELE. 461 tenth year, very rarely, if ever afterwards, become affected with it; and Kortum states, that it never occurs in infants, and in adults ofthe male sex. These assertions are, however, wholly unfounded, and have been abundantly contradicted by later observations. Hacquet, for instance, states that he has met with goitre in infants; and he has known the disease to come on after the fiftieth year of age.* It is even asserted that infants have been born with goitrous tumours. Fodere,t Consbruch,f; and Sterndale,§ have related in- stances of this kind. Iphofen, however, contends that true conge- nital bronchocele never does take place, and that the cases which have been recorded as such, were, in all probability, lymphatic tumours of a different character,|| or simply an unusually developed state of the thyroid gland. In general when the disease occurs in females after marriage, it is during the state of pregnancy that the tumour first makes its appearance. (Fodere.) It would appear that cold weather has a tendency to retard the increase, or even to dimi- ish goitrous tumours; for it is by no means uncommon to find the enlarged gland perceptibly smaller during the winter than in the warm months of summer. Goitre occurs also in the inferior orders of animals—particularly in sheep, horses, and horned cattle.1T In relation to the remote causes of goitre, a great variety of opinions have been advanced; but our knowledge upon this inte- resting subject amounts, as yet, to little more than to some very gene- ral facts and a few plausible conjectures. It has been supposed that the habitual use of water impregnated with limestone or other cal- careous substances, is the principal cause of this affection, (Coxe, de Luc;) and this appears to be the generalopinion in Switzerland and Savoy. This, however, is satisfactorily contradicted by the fact that goitre prevails in districts where not the smallest portion of calcareous matter occurs in the water used by the inhabitants; and in many localities, where the water is highly charged with limestone, this affection is wholly unknown. (Barton, Iphofen.) Another opinion still entertained by many is, that the use of snow water, abounding in mountainous districts, is the cause of this malady, (Darwin, Selle, Percival, Desgenettes;) but there are many facts which conclusively contradict this view of the causation of the dis- ease. Thus, in the valley of Chamouni, " where the water is nothing else than the droppings of snow water from Mount Blanc," bron- chocele is but very rarely seen; while on the other side of the Col de Balme, in the valley of the Rhone, we hardly see any thing else than goitre and cretinism. Again, in Lapland, where snow water is * Neii Physic. Politische Reise, durch die Dacischen und Sarmatischen oder nord. Karpathen., p. 129, as quoted by Richter. t Traite du Goitre et du Cretinisme, p. 18. X Klin. Taschenbuch., t. ii, p. 281. $ Lond. Med. Repository, vol. x, p. 200. || Der Cretinismus Philosoph. und Med. Untersucht., Dressten, 1817, p. 4. If Barton's Memoir on Goitre. Dr. Alexander Coventry—in the New York Medical and Physical Journal 462 BRONCHOCELE. constantly used, goitre is a very uncommon affection; and on the contrary, the disease is known to prevail extensively in some parts of Africa, and in other warm climates, where snow and ice scarcely ever occur—as in the island of Sumatra.* The following observa- tions made by Dr. Richardson, who accompanied Captain Franklin in his voyage to the polar sea, is decisive on this point. " Broncho- cele is a common disease at Edmonston. The disorder attacks those only who drink the water of the river. It is, indeed, in its worst form, confined almost entirely to the half-breed women and children who reside constantly at the Fort, and make use of river water, drawn in winter, through a hole in the ice. The men, from being often from home on journeys through the plain, where their drink is melted snow, are less affected; and if any of them exhibit, during winter, some incipient symptoms of the disease, the annual summer voyage to the sea coast generally effects a cure. The na- tives who confine themselves to snow water in winter, and drink of the small rivulets which flow through the plain in summer, are ex- empt from the attacks of this disease." Iphofen (loc. cit., p. 50) main- tains that bronchocele is produced by the use of water entirely devoid of carbonic acid gas, but this, like the other opinions men- tioned, is not sufficiently supported by facts to entitle it to any par- ticular attention. Many writers have attributed this disease to the use of particular articles of food. Thus, Dr. Drug, who saw a great deal of goitre in Derbyshire, conceives that goitrous affections are very generally produced in that district, by the use of sour oatcake, and other in- nutritious aliment, more especially inferior potatoes, &c. Magneti and Roncalli also have ascribed the disease to the abundant use of heavy and indigestible articles of food, particularly to fat and oily substances and chestnuts, which, in some parts of Switzerland, con- stitute a large proportion of the ordinary nourishment of the pea- santry. Its dependence, however, on causes of this kind, is decidedly contradicted by a variety of facts bearing directly on this point. Thus of different contiguous localities, we find the disease extremely preva- lent in some, whilst in others it occurs but seldom, although the gene- ral diet and mode of living are the same. Besides the foregoing causes, various others have been mentioned as the probable source of this affection; such as the inordinate use of vinous liquors ; the repulsion of cutaneous diseases; mechanical injuries of the thyroid gland by carrying heavy burthens on the head, &c. The opinion that the disease depends on certain atmospheric causes, has received many advocates; and there are various circum- stances, indeed, which favour this view of its origin. It is supposed by some, that a dense, stagnant and humid atmosphere is the or- dinary source of the disease ; and this idea is countenanced by the circumstance that goitre is known to prevail extensively in many situations where the atmosphere is constantly loaded with moisture, as in the deep and shady valleys of the Alpine countries. (Foderd, * Marden's Geschichte und Beschreibung von Sumatra, 64. BRONCHOCELE. 463 Saussure, Chavassien, d'Aubert.) Fodere asserts that the frequency ofthe disease is found in many localities to bear a pretty close relation to the hygrometrical states of the atmosphere. In many deep, damp, and woody valleys, goitre is extremely prevalent; but in proportion as we ascend towards the more elevated and dry situations on the sides and tops of the adjacent mountains, the disease becomes less and less frequent. It is well known, moreover, that when young persons affected with goitre remove from the valley in which the disease was contracted, to high and dry situations, the tumour almost always becomes considerably diminished in size, and in many instances dis- appears altogether.* It is even asserted, that in some foundling hospitals, where the air was suffered to become damp and malarious, goitre has been known to occur endemically—and that it disappeared again, after the air was rendered purer and dryer.t These facts cer- tainly appear very strongly to countenance the opinion that the dis- ease depends on atmospheric causes; but they may be used with equal propriety as arguments in favour of the dependence of the disease on some peculiar impregnations of the water used in the localities where it prevails. It must be observed, too, that broncho- cele is known to prevail extensively in some elevated situations, where the air circulates freely, and is not charged either with hu- midity or paludal exhalations. Thus, at Annaberg, at Marienberg, and in several other localities pointed out by Iphofen, (loc. cit., p. 42,) the air appears to be pure and dry, and yet goitre is a very common affection. Again, it is unquestionable that there are a vast number of deep valleys in every country, in which the air is stagnant, and particularly loaded with moisture and terrestrial exhalations, but in which goitre is nevertheless entirely unknown. Humboldt advanced the opinion, that a deficiency of electricity in the atmosphere is intimately concerned in the production of endemic bronchocele;% and the same doctrine is strenuously advocated by Iphofen. It would appear from the experiments and facts adduced by the latter writer, that in all the situations where goitre prevails endemically, there is a constant deficiency of the electric fluid in the atmosphere ; and he asserts, that when goitrous tumours are lessened or removed by a change of residence, from the low and humid situa- tions in which they were produced, to elevated and dry districts, it is chiefly by the abundance of electricity which the atmosphere contains in the latter situations, that the salutary effect on the disease is produced. Notwithstanding the plausible facts that may be adduced in evi- dence.of the aerial character of the remote causes of goitre, it appears to me much more probable that it is not in the atmosphere, but in the water of goitrous districts, that we must look for the cause of this malady. It cannot, indeed, be maintained that it is either snow water, or calcareous matter contained in the common water, that * Edinburgh Med. and Surg. Journal, vol. v, p. 53. t Richter, Chirurg. Biblioth., bd. viii, p. 500. X Ueber d. gereizte Muskel. und Nervenfassern, b. ii, p. 208.—Richter. 464 BRONCHOCELE. gives rise to the disease; but there are many facts which appear to me very clearly to show that the origin of the disease is connected with some peculiar condition of the water habitually used in those districts of country where the disease prevails. The account given of a goitrous family near Fort Schuyler, in the State of New York, by Dr. Coventry, demonstrates very conclusively the correctness of this view of the etiology of goitre. This family resided on the banks of a small stream, running through a bed of schist and slaty gravel. It consisted of seven members, all of whom, with but one exception, were affected with bronchocele. They were in the habit of using the water of the brook for all culinary and other purposes. In the spring of 1798, Dr. Coventry settled within three quarters of a mile from this family. " There being no well, and prepossessed with the idea of the hereditary nature of the disease," says Dr. C, " niy family also used the brook-water; when towards the approach of winter, to my no small mortification and vexation, I perceived an evident thick- ening in the necks of my daughters. Then I first began to suspect the water of Regel's creek. The next summer I sunk a well, and since we commenced the use of it, none of my family has been sub- ject to goitre." The goitrous family removed to Onondaga, and be- came entirely freed from the disease.* Dr. Johnson, in relation to the etiology of goitre, observes that " the upper Rhone, where it falls into the lake of Geneva, is turbid, even to whiteness, with the attritus which its tributary Alpine streams carry along; but its waters, while nearly quiescent in the lake, be- come clear, and pass through the city of Geneva like translucent streams of bluish crystal. Among those who inhabit the banks, and drink the waters of the upper or turbid Rhone, there are twenty cretins and goitres for one that can be seen on the banks of the lower or filtered Rhone."! Dr. Coventry seems to think it probable that the substance with which the waters that give rise to this disease is impregnated, consists in aluminous particles. In dry seasons the surface of the schist, after having been acted on by the air, " becomes covered with a white efflorescence, which, on examination, is found to be alum." The material which furnishes the alum manufactured near Glasgow, in Scotland, is found " in the schist rock which forms the sides, bottom, and roof, of an exhausted coal-pit." This observa- * Dr. Coventry adds the following highly interesting facts. " A few years after this, I leased a small house, standing near the brook, to a Mr. Walworth, who had a son about twelve years old. This lad, in the course of a few months, exhibited appearances of bronchocele; he was sent from home, and his neck returned to its natural size; but in the succeeding season began to enlarge, and the family moved away." "About the autumn of 1802, I put a small flock of sheep into a pasture, through which the stream ran; next spring one lamb proved goitrous; the succeeding season every lamb had a swelled neck, and seven out of eight died. My next neighbour had sheep in an adjoining pasture, which was watered by a spring; his sheep had no distemper."—New York Med. and Phys. Journ., June, 1824. t Med. Chir. Rev., April, 1825, p. 443. BRONCHOCELE. 465 tion receives support, by the fact, that in certain districts in Europe, where alum is extensively manufactured, although elevated and dry, bronchocele is extremely common. (Iphofen.) Whatever may be the remote cause of goitre, Dr. Gibson thinks, that " the disease arises immediately from an obstruction of the tra- chea-thyroidal passages of Borden—of the openings communicating with the sacculus laryngeus and the thyroid and of other passages with which we are unacquainted." " I am inclined," he says, " to draw this conclusion from the circumstance of a watery fluid being found to occupy naturally the cells of the thyroid gland—from this fluid being increased in quantity in almost every goitrous tumour— and from the passages of Borden being much smaller in the first dis- section I made of bronchocele than they are usually met with in sub- jects without such disease. This is a mere conjecture ; neither is it original—but was advanced by one ofthe older writers on surgery." (Loc. cit., p. 65.) Treatment.—Since the discovery of the extraordinary remedial powers of iodine'm bronchocele, it is scarcely necessary to pay any attention to the various other means that were formerly resorted to for the cure of this affection; for it can hardly be presumed, that where the judicious employment of iodine fails, there can be any par- ticular advantage obtained from any other remedies at present known. Although but a few years have elapsed since this remedy has become generally known to the profession, a very great number of instances of its successful employment in this affection have been reported. Dr. Manson has given a tabular statement of 116 cases of bronchocele treated by this article; and of this number, seventy-seven were com- pletely cured, eleven much relieved, and but two not relieved; the remainder were discharged for non-attendance, or remained, improv- ing under the treatment.* Dr. Manson used the iodine both internally, and externally in the form of a liniment,t rubbed into the tumour. In individuals of a very irritable or plethoric habit of body, or where the stomach and bowels are in a deranged condition, the free and protracted internal employment of iodine will sometimes give rise to various unpleasant symptoms, such as " headache, giddiness,sickness at the stomach, with some degree of nausea, languor and inaptitude for exertion." By suspending the use of the medicine for three or four days, these affections, in general, soon disappear. Where the inconveniences occasioned by the iodine are moderate, it will be suffi- cient to exhibit it in diminished doses. It is evident, however, from the experience of Dr. Manson and others, that the tendency of this article to produce unpleasant effects, has been much exaggerated by some writers. Dr. M. states that no inconvenience resulted from the internal use of this article, in any of the cases in which he employed it; but on the contrary, it generally appeared to produce a cordial * Medical Researches on the Effects of Iodine in Bronchocele. t fi.—Liniment, sapon. gi. Tinct. iodii 3b—Misce. This was rubbed into the tumour once, and in some cases twice daily. VOL. II.—31 466 BRONCHOCELE. and tonic effect, unless it was given in too large a dose. <: Patients generally found themselves in better health and spirits after a course of treatment with the iodine, than they had previously been for years; and this observation applies not only to those who laboured under bronchocele, but also to those who laboured under other diseases in which iodine was exhibited." I have used this medicine in perhaps twenty cases of different diseases, both internally and externally in full doses, continued in some instances for six or eight weeks, without having ever observed any unpleasant consequences to result from its operation. It cannot be doubted, however, that in certain habits of body, it may give rise to unpleasant and even injurious effects; but this may be said, with equal justice, of every important article ofthe materia medica. Dr. Kolley, in a very interesting memoir on the medicinal powers of iodine, observes, as the result of his experience, that iodine is incomparably the most powerful remedy in goitre which has yet been discovered; but in order to employ it successfully, it is necessary: 1, that the disease be confined to the thyroid gland; 2, that the tumour be devoid of a scirrhous or sarcomatous character; 3, that the disease be not inveterate, or of very long standing; 4, that the general health be not particularly deranged or impaired; and 5, that the goitrous tumour be free from inflammation. Where these conditions are not present, the iodine will almost invariably effect a cure. It would appear, that in general this remedy is most apt to give rise to unfavourable effects, where there is a tendency to conges- tions of the head and of other internal organs ; and Dr. Kolley ob- serves, that individuals of a robust, muscular, and what is usually termed atrabilious habit, do not, in general, bear the action of iodine without more or less inconvenience—particularly when unaccom- panied by the use of laxatives. " In such constitutions, the tendency to local congestion increases; the head becomes confused, and cepha- lalgia often rises to such an extent as to threaten delirium." A de- ranged state of the digestive organs, all local inflammatory affections, diarrhoea, and phthisis pulmonalis, are unfavourable to the beneficial operation of this remedy.* In general, the external application of the iodine in the form of an ointment, or liniment, will procure all the benefit that can be derived from this remedy in goitre. Mr. Coindet has entirely left off its internal employment, and recommends frictions on the tumour with the following ointment.t Internally, ten drops of a tincture made by dissolving forty-eight grains of the iodine in an ounce of alcohol may be given twice daily. Of the various other remedies that have been particularly recom- mended for the cure of bronchocele, it will be sufficient merely to * Reflexions et Observations sur l'Emploie de l'lode en Medecine. Par le Docteur Kolley. f R.—Hydriod. potasses 9 ii. Axungiae §iss. Liq. potassae caust. gr. iv. Ft. ungt. BRONCHOCELE. 467 mention the following: Burned sponge ; this article, no doubt, owes its remedial powers, in this affection, to the small portion of iodine it contains. It is given in doses of from a scruple to a drachm daily, and will occasionally remove goitrous tumours. Calcined egg shells ; the external application of sea water, (Lieutaud ;) hepar sulphuris, (Selle, Fodere;) the vinegar of squills; kermes mineral; belladonna; and especially, conium maculatum; digitalis; burned boletus sua- veolens, in union with small portions of muriate of soda and lime; the muriate of barytes ; and the different preparations of mercury and antimony. Externally, repeated blistering; frictions with stimulating liniments; mercurial ointment; various stimulating plas- ters ; cataplasms, or bags of emollient herbs, applied over the tumour; and compression; have all been recommended, and occasionally used with advantage in this affection. In some cases, however, the disease bids defiance to the powers of medicine, and the tumour goes on increasing until it becomes so large as to endanger suffocation, or some other fatal consequences. Jn instances of this obstinate and dangerous character, the passage of a seton through the tumour appears to promise more success than any other mode of treatment. Dr. Quadri has published an interest- ing memoir on the treatment of this affection by setons ;* and Mr. Copeland Hutchinson has adopted this practice with complete suc- cess t "He passed a long and narrow seton needle, armed with half a skein of silk thread, obliquely through the substance of the gland from the left lobe upwards, leaving a space of nearly two inches from the entrance and escape of the instrument." Mr. Hutchinson refers, also, to a case successfully treated in this way, by Mr. Thomp- son, and to another one by Mr. James, of Exeter and Devon Hospital. An instance of the successful use ofthe seton by Mr. Lyford, is related in the Med. Chir Rev. for July, 18274 . . Extirpation has also been resorted to, and, it is said, in a tew * Medico-Chirurg. Transact., vol. x. t Medico-Chir. Rev., March, 1822. X TThe seton sometimes produces excessive inflammation of the tumour, and has been followed by fatal results. It is chiefly in cases of hydro-bronchocele, or hydrocele ofthe neck, that setons and stimulating injections have proved service- able I have met with more decided success, however, from free incisions and the subsequent introduction of lunar caustic into the cavity of these cysts so as to excite discharges of pus and the growth of granulations. I have repeatedly ex- tirpated large tumours, both encysted and sarcomatous, from the thyroid with suc- cess. In one case I removed the entire enlarged gland and saved the patient from suffocation thereby. When the gland is ^^^T^^l^l reasonably expect to disperse the swelling by jud^ous ^^^^1 employed. But surgical remedies will be required when any actual disorgamza- Tn has taken place. The diagnosis is always sufficiently easy. The expe- ^pmSlr will not confound the hard irregular lobulated masses which Tu,e re ^01 degenerations ofthe thyroid gland, with the smooth and uniform rountd: tumours, unaccompanied with any change m the colour of the skin, and in which mere fleshy hypertrophia is perceptible.-Mc] 468 SCURVY. instances with success. Fodere refers to some cases where tumours of this kind were removed by excision; and Dr. Harris has given an account of two instances of the successful extirpation of bron- chocele. It must be observed, however, that this operation is always attended with much danger; and many cases might be collected from writers, in which the attempt to extirpate bronchocele was followed by fatal hemorrhage, or some other disastrous consequences. There is another operation which has been performed with more or less advantage by several surgeons—the tying up the thyroid arteries. The operation was first performed by Mr. Blizard, of London. The tumour, in the instance he relates, diminished one- third in size, in the course of a week after the operation ; but an attack of hospital gangrene, followed by repeated secondary hemorrhages, finally destroyed the patient's life. Dr. Jameson, of Baltimore, also took up the superior left thyroid artery in an inveterate case of goitre, with the effect of considerably diminishing the size of the tumour; and other instances of this operation, attended with still more decided success, have been recorded. CHAPTER X. CHRONIC DISORDERS OF THE ASSIMILATIVE FUNCTIONS. Sect. I.—Scorbutus—Scurvy. Scurvy does not appear to have been much observed until about the middle of the sixteenth century. Soon after that period, however, it became an object of particular attention, and in conformity with the prevailing notions concerning the agency of morbid humours in the production of diseases, almost all chronic affections—gout, rheumatism, hypochondriasis, and particularly cutaneous affections, were ascribed to a scorbutic disposition and acrimony of the blood. Masked scurvy was supposed to be present in almost every variety of acute and chronic disease; and there has perhaps never been an opinion in pathology which has been carried to so injurious an extent as the doctrine of a latent scorbutic humoral diathesis.* At present, however, the term is properly restricted to a peculiar form of the disease, which is undoubtedly connected with a morbid condition of the blood, arising from a want of proper nourishment, or other causes tending to derange the assimilating functions. This af- fection seldom occurs in its more aggravated form, except among sea- men ; although slight, and occasionally even very severe, cases are met with in individuals, deprived of wholesome nourishment and a pure air, who have always resided on shore. * Richter, Specielle Therapie, bd. p. 795. SCURVY. 469 Symptoms.—The disease commences with an unusual degree of lassitude and want of muscular energy; a feeling of stiffness of the knees and feet is experienced, attended with depressed spirits, and a great disinclination to corporeal exertions. The muscular weakness gradually increases, and the respiration becomes short and panting on the slightest bodily exertions. The countenance exhibits a pale and sallow, or lead-coloured and bloated appearance; the skin is dry, and sometimes peculiarly tense and shining, and separates in small scales on different parts ofthe body. Sooner or later, brown or livid spots make their appearance on the surface, generally first on the legs, then on the thighs, and last on the arms and abdomen, but they very rarely appear on the face. In connection with the appearance of these maculae, oedematous swellings ofthe feet and legs occur; and in hot climates, extensive anasarcous effusions sometimes ensue, without any of the ordinary scorbutic blotches. Simultaneously with the oc- currence of the spots on the skin, and in many instances at an earlier period, the breath becomes fetid, and the gums tender and spongy, and extremely apt to bleed on being even lightly touched. The pa- tient complains of a putrid taste, and usually expresses a strong desire for fresh vegetable food and acids. The urine is turbid and dark- coloured; the vision becomes more or less impaired; and the muscular powers so prostrated, that the patient can scarcely maintain,the erect position. The blood is thick, dissolved, and very dark; the pulse weak and soft. As the disease advances, stiffness of the joints and indurations in the muscles occur, accompanied with severe pains in the thighs, back, and loins, particularly in the knees; and the patient, at times, experiences violent spasmodic or flatulent pains in the bowels, attended with retraction of the umbilicus, and constipation. The respiration is constantly more or less oppressed; subcuticular extravasations of blood appear on the extremities, and occasionally on other parts of the body; and passive hemorrhages occur from the gums, nose, rectum, bladder, &c, at the same time that ulcers are formed on the calves ofthe legs and thighs, exhibiting an oedematous and flabby appearance, with irregular and bloody edges, and discharg- ing a red ichorous fluid. The gums separate from the teeth and slough, and the teeth become loose in their sockets and often drop out; old and cicatrized wounds re-open; the bones become brittle, and syncope occurs on slight corporeal exertions. If the disease continues un- checked in its progress, extreme prostration at last ensues; respiration becomes exceedingly anxious, fatiguing, and oppressed; syncope, even while the patient is at rest, or merely by turning himself in bed, occurs frequently; a cadaverous or fetid effluvium exhales from the body; emaciation goes on rapidly, and in some instances paralysis of one or more extremities ensues, or extensive dropsical effusions, jaundice, diarrhoea, or dysenteric discharges, and finally a rapidly exhausting irritative fever, or coma and convulsions, close the scene. The duration of scurvy is, in general, protracted ; but there never- theless occurs a very considerable diversity in this respect. In violent instances of the disease, where its progress is favoured by previous habits of living or, perhaps, by a peculiar constitutional predisposition, 470 SCURVY. the disease sometimes acquires great severity in the course of a few weeks. This, however, is rarely the case with land scurvy—the most rapid and Yatal instances usually occurring on board of ships while at sea. Land scurvy very rarely appears in the violent form described above. In many instances it continues for a long while, with no other symptoms than languor, a fetid breath, spongy and hemorrhagic gums, and brownish spots on the legs, with slight oedema ofthe feet, and a pale and puffy countenance—the patient being all the while able to be up and about. Sometimes it shows itself chiefly by blotches of extravasated blood on the inferior extremities, and foul and bleeding ulcers on different parts of the body, with spongy and tender gums. Post-mortem phenomena.—The different cavities ofthe body gene- rally contain an abundance of serous fluid, mixed, in many instances, with more or less blood. The mucous membrane and surface of the viscera commonly exhibit dark and apparently gangrenous spots; and blood is found extravasated in different parts of the cellular tissue, under the membranes, and sometimes into the alimentary canal, the lungs, and even into the abdomen. The heart is flaccid and pale ; the spleen soft, and turgid with dissolved blood; the muscles livid, and often so soft, that they may be easily broken down between the fingers. The bones are usually very brittle, or preternaturally soft— particularly the epiphyses, which may sometimes be separated from the bones with great ease. The blood is universally found in a dis- solved state, and very black. Causes.—Persons of a debilitated and phlegmatic habit of body, with a disposition to obesity, are said to be most subject to this disease. The exciting causes are: the habitual use of innutritious, unwholesome, or an exclusive salt animal or vegetable diet, more especially when conjoined with much fatiguing labour, and exposure to a damp and impure atmosphere. Anxiety of mind, with a se- dentary mode of life, and the habitual intemperate use of spirituous liquors, contribute also very considerably to the production of scurvy. Damp and impure air, however, in conjunction with a vitiated or exclusive salt animal diet, is by far the most common source of this malady, whether it originate on land oA on sea. In relation to the essential nature or proximate cause of scurvy, pathologists have expressed a variety of opinions. That the blood exhibits a morbid condition, is unquestionable; but whether this state of the humours is primary or secondary, in reference to the occur- rence of the disease, has been a subject of much controversy. Lind, Milman, Sprengel and Dreysig contend that scurvy consists essen- tially in a weakened and relaxed state of the solids, of which the changes which occur in the blood are mere consequences. On the other hand, Hoffman, Trotter, Jackson, Cullen, and some later writers, consider a putrescent or morbid state of the blood as the primary and essential condition upon which the debility and relaxation ofthe solids and the other characteristic phenomena of scorbutic affections, more or less directly depend. From a view of the nature ofthe most com- mon and powerful remote causes of this disease—namely, unwhole- SCURVY. 471 some, innutritious, and especially an exclusive salt animal diet, the idea of its dependence on a deranged or vitiated state of the blood appears very plausible ; and the more so, as we know that the chyle, and, we may presume, the blood, also, are manifestly modified, accord- ing to the nature ofthe aliment used. The circumstance, too, that a scurvy which occurs while the individual is confined to a particular kind of diet, almost invariably soon begins to disappear when the aliment is changed, argues directly and,strongly in favour of its hu- moral origin. It is nevertheless most probable, that the fundamental affection consists in a deranged condition of the chylopoietic functions and ofthe process of sanguification; for it can scarcely be admitted, that any considerable change could occur in the composition of the blood, without a previous derangement of the functions that are more immediately concerned in the elaboration of this fluid. That the mor- bid condition of the blood, resulting from a disordered action of the functions just named, has a direct, and perhaps a principal share in the production and support of the characteristic phenomena of the disease, cannot, I think, be doubted ; for an intimate depravation of the general mass of the blood, from whatever cause it may arise, must, one may suppose, necessarily give rise to a universal morbid condition of the organization—more especially to the reproductive or vegetative functions of the system. Prognosis.—In general, the prognosis in scurvy is not very unfa- vourable ; and in the ordinary cases of the disease, manifestly the result of some peculiar and exclusive aliment, it very rarely resists an appropriate change of regimen. Indeed, it is surprising how rapidly even very aggravated instances contracted at sea, will often disappear as soon as the. patient is put on shore, or is allowed a fresh vegetable and acescent diet. In severe cases, however, the influence of the land air is occasionally, though indeed very rarely, manifestly injurious, and greatly hastens the progress of the malady. (Richter.) After the disease has continued until symptoms of extreme prostration and universal depravation of the solids and fluids are induced, such as great difficulty of respiration, frequent syncope, and sloughing ofthe gums, with extensive oedema, or dropsical effusions, there is but little advantage to be expected from any mode of management. When the disease occurs in persons of a gouty habit of body, or is complicated with syphilis, the prognosis is always to be regarded as unfavourable; and a broken-down constitution, by the frequent use of mercury, is also particularly calculated to enhance the obstinacy and dangerous consequences ofthe malady. Treatment.—The first and most important part of the remedial management of scurvy is the removal of the causes which produced the disease. When it is the result of impure diet, and a vitiated and damp air, more wholesome food and a purer atmosphere are indis- pensable. The scurvy which occurs at sea, is almost universally the consequence ofthe exclusive and long-continued use of salt animal food and of bad and impure water; and hence cases of this kind almost always disappear very speedily, as soon as the patient is-put upon the use of fresh vegetable and animal food, and vegetable acid 472 SCURVY. drinks—such as lemon juice and good vinegar. The employment of acids of this kind, particularly the lemon juice, is one of the most effectual means for preventing or arresting the progress of this affec- tion, when it arises from the use of old and salted meats. It appears, however, that vegetable acids are not so universally beneficial in this affection as has been supposed. An interesting account of the total failure of lemon juice in arresting the progress of scurvy on board of the British ship Leander, is given in the Med. Chir. Rev., for June, 1824.* After this acid had been fully tried, without the least benefit, the disease was quickly vanquished, by the free use of fresh animal food, in conjunction with vegetables. Dr. Bampfield, also, in his work on tropical dysentery, speaks of the great benefit which may sometimes be derived from fresh animal food, in sea scurvy. In gene- ral, however, a mixed diet, composed of fresh animal and vegetable articles of food, is the most salutary in scurvy arising from the ex- clusive use of old and salted meats, or of unwholesome, coarse, and oily aliment. There are certain vegetables, which experience has shown to be especially beneficial in this affection; and they should undoubtedly be used whenever they can be had. The principal of these are ; horseradish ; scurvy-grass, garden-cresses, water-cresses, garlic, onions, the fruit of cloud-berries, lettuce, celery, endive, spi- nage, carrots, cabbage, oranges, mustard, and all kinds of acid fruits. Of all these vegetable substances, however, cabbage in the form of sour-krout is decidedly the most valuable, both as a preventive and curative means. Fermented liquors, buttermilk, fresh milk, vinegar and water, but especially water acidulated with lime juice and a de- coction of malt, taken freely as common drink, are highly proper beverages in scorbutic affections. Medicinal articles are seldom of very material service in the treatment of scurvy; and without the proper changes in diet already mentioned, they are always wholly ineffectual, and may even prove * " In the year 1822, his majesty's ship Leander sailed from Trincomalee for the Cape of Good Hope, taking on board the mechanics of the dock yard esta- lishment then reduced on the island. There were also embarked twenty-six in- valids, and all the sick that could be removed from the hospital. These invalids and sick were principally affected with chronic hepatitis, dysentery, and phthisis pulmonalis, all of which (even some who were expectorating large quantities of purulent matter), recovered on the passage to the Cape. This good fortune was counterbalanced by scurvy, which broke out among the crew, and, in spite of large quantities of lemon juice plentifully administered, in conjunction with every other antiscorbutic which the ship could produce, spread to an alarming extent, and in one case proved fatal. Had they not reached the Cape at the time they did, the Leander would have presented as deplorable a spectacle as the Anson, at Juan Fernandez, notwithstanding the supposed specific lemon juice, which in no instance on board the Leander had the slightest effect in even checking the ravages of scurvy. Immediately the ship reached the Cape, and the crew got plenty of fresh animal food, in conjunction with vegetables, they rapidly recovered. Specimens of the lemon juice were transmitted to the Victualing Board, and carefully ana- lyzed in London. It was found perfectly good." CHLOROSIS. 473 injurious under the most careful management. Mr. Patterson, how- ever, speaks very favourably of the effects of a solution of nitre in vinegar, in the proportion of four ounces of the former to a quart of the latter—given in doses of from half an ounce to two ounces twice or thrice daily. Mr. Charles Cameron, a naval surgeon to the British Naval Medical Board, has lately published a statement confirming Mr. Patterson's favourable account ofthe effects of nitre in this affec- tion. This disease broke out among the convicts on board the Fer- guson transport, on her passage from Ireland to New South Wales; and threatened by its violence, to exterminate the crew. After em- ploying the usual means with but little success, Mr. Cameron had recourse to nitre and vinegar; and the effects, he says, were highly and promptly beneficial. " The oppression and sinking at the pit of the stomach," which were so distressing to the majority of patients, yielded almost without exception to a few doses of this mixture. "Eight ounces of nitre were dissolved in so much vinegar as would make the solution amount to sixty-four ounces." One ounce of this solution was given at a dose from three to eight times daily.* During the stage of convalescence, some advantage may be derived from tonics, particularly iron, cinchona, calamus aromaticus, cort. aurantior., cort. winteranus,cascarilla, and the mineral acids. Richter mentions the following infusion as often very useful in the treatment of land- scurvy.t An infusion of calamus and Peruvian bark, with the addition of elixir vitriol, is particularly praised by Jahn. Kotrum asserts that he has derived considerable advantage from the use of savin in this affection; and the bark of the betula alba is said to have been very beneficially employed in this affection. As a local application to scorbutic ulcers, whether situated in the mouth or else- where, a strong solution of the muriate of lime will in general answer a very good purpose. Water acidulated with muriatic acid and sweetened with honey, forms an excellent lotion for the gums. A weak solution ofthe sulphate of copper, or of lunar caustic, may also be beneficially employed for this purpose. Sect. II.—Chlorosis.% This disease occurs principally in young, unmarried females, and occasionally also in married women, at various periods of life. It is not, however, exclusively confined to the female sex, for its occur- * Medico-Chir. Rev., Feb., 1830, p. 484. t R-—Rasur. raphan. rustic, giii. Perri. pulverat. Ji. P. rad. rhaei gss. Rad. zingiberis 3H. Vin. alb. generos. Ibii.—M. Stent in infus. per xii horas, cola. Take a teacupful three times daily. X See Dr. Marshall Hall's excellent little work " On the Disorders of the Di- gestive Organs," &c. &c. 474 CHLOROSIS. rence in males, during the period of adolescence, and even at mature age, is sometimes, though indeed but rarely, noticed. Symptoms.—In the commencement of chlorosis, the countenance exhibits a peculiarly pallid appearance, and the lips especially appear to be bloodless with a puffiness of the upper and lower eyelids, and a slight appearance of tumidity of the face. The lower eyelids are often encircled with a streak of a dark or leaden hue, and in some instances the eyelids exhibit a greenish sallow tinge. As the disease slowly proceeds in its course, the whole surface ofthe body becomes very pale, more especially the hands, fingers, and nails, and presents a white, puffy and flabby state, with more or less oedema of the ankles and legs, and an evident tendency to emaciation. The tongue is pale, and covered with a transparent mucus, and exhibits a swollen or bloated appearance, with numerous and enlarged papulae, and the edges indented by the pressure of the teeth. The gums and internal surface of the cheeks also become tumid, and paler than natural, and the breath is generally foul. From the commencement of the disease, much general languor and listlessness prevail, with great indisposi- tion to corporeal or mental exertion. Headache, ringing or noise in the ears, and vertigo are common symptoms, and the energies of the mind are subdued, accompanied, in many instances, with a drowsy, peevish, and spiritless condition. In the more acute cases of chlo- rosis, considerable pain is apt to be experienced in the hypochondriac regions; and in some instances, cough, oppressed respiration, parox- ysms of palpitation of the heart, or partial syncope, " and almost universally a sense of fluttering about the prascordia," are experi- enced by the patient. The appetite is usually weak; but in many instances there is a distressing morbid craving for particular articles, particularly for acids and absorbent earths, as magnesia, chalk, or even clay. The bowels are generally torpid, with occasional tran- sient attacks of diarrhoea and griping—the feces usually presenting a very unnatural appearance, with thick and sedimentous urine. The catamenial function always becomes early deranged, and in many cases the menses are suppressed before the occurrence of the chlorotic symptoms. When the disease continues until it becomes confirmed, the counte- nance acquires a still more pallid, bloodless, and puffy appearance ; the prolabia assume a pale lilac hue, and the skin becomes smooth, dry, puffy, and of a singularly pale yellowish colour. By degrees the tongue acquires a clean and smooth surface, and exhibits a peculiar, semitransparent, exsanguious, and pale lilac appearance. The general languor and debility increase, and the occasional attacks of pain in the head and side become more severe. In this confirmed stage of the complaint, the morbid cravings of the stomach are often peculiarly strong and singular. The patient experiences an indomi- table desire for certain indigestible substances, such as chalk, cinders, sand, coffee-grounds, tea-leaves, flour, clay, &c. The catamenia, if they have not previously ceased, are attended with pain, and become pale, smaller in quantity, and usually terminate in more or less pro- CHLOROSIS. 475 fuse leucorrhcea, where this affection does not precede or accompany the chlorotic disease in its course from its commencement. In inveterate cases of chlorosis, emaciation goes on slowly but progressively. The muscular debility is extreme; the oedema in- creases, and acquires the form of anasarca; the pulse is very small, frequent, and in many instances, quick and corded ; the confusion and pains in the head are more permanent; the mind extremely excitable, or unusually torpid and sluggish ; and the attacks of dysp- noea and palpitation of the heart become more frequent and distress- ing. Sometimes diarrhoea ensues—the matter discharged exhibiting a dark, or even black appearance, resembling in all respects the eva- cuations of melaena. In cases of a more chronic character, " there is a continued though variable state of sallowness, of yellowness, or icterode hue, of dark- ness, or of a wan,^squalid, or sordid paleness of complexion, or a ring of darkness surrounding the eyes, and extending a little perhaps towards the temples and cheeks, and sometimes encircling the mouth, without tumidity as well as without the pallidness of the prolabia already mentioned." In the severer cases of chronic chlorosis, the nails are apt to become deformed in a peculiar manner, sinking down in the middle, and breaking off in brittle laminae on the anterior margin. The tongue, in such instances, (chronic chlorosis,) exhibits various appearances. In general it is clean, moist, often of a bright red, and sometimes of a light green or pale lilac colour, with a smooth, shining, or a granulated raw appearance of the sur- face, sometimes divided into lobules by deep creases, and at others bloated and indented along the margin by the pressure of the teeth. The blood in chlorosis is usually attenuated, the relative propor- tion of the crassamentum, or red part, being invariably less than natural. (Hall.) Chlorosis is peculiarly liable to frequent changes and exacerbations of its symptoms. Dr. Hall observes that he has often observed " an eruption of urticaria, in very large, elevated wheals, sometimes soli- tary, and at others in considerable numbers, in chlorotic patients." Diagnosis.—Chlorosis is liable to be confounded with certain forms of insidious organic disease. From disorders of this kind, however, we may in general distinguish chlorotic affections, without much dif- ficulty, by the following circumstances. The pallid countenance of organic diseases is usually attended, at times, with a slight flush of the cheeks; and the prolabia are free from that peculiar bloodless and semitransparent pallidness or lilac hue, which is so characteristic of chlorosis. The countenance, too, is generally expressive of pain and suffering in organic diseases, which is seldom met with in chlorosis, except in the latter periods of aggravated cases; and the whole sur- face of the body remains either nearly in a natural state, or becomes slightly icterode, whilst emaciation usually commences early and proceeds rapidly. From chronic disease of the liver, with which chlorosis is most apt to be confounded, we may distinguish it, by the icteric appearance of the conjunctiva, and of the surface generally, as well as the clay-coloured feces, the bilious urine, and the usual 476 CHLOROSIS. tenderness and fullness of the right hypochondrium, which occur in organic hepatic affections. Causes.—A sedentary and confined habit of life, more especially when assisted by impure or stagnant air, is a common and powerful cause of chlorosis. " The mimosis decolor," (chlorosis,) says Dr. Hall, " is the prevailing affection of those females who, in manufacturing towns, are doomed to sit from morning till evening, at the lace-frame, or the tambour, or engaged in mending, seaming, chevening," &c. Unwholesome and indigestible diet, particularly when accompanied with indolence, want of cleanliness, and want of exercise in the open air, is especially calculated to produce this disease. Too long lacta- tion ; frequent hemorrhages; protracted or long-continued menor- rhagia; leucorrhoea ; the depressing mental affections; long-continued and exhausting labour; and unsatisfied sexual desires; are not un- frequently the source of chlorotic affections. There are few circum- stances, probably, more frequently concerned in the production of this disease, than chronic intestinal irritation ; and consequent derangement of the digestive functions. A torpid and loaded state of the bowels, in young females, when co-operating with one or more of the above- named causes, rarely fails to give rise to more or less of a chlorotic condition. Chlorosis sometimes occurs apparently in consequence of the tardy, or non-appearance of the menses, after the sexual or- ganization is fully developed, and the same occasionally results from suppressed menstruation in females of a delicate and leucophlegmatic habit of body. Occasionally, however, the disease comes on gradually, while the menses are regular, without any obvious exciting cause ; but in instances of this kind, the bowels will generally be found, on inquiry, to be torpid, and the appetite variable and disordered. Treatment.—Little or no benefit can be derived from remedial treatment, so long as the exciting causes continue to act on the pa- tient. These, therefore, must be obviated as early and effectually as possible. If the disease be contracted under the influence of a sedentary habit, and an impure or confined air, regular exercise in the open air will be indispensable to the removal of the malad»y. If deficient and unwholesome nutriment has contributed to the production of the disease, the use of a more pure and nourishing diet is necessary. Where grief and despondency have exercised an injurious influence in this respect, efforts must be made to dissipate the mental depression, by proper society, travel, and conversation. In the majority of cases, conspicuous symptoms of a loaded or other- wise disordered state of the alimentary canal are present; and to these symptoms of intestinal derangement it is particularly important to pay immediate and especial attention. Dr. Hamilton has laid great stress on the value of purgatives in the cure of chlorosis, and although his estimate of their usefulness is undoubtedly too favourable, it must be admitted, that under judicious management, they are generally de- cidedly beneficial, and in many cases perhaps absolutely indispensable to successful treatment. Where the abdomen is tumid and tense, and the bowels torpid, laxatives must be employed until the accumulated feculent matter has been thoroughly evacuated. It is to be particu- CHLOROSIS. 477 larly observed, however, that active cathartics, or such as excite copious liquid stools, are calculated to do much mischief. Two or three consistent or soft alvine evacuations in the course of twenty-four hours, will be sufficient to procure all the advantages that can be de- rived from aperients, without the risk of doing injury by increasing the debility, or exciting permanent intestinal irritation. Moderate doses of aloetic aperients are, I think, decidedly the best remedies for thi« purpose. From three to four grains of rhubarb, in union with one or two grains of aloes, taken in the evening, will in general pro- cure one or more full and consistent evacuations on the following morning; and this dose may be given every third or fourth evening, until there is reason to believe that the bowels have, been freed ot their vitiated and accumulated contents. As the liver almost in- variably partakes of the morbid excitement of the alimentary cana , it will be proper from time to time to exhibit small doses of blue pill or calomel. Dr. Hall recommends the administration of five grains of the latter article once everv week, or every ten or fourteen days, according to the degree of hepatic derangement indicated by the symptoms; whilst « on the intermediate days, a sufficient consistent alvine evacuation must be procured, by pills of aloes and rhubarb, or by infusion of senna, with sulphate of magnesia." In the use ot mercury, the utmost caution is necessary to prevent a general mercu- rial impression on the system, the object in employing it being solely to correct the hepatic and intestinal secretions. Where the disease continues, until diarrhoea, with small, unnatural and fetid discharges occur, small doses of blue pill, in union with ipecacuanha and the extract of hyoscyamus, will in general afford much benefit. A grain of the blue mass, with two grains of ipecacuanha and one grain ot the hyoscyamus, may be given every night on going to bed. I have known this combination to produce the happiest effects in an instance attended with such symptoms. Dr. Hall has obtained very good effects from the conjoined employment of opium and blue pifl, in cases attended with diarrhoea. If opiates are indicated, Dover si powder will in general do more good than any other preparation of this "^conjunction with the use of remedies calculated to correct the henatic3 intestinal functions, it is particularly important to regu ate tldiet o'he^patient. The aliment should be simple, nourishing, and of the nW digestible kind. In the commencement, before the bowels have been adequately evacuated, the more nourishing kinds of flnna'ceous fluids an'd light broths should be used sucnas pre pa a tinns of harlev rice, arrow-root, oatmeal, &c; but after the accumu d feces'hale been removed and the hepatic.and ~ -£ tions in some degree corrected ^«^ 6»d^'X^fnl jean parts of mntton amb vem on( and very^ ^ ^ ^ boiled fowl, with stale Dreao^or , e a|1 ^ dSc ^e'r.aidTwn Srt^ment of the first stage of in- digestion. 478 CHLOROSIS. The enjoyment of a pure country air, and regular exercise by gestation, are powerful auxiliaries in the treatment of this affection ; and along with an appropriate diet and gentle aperients, are generally adequate, without any other means, to restore the health of the pa- tient. After the system has regained some degree of vigour, advan- tage may be obtained from sea-bathing; but this will seldom be admissible until convalescence has already considerably advanced. At an earlier period, however, " sponging the body with cold water, or with vinegar and water," or the tepid shower-bath in summer, will often do much good; but even these applications cannot be freely used with propriety, where the powers of vital resistance are greatly reduced. Dr. Marshall Hall does not seem to entertain a favourable opinion of tonics administered internally, with the exception of iron, which he thinks may be used with some advantage. After due alvine evacuations, and an amendment of the intestinal and hepatic secre- tions have been effected, by the cautious use of aperients and mercury, I am disposed to ascribe very considerable importance to the internal employment of tonics. When early employed, and in large doses, previous to the preparations just mentioned, they are, no doubt, well calculated to do mischief, and at all events, can rarely prove in any degree beneficial. Iron is the best tonic we possess in chlorotic affec- tions. No preparation of iron has appeared to me so useful in dis- eases of this kind as the black sulphuret of this metal. From eight to ten grains may be given three times daily. Its peculiar usefulness would seem to depend on the tendency which it generally manifests to excite a moderate diaphoresis, in conjunction with the ordinary tonic powers of the ferruginous remedies. The tartrate of iron, too, is a valuable tonic, on account of its tendency to keep up a regu- lar action of the bowels—so contrary to all the other preparations of this metal. From a scruple to two of the tartrate may be given twice or thrice daily, dissolved in some sweetened water. The phosphate and carbonate are so apt to give rise to constipation, that they are, in general, objectionable on this account, unless diarrhoea be present, when they may be appropriately used. Richter observes, that after the exciting cause has been obviated, and the alimentary canal suffi- ciently evacuated, the following combination " cannot be too highly recommended."* Where the digestive powers are much debili- tated, we may administer the iron in union with some of the tonic vegetable bitters with peculiar advantage.! Among the Germans, * R.—P. lig. quassia;, Sacch. alb., aa ^i. Flor. martialis gr. x.—M. Divide into twenty-four equal parts. S. Take one every four hours. This mixture, he says, possesses the advantage of not being liable to cause constipation. t R.—Ferri phosphat. 3b Pulv. cort. aurant. sjiii.—M. Divide into ten equal parts. Give one three times daily. GONORRHOEA. 479 Wieckart's pills* have been highly recommended in obstinate cases of chlorosis. Kopp declares that he has employed them with great success in this affection. The chalybeate mineral waters are espe- cially beneficial in chlorotic cases. The use of the ferruginous reme- dies should be continued until the health of the patient is completely restored. The clothing should be sufficiently warm to favour the regular action of the skin; and the influence of damp and inclement weather must be carefully avoided. Dr. Bland says: « The real cause of chlorosis, under all its Protean forms, is a vicious and imperfect sanguification; the blood being defective in crassamentum and co- louring matter, and in consequence becoming less capable of imparting functional energy to the body. In some cases severe gastrodyma attends not to be relieved by ordinary remedies. Occasionally fre- quent attacks of asthma, sometimes excruciating headaches, murmur- ins noise in the head, and symptoms of diseased heart." Dr Bland considers iron as among the very best remedies. He thinks that it is not, generally, given in sufficient doses to derive the benefit which it is capable of affording. His favourite formula is thus: R.—Ferri sulphat, Potassa? subcarb., aa gss.—M. In pil. forty-eight dividend. The dose, at first, is one pill night and morning, to be increased gra- dually in a fortnight to four pills morning, noon and night.—(Revue Mtdicale.) CHAPTER XI. CHRONIC DISEASES OP THE SEXUAL ORGANS. Sect. I.—Gonorrhoea. A running or discharge of purulent matter from the urethra has befn noticed as a loathsome affection « by successive authors, from the earliest periods in which we have any medical records," but it wasnoconsidered as having any essential connection with syphilis until upwards of half a century after the introduction of this latter iseLeK Europe. Since that period, the relation subsisting be- Iween the^eiwo affections has been a subject of much controversy; * R.—G. aloes socc. 3b Ferri. pulver. Qii. Sulph. antimon. aurant. 3ss. Submur. hydr-Bi. 01. sabin. xx. Syrup, cort. aurant. q. s. Ut fiant pib gr. iii- Take two every evening. 480 GONORRHOEA. but the general opinion at present is, that they are radically distinct, each depending on its own specific virus, although some eminent physicians still contend for their identity. The experiments of John Hunter, which appeared to prove that gonorrhceal matter is capable of forming chancre, and, on the contrary, that matter taken from a chancre, when brought in contact with the urethra, will form gonor- rhoea, have been contradicted by various experimenters—more espe- cially by Mr. Benjamin Bell; and the very frequent occurrence of gonorrhoea, where of course the virus is largely and constantly applied to the glans penis, without the appearance of chancre, is strongly opposed to the opinion of their specific identity. It must, indeed, be admitted, that chancre and gonorrhoea frequently appear together, but where this is the case, there can exist but little doubt that the two poisons were communicated either at the same impure venereal intercourse, or at distinct connections. I have lately seen an instance illustrative of this fact. The patient laboured under gonorrhoea of about six weeks' standing: before it was cured he had connection with a woman; and in six days afterwards a genuine excavated syphilitic chancre made its appearance. Gonorrhoea generally comes on in three or four days after an impure connection; but in some instances it appears within the first forty- eight hours, and occasionally not until the expiration of eight or ten days after the application of the virus. At first, a disagreeable itch- ing or pricking sensation is felt in the point of the urethra, passing a short distance up from the orifice, which on examination will be found slightly reddened and somewhat tender. After this sensation has continued for ten or twelve hours, the mouth of the urethra becomes sensibly inflamed and swollen, and a limpid or yellowish matter begins to ooze from it. The stinging and itching increase, and the emission of urine occasions a severe smarting and burning pain in the anterior portion of the urethra. The pain now extends more or less speedily inwards along the urethra; the glans penis becomes swollen, dark red, and tender to the touch, and the dis- charge acquires a yellow-greenish colour, resembling diluted pus. Frequent and very painful erections harass the patient—more espe- cially after he has been some time in bed ; and on passing water, the pain, in some instances, is exceedingly smarting. In many cases the inflammation extends from the mucous membrane of the urethra to the corpus spongiosum, giving rise to much tenderness and hardness of this part, and particularly to a most painful affection called chordee, which consists in strong and protracted erections, whilst, from the inflamed and unyielding state of the corpus spongiosum, the penis is thrown into a curved form, with the frsenum drawn down and the body forced upwards. At this stage small portions of blood are often mixed with the gonorrhceal discharge ; and the prepuce some- times becomes much inflamed, tumid, and slightly excoriated at the edges and in spots on its internal surface. In some instances, one or more of the inguinal glands become inflamed and swollen, and a knotted cord of inflamed lymphatic vessels is felt along the dorsum of the penis. Many patitnts expe- GONORRHOEA. 481 rience a constant aching pain in the glans and body of the penis; and occasionally one or both testicles become tender, inflamed and much swollen, attended with pain along the whole course of the spermatic cord. Considerable symptomatic fever always attends, when the inflammation becomes thus extended from the urethra to the neigh- bouring structures. Not unfrequently the whole track of the urethra becomes inflamed, giving rise to harassing sensations of burning and titillation in the neck of the bladder and anus, and very severe cutting pains in the perineum on making water. The patient, under these circumstances, feels a continual urgency to make water, but from the great tenderness of the neck of the bladder and urethra, only a few scalding drops are voided at a time. When the testicles become inflamed, the gonorrhceal discharge is always sensibly diminished, and in many cases entirely suppressed. Sometimes some of the engorged capillaries of the mucous membrane burst, and more or less of pure blood passes off. After an uncertain period, these in- flammatory symptoms begin to subside. The scalding pain in mak- ing water gradually ceases; the erections become less frequent and painful; and the gonorrhceal matter acquires a greater consistence and becomes white and ropy. The specific inflammation of gonorrhoea is primarily seated in the mucous membrane of the urethra, a short distance above its orifice in the fossa navicularis, and chiefly affects the lacunae mucosae of Morgagni, and their excretory ducts. From this point, however, it often extends higher up the urethra, to the membranous portion, the vera montanum, and neck of the bladder. Sometimes the gonorrhceal matter, in the first instance, does not penetrate the urethra, during impure venereal connection; but being applied to the glans penis, it gives rise to irritation and a discharge of thin purulent matter from the sebaceous glands situated around the corona glandis. Much more commonly, however, the matter discharged from the urethra comes in contact with the internal sur- face of the prepuce and the glans, and causes excoriations of these parts, from which a thin whitish or whey-like fluid is discharged. These excoriations usually appear in the form of irregular patches, leaving interstices of sound skin between them. It would seem, too, that the virus of gonorrhoea, when brought to act on the glans and internal aspect of the prepuce, often produces a peculiar variety of venereal ulcer, of a mild character, exhibiting a smooth, level, and nearly circular surface, slightly raised above the surrounding skin, having a healthy colour, but without granulations and induration, and exhibiting somewhat of a fungous appearance. (Carmichael.) These ulcerations are most commonly seated on the anterior and posterior verge of the prepuce, or beside the frsenum, and generally connected with more or less phimosis. In some instances, gonorrhceal discharge from the urethra is accompanied both by excoriations and ulcers of the kind just mentioned; but more frequently the disease is attended with simple excoriations of the prepuce and glans. Gonorrhoea is sometimes succeeded by constitutional symptoms—and this is most apt to be the case in those instances of the disease that are attended vol. ii.—32 482 GONORRHOEA. with the primary excoriations or ulcers just mentioned. Mr. Travers asserts, that so long as the mucous surface remains sound, or un- broken by excoriation, gonorrhoea is not capable of producing second- ary symptoms.* He contends that the absorption of the virus or matter, is indispensable to the production of constitutional symptoms, and that "the inflammatory secretions of sound surfaces are not absorbed into the system." Experience, it must be admitted, sup- ports the assertion, that secondary constitutional symptoms very rarely occur, except in cases that are attended with primary gonorrhoeal ex- coriations or lesions of the mucous surface from which the discharge occurs; but it admits of much doubt whether such lesions are indis- pensable to the production of secondary symptoms; and still more, whether the assertion that absorption cannot take place from an in- flamed mucous surface, be strictly correct. In some instances, the secondary symptoms of gonorrhoeal sores are almost as strongly marked as those of lues; sometimes'the glands of the groin become much enlarged and indurated. The inflamma- tion in the fauces is usually diffuse and superficial, the surface of the velum palati and uvula being often " roughened with innume- rable small tufts of white lymph, or pitted with small and shallow indentations where ulceration has taken place." Sharp, deep and clean fissures of the tonsils sometimes succeed gonorrhoeal ulcers on the genitals. The cutaneous affection is always mild, consisting of minute papular eruptions, varying from a pale red to a deep crimson colour, which are ushered in by pyrexia and redness, pain and swelling of the joints. These papulae do not come out together, but follow each other in succession. Some of them are simply pimples, while others are almost advanced to the pustular form. These are most numerous, and in some instances almost altogether confined to the parts about the shoulders, arms, and back. The febrile symptoms are transient, and the papular affection usually disappears without difficulty under the use of purgatives, a simple and unirritating diet, antimonials, and an equable and dry air. In women, gonorrhoea is very rarely attended with the painful symptoms that accompany the disease in men. Indeed, in many instances there is so little uneasiness and pain experienced by females from this disease, that the discharge is often regarded as simple fluor albus. It is very remarkable, that gonorrhceal inflammation in females is exceedingly seldom, if ever, extended to the urethra. Swediaur asserts that he has "never seen a woman in whom the disease was seated in the urethra." The orifice of this canal, how- ever, is generally more or less irritated, and in some instances it be- comes so very sensible, that the urine in passing off gives rise to extremely severe pains. The seat of the disease is usually either in the clitoris, round the orifice of the urethra, and on the nymphae in the cavity of the vagina, or at the inferior commissure of the labia and rapha. (Swediaur.) Women affected with gonorrhoea, generally experience a disa- Observations on the Pathology of Venereal Gonorrhoea. GONORRHOEA. 483 greeable itching and titillation about the orifice of the vagina, and at the rapha. In severe cases, the labia, nymphae and clitoris be- come swollen and extremely tender; and there is generally a severe burning and stinging pain felt in voiding the urine. In violent in- stances of the disease, there is a constant aching pain, experienced in the bladder, womb, groins and back; and the upper and inner surface of the thighs often becomes inflamed, excoriated, or covered with an inflamed pustular eruption, from the irritation occasioned by the gonorrhceal discharge. In general, the mucous surface from which the gonorrhoeal matter proceeds, is entirely free from ulceration or excoriation. But this does not appear to be always the case, as was formerly asserted by writers; for, according to the observations of Whately, irregular patches of excoriation, similar to those which appear on the prepuce and glans, sometimes occur on the lining membrane of the urethra. It must be observed, however, that excoriations or ulcers of the mucous membrane of the urethra in this affection, are by no means essential conditions of the disease. It should not be forgotten, that a purulent discharge from the urethra in men, and vagina, in women, resembling in all respects genuine venereal gonorrhoea, may occur without any impure connection or infection, by a specific gonorrhoeal virus. A knowledge of this fact will sometimes enable the physician to allay the most painful sus- picions, and to establish peace and confidence in families divided and distressed by the occurrence of such affections. Mr. Travers has made some very judicious observations on this subject.* An inflam- matory action of the mucous membrane of the vagina, in whatever way it may be produced, will convert the vaginal mucus into a puru- lent or puriform fluid; and it seems to be well ascertained, that such a morbid vaginal secretion is capable, at times, "of communicating the inflammatory irritation to other mucous surfaces either of the same or of another individual." " It is well known," says Mr. Travers, " that a woman affected with inflammatory leucorrhoea, sometimes communicates a discharge to her husband ;" and the origin of puru- lent ophthalmia, in infants, from the same source is equally well ascertained. Treatment.—Gonorrhoea appears to have a natural tendency, if left to itself, to terminate spontaneously. At first, as has already been stated, the matter is thin, and communicates a greenish stain to the linen; but as the inflammation gradually subsides, the discharge be- comes thicker, cream-like, and less abundant; and if the general habit is not phlogistic or irritable, and the patient avoids the influence of stimulating causes, the secretion ofthe gonorrhoeal fluid often gradu- ally diminishes, until, in the course of six or eight weeks, it ceases entirely. There are few individuals, however, who are willing to delay the use of the remedial measures, or who are sufficiently prudent to ab- stain from stimulating ingesta and other causes calculated to keep up * Loc. citat. 4S4 GONORRHOEA. the phlogistic habit ofthe system, to obtain such a favourable result; and in most instances, either from injudicious attempts to arrest the discharge, or from a general inflammatory and irritable diathesis, favoured by stimulating diet and drink, the disease, if it is not sub- dued by an appropriate treatment, degenerates into a chronic urethral discharge, consisting of a milky fluid, usually called gleet. During the inflammatory stage of the complaint, it should be treated strictly as a local inflammatory affection, without any regard to the peculiar nature of the inflammation, or the attending niuco-pururfent discharge. In plethoric habits, particularly where the pulse is hard and active, blood should be freely drawn ; and the inflammatory state of the system must be reduced by the use of internal antiphlogistic remedies. For this purpose, the saline purgatives, nitre, and tartar- ized antimony, are the most useful remedies we possess. Dr. Car- michael is particularly partial to the use of the tartarized antimony, dissolved in a solution of sulphate of magnesia; and when given so as to keep up a slight degree of nausea, and procure four or five alvine evacuations during the day, this combination is, in fact, a highly efficient remedy during the inflammatory period of this complaint.* Nitre and antimony dissolved in a large proportion of some mucila- ginous fluid, such as a solution of gum Arabic, barley-water, or flax- seed tea, is in general very serviceable, as a means for lessening both the scalding of the urine, and the general and local inflammatory action.! In conjunction with these remedies, the patient should drink freely of some bland, mucilaginous fluid. For the relief of the painful erections and chordee, which usually harass the patient, particularly at night in bed, cold applications may be tried; but although occa- sionally beneficial, they frequently procure but very little relief. Warm fomentations, or emollient cataplasms, are more frequently serviceable, in this respect, than cold applications to the part. Opium, given in full doses, is in general a very useful remedy for this purpose ; and its good effects are often considerably enhanced by giving it in union with camphor. From one to two grains of the former to eight or ten grains of camphor, taken an hour before going to bed, will generally prevent the occurrence of these painful affections during the night. Mr. B. Bell strongly recommends the use of camphor and hyoscyamus, as a means for alleviating the sufferings occasioned by chordee. These articles, he says, should be given in large doses. In general, half a drachm of the former, with a scruple of the latter, given in the course of twenty-four hours, will be found sufficient to allay this affection; but in some instances, he gave it to twice this * R.—Sulphat. magnesia? 3jii. Tart, antimonii gr. ii.—M. Take a tablespoonful every two or three hours. t R.—G. Arab. §iss. Nitrat. potassa? 3b Tart, antimonii gr. i. Infos, sem. lini. ^xvi. Of this a wineglassful may be taken every hour. GONORRHOEA. 485 extent in the same period of time.* If bleeding takes place from the urethra, it ought not to be arrested, unless it becomes too copious, which very rarely happens. When it is desired to stop the hemor- rhage, pressure made upon the urethra with the hand for twenty or twenty-five minutes, will almost always suffice to arrest it. Rest and a mild and unirritating diet always contribute very materially to the reduction of the inflammatory symptoms. Much advantage may also be obtained from the application of warm fomentations to the penis, during the inflammatory stage of the complaint. Nothing is more common than the employment of astringent in- jections, almost as soon as the disease commences; and although the discharge may sometimes be speedily arrested in this way, the con- sequences are often extremely injurious. "This practice," says Mr. Carmichael, " is attended with such risk of exciting inflammation of the entire urethra and bladder, and all the immediate, as well as the secondary train of evils attendant upon this calamity, that I have no hesitation in saying, that it is a practice that cannot be too strongly deprecated." As soon as the general and local inflammatory symptoms are in some degree reduced, and the discharge has become thick and more purulent, balsam copaiva, cubebs, or what are called the terebinthi- nate remedies, must be resorted to. Almost all writers agree in giving a preference to the balsam copaiva, as a remedy in this affection; and when given in large doses, it will, in fact, more frequently put a stop to the disease than any other article we possess. To obtain the full advantages which it is capable of affording, it should be given in as large doses as the stomach will bear. The following is an excel- lent formula for administering this article.! Balsam copaiva may be safely and beneficially administered in this affection, where the general habit is not very irritable or phlogis- tic, even though the local inflammation may still remain in an active state. I have often given it in the beginning of the disease, as soon as the bowels were freely evacuated by a saline cathartic, with com- plete success. Indeed, many eminent practitioners do not hesitate to administer it in large doses, soon after the commencement ofthe disease; and where the inflammation is not particularly violent, and the general arterial system does not sympathize with the local affection, it may be em- ployed with advantage. Dr. Johnson observes, that according to his experience, this article " may be safely administered in drachm doses, during the inflammatory stage of the disease, and with palpable suc- cess. Under such a treatment, incipient gonorrhoea has ceased in two or three days." * Edinb. Journal of Medical Science, No. 1, January. 1826. t R.—Bals. copaiv. §i. Spir. nit. dulc. gss. Tinct. opii, Spirit, camphors, aa 31.—M. Of this a teaspoonful should be taken four times daily. 486 GONORRHOEA. Cubebs, also, are an excellent remedy in gonorrhoea. They are, however, much more stimulating than the preceding article, and must be given with more caution during the inflammatory stage of the disease. Mr. Jeffries states, that where cubebs are serviceable, they usually begin to manifest their beneficial influence within forty- eight hours after the first dose ; and where no material relief is ob- tained in the course of five or six days, their further use will rarely be attended with advantage.* This remedy appears to be most apt to do good in relaxed and leucophlegmatic habits; and in order to derive the full advantage which it is capable of affording, it should be given in large doses. From six to eight drachms of the powdered cubebs may be given in the course of twenty-four hours, where the inflammatory action of the affected parts has been previously consi- derably reduced. The tincture is an excellent mode of administering the cubebs. I usually direct a large teaspoonful of it every four hours. Much more commonly, however, I have given it in combination with balsam copaiva, according to the following formula.! In cases entirely free from general irritation, and inclining to a chronic character, I have often united the balsam copaiva, cubebs, and spirits of turpentine, with peculiar advantage; and in gleet, I know of no remedy which so frequently succeeds in making a decid- edly favourable impression on the disease as the tincture of cubebs in union with the spirits of turpentine, in the proportion of two parts of the former to one of the latter, given in teaspoonful doses, three or four times daily. J * Practical Observations on the Use of Cubebs in the cure of Gonorrhoea, p. 18. f R.—Bals. copaiv. Tinct. cubeba;, aa gi. Spir. nit. dulc. ^ss. Tinct. opii 3L Sacch. alb. %i. P. g. Arab. 3b Aq. fontana? 3jviii.—M. Take a tablespoonful three or four times daily. X My friend Dr. Dodd, of the United States Navy, has informed me that he has employed the extract ofcicuta with great success in gonorrhoea. He avers that in the very considerable number of instances in which he prescribed this article, it generally removed the disease completely in three or four days, and not unfre- quently sooner; but " under very unfavourable circumstances, the cure was not effected under eight or ten days." He employs it as follows: R.—Extract cicutae gi; G. opii gr. x.—M. Divid. in pil. No. xv. Two of which are to be taken every two hours, and continued until vertigo and a disagreeable sense of fullness in the head are experienced. His object is to put the system under the narcotic influence ofthe cicuta, and to sustain this influence until the discharge ceases, which seldom requires more than two or three days. Dr. Edward Graffe, of Berlin, has employed the chloride of lime with much suc- cess in gonorrhoea. When there is much burning in the urethra and chordee, he directs a tablespoonful every two hours of a solution of one drachm ofthe nitrate of potass in eight ounces of almond emulsion. When by this remedy the burning and chordee are considerably allayed, he orders a tablespoonful of the following GONORRHOEA. 487 It is proper to observe, that the use of medicines of this kind ought always to be continued for four or five days after the discharge has been arrested by them ; for when they are discontinued as soon as the running ceases, it very frequently returns in the course of five or six days; and when this happens, we rarely find the medicine to produce the same beneficial effect as it did in the first instances. Many of the obstinate cases I have met with were relapses of this kind, after the discharge had been suspended by the use of terebin- thinate remedies. When, notwithstanding the free employment of the medicines of this kind, the discharge continues, recourse should be had to astring- ent injections. Under judicious management, and after the inflam- matory stage has passed off, local astringent applications may be used without the least risk of injury, and very generally with speedy success. A great variety of articles have been recommended for this purpose; but in general the sulphate of zinc will prove more promptly beneficial than any other astringent we possess. The injec- tion should at first be weak—not above a grain and a half of this article to an ounce of water —but in proportion as the disease assumes a chronic character, the quantity of the zinc should be increased to eight and even ten grains to the ounce. It is a very common practice to unite the sulphate of zinc and acetate of lead in injections for this complaint; but it has never appeared to me that any peculiar advan- tages are to be derived from such a combination. It must, never- theless, be observed, that there occurs much diversity in different cases, with regard to the utility of different astringent injections. We sometimes find a variety of injections wholly ineffectual in this com- plaint, when at last some particular combination or article will speedily put a stop to the discharge. This, no doubt, generally depends on the peculiar grade of the irritation of the mucous mem- brane of the urethra. In the atonic stage of the disease, I have often employed the diluted sulphuric acid with success, after the zinc and other articles of a similar character had failed to arrest the disease. A drop or a drop and a half of the oil of vitriol to an ounce of water, forms an injection of the proper strength. The sulphate of copper, too, may be advantageously used for this purpose. Two grains of this article to an ounce of water form an injection of the medium strength; but it will, in general, be better to commence with a grain to the ounce, and to increase it to three or four grains afterwards, according as the disease assumes a chronic character. In some instances the nitrate of silver, in the proportion of two grains to an mixture every three hours: R.—Chloride of lime 3i; Almond emulsion gviii; Mucilage g. Arab. ^i. In general, after three or four doses of this mixture are taken, the patient experiences painful erections, burning in the course of the ure- thra and pain in voiding urine. All these symptoms, however, usually abate in the course of two or three days; and by the time that they are entirely removed, the gonorrhoeal discharge also ceases. The cure is thus generally effected in the course of five or six days.—Journal fur Chirurgie und Augenheilkunde. bd. xiv, s. 9. —Amer. Journ. Med. Sciences, vol. 8, p. 240. 488 GONORRHOEA. ounce of water, will succeed very speedily; and in gleet or atonic gonorrhoea, the proportion of the silver may be increased to three or four grains, to the ounce.* I have in a few instances of very obsti- nate gonorrhoea, succeeded with an injection prepared from the bal- sam copaiva in the following manner. Two drachms of the balsam are to be triturated in a mortar with a drachm of carbonate of mag- nesia. After they have been rubbed together, eight ounces of warm water must be added, and well mixed with the magnesia and balsam. It must then be suffered to stand until the water becomes clear, when it must be poured off and used as an injection. Mr. Foot, in a work on the venereal disease, published in London about ten years ago, strongly recommends the following solution as an injection in gonor- rhoea, after the inflammation has subsided. Dissolve some sulphate of copper in a sufficient quantity of water; precipitate the solution with lixivium of tartar ; suffer it to separate, then pour off the clear liquor. Wash the precipitate until the water becomes insipid ; then make a saturated solution of carbonate of ammonia in water, and mix as much of the precipitate with the filtered solution of the am- monia as will dissolve, which reserve for use. Six drops of this ammoniated copper to an ounce of water, form an injection of the proper strength. Six or eight years ago, I used this injection in various instances, and generally with benefit. In obstinate cases of gleet, the long-continued use of the tincture of cantharides, in conjunction with astringent injections, particularly a solution of the nitrate of silver, will sometimes succeed better than any other remedy. The cantharides should be given in gradually increasing doses, commencing with about thirty drops three times daily, until symptoms of strangury ensue, when it must be discon- tinued, and resumed after the ardor urinae has disappeared. I have often succeeded with the internal use of the spirits of turpentine, in conjunction with injections; but this article is much more offensive to the stomach than the cantharides, and patients will seldom con- tinue it a sufficient length-of time to obtain the full advantages which it is capable of affording. The direct application of astringent and exciting applications by means of a bougie, will sometimes succeed, after all other remedies have failed. I have in several instances removed the disease by introducing a bougie, upon which some citrine ointment was smeared; and in one very obstinate and pro- tracted case, I latelj7- succeeded in effecting a cure, by applying in this manner the lunar caustic rubbed up with lard. Twenty grains of the caustic may be triturated with half an ounce of lard, as an application for this purpose. A gleety discharge is, however, very frequently dependent on the irritation of stricture of the urethra; and when this is the case, nothing but the removal of the stricture * [The alterative plan of treatment is now frequently adopted by surgeons. It consists in applying the solid caustic by means ofthe porte caustique; or in throw- ing up a strong solution by means of a glass syringe. This is a mere revival of Hunter's plan of cure by exciting a new action or counter-irritation. It is also accomplished by giving large quantities of cubebs in tablespoonful doses three or four times a day.—Mc] GONORRHOEA. 489 by the judicious employment of bougies will effect a cure. When- ever a thin milky discharge continues obstinately after the use of the foregoing means, we may suspect the existence of stricture; and on being consulted for aid in a long-standing case of this kind, it is always proper, before any remedial measures are adopted, to make the proper examination, in order to ascertain the state of the urethra in this respect. It may be proper again to say, that where there is much irritability or active inflammation of the uretha present, all astringent or irritat- ing injections are highly improper. When used under circumstances of this kind, they are apt to give rise to various distressing affections —particularly to obstinate chordee, inflammation of the body of the penis, of the neck of the bladder, and of the testes, and to strictures in the urethra. In relation to the formation of strictures, however, Mr. Carmichael makes the following observations, which are entirely accordant with my own views. " Strictures," he says," are more generally attributed to the use of injections than any other attendant of gonorrhoea; but I have so often witnessed their occurrence where injections have never been used, that I am more inclined to ascribe these affections to the irritation of gonorrhoea than to any other cause. The sooner such irritation is removed, the more likely is the patient to avoid those unpleasant visitations which are far more to be dreaded than the original disease. I have, therefore, no hesitation in putting as speedy a stop to the discharge as I can, by the use of astringent injections, if the internal remedies mentioned disappoint my expecta- tions." The observations made above in relation to the propriety of con- tinuing the internal terebinthinate remedies for several days after the disappearance of gonorrhoeal discharge, are entirely applicable also to the employment of injections. In using injections care should be taken to prevent the passage of the fluid into the neck of the bladder, which may be readily done by making pressure over the posterior part of the urethra, near the margin of the anus, at the time of using the syringe. The secondary symptoms of gonorrhoea do not, in general, require any very active treatment.* An attention to cleanliness, with the use of the ordinary diaphoretic alterative ptisans, such as infusion of sarsaparilla, in conjunction with a mild mercurial course, the occa- sional use of the warm bath, and proper dietetic regulations, rarely fail to remove all these secondary affections. In relation to the employ- * [Authors have differed in their opinions respecting the occurrence of secondary symptoms after gonorrhoea. Many have spoken of the cotemporaneous and subsequent occurrence of a troublesome species of rheumatism which is called " gonorrhoeal rheumatism," and most appear to believe in the papular form of venereal disease of Carmichael, which he ascribes as a secondary consequence to gonorrhoea. But the great authority of Ricord is decisively against the possibility of any secondary constitutional form of this disease. He attributes the supposed secondary eruptions, in all cases of gonorrhoea, to internal or concealed chancres, " chancres larvees."—Mc] 490 SYPHILIS. ment of mercury, however, much discrepancy of opinion has .been expressed by writers on this subject. My own experience is decid- edly in favour of gentle mercuriahzation in these affections. It is, indeed, not at all improbable, that all the secondary consequences of gonorrhoea may be cured without this potent medicine; but many of the most experienced physicians of the present day believe that the gentle action of mercury very considerably expedites the radical removal of these affections. Mr. Travers, among other late writers, speaks decidedly in favour of mercurial remedies in cases of this kind. " The disadvantage," he says, " of slowness in the cure, and a con- tinual tendency of the disease to relapse, or reappear in a new form, long since compelled me to abandon, as a general principle, that of treating these cases without mercury." The sarsaparilla should always be employed conjointly with the mercurials. In mild cases, Mr. Travers gives the compound decoction of sarsaparilla, " with free doses of the diluted nitric acid, with or without an equal portion of the tincture of henbane," and omits the mercurial remedies. Small doses of blue pill, with moderate doses of Dover's powder, form an excellent combination where there is much irritability present. I have more generally, however, resorted to minute doses of corrosive sublimate, in union with the extract of conium, or opium, as recom- mended by Mr. Travers. This combination seems to be particularly useful where there is much disease in the fauces. In cases attended with much constitutional debility, Mr. Travers uses the hydrarg. cum creta with a small portion of rhubarb, or of Dover's powder. Sect. II. — Syphilis. The origin of syphilitic diseases is still involved in much obscurity. The general opinion of its having been introduced into Europe from South America, by the sailors who accompanied Columbus, admits of a great deal of doubt. Dr. Thomson, who has investigated this subject with much learning and discrimination, observes, that it " is extremely improbable that sailors, after a long and successful voyage, landing on the northern coast of Spain, objects of curiosity, ready to embark again to reap the fruits of their discoveries, and the wealth the new countries were supposed to abound with, should have been sent off to act as soldiers at the. siege of Naples, labouring under a new and horrid disease, which must have been of some months', dura- tion, and have incapacitated them for every kind of exertion. That neither Columbus himself, nor his brother, who left such accurate narratives of his voyage, should make the least mention of such dis- ease being discovered among the natives, or prevailing among the crews of their vessels, is certainly still more difficult to be reconciled with reason, and affords strong presumption of error."* He thinks it probable that the disease has existed more or less, and under different grades of severity in all ages, and that " it has been thousands of times * Medico-Chirurg. Review, December, 1821, p. 617. SYPHILIS. 491 generated de novo by impure sexual intercourse." The circumstance which especially attracted the attention of physicians to the disease, about the period of its supposed importation into Europe, was proba- bly its having assumed, at that time, an extraordinary degree of vio- lence ; for it is very evident, from the records of medicine, that the disease has varied very much since the first accounts that were given of its phenomena and character; and it is certainly very far from possessing the terrible severity now which it manifested during a long period after it was particularly noticed. It is not improbable, too, that the connection between primary ulcers on the genitals, and what we now call the secondary constitutional symptoms, was overlooked by the ancients : for as the former would very generally heal before the latter could make their appearance, and more especially as these constitutional affections were free from the power of infecting jfhe healthy, they might very readily have been regarded as distinct dis- eases, wholly independent of primary sores on the organs of genera- tion. Besides, although ulcers were abundantly noticed and described on these parts, their origin from impure venereal intercourse may have escaped detection. It is certain, at least, that Celsus describes various species of ulcers on the genitals ; and it appears to me difficult to read his sections De cancro qui in cole nascitur ; De phagedena in cole nascente ; and De carbunculo qui in cole nascitur, without being impressed with the conviction, that he had reference to the various species of sores now known under the name of syphilitic chancre. The opinion that syphilis is an ancient disease, but that it has been subject to various modifications from the influence of some occult cause in different ages, is strongly illustrated by the following account of the " new syphilitic disease which has lately appeared in Canada, in the last edition of Swediaur's valuable work on syphilis. "A new disease " says the writer," broke out some time ago in Canada, espe- cially i'n St. Paul's Bay. This disease has made rapid progress within these few years among the inhabitants of Canada. The parents transmit it to their children. It is communicated by eating, drinking, &c If it once enters a family, rarely any one escapes catching it. Some habits seem to absorb the virus, and then sometimes it remains concealed or dormant for years, and then breaks out, at last, with al the symptoms of the third stage. The patients, often dragging out a miserable existence to old age, lose, by degrees eyes, nose, cheeks velum pendulum, and the whole basis of the skull, &c They ca I it malAnglois, (the English disease,) because they think the English brought first amonl them." This accords with the violent and exceedingly contagious character which syphilis is said to have had during thefirst century of its ravages in Europe. It was communi- cated « by lying in the" same bed, by the clothes gloves, or money of the patient-" Snd even the breath was thought to be sufficient to LCnicate the disease ; for it is stated that Cajdtna Wosey; was indicted "for whispering in the kl^*eh^ khonrinz under the venereal disease." (Thomson, loc. cit.; tfinany, U mus bge observed, that some of the earliest writers did not consider ^affection in Europe as of transatlantic origin. Fracastonus as- 492 SYPHILIS. cribed it " to the different constitutions of heaven and stars, which but seldom happen,but may effect great matters when they do coincide;"* and he, as well as others, believed that it was one of those diseases which rise, cease, and again return, at long intervals of ages.t But although inquiries into the origin ofthe disease are highly interesting, and not altogether useless, the immediate scope of this work does not admit of an extended discussion on this point, and I proceed, there- fore, to the more practical details of the phenomena and modes of remedial management of this malady. Syphilis, when suffered to proceed in its course, passes through two distinct stages or series of phenomena ; the first, or primary, which is altogether local;—and the second, or constitutional, in which the system generally becomes implicated in the disease. Primary ulcers, or chancres.—At an uncertain period, varying from a few days to several weeks after an impure venereal inter- course, one or more small pimples, excoriations, or ulcers, preceded, usually, with an itching in the part, appear on some part of the genital organs, most commonly on the internal surface of the prepuce, the corona glandis, the glans, or on the frsenum ; and occasionally on the external surface of the prepuce, skin of the penis, scrotum or thighs in men ; and in females, on the internal or external surface of the labia pudendi, on the clitoris, the nymphae, in the vagina, or on the thighs. Authors have of late years distinguished with great minuteness the primary venereal ulcers; and some have arranged them under distinct heads, ascribing to them specific differences, with the view, princi- pally, of establishing certain indications in relation to the propriety of administering or withholding mercurial remedies for the prevention and cure ofthe secondary constitutional symptoms which may ensue. That there are divers local affections of this kind, is unquestionable. The observations of Hunter have long ago established this fact very conclusively; but it may be greatly doubted, whether the classifi- cations and hair-splitting distinctions which have been announced as absolute and essential differences in the various ulcers of this kind, are entitled to our confidence, at least to the full extent to which they have been carried by some writers. Carmichael asserts, that there is but one of the four classes of the primary ulcers he describes—namely, the indurated and excavated chancre of Hunter—that is capable of giving rise to the true secondary symptoms of lues. This assertion, however, is by no means established on incontrovertible observations; for it may be affirmed, on the authority of competent testimony, that constitutional symptoms, differing in no material point from those * Aphrodisiac, p. 202, as quoted by Van Swieten. t Quam tamen (seternum quoniam dilabitur awum.) Non semel in terris visam, sed saepe fuisse, Ducendam est: quanquam nobis nee nomine nota Hactenus ilia fuit: quoniam longseva vestustas Cuncta situ involvens et res, et nomina delet: Nee monumenta patrum seri videre nepotes. SYPHILIS. 493 which are regarded as truly syphilitic, may arise from various primary venereal sores, distinct from the excavated and indurated chancre. One thing, at least, is certain, that it is often extremely difficult, and sometimes impossible, to determine, from the appearance of the chan- cre, to which of the species, usually described, it may belong; for in their external characters they sometimes pass into each other so insensibly—and the varieties of appearance met with in practice are so multifarious, that it will often baffle all our attempts to form a satis- factory diagnosis on this point. Even the unquestionable syphilitic chancre, so accurately described by Hunter, is liable to be confounded with other venereal sores, from these latter occasionally assuming the appearance of the excavated and indolent chancre.* Dr. Hennen, whose opportunities for carefully observing these affections were very extensive, confesses his inability to point out « any invariable cha- racteristic symptoms, by which to discriminate the real nature of the primary sore." " It would," he observes, " be by no means difficult to show, that the high round edge, the excavated sore, the preceding pimple, the loss of substance, the hardened base and edge, whether circumscribed or diffused, and the tenaciously adhesive discharge of a very fetid odour, are all observable in certain states and varieties of sores unconnected with venereal origin. The hardened edge and base, particularly, can be produced artificially, by the application of escharotics to the glans penis of a sound person; and if any ulceration or warty excrescence previously exists on these parts, this effect is still more easily produced."! Indeed, when we take into consideration the variety of textures which compose the parts upon which these primary sores occur, the diversity which exists in individual constitutions, and the various influences which are continually modifying the general habit of the body, we can readily conceive that sores, even from the same virus, must be liable to very different aspects in different mdi- V1Inamaking these remarks, I would by no means wish to be un- derstood as regarding all distinctions of this kind as unfounded or nugatory; but to attempt to classify these primary venereal sores as fixed and essential diversities, merely from their external characters, and to propose them as indications for the employment or rejection * [The experiments of Ricord, in Paris, have done more in the way of elucidat- ing this subject than all former experience. He inoculates his hospital patients w5h the matter of all suspected sores, and produces a small P^/^Tbv virus, which can always be cured without any danger of being ™w£M secondary symptoms during the first eight days,by the applioaU^ rf»M cau*c followed bya dressing of lint, dipped in aromatic wine. *fT^™^ pustule or ulcer begins to show an indurated base or edge, and then ^k> » d« eroftheoccurrenceofsecondarysymptoms.^-^to^S ^^ = £io^^ ternally.—Mc] t Principles of Military Surgery, &c, p. 517. 494 SYPHILIS. of particular remedies, appears to me obnoxious to very serious objections.* In relation to the diversities which occur in the primary as well as the secondary venereal affections, it must, in the first place, be ob- served, that there are two distinct classes of these maladies, namely: 1, genuine lues, or syphilis, for the cure of which mercury is indis- pensable ; and 2, venereal affections, often closely resembling, though differing essentially from the former, and which may, in general, be cured without mercury. I. The true syphilitic chancre is thus described by Mr. Hunter:— " The sore is somewhat of a circular form, excavated, without granu- lations, with matter adhering to the surface, and with a thickened edge and base. This hardness and thickening is very circumscribed; not diffusing itself gradually and imperceptibly into the surrounding parts, but terminating rather abruptly." When examined, by press- ing the chancre between the fingers, it will be found that the whole excavated surface of the ulcer is surrounded by a hard or indurated basis. In some instances, a small indolent ulcer is seated as it were in an indurated knob on the glands; and occasionally indurated tubercles passing deep beneath the surface with scarcely any visible ulceration, will be followed by constitutional symptoms of syphilis— but in cases of this kind, " we will probably learn, a small ulcer ex- isted at first on the callous part, which healed under the use of some local application." (Carmichael.) When the syphilitic chancre is situated on the body ofthe penis, it presents a dark livid colour, with- out being scooped out or excavated, and the surrounding parts are less indurated than when it occurs on the glans penis. True syphilitic chancre is always of an indolent character—very slow in its progress. The excavated and circumscribed state of the ulcer, its indurated edges and base, and its slow progress, constitute the characteristic marks of the syphilitic chancre: but it must not be forgotten, that almost any sore situated on the glans penis is apt to acquire a more or less indurated condition from being frequently irritated by im- proper applications; and hence, " in forming a diagnosis, we should always take into consideration the previous management of the ulcer." (Carmichael.) The constitutional symptoms which proceed from the true sy- philitic chancre, appear first upon the skin, the throat and mouth ; and finally upon the periosteum, bones, and deep-seated parts. The true syphilitic eruptions appear in distinct circular patches, from a few lines to half an inch in diameter. They are slightly raised, and covered with thin, whitish, hard scales, easily separated, leaving smooth, shining, copper-coloured spots, somewhat elevated above the * " It is not," says Swediaur, "by the external characters alone that we can discover the nature, and distinguish the different kinds of ulcers alluded to; to inspection and practical knowledge, we must join a profound acquaintance with the diseases, an attentive examination into the actual state of the patient, his con- stitution, and the remedies and regimen which he has adopted." SYPHILIS. 495 surrounding skin. In some instances a small white band encircles the base of each disk; and occasionally several of the spots unite, forming large irregular copper-coloured patches, with portions of scales adhering to them. These scaly copper-coloured spots are sometimes in a great measure confined to the forehead, neck, breast, forearms, legs, and anterior part of the abdomen. Syphilitic eruptions occasionally appear in the palms of the hands and soles of the feet, presenting a very peculiar aspect—namely, masses of dry friable scales, very easily removed, and exposing spots of a livid colour, with an indurated state of the skin and subjacent structure. When the syphilitic patches are situated on parts opposed by ano- ther skin —as between the nates, under the arms, between the thighs and scrotum, &c, they do not present a dry and scaly appearance ; but an elevated, soft, moist, and flat surface, discharging a thin whitish matter. Sometimes the upper part of the extremities of the fingers and toes become affected, and the nails are gradually separated. If the disease is not opposed by the employment of mercury, " every succeeding scurf which is formed becomes thicker than the preceding, till at length it forms a crust, under which matter collects, and it becomes a true ulcer." These ulcerations spread very slowly. After the eruption has made more or less progress, the throat also becomes ulcerated) generally about the tonsils and soft palate. These ulcerations are not preceded by much, inflammation or swell- ing, and the tonsils exhibit ulcerated cavities with well-defined edges, similar to the primary syphilitic ulcers on the glans penis. As the disease proceeds, the periosteum, the fasciae, ligaments and bones become affected; and of the bones, those nearest the surface, as the cranium, clavicle and sternum, are most liable to become the seat of its destructive ravages. " The true syphilitic node is a solid enlarge- ment of the bone," unaccompanied, during the earlier periods of its progress, by any discoloration of the skin, nor is there much pain, until it has arrived at a considerably advanced state. II. Of the non-syphilitic venereal sores, and in which mercurial remedies are, in general, unnecessary, and often injurious, the fol- lowing are the principal varieties: — 1. Venerola vulgaris*-—or the simple primary venereal ulcer of Carmichael. This is by far the most common variety of venereal ulcerations. The simple venereal ulcer commences from three to seven or eight days after the impure sexual connection, by an itching or redness, which is speedly succeeded by a small pustule surrounded with a red margin. In a few days the pustule becomes converted into a thin crust, under which more or less matter collects, andrgives rise to considerable pain. The scab gradually enlarges, and ac- quires a triangular or circular shape, varying in colour from yellow to dark brown. This scab soon separates, and exposes an excavated, round, or oval ulcer, with a glossy reddish or dirty yellow colour, * Pathological and Practical Remarks on Ulcerations of the Genital Organs. By James Evans, Surgeon, &c. &c. 496 SYPHILIS. surrounded by a narrow red areola. The bottom of the sore now begins to fill up; it rises above the level of the surrounding parts, and exhibits a smooth surface, seated on a fungoid basis, without granula- tions, and of the colour of a healthy sore, the base and edge being usually a darker red than the disk of the sore. Between the four- teenth and fifteenth days, the ulcer generally has risen to its greatest height; but the process of ulceration, as well as the surrounding ef- florescence, generally ceases as soon as the fungoid stage commences. In some instances, the top of the elevated sore extends beyond its base over the surrounding sound skin, giving it the appearance as if a ligature were tied about it beneath the surface. In this state the sore remains stationary for some time, and then gradually and usually slowly declines and heals, the average period of the commencement to the termination of the ulcer occupying from four to six weeks. " Wherever may be the seat of these ulcers, on the inner part ofthe prepuce, their characters are seldom doubtful after the ninth day ; for by drawing the skin well back, and making allowance for the form of the parts, the raised edge and surface cannot escape discovery; for although these may not be plainly discernible all around, they will be so on some one side." (Evans.) These ulcers are particularly apt to excite phimosis, and are frequently accompanied with patchy excoriations on the glans and prepuce, and occasionally with a pro- fuse gonorrhoeal discharge. The causes of venerola vulgaris consist of gonorrhoeal matter and of other morbid vaginal secretions communicated by the sexual in- tercourse. With this variety of venereal ulcerations, we may place the "patchy excoriations," already mentioned, for they proceed from the same cause, and may exist either conjointly or separately. Secondary, or constitutional symptoms sometimes succeed or attend this variety of primary venereal ulcers; but these are always mild, and readily disappear under mild aperient and diaphoretic treatment. These symptoms consist in slight febrile excitement, attended with headache, and aehing pains in the joints, and occasionally also in the chest, succeeded by a papular eruption on the forehead, chest, and back, and scattered more thinly over the extremities. Fresh crops of these papulae appear, at the same time that the slight febrile irri- tation and nocturnal pains in some of the joints continue. " The papulae vary from a pale red to a deep crimson colour," some of them preserving the character of pimples, whilst others are more of a pustular form. They may appear from five weeks to three or four months after the infection. When they are about declining, they be- come paler, and often assume a copper tint, " while the exfoliation of the cuticle gives them an appearance of scaliness "—»a state in which they may be confounded with the scaly eruption of true syphilis. " But they may be readily distinguished from each other; for when the papular eruption is on the decline, and has assumed a pale-red or copper colour, on examining the patient we shall find other spots in their papular or pustular form, which will at once point out the cha- racter of the eruption." (Carmichael.) SYPHILIS. 497 The fauces generally become affected, but not with excavated or spreading ulcers. The patient complains of soreness on swallowing; and on looking into the fauces, the entire cavity exhibits a red and oedematous appearance, with swollen tonsils. 2. Venerola superficialis of Mr. Evans, or the primary ulcer of the pustular syphilitic eruptions of Carmichael.—This variety begins with a small pustule, which soon breaks, and forms a crust, under which the cuticle ulcerates in a circular or oval form. When the crust separates, it exposes an ulcer of a reddish brown surface, on a level with, or somewhat elevated above the surrounding skin, with raised and well defined edges. It is free from marginal or surrounding induration, of a granulated appearance, and seldom attended with considerable pain. It varies from the size of a pea to that of a shilling; but when neglected or improperly managed, it sometimes increases to a much greater extent. It occurs most fre- quently on the external surface of the prepuce and body of the penis, and is sometimes met with on the anterior aspect of the scrotum. In some instances this variety of ulcer surrounds the orifice of the prepuce, and occasions, when the ulcer heals, a permanent phimosis. It is generally tedious in its progress, and does not manifest any tendency to spread. This ulcer has not the smooth fungous appear- ance of the former variety, and is strictly defined in its circumference. Venerola superficialis, when left to itself, is almost invariably fol- lowed by constitutional symptoms. These consist usually of a pus- tular eruption coming out in succession, and terminating speedily in scabs and superficial sores, so that " at the same time, on the same individual, there will appear some new formed pustules, and others in their scabbing stage, with an intermixture of small ulcers, whose crusts have fallen off, and of discoloured patches of the skin, where they have healed." Considerable inflammation and ulceration of the tonsils and pharynx, attended with pains resembling acute rheu- matism, are particularly apt to follow this variety of primary ulcer. Mr. Evans asserts that he never met with an instance that was not followed by secondary symptoms. Mr. Carmichael thinks that this variety of venereal disease forms " the natural link between the sim- ple ulcer and its consequences, and the phagedenic venereal disease." 3. Venerola indurata, or the indurated sloughing primary ulcer. —This variety of venereal ulcer is characterized by great derange- ment of the general health, much inflammation of the part, local pain a strong tendency to sloughing or destruction of the parts, and by a'cartilaginous induration of the base, unless seated on the glans. The situation of this sore is frequently at the duplication of the pre- puce behind the corona glandis, in which case the ulcer generally burrows deep between the skin and the body of the penis When it is situated on the internal surface of the prepuce, which is very common, the peculiar hardness of the base is very remarkable; and file surface of the sore, whether seated on the prepuce or glans, pre- ents a dark hver-coloured slough, " which falls off, and is succeeded rapidly by other sloughs, destroying -the parts rather in depth than vol. n.—33 498 SYPHILIS. in breadth." (Bacot.)* Wrhen the general and local inflammatory action is very severe, mortification to a greater or less extent is by no means uncommon. Mr. Evans says, that he has "known gangrene to take place as early as twenty-four hours after the appearance of the disease, and in less than seventy-two hours after the venereal connection. When these sores heal, they are apt leave indurated spots, which are peculiarly disposed to ulcerate again from irritation, or want of cleanliness." (Evans.) This variety of sloughing ulcer is distinguished from the phagedenic ulcer by the presence of the indurated base. The constitutional symptoms commonly show them- selves at a very early period, even before the active progress of the ulcer is completely arrested, and do not differ materially from those which succeed the next variety—namely : 4. The phagedenic primary ulcer of Carmichael.—This ulcer exhibits an irregular, corroded appearance, without granulations and surrounding indurations. It sometimes spreads rapidly, and causes extensive destruction of the parts in a few days. Sometimes it "creeps on slowly, healing in one part and making progress in an- other." The internal use of mercury very generally renders its course more rapid and destructive. It is usually seated on the glans near the prepuce, which "it often entirely consumes, and continuing its depredations on the corona and glans, at last effects their total destruction. When this event takes place, the ulceration usually receives a sudden and permanent check; but in some instances, pro- fuse hemorrhage occurs before the glans is entirely destroyed, in which case a favourable change usually takes place in the ulcer. Occasion- ally, though indeed rarely, the disease slowly proceeds until the whole penis is destroyed." (Carmichael.) It is highly probable, as Dr. Emerson observes,! that the last two varieties of venereal ulcer owe their characteristic phenomena " more to circumstances of climate, constitution, and habits ofthe patient, than to a peculiar or distinct specific virus." Of this, indeed, I do not in the least doubt. "A southern climate predisposes most to these forms of primary syphilis, which are comparatively rare in the more northern and temperate latitudes. In the south of Europe, the pre- . disposing causes seem to be far more active, and particularly so in their operation upon northern visitors. The crews of our men of war and merchantmen have occasionally suffered very much from this form of syphilis in the Mediterranean, especially on their visits to the Italian and Spanish ports." Persons of a scorbutic and irrita- ble habit—and especially those whose constitutions have been im- paired by breathing an unwholesome atmosphere, or by a spare and unwholesome diet, or finally, by long residences in hot climates, are most liable to the sloughing and phagedenic varieties of venereal ulcerations. (Evans, loc. cit., 109.) * Observations on Syphilis, principally with reference to the use of Mercury in that Disease. By John Bacot, Member of the Royal College of Surgeons, &c. t See his edition of Carmichael's work on Venereal Diseases. Philadelphia, 1825, p. 164. SYPHILIS. 499 According to Carmichael, the secondary constitutional symptoms of the last two varieties of primary ulcer are: tubercles, pustules, or spots of a pustular tendency—degenerating quickly into ulcers, with thick scabs, healing usually from the centre, while the ulcera- tion spreads along the circumference. Strong fever often ushers in this eruption; but in many cases a general feeling of indisposition, of listlessness, pallid countenance, languid eye, and broken rest, precede for several days the appearance of the eruption, unaccom- panied by distinct febrile movements. In other instances, "noctur- nal headaches, tenderness ofthe scalp, slight dyspnoea, with soreness of the sternum and of the breast, generally occur previous to the appearance of the constitutional symptoms." Phagedenic ulcerations in the throat, tending to destroy the pharynx; the spongy bones of the nose; soft palate and tonsils; severe and obstinate pains in the joints—particularly of the knees and wrists; and obstinate enlarge- ment ofthe testes, are among the most common constitutional affec- tions from primary ulcers of this kind. When the ulcers in the throat extend into the larynx, which is not very uncommon, "there is but little chance of saving the patient's life." This occurrence is an- nounced by "a whispering, stridulous voice, constant cough, and copious expectoration of viscid matter; restlessness, great anxiety of countenance, emaciation, night sweats, rapid pulse, and all the concomitants of phthisis." Treatment.—In perusing the various writers of acknowledged authority on this subject, it would seem almost impossible to come to any satisfactory conclusion as to the proper mode of treating both the local and general symptoms of this malady. All indeed agree, that in genuine syphilis, mercury is indispensable to the removal of the disease; but this forms but a small portion of the great number of venereal cases met with in practice, and it is moreover admitted, and very justly, too, that it is frequently almost impossible to deter- mine, from the external character of the disease, whether it be true lues, or only one of the various venereal affections which have been described. Some writers condemn the useof mercury, without ex- ception, in the various non-syphilitic venereal affections; others admit its utility in certain varieties and under certain conditions, but they disagree among each other as to the particular varieties and circumstances which call for its employment. Others, again, less scrupulous in the use of mercury, affirm that, with very few excep- tions, and under cautious management, it may be used not only safely but very beneficially, in almost every variety of primary and second- ary venereal affections. The result of all this disparity of opinion would seem to be that there is "a proper medium," in relation to the employment of mer- cury in affections of this kind ; and that the entire rejection of its aid is just as apt to lead to disastrous consequences, as its indiscriminate and universal employment. Mr. Bacot observes that " with the ex- ception of the sloughing and phagedenic venereal sores, the exhibi- tion of mercury, in the majority of primary ulcers is so safe and so generally beneficial, that where a sore of this kind continues for a 500 SYPHILIS. certain time to pursue its course, and to resist all those mild methods of cure, both external and internal, which influence the progress of sores in other parts, I should not hesitate to have recourse to its exhibition." In reference to the late discussions concerning the non- mercurial treatment of venereal affections, this experienced writer makes the following observations, to the correctness of which I am entirely disposed to subscribe. " It is assumed, therefore, as an estab- lished fact, that all ulcers upon the parts of generation are curable without the use of mercury; but I cannot concede that, generally speaking, they are cured with equal celerity: they require more strict confinement; more attention to the state of the general health and to regimen, than is found necessary under a mercurial treatment care- fully conducted ; and in some instances, the length of time requisite for their complete cicatrization is alone a serious evil. It may also be added, that under the non-mercurial treatment, they frequently heal with hardend and elevated cicatrices." It must be admitted, moreover, that a much greater proportion of cases are followed by constitutional symptoms, when the primary stage is treated without mercury, than where a cautious exhibition of this mineral is resorted to. " From these circumstances, therefore," says Mr. Bacot, " I would advocate the moderate and gentle use of mercury in all those cases of primary sore, where a mild mode of local and general treat- ment is productive of no beneficial change in the course of a reason- able period; at the same time being perfectly prepared to do without it in all those cases and in those constitutions where its employment appears to be pernicious, being convinced that it is both much wiser and more safe to postpone the exhibition of this remedy where the habit is irritable, and it appears to operate upon the system as a poison only, calling into action that peculiar and anomalous class of symptoms usually called cachexia syphiloida." (Loc. cit., p. 35.) Mr. Hennen observes: " In every primary ulcer, I would give up the idea of using mercury at first, treating it as if it were a simple ulceration, by cleanliness, rest, and abstinence, and applying to it the most simple and mildest dressings. If the sore did not put on a heal- ing appearance in a reasonable time, the extent of which must de- pend on the circumstances of the patient, I should make use of more active dressings. But if beyond all calculation it remained open, I should certainly sacrifice every dislike to mercury, knowing how many persons have been seriously benefited by a judicious and mild administration of that remedy." These sentiments appear to me unexceptionable, as general precepts, and I have for five or six years uniformly treated the cases that have come under my care in con- formity with them. It will be proper, however, to give a more par- ticular detail of the management of the various primary ulcers. The simple venereal ulcer—venerola vulgaris, usually runs its course in spite of remedial applications; and where the irritation is not con- siderable, nothing but the lightest emollient dressings are necessary, so long as the scab has not separated and exposed the fungoid and raised surface of the ulcer. Warm emollient poultices should be applied imtil the crust comes away, when the ulcer is on the external SYPHILIS. 501 part of the penis; when the ulcer is seated on the inner surface of the prepuce, a piece of linen kept constantly moist with a weak solution of lead should be laid over the part; and when phimosis attends, the same liquid should be frequently injected with a syringe between the prepuce and glans. When the scab separates and exposes a raised and fungous ulcerated surface, nothing in general answers better than the application of a weak solution of the sulphate of copper, (in the proportion of about four grains to an ounce of wa- ter,) two or three times daily; and in the advanced stage of the complaint, the same may be,injected under the prepuce, if phimosis attends. 1 have derived much benefit in the fungoid state of this variety of venereal sores, from the application of citrine ointment softened down with an equal proportion of lard. The aqua pha- gedenica—made by dissolving eight grains of corrosive sublimate in four ounces of lime water, or a very weak solution of lunar caustic, may also be usefully employed. All such applications, however, should be weak; for the object is not to destroy the raised surface of the ulcer by an escharotic, but simply to stimulate it. Mr. Car- michael recommends the zinc ointment, either alone or mixed with a third or fourth part of the citrine ointment. During the early stage the patient should use a light, unirritating diet, remain quiet, take mild aperients; and where the constitutional irritation is considerable, venesection and perfect quietude in bed are proper. When phimosis attends, emollient poultices, efficient blood-letting and nauseating doses of antimony should be resorted to. Some- times the attendant inflammation terminates in the formation of matter under the ligament of the penis. In this case the tension and pain are excessive and obstinate—the skin becomes discoloured, but, from the extreme tension of the part, no fluctuation can be felt. The ex- cessive pain, induration, tension, and obstinancy of the affection, are the only circumstances by which the formation of pus under the liga- ment can be inferred with sufficient confidence. If the matter is not evacuated by a free incision into the dorsum penis, it usually makes its way up the dorsum, an escapes by an ulcer near the pubis. Venerola superficialis, or the primary superficial ulcers with ele- vated and perfectly defined edges, are seldom benefited by stimulat- ing and caustic applications; but often rendered much worse. Mode- rately astringent and soothing applications are in general beneficial —such as weak solutions of sulphate of zinc, sugar of lead, althea or tutty ointment. When the constitutional irritation is very considerable the lancet, purgatives, antimonials, nitre, and other refrigerant dia- phoretics, with local, emollient, and sedative applications, will be necessary. The internal use of mercury generally renders the pro- gress of primary ulcers with elevated edges, extremely obstinate. " I have frequently," says Mr. Carmichael, " seen mercury, exhibited in full doses, maintaining a strong mercurial action in the system for several months, without inducing ulcers of this kind to heal." In the indurated sloughing ulcer, where there is much surround- ing hardness, and the surface of the sore covered with a dark liver- coloured slough, from which a thin dark-coloured ichorous fluid issues, 502 SYPHILIS. mercury, according to the experience of Mr. Bacot, is decidedly beneficial, until the hardness of the surrounding parts disappears. It does not appear, however, that the most careful administration of this medicine is capable of protecting the constitution from the second- ary symptoms; but when the copper-coloured eruption has once made its appearance, " it is as much under the influence of mercury as the primary sore"—disappearing in general without difficulty under the moderate employment of this remedy. When the constitutional irritation is high, attended with an evident disposition to gangrene, great anxiety, heat and dryness of the skin, furred tongue, and much pain and swelling of the prepuce, vigorous antiphlogistic measures must be adopted. The lancet, cathartics, antimonials in nauseating doses, cold applications, and a rigorous antiphlogistic treatment, are indispensable in such cases, and the patient should remain in bed. When the local and general inflammatory action is moderated, and the system is much debilitated, recourse should be had to tonics— particularly quinine and opium; and the separation of the sloughs may be promoted by warm emollient poultices. Mercury can only be safely employed where the surrounding inflammation and pain are moderate. The sores must be dressed with mild applications— such as weak solutions of acetate of lead, or a solution of sulphate of copper, in the proportion of two grains ofthe sulphate to an ounce of water, or the black lotion (calomel 9i, limewater gvi). The phagedenic, soft, sloughing primary ulcer, free from very conspicuous surrounding hardness, is often especially unmanageable/ The most prompt and vigorous antiphlogistic measures are necessary to arrest the progress ofthe ulceration; but the employment of mer- cury in this variety of primary ulcer, is almost invariably perni- cious, " and often productive of the ivorst consequences." (Bacot.) The measures to be confided in, during the inflammatory stage, are: rest in a recumbent posture; venesection; nauseating antimonials; warm fomentations injected under the prepuce, or applied by stup- ing ; warm emollient poultices; together with the internal use of opium, hyoscyamus and cicuta. When the violence of the inflam- mation and the active progress of the ulceration have been moderated, and the ulcer " creeps slowly along," healing in one place while it advances in another, a weak solution of the nitrate of silver, (one, two, or three grains to an ounce of water,) " or the black or yellow mercurial ivashes, do well in some cases ; but in some cases no ap- plications seem to be capable of checking the progress of the ulcera- tion." (Carmichael.) If spontaneous hemorrhage ensues in obstinate cases of this kind, an immediate check to the progress of the disease is usually the result. Mr. Carmichael states, that he has in some instances derived decided advantage from " paring off the irregular and jagged superficies of the ulcer, and encouraging the bleeding afterwards by immersing the part in warm water." When a band or strip of integument connects one portion of the ulcer with another, or the ulcer has penetrated through the frenum, leaving its anterior part attached to the glans, and the disease has assumed a chronic 6tate, it will be proper to divide it by an incision. SYPHILIS. 503 In sloughing ulcers, without indurated bases, we may often derive much benefit from stimulating applications. Carmichael particularly recommends Venice turpentine, or balsam copaiva, mixed with one or two parts of olive oil. I have known very prompt advantage derived in sloughing ulcers of this kind, from the application of poul- tices made of crumbs of bread and a strong decoction of oak bark. A lotion of one part of the tincture of myrrh to seven parts of cam- phorated mixture, may also be very beneficially applied where the sloughs are extensive. (Carmichael.) A pure air is all-important in the management of this variety of venereal sores. The true syphilitic chancre. — When early resorted to, the excision or destruction of the chancre with caustic, will frequently arrest the further progress of the local affection, and prevent the occurrence of the secondary constitutional symptoms. This practice is, however, not always free from unpleasant consequences; for although the sore may be thus speedily healed, buboes will occasionally appear; and the virus is sometimes confined under the eschar produced by the caustic, and corrodes the parts underneath, so as to form a deep ulcer. In irritable and depraved constitutions, too, the irritation produced by the caustic is apt to give rise to very injurious consequences. Swe- diaur asserts, that he has seen " the most dreadful symptoms produced by this application." Although mercury is unquestionably our only means for counteracting the formation of secondary affections, it does not appear to possess any especial controlling power over the primary local affection. Nevertheless, as it is of much importance to protect the system against the occurrence of a general syphilitic taint, it will be proper to put the patient, at once, under the use of a gentle mercu- rial influence, in conjunction with proper local applications to the chancre, unless the primary sore be irritable, and the general system inflammatory, or of a manifestly depraved or scorbutic habit. When these contra-indicating conditions to the employment of this remedy exist, measures must be previously taken to remove the irritable and phlogistic state of the system by pure air, diaphoretics, opium and laxatives. Most of the recent writers recommend the mildest local applications—simple ablution to keep the parts clean, and dressing the chancre with dry lint, or the most soothing ointments; and in the majority of instances, these will be found better than the irritating applications formerly so much employed. Swediaur, however, is a strenuous advocate for the employment of the red oxide of mercury mixed with lard, as a local remedy for syphilitic chancre. He also speaks very favourably of the effects of " finely powdered corrosive sublimate, mixed with a little saliva, and rubbed for five Or six minutes, once or twice a day, on the ulcers. These remedies, (he asserts,) are generally highly useful, notwithstanding the assertion of modern writers." To sum up all, he says, " I am of opinion that mercury, topically applied, is never injurious in syphilitic ulcers; but on the contrary that it is extremely serviceable, and almost sufficient to effect a cure, when the ulcers are local, and arise from a primary disease • lastly, that it is always necessary when the progress of the disease 'is rapid and alarming." I have repeatedly resorted to appli- 504 SYPHILIS. cations of this kind with very satisfactory results, although, in general, I have abstained from them until the system was put under a mode- rate mercurial influence. My usual mode of proceeding is to destroy the chancre with lunar caustic, when I am consulted during the first five or six days after its appearance, but when the chancre has already made considerable progress, I at first simply keep the parts clean by frequent ablution, and direct it to be dressed with simple cerate; as soon, however, as the system is moderately impregnated with mercury, I destroy the callous edges of the chancre with caustic, and direct the sore to be dressed with red precipitate ointment; or to be touched frequently, during the day, with a solution of the sulphate of copper (four grains to an ounce of water); or finally, to be washed repeatedly with the black mercurial lotion. The mercurial impression should be kept up for six or eight weeks; but it is of the utmost importance that the patient should avoid a damp and cold atmosphere, and that he should be particularly cautious to keep up an equable action of the skin by warm clothing. He should use a mild and unirritating diet, and abstain, wholly, from the use of stimulating drinks. During damp and variable weather, there is great risk of receiving injury from cold, while the system is under the mercurial influence; and to avoid this accident, the patient should, if possible, remain within doors. The treatment proper for the removal of the constitutional vene- real symptoms, has been particularly a field of much contention—all turning upon the point, how far mercurial remedies may be neces- sary or injurious in the management of these affections. It is now, however, very generally admitted, that in what are termed the pseudo- syphilitic symptoms, the employment of this potent remedy may, often, be very properly dispensed with—that it is calculated, under certain circumstances, to do much injury, and that in no instance is it necessary to carry its employment to the great extent which was formerly so indiscriminately and generally practised. Nevertheless, we may, upon good grounds, I think, refuse to join in the hue and cry set up against the employment of mercury in venereal cases—for there is much reason to believe that many of the baneful consequences, which have occurred from its administration, have proceeded rather from its abuse than its use, or from accidental influences contraven- ing its salutary influence. The most violent declaimers against mer- cury are those who have practised in hot climates—and in military and other hospitals, and generally among patients whose previous modes of living were such as to deprave the general constitutional habit—all of which circumstances are certainly very well calculated to interfere with the salutary operation of this remedy, and to convert it, often, into a decidedly deleterious agent. It must be admitted that the various forms of constitutional vene- real affections may, in general, be ultimately removed by a long course of the usual diaphoretic ptisans, proper regimen, and other simple measures, calculated to improve the general health of the system. This is more especially practicable, so long as the second- ary symptoms are confined to the skin and throat; but even in this stage of the progress of such affections, the moderate and gentle use SYPHILIS. 505 of mercury will almost always greatly expedite the cure, and in some instances will be found indispensable to the entire eradication ot the malady. Although very generally a mild mercurial influence, regu- larly sustained, will be sufficient to procure all the benefits that may be derived from this remedy, yet instances do sometimes occur, which, after along course of gentle mercurial action without any permanent advantage, will readily yield to a full salivation. About four years ago, I met with a striking illustration of this fact. 1 he natient had for three years laboured under secondary venereal symp- toms which were the consequence of a phagedenic primary ulcer He had undergone three moderate, but long-continued mercuna com es Tth Snly very temporary benefit, and during the eight non hs immediately before I saw him, he daily took the sarsaparilla Jetton STd svrup-of the latter of which he had already taken abov^ forty bottles. His nose and internal fauces were much ulcer- ted and virions painful swellings on the ulnae, tibiae arid cramtun had reduced him to a most distressing condition. I put him imme dialelv uponTe use of large and repeated doses of calomel, and confinedhim to his bed. In five days very profuse ptyalism was nduced, which was kept up for two weeks, and then left to subside gradually under the use of sarsaparilla infusion In six weeks he was entirely cured, and he has since enjoyed, apparently, a perfect %ehe^tor form of venereal eruption will very generally dis- Hrinbi^M^^d^ oSshould be had to mercurial remedies which wdl rarely fad in n «hnrt time to manifest a most beneficial effect. The/.i; g. opii. gr. ii; pulv. camph. gr. v.—M. Divide into five pills. The patient should not be permitted to walk about or even to sit up. If the extremities are cool and the surface pale and shrunk, the patient should bathe his feet in warm water im- pregnated with salt, then lie down in bed well covered, " with warm applications to the feet, as bottles of warm water, warm bricks, irons, or bags of heated oats, or sand, &c."* When at this early period the patient complains of nausea, I have found nothing so effectual in giving relief as small doses of a solution of camphor in sulphuric ether. From six to ten drops every twenty or thirty minutes of a solution of thirty grains of camphor in an ounce of the ether, will seldom fail to allay the nausea and vomiting at this stage of the complaint. This solution with the addition of small doses of laudanum is particularly beneficial where the incipient stages are attended with symptoms of a decidedly nervous character. Dr. Samuel Jackson states, that in cases of this kind, he has frequently used the following prescription, with the most satisfactory results: R.—Tinct. lavend. compos.; tinct. camphorae, aa 3iv ; liq. Hoff. anod., tinct. opii, aa 3ij.—M. ft. mist. From ten to twenty drops of the above are to be administered at appropriate intervals. By the preceding mode of management, the premonitory or incipient symptoms of the disease have, in a large majority of instances, been speedily and effectually subdued, and the full development of the disease pre- vented. After the irritable state of the stomach and bowels has been allayed a mild purgative should be ordered. • For this purpose, pow- dered rhubarb, or the compound extract of colocynth, or fresh castor oil, will answer very well. The operation of the purgative should be followed by an anodyne. During convalescence from these symp- toms, and, indeed, for a considerable period after their disappearance, the patient ought to use a mild, digestible and nutritious diet and especially to avoid over-distending the stomach with food or drinks. Many relapses have occurred in consequence of some error in this respect. If, notwithstanding these remedial, measures, the disease assumes a more serious character, that is, if the evacuations begin to assume, or have assumed, the appearance of rice-water, and the patient ex- periences cramps in the extremities, then the primary objects are, to allay the cramps, vomiting, and purging, and to support the ac- tion of the heart and capillary circulation. From eight to ten grains of calomel, in union with half a grain of opium, should.be given every hour. Many respectable authorities recommend much larger doses of calomel, whilst others, of equal respectability, employ it * Dr. Samuel Jackson, Amer. Journ. of Med. Sciences, vol. xi. p. 324. CHOLERA ASPHYXIA. 545 but sparingly. That calomel is a valuable remedy in this disease admits, I think, of no doubt; but my own experience has fully con- vinced me, that all the benefits which this remedy can afford, may be obtained from the doses 1 have just mentioned.* To allay the nausea and vomiting, the aetherial solution of camphor, already men- tioned, is an excellent remedy. From ten to twenty drops should be given every half hour, or hour, according to the urgency of the symptoms. Dr. Jackson recommends the following mixture for this purpose, and I have no doubt of its usefulness. R.—Bi-carbon. po- tassae 3iv; acetat. opii gtt. xv; aquae camphorae Ziv.—M. ft. solut. Half an ounce, mixed with an equal quantity of lemon juice, should be taken in the act of effervescing, every half hour. A sinapism should be laid over the abdomen; and dry heat assiduously applied to the extremities. The employment of the warm bath has been strongly recommended by some writers; but the relaxing and debilitating effects of the bath, together with the agitation and fatigue of the body almost necessarily attending its use, have often done very serious injury. In the " India Reports of Cholera," many instances are mentioned, " where the warm bath, in the second stage of cholera, manifestly hastened the death of the patients." These objections do not apply to the use of the alcoholic vapour bath. This applica- tion may be made, without disturbance or fatigue to the patient; and I have known it to be resorted to, in the early periods of the dis- ease, with very decided advantage. There is no remedial measure that has been more urgently advocated by some, and more strongly reprobated by others, than sanguineous depletion. To draw blood from the body, in a disease so strongly and so certainly tending to total prostration of the vital powers, does, indeed, at first sight, appear very unpromising. Ample experience, however, has satisfactorily established the fact that, in the early periods of the disease, before collapse of the vital energies has taken place, and in subjects not enfeebled by age, or previous ill-health, blood-letting is sometimes attended with the most favourable results. Many of the most respectable physicians of India speak in strong terms of praise, of the effects of general bleeding in cholera. Dr. Taylor, in his report to the president of the Bombay Medical Board, says, that "when the principal symptoms are great oppression at the breast, laborious breathing, and a feeling of suffocation, or when the patient was affected with general tremors, giddiness, or locked jaw, bleeding was the only remedy which afforded effectual relief. But while blood-letting, in the early stage of the disease, and under certain circumstances, almost uniformly produced the most decided salutary effects, it was, in general, unavailing in the latter stages, when the * By some of my western brethren the dose of calomel I have stated above, will be deemed very inadequate. The quantities of this article, which have been administered in cholera, by some highly respectable western physicians, are, in- deed, truly enormous. I have it from unquestionable authority, that in not a few instances, one pound and a half, at least, has been given to the patient, in the course of forty-eight hours. VOL. II.—36 546 CHOLERA ASPHYXIA. limbs were cold, the pulse not to be felt, and the eyes fixed and sunken." Indeed, when once the disease has advanced to the state of collapse, it is almost impossible to procure the discharge of blood, which merely trickles forth in drops, and often fails entirely to issue from the orifice. Dr. Kennedy, in his excellent treatise on this disease, declares, that "every patient from whom blood could be freely obtained, was almost sure of recovery;" and this declaration is supported by the majority of his medical brethren in India. In our own country, many physicians of the highest respectability have recorded their testimony in favour of general blood-letting, in this malady. Dr. Hopkinson, of Philadelphia, a young physician, rising rapidly to eminence and distinction in his profession, says, " to over- come or remove the universal venous congestion in cholera, there is no substitute for venesection. The blood must be drawn from a vein. It will not do to open an artery ; this exhausts the patient, but does not relieve the venous congestion. If the pulse is not per- ceptible, or if it be very feeble, it is better to begin by applying cups over the abdomen, and if then the pulse rise, we may open a vein in the arm or in the foot, and watching the pulse, let the blood flow until reaction, or the improved condition of the patient indicates the attainment of our object." These precepts accord fully with my own sentiments on this subject. Local depletion by cupping or leeching, is, by some, regarded as, in general, decidedly preferable to blood-letting from a vein ; and doubt- less in many cases, it is capable of affording all the advantages that can be derived from depletion, with less risk of hastening prostration, than would attend the opening of a vein. In the early period ofthe disease, when the pulse is yet moderately full and active, almost im- mediate relief sometimes follows the application of leeches or cups to the epigastric and iliac regions. Dr. Samuel Jackson says: " It is sur- prising to witness how prompt, often, is the alleviation and abatement of the symptoms, following the application of from thirty to sixty leeches to the epigastric or iliac regions. In no instance did I find it necessary, in the patients I treated, in the first stages, to repeat the local depletion. One application was sufficient to procure a favour- able result. In several instances, general depletion made but little impression, whilst prompt relief ensued upon local depletion." It was not until near the termination of the last epidemic cholera in this city, that I ventured on sanguineous depletion in its remedial management; and the few cases in which I at last adopted this practice, gave me cause to regret, very much, that I had not sooner resorted to this important remedy in the treatment of this malady. As a general rule, local bleeding, by cupping or leeching is, without doubt, preferable to venesection; but when the pulse is moderately full and active, and the patient not of a feeble and nervous habit, blood may be freely drawn from a vein, with little or no risk of injury, and generally with decided advantage. But besides the general ab- straction of blood, and consequent relief of the internal venous con- gestion, which the application of leeches or cups to the epigastrium affords, in common with venesection, it has the additional advantage CnOLERA ASPHYXIA. 547 of acting more directly on the abdominal organs, and by its derivative and sedative effects, of obviating the congested and irritable condition of the stomach and bowels. To allay the thirst, which is generally extremely harassing, the pa- tient must be allowed to drink weak iced lemonade, iced gum water, barley water slightly acidulated and sweetened, artificial Seltzer with or without lemon syrup, and iced water in small quantities. When the thirst is attended with a sense of heat and burning in the stomach, much relief may often be obtained by swallowing small pieces of ice. " In many instances," says Dr Jackson, "ice itself was given in very- small pieces," and the effect, he states, was most grateful, and mani- festly salutary. If the disease advances, and the temperature of the body and action of the heart begin to sink—if the pulse becomes small and feeble, and the hands and feet assume a corrugated and livid appearance, unceasing efforts must be made to sustain the activity ofthe capillary circulation, and the warmth of the body. Frictions with flannel moistened with a strong infusion of capsicum, or some other irritating liniment, or dry frictions with a flesh brush, together with sinapisms to the abdomen and extremities, are best adapted to answer this intention. It will also be proper to administer stimulants internally; such as small portions of brandy and water, ammonia, turpentine, ether, &c. To check the excessive serous discharges from the stomach and bowels some practitioners have advised the internal employment of the sugar of lead; and from what I have seen of its effects in this disease, I am inclined to think, that much advantage may, often, be derived from it in this respect. Two grains of the acet. plumb, in union with a grain of camphor, may be given every half hour, until the watery discharges cease ; or from twenty to thirty grains, dissolved in a small quantity of water, may be injected into the rectum. I have employed this article, in both these ways, in three or four cases; and as it appeared to me, with a very manifest effect in diminishing the quantity and frequency of the serous evacuations. When the disease has advanced to the third stage, or the state of collapse, the treatment already mentioned must be continued; and to restore the fluids drained from the blood-vessels, by the excessive discharges through the stomach, bowels, and skin, the patient should drink freely of some agreeable beverage, such as barley water, rice water, water mixed with a small portion of brandy ; soda water, Seltzer water, or weak chicken, mutton, or beef tea. As soon as the evacuations have ceased or are suppressed, the opium which was directed with the calomel, should be omitted, or given only in very small portions. When freely given in this stage ofthe disease, opium may do serious injury, either by blunting the sensibility of the system, already too torpid, or by promoting a dangerous determination to the brain should reaction take place, To persons who have been intem- perate or who have been addicted to the use of spirituous drinks, stimulants must be pretty freely allowed, in this stage of the disease. The carbonate of ammonia is an excellent stimulant for this purpose, 548 CHOLERA ASPHYXIA. and generally agrees better with the stomach than any other remedy of this kind. Much has been said in favour of mustard emetics, in the collapse, or " blue" stage of cholera. Dr. Gibson, of Sunderland, declares that he has employed this remedy with the happiest effect in the advanced stages of the disease; and Greenho w says, " In the cold, blue or pulse- less stage of the intense type of the disease, I believe it to be a very valuable remedy in relieving the irritation ofthe stomach, and excit- ing reaction." In this city, the mustard emetic was employed both in this and in an earlier period ofthe disease, by several of my medical brethren, and, I have understood, often with decided advantage. My own experience, however, has not furnished me with any evidence of the usefulness of this practice in the stage of collapse ; but I have derived very manifest advantage from this emetic at an early period of the disease.* The tendency of forcible vomiting to excite the action ofthe heart and arteries and to impel the blood from the cen- tral vessels to the circumference, is indeed well known ; and it does not appear improbable, therefore, that any article which is capable of producing a sudden and vehement vomitive exertion, should occa- sionally give a salutary impulse to the circulation in this malady. Dr. Stevens, conceiving that the proximate cause of cholera con- sists in a deficiency of the saline elements of the blood, administered the non-purgative salts ; and the result, he informs us, was highly encouraging. In the account which he gives of his experience with this remedy, he states, that in some cases, where the pulse had already ceased in the extremities, the administration of the carbonate of soda was speedily followed by a return of the pulse, and an increased tem- perature of the body. This treatment has been adopted by many other physicians, both in this country and in Europe, and several statements have been published strongly in favour of its usefulness. Mr. Wakefield, an English physician of great respectability, declares that he employed this remedy, in the cholera, as it occurred in the prison at Cold Bath Fields, with extraordinary success. Fifteen fully developed cases of cholera, were " put under the saline treatment, and all of them recovered. When the patients were first admitted, the following powder was immediately given, either in half a tumbler of tepid water, or occasionally, in a little thin, clear beef tea. R.—Super- carbonate of soda 3ss ; muriate of soda Bi; chlorate of potass grs. vii. This was repeated every hour, and continued until the patients were recovering from the state of collapse; after which it was dimi- nished in frequency in proportion as the reaction increased."! When the stomach is very irritable, the tartrate of soda, in a state of effer- vescence, is said to be the most agreeable and effective form of ad- ministering the alkali. Mr. Wakefield advises, that, in addition to the use ofthe powder just mentioned, enemata should be administered, * The mustard emetic is thus prepared. Dissolve a teaspoonful of common salt in a gill of warm water, and then mix with it a teaspoonful of finely powdered mustard. This is to be taken at one draught. t London Med. Gazette. Amer. Journ. of Med. Scienc, vol. x, p. 51. CHOLERA ASPHYXIA. 549 every two or three hours, composed of a large tablespoonful of muri- ate of soda, dissolved in warm water. Mr. Whitmore states, that of eleven cases of cholera, which occurred " amongst a small colony of Italians, the first three were treated by bleeding, brandy and opium, and they all died. The other eight cases were put under the saline treatment, as recommended by Mr. Wakefield, and all but one, speedily and completely recovered." In accordance with the senti- ments of Dr. Stevens, saline fluids have, also, been injected into the veins in the cold or " blue" stage of this malady. Dr. Thomas Latta, of Leith, resorted to this practice, in a considerable number of cases; and he assures us, that, " in every case, even the most desperate cholera symptoms were removed." The quantity of saline fluid in- jected, amounted in some few instances to one hundred and twenty ounces; and, it would appear that, unless the quantity introduced into the veins is very considerable, (from eighty to one hundred and twenty or thirty ounces,) no reliance can be placed on the permanency of its beneficial effects. In New York and Philadelphia, this remedy was repeatedly tried, and a few cases have been mentioned in which it proved successful. Both this and the preceding mode of employ- ing alkalies in this malady, have entirely failed, in the hands of many judicious practitioners, and however successful this mode of treat- ment may have been, in the practice of some, its claims to particular attention are still very doubtful. I have seen the carbonate and tar- trate of soda freely administered, in six or seven cases, in the cholera hospital of this city, without, in a single instance, observing any decided beneficial effects from its influence. Dr. Charles Lee, of the Greenwich Hospital, New York, relied wholly on the employment of external applications, for exciting reac- tion in the stage of collapse. "At first," he says, "we relied on powerful internal stimulants and external revulsives; but our success was small; no permanent reaction could be produced. At length I concluded that there was no absorption from the mucous membrane ; that from the violent action it had undergone, its functions were lost, and brought into the same condition as that of the skin. The only thing then left, was to undertake to introduce medicines into the cir- culation, mechanically through the skin. The indications were, to restore the circulation, relieve spasm, promote the action of the ab- sorbents, and unlock the secretions. To effect these objects, I pre- pared the following mixture. R.—Strong mercurial ointment Ibi; powdered camphor Ibss; powdered Cayenne pepper 3iv. Mix well together, and have the patient rubbed all over for half an hour at a time, and repeat the operation, accordingly, till the mouth is affected. The success of this plan was perfectly astonishing. Without ad- ministering a particle of medicine internally, reaction is sure to follow, in from one to three hours, even in the most perfect collapse." This plan of treatment appears to be well adapted to fulfil the principal in- dications in cholera; but it is extremely doubtful whether this, or any other remedy, can avail aught in the state of " perfect collapse." When the disease has proceeded to this extent, all remedial efforts are probably wholly unavailing; and if recovery from perfect collapse 550 CHOLERA ASPHYXIA. does take place, it must be the result, rather of a spontaneous effort of the vital energies, than of any remedial impulse. The application of irritating applications over the tract of the spine, is said to have produced very excellent effects in the spasmodic and more advanced periods of the disease. Sinapisms, tartar emetic oint- ment, and turpentine, have been employed for this purpose. In a case which occurred in the practice ofthe late Dr. Staughton, the ap- plication of cups over the spine, just as the patient was passing into a state of collapse, was speedily followed by decided melioration of the symptoms. Would not the application of moxa to the epigas- trium and spine prove beneficial in this disease. M. Petit, of the Hotel Dieu, in Paris, thinks, that the principal indication to fulfil, in the treatment of cholera, " is to keep up a constant impression upon the spinal marrow." With this view, he applies " over the whole tract of the spine, a strip of flannel, wet with a liniment composed of an ounce of the spirits of turpentine, and a drachm of aqua ammo- nia, and passes slowly over it a very hot flat-iron." This almost immediately produces vesication; and is, we are told, generally speedily followed by a return of the warmth of the skin, renewed activity of the circulation, and cessation of the vomiting and cramps. In addition to this application, frictions of the extremities, with a de- coction of mustard, to which some aqua ammonia is added, must be diligently made. If reaction takes place, there is generally much danger of excessive determination of blood to the head ; and many cases have terminated fatally, from sudden oppression of the brain, producing violent de- lirium or coma, or even convulsions, in the stage of reaction. During the first five or six hours after reaction commences, the case ought to be carefully watched, and the febrile action moderated, if it tends to become violent, by blood-letting. Very often, indeed, delirium or deep coma ensues, with but a moderate degree of arterial reaction, as indicated by the pulse. In cases of this kind, sinapisms, or warm applications should be made to the feet, while ice, or flannel wet with iced water, is constantly applied to the head, having previously ap- plied leeches or cups to the temples. During convalescence from cholera, the diet should be mild, digesti- ble, and nourishing—and the patient ought to be particularly cautioned against indulging too freely in eating. Above all, he should avoid crude vegetables, and rich pastry. Dr. Kennedy states that a copious draught of cold water, during convalescence from this disease, has fre- quently brought on a relapse. Fatigue of body and mind, too, ought to be avoided, more especially in persons of a weak and delicate habit of body. INDEX. Kj* The Numerals refer to the Volume—the Figures to the Page. B. Amaurosis, ii. - 197 Bilious pleurisy, i. - . . 302 Symptoms, ii. - - 199 Treatment . . 308 Diagnosis, ii. - - 200 rheumatism, i. . . 382 Prognosis, ii. - - ib. fever, i. « . 128 Causes, ii. - 201 colic, ii. . . 313 Treatment, ii. - - 202 Bladder, inflammation of, acute, i . 365 Amenorrhoea, ii. - 513 chronic »i- 367 Causes, ii. - ib. Brain, inflammation of, i. 277 ,295 Treatment, ii. - - 514 Bronchitis, acute, i. . . 330 Anasarca, ii. - 425 Diagnosis, i. . . 332 Angina Pectoris, ii. - 266 Post mortem appearances, i. . ib. Pathology, ii. - - ib. Prognosis, i. . . 333 Treatment, ii. - - 270 Treatment, i. - . . ib. Aorta, aneurism of, ii. - 257 Bronchitis, chronic, i. . . 336 Apoplexy, ii. - 12 Diagnosis, i. . . 338 Perfect or strong, ii. - 13 Post mortem appearances, i. . 339 Hydrocephalica, ii. - 14 Causes, i. . . 340 Diagnosis, ii. - - 15 Treatment, i. - . . i*. Prognosis, ii. - - 16 Bronchocele, ii. . . 457 Causes—predisposing, ii. - 18 Diagnosis, ii. - - . 459 exciting, ii. - ■ 19 Etiology, ii. - . 460 Pathology, ii. - - 21 Treatment, ii. - . . 465 Treatment, ii. - - 26 Bubo, ii. . . 510 Arachnitis, i. - - - 282 Symptoms, i. - - 283 C. Diagnosis, i. - - 286 Pathology, i. - - 287 Catalepsy, ii. - . 72 Causes, i. - 289 Diagnosis, ii. - - - 75 Treatment, i. - - 290 Causes, ii. . . ib. Ascites, ii. - - 423 Prognosis, ii. - - . 77 Asphyxia, ii. - 231 Treatment, ii. - - - ib. from drowning, - ib. Catarrhal consumption,i. . . 337 Treatment, ii. - 235 ophthalmia, i. - . 412 from irrespirable g ises, ii .238 Causes of fever in genera ,i. - 43 Treatment, ii. - 239 Their general character and from electricity, ii. - 240 sources, i. - - 46 Treatment, ii. - 241 Cerebritis, or softening of the brain, i 295 from cold, ii. - ib. Symptoms, i. - - - 296 Treatment, ii. - 242 Treatment, i. - - - 298 Asthma, ii. - - 206 Chancre, ii. - - 492 Symptoms, ii. - - 207 Syphilitic, - - 498 Prognosis, ii. - - ib. Pseudo-syphilitic, ii. - - ib. Causes, ii. - 209 Chicken-pox, i. - - 453 Pathology, ii. - - 210 Chlorosis, ii. - - 473 Treatment, ii. - - 213 Symptoms, ii. - - - 474 Atmospheric heat, its relations with the Causes, ii. - - 476 animal system, i. - 48 Treatment, ii. - - - ib. 552 INDEX. PAGE rAGE Cholera Asphyxia, spasmodic, ii. - 533 Cynanche, diagnosis, i. - ■ 323 Phenomena, ii. . 534 Treatment, i. - - - 324 Cholera, diagnosis, ii. - 537 Cystitis, i. - - - 365 Post-mortem appearances, ii. - 538 Symptoms, i. - - ■ ib. Pathology, ii. - - 539 Suppuration, i. - - ib. Causes, ii. . 540 Causes, i. - - 366 Not contagious, ii. . 542 Treatment, i. - - - ib. Treatment, ii. - . 543 Cys tilis, chronic, i. - - - 367 Cholera, of adults, ii. . 297 Symptoms, i. - - - 368 Pathology, ii. - . 298 Treatment, i. - - - 369 of infants, ii. . 300 Cynanche tonsillaris, i. - - 206 Treatment, ii. - . 303 Symptoms, i. - - - ib. Treatment ofcholera infantum, i .305 Causes, i. - . 207 Chorea, ii. - . 79 Treatment, i. - . - 208 Causes, ii. . 82 Pathology, ii. - . 84 D. Prognosis, ii. - - ib. Treatment, ii. - - 85 Delirium tremens, ii. - - 171 Clap,ii. ... - 479 Symptoms, ii. - - - 173 Cold, its effects on the animal system , i.48 Pathology, ii. - - - 174 Colica pictonum, ii. - 318 Prognosis, ii. - - - ib. Causes, ii. . 320 Treatment, ii. - - - 175 Pathology, ii. - . ib. Dementia, ii. . . 163 Treatment, ii. - . 321 Diabetes insipidus, ii. - - 380 Colic, flatulent, ii. - . 311 Symptoms, ii. - - - 382 Treatment, ii. - . 312 Causes, ii. - - ib. bilious, ii. . 313 Treatment, ii. - - - 383 Treatment, ii. - . 315 Diabetes mellitus, ii. - - 367 Constipation,ii. . 330 Symptoms, ii. - - . 368 Causes, ii. . ib. Causes, ii. • - 370 Remedies, ii. - . 331 Pathology, ii. - - ■ 371 Consumption, pulmonary, i. - 346 Post-mortem appearances, ii. - 373 bronchial, i. . 336 Prognosis, ii. - - - ib. catarrhal, i. - . 337 Treatment, ii. - - - ib. Contagion, i. - - - 68 Dia gnosis, general, i. - - 80 fixed, solid, i. - ib. Order of inquiry, i. - ■ 82 volatile, effluvium, i. . ib. by the countenance , i* . 85 Modes of disinfecting, i. . 71 attitude and motions , i- 91 Conlinued fever, i. - . 153 nervous system, i. 95 Convulsions, of children, ii. . 91 alimentary canal, i. - 98 Prognosis, - 94 blood vessels, i. - 99 Carpo-pedal, ii. - 95 respiratory organs, i ib. Treatment, ii. - • 98 cnticular surface, i. - 102 puerperal, ii. - 115 lymphatic system, i. - 103 Treatment, ii. - . 118 secretions, i. - - ib. Cow-pox, i. - . 441 Diarrhoea, ii. - . 288 Its origin, i. . ib. Causes, ii. - . 290 Appearances, i. . 442 Prognosis, ii. - ■ - 292 Prophylactic powers, i. - 446 Treatment, ii. - - - ib. Causes of deterioration, i. - ib. Dropsy, ii. - . . 417 Effects upon diseases, i. . 447 of the abdomen, ii. . . 423 Croup, i. - - 318 ofthe brain, i. . - 2^2 Symptoms, i. - • ib. ofthe chest, ii. - - 424 Causes, i. - 319 ofthe cellular membranes , b .425 Prognosis, i. - . 323 Treatment, ii. . 426 Diagnosis, i. - - ib. Drowning, suffocation from, ii. . 231 Treatment, i. - - 324 Dy sentery, (mucous enteritis,) i. . 229 Cynanche laryngea, i. - 318 Symptoms, i. - - • 230 Symptoms, i. ■ ib. Causes, i. . . 231 Treatment, i. - - ib. Pathology, i. - . . 233 Cynanche trachealis, i. . 319 Prognosis, i. . . 234 Pathology, i. - 320 Treatment, i. - - - ib. INDEX. 553 PAGE PAGE Dysmenorrhoea, ii . . 519 Fe ver, Broussais's doctrine, i. . 21 Symptoms, ii. - 520 general etiology, i. - - 43 Pathology, ii. - - 521 general course and type, i. - 73 Treatment, ii. - - 523 various stages, i - ib. Dysury, ii. - - - 410 definition of type, i. - - 74 Causes, ii. - - ib. Fe ver, intermitting, i. - 104 Treatment, ii. E. ib. stages of, i. -inflammatory variety, i. congestive, i. gastric, i. - - 106 ib. 107 ib. Eczema, i. - - - - 524 malignant, i. - ib. Simplex, i. ■ - - ib. anomalous intermittents, i. - ib. Rubrum, i. - - - 525 Prognosis, i. - - 110 Impetiginodes i- - - ib. Causes, i. - - . 111 Chronic, i. - - . ib. Treatment, i. - - 113 Causes, i. - - ■ 526 of inflammatory, i 116 Diagnosis, i. - - ■ ib. of congestive, i. - 117 Treatment, i. - - - ib. of gastric, i. - ib. Enteritis, acute peritoneal, i. - 222 of malignant, i. • 119 Symptoms, i. - - - ib. Fe rer, synocha, i. - - 154 Diagnosis, i. - - - 223 synochus, i. - ■ 155 Poit-mortem appearances, i. - 224 typhous, i. - - 156 Causes, i. - . - ib. Fe^ ier, remitting, i. - . 128 Prognosis, i. - - - ib. Symptoms, i. - - ib. Treatment, i. - ■ - 225 gastric remittents, i. . 131 Enteritis, chronic, i. . - 244 hepatic remittents, i. . 132 Causes, i. - ■ - 245 Causes, i. . 134 Post-mortem a ppearances, i. - ib. Prognosis, i. . ib. Treatment, i. . - - 246 Treatment, i. - . 135 Enteritis, mucous, i. . . 229 Fei ier, Yellow, i. . 145 Causes, i. - - - 231 Symptoms, i. - - 146 Prognosis, i. - - ■ 234 Etiology and origin, i. - . ib. Treatment, i. - - - ib. Black vomit, what,i. - . 147 Enuresis, ii. - - - 412 Post-mortem appearances, i. . 148 Epilepsy, ii. - - - 49 Treatment, i. - . 150 Causes, ii. - - - 53 Fe irer, inflammatory, i. . 157 Pathology, ii. • - - 55 Symptoms, i. - - 158 Diagnosis, ii., - - - 56 Causes,i. - 159 Prognosis, ii. - - - ib. Treatment, i. - . 167 Treatment, ii. - - - 58 Fe ver, common continued synochus, i .161 Epistaxis, i. • . - 544 different forms of, i. - - 162 Causes, i. - - . ib. Causes, i. - - - ib. Prognosis, i. . - . ib. Diagnosis, i. - - 163 Treatment, i. . . . 545 Prognosis, i. - . - 167 Erysipelas, i. - - - 488 Treatment, i. - - ib. phlegmonodes, i. - 490 Fever, typhus, i. - 177 cedematodes, i. ■ - 491 Symptoms, i. - - ib. biliosum, i. - - ib. Causes and' origin, i. - - 181 neanatorum, i. . • 492 Prognosis, i. - - 185 gangrenosum, i. - ib. Treatment, i. - - 186 Causes, i. . - 494 Fever, scarlet, i. - 466 Pathology, i. . - 495 varieties of, i. - 467 Treatment, i. - - 496 sequela, i. - - 471 Erythema, i. - - 529 Diagnosis, i. - - 472 Causes, i. . - ib. Treatment, i. - - 475 Diagnosis, i. . . 530 Fluor Albus, ii. - 525 Treatment, i. . - ib. Causes, ii. - ib. Exanthemata, i. . - 426 Symptoms, ii. - - 526 minor, i. ■ • 502 Treatment," ii. - - 528 F. G. Fever, general pat lology, i. - 17 Gastralgia, ii. - 183 554 Gastralgia, nature of, ii. Treatment, ii. - Gastritis, acute, i. - Diagnosis, i. Causes, i. Prognosis, i. - Post-mortem appearances, i. Treatment, i. - Gastritis, chronic, i. Symptoms, i. - Diagnosis, i. Causes, i. Post mortem appearances, i. Treatment, i. - Glossitis, i. Treatment, i. - Goitre, ii. - where found, ii. Causes, ii. Treatment, ii. - - Gonorrhoeal rheumatism, i. Gonorrhoea, ii. Symptoms, ii. - in women, ii. Secondary symptoms, ii. Excoriations, ii. Treatment, ii. - Gout, regular, i. - irregular chronic, i. - Diagnosis, i. - Causes, i. proximate, i. - Treatment, i. - H. Haematemesis, i. - Causes, i. - - Prognosis, i. - Treatment, i. - Haematuria, i. Causes, i. Treatment, i. - Haemoptysis, i. Predisposition, i. Causes, i. - - Prognosis, i. - Treatment, i. - Hemorrhagia, i. - Causes, i. Treatment, i. - Hemorrhages, i. - Pathology, i. - Effects on the system, i. Causes, i. Prognosis, i. Treatment, i. - Hemorrhoids, ii. Molimina and consequences, i Local affections, ii. Causes, ii. Treatment of local affections, INDEX. PAGE PAGE 195 Treatment of hemorrhage, ii. 350 196 Treatment of tumours ii. - 352 211 Heart, chronic diseases of, ii. - 247 212 hypertrophy of, ii. - - 254 213 dilatation of, ii. - - 255 ib. sympathetic disturbance of ii. 257 213 Treatment, ii. - - - 258 ib. Heat, atmospheric, i. - - 48 215 Hemiplegia, ii. - - 34 216 Treatment, ii. - - ■ 42 ib. Hepatitis, acute, i. - - - 260 218 Terminations, i. - ■ 261 219 Causes, i. - . 262 220 Diagnosis, i. - . 263 204 Treatment, i. - . . 266 205 Hepatitis, chronic, i. - . 269 457 Post-mortem appearances, i. - 271 458 Treatment, i. - . . ib. 460 Herpes phlyctenodes,i. - - 503 465 Diagnosis, i. - - ib. 383 zona zoster, i. - . 504 479 Treatment, i. - . 505 480 circinatus, i. . . 506 482 Treatment, i. - - 507 483 labialis, i. - - . ib. ib. preputialis, i. - - 508 ib. Treatment, i. . - ib. 398 Hydrocephalus acutus, i. - - 282 461 Symptoms, i. - - - 283 403 Diagnosis, i. - • 286 ib. Pathology, i. - - 287 405 Post-mortem appearances, i. - 288 406 Causes, i. - - 289 Treatment, i. - - . 290 Hydrophobia, ii. - - 135 Symptoms, ii. - - - 139 547 Post-mortem appearances, ii. - 142 548 Treatment, ii. - - • 143 ib. Hydrops, ii. - - 417 ib. General symptoms, ii. - - 421 549 Hydrothorax, ii. - - 424 550 Hysteria, convulsive, ii. - - 102 551 chronic, ii. . - ib. 552 Hysteric torpor, ii. - ■ 103 553 Pathology, ii. - - - 104 554 Causes, ii. - - 105 ib. Diagnosis, ii. - - . 107 555 Treatment, ii. - - . 108 568 Hysteritis, acute, i. - - . 370 560 Treatment, i. - . . 372 561 Hysteritis, chronic, i. - . 374 537 Phenomena, i. - - . ib. 538 Treatment, i. - . . 375 539 541 I. 542 543 Icterus, ii. - . . 355 343 Causes, ii. . . 358 ib. Pathology, ii. - . . 359 345 Prognosis, ii. - - . 361 347 Treatment, ii. - . . 362 . 348 Idio-miasmata, i. - - 60 INDEX. 555 PAGE 61 Effects on the human system, i Effects in conjunction with koino-miasmata, i. - Idiotism, ii. ... Ileus, ii. - Pathology, ii. - Treatment, ii. - Indigestion, ii. Causes, ii. - Symptoms, ii. - Treatment, ii. - Inflammation in general, i. Phenomena, i. - Pathology, i. - Terminations, i. Inflammation of the brain, i. 277 & 295 of the meninges, i. - 289 ofthe stomach, acute, i. 221 ofthe stomach, chro- nic, i. - - of the peritoneum, acute, i. of the peritoneum, chronic, i. - of the bowels, perito- neal, i. of the bowels, acute, mucous, i. - of the bowels, chronic mucous, i. ofthe liver, acute, i. chronic, i. of the spleen, acute, i. chronic, i. ofthe kidneys, acute, i. 360 ofthe bladder, acute, i. 365 of the bladder, chro- nic, i. of the trachea, i. of the bronchia, mu 62 164 325 326 328 272 273 277 279 198 ib. 199 200 215 248 256 211 212 229 270 274 275 ib. 367 318 Intermitting fever, i. Intestinal worms, ii. Causes which favour their pro- duction, ii. - Their origin, ii. Tricocephalus dispar, ii. Ascaris vermicularis, ii. Ascaris lambricoides, ii. Taenia lata, ii. Taenia solium, ii. Symptoms, ii. - Treatment of ascarides, ii. of lumbrici, ii. - of tcenia, ii. Alston's method, ii. Desault's method, ii. Herrenschwand's method, ii. - Hufeland's method, ii. Nouffer's method, ii. - Schmucker's method, ii. Bremser's method, ii. Iritis, i. - Treatment, i. - Ischuria renalis, ii. Causes, ii. - Prognosis, ii. - Treatment, ii. Jaundice, ii. - Causes, ii. Pathology, ii. Treatment, ii. cous, 1. - of the bronchia, chro- nic, i. of the pleura, acute, i. of the lungs, i. of the larynx, i. ofthe tonsils, i. of the tongue, i. of the eyes, i. catarrhal, i. of the eyes, rheuma- tic, i. of the eyes, gonor- rhoeal, i. - of the eyes, purulent, i. of the eyes, scrofu- lous, i. ofthe iris, i. - of the parotid gland, i. ofthe pericardium, i. of the womb, acute, i. chronic, i. PAGE 104 332 334 ib. ib. 335 ib. ib. ib. 336 338 ib. ib. 339 ib. ib. ib. 340 ib. 341 424 425 394 396 397 398 355 358 361 362 330 336 299 300 314 206 204 412 ib. 414 417 415 420 424 209 377 370 374 K. Koino-miasmata, i. - - How generated, i. - Physical characters, i. Effects on the animal system, i. Union of koino and idio-mias- mata, i. L. Laryngitis, i. Symptoms, i. - Prognosis, i. Treatment, i. - Leucorrhoea, ii. - Causes, ii. - Symptoms, ii. - Pathology, ii. - Treatment, ii. - Lichen, simplex, i. Agrius, i. - Causes, i. Diagnosis, i. Treatment, i. Lithiasis, ii. Urinary deposits, ii. 54 ib. 57 62 66 314 ib. ib. 315 525 ib. 526 527 528 521 522 ib. 523 ib. 385 ib. 556 Pulverulent deposits, ii. Crystallized do. ii. Solid concretions, ii. Lithic acid diathesis, ii. Amorphous lithic sediments, ii. Yellow deposits, ii. Red or lateritious sediments, ii. Pink sediments, ii. Causes of the lithic acid sedi- ments, ii. Causes of crystallized depo- sits, ii. . . . Phosphatic diathesis, ii. Treatment, ii. - - - Treatment of lithic acid diathe- sis, ii. of phosphatic dia- thesis, ii. Liver, inflammation of, acute, i. ^ , /W/chronic'1;- M.- Malaria, (marsh) i. - Mania, ii. .... Mania-a-potu, ii. - Cause, ii. - Symptoms, ii. - - - Treatment, ii. - Measles, i. - inflammatory, i. - congestive, i. typhous or malignant, i. - gastric, i. - Sequelae, i. - Diagnosis, i. - Prognosis, i. - Treatment, i. - Menorrhagia, i. - chronic, i. - Effects on the system, i. Causes, i. Treatment, i. - Mental derangement, ii. Causes, ii. - Prognosis, ii. - Post-mortem appearances, ii. Treatment, ii. - Miasmata, idio, i. - Miasmata, koino, i. - Infection, what, i. - - Physical character, i. - Morbific influence, i. - Union of koino and idio-mias- mata, i. - Miliary fever, i. Causes, i. Nature, i. Treatment, i. - Modified small-pox, i. Monomania, ii, - Morbilli, (measles,) i. IND EX. PAGE PAGE 385 ib. 386 Mumps, (parotitis,) i. 209 N. 387 ib. Nephritis, i. ... 360 ib. Diagnosis, i. 361 ib. Causes, i. - 362 ib. Treatment, i. - 363 Nervous affections, chronic, ii. 9 ib. Nettle rash (urticaria) i. - 515 Treatment, i. - 518 388 Neuralgia, ii. 179 389 Symptoms, ii. 180 391 Causes, ii. - 185 Pathology, ii. - ib. ib. Diagnosis, ii. - 188 Treatment, ii. - ib. 393 260 O. 269 w Ophthalmia, i. 412 17/ catarrhal, i. - ib. BS8 5 ® • i jo Aavaau ivnoiivn inoiql L LIRRARY OF MEDICINE NATIONAL LIRRARY OF MEDICINE NATIONAL LIRR ART OF ME 0 ICtN I F\. £ sP^PF • F&s^ ' - S ^tvO I FW v \ >\\My I N JO ARVaill IVNOIIVN IN 13 Id 1W JO >l«llll IVNOIIVN IN I 3 ia iw jo Aavaan IVNOIIVN \ p^> lan ivnon v jo Aavaan ivnoiivn inijioin jo Aavaan ivnoiivn indiojw jo Aavaan ivnoiivn I FW * \ L LIRRARY OF MEDICINE NATIONAL LIRRARY OF MEDICINE NATIONAL LIRRARY OF M EOlCINI 1 ✓^ sp : F- i ;^S : &J * ~^ h jo Aavaan ivnoiivn indioin jo Aavaan ivnoiivn indioiw jo Aavaan lVNom r> : r-- \jF>P>Um I V4 \SF LI LiaRARY OF MEDICINE NATIONAL IIRRARY OF MEDICINE NATIONAL LIBRARY OF MEDICII 0 r/vj>fe i j c W jo Aavaan ivnoiivn indioiw jo tivam ivnoiivn indioiw jo Aavaan ivnoih ..? p\y' I \/\ ! 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